Cancer Flashcards
1
Q
Define prostate cancer
A
A primary malignant tumour/neoplasm of glandular origin situated in the prostate which is commonly seen in older men. Usually an adenocarcinoma.
2
Q
What is the aetiology/risk factors of prostate cancer?
A
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
3
Q
Summarise the epidemiology of prostate cancer
A
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
4
Q
What are the presenting symptoms of prostate cancer?
A
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
5
Q
What are the signs on physical examination of prostate cancer?
A
Asymmetrical, nodular prostate on DRE and loss of midline sulcus
Palpable lymph nodes
6
Q
What are appropriate investigations for prostate cancer?
A
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
7
Q
What is the management of prostate cancer?
A
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
8
Q
What are the possible complications of prostate cancer?
A
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
9
Q
What is the prognosis of prostate cancer?
A
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
10
Q
Define squamous cell carcinoma
A
Cancer of keratinocytes in the epidermis which can invade local tissue and metastasise.
11
Q
Explain the aetiology of squamous cell carcinoma
A
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
12
Q
Summarise the epidemiology of squamous cell carcinoma
A
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
13
Q
What are the presenting symptoms of squamous cell carcinoma?
A
Hyperkeratotic (scaly, crusty), ill-defined nodule which may ulcerate Skin lesion Ulcerated Recurrent bleeding Non-healing Rolled, red, erythematous edges
14
Q
What are the signs on physical examination of squamous cell carcinoma?
A
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
15
Q
What are the appropriate investigations for squamous cell carcinoma?
A
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
16
Q
Define basal cell carcinoma
A
Slow-growing cancer of the keratinocytes in the stratum basale of the epidermis which can show local invasion but rarely metastasise
17
Q
Summarise the aetiology of basal cell carcinoma
A
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
18
Q
Summarise the epidemiology of basal cell carcinoma
A
Basal cell carcinoma is the most common skin cancer
More common in men
Incidence increases with age
Common in ares of high sunlight exposure
19
Q
What are the presenting symptoms of basal cell carcinoma?
A
A chronic slowly progressive skin lesion
Usually found on the face, scalp, ears and trunk
20
Q
What are the signs on physical examination of basal cell carcinoma?
A
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
21
Q
What are the appropriate investigations for basal cell carcinoma?
A
Mainly a CLINICAL DIAGNOSIS
Biopsy rarely necessary
22
Q
Define melanoma and melanocytic lesions
A
Melanoma is a malignant cancer of the melanocytes in the epidermis which shows local invasion and is very likely to metastasise.
23
Q
Summarise the aetiology of melanoma
A
Risk factors: UV exposure Family history Immunosuppression Light skin Genetic predisposition - familial melanoma: CDKN2A gene DNA repair defects (xeroderma pigmentosum) History of moles
24
Q
Summarise the epidemiology of melanoma
A
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
25
What are the presenting symptoms of melanoma?
```
Rapidly change in size, shape or colour of a pigmented skin lesion
Redness
Bleeding
Crusting
Ulceration
```
26
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
27
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
28
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)
29
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)
30
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
31
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
```
32
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
```
33
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)
```
34
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
35
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
36
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
37
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
38
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
39
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
```
40
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
41
Define Hodgkin Lymphoma
A haematological malignancy of lymphocytes, specifically mature B cells which is characterised by Hodgkin cells and Reed-Sternberg cells
42
Summarise the aetiology of Hodgkin lymphoma
Aetiology is unknown
Association with viruses - HIV, EBV
Genetic predisposition
EBV genome detected in 50% of Hodgkin lymphomas
43
Summarise the epidemiology of Hodgkin lymphoma
Uncommon
More common in men
Bimodal distribution - peaks at 15-34 years old and over 60
44
What are the presenting symptoms of Hodgkin lymphoma
Painless cervical lymphadenopathy - usually only one group of lymph nodes affected
Pruritis
B symptoms:
Fever >38 degrees
Weight loss
Night sweats
Pain in lymph nodes following alcohol
Node is enlarging
Mediastinal adenopathy:
Cough, Chest Pain, SOB
Abdominal pain
Tonsillar enlargement (may be indicative of tonsillar lymphoid tissue)
45
What are the signs on physical examination of Hodgkin lymphoma?
Fever
Non-tender firm rubbery lymphadenopathy (may be cervical, axillary or inguinal)
Splenomegaly
Skin excoriations
Signs of intrathoracic disease (e.g. pleural effusion, SVC obstruction)
46
What are the appropriate investigations for Hodgkin lymphoma?
FBC: Anaemia of Chronic Disease, increased neutrophils and eosinophils, lymphopenia in advanced disease
LFTs: (increased LDH, increased transaminase if the liver is involved)
High ESR and CRP
Lymph Node Biopsy
Bone Marrow Aspirate and Trephine Biopsy
Blood film - Hodgkin cell (large mononucleated cells) and Reed Sternberg cells (bilobed nuclei)
Imaging:
CXR - may show mediastinal adenopathy
CT (thorax, abdo & pelvis) - show enlarged lymph nodes - used for staging
Gallium Scan, PET - show bright at affected areas
47
Define non-Hodgkin's lymphoma
Neoplasm of lymphoid cells originating in lymph nodes involving both T and B cells. There is no presence of reed-sternberg or Hodgkin cells.
They are most commonly B cell lymphomas - 85%
15% T cell and NK cell forms
48
Summarise the aetiology of non-Hogdkin lymphoma
Associated with viral infection eg EBV
Associated with autoimmune conditions eg rheumatoid arthritis, coeliac disaease
Complex process involving the accumulation of multiple genetic lesions
The changes in the genome in certain lymphoma subtypes have been associated with the introduction of foreign genes via oncogenic viruses (e.g. EBV and Burkitt's lymphoma)
49
What are the risk factors for non-Hodgkin lymphoma?
```
Age >50 years
Male
Immunocompromised
Radiotherapy
Immunosuppressive agents
Chemotherapy
Infection: HIV, HBV, HCV
Connective tissue disease (e.g. SLE)
Auto-Immune diseases (Sjogren’s)
```
50
Summarise the epidemiology of non-Hodgkin lymphoma
More common in men
More common in white patients
Incidence increases with age - more common >50 years old
More common in the Western world
51
What are the presenting symptoms of non-Hodgkin lymphoma?
Painless lymphadenopathy with enlarging mass in neck, axilla or groin
B symptoms:
Fever
Weight loss
Night sweats
Bowel extra-nodal involvement:
Bowel obstruction - constipation
Spinal cord extra-nodal involvement:
Weakness
Loss of sensation in legs
Bone marrow extra-nodal involvement:
Fatigue
Easy bruising
Recurrent infections
```
Other extra-nodal symptoms:
Skin rashes
Headache
Sore throat
Abdominal discomfort
Testicular swelling
Cough
Shortness of breath
```
52
What are the signs on physical examination of non-Hodgkin lymphoma?
Painless firm rubbery lymphadenopathy
Skin rashes: Mycosis fungoides (cutaneous T-cell lymphoma)
Hepatosplenomegaly
Signs of bone marrow involvement:
Pallor (due to anaemia)
Infections
Purpura (due to thrombocytopenia)
53
What are the appropriate investigations for non-Hodgkin lymphoma?
```
Bloods:
FBC: anaemia, neutropenia, thrombocytopenia, leukopenia
High ESR and CRP
Calcium may be raised
HIV, HBV and HCV serology
```
Blood Film: Lymphoma cells may be visible in some patients
Bone Marrow Aspiration and Biopsy
Imaging:
CXR, CT, PET
Lymph Node Biopsy: allows histopathological evaluation, immunophenotyping and cytogenetics
54
Define renal cell carcinoma
A primary renal tumour of the parenchyma/cortex, particularly the epithelial cells of the proximal convoluted tubule.
55
Summarise the aetiology of renal cell carcinoma
```
Renal clear cell carcinoma (80%): UNKNOWN CAUSE
Papillary carcinoma (10%): UNKNOWN CAUSE
```
```
Risk Factors:
Smoking (most established modifiable risk factor)
Family history of renal cell cancer
Polycystic Kidney Disease
Chronic Dialysis
Male Sex
Hypertension
Obesity
Increasing age
Pelvic radiation exposure
```
```
Associated with certain inherited conditions:
von Hippel-Lindau disease - autosomal dominant mutation in VHL on chromosome 3 - headaches, dizziness, limb weakness, increased BP
Tuberous sclerosis (rare genetic condition causing growth of benign tumours)
```
Inherited RCC:
Bilateral
Affects younger men and women
Sporadic:
Unilateral
Usually upper pole
Old men
56
Summarise the epidemiology of renal cell carcinoma
Most common type of malignant kidney cancer in adults
6th-8th most common malignancy in adults
More common in men
Peak incidence = 55-84 years old
57
What are the presenting symptoms of renal cell carcinoma?
Usually asymptomatic and presents late
```
Pain in flank or hip
Haematuria
Palpable abdominal/lower back mass if in lower zone
Fever
Weight loss
```
Symptoms of paraneoplastic syndrome:
Erythropoeitin - symptoms of polycythaemia eg headache, visual disturbance
PTHrp - symptoms of hypercalcaemia (stone, moans, bones, abdominal groans)
ACTH - symptoms of Cushing's
58
What are the signs on physical examination of renal cell carcinoma?
Weight loss
Abdominal mass
Signs of Hepatic Dysfunction: ascites, hepatomegaly, spider Naevi
Left Sided Scrotal Varicocele: obstruction of left testicular vein as it joins renal vein by left RCC
Paraneoplastic syndrome signs:
Renin secretion - hypertension
59
What are the appropriate investigations of renal cell carcinoma?
Urinalysis: Haematuria and/or proteinuria, cytology
FBC - shows signs of paraneoplastic syndrome, elevated RBC
Calcium - elevated if paraneoplastic PTHrp secretion
LFTs
U&Es - increased creatinine with reduced clearance
ESR - increased in 75% of patients
Abdominal Ultrasound: can distinguish between SOLID MASSES and CYSTIC STRUCTURES
CT/MRI: useful for staging – use the Robson Staging System
60
Define testicular cancer
A malignant tumour of the testes, most common in young adult men.
Seminomas: MOST COMMON - 50%
Non-seminomatous germ-cell tumours and teratomas: 30%
RARE: Gonadal Stromal Tumours (Sertoli and Leydig cell tumours), Non-Hodgkin's lymphoma
61
Summarise the aetiology of testicular cancer and risk factors
Aetiology is UKNOWN
Thought to be due to a precancerous lesion that will lead to malignant growth
Environment factors eg trauma, atrophy, hormones
Genetic predisposition
```
Risk factors:
FHx
Previous testicular cancer
Kleinfelter's syndrome
Cryptorchidism - failure of descent of testes
Ectopic Testes
Atrophic Testes
HIV
White Ethnicity
Inguinal Hernia
```
62
Summarise the epidemiology of testicular cancer
Highest incidence in 25-35 year olds
Highest incidence in white men
Most common solid tumour in men aged 20-35
RARE - only accounts for 1% of cancers
63
What are the presenting symptoms of testicular cancer?
Painless, hard lump in testicle
May have sharp or dull pain in testicle or abdomen
Swelling or discomfort of the testes
Lung metastases:
Dyspnoea
Haemoptysis
Skeletal metastases:
Bone Pain
Lumbar Back Pain (involvement of Psoas Muscles and Nerve roots)
64
What are the signs on physical examination of testicular cancer?
Hard, painless, firm lump in testicle
Lump non trans-illuminable
Gynaecomastia - due to hCG release
Lymphadenopathy (e.g. supraclavicular, para-aortic)
Lower extremity swelling (venous occlusion)
Signs of hyperthyroidism
65
What are the appropriate investigations for testicular cancer?
Tumour markers - elevated hCG, AFP, LDH
USS colour doppler of testes - see solid mass
CT/MRI chest and abdomen - stage and see metastases, retroperitoneal lymph node enlargement
CXR - mediastinal and lung metastases
Staging System: Royal Marsden Hospital Staging
Urine Pregnancy Test - will be positive if the tumour produces β-hCG
66
Define bladder cancer
Common form of cancer developing from the lining of the bladder
Most often these are transitional cell carcinomas however rarely they can be squamous cell carcinoma or adenocarcinoma associated with chronic bladder inflammation due to Schistosoma infection
67
Summarise the aetiology of bladder cancer
Squamous cell carcinoma:
Chronic irritation eg recurrent UTI, kidney stones
Schistosoma infection
Adenocarcinoma:
Schistosoma
```
90% are transitional cell carcinomas:
SMOKING
Alcohol
Phenacitin
Analine dye
Cyclophosphamide
Increasing age
Extended dwell time
p53 mutation
Pelvic irradiation
Chronic Bladder Inflammation i.e. UTIs
Kidney and bladder stones
Schistosomiasis
Family history
Male
Age >55
Type 2 diabetes
```
p53 dependent tumours are flat and invasive
Non-p53 tumours are papillary
68
Summarise the epidemiology of bladder cancer
9th in worldwide cancer incidence
Egypt, Western Europe and North America have highest incidence
Asia has lowest incidence
Incidence increases with age - 70% are >65
2% of cancers (2nd commonest cancer of the genitourinary tract)
2-3 times more common in males
Peak incidence: 50-70 years
69
What are the presenting symptoms of bladder cancer?
Painless haematuria!!! - usually gross haematuria
Mucusuria in adenocarcinoma
Bladder irritation/storage problems - Frequency, Urgency, Nocturia
Recurrent UTIs
Rarely: ureteral obstruction
Advanced:
Pelvis or bone pain
70
What are the signs on physical examination of bladder cancer?
Often no signs
71
What are the appropriate investigations for bladder cancer?
Cystoscopy and biopsy - allows visualisation of tumour and histology to diagnose type
Urinalysis - haematuria with no casts or crystals
```
Ultrasound (renal & bladder): visualisation of tumours and/or upper tract obstruction
CT (preferred) or Intravenous urogram
CT/MRI for staging
Bone scan
FBC - may show mild anaemia
```
72
Define pancreatic cancer
Malignancy arising from the exocrine or endocrine tissue of the pancreas, often characterised by painless obstructive jaundice and weight loss.
73
Summarise the aetiology and risk factors of pancreatic cancer
Aetiology unknown
5-10% are hereditary
```
Risk factors:
Smoking
Obesity
Increased age
Male
Family history - BRCA2 gene
Increased red meat diet
```
```
Associated with:
Diabetes
Chronic pancreatitis
Liver cirrhosis
Alcohol
```
74
Summarise the epidemiology of pancreatic cancer
Most common aged 65-75 years old
| Most common in men
75
What are the presenting symptoms of pancreatic cancer?
Initial symptoms non-specific
Fatigue
Nausea and vomiting
Weight loss - anorexia or due to malabsorption
Greasy smelly stool (obstruction of CBD)
Mid epigastric pain radiating to back and worse on lying down
Swelling, erythema and tenderness at extremities
Feel small lumps under skin
Pruritis
Abdominal, non-tender mass
Dark urine
Symptoms of DM: thirst, polyuria, nocturia
76
What are the signs on physical examination of pancreatic cancer?
Painless jaundice
Courvoisier's sign - enlarged, palpable, non-tender gallbladder with painless jaundice (unlikely due to gallstones)
Trousseau sign - blood clots felt under the skin as small lumps
Epigastric tenderness and/or mass
Hepatomegaly (if hepatic involvement)
77
What are the appropriate investigations for pancreatic cancer?
CEA - elevated
CA19-9 - elevated
Obstructive jaundice - raised bilirubin, ALP, transaminases
Serum amylase and lipase - elevated
Deranged clotting - prolonged PT
FBC - anaemia if GI bleeding, thrombocytopenia if DIC
Abdo USS - pancreatic mass, dilated bile ducts, liver mets
CT with/without guided biopsy
Staging Laparoscopy OR Intraoperative Ultrasound
78
Define thyroid cancer
A malignancy arising in the thyroid gland. There are four main types:
Differentiated - papillary (most common type of thyroid cancer) and follicular (2nd most common type of thyroid cancer)
Medullary - associated with MEN 2A and 2B
Anaplastic
79
Summarise the aetiology and risk factors of thyroid cancer
Genetic mutations
Papillary - BRAF mutation
Medullary - RET mutation leading to oncogene
Risk factors:
Age >65
Previous radiation therapy to the head or neck
Age <20
Family history
Medullary thyroid cancers may be familial and are associated with MEN 2A or 2B
Lymphoma is associated with Hashimoto's thyroiditis
80
Summarise the epidemiology of thyroid cancer
Most common type of endocrinological malignancy
More common in women
Often diagnosed between 45 and 54 years old
Papillary: 20-40 years
Follicular: 40-50 years
Anaplastic: more common in the ELDERLY
81
What are the presenting symptoms of thyroid cancer?
Often asymptomatic and found incidentally
Firm, non-tender, immobile thyroid nodule
Hoarse voice
Dysphagia
Lump in neck slow-growing
82
What are the signs on physical examination of thyroid cancer?
Tracheal deviation
Unilateral, solitary, firm thyroid nodule which is immobile and non-tender
Cervical lymphadenopathy
Patient usually EUTHYROID as often non-functional therefore no hyperthyroid signs
83
What are the appropriate investigations of thyroid cancer?
Thyroid USS - visualise nodules and evaluate size, consistency, borders etc
Tumour markers:
Thyroglobulin tumour marker in papillary and follicular cancers
Serum calcitonin - increased in medullary thyroid cancer
Radioiodine uptake scan - cold nodule (white circle) suggests a malignant nodule
TSH, T3/T4 - normal as usually non-functional so EUTHYROID
FNA of thyroid nodule - histological diagnosis
Excision Lymph Node Biopsy: If there is cervical lymphadenopathy
84
Define acute leukaemia
ALL:
Malignant clonal disease of the bone marrow and blood caused by uncontrolled division of lymphoid precursor cells, often in children.
AML:
Malignant clonal disease of the bone marrow and blood caused by uncontrolled division of myeloid precursor cells, often in older adults.
85
Summarise the aetiology of acute leukaemia
ALL:
Lymphoblasts undergo malignancy transformation and proliferation, replacing normal marrow elements, leading to bone marrow failure and infiltration into other tissues.
Risk Factors: Radiation, Smoking, Viral Infection, Genetic (Down's syndrome, Neurofibromatosis type 1, Fanconi's anaemia, Xeroderma Pigmentosum), Age < 6 or mid-late 30s/mid 80s, Family history, History of malignancy
AML:
Risk Factors:
Age > 65
Family history
Radiation Exposure
Benzene Exposure
History of chemotherapy
Constitutional Karyotype Abnormalities (i.e. Down’s Syndrome, Klinefelter’s)
Genetic Conditions (i.e. Fanconi’s anaemia)
Hx Haematological disorders - aplastic anaemia, myelodysplastic sydnrome
86
Summarise the epidemiology of acute leukaemia
ALL:
Most common malignancy in children
75% of cases children under 6
AML:
More common in elderly - median age 65 years old
More common in men
Incidence increases with age
87
What are the presenting symptoms of acute leukaemia?
```
Symptoms of anaemia:
Fatigue
Pallor
Weakness
Dyspnoea
Palpitations
Dizziness
```
Symptoms of thrombocytopenia:
Easy bruising/bleeding, epistaxis, menorrhagia
Symptoms of leukopenia:
Recurrent infections
FLAWS
ALL - symptoms of organ infiltration:
Testicular enlargement
Painless lympahdenopathy
Bone pain
AML:
Gum enlargement due to monocytic infiltration
CNS involvement (headaches, nausea, diplopia)
Lymphadenopathy
88
What are the signs on physical examination of acute leukaemia?
Signs of anemia - pallor, tachypnoea
Signs of thrombocytopenia - bruises, purpura, ecchymoses
```
ALL - organ infiltration:
Lymphadenopathy
Hepatosplenomegaly
Painless unilateral testicular enlargement
Renal enlargement
Mediastinal/abdominal mass - T cell ALL
```
AML:
Skin rashes i.e. Pyoderma Gangrenosum (characterised by presence of ulcers on leg)
Gum hypertrophy (gingival enlargement)
Deposit of leukemic blasts in the eye, tongue and bone (RARE)
Lymphadenopathy
89
What are the appropriate investigations for acute leukaemia?
FBC - thrombocytopenia, leukopenia, normocytic anaemia
Peripheral blood smear - increased blast cells, ALL = increased lymphoblasts, AML = increased myeloblasts, Auer rods
Bone marrow biopsy - >20% blasts
Lactate Dehydrogenase - increased
U&E’s - increased Ca2+, K+, Uric Acid, Lactic Acid
Immunophenotyping: using antibodies to recognise cell surface antigens
Cytogenetic: karyotyping to look for chromosomal abnormalities or translocations
CXR: may show mediastinal lymphadenopathy, pleural effusion, lytic bone lesions
Bone Radiographs: mottled appearance with punched out lesions due to leukaemic infiltration
AML:
Clotting studies, fibrinogen and D-dimers - if abnormal suspect DIC due to promyelocytic leukaemia
90
Define chronic leukaemia
CLL:
Progressive accumulation of functionally incompetent lymphocytes, which are monoclonal in origin. Cells are normally differentiated but excess proliferation
CML:
Malignant clonal disorder of the haematopoietic stem cell that results in marked myeloid hyperplasia of the bone marrow
91
Summarise the aetiology of chronic leukaemia
CLL:
Aetiology is UNKNOWN - may be a result of multiple genetic events affecting oncogenes and Tumour Suppressor Genes - leads to increased cell survival and resistance to apoptosis
Risk Factors:
Age > 60 (median age at diagnosis is 70), Male, white ethnicity, Family history
CML:
Most often have translocation between chromosome 9 and 22 - Philadelphia chromosome forming BCR-ABL fusion protein which enhances tyrosine kinase activity
92
Summarise the epidemiology of chronic leukaemia
CLL:
Most COMMON leukaemia in western world
90% are > 50 years old
More common in men
CML:
Incidence peaks between 65 and 74 years old
Increases with age
More common in men
93
What are the presenting symptoms of chronic leukaemia?
May be asymptomatic
Symptoms of anaemia - fatigue, dizziness, dyspnoea, palpitations
Symptoms of thrombocytopenia - easy bruising and bleeding, epistaxis, menorrhagia
FLAWS
CLL:
Enlarged lymph nodes
94
What are the signs on physical examination of chronic leukaemia?
Pallor, dyspnoea
Bruises, ecchymosis, purpura
HepatoSplenomegaly
Lymphadenopathy
CLL:
Cardiac flow murmur
95
What are the appropriate investigations of chronic leukaemia?
FBC - thrombocytopenia, anaemia, lymphocytosis
Peripheral blood smear - increased mature leukocyte cells, CLL - smudge cells
Bone marrow biopsy - lymphocytic replacement of normal marrow
CML:
FBC - Elevated basophils/neutrophils/eosinophils
Elevated uric acid
Decreased neutrophil alkaline phosphatase
Elevated B12 and transcobalamin I (B12 binding protein)
Cytogenetics - find Philadelphia chromosome
96
Define tumour lysis syndrome
Metabolic or electrolyte derangement due to excessive lysis of cells often in patients with haematological malignancies, following start of chemotherapy treatment or suddenly
97
Summarise the aetiology of tumour lysis syndrome
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Sudden lysis of cells causes the release of their toxic contents resulting in:
Hyperkalaemia
Hyperphosphataemia
Hyperuricaemia
Hypocalcaemia
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This is common following the initiation of cytotoxic medications in patients with high proliferating rate: non-Hodgkin lymphoma and ALL
98
Summarise the epidemiology of tumour lysis syndrome
More prevalent in malignancies with high proliferative rates
| More likely in increasing age
99
What are the presenting symptoms and signs on physical examination of tumour lysis syndrome?
Hyperkalaemia:
Arrhythmias - chest pain, syncope, dyspnoea
Severe muscle weakness and paralysis
Paraesthesia
Hyperphosphatemia:
Acute kidney failure due to deposition of calcium phosphate crystals in the kidney
Peripheral oedema
Oliguria/anuria/haematuria
Hypocalcaemia:
Tetany
Parkinsonism
Myopathy
Sudden mental incapacity
Trousseau - inflating BP cuff on upper arm causes carpopedal spasm
Chvostek sign - tapping facial nerve anterior to ear causes facial twitch
Hyperuricaemia: Leads to gout
Splenomegaly, Lymphadenopathy, Lethargy, Diarrhoea, Nausea & Vomiting, Anorexia
100
What are the appropriate investigations of tumour lysis syndrome?
Check levels of all the deranged metabolites: Potassium, Phosphate, Calcium, Uric Acid
Bloods: FBC, Serum Urea, Creatinine, Lactate Dehydrogenase
ECG: arrhythmia due to hyperkalaemia
