Cancer Care - Big 5 Cancers Flashcards
Lung Cancer
Prevalence and Prognosis
Risk Factors
Common Presentations
Referral Criteria
1.) Prevalence and Prognosis
- 2nd most common type of cancer overall and most common cancer leading to death, more prevalent in low socio-economic groups due to ↑smoking rates
- no screening program in the UK
- poor prognosis: 5% 5yr survival rate, majority present already at stage 3/4 disease
2.) Risk Factors
- smoking is the most significant cause of lung cancer
- advanced age, family history, diet
- exposure to carcinogens e.g. asbestos, radon and other occupational carcinogens such as chromium, nickel, and arsenic
- interstitial lung disease e.g. IPF
3.) Common Presentations
- chest signs: persistent cough (>3wks), haemoptysis, dyspnoea, wheeze, chest pain, recurrent pneumonia
- fatigue, poor appetite, weight loss
- hoarseness of voice, signs of SVCO syndrome
- examination: fixed monophonic wheeze, clubbing, lymphadenopathy (supraclavicular, cervical)
- raised platelets can be a sign of lung cancer
4.) Referral Criteria - 2 types
- 2WW CXR: >40 w/ 2+ (1 if ever smoked) of cough, SOB, chest pain, fatigue, weight loss, appetite loss
- 2WW referral: >40 w/ unexplained haemoptysis or CXR findings suggestive of lung cancer
Types of Lung Cancer
Small Cell Lung Cancer (SCLC)
Non-Small Cell Carcinoma (NSCLC)
Squamous Cell Carcinoma (SCC)
Adenocarcinoma
Other Non-Small Cell Lung Cancers
Mesothelioma
1.) Small Cell Lung Cancer (15%) - very aggressive so often caught in late-stage (already metastasised)
- commonly spreads to the bone, brain, and liver
- often caused by smoking, more common in females
- cells contain neurosecretory granules that can release neuroendocrine hormones –> paraneoplastic syndromes
2.) Non-Small Cell Carcinoma (85%) - less invasive so less likely to metastasize, grows more in the peripheries whilst SCLC grow more centrally
3.) Adenocarcinoma - 40% - NSCLC
- glandular cells secreting mucin/mucous
- most common type in non-smokers and most common type of lung cancer in general
- prognosis is 50% survival at 5 years
4.) Squamous Cell Carcinoma (30%) - NSCLC
- affects the cells lining the airways (central disease)
- most associated with cavitating lesions on a CXR
- highest link to smoking of all NSCLCs
5.) Other Non-Small Cell Lung Cancers
- large cell carcinoma (5%): very large and round cells
- carcinoid tumours (5%): tumour of neuroendocrine cells, has no link to smoking
6.) Mesothelioma - malignancy affecting mesothelial cells of the pleura caused by asbestos exposure
- not a form of lung cancer
- can be up to 45yrs between exposure to asbestos
- very poor prognosis, chemo is essentially palliative
Extrapulmonary Manifestations of Lung Cancer
Superior Vena Cava Obstruction
Nerve Palsies
Paraneoplastic Syndromes of SCLC
Paraneoplastic Syndromes of Non-SCLC
1.) SVC Obstruction - compression of the tumour on the superior vena cava, this is a oncological emergency
- sx: SOB, facial swelling, headache (worse in morning), distended neck and upper chest veins
- Pemberton’s sign: raising the hands over the head causes facial congestion and cyanosis
- Mx: endovascular stenting for symptom relief, radical chemo/radiotherapy can be used instead
2.) Nerve Palsies - compression of nerves causes:
- recurrent laryngeal nerve: hoarse voice
- phrenic nerve: elevated/weak diaphragm –> SOB
- Horner’s syndrome: Pancoast tumour (tumour in the pulmonary apex) presses on sympathetic ganglion
- brachial plexus: arm and hand weakness/pain
- Pancoast tumour is a SCC often found in the right apex of the lung that can cause all of the above as well as some paraneoplastic syndromes as well
3.) Paraneoplastic Syndromes of SCLC
- SIADH: ectopic ADH, presents w/ hyponatraemia
- Cushing’s syndrome: ectopic ACTH
- Lambert-Eaton Syndrome: antibodies against presynaptic VGCa channels in PNS leads to myasthenia gravis type sx in the lower limbs (rather than the face)
- limbic encephalitis: (anti-Hu) antibodies to tissues in the brain by SCLC, causes memory impairment, hallucinations, confusion and seizures
4.) Paraneoplastic Syndromes of Non-SCLC
- squamous cell carcinoma: hypercalcemia (PTHrP), hyperthyroidism (ectopic TSH), finger clubbing, hypertrophic pulmonary osteoarthropathy (HPOA)
- adenocarcinoma: gynaecomastia (↑ß-hCG /oestro), hypertrophic pulmonary osteoarthropathy (HPOA)
Investigations in Lung Cancer
Initial Investigations
Biopsy
Staging Imaging
TNM Staging
1.) Initial Investigations
- CXR: hilar enlargement, peripheral opacity, pleural effusion (often unilateral), collapse, cavitating lesions (seen in SCC), however CXR can be normal in up to 10% of patients w/ lung cancer
- bloods: FBC (↑platelets)
- WHO performance status: baseline level of fitness:
0: fully active, 1: light activity, 2: all self-care, 3: limited self-care, 4: bed-bound, 5: dead
2.) Biopsy - required for histological diagnosis
- sputum cytology (poor sensitivity, not really done)
- endobronchial ultrasound (EBUS): samples central lymph nodes so is suitable for central lesions but it can also sample paratracheal or peribronchial tumours
- bronchoscopy: samples primary tumour itself (bronchial washing can be used for flow cytometry)
- CT-guided biopsy: used for peripheral tumours (10% risk of a pneumothorax)
- thoracentesis (pleural fluid aspiration) if pleural effusion is present
- thoracoscopy: imaging of the pleura, used for mesotheliomas or if pleural effusion is present
3.) Staging Imaging
- CT-CAP w/ contrast (gold): assess TNM staging, lymph node involvement and presence of metastases
- PET-CT: only used in Non-SCLC to establish eligibility for curative treatment, has better sensitivity for local and distant mets spread in Non-SCLC
4.) TNM Staging - helps determine treatment options
- all metastases are bad, suggests stage 4 lung cancer
- T >5cm is bad as it cannot be surgically resected
- <5cm w/o lymph node involvement is curable
- radiotherapy is only offered for peripheral cancers as it can damage surrounding structures
Management of Lung Cancer
Non-Small Cell Lung Cancer
Lung Cancer Surgery
Small Cell Lung Cancer
1.) Non-Small Cell Lung Cancer
- surgery: only suitable for 20%, contraindications are: any metastases, vocal cord paralysis, SVCO, malignant pleural effusion, a tumour near the hilum, FEV1 <1.5L
- radiotherapy only (can be curative or palliative) as NSCLC has a poor response to chemotherapy
- immunotherapy: pembrolizumab and nivolumab target PDL-1 ligands in some types of Non-SCLC
2.) Lung Cancer Surgery
- removal options include segmentectomy or wedge resection (a portion of one lobe), lobectomy (entire lobe), pneumonectomy (removing an entire lung)
- types: video-assisted thoracoscopic surgery (keyhole), and robotic, thoracotomy (open surgery)
- thoracotomy incisions: posterolateral (most common), anterolateral, axillary
- chest drain is left in after thoracic surgery to allow drainage of air and fluid to exit the thoracic cavity and the lungs to expand
3.) Small Cell Lung Cancer
- usually metastatic disease by the time of diagnosis
- most patients with limited disease receive a combination of chemotherapy and radiotherapy
- extensive disease: palliative chemotherapy
- patients with very early-stage disease (T1-2a, N0, M0) are now considered for surgery
Breast Cancer
Risk Factors
Clinical Features
Investigations
Breast Cancer Screening
Prognosis
1.) Risk Factors
- ↑age, BRCA1/2 mutations (chromosome 17), FH
- ↑exposure to unopposed oestrogen: early menarche, late menopause, nulliparous, OCPs/HRT
- benign breast disease, obesity (very strong risk factor), alcohol, geographic (developed countries)
2.) Clinical Features
- lump: firm, fixed, single mass w/ craggy surfaces
- asymmetry, swelling, mastalgia, abnormal discharge (clear/bloody), nipple retraction, lymphadenopathy
- skin changes: peau d’orange, Paget’s-like changes
- differentials:
3.) Investigations - triple assessment (‘one stop’ clinic (2WW) for suspicious breast lesions, referral criteria:
- >30 w/ an unexplained breast lump
- >50 w/ discharge, retraction, or concerning nipple changes in only one nipple
- triple assessment: 1.) history and examination
- 2.) imaging: mammogram (X-Ray) or USS in <35s (due to denser breast tissue)
- 3.) histology: core biopsy >FNA (provides full histology)
4.) Breast Cancer Screening - offered to 50-70yr olds
- women are offered a mammogram every 3 years
- self-referrals are available after the age of 70
- breast cancer patients that undergo treatment will receive follow-up mammograms every year for 5 years and will then return to screening
- can offer screening at a younger age for women at increased risk of breast cancer due to their FH:
- one close relative with breast cancer at <40 OR bilateral breast cancer OR male
- two or more close relatives with breast cancer
- Ashkenazi Jewish ancestry
5.) Prognosis - Nottingham prognostic index (NPI)
- calculates using size, nodal status and grade
- grading is using Bloom-Richardson classification
- poor prognosis: large size, high grade, lymph node spread, <35 at diagnosis, ER-ve, Her2+ve, BRCA 1/2+ve,
Types of Breast Cancer
Ductal Carcinoma
Lobular Carcinoma
Paget’s Disease
1.) Ductal Carcinoma - malignancy of the ductal tissue
- most common type of breast carcinoma
- in-situ is contained within the basement membrane
- in-situ (DCIS) is treated w/ complete wide excision (mastectomy if widespread or multi-focal)
- invasive (IDC) is most common breast cancer and can be further classified into 4 different types all showing distinct growth patterns
2.) Lobular Carcinoma - malignancy of secretory lobules (in-situ contained within basement membrane)
- LCIS usually before menopause and ↑risk -> invasive
- low grade LCIS monitored rather than excised
- ILC harder to detect (presents asymptomatically)
3.) Paget’s Disease of Nipple - underlying neoplasm
- painful and sensitive, itching or redness in nipple +/- areola w/ flaking and thickening skin on/around nipple
- mistaken for dermatitis or eczema (spares nipple)
- surgical removal of nipple and areola often needed
Management of Breast Cancer
Surgery
Supportive Surgical Procedures
Hormonal Therapy
Chemo/Radio/Immunotherapy
1.) Surgery - offered to most patients except frail, elderly patients with metastatic disease
- mastectomy indications: multifocal or central tumours, large tumour in small breasts, DCIS >4cm, risk reduction in those with high risk of developing breast cancer
- wide local excision indications: solitary or peripheral tumours, small tumour in large breast, DCIS <4cm
- mastectomy complications: breast swelling, soreness, hardness, phantom breast pain, seroma, depression
2.) Supportive Surgical Procedures
- sentinel lymph node biopsy: assess nodal burden in those w/ positive pre-op axillary node ultrasound
- axillary node clearance: for positive sentinel lymph node biopsy or clinically palpable lymphadenopathy, can lead to lymphoedema and functional arm impairment
- cosmetic breast reconstruction: offered to all women
3.) Hormonal Therapy - used in ER+ve tumours
- used as adjuvant or prevention in high-risk women
- Tamoxifen is a SERM (blocks ER in the breast) which is used in pre-menopausal women, but there’s ↑risk of VTE and endometrial cancer (stimulates ER in endo…)
- Anastrozole is an aromatase inhibitor (↓oestrogen) used in post-menopausal women because it inhibits adrenally produced androgens (↑risk of osteoporosis)
4.) Chemo/Radio/Immunotherapy
- adjuvant radiotherapy routinely performed to reduce recurrence risk
- neoadjuvant or adjuvant chemotherapy: dependent on size, grade, node, receptors menopausal status
- immunotherapy: trastuzumab (Herceptin) can be used in HER2+ve tumours (contraindicated in heart disorders)
Prostate Cancer
Pathophysiology
Clinical Features
PSA Testing
Initial Investigations
1.) Pathophysiology
- majority are adenocarcinomas (95%), arise from the peripheral zone (75%), and are often multifocal
- acinar adenocarcinoma: originates in glandular cells lining the prostate gland (most common)
- ductal adenocarcinoma: originates in cells that line the ducts of the prostate gland (metastasise faster)
- risk factors: ↑age, obesity, afro-Caribbean, FH, BRCA2/1 gene,
3.) Clinical Features
- localised prostate cancer is often asymptomatic as it’s often in the periphery so doesn’t cause obstructive sx
- LUTS, dysuria, haematuria, haematospermia,
- incontinence, pelvic/suprapubic pain, rectal tenesmus
- lethargy, weight loss, ↓appetite, bone pain (mets)
- DRE: asymmetry, nodularity, fixed irregular mass, with loss of median sulcus
4.) PSA Testing - PSA is an enzyme produced by normal and malignant prostate epithelial cells
- normal level: <3 (50-59yrs), <4 (60-69), <5 (70+)
- has poor sensitivity and specificity as it can also be raised in: BPH, prostatitis, UTI, ejaculation, vigorous exercise, retention, urinary tract instrumentation
- PSA test should be delayed: >1mth after UTI tx, >48hrs after ejaculation, >48hrs after vigorous exercise
4.) Initial Investigations - suspected cancer is based on symptoms, abnormal DRE, ↑PSA, FH + other risk factors
- 1°multiparametric MRI - Likert score of 3+/5 suggests ↑risk of prostate cancer so a biopsy is required
- 2°TRUS biopsy: invasive procedure w/ complications inc pain, fever, sepsis, bleeding/haematuria
- biopsy produces a Gleason score
Management of Prostate Cancer
Staging of Prostate Cancer
Low Risk Disease
Intermediate/High Risk Disease
Metastatic Disease
Castrate-Resistant Disease
1.) Staging of Prostate Cancer - risk stratification is based on the PSA, Gleason score, and the tumour size
- Gleason score: 2-10, 2 grades on a scale of 1-5, most dominant grade written first (4+3 is worse than 3+4)
- imaging: staging CT (CT-CAP) and PET scan for intermediate or high risk disease
- T1/T2: localised prostate cancer
- T3/T4: locally advanced prostate cancer
2.) Low Risk Disease - PSA<10, Gleason <6, T1-T2a
- active surveillance: assessing for progression with 3mthly PSA, 6-12mthly DRE, re-biopsy 1-3 yr intervals, radical treatments if evidence of disease progression
- watchful waiting: sx guided, intent is not curative (reserved for older patients with ↓life expectancy)
3.) Intermediate/High Risk Disease: intermediate (PSA 10-20, G7, T2b), high (PSA >20, G8-10, T2c+)
- open/lap/robotic radical prostatectomy: side effects inc erectile dysfunction, stress incontinence
- external-beam radiotherapy and brachytherapy can be curative for localised prostate cancer
- intermediate can have surveillance or treatment
4.) Metastatic Disease - anti-androgen hormone ther…
- synthetic GnRH agonist (Goserelin) or antagonists
- bicalutamide: non-steroidal, block androgen receptor
- abiraterone: androgen synthesis inhibitor
- bilateral orchidectomy: rapidly ↓testosterone levels
- chemotherapy: docetaxel, cabazitaxel (if relapsed)
5.) Castrate-Resistant - hormone-relapsed disease
- further chemotherapy, corticosteroids
Colorectal Cancer
Pathophysiology
Referral Criteria/Clinical Features
Colorectal Cancer Screening
Investigations
1.) Pathophysiology - 3rd most common type of cancer
- locations: rectal (40%), sigmoid (30%), descending (5%), transverse (10%), ascending and caecum (15%)
- types: sporadic (95%), HNPCC (5%), FAP (<1%)
- HNPCC (Lynch syndrome): autosomal dominant, highly aggressive, ↑risk of other cancers (endometrial)
- FAP: autosomal dominant, mutation of APC gene (TSG) –> adenomatous growth (polyps) –> carcinoma
- other risk factors: ↑age, IBD, low fibre, smoking, alcohol, meat
2.) Referral Criteria - urgent 2WW to colorectal services for a colonoscopy (and gastroscopy for ID-anaemia)
- >60 w/ change in bowel habit OR ID-anaemia
- >50 w/ unexplained rectal bleeding
- >40 w/ abdominal pain + unexplained weight loss
- ‘consider’ 2WW: unexplained mass (abdominal rectal, or anal) or anal ulceration, <50 w/ rectal bleeding + one of: abdominal pain, change in bowel habit, weight loss, iron deficiency anaemia
3.) Colorectal Cancer Screening - 60-74 every 2 years
- faecal immunochemistry test (FIT): type of faecal occult blood (FOB) test that detects and quantifies human haemoglobin in a stool sample
- patient is informed if the test is normal or abnormal and is then offered a colonoscopy if needed
4.) Investigations
- bloods: FBC, carcinoembryonic antigen (CEA)
- gold: colonoscopy (w/ biopsy) (if contraindicated: flexible sigmoidoscopy or CT colonography)
- TNM classification: T1 involves submucosa, T2 involves muscularis propria, T3 involves (sub)serosa, T4a is spread through serosa, T4b is other tissues, N1 is spread to 1-3 nodes, N2 is >3nodes, M1 is mets
- staging: stage 1 is T1/T2, stage 2 is T3/T4, stage 3 is N1/2, stage 4 is M1
- staging CT-CAP for mets and other cancers
- rectal cancer: MRI rectum, endo-anal ultrasound
Surgical Management of Colorectal Cancer
Surgical Resection
Surgical Operations
Other Management
1.) Surgical Resection - most common
- can be potentially curative or used palliatively to reduce the tumour size and improve symptoms
- laparoscopic or robotic surgery is preferred
- end-to-end anastomosis OR a stoma is created
2.) Surgical Operations
- 1.)anterior resection: high rectal tumours (>5cm from anus), loop ileostomy to protect anastomosis
- 2.) abdominoperineal (AP) Resection - low rectal tumour, remove distal colon, rectum, and anal sphincters, resulting in a permanent colostomy
- 3.) sigmoid colectomy: sigmoid colon tumours, the IMA is fully dissected out w/ the tumour
- 4.) left hemicolectomy: descending colon tumours, remove left middle colic vessels, left colic vessels
- 5.) right hemicolectomy: caecal or ascending colon extended right hemicolectomy for transverse colon, remove ileocolic, right colic and right branch of the middle colic vessels
3.) Other Management
- adjuvant chemotherapy (5FU and oxaliplatin) for those with risk factors for disease recurrence: e.g. stage 3+
- neoadjuvant radiotherapy for rectal cancer
- palliative care: endoluminal stenting or stoma formation for bowel obstruction
