Cancer Care Flashcards
Which tumours most commonly metastasise to the brain?
lung (most common) breast bowel skin (namely melanoma) kidney
What are the non-modifiable risk factors for breast cancer?
Female
Age 50-70
Genetics - BRCA1&2, ERBB2/HER2, TP53
Increased Oestrogen exposure - early menarche, late menopause (increased number of menstrual cycles)
What are the modifiable risk factors for breast cancer?
Oestrogen exposure - nulliparity, later age of pregnancy, HRT, COCP
Ionising radiation exposure
LIfestyle - obesity, alcohol, smoking
What are the 3 types of invasive breast cancer?
Invasive ductal carcinoma (75-85%)
Invasive lobular carcinoma (10%) (older women, more difficult to detect)
Other subtypes (5%), such as medullary carcinoma or colloid carcinoma
What is a carcinoma in situ? What are the two types of breast CIN?
Malignancies that are contained within the basement membrane tissue. Pre-Malignant and rarely symptomatic
I.e. high grade dysplasia
Ductal (most common) and Lobular
What is ductal carcinoma in situ?
malignancy of the ductal tissue of the breast that is contained within the basement membrane
What is lobular carcinoma in situ
malignancy of the secretory lobules of the breast that is contained within the basement membrane
more at risk of becoming invasive
What is the management of ductal and lobular carcinoma in situ?
Ductal = wide local excision
Lobular = Monitor if low grade
What is the clinical presentation of a breast carcinoma?
Lump! (craggy, irregular, matted, non-tender, immobile)
Nipple changes - pagets = itchy, red, crusty, retraction, abnormal discharge
Skin changes - swelling, peau d’orange
Mastalgia
Lump in axilla
What is the triple assessment for breast cancer?
Examination
Imaging - mammogram
Histology or cytology - USS biopsy
What are the two types of biopsy that can be taken from a breast?
FNAC - quick n easy but if malignant have to do a core biopsy anyway
Core = longer and more painful but gives receptor status and grading
Describe the vascular supply to the breast
External and internal mammary arteries give rise to intercostal, internal thoracic
Branch from axillary?
What are the localised complications of breast cancer?
Localised inflammation = fibrosis of suspensory ligaments and lactiferous ducts
Invasion of nearby tissue
Lymph node involvement = peau d’orange as lymph builds up but suspensory ligaments don’t allow swelling
Where are the 6 most common places for breast cancer to spread?
Bone Brain Lung Liver Adrenal Ovary
Describe the surgical options for breast cancer treatment
Mastectomy +/- reconstruction
Wide local excision - excision of the tumour ensuring a 1cm margin of macroscopically normal tissue is taken along with the malignancy.
Axillary clearance
Then give adjuvant radiotherapy
What are the indications for a mastectomy?
multifocal disease
high tumour:breast tissue ratio
disease recurrence
patient choice
risk-reducing cases
When would hormonal therapy be used to treat breast cancer?
malignant non-metastatic disease as an adjuvant therapy
What are the three drugs used for hormonal therapy when treating breast cancer?
Aromatase inhibitor (Letrozole) - prevents oestrogen production. Post menopausal women only
Tamoxifen - Oestrogen receptor antagonist. Pre and post menopausal women
Immunotherapy - Herceptin if HER2 positive, a monoclonal antibody
What are the positive and negatives of aromatase inhibitors?
+ves = lower risk of VTE
-ves = increased risk of osteoporosis
What are the positive and negatives of Tamoxifen?
+ves = Bone protection
-ves = Increased risk of VTE and endometrial cancer
What are the main types of lung cancer and where are they located?
Small Cell Lung Cancer (neuroendocrine) = Bronchial Mucosa
Non Small Cell Lung Cancer = Squamous, large cells, Adenocarcinomas
What are the non-modifiable risk factors for lung cancer?
Age >75
Male
Family history
What are the modifiable risk factors for lung cancer?
Lifestyle - Smoking!!! (adenocarcinoma)
Chronic lung disease - COPD, Pulmonary Fibrosis, TB
Radiotherapy
Toxin exposure - Asbestos (mesothelioma), Radon gas
What are the three types of NSCLC? How do they differ from SCLC?
Adenocarcinomas
Squamous Cell Carcinomas
Large cell carcinomas
Metastasise but DON’T produce hormones
SCLC met quickly, grow centrally and quickly
Which hormones can be produced by SCLC?
ACTH (Cushing’s)
ADH (SIADH)
(LEMS is also a thing but not hormones is instead antibodies)
Where does a mesothelioma arise from?
Lining of the pleura
What are the symptoms of a lung cancer?
Respiratory = cough, SOB +/- blood, recurrent chest infections, chest pain
Cancer = Weight loss, anorexia, lymphadenopathy, cachexia
NSCLC = ? hoarse voice +/- horner’s, ?hypercalcaemia
What are 4 signs of a lung cancer?
Clubbing, monophonic wheeze, consolidation, collapse
What are the bedside tests for a lung cancer?
Baseline obs
Sputum sample for cytology
PFT/peak flow
What are the blood tests for a lung cancer?
Carcinoembryonic Antigen for NSCLC
Baseline bloods otherwise (FBC, U&E, CRP, LFT, Bone profile)
What imaging should be done to investigate a lung cancer?
CXR - mass, mediastinal widening, hilar lymphadenopathy, lobar collapse
Biopsy - EBUS or bronchoscopy or CT guided
When should someone be referred for an urgent CXR (ie 2WW)?
> 40 + 2 red flags: cough, fatigue, SOB, chest pain, weight loss, anorexia OR ever smoked + 1 red flag
OR
> 40 + any of: recurrent chest infection, unexplained clubbing, thrombocytosis, chest signs, persistent supraclavicular lymphadenopathy
OR
> 40 and unexplained haemoptysis
What is a pancoast tumour?
A non-small cell lung cancer
Leads to compression of the brachiocephalic vein, sympathetic chain, recurrent laryngeal + phrenic nerves, subclavian artery
What are the non-modifiable risk factors for colorectal cancer?
Genetics - HNPCC (endometrial, ovarian, other GI), FAP (AD in APC gene), 1st degree relative <45 = familial colorectal cancer
Male
Age >70
What are the modifiable risk factors for colorectal cancer?
Lifestyle - smoking, obesity, alcohol
Diet - red meat, processed meats, low fibre
What is the pathophysiology behind colorectal cancer?
Polyp - Adenoma - Adenocarcinoma (most common)
Where are the most common locations for colorectal cancer?
Rectum
Sigmoid Colon
Rest of bowel
What is the clinical presentation of bowel cancer?
Blood in stools - fresh red = rectum, darker = partially digested so from higher +/- anaemia
Frequent change in bowel habit i.e. diarrhoea or constipation cycling v quickly
Tenesmus - feeling of incomplete emptying
Abdo/PR mass
How does the clinical presentation of bowel cancer change depending on the location of the tumour?
Left sided = pain
Right sided = bleeding +/- iron deficiency anaemia, weight loss, weakness
What are some trigger questions to ascertain late GI effects?
Woken at night?
Have to rush to toilet?
Loss of control?
Preventing from living a good life?
Which patients presenting with a suspcision of bowel cancer should be 2WWed?
> 40
PR bleeding
Change in bowel habit for >6 weeks
What are the blood tests to do to investigate bowel cancer?
FBC (anaemia)
CEA - not sensitive or specific
Tumour markers
What imaging should be done to investigate bowel cancer?
Colonoscopy + biopsy
MRI to see extent of primary tumour
CT for staging
What is the Duke’s Criteria?
A - tumour confined to bowel wall
B - tumour extends across bowel wall
C - Nodes at site of primary growth
D - Proximal nodes
What is the T staging of colorectal cancer?
T1 = submucosa T2 = through submucosa and across bowel wall T3 = into serosa T4 = through serosa into peritoneum
What is the surgical management of colorectal cancer?
Location dependent - anterior resection or hemicolectomy (R, L, Extended R)
When is radiotherapy appropriate for colorectal cancer?
Neoadjuvant
Palliative
When is chemotherapy appropriate for colorectal cancer?
Neoadjuvant
Adjuvant
Mets
Which other drugs could be used as medical management for colorectal cancer?
VEGF inhibitors
EGFR inhibitors
SE = dry skin, acne form rash, pruritus, nail changes
What is a melanoma? What are the 4 different types?
A malignant tumour arising from melanocytes
Superficial spreading (most common)
Nodular
Lentigo Maligna
Acral Lentigous
What are the non-modifiable risk factors for melanoma?
FHx
PHx
Increasing age
Fitzpatrick skin type 1 & 2 - Red/blonde hair, lots of moles/freckles, burns easily
What are the modifiable risk factors for melanoma?
Organ transplant recipient/immunosuppression
Lifestyle - tanning beds, sunburn esp if blisters in childhood
Give 4 differentials for a melanoma
Naevus
Pigmented Basal Cell Carcinoma
Sebhorrhoeic Keratosis
Dermatofibroma
How does a melanoma look on examination?
‘Ugly duckling’
A - asymmetrical (not a mirror image in all 4 quadrants)
B - Borders = irregular e.g. notched/scalloped
C - Colour Change +/- bleeding
D - Diameter >6 mm
E - Evolution - change in size, shape and elevation
How does the ABCDE of a melanoma help with diagnosis and management/
Goes into a weighted 7 point checklist
3+ points/ strong clinical concern = 2WW
2 points = Red flags, change in size, irregular border or colour
1 point = >7mm, inflammation, oozing or crusting
How should a melanoma be investigated?
Incisional biopsy if smaller, or excisional biopsy if larger (these are the deepest biopsies so can see between lesion and normal tissue) - diagnostic and potentially curative
Shave biopsy (less invasive but can’t see if tumour has invaded)
Punch biopsy (dermis)
What is the management of a melanoma?
Prevention - hat, sunscreen, protective clothing, regular skin checks
Early = complete excision, wide margin surgery, sentinel lymph node biopsy
Late = chemo or radio
What is Bowen’s disease?
A squamous cell carcinoma in situ (abnormal growth of keratinocytes)
BM not invaded
Red, scaly patch that is slow growing and usually in sun exposed areas
What is the management of Bowen’s disease?
Biopsy > breslow thickness
What is actinic keratosis?
Thickened skin due to sunlight exposure that can be itchy
Rough and sandpapery patch that has a variable colour and diameter and can become scaly or warty
What is the management of Bowen’s disease and actinic keratosis?
Chemo cream - 5-fluorouracil (gets worse before better)
Immuno cream - imiquimod
Curettage and electrocautery
Photodynamic therapy
Surgery
Cryotherapy
(can watch and wait if actinic keratosis is small)
What are the non-modifiable risk factors for prostate cancer?
Age 60-80
Black and asian ethnicity
FHx (1st degree relative), BRCA2 and HNPCC
What are the modifiable risk factors for prostate cancer?
Lifestyle - high red meat and low veg, smoking
High pesticide exposure
What are 4 differentials for prostate mass?
Malignancy
BPH/Normal variation
Calficiation
Cyst
Which zones of the prostate are most likely to become an adenocarcinoma?
1) Peripheral Zone
2) Transitional Zone surrounding prostatic urethra (more likely to be BPH)
3) Central zone surrounding ejaculatory duct
What is the clinical presentation of prostate cancer?
Early = asymptomatic
Late = urinary obstruction = frequency, hesitancy, urgency, post mic dribble, incomplete emptying
Increased UTIs, haematuria, haematospermia
Mets = bone pain +/- SC compression
Where is prostate cancer most likely to metastasise too?
Direct = bladder, seminal vesicles
Lymphatic = Inguinal
Haematogenous = Bone, lung, liver
Which blood tests should be done to investigate prostate cancer?
PSA, calcium
FBC, U&E, LFTs
What imaging should be done to investigate prostate cancer?
BONE scan
CT
MRI
BIOPSY + TRUS = DIAGNOSTIC
Other than prostate cancer, what else can cause a raised PSA? And alternatively, what can cause a low PSA?
UTI BPH Ejaculation DRE Prostatitis Cystoscopy
Low = NSAIDs
What is the Gleason score?
ranges from 1-5 and describes how much the cancer from a biopsy looks like healthy tissue (lower score) or abnormal tissue (higher score)
What is the criteria for low risk prostate cancer?
PSA <10 AND
Gleason 6+ AND
Can’t feel prostate on exam
What is the criteria for intermediate risk prostate cancer?
PSA 10-20 OR
Gleason 7 OR
T2b T2c
What is the criteria for high risk prostate cancer?
PSA >20 OR
Gleason 8-10 OR
T3/T4
What is the management of localised prostate cancer?
Active surveillance/watchful waiting
Radical prostatectomy
External beam +/- radiotherapy +/- brachytherapy +/- hormone
Have to include informed choice
What is the different between watchful waiting and active surveillance?
WW = aim is symptom control, fewer tests and less close monitoring
AS = Aim is curative treatment if disease progresses. Closer monitoring and regular tests and exams
What is brachytherapy?
Place a radioactive source next to the tumour to emit radiation
Kill tumour cells
Only for solid, local, small tumours that can be reached by surgery
What is the management of intermediate risk prostate cancer?
Radical prostatectomy
External beal radiotherapy + brachytherapy +/- hormonal therapy
What are the disadvantages of a radical prostatectomy?
Regrowth
erectile dysfunction
urinary incontinence
infertility
Bowel problems
What are the treatment options for locally advanced prostate cancer?
Hormonal therapy - GnRH analogue (Goserlin, Leuprotein)
Chemo
What is the MOA of Goserlin?
Same as GnRH - Increases LH and FSH
Get an initial flare of sex hormone so symptoms can worsen
Then desensitises receptors so LH and FSH are reduced
What are the 5 oncological emergencies?
Metabolic = hypercalcaemia
Haematological = Neutropenic sepsis
Treatment related = Tumour lysis syndrome
Structural = Superior Vena Cava Obstruction, Spinal Cord Compression
Define tumour lysis syndrome
A combination of metabolic and electrolyte abnormalities that occurs in patients with cancer, usually after beginning a cytotoxic treatment regime (chemo)
What is the pathophysiology of tumour lysis syndrome?
Rapid destruction of tumour cells = rapid release of intracellular contents leading to:
Hyperuricaemia, hyperkalaemia, hyperphosphataemia
Hypocalcaemia
What are the non-modifiable risk factors for tumour lysis syndrome?
Haem malignancy (NHL, ALL)
High tumour burden
Pre-existing renal compromise
What are the modifiable risk factors for tumour lysis syndrome?
Recent chemo (usually within first 48hrs but have to monitor for first week)
Dehydration
What are the symptoms of tumour lysis syndrome?
GI - N&V, diarrhoea, anorexia
Neuro - parasthesia and serious tetany
MSK - muscle cramps
Lethargy
What are the signs of tumour lysis syndrome?
HTN
Hypotension
Arrhythmias
What are the bedside tests to manage tumour lysis syndrome?
Baseline obs - need an ECG to monitor for arrhytmias
What are the blood tests to manage tumour lysis syndrome?
Diagnosis = Biochemistry - serum uric acid, phosphate, potassium, calcium. LDH, FBC
What is the conservative management of tumour lysis syndrome?
Low risk = monitor
Med - high risk = IV fluids prior to chemo/intensive fluid resus if acute syndrome
What is the medical management of tumour lysis syndrome?
Acute = Rasbiscurase or Allopurinol
Phosphate binder
Correct electrolyte imbalance
What is the MOA of Rasbiscurase?
Converts uric acid to allantoin which is easier to excrete than uric acid
Only acts on current UA so not prophylactic
What is the MOA of Allopurinol?
Xanthine Oxidase inhibitor
Prevents uric acid formation so can be used prophylactically
What is a fibroadenoma?
Common in women under the age of 30 years
Often described as ‘breast mice’ due as they are discrete, non-tender, highly mobile lumps
What is Fibroadenosis?
fibrocystic disease, benign mammary dysplasia
Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
What is Paget’s disease of the breast?
intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the nipple/areola
What is mammary duct ectasia?
Dilatation of the large breast ducts
Most common around the menopause
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’
What is a duct papilloma?
Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
May present with blood stained discharge
What is fat necrosis relating to the breast?
More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is always warranted
What is the purpose of cancer screening?
Detection of cancers in otherwise healthy people as early as possible when the chance of curing is the highest
Describe the cervical cancer screening programme
Women aged 25-49 are invited every 3 years
Women aged 50-64 are invited every 5 years
If they are registered with a GP
Tests for HPV and if they are high risk then they are tested for dyskaryosis and if they are low risk they return to the screening programme
Can’t do it if you’re on your period
Describe the breast cancer screening programme (in England)
Women (who are registered with a GP) aged 50-70 are invited for a mammogram + UUS +/- biopsy (triple assessment) every 4 years
Describe the screening for colon cancer in England
Everyone aged 60-74 is sent a home testing kit every 2 years
Send off a poo sample for faecal immunochemical testing
+/- bowel scope screening at 55 (only available in some areas)
What counts as a ‘higher risk woman’ who are invited for breast screening earlier?
Strong FHx =
2+ close relatives on the same side have had cancer
Cancer developed before 50
1 Relative has a known gene fault (BRCA or TP53)
Give 2 positives of screening for cancer
Reduces incidence of cancer and advanced disease
Reduces mortality as more likely to be treated
Give 5 negatives of screening for cancer
Lead time bias - early diagnosis gives false impression that people are living longer (but there’s actually no difference)
Length time bias - overestimation of survival due to relative excess of cases that are slowly progressing asymptomatically
Detection not prevention
Over diagnosis = over treatment?
False positives
Define sensitivity
% of true positives
Good at recognising disease/people who have the disease and does not miss those who are ill
Define specificity
% of true negatives
Good at recognising when the disease is not present
Give 4 examples of hereditary/genetically linked cancers
BRCA1 and BRCA2 - breast, ovarian and prostate cancer
HNPCC - Autosomal dominant for colorectal and endometrial (and ovarian, stomach etc)
FAP - colorectal
MEN1 - Thyroid, parathyroid, pituitary, bowel
What are the 6 hallmarks of cancer?
- Self sufficiency/growth factor independence
- Insensitive to anti-growth signals
- Avoidance of apoptosis
- Angiogenesis
- No limit to cell division
- Invasion and metastases
What is tumour burden?
The ability of malignant cells to spread to distant sites
What are the 4 most common sites of mets?
Lung
Bone
Liver
Brain
Which cancers most commonly metastasise to the bone?
Breast Bronchus Kidney Thyroid prostate
What is adjuvant and neoadjuvant in terms of treatment?
Adjuvant = eliminates micrometastases and is given in addition to the primary treatment
Neoadjuvant = given before metastasis and in advance to the primary treatment
Define neutropenic sepsis
Neutrophil levels <0.5, temperature >38, +/- other signs of sepsis
Recent chemo (in past 7-10 days)
Why does neutropenic sepsis occur?
Patient is neutropenic due to recent chemo (kills rapidly dividing cells), have a haem cancer or radiotherapy
then get an infection/more likely to get an infection anyway
How does neutropenic sepsis present?
Really unwell = get sepsis signs, high NEWS score
Post chemo
?have an infection site e.g. picc/hickmann line, skin wounds, mouth ulcer
What is the management of neutropenic sepsis?
Activate sepsis 6
Give empirical abx (tazocin) within the hour
Supportive care - A-E, escalation, GCSF if very profound
What is superior vena cava obstruction?
Compression of the superior vena cava due to malignancy. Usually lung (NSCLC), NH Lymphoma or IVC thrombosis
Quite rare
What are the early and late signs of SVCO?
Early = puffy neck and face, non-collapsible veins
Late = distended neck and chest wall veins, swollen neck, face and arms, drowsy
How is SVCO managed?
Conservative - sit up and give high flow o2
Medical - steroids, ?chemo ?radio
Surgical - SVC stent (rapid symptom relief but doesn’t treat cause)
Define malignant spinal cord compression
Spinal cord/cauda equina compression by direct pressure (cauda equine if below L2)
+/- induction of vertebral collapse/instability by metastatic spread or direct extension of malignancy that may lead to neurodisability
Most common in breast, lung, prostate cancer, myeloma
What is the clinical presentation of malignant spinal cord compression?
Initial = oedema, venous compression, demyelination (reversible)
Later = vascular and cord injury = damage = saddle anaesthesia, loss of urinary and bowel continence OR retention and constipation, motor weakness
BACK PAIN - worse when lying, radicular pain
What investigations should you do for hypercalcaemia of malignancy?
Bed = urinalysis
Bloods - serum calcium and bone profile (and baseline bloods)
Imaging - Bone profile/scan, XR to areas of pain for pathological fractures, CT for staging
What is the management of hypercalcaemia of malignancy?
Hyperhydration - 3l/hr ish
Bisphosphonates (zolendronic acid/pamidronate)
Manage nausea - haloperidol
What are the most likely causative organisms of neutropenic sepsis?
Gram +ve = staph aureus/epidermidis, MRSA, enterococcus
Gram -ve = pseudomonas
What medication can be given as neutropenic sepsis prophylaxis?
Fluoroquinolone
Define paraneoplastic syndrome
A collection of symptoms that are a consequence of a signalling or immune response and not a direct effect of the cancer itself
Cushings, SIADH, LEMS,
What is the management of malignant spinal cord compression?
Analgesia
Steroids - PO Dexamethasone
Anticoagulation
Surgery/radiotherapy to remove/shrink
Which tumours may secrete ACTH?
Pituitary adenoma
Ectopic = Small Cell lung cancer, thyroid cancer
Which tumours may secrete ADH?
Small cell lung cancer
Pancreatic cancer
Head and neck SCC
Lymphoma
Which tumours may secrete PTHrP?
SCC, Breast, Renal, Melanoma, Prostate
Which tumours may secrete calcitriol?
Lymphoma
What is a side effect of bleomycin?
Pulmonary Fibrosis
What is a side effect of Doxorubicin?
Cardiotoxicity/myopathy
What are 3 side effects of Methotrexate?
Myelosuppression
Mucositis
Liver and Lung fibrosis
What is a side effect of vincristine?
Peripheral neuropathy
