Cancer Flashcards
What causes cannonball lung mets?
- Testicular cancer
- Choriocarcinoma
- Renal carcinoma
- Thyroid cancer
- Melanoma
- Osteosarcoma
- Metastatic adenocarcinoma
What is the difference between ionising and non-ionising radiation?
Ionising
- High energy
- From x-rays, gamma rays
- Has the ability to displace electrons from atoms
Non-ionising
- Lower energy
- From UV radiation (particularly B)
- Has the ability to excite electrons, leading to a chemical change in the tissue
Which tissues are particularly susceptible to ionising radiation?
Breast, thyroid and bone marrow
What is xeroderma pigmentosum?
A condition in which the repair pathway for non-ionising radiation is faulty, leading to multiple melanomas from UVB exposure at a very young age
What will happen if you give a 16 year old radiotherapy for lymphoma?
She is likely to develop breast cancer later in life, due to the exposure to ionising radiation at a young age
What are the 3 steps of carcinogenesis?
INITIATION - mutation in key regulatory pathways
PROMOTION - selective growth advantage induced in the initiated cells (NB usually without mutation)
PROGRESSION - multiple mutations from genetic instability leading to further degrees of invasiveness
What cancers do tobacco smoke cause?
Anywhere!! Often lung, bladder
NOT endometrial
What cancers do dye/rubber cause?
Bladder cancer
What cancer does chemotherapy sometimes lead to?
AML
What cancer is schistoma associated with?
Bladder cancer
What cancer is malaria and EBV associated with?
Burkitts lymphoma
Which environmental factors can cause cancer?
- Radiation
- Chemicals
- Infections
- Hormones
- Diet (most important RF?)
What cancer is related to:
a) prolonged oestrogen exposure
b) more ovulatory cycles
a) endometrial cancer, breast cancer
b) ovarian cancer
What is a germline mutation?
A mutation in a germ cell (testes/ova) at embryogenesis which can be passed on to future generations, and affects all cells.
eg. Hereditary cancer syndromes
What is a somatic mutation?
A mutation in any cell except a germ cell, at any point during a persons lifetime. This mutation will only affect the direct cell lineage, and will not be passed on to future generations.
eg. Sporadic tumours
What is Knudsons hypothesis?
If a gene has a faulty allele (ie. a germline mutation) , is only takes one mutation to become cancerous. In this way it is genetically predisposed to cancer
What is an oncogene?
A gene that promotes cell proliferation by mimicking growth signals and should be switched on in embryonic life but switched off in adult tissue.
protoonco = switched off
Give an example of where a ‘gain of function’ mutation has switched back on a proto-oncogene in cancer
RET gene on chr 10q11
If turned back on, it leads to MULTIPLE ENDOCRINE NEOPLASIA TYPE 2
NB with oncogenes only 1 gene copy needs to be affected (dominant)
What cancers are associated with MEN2?
MEN2a: thyroid/parathyroid/phaeochromocytoma (adrenal gland)
MEN2b:
mucosal neuromas in eye, mouth and endocrine glands
What is a tumour suppressor gene?
A gene that protects the cell from proliferating
NB with tumour suppressor genes both copies need to be affected (recessive)
Give 3 examples of where a ‘loss of function’ mutation in a tumour suppressor gene has lead to cancer
Mutation in RB1 - retinoblastoma
Mutation in BRCA1/2 - breast/ovarian/prostate
Mutation in APC - FAP
What is a mismatch repair gene?
A gene that produces proteins that detect mismatch and directs repair machinery towards it
By which 3 ways can cell death occur in normal tissue ?
- Apoptosis
- Necrosis
- Autophagy
Describe apoptosis
- Regulatory elements sense apoptotic signals (activation of cyclin E, removal of IL-3/IGF-1)
- Nuclear fragmentation
- Chromosomal condensation
- Cell shrinkage
- Bleb formation
- Phagocytosis of blebs
This is programmes cell death.
Describe 4 ways in which cancer cells can evade apoptosis
- Loss of p53 tumour suppressor function
- Increased survival signals (Bcl-2/xl)
- Decreased bax, bim, puma
- Short circuited ligand-induced death pathway
Describe autophagy
Lysosomes degrade cellular contents in response to stresses, allowing the metabolites to be recycled
How does cancer evade autophagy?
Cancers can survive stress (such as chemo/radio) and can shrink to a reversible dormancy, enabling regrowth after removal of stress
Describe necrosis
Unprogrammed chaotic cell death from noxious stimuli, involving inflammatory immune cells
How do cancer cells use necrosis to their selective advantage?
Necrosis of tumour cells leads to angiogenesis, cellular proliferation and tissue invasion, as it stimulates neighbouring cells in an uncontrolled way
How do tumour suppressor genes affect the cell cycle?
They inactivate cyclin-CDK complexes, which halts the cell cycle
Which cell cycle checkpoint is sometimes lost in cancer?
G1 checkpoint- this means that there is no ‘checking’ of the damaged cancerous genome before DNA synthesis (S phase)
Give an example of where cancer can cause increased expression of growth factor receptors
EGFR overexpression in GI/lung cancer
HER2 overexpression in breast cancer
This both activate Ras-Raf-MAP kinase causing cell proliferation
Give an example of where cancer can cause ‘ligand independent signalling’
RAS mutations - activate MAP kinase in the absence of a binding of a growth factor ligand
Give 3 ways in which cancer cells can evade growth suppression
- Lack of response to p53 and Rb inhibitory signals
- Loss of contact inhibition
- Mutations in tumour suppressor genes (Rb, tp53, tp21/27)
How do cancer cells enable replicative immortality?
They possess a telomerase enzyme that adds nucleotides to telomeres to allow continued cell division
How do cancer cells induce and maintain angiogenesis? How are these blood vessels different to normal ones?
- Production of growth factors (VEGF, PDGF)
- Suppression of angio inhibitors (TSP1)
- Maintenance of vasculature by pericytes and myeloid cells (although vessels are much more leaky and likely to haemorrhage)
Tumour cells cannot grow beyond 1mm cubed without their own blood supply
Name 2 therapies that target cancer-induced angiogenesis
Bevacizumab - VEGF antibody
Sunitinib - PDGF inhibitor
What does cadherin-1 do, and how is this involved in metastasis?
What is the name of this transition?
Cadherin-1 is a protein that usually organises cell tissue sheets.
In cancer, a mutation or downregulation of CDH1 gene means the cell becomes more disorganised and more motile, invasive and aggressive.
This is known as the epithelial-mesenchymal transition
Following the epithelial-mesenchymal transition, how do the new mesenchymal cells stimulate invasive behaviour?
They produce CCLs, which together with IL2 and IFNgamma, induce WBC infiltration.
Macrophages degrade the matrix with enzymes, allowing for invasion of the basement membrane
What is aerobic glycolysis and how is it involved in cancer?
ie. how do cancer cells reprogram energy metabolism?
It is the ability to to limit energy production to glycolysis, even when oxygen is present. (Usually cells use oxidative phosphorylation when oxygen is present)
This is helpful because the intermediates from glycolysis are necessary for production of new cancer cells
How can inflammation influence tumour development?
Once leucocytes have moved into tissue, they release reactive oxygen species, which are mutagenic to surrounding tissue.
How do tumour cells evade immune destruction?
They can recruit T helper and suppressor cells that enable them to not be recognised by immune cells.
Why are HIV patients predisposed to cancer?
Deficiency of CD4 cells means that their immune systems will not be strong enough to identify and destroy cancerous cells
What is the pathology of familial adenomatous polyposis?
Mutation in the APC gene, involved in the tumour suppressor pathway. This leads to a cascade of mutations leading to a ‘multistep carcinogenesis’
What are the two main types of FAP?
- Classical - 1000s of adenomas, 100% risk of malignancy (do colectomy)
- Attenuated - 100s of adenomas, increased but not certain risk of malignancy
What are the symptoms of FAP?
Blood in stool
Change in bowel habits >6wks
Abdo pain
What are the extracolonic features of FAP?
- You get polyps all over the gut
- Retinal pigmentation
- Childhood hepatoblastoma
- Thyroid cancer
- Sebaceous/jaw cysts
A patient has retinal pigmentation, bloody stools and change in bowel habits. His dad had to have a colectomy when he was young. What condition are you worried about, and what screening should they have?
FAP
Annual screening (colonoscopy) from age 11
A patient with known FAP presents with an osteoma and a soft tissue tumour. What are you worried about?
Gardners syndrome
A patient with known FAP presents with confusion and CT scan shows brain tumour. What are you worried about?
Turcot syndrome
What is the pathology of Lynch Syndrome (aka HNPCC)
Mutation in MLH1 mismatch repair gene, leading to a cascade of mutations that cannot be repaired.
This will occur at areas of repeated DNA sequences known as microsatellites.
This leads to a frameshift mutation and a new truncated peptide.
This has two actions:
- Generation of adenomas
- The body mounts an inflammatory response against this foreign peptide
What is micro satellite instability?
Failure to repair repetitive sequences of DNA, due to faulty mismatch repair genes. This is characteristic of lynch syndrome and is rarely seen in sporadic colorectal cancer
What are the symptoms of lynch syndrome?
Usually none!!
What are the complications of lynch syndrome?
Colorectal cancer
Endometrial cancer
What is the Amsterdam Criteria (321)?
It says that lynch syndrome is likely if there are
3 colorectal tumours
across 2 generations
with at least 1 diagnosed before 50
If it fulfils this, do colonoscopy every 2 years after the age of 25
How can biopsy differentiate between Lynch syndrome and sporadic colon cancer?
Do a biopsy of tumour tissue and do MSI and BRAF test.
MSI high - lynch syndrome
BRAF high - sporadic cancer
How is lynch syndrome managed?
- Surveillance
- Chemoprophylaxis with low dose aspirin
- Surgical prophylaxis (colectomy)
- Family cascade testing
A person with known lynch syndrome presents with sebaceous skin tumours. What are you worried about?
Miur Torre Syndrome
A patient presents with mucosal neuromas on the tongue, long fingers and skin pigmentation. Her father had to have his adrenal gland removed. What are you worried about?
MEN2b - mutation of RET gene associated with those features + phaemochromocytoma + thyroid cancer
What exam finding would in hereditary retinoblastoma give you?
White pupillary reflex
Two different coloured eyes with ‘flash’
Hereditary - more likely to be bilateral
What are Wilsons Criteria for evaluating a screening programme?
- Important health problem
- Understood natural history of condition
- Easy to perform test
- Recognised treatment
- Treatment more effective if started early
- Policy on who should be treated
- Diagnosis and treatment cost effective
- Continuous case-finding
What are the features of Peutz-Jeghers syndrome?
Wine coloured lip staining
Cancers of pancreas, lungs, liver, breast ovary and uterus
How are people with known PJ syndrome screened?
Screening every 6 months by OGD/capsule, from 8 years
Describe the genetics of PJ syndrome
Mutation of STK11 gene tumour suppressor
What is a CUP and why is it difficult to manage?
Cancer of unknown primary
- More aggressive
- Early dissemination
- Unpredictable metastatic pattern
What approach do you use to manage a CUP?
- Search for primary site
- Rule out potentially treatable/curable cancers
- Treat with curative or palliative intent
What is the gold standard for a diagnostic work up of a CUP?
Immunohistochemistry
What are the five main subtypes of CUP?
- Moderately well differentiated adenocarcinoma (better prognosis)
- Poorly or undifferentiated adenocarcinoma
- Squamous cell carcinoma
- Undifferentiated carcinoma
- Carcinoma of neuroendocrine differentiation
What is the main predictor of suitability for chemo?
Performance status
What are the symptoms of lung cancer?
Respiratory - Cough, dyspnoea, chest pain, haemoptysis, recurrent chest infections
Systemic - fever, weight loss, fatigue
Specific - dysphagia, hoarsness
Why do you get dysphagia in some lung cancers?
Extrinsic oesophageal compression by the primary tumour
Why do you get hoarseness in some lung cancers?
Invasion of the recurrent laryngeal nerve
What are the 4 characteristcs of clubbing?
- Increased curvature
- Soft tissue swelling
- Nail fluctuance
- Loss of nail bed angle
What are the signs of lung cancer?
Nicotine staining, clubbing, retention flap
Pulmonary collapse/effusion/consolidation
Lymphadenopathy, SVC obstruction
For a pleural effusion what is the:
a) expansion
b) mediastinum
c) vocal fremitus
d) percussion
e) breath sounds
f) air entry
And what other 2 features do you often hear?
a) reduced
b) central
c) reduced
d) reduced
e) dull
f) reduced
Whispering pectoliruquy - loud on whispering
Pleural rub
What is acanthosis nigricans?
A paraneoplastic syndrome causing velvety dark patches, particularly under the arms, associated with lung cancer
What is Pancoats syndrome, and what 4 features does it cause?
Apical malignant neoplasm (usually sq) that invades the brachial plexus and cervical sympathetic nerves causing:
- Chest/shoulder pain at T1
- Horners syndrome
- Atrophy of hand and arm muscles
- SVC obstruction
What are the features of Horners syndrome?
- Meiosis
- Anhydrosis
- Ptosis
- Enopthalmous
Why is T1 level significant?
It is the most common place for NSCLC to metastasize and will cause chest/shoulder pain
What investigations should be done in someone with suspected lung cancer?
BEDSIDE - sputum, sats
BLOODS - FBC (can get anaemia), CRP, LFTs, U&Es, bone profile, LDH
IMAGING - CXR, bronchoscopy, transthoracic needle biopsy, CT (always couple imagine with biopsy)
SPECIAL - pleural tap (exudative)
What further investigations should be done in someone with confirmed lung cancer?
Pulmonary function tests V/Q MRI USS Scope
These are to assess metastatic spread and operability of cancer/performance status
What blood test should always be done in a patient with unexplained confusion?
CRP - most common cause of confusion in the elderly is UTI
Calcium
What is the main type of lung cancer? What are the subtypes?
Non small cell carcinoma (85%)
- Adenocarcinoma (40%)
- Squamous (30%)
- Large cell carcinoma
- Broncheoalveolar carcinoma
Describe an adenocarcinoma NSCLC
- Peripheral lung
- Slow growing but metastatic
- Asbestos
Which NSCLC is most common in non-smokers and women?
Adenocarcinoma
Describe a squamous NSCLC
- Central, cavitating lesion (can haemorrhage)
- Proximal bronchi
- Slow growing
- Smoking association
Describe some CXR changes with lung cancer
Mass lesion (nb if patient has pneumonia, repeat in a month)
Pleural Effusion
Diaphragm
Describe a large cell NSCLC
- Very large peripheral mass
- Subtle initital symptoms (due to peripheral location)
- Fast -growing
- Incurable once LN are involved
- Mucus secreting
What is the fastest growing NSCLC?
Large cell
Describe a broncheolaveolar carcinoma NSCLC
- Multiple bilateral nodules
- Non-invasive
- Frothy pink sputum
- Drug resistant
A patient has drug resistant lung cancer with frothy pink sputum. What is the mst likely diagnosis?
Broncheoalveloar carcinoma
Describe a small cell carcinoma
- Found all over the lung
- Hilar/mediastinal lymphadenopathy
- Highly metastatic
- Fast-growing
- Responds well to therapy
OFTEN PARANEOPLASTIC (as they originate from neuroendocrine cells)
A patient with lung cancer has an xray showing mediastinal/hilar lymphadenopathy. What is the diagnosis? What paraneoplastic syndrome are you worried about?
Small cell carcinoma
Cushings (ACTH)
SIADH (ADH)
Describe a malignant mesothelioma
- Arises from the pleura (of any organ!)
- Manifests as unilateral pleural effusion
- Restrictive defect
- Asbestos