Cancer Flashcards
Define basal cell carcinoma.
The commonest form of skin malignancy.
= rodent ulcer
Explain the aetiology / risk factors of basal cell carcinoma.
- Prolonged sun exposure or UV radiation
- Photosensitizing pitch
- Tar
- Arsenic
Associated with abnormalities of the patched / hedgehog intracellular signaling cascade as seen in Gorlin’s Syndrome (naevoid basal cell carcinoma syndrome).
Summarise the epidemiology of basal cell carcinoma.
Common in those with fair skin and areas of high sunlight exposure, elderly, rare before 40 years
Lifetime risk in Caucasians = 1:3
Recognise the presenting symptoms of basal cell carcinoma
A chronic slowly progressive skin lesion usually on the face but also on the scalp, ears or trunk.
Recognise the signs of basal cell carcinoma on physical examination.
Nodulo-Ulceractive:
- Small glistening translucent skin over a coloured papule
- Slowly enlarged (early)
- Central ulcer with raised pearly edges
- Fine telangiectatic vessels run over the tumour surface
- Cystic changes in larger, more protuberant lesions
Morphoeic:
- Expanding
- Yellow / white waxy plaque
- Ill-defined edge - more aggressive
Superficial:
- Most often on trunk
- Multiple pink / brown scaly plaques with a fine whipcord edge expanding slowly
- Can grow to more than 10cm in diameter
Pigmented:
- Specks of brown or black pigment
Identify appropriate investigations for basal cell carcinoma and interpret the results.
Biopsy rarely necessary - diagnosis based on clinical suspicion.
Define cholangiocarcinoma.
Cancer arising from the bile duct epithelium.
Intrahepatic or extrahepatic.
[Perihilar or distal]
Perihilar - involves bifurcation of the ducts = Klatskin’s tumours.
Slow growing
Explain the aetiology / risk factors of cholangiocarcinoma.
Causes:
- Flukes
- Caroli’s disease
- Biliary cysts
Risk factors:
- 50 years +
- Cholangitis
- Choledocholithiasis
- Cholecytolithiasis
Summarise the epidemiology of cholangiocarcinoma.
95%+ are adenocarcinomas.
Recognise the presenting symptoms of cholangiocarcinoma.
- Abdominal pain - right upper quadrant
- Fever
- Pruritus - itchy skin
- Malaise
Recognise the signs of cholangiocarcinoma on physical examination.
- Painless jaundice
- Weight loss
- Palpable gallbladder
- Hepatomegaly
Identify appropriate investigations for cholangiocarcinoma and interpret the results.
- Bloods - bilirubin, AlkPhos, gamma-GT, aminotransferase, PT time
- Abdominal ultrasound
- Abdominal CT, MRI
- MR angiography
- ERCP
Define colorectal carcinoma.
Malignant adenocarcinoma of the large bowel.
Explain the aetiology / risk factors of colorectal carcinoma.
Sequence from epithelial dysplasia to adenoma and carcinoma - involves oncogenes (APC, K-ras) and tumour suppressor genes (p53, DCC).
Risk factors:
- Increasing age
- Adenomatous polyposis coli (APC) mutation
- Lynch syndrome - hereditary non-polyposis colorectal cancer
- MYH-associated polyposis
- Chronic bowel inflammation - e.g. IBD
Summarise the epidemiology of colorectal carcinoma.
60% in rectum and sigmoid colon.
20% in ascending colon
20% in transverse and descending colon
3rd most common cancer in western world.
4th leading cause of cancer deaths in the US.
Rare below 40yrs.
Recognise the presenting symptoms of colorectal carcinoma.
Depends on locations.
Left-sided colon and rectum:
- Change in bowel habit
- Rectal bleeding
- Blood / mucous in stool
- Tenesmus - sensation of incomplete emptying after defecation
Right-sided colon:
- Later presentation
- Symptoms of anaemia, weight loss and non-specific malaise or lower abdominal pain
Recognise the signs of colorectal carcinoma on physical examination.
- Anaemia only sign in right-sided lesions
- Abdominal mass
- Low-lying tumours palpable on rectal examination
Metastatic disease:
- Hepatomegaly
- Shifting dullness of ascites
Identify appropriate investigations for colorectal carcinoma and interpret the results.
- Blood
- Stool
- Endoscopy
- Barium contrast studies
- Abdominal ultrasound scan
Blood
- FBC - for anaemia
- LFT
- Tumour markers - CEA to monitor treatment and reoccurance
Stool
- Occult or frank blood in stool
- Screening
Endoscopy
- Sigmoidoscopy
- Colonoscopy
- Visualisation & biopsy
- If small isolated carcinoma, perform polypectomy
Barium Contrast Studies
- Apple core stricture on barium enema
Abdominal Ultrasound Scan
- For hepatic metastases
- CXR, CT, MRI, endorectal ultrasound
Define gastric cancer.
Gastric malignancy, most commonly adenocarcinoma, more rarely lymphoma, leiomyosarcoma.
Explain the aetiology / risk factors of gastric cancer.
Environmental insult in genetically predisposed individuals –> mutation, unregulated cell growth
Risk factors:
- H.pylori infection
- Atrophic gastritis
- Diet high in smoked, processed foods, nitrosamines
- Smoking
- Alcohol
Summarise the epidemiology of gastric cancer.
Common cause of death worldwide
Highest incidence - Asia, Japan
6th most common cancer in UK
UK annual 15/100,000.
M:F 2:1
Age >50 yrs
Reducing incidence of cancer of antrum/body
Cardia and GI/Oesophageal increasing.
Recognise the presenting symptoms of gastric cancer.
Early - asymptomatic
- Early satiety
- Epigastric discomfort
- Weight loss
- Anorexia
- N&V
- Haematemesis
- Melaena
- Symptoms of anaemia
- Dysphagia - tumours of the cardia
- Symptoms of metastases - e.g. abdominal swelling, jaundice
Recognise the signs of gastric cancer on physical examination.
- May be normal
- Epigastric mass
- Abdominal tenderness
- Ascites
- Signs of anaemia
- Virchow’s node/Troisier’s sign - lymphadenopathy in left supraclavicular fossa
- Sister Mary Joseph node - metastatic nodule on umbilicus
- Krukenber’s tumour - ovarian metastases
Identify appropriate investigations for gastric cancer and interpret the results.
- Upper GI endoscopy - multiquadrant biopsy of gastric ulcers
- Blood - FBC (anaemia), LFT
- CT/MRI - staging of tumour, surgery
- US of Liver - staging of tumour
- Bone scan - staging of tumour
- Endoscopic Ultrasound - assess depth of invasion, lymph node spread
- Laparoscopy - determine if resectable
Define hepatocellular carcinoma.
Primary malignancy of hepatocytes, usually occurring in a cirrhotic liver.
Explain the aetiology / risk factors of hepatocellular carcinoma.
- Chronic liver disease - e.g. alcoholic liver disease, Hep B/C, autoimmune disease
- Metabolic disease - e.g. haemochromatosis
- Aflatoxins - e.g. Aspergillus flavus fungal toxin on stored grains or biological weapons
Risk factors:
- Cirrhosis
- Chronic Hep B/Hep C
- Chronic heavy alcohol use
Summarise the epidemiology of hepatocellular carcinoma.
1-2% of malignancies - common
Less common than secondary liver malignancies
Rare in the west - 1-2 per 100,000/year
Common in HepB/C endemic countries - e.g. Asia and sub-Saharan Africa - 500 per 100,000/year
Recognise the presenting symptoms of hepatocellular carcinoma.
Symptoms of malignancy:
- Malaise
- Weight loss
- Loss of appetite
Symptoms of chronic liver disease:
- Abdominal distension
- Jaundice
History of Carcinogen Exposure:
- High alcohol intake
- Hep B/C
- Aflatoxins
Recognise the signs of hepatocellular carcinoma on physical examination.
Signs of malignancy:
- Cachexia
- Lymphadenopathy
Hepatomegaly:
- Nodular
- Deep palpation elicits tenderness
- Bruit heard over the liver
Signs of chronic liver disease:
- Jaundice
- Ascites
Identify appropriate investigations for hepatocellular carcinoma and interpret the results.
- Bloods - high AFP, VitB12-binding protein, LFT may show biliary obstruction (poor sensitivity and specificity)
- Abdominal US - not sensitive if <1cm
- Duplex scan of liver - demonstrate large vessel invasion
- CT (thorax, abdomen, pelvis) - define structural lesion and spread
- Hepatic angiography - using lipiodol
- Liver biopsy - confirms histology (small risk of tumour seeding along biopsy tract)
- Staging - CXR, CT (throax, abdomen, pelvis), radionuclide bone scan
- Screening - AFP, abdominal ultrasound in at-risk individuals
Define oesophageal cancer.
Malignant tumour arising in the oesophageal mucosa.
2 major histological types - squamous cell carcinoma and adenocarcinoma.
Explain the aetiology / risk factors of oesophageal cancer.
Barrett’s oesophagus (intestinal metaplasia) can progress to low-grade, high-grade and invasive carcinoma.
Spread is typically initially direct (no serosa on oesophagus) and longitudinal –> via submucosal lymphatics to tracheobronchial, mediastinal, coeliac, gastric or cervical nodes.
Rare oesophageal tumours = lymphoma, melanoma, leiomyosarcoma.
Squamous Cell Carcinoma:
- More common in mid-upper oesophagus
- Alcohol
- Tobacco
- Nutritional deficiency - e.g. vitamines, trace elements
- HPV infection
- Achalasia
- Paterson-Kelly (Plummer-Vinson) Syndrome
- Tylosis (Howel-Evans Syndrome)
- Scleroderma
- Coeliac disease
- Lye stricture
- History of previous thoracic radiotherapy or upper aerodigestive squamous cancer
- Dietary nitrosamines
Adenocarcinoma:
- More common in lower oesophagus or gastro-oesophageal junction
- GORD
- Barrett’s oesophagus - intestinal metaplasia of distal oesophageal mucosa
Summarise the epidemiology of oesophageal cancer.
8th most common malignancy - UK 7000-8000 per year
M:F 3-4:1
High incidence in northern China, Iran, southern Russia
Adenocarcinoma more common in Westernized countries - 65% cases in UK, increasing by 5-10% per year
Peak incidence 60-70 years
Recognise the presenting symptoms of oesophageal cancer.
Early:
- Symptomatic of reflux
Late:
- Dysphagia
- Regurgitation
- Cough
- Choking after food
- Odynophagia
- Weight loss
- Fatigue
- Voice hoarseness (recurrent laryngeal nerve palsy?)
Recognise the signs of oesophageal cancer on physical examination.
No physical signs evident
- Weight loss
- Supraclavicular lymphadenopathy
- Hepatomegaly
- Aspiration or direct tracheobronchial involvement –> respiratory signs
Identify appropriate investigations for oesophageal cancer and interpret the results.
- Endoscopy
- Imaging
- Other
Endoscopy - tumour location and biopsy, using narrow band imaging or magnification to grade and detect
Imaging - e.g. Barium swallow, CT (chest, abdo, pelvis), PET (metastasis)
Other - Bronchoscopy (if risk of tracheobronchial invasion), bone scan, laparscopy, peritoneal washings, thoracoscopy
Define pancreatic cancer.
Malignancy arising from the exocrine or endocrine tissues of the pancreas.
[primary pancreatic ductal adenocarcinoma - 85%+ of pancreatic neoplasms]
Explain the aetiology / risk factors of pancreatic cancer.
Unknown cause.
5-10% familial component
- Hereditary syndrome - BRCA2 mutation
- Familial atypical multiple mole melanoma (CDKN2A)
- Peutz-Jeghers (STK11/LKB1)
- Hereditary pancreatitis (PRSS1)
- MEN
- HNPCC
- FAP
- Gardner
- von Hippel-Lindau Syndromes
Precursor lesions - e.g. pancreatic intraductal neoplasia, intraductal pancreatic mucinous neoplasm, mucinous cystic neoplasm
Linear progression from pre-invasive pancreatic intraductal neoplastic lesions to invasive ductal adenocarcinoma.
Risk factors:
- Smoking
- Family history of pancreatic cancer
- Other hereditary cancer syndromes
- Chronic sporadic pancreatitis
Summarise the epidemiology of pancreatic cancer.
8-12/100,000
8th cause of cancer deaths worldwide
x2 males
60-80 years (peak age)
Recognise the presenting symptoms of pancreatic cancer.
Very non-specific:
- Anorexia
- Nausea
- Malaise
- Weight loss
Later:
- Jaundice
- Epigastric pain
Recognise the signs of pancreatic cancer on physical examination.
- Weight loss
- Epigastric tenderness
- Epigastric mass
- Jaundice
- Palpable gallbladder
- Hepatomegaly (metastasis)
- Trousseau’s sign (due to superficial thrombophlebitis) - carpopedal spasm caused by inflating the blood-pressure cuff to a level above systolic pressure for 3 minutes
[Courvoisier’s law - palpable gallbladder + painless jaundice isn’t gallstones]
Identify appropriate investigations for pancreatic cancer and interpret the results.
- Bloods
- Imaging
- Other
Bloods
- Tumour markers CA19-9, CEA elevated
- If jaundiced, high bilirubin, high ALP, deranged clotting
Imaging
- US
- Endoscopic ultrasound
- FNA
- CT
- MRI
- PET
- Laparoscopy
- ERCPY - biopsy, bile cytology, stenting
Other
- Staging laparoscopy
- Intraoperative ultrasound
Define breast cancer.
Malignancy arising from breast tissue.
Explain the aetiology / risk factors of breast cancer.
Combination of genetic and environmental factors.
Polygenic risk - 5-10% inherited
- BRCA-1 (17q), BRCA-2 (13q) in 2% - 87% risk for carriers
- Li-Fraumeni Snydrome - TP53
- Cowden’s Syndrome - PTEN
- Peutz-Jeghers Syndrome - STK11 / LKB1
- Ataxia-telangiectasia - ATM
- Muir-Torre Syndrome - MSH2/ MLH1
Risk Factors:
- Age
- Prolonged exposure to female sex hormones - particularly oestrogen
- Nulliparity
- Early menarche
- Late menopause
- Menopausal hormone replacement therapy
- Obesity
- Alcohol
Summarise the epidemiology of breast cancer.
Worldwide, leading cause of cancer death in women - 2nd to lung cancer.
Lifetime risk if 1:9 in the UK.
Peak incidence - 40-70 year olds
Rare in men - <1% of all breast cancers
Recognise the presenting symptoms of breast cancer.
Detected from screening
Symptoms of Primary:
- Breast lump
- Painless
- Changes in breast shape
- Nipple discharge
Symptoms of Secondary Spread
- Axillary lump
- Bone pain
- Weight loss
- Paraneoplastic syndromes - e.g. cerebellar syndrome
Recognise the signs of breast cancer on physical examination.
Inspection of the breasts with teh patient upright and supine, assessing for asymmetry, peau d’orange appearance of the skin (oedema), dimpling or tethering, nipple scaling or inversion or, in advanced cases, ulceration.
Palpation using clockwise radial technique (for hard, irregular, fixed lumps)
Examination for palpable axillary, supraclavicular lymph nodes, chest abnormalities, hepatomegaly, bony tenderness.
Identify appropriate investigations for breast cancer and interpret the results.
Triple Assessment - standardized approach to investigating a breast lump, consisting of clinical examination, imaging (mammography, ultrasound, MRI) and tissue diagnosis (cytology or biopsy)
Mammogram
- Useful screening investigation in women > 35 years
- UK Screening - >50 years
- Craniocaudal and mediolateral oblique views
- Features of malignancy - branching or linear microcalcifications and spiculated lesions
US
- Identify cystic lesions from sinister solid lesions
- More useful in women <35 years
Fine-Needle Aspiration
- Minimally invasive
- Allows cytology of discrete breast lumps and draining of cysts
Core Biopsy
- Can be image-guided, enables histological diagnosis
Sentinal Lymph Node Biopsy
- Radioactive tracer and / or blue dye is injected near the breast lesion
- A nuclear scan identifies the sentinel node
- Node is biopsied to detect spread
Staging
- CT - chest, abdomen, pelvis
- PET or bone scanning for metastases
Bloods
- FBC
- U&E
- Ca2+
- Bone profile
- LFT
- Tumour marker - CA-15-3
Histology
- In situ carcinoma - non-invasive with basement membrane intact - ductal or lobular carcinoma in situ (DCIS, LCIS)
- Invasive - ductal carcinoma (75% of breast cancers)
- Others - lobular (10-15% with Indian filing arrangement of cells), tubular, mucinous, medullary, cribiform, papillary, Paget’s disease of the nipple (ductal carcinoma in situ infiltrating the nipple)
Grading:
- Nottingham modification of the Bloom and Richardson grading system
- Tubule formation, nuclear size / pleomorphism and number of mitoses
- Scores used to generate Grades 1 to 3
Staging
- The UICC TNM-staging system
- Tumour size - T1 <2cm, T2 2-5cm, T3 >5cm, T4 - any size with chest wall or skin extension
- Nodes - N1 mobile ipsilateral axillary, N2 fixed ipsilateral axillary, N3 ipsilateral internal mammary nodes
- Metastases - M0 no distant metastases, M1 distant metastases
Define deep vein thrombosis (DVT).
Formation of a thrombus within the deep veins - most commonly of the calf or thigh
Explain the aetiology / risk factors of deep vein thrombosis (DVT).
As it is has come to be known today, Virchow’s triad consists of stasis, vessel damage, and hypercoagulability, and is used to describe the etiology and assess the risk of thrombosis, especially of deep vein thrombosis (DVT.)
Risk factors:
- Medical hospitalisation within the past 2 months
- Major surgery within 3 months
- Active cancer
- Lower-extremity trauma
- Severe trauma
- Increasing age
- Pregnancy
- Factor V Leiden
- Prothrombin gene mutation G20210A
- Protein C or S deficiency
- Anti-thrombin deficiency
- Antiphospholipid antibody syndrome
- Medical comorbidity
- Use of specific drugs
- Smoking
- Obesity
- Recent long-distance air travel
- Family history
Summarise the epidemiology of deep vein thrombosis (DVT).
The precise number of people affected by DVT/PE is unknown, although as many as 900,000 people could be affected (1 to 2 per 1,000) each year in the United States. Estimates suggest that 60,000-100,000 Americans die of DVT/PE (also called venous thromboembolism).
Recognise the symptoms of deep vein thrombosis (DVT).
- Calf swelling
- Localised pain along deep venous system
- Asymmetric oedema
- Prominent superficial veins
- Swelling of entire leg
- Phlegmasia cerulea dolens
Recognise the signs of deep vein thrombosis (DVT).
- Examine for swelling
- Examine for calf tenderness
- Severe leg oedema and cyanosis (phlegmasia cerulea dolens) is rare
- Respiratory examination for signs of a PE
Use Wells Clinical Prediction Score
Identify appropriate investigations for deep vein thrombosis (DVT).
- Doppler ultrasound
- Bloods
- ECG, CXR, ABG - if PE?
Doppler US
- Gold standard
- Good sensitivity for femoral veins
- Less sensitive for calf veins
Bloods
- D-dimers = fibrinogen degradation products - sensitive but non-specific and only useful as a negative predictor in low-risk patinets
- Thrombophilia screen, prior to starting anticoagulation - if recurrent episodes
- FBC - platelet count prior to starting heparin
- U&E
- Clotting
Generate a management plan for deep vein thrombosis (DVT).
Anticoagulation:
- Heparin - whilst awaiting therapeutic INR from warfarin anti-coag
- DVT below knee treated with anti-coagulation for 3 months
- DVT above knee treated with anticoagulation for 6 months
- Recurrent DVT - long term warfarin
- If active anticoagulation is contraindicated and/or high risk of embolisation - place IVC filter by IVR to prevent embolus in lungs
Prevention:
- Use of graduated compression stockings
- Mobilisation if possible
- At-risk groups should have prophylactic heparin - e.g. low-molecular weight heparin if no contraindications
Identify the possible complications of deep vein thrombosis (DVT) and its management.
Of the disease:
- PE
- Damage to vein valves
- Chornic venous insufficiency of the lower limb (pro-thrombotic syndrome)
- Venous infarction - phlegmasia cerulea dolens
Of the treatment:
- Heparin-induced thrombocytopaenia
- Bleeding
Summarise the prognosis for patients with deep vein thrombosis (DVT).
Depends on extent of DVT, below-knee DVTs lower risk of embolus.
More proximal DVTs have higher risk of propagation and embolisation, which if large, may be fatal.
Define pulmonary embolism.
Occlusion of pulmonary vessels, most commonly caused by a thrombus that has travelled to the vascular system from another site.
Explain the aetiology / risk factors of pulmonary embolism.
- Thrombus
- 95% originate from DVT of lower limbs
- Rarely from right atrium in patients with AF
- Amniotic fluid embolus
- Air embolus
- Fat emboli
- Tumour emboli
- Mycotic emboli from right-sided endocarditis
Risk factors:
- Surgical patients
- Immobility
- Obesity
- OCP
- Heart failure
- Malignancy
Summarise the epidemiology of pulmonary embolism.
Fairly common, especially in hospitalized patients
Occur in 10-20% of those with a confirmed proximal DVT.
Recognise the symptoms of pulmonary embolism.
Depends on site and size.
Small - may be asymptomatic
Moderate
- Sudden onset dyspnoea
- Cough
- Haemoptysis
- Pleuritic chest pain
Large
- Sudden onset dyspnoea
- Cough
- Haemoptysis
- Severe pleuritic chest pain
- Shock
- Collapse
- Acute right heart failure
- Sudden death
Multiple Small Recurrent
- Symptoms of pulmonary hypertension