Cancer Flashcards
How do you name different types of cancer ?
What these prefixes mean ?
adeno chondro erythro hemangio hepato lipo lympho melano myelo myo osteo
What do these suffixes mean ?
- oma
- carcinoma
- sarcoma
- blastoma
Suffix Meaning
- oma benign tumour
- carcinoma epithelial cancer
- sarcoma mesenchymal cancer
- blastoma primitive cell cancer
adeno- gland chondro- cartilage erythro- red blood cell hemangio- blood vessels hepato- liver lipo- fat lympho- lymphocyte melano- pigment cell myelo- bone marrow myo- muscle osteo- bone
What is cancer ?
How does it happen ?
Unregulated cell growth - loss ability to control cell growth & replication——————> form a malignant tumor (can spread to other tissues and invade tissues. )
Mechanisms of cancer
0 CDK
CDK - cyclin dependant kinases - involved in cell regulation :
o too little - cell does not progress.
o too much - unregulated proliferation of cells.
0 Mutations
- cause cell to converted into cancerous cell by 2 mechanisms :
o activation of oncogenes (mutations of proteo-oncogenes- which regulate cell cycle ) e.g RAS , MYC gene
causes call to bypass checkpints and growth becomes unregulated.
- mutation in the RAS gene - produces RAS protein which are already activated ———————> constant intacellular phosphorylation of proteins & activation of transcription factor ——————-> overproduction of cyclins & CDK
MYC gene - makes proteins for cell growth , survival & activity. (Mutation ————> more of this———– cell becomes cancerous )
o Deactivation of tumour suppressor gene.
(p53 , APC , BRCA 1 & 2 )
e.g activation of p53 - not able to put cell into arrest , die or be repaired so cells grow unregulated.
What is the normal role of RAS gene in cell growth ?
Growth factor receptor ——————–growth factor binds to receptor ———————–> stimulated Growth factor receptor activates RAS protein on membrane ————————-> stimulates cascade of intracellular phosphorylation of other proteins which activates transcription factor. ——————————————> activated transcription factor hoes to gene and makes proteins fr cell growth e.g CDK AND CYCLINS.
What is the function of tumor suppression genes ?
Damaged DNA ———————-> production of P53 transcription factor ————————-> make proteins for cell arrest (e.g p21 - inhibits CDK and cyclins - cell cycle does not progress) & cell repair (so when cell is arrested cell is repaired ) % apoptosis ( if cell cant be repaired has to die. )
Characteristics of cancer cells ?
Anaplasia - loss of differentiation & organisation.
Autonomy - independent of cell cycle control.
normal —> dysplasia (normal cells undergo transformation by mutations , carcinogens , infection etc )——————> neoplasia ( abnormal cells form tumour - cancerous cells stack on top of each other (not normal ) - blood vessels start to form supplying new tumour (ANGIOGENSIS )————————————— > Invasive neoplasia – ( tumour continues to grow & cells divide & extensive BV supplying it ————> Tumour starts to penetrates through basement membrane into BV and cancerous cells enter blood and spread throughout body.
Types of lung cancer Lung cancer ?
2 Types
0 Small cell carcinoma
- aggressive - 2/3rd present with metastasis.
- primarily develops in older adult smokers.
- tend to occur close to hilium of lungs
- poor prognosis
- Linked to paraneoplastic syndrome (this cancer involves neuroendocrine cells which produce hormones ( should not be able to ) . )
0 Non - small cell carcinoma
- 85 % of lung cancers
e.g
o adenocarcinoma -(- most common non small cell - tend to occur (TTO) in peripheral lung tissue
)
o squamous cell carcinoma
(- 2nd most common
- TTO near bronchus - can cause obstruction of the airways.
- involves columnar cuboid epithelial cells lining bronchus converted into squamous cancerous cells ))
o Large cell carcinoma
- rapidly grow
- proximal or peripheral lung tissue. )
Common symptoms of Lung cancer ?
o Cough - airway obstruction ————-> intiates cough reflex ( so present with cough & dyspnoea )
o Weight loss
o Dyspnoea
o Chest pain
o Haemoptysis - angiogensis - New BC are leaky and prone to rupture
There can be blood involvement e,g :
- Anaemia ( fatigue & dyspnoea ) - leukocytosis - thrombocytosis - hypercoagulable disorders
Medistinal involvement of lung cancer ?
Pancoast tumor ( tumor at the apex of the lung ) -
- non small cell
- can compress brachial plexus – should arm pain , weakness , atrophy on the same side )
- can cause horner’s syndrome - damage to sympathetic nerve pathway from hypothamulus to face via upper spinal cord near carotid artery (CA)(causes by lesions to head a neck e.g tumor (pancoast or neuroblastoma ) ,surgery, dissection of CA ,
o Dropping eyelid
o contacted pupil
o dryness - lack of sweating on same side as affected eye
( unilateral )
0 Pleural effusion
0 Pericardial effusion
0 SVC blocked - Vena cava syndrome .
Lung cancer metastasis ?
spreads from lung ——————–> to heart———-. pumps tumor / cancer cells either to : brain , upper limbs or down to abdomen area.
Common sites
- Brain
- Liver
- bone
- adrenal gland.
What is the paraneoplastic syndrome ?
group of disorders triggered by abnormal immune response to a cancerous tumour——————> causes collateral damage to nervous system
- they occur at sites distant or tumour or its metastasis
e.g
ectopic cushing syndrome ——–> NE cells release ATCH —————> stimulate adrenal glands to release Cortisol
- neuroendocrine (NE) cells release ADH—————–> water rentention
& Parathyroid like substance ————————-> cause bone breakdown and release of CA ———-> Hypercalcemia
Hypertrophic pulmonary osteoarthropathy (HPOA) – group of symptoms :
o Clubbing - swelling of ends of fingers
o Spoon shaped nails
o Inflammation , swelling and pain in hands , fingers , knees and joints.
- peritonitis - inflammation of periosteum ( band of tissue surrounding bone )
- can happen in variety of conditions but when link to cancer considered a PN syndrome - most common in lung cancer.
Investigations of lung cancer ?
Chest x ray - 1 st - helps rule out differential diagnosis . - what you may see: o pulmonary opacity o pleural effusion o lung collaspe o hilum enlargement o rib bone lesions
CT scan - further assessment -detemine stage & management of cancer
sputum cytology - detect cancerous cells in sputum.
investigations to consider
- lung biopsy - Bronchoscopy and sample is taken.
- Thorocentesis - fluid sampled.
Difference between treatment of non small cell and small cell carcinoma ?
Small cell carcinoma - most present with metastasis - so surgery will be effective , Chemo -first line vs non small cell - Surgery first line for less advance stages.
Stages of cancer ?
5 stages
Stage 0 - cancer is in situ - hasn’t spread
Stage 1 - cancer no longer spread , but still not spread
Stage 2 - Cancer grown . not spread
Stage 3- larger & may have spread to surrounding tissue & lymph nodes
Stage 4 - Spread to secondary organ - metastatic.
TMN - Tumour T0- no tumour TIS - carcinoma in situ T1 , 2, 3, 4 - size & extent N - nodal status - NO - no nodular maliglancy N1, N2,N3 - increasing number of lymph node involved M - Metastasis M0 - no metastasis M1 . M2 - location of metastasis
What is colorectal / bowel cancer ?
Cancer that occurs in colon or rectum
- 3rd most common cancer
RISK FACTORS
- rare below age 40.
0family history link
- FAP - familal adenomatous Polyposis
- HNPCC - Hereditary nonpolyposis colorectal cancer / lynch syndrome (inherited)
- personal history of colon cancer
- history of inflammatory conditions of colon e.g IBD (UC & CD)
SYMPTOMS
0 Diarrhoea,
0constipation (sometimes referred to as ‘change of bowel habit’),
0 rectal bleeding
0 loss of weight
0 abdominal pain.
- may present with anaemia, particularly iron-deficiency
- Can be misdiagnosed as non -maligant conditions e.g IBD.
- right sided tumours typically present at a more advanced stage with symptoms of weight loss and anaemia (mostly asymptmatic apart from these so are diagnosed later allowing them to grow )
whereas left sided tumours ( mostly in - descending-sigmoid area) often present with rectal bleeding, change in bowel habit, and tenesmus ( cramping rectal pain - feel like you need to go to the toilet even though you dont.
rectal location - deep red blood on surface of stools
- deep bright red blood indicates bleeding is in rectum or low in colon
- darker maroon blood indicates bleeding higher up in colon.
When to refer for suspected colorectal cancer?
referral (for an appointment within 2 weeks) for colorectal cancer if:
0 They are aged 40 years and over with:
- unexplained weight loss
- abdominal pain
0 They are aged 50 years and over with unexplained rectal bleeding
0 They are aged 60 years and over with:
- Iron-deficiency anaemia
- Changes in their bowel habit, or
- Tests show occult blood in their faeces.
0 Consider in people with a rectal or abdominal mass.
0 Consider in adults aged under 50 years with rectal bleeding and any of the following unexplained symptoms or findings:
- Abdominal pain.
- Change in bowel habit.
- Weight loss.
- Iron-deficiency anaemia.
What are hereditary colorectal cancer syndromes ?
- FAP - familal adenomatous Polyposis
o person devlops more than 100 adenomatous polyps)- classical FAP - more than 1000 & risk
of CRC (colorectal cancer )by age 40 - attenuated FAP - less than 100 & later
onset of CRC
o Polyps are benign but can become cancerous.
(if not recognised and treated very high likelihood of developing CRC — can develop other cancers too. )
- classical FAP - more than 1000 & risk
- most people will go on to develop colorectal cancer
- HNPCC - Hereditary nonpolyposis colorectal cancer / lynch syndrome (inherited)———————–> get colon polyps—->increases risk of cancers (predisposed).
- nonpolyposis - means only small number of polyps present vs FAP
Investigations
0 abdominal exam / rectal exam - check for masses
0 Colonscopy
0 extended side viewing oesophagogastrodupdenoscopy
0 Blood investigations
Investigations for suspected colorectal cancer ?
0 FBC - iron defieciency amaemia may be present - 90 % in right sided
0 abdominal exam / rectal exam - check for masses
0 Colonscopy
(oral laxatives are given to clear bowel - give good view )
- colorectal cancer can present as an ulcer , polyp ,
0 Blood investigations
if colorectal corfirmed
- CT scan - for staging
of thorax , abdomen , pelvis.
Treatment of colorectal cancer ?
Colon cancer - stage 1-3 - suitable for surgery :
0 Colonectomy with removal of regional lymph nodes - first line + adjunct post - operative chemo
Stage 4 - pre - operative chemotherapy then colonectomy (surgical resection)
surgery not suitable -
Chemo - 1st line
VEGF (Vascular or endothelial growth factor )
- e.g Bevacizumab
aflibercept etc. - ADJUNCT
Rectal cancer
Stage 1 - low risk - local excision or radation excsision
Stage 1 high risk , 2 &3 - radical resection + Adjunct pre-operative chemoradiotherpay (stage 2-3 - have the chemo on its own -the radiotherapy )
Stage 4 - surgical resectiion + adjunct chemoradiotherpapy
NOT SUITABLE FOR SURGERY
Stage 1 -4
Chemotherapy - first line + adjunct VEGF OR EGFR INHIBITOR.
What is bladder cancer ?
urogenital cancer
strongly associated with smoking
over 90% are urothelial carcinomas - occur in urothelium (transitional cell carcinomas )
DIFFERENT TYPES
- Urothelial
- Sqauamous cell carcinoma
- adenocarcinoma
DIFFERENT SHAPES
0 carcinoma in situ - confined to urothelium (or a specific layer)
0 Sessile - flat
0 papillary tumors - project out (finger like )
RISK FACTORS
- over 55 years
- men at greater risk - 4X
- exposure to
- chemical carcinogens
- tobacco exposure
- Pelvic radiation (e.g in treatment for prostate cancer etc )
- systemic
chemotherapy e.g cyclophsosphamide - family history of bladder cancer
What are the layers of the bladder ?
0 Urothelium - contains transitional cells / epithelium
0 lamina propria - contains the BV.
0 detrusor muscle (musclaris propria )
0Adventitia - fatty connective tissue.
Symptoms of bladder cancer
0 Haematuria - often painless
(blood in the urine )
0 Dysuria
- retention
- urgency
- change in
frequency
Investigations of bladder cancer ?
Urinalysis - 1st line
- checks for protein , glucose , infection , WBC etc
(Haematuria , PYURIA (increased WBC in urine ) can be seen causing it to be mistaken for infection )
TEST TO CONSIDER
0 urine cytology - look to see if there are abnormal cells in urine under microscope.
- positive - abnormal cells found
- negative - no abnormal cells found.
FBC
EUC - electrolyte urea & creanitine
CRP
- Renal & bladder ultrasound - les
- CT urogram
- cystoscopy - cytoscope ineserte in urethra and advanced into bladder - gold standard
(biopsy can be taken )
PET /CT SCAN USED TO STAGE
Management of non muscle / muscle invasive disease ?
Bladder cancer
non muscle invasive - not invaded detrusor muecle - complete transurethral resection.
(chance of recurrance is high )
+ intravesical chemotherapy (chemotherapy is installed locally in the bladder )
muscle invasive - (poorer prognosis )
o neoadjunct chemotherapy prior to surgery
o cystoprostatectomy
(have do a urinary diversion - reattchment of ureter to somewehere else so urine can still exit
o extended pelvic lymphadenectomy.
Management of non muscle / muscle invasive disease ?
Bladder cancer
NON MUSCLE INVASIVE - NOT INVADED DETRUSOR MUSCLE
0 complete transurethral resection.
(chance of recurrance is high )
+ immediate intravesical chemotherapy (chemotherapy is installed locally in the bladder )
(special cases - high risk,e.g reoccurance , multiple high grade tumours with diffuse carcinoma in situ or invasion in blood or lymph, - radical cystectomy (removal of the bladder)
* in most cases of high risk this would be an over treatment if tumour has not invaded muscle.
MUSCLE INVASIVE (POORER PROGNOSIS ) 0 neoadjunct chemotherapy prior to surgery - ADJUNCT
1st line
o cystoprostatectomy (men )
o radical cystectomy often with hysterectomy
+ pelvic lymph node dissection.
(BEST CHANCES OF CURE)
(have do a urinary diversion - reattachment of ureter to somewhere else so urine can still exit )
- neobladders (replacement bladder can be put in place - made out of a section of bowel with urethra attached - increase risk of night time incontinence or retention requiring intermittent self - cathetrisation
o extended pelvic lymphadenectomy.
-bilateral pelvic lymph node dissection & extended lymph node dissection ( extended improves treatment )- ADJUNCT
2nd line - immunotherapy e.g atezolizumab (lumabs ) - after post operative chemotherapy.
T3a - b (non organ contained ) - only difference to T2a - b - partial cystectomy not offerered only radical .
T4a - b (non organ contained ) -
1st line
Chemotherapy (disease can not be treated by local removal , now systemic )
ADJUNCT - radiotherapy
ADJUNCT - Radical cystectomy (only when tumour has responded to chemo & no longer palpable )
2nd line
Immunotherapy
Metastatic disease - spread 1st line Chemotherapy ADJUNCT - surgery ADJUNCT - radiotherapy 2nd line Immunotherapy.
Contraindications of radiotherapy in bladder cancer ?
0 previous pelvic radiation
0 contracted bladder
0 irritable bladder symptoms
contracted bladder - end stage of chronic inflammatory disorders of the bladder or results from the treatment of carcinoma such as post radiotherapy. The chronic fibrotic damage to the bladder causes the bladder function to deteriorate severely - can’t hold as much volume and reduced compliance.
What imaging is used to stage cancers ?
0 CT
0 PET
0 medistinal sampling ( lungs )
What is prostate cancer ?
Malignant tumour - glandular origin in prostate.
SIGNS AND SYMPTOMS
- mostly you just find - abnormal digital rectal exam
UNCOMMON 0 Nocturia 0 urinary frequency & hesitancy 0 dysuria 0 haematuria 0 weight loss / anorexia 0 lethargy 0 bone pain , 0 palpable lymph nodes (associated with metastatic disease)
RISK FACTORS
- age > 50 yrs
- Black
- other groups also
- Fx
uncommon - high fat diets
- obesity
Investigations of Prostate cancer?
Serum PSA - elevated
( can be increased in non - malignant conditions & some can be normal in cancer )
Prostate biospy - if suspicious - abnormal Digital rectal exam and/ or elevated PSA (above 4 micograms/L)
Need to check baseline levels - if androgen deprivation therapy needed :
0 Testosterone
0 LFTS
0 FBC (anaemia)
0 renal function
CONSIDER - if metastases suspected
Bone scan
Radiographs
Pelvic Ct scan / MRI in those with high or very high risk fo prostate cancer with > 10 % risk of pelvic lymph node involvement.
