Cancer Flashcards
Define prostate cancer
A primary malignant tumour/neoplasm of glandular origin situated in the prostate which is commonly seen in older men. Usually an adenocarcinoma.
What is the aetiology/risk factors of prostate cancer?
Aetiology is unknown
Proposed aetiological factors: high fat diet, genetic factors
Risk factors: Age >50 years Black ethnicity North American or Northwest European descent Family history of prostate cancer High fat diet Occupational exposure to cadmium BRCA2 gene
Summarise the epidemiology of prostate cancer
14% of men will develop prostate cancer in their life
Median age of diagnosis is 66 years old
Highest incidence amongst black men
2nd most common cause of cancer death amongst men
What are the presenting symptoms of prostate cancer?
Lower UT obstruction symptoms - FUNDHIPS Frequency Urgency Nocturia Dysuria Haematuria/Hesitancy Incontinence/intermittency Post-micturition dribbling Weak Stream
Metastatic spread: Weight loss Bone pain Lethargy Anorexia Cord compression
What are the signs on physical examination of prostate cancer?
Asymmetrical, nodular prostate on DRE and loss of midline sulcus
Palpable lymph nodes
What are appropriate investigations for prostate cancer?
Bloods:
SERUM PSA - >4micrograms/L however may be elevated in non-malignant conditions (BPH, prostatitis) or normal in those with prostate cancer
Testosterone - normal
LFTs - normal
FBC - normal unless in metastatic disease
DRE
Transrectal USS and Prostate biopsy (12 biopsies) - findings of malignant cells used in diagnosis and staging
Bone scan - check for metastases
X-rays - look for bone metastases
Pelvic CT - enlarged prostate, enlarged pelvic lymph nodes
What is the management of prostate cancer?
Watchful waiting (elderly, comorbid patients)
Active surveillance (low risk low volume)– regular DRE, biopsy
Brachytherapy
External beam radiotherapy
Radical prostatectomy and lymph node dissection
In metastatic disease - Hormonal therapy (shrinks tumour, doesn’t cure)
- LHRH agonists e.g. goserelin
- Anti-androgens e.g. bicalutamide
What are the possible complications of prostate cancer?
Often related to treatment
Radiation induced complications: Dysuria Frequency Rectal bleeding Urinary incontinence Urinary urgency Nocturia Diarrhoea Urinary stricture
Hormone induced complications:
Cognitive impairment
Gynaecomastia
Hot flushes
What is the prognosis of prostate cancer?
Prostate cancer is a curable cancer
Overall survival depends on initial stage at diagnosis
Can be high morbidity from treatment
Gleason score 2-4 on biopsies have minimal risk of death from prostate cancer in 15 years
Define squamous cell carcinoma
Cancer of keratinocytes in the epidermis which can invade local tissue and metastasise.
Explain the aetiology of squamous cell carcinoma
Risk factors:
UV exposure
Family history
Light skin
Actinic keratosis - pre-cancerous condition
Immunosuppression
HPV infection
Genetic predisposition
Carcinogens (e.g. tar derivatives, cigarette smoke)
Chronic skin disease (e.g. lupus) or chronic inflammation
Summarise the epidemiology of squamous cell carcinoma
2nd most common skin cancer
More common in men, individuals with light skin and those over 40 years old
Mainly in MIDDLE AGED and ELDERLY patients
What are the presenting symptoms of squamous cell carcinoma?
Hyperkeratotic (scaly, crusty), ill-defined nodule which may ulcerate Skin lesion Ulcerated Recurrent bleeding Non-healing Rolled, red, erythematous edges
What are the signs on physical examination of squamous cell carcinoma?
Variable appearance - may be ulcerated, hyperkeratotic, crusted or scaly, non-healing
Often on sun-exposed areas
May be local lymphadenopathy
May be neurological signs and symptoms if brain mets are present
What are the appropriate investigations for squamous cell carcinoma?
Mainly a CLINICAL DIAGNOSIS
Dermatoscope
Skin biopsy for definitive diagnosis of type
Fine-needle aspiration or lymph node biopsy - if metastasis is suspected
Staging - using CT, MRI or PET
Define basal cell carcinoma
Slow-growing cancer of the keratinocytes in the stratum basale of the epidermis which can show local invasion but rarely metastasise
Summarise the aetiology of basal cell carcinoma
Risk factors: UV light exposure Family history Light skin Immunosuppression History of frequent or severe sunburn in childhood Skin type I (always burns, never tans) Increasing age Male sex Genetic predisposition Photosensitising pitch Toxins: tar, arsenic
Summarise the epidemiology of basal cell carcinoma
Basal cell carcinoma is the most common skin cancer
More common in men
Incidence increases with age
Common in ares of high sunlight exposure
What are the presenting symptoms of basal cell carcinoma?
A chronic slowly progressive skin lesion
Usually found on the face, scalp, ears and trunk
What are the signs on physical examination of basal cell carcinoma?
Nodular/Nodulo-ulcerative (commonest):
Small glistening translucent skin over a coloured papule
Slowly enlarges
CENTRAL ULCER (rodent ulcer) with raised PEARLY EDGES
Fine surface TELANGIECTASIA
ROLLED EDGES
Morphoeic (sclerosing): Expanding Yellow/white waxy plaque with an ill-defined edge More aggressive than nodulo-ulcerative Scar like
Superficial (plaque like):
Most often on trunk
Multiple pink/brown scaly plaques with a fine edge expanding slowly
FLAT
Pigmented:
Dense colour
Looks like squamous cell carcinoma
What are the appropriate investigations for basal cell carcinoma?
Mainly a CLINICAL DIAGNOSIS
Biopsy rarely necessary
Define melanoma and melanocytic lesions
Melanoma is a malignant cancer of the melanocytes in the epidermis which shows local invasion and is very likely to metastasise.
Summarise the aetiology of melanoma
Risk factors: UV exposure Family history Immunosuppression Light skin Genetic predisposition - familial melanoma: CDKN2A gene DNA repair defects (xeroderma pigmentosum) History of moles
Summarise the epidemiology of melanoma
Melanoma is the most aggressive and deadly skin cancer
Most common in Australia
One of the most common cancers in young people
More likely in men and fair-skinned patients
Steadily increasing in incidence
What are the presenting symptoms of melanoma?
Rapidly change in size, shape or colour of a pigmented skin lesion Redness Bleeding Crusting Ulceration
What are the signs on physical examination of melanoma?
ABCDE A - ASYMMETRY B - IRREGULAR BORDER C - PIGMENTED AND COLOUR VARIATION D - DIAMETER >6MM E - RAPID EVOLUTION
Neurological signs and symptoms if metastasises to brain
What are the different types of melanoma and how do you distinguish between them?
Superficial Spreading (70%):
Arises in a pre-existing naevus
Expands in a radial fashion before a vertical growth phase
Common on the lower limbs in young/middle-aged adults
Related to intermittent high-intensity UV exposure
Nodular (15%): Arises de novo AGGRESSIVE NO radial growth phase Common on the trunk RAPID GROWTH Domed shape
Lentigo Maligna (10%): More common in ELDERLY with sun damage Large flat lesions Progresses slowly Usually on the face Related to long-term cumulative UV exposure
Acral Lentiginous (5%):
Arise on palms, soles and subungual areas
Most common type in NON-WHITE populations
Common in elderly and no clear relationship with UV exposure
What are the appropriate investigations for melanoma?
Excisional Biopsy - histological diagnosis and determination of Clark’s Levels and Breslow Thickness (two methods of determining the depth of penetration of a melanoma)
Dermatoscopy
Lymphoscintigraphy - a radioactive compound is injected into the lesion and images are taken over 30 mins to trace the lymph drainage and identify the sentinel nodes
Sentinel Lymph Node Biopsy - check for metastatic involvement
Staging - using ultrasound, CT or MRI, CXR
Bloods - LFTs (because the liver is a common site of metastasis)
Define oesophageal cancer
Malignant tumour arising in the oeseophageal mucosa. There are two main types:
Squamous cell carcinoma (upper 2/3rds of the oesophagus)
Adenocarcinoma (lower 1/3rd of the oesophagus affecting columnar epithelial cells)
Summarise the aetiology of oesophageal cancer
Squamous cell carcinoma: Cigarette smoke Alcohol HPV Hot food/fluids Caustic strictures (stricture following consumption of caustic substances eg bleach) Plummer-Vinson Syndrome (glossitis, cheilosis, oesophageal webs, iron deficiency anaemia) Palmoplantar keratosis Scleroderma Coeliac Disease Nutritional Deficiencies Dietary Toxins (i.e. nitrosamines) Hx Thoracic Radiotherapy
Adenocarcinoma: GORD Barrett's oesophagus (metaplastic change from squamous cell to columnar epithelial) Obesity Male
Risk factors for both:
Age >40
Achalasia
Summarise the epidemiology of oesophageal cancer
Incidence varies based on geography Squamous cell more common worldwide Adenocarcinoma more common in Western countries 8th most common malignancy Incidence increasing More common in men
What are the presenting symptoms of oesophageal cancer?
Asymptomatic until late stages - early presentation may be symptoms of reflux Progressive dysphagia starting with solids and moving to liquids Odynophagia Heart burn Vomiting Chest and back pain Weight loss Post-prandial cough Hiccups if affects diaphragm Hoarseness of voice
What are the signs on physical examination of oesophageal cancer?
There may be NO PHYSICAL SIGNS – may have signs of weight loss
Metastatic disease may cause: Supraclavicular lymphadenopathy (right) Hepatomegaly Hoarseness Signs of bronchopulmonary involvement (may be due to aspiration or tracheobronchial involvement)
What are the appropriate investigations of oesophageal cancer?
OGD (endoscopy) and biopsy - mucosal lesion with histology showing SCC or adenocarcinoma
Imaging: barium swallow & CXR - see location and complications eg ulcers, stenosis
PET scan - look for metastases and response to chemo
Staging: CT Chest & Abdomen
Bronchoscopy (if risk of tracheobronchial invasion)
Bone Scan
Lung Function Tests (normal/low)
ABG’s
Echo
Define multiple myeloma
A haematological malignancy characterised by excessive proliferation of plasma cells (mature B cells), resulting in excessive monoclonal immunoglobulin production - usually IgG or IgA
Summarise the aetiology of multiple myeloma
No clear aetiology
Genetic inheritance
Association with exposure to ionising radiation or petroleum products, agricultural work or occupational chemical exposure
Possible viral trigger
Summarise the epidemiology of multiple myeloma
Median age of diagnosis is 72y/o
Most common primary tumour in bone in over 50 year olds
Afro-Caribbean > White People > Asians People
What are the presenting symptoms of multiple myeloma?
CRAB Hypercalcaemia symptoms: Nausea Abdominal pain Confusion Depression Bone pain Polyuria Polydipsia Constipation
Renal Failure
Anaemia:
Fatigue
Bone pain - often LOWER BACK PAIN
Recurrent infection - neutropenia
Easy bruising and bleeding - thrombocytopenia
Hyperviscosity symptoms:
Headaches
Visual disturbances
What are the signs on physical examination of multiple myeloma?
Abdominal tenderness Pallor Bruising Hepatosplenomegaly Macroglossia Tachycardia Flow Murmur Signs of Heart Failure Purpura Dehydration Carpal Tunnel Syndrome Peripheral Neuropathies
What are the appropriate investigations for multiple myeloma?
Bloods: Hb - normocytic anaemia FBC - thrombocytopenia, neutropenia Elevated IgG, IgA Creatinine and BUN - elevated due to renal failure Serum calcium - elevated CRP - raised
Chest, Pelvic or Vertebral X-Ray: Osteolytic lesions without surrounding sclerosis, Pathological fractures
Blood film - erythrocytes in rouleux formation, pancytopenia, increased plasma cells, bluish background
Serum or urine electrophoresis - monoclonal proteins, M spike
Bone marrow aspirate - increased plasma cells, atypical cells - DIAGNOSTIC TEST
Bence-Jones proteinuria - monoclonal Ig light chain
Fundoscopy - retinal haemorrhage
