Cancer 3 Flashcards
What is renal cell carcinoma `? (RCC)
Most common form of kidney malignant cancer in adults
- arise in the epithelial cells of the PCT of kidney (renal cortex / parenchyma)
- linked to mutation in chromosome 3.
Can either be: 0 Sporadic 0 Inherited syndrome (e.g Von - Hippel - Lindau disease
- more common in older men - when carcinoma is sporadic
- accounts for 85% of kidney cancers.
- silent cancer , often asymptomatic until tumour is very large.
What is Von Hippel Lindau syndrome ?
Inherited disorder
- formation of tumors
and cysts in different areas of the body.
- number 1 cause of death is development of Renal cell carcinoma.
CAUSE
- mutation in VHL (tumour supressor gene )
Common characteristic
Hemangioblastomas - o non - cancerous tumours in the lower part of the brain, spinal cord, or retina. The tumor develops in the lining of a blood vessel. o don't invade nearby tissue. o cause ; if in brain or spinal cord
- headaches
- vomiting
- weakness
- ataxia (loss of muscle coordination)
if in retina (back of eye )
- cause vision loss
Associated with :
0 cyst in kidneys , pancreas , genital tract
0 increased risk of :
- kidney cancer (RCC - renal cell carcinoma )
- pancreatic neuroendocrine tumour - pancreatic cancer
- Pheochrmomcytoma - in andrenal gland (particularly dangerous in times of stress or surgery.) (associate with: -headaches - panic attacks - excess sweating - dangerously high blood pressure that may not respond to medication.
- endolymohatic sac tumours - in inner ear
present with :
Hearing loss
What are the symptoms of Renal cell carcinoma ?
Classic triad:
0 Flank pain
0 Haematuria
0 Palpable abdominal mass
all three can can happen as part of the triad or on its own.
They can have other symptoms which are more uncommon
0 non specific systemic : - pallor - weight loss - sweats - cachexia - myoneuropathy (dysfunction of the nerves supplying the muscle ?)
0 signs of hepatic dysfunction
- ascities
- hepatomegaly
- spider angiomata (naevus ) - swollen BV found under the skin.
others too.
Risk factors of Renal cell carcinoma ?
0 Smoking 0 male sex 0 aged over 55 years 0 black / american -indian ethnicity 0 Fx of RCC 0 Obesity 0 Hypertension 0 History of heritary conditions - Von Hippel Lindau -0 History of acquired renal cystic disease. ( condition occurs in end stage renal disease - common in people on renal dialysis. cysts develop in the kidneys.
Polycystic kidney disease vs acquired renal(kidney cystic disease?
Polycystic kidney disease - multiple/ clusters of cysts develop in the kidney , causing enlargement and loss of function.
- genetic
- kidneys become enlarged
- cyst can develop in other parts of the body e.g liver.
Acquired cystic renal disease
- no genetic link
(happens in end stage renal disease) - kidneys are normal sized or smaller
- cyst on develop in kidney.
Investigation of Renal cell carcinoma ?
0 CT abdomen / pelvis - can be contrast enhanced.
diagnosis and staging
(looking for renal mass , regional lymphadenopathhy , visceral / bone metastastes
0 MRI abdomen / pelvis
- can be used ADJUNCT to CT
or when contrast is contraindicated.
0 Ultrasound - pelvic /abdo
(contrast induced is best )
0 urinalysis -presence of blood or protein
0 Creatinine
elevated levels signal reduced renal clearance
0 LFT
(elevated AST - aspartate animotransferase, ALT - alanine animotransferase)
- metastastes
- Paraneoplastic syndrome
(conditions / signs & symptoms due having a cancer in the body due to ;
o Production of chemical signalling models e.g hormones
0 Immune response against tumour.
e.g - reduced HB , elevated RBC - FBC
Elevated RBC - (cause by tumour producing EPO —————-> increased RBC production & polycthemia
0 Hypertension - tumor releases renin.
0 corrected calcium -elevated
- Tumour releases PTHrH - (parathyroid related hormone )
0 Tumour can release ATCH ————-> cortidol release from adrenal gland——————> cushings syndrome.
- If tumour invades left renal vein into IVC then cancer will spread via the blood and reach the lungs .
Stages of renal cell carcinoma ?
Early stage RCC
Stage 1 and 2
0 confined to kidney with no regional lymph node or distant metastasis.
Stage 3
may be outside the kidney - but still in renal / Gerota’s fascia
- spread to nearby nodes, no distant metastasis
Stage 4
- tumour beyond renal fascia - may have grown into adrenal gland
(absolute )
can either or not spread to lymph node & distant organs.
Difference between kidney cancer / mass in the left vs the right kidney/?
Left testicular vein ————————-> left renal vein ——————> IVC
Right testicular vein ————————–> IVC
0 Mass in left kidney can grow large enough to compress the left renal vein preventing drainage of the left testicle - varicoclele on testicle appear.
Compression of renal vein can also cause hydronephrosis - kidney fills with urine becoming stretched and swollen.
Right testicular veins drains straight into the IVC - bypasses Right renal vein - so its compression will not affect it.
Treatment of renal cell carcinoma ?
RCC does not respond well to chemo and radiotherpay usually .
Small mass / RCC stage 1 or 2
1st line
Surgery - surgical resection
or
Local ablation therapy (LAT)
(ABLATION clinical intervention which destroys or removes body part
uses either :
o Radiofrequency Ablation - heat generated from current used to destroy tumour.
o cyroablation - kill tumour with extreme cold.
NON SURGICAL CANDIDATE - <3CM and slow growing
1st line
0 Survelilance
NON SURGICAL CANDIDATE - >3CM and fast growing
1st line
Sureveillance
ADJUNCT
- LAT
- consider for clinical trials.
RCC Stage 3
1st line 0 Surgery 0 ADJUNCT - Sunitinib - protein kinase inhibitor - blocks abnormal protein cancer cells need to multiply.
NON SURGERY CANDIDATE
1st line
- consider for clinical trails.
RCC Stage 4 (metastatic / advanced )
1st line
0 target therapy
e.g immunotherapy
pembrolizumab +axitinib
OR
nivolumab +
ipilimumab
OR
pazopanib
OR
sunitinib
etc.
- umabs
- tinibs
-limus
(everolimus or temsirolimus )
ADJUCNT
- Surgery
- clinical trials
- chemo - if all other avenues taken
- local radiate - pallative - for pain relief and symptom control.
- biphosphonate
(Zolendronic acid ) - bone matastases - can delay bone related symptoms.
Which cancers commonly spread to the bone ?
The five types of cancer that commonly spread to bone are breast, bronchus (lung), thyroid, kidney (renal cell carcinoma) and prostate.
Bowel cancer, testicular cancer and lymphoma less frequently spread to the bone.
Glioblastomas are primary brain tumours and locally invade and spread within the brain, they do not cause distant metastases
What are your differential for a 70 year old women presenting with :
Confusion of unknown cause - increasing worse over 2 weeks
- abdominal pain
- constipated
- not opened bowel in 10 days
History
- hypertension, mitral
- regurgitation
- breast cancer
- diverticular disease.
Drug history
- Rampril
- Aspirin
- Co- codamol
OE : HR - 95 bpm RR - 18 / min Temp ; 36 BP - 104/53 sp02 : 96% BM : 4.9 dry mucus membranes JVP down abdomen tender with fecal loading. GCS ; 14/15
0 Sepsis - always consider this in an older person with confusion
0 UTI - abdominal pain
0 Hypercalcemia - can be a reason for her non specific symptoms (confusion , abdominal pain , etc) stones , moans , abdominal groans & pyschic moans
(can cause constipation & constipation can cause urostatsis —————-> UTI )
Hypercalacemia of malignancy
(history of breast cancer which can spread to the bone & tumour can secrete PTHrH cause increased serum calcium etc. - there are other reasons. )
- can be found in people with advanced stage cancers.
- patient has high calcium levels and is
symptomatic. )
0 Opiod toxicity
(is taking Co- codamol - can cause confusion & conspitation )
What is hypercalcaemia of malignancy ?
- CAUSES
- RISK
FACTORS - SIGNS /
- SYMPTOMS
0 Humoral hypercalcaemia of malignancy : Tumour secretion of parathyroid hormone-related peptide [PTHrP])
0 Local osteolytic hypercalcaemia :
Local release of factors, including PTHrP, by bony metastases that promote osteoclast differentiation and function
0 Calcitriol (1,25-dihydroxyvitamin D)-mediated hypercalcaemia (characterised by autonomous production of calcitriol by lymphoma cells) —- ( increase Vitamin D synthesis more CA absorbed from the gut )
0 Ectopic hyperparathyroidism (characterised by tumour production of parathyroid hormone), which is very rare.
RISK FACTORS
- history of malingancy
(occurs in 20 -30 %)
e.g. spread to bone , Lymphoma or non spreading cancer.
- Use of hypercalcaemia inducing medications e.g
- thiazide diuretics - lithium
- calcium
- over the counter antiacids
- large doses of Vitamin D.
SIGNS / SYMPTOMS
- bones , stones , abdominal groans & physic moans
0 renal stones
(Hypercalcemia + Hypercaluria = renal stones )
- Polyuria
- Polydipisa (thirst - due to excessive urination 7 dehydration )
0 Abdominal pain - abdominal groans
- constipation
( too much calcium - slow muscle contraction - peristaltic movement affected. )
Psychic moans
- confusion
- depression
- nausea and vomiting
- fatigue
- ## bone pain
Investigation of Hypercalcaemia of malignancy ?
Serum : Total Calcium Ionised calcium (either one ) 0 Albumin 0 PTH 0 PTHrH (done if PTH levels are low despite known malignancy) 0 Calcitriol - (1 , 25 dihydroxyvitamin D - Vitamin D ) 0Phosphorus ( humoral hypercalcaemia of malignancy, PTHrP acts at the level of the kidney to reduce calcium clearance, as well as to reduce the renal phosphorus threshold, leading to hyperphosphaturia and hypophosphataemia. ) - results would show : low PH in blood but high CA.
0 Serum 25-hydroxyvitamin D
(Serum 25-hydroxyvitamin D should be checked if intravenous administration of bisphosphonate or subcutaneous denosumab is being considered, as vitamin D deficiency needs to be corrected prior to administration to avoid the risk of hypocalcaemia and, possibly, osteonecrosis of the jaw.)
25 - hydroxyvitamin D - major circulating form of Vitamin D in blood.
(biphosphonates, denosumab (monoconal antibody used to treat osteporosis ) increasease bone density )
TO CONSIDER
0 CXR
0 Skeletal survey.
Treatment of Hypercalcaemia of malignanacy ?
Mild / asymptomatic
- treat underlying cancer + supportive measures + monitoring.
MODERATE - SEVERE / SYMPTOMATIC + ADVANCED KIDNEY DISEASE
1st line
Saline + IV bisphonate (zondronic acid - ex ) or densumab
ADJUNCT
- Calcitonin
(only if Biphos doesnt work )
- Furosemide
(if fluid overload is present )
- avoid excaberating medicines
o thiazide
diuretics
o
Calcitriol [(1,25-dihydroxyvitamin D)]
o Calcium supplementation
o antacids
o lithium
(worsen hypercalcemia )
o sedatives o hypnotics o analgesics if possible (worsen symptoms of hypercalcemia )
- treat underlying malignancy
- Corticosteriod
MODERATE - SEVERE / SYMPTOMATIC + ADVANCED KIDNEY DISEASE
1st line
0 Renal dialysis + denosumab.
Serum levels
0 Mild - 2.6 to 2.9 mmol/L (10.5 to 11.9 mg/dL)
0 Moderate - 3.0 to 3.4 mmol/L (12.0 to 13.9 mg/dL), 0
0
Severe hypercalcaemi3.5 mmol/L (14.0 mg/dL) or greater.
Other causes of Hypercalcamia other than primary hyperparathyroidism and cancer ?
- – Sarcoidosis
- Thyrotoxicosis
- Thiazide diuretics.
- Renal failure causes secondary parathyroidism
( causing Hypocalcaemia
It is a consequence of failure of renal vitamin D hydroxylation and the retention of phosphate. This depresses serum Ca2+ and stimulates PTH release, leading to renal bone disease.)
????//??/////???/
bone metastastis / bone cancer
Palliative radiotherapy is an effective treatment of a specific bone metastasis causing pain. A single 8 Gray (dose) in one fraction (treatment) has been shown to reduce pain caused by bone metastases.
Zoledronic acid is a bisphosphonate that has been shown to be effective in relieving bone pain and reducing skeletal related events. Bisphosphonates work by inhibiting osteoclast-driven bone reabsorption.
A JJ stent is a ureteric stent used to relieve hydronephrosis
Vertebroplasty involves the image-guided injection of bone cement into a collapsed vertebral body.
Kyphoplasty involves inflating a balloon in the collapsed vertebral space, then inserting surgical cement.
A surgical option would only be considered if medical management and/or radiotherapy had failed.
What primary cancers spread to the brain ?
- Lung
- breast cancer
- malignant melanoma
- Primary brain cancer are less common that metastatic spread to the brain.
brain cancer
Headache is the most significant symptom in patients with a brain tumour, often due to raised intra-cranial pressure. The headache can be non-specific and does not have to have the traditional features of being associated with nausea, being worse in the morning or worse when bending down.
A Jacksonian seizure starts with a focal seizure that then develops into a grand mal seizure, it suggests a structural lesion in the cortex and so could be consistent with a brain tumour.
Ataxia could occur with a cerebellar lesion.
Raised intra-cranial pressure secondary to the tumour can cause confusion.
A right occipital tumour could cause a left homonymous hemianopia.
A Jacksonian seizure starts with a focal seizure that then develops into a grand mal seizure, it suggests a structural lesion in the cortex and so could be consistent with a brain tumour.
Ataxia could occur with a cerebellar lesion.
Raised intra-cranial pressure secondary to the tumour can cause confusion.
A right occipital tumour could cause a left homonymous hemianopia.
What is the classical history of a sub-arachnoid haemorrhage ?
- Capsule.
sudden onset ‘thunderclap’ occipital headache.
Gli >oblastomas
Glioblastomas spread as a spider web across brain tissue, micro-metastases can be 2.5-3cm from the main tumour, this means they cannot be completely excised during surgery. Grade 4 tumours have a poor prognosis; 3 year survival is 16% in those fit enough to undergo radical radiotherapy and chemotherapy. Mean survival as a group is 12 months. Gliomas are classified by grade based on a biopsy. Grade 1 and 2 are less aggressive than Grade 3 and 4. If a tumour is described as a grade 4 tumour it can also be described as a glioblastoma multiforme (GBM). Gliomas are incurable brain tumours. They are rare cancers. They spread within the brain. They do not invade bone, but can metastasise with the brain.
What is brain cancer?
Caterogorised by site location e.g.
0 Supratenorial
(Tentorium )
0 Infratentorial ( below Tentorium )
or
Cell Type
0 Astrocytoma (Mutated Astrocytes ) e.g Grade 1 - Pilocyctic Grade 2- Diffuse Grade 3- Anaplastic - Grade 4- Glioblastoma
Astrocytes -found in brain & spinal cord so these types of cancers can form in all these places.
Also form part of the Blood - brain barrier.
0 Meningioma
(come from cells in Arachnoid mater of the meninges
0 Pituitary ademoma
What is Glioblastoma ?
Types of Astrocytoma
- most common form
- Very aggressive
Glioblastoma
- only Grade 4 (often)
- Highly malignant (rapidly crosses corpus Callosum - seperates left and right hemisphere )
- don’t spread to other body parts
- can within the brain
- incurable cancer
(Treatment is Palliative - e.g Pallative radiotherapy , Chemo , surgery ) - Grade 4 - Poor Prognosis
What is Glioblastoma ?
Supratentorial Tumours
- Mostly in cerebral hemispheres
Other names :
Stage 4
- Astrocytoma
- Glioblastoma Multiforme
Types of Astrocytoma
- most common form
- Very aggressive
Glioblastoma
- only Grade 4 (often)
- Highly malignant (rapidly crosses corpus Callosum - seperates left and right hemisphere )
- don’t spread to other body parts
- can within the brain
- incurable cancer
(Treatment is Palliative - e.g Pallative radiotherapy , Chemo , surgery ) - Grade 4 - Poor Prognosis - death within 12 months usually.
SYMPTOMS
Generalized - Headaches - Seizures - Nausea - Vomiting - decrease in normal function (these are due increased Intracranial pressure )
Focal
- depending on where tumour is e.g if area respnsible for language & communication = speech difficulties.
What is meningioma ?
- orginates from Arachnoid Pap cells Arachnoid mater of the meninges
- Predominantly benign tumour of the meninges - occuring in cranial & spinal area
- Can be a Primary brain cancer
- Slow growing
- Grades 1 -3
- can form psoma bodies - calcifications
- Form in :
O Parsagittal region
( plane adjacent to the sagittal plan -divides body into half - vertical line )
O - Under the dura mater -surface of the brain.
RISK FACTORS
fx - of brain tumour
- History of previous cancer
- History of radiation exposure
SIGNS / SYMPTOMS
- Headache
- Neurological deficit
- Seizure
Treat of Meningioma ?
65 OR UNDER - GOOD SURGERY CANDIDATE
Asymptomatic
1st line
- Observation
Symptomatic - any size
1st line
- Surgical resection
- ADJUNCT
Stereoactic radiosurgery
(needed after incomplete surgical resection - if complete resection was not possible )
ADJUNCT
Fractiated sterotactic radiotherapy (FSRT)
(used instead of SRS with tumours larger in size and involving critical structures e.g optic nerve etc - less tolerant to large does of radiation. )
2nd line
- Salvage surgery
(treatment after intial treatments failed )
or Chemo
(used instead if Salvage surgery not an option. )
OVER 65 /POOR SURGERY CANDIDATE
0 Asymptomatic
- Observation
0 Symptomatic
- tumour < 3cm
1st line
-Observation
2nd line
SRS or FSRT
3rd line
- surgical resection
ADJUNCT
- FSRT
- Tumour > 3cm
1st line
- Observation
2nd line
Surgical resection
ADJUNCT
SRS or FSRT
RECURRENT AFTER SURGICAL RESECTION
1st line
- Salvage therapy - even for those who are poor surgical candidates.
SRS - non - surgical , deliver fewer high dose radiation - precisely targeted - preserve healthy tissue
FSRT - delivers multiple low - dose radiation
What are Astrocytomas ?
0 Astrocytoma (Mutated Astrocytes ) e.g Grade 1 - Pilocyctic Grade 2- Diffuse Grade 3- Anaplastic - Grade 4- Glioblastoma
Astrocytes -found in brain & spinal cord so these types of cancers can form in all these places.
Also form part of the Blood - brain barrier.
RISK FACTORS History of : - neurofibromatosis Type 1 - Tuberous sclerosis - Li - Fraumeni - Turcot's cancer syndrome - exposure to radiation
SIGNS / SYMPTOMS
- altered mental status
- headache
- nausea & vomiting
- gait abnormality
- Ataxia - associated with cellebular lesion
- Weakness
- seizures
FOCAL - depending on region
- Visual disturbances
- speech deficit (D)
- sensory D
- motor weakness
(lesion in contralateral posterior frontal lobe or descending coticospinal tract ) - Papilloedema -
(more common in posterior fossa tumour ) - A cranial nerve palsy + other unrelated (?) symptoms
Investigation of Brain tumour ?
MRI head - most sensitive - first choice
CT scan
If presentation is acute - need to rule out other causes e.g stroke , hemorrhage.
Spectroscopy MRI head
Perfusion MRI head
both used to
- determine grade of cancer
0 Biopsy
if patient present with Hypopituitarism or known hypothalamic or pituary lesion.
- Pituitary hormone test
Intial Treatment of Aystrocytomas ?
if Elevated Intercranial pressure of vasogenic oedema
-1st line
Corticosteriod (e.g Dexamethasone )+/- mannitol
if having seizure as well ;
IV Phenytoin (followed by oral ) or Levetiracetam
(prefered - less side effects )
if also in coma
or intubated (Endotracheal tube inserted to assist with breath - allow them to placed on
ventilator ) :
- Temporary Hyperventilation.
What is the treatment of Astrocytomas after Intial treatment ?
If accesible -most will undergo :
Maximal safe resection
Accessible without symptoms
Observation
Unaccessible with symptoms
Radiotherapy or radiosurgery
Diffuse potina glioma
- always radiotherapy
if recurrent diffuse :
0 Chemo
Above grades 4 or equal
- MSR & radiotherapy & chemo - if accesible
if not just radio & chemo
Grade 3 - similar to grade 4
but you can choose to use chemo ot not for both accessible or not.
(+ / - )
https://bestpractice.bmj.com/topics/en-gb/729/treatment-algorithm#patientGroup-1-0
too much to write look at link.
What is pituary ademona ?
Most are Benign either : 0 Functional (hormone secreting) - may cause hypersecretion of hormones - Cortisol - Cushing's Syndrome - Growth Hormone- Acromegaly -
0 Non Functional
(non horomone secreting )
can be microademoas (< 1cm or macroadenomas .( > 1cm )
Oligodendroloma
Because oligodendrocytes are found through the brain and spinal cord, oligodendrogliomas can form in any of these locations, but adult oligodendrogliomas typically form in the frontal lobes of the cerebral cortex because those neurons are the most heavily myelinated.
These tumors are categorized as grade II or III, with an overall tendency to be relatively slow-growing tumors, though they still have the ability to become malignant.
Histologically, prominent features can vary from fairly small, round nuclei, surrounded by well-defined “halos” or thick white borders of cytoplasm giving them a “fried egg” appearance in grade II tumors; to having a “chicken wired” pattern of nearby blood vessels with areas of calcifications in grade III tumors.
Ok, so, now let’s focus on an infratentorial adult tumors, a hemangioblastoma.
These tumors derive from cells with blood vessel origins, so while they can develop anywhere in the brain they are most often found in the cerebellum, especially in a middle-aged person.
They are slow-growing tumors and are typically grade I.
Histologically, there are often thin-walled capillaries that are arranged close to one another.
Now, the most common symptoms of brain tumors include headaches, nausea, vomiting, and seizures - and they are a result of the compression and destruction of healthy brain tissue.
In addition, it’s important to consider the cell type that’s involved.
So, for example, a pituitary adenoma causing an increase in prolactin secretions may lead to amenorrhea in women and infertility in men.
In addition, as the tumor grows in size, it can compress nearby cells and structures, interrupting their normal functions.
For example, as meningiomas enlarge - the mass of the tumor can compress nearby ventricles blocking the flow of cerebrospinal fluid, causing swelling which results in hydrocephalus.
Generally, the diagnosis of central nervous system tumors includes medical imaging, like CT scans but more commonly MRIs.
But definitive diagnosis needs to be made based on the histologic and molecular characteristics of a tissue biopsy.
Treatments depend on the tumor type, grade, and symptoms. And can include surgical removal, radiotherapy, or chemotherapy - frequently in a combination.
But specific courses of treatment are guided by the molecular characteristics of the tumor based on the biopsy.
Finally, the chance of recurrence gets higher in high grade tumors and in tumors that have not been fully removed or destroyed.
What is pancreatic cancer ?
Neoplasia /tumour (mass) in the pancreas
Pancreatic ductal Adenocarcinoma
(adeno - glands ) -
Pancreatic cancer usually occurs in the head of pancreas (affecting the ductal epithelium - in the glands)
SIGNS / SYMPTOMS
0 Pain in epigastric region which refer to back.
0 Jaundice
( be aware that there can painless obstructive jaundice - so if havent found a reason for jaundice could be pancreatic cancer)
0 weight loss and anorexia
(* rapid weight loss is associated with unresectability)
OTHER SIGNS
- Steatorrhoea (excess fat in stools , bulky & difficult to flush ) cancer can block pancreatic ducts causing exocrine dysfunction - digestive enzymes not released ——> malabsorption)
- New onset diabetes (if no predisposing features or postive Hx of diabetes - consider Pancreatic cancer )
(Endocrine dysfuntion (inability to release hormones can cause ————————-> thirst , polyria , nocturia , weight loss - these can cause new onset diabetes)
PC should be ruled out in pl with unexplained episode of pancreatitis with nausea & V , anorexia & mid- epigastric pain.
SIGNS OF ADVANCE DISEASE
- epigastric abdominal mass
- positive courvoisier’s sign (painless palpable gallbladder and jaundice )
- Positive Trousseau’s sign - BV - formation of Blood causing inflammation of BV which is recurrent or migrates. associated with cancer (pancreatic , gastric , lung acncer)
- Hepatomegaly
(suggest hepatic metastases)
RISK FACTORS
- Smoking
- FHx of pancreatic cancer
- Other hereditary cancer syndromes.
What is carcinoma , sacrcoma ?
Carcinoma - cancer of epithelial tissue (like to metastasis to lymph nodes)
Sarcoma - cancer of muscle (like to metastise to blood )
Diagnosis of pancreatic cancer ?
Pancreatic protocol CT - all patients suspected of PC.
0 Abdominal ultrasound - but Pancreatic protcol CT is better & always done.
if pancreatic protocol CT
if PPCT unclear & they have jaundice - do ERCP (endoscopic retrograde cholangiopancreatography and / r EUS guided tissue sampling.
if they have no jaudice do :
- FDG- PET / CT
0 LFT
can do ;
- PT
- ## FBC
Treatment of Pancreatic cancer ?
Resectable/ Borderline - Surgery resesction
ADJUNCT - neoadjunvant radio / chemotherpay (given to strink tumout before surgery (only offer as part of clinical trail )
PLUS - Nutritional support - PANCREATIN -Pancreatic enzymerelacement therapy
* if has pancreatdudenectomy (give early enteral nutrition (relies on GI tract e.g. through mouth , esophagus , stomach , intestines - e.g. can place tube directly into stomach ?rather than parenteral )
Locally advanced pancreatic cancer
1ST LINE
- Systemic combination chemotherapy e.g .
if not tolerated ; Gemcitabine - chemotherapy drug
Metastatic
1ST LINE
FOLFIRNOX (oxaliplatin , fluorouracil , irinotecan , folinic acid ) - Combination chemotherapy drugs.
(do a ECOG score - measure ability of pateints to take care of themselves (Should be btw 0-1)
if FOLFIRINOX - not well enough to tolerate give Gemcitabine combination therapy
(if not well enough to tolerate combination give - just gemcitabine)
2ND LINE
- IF cancer has progressed since FOLFIRINOX started - Gemcitabine - based - chemotherpay
or can give oxaliplatin - based chem - if not used in first line
PAIN MANAGEMENT FOR ALL - if :
- uncontrolled pancreatic pain
- unacceptable opiod adverse effects
- receiving escalating doses of analgesics
GIVE EUS or image guided percantaneous neurolytic coeliac plexus block.
What is Hepatocellular cancer ?
OTHER NAME
Hepatoma - Cancer arising from the hepatocytes (usually due presence of cirrhosis but can happen in its absence )
SIGNS / SYMPTOMS
- RUQ pain
- Abdomainal distension ( due to ascities - associated with cirrhosis)
- leg oedema
- weight loss
- cachexia
- oesphageal or gastric variceal bleeding
- early satiety (early fullness - compression of the stomach by ascites)
- Hepatic encephalopathy (asterixis & fector hepaticus (STRONG MUSTY BREATH - sign that liver is failing to removing toxins) these indicate decompensated cirrhosis resulting in hepatic encephalopthy)
Normal signs of cirrhosis (which is precipating for HC)
0 Jaundice
0 splenomegaly (cirrhosis most common cause of Hepatic Cancer ————> cirrhosis leads to portal hypertension )
0 Palmar erythema
0 spider naevi
0 periumbilical collateral veins
(normal venous channels are not working so blood collects in collateral veins )
RISK FACTORS
- Cirrhosis
- Chronic Hepatitis B infection
- Chronic hepatitis C cirrhosis
- chronic heavy alcohol use
Diagnosis of Hepaticellular carcinoma ?
0 FBC - anaemia
0 Basic metabolic pattern
0 Liver function test (LFTs)
0 PT / INR ( elevated - lack of clotting factors usually produced by liver )
0 Viral hepatitis panel (viral hepatitis may have caused cirrhosis which can be a precrusor for hepatci cancer)
0 Alpha fetoprotein ( elevated - AFP produced by liver cells when the are regenerating - so chronically elevated in liver cancer , hepatitis etc.
0 Abdominal ultrasound .
0 Contrast CT scan ( superior to ultrasound)
What is child pugh score ?
System used to determine how severe liver damage is & the prognosis .
Score up to 3 given to each of these 5 catergories .
0 Total bilirubin 0 serum albumin 0 Prothrombin time 0 ascites 0 Hepatic encephalopathy
ex - no ascities (1)
- ascities - mild/ responds to diuretics (2) - ascities moderate / no response to diuretics (3)
Class A ( 5-6 points) Class B (7-9 points) Class C (10 -15 points )
Treatment of Hepatocellular cancer ?
Resectable (good surgical candidate - Stage A
1ST LINE
Resection
if not possible (unrestectable - DO LIVER TRANSPLANT)
IF this not possible either consider :
- percutaneous ablation ( destruction of tumour cells by chemicals)
- Atezolizumab plus bevacizumab
- Lenvatinib
- Sorafenib , regorafenib
not completely sure about treatmebt for stage B , C
