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Cancer conditions Flashcards

c.3109C>T_p.Gln1037X BRCA2 change www.royalmarsden.nhs.uk/our-consultants-units-and-wards/clinical-units/cancer-genetics-unit A beginners guide to brca1/2

1
Q

Bladder cancer

  1. Definition
  2. Explain aetiology/risk factors
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Malignancy of bladder cells - most transitional cell carcinomas but rarely may be squamous cell carcinomas associated with chronic inflammation
  2. Unknown; RF = smoking, dye stuffs, cyclophosphamide treatment, pelvic irradiation, chronic UTIs, schistosomiasis
  3. 2% of cancers, 2-3x more common in males with peak incidence = 50-70yrs
  4. Painless microscopic haematuria, irritative/storage syx (freq, urgency, nocturia), recurrent UTIs, and rarely, ureteral obstruction
  5. No sx often, bimanual examination may be part of disease staging
  6. Cytoscopy for visualisation, biopsy or removal, USS, IV radiography, CT/MRI for staging
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2
Q

Breast cancer

  1. Definition
  2. Explain aetiology/risk factors
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Malignancy of breast tissue - invasive ductal carcinoma
  2. Genetics (BRCA-1/BRCA-2), environmental factors, RF = age, prolonged exposure to oestrogen (nulliparity - not having kids, early menarche, late menopause, obesity, COCP, HRT), FHx of breast cancer
  3. Most common cancer in women, peak at 40-70
  4. Breast lump (painless), changes in breat shape, nipple discharge (bloody?), axillary lump, syx of malignancy = weight loss, bone pain, paraneoplastic syndrome
  5. Breat lump (firm, irregular, fixed to surrounding structures), peau d’orange, skin tethering, fixed to chest wall, skin ulceration, nipple inversion, Paget’s disease of the nipple (eczema-like hardening of the nipple - ductal carcinoma in situ infiltrating the nipple
  6. triple assessment = clinical assessment, imaging = US (<35) OR mammogram (>35), tissue diagnosis = fine needle aspiration OR core biopsy; Sentinel LN biopsy (radioactive tracer injected into tumour, ID sentinel LN and then biopsy node for spread); staging = CXR, liver US, CT (brain/thorax); bloods = FBC, U&Es, Ca, bone profile, LFTs, ESR
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3
Q

Cholangiocarcinoma

  1. Definition
  2. Explain aetiology/risk factors
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Primary adenocarcinoma of the biliary tree
  2. Unknown; RF = UC + 1ry sclerosing cholangitis, choledochal cyst, caroli disease, parasitic infection of biliary tract
  3. Very rare; more common in developing world due to increased prevalence of parasitic infections
  4. Obstructive jaundice syx = yellow sclera, pale stools, dark urine, pruritus; abdo pain/fullness, systemic syx of malignancy = weight loss, malaise, anorexia
  5. Jaundice, palpable gallbladder (courvoisier’s law - jaundice + palpable gallbladder (non-tender) is unlikely to be gallstones), epigastric/RUQ mass, may be hepatomegaly
  6. Bloods = FBc, U+Es, LFTs (high ALP and GGT), clotting screen, tumour markers (CA19-9 is marker of pancreatic cancer and cholangiocarcinoma); endoscopy; USS, CT, MRI, Bone scan for staging
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4
Q

CNS tumours

  1. Definition
  2. Explain aetiology/risk factors
  3. Epidemiology
  4. Presenting Syx and Sx
  5. Investigations
A
  1. Tumours of CNS -> high grade = tumour grows rapidly and aggressively: glioma and glioblastoma multiforme, primary cerebral lymphoma, medulloblastoma; VS Low grade = tumour grows slowly and may/not be successfully treated: menangioma, acoustic neuroma, neurofibroma, pit tumour, craniopharyngeoma, pineal tumour.
    1. Brain metastases arise commonly from = lung, breast, stomach, prostate, thyroid, colorectal
  2. Arise from any of the cells in the CNS, RF = ionising radiation, immunosuppression, inherited syndromes (neurofibromatosis, tuberous sclerosis)
  3. AIDS pts have an increased risk of developing CNS tumours, develop at any age, more common between 50-70
  4. Presentation depends on size and location of tumour; headache worse in morning and when lying down, nausea and vomiting, seizures, progressive focal neurological deficits, cognitive and behavioural syx, papilloedema
  5. Bloods = CRP/ESR to eliminate others (temporal arteritis), CT/MRI, biopsy and tumour removal, Magnetic resonance angiography - define changing size and blood supply of the tumour; PET
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5
Q

Colorectal cancer

  1. Definition
  2. Explain aetiology/risk factors
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Malignant adenocarcinoma of large bowel, 60% rectum and sigmoid, 30% desc colon, 10% rest of colon
  2. Environmental and genetic, sequence of genetic changes from normal bowel to cancer; RF = western diet, colorectal polyps, previous colorectal cancer, FHx, IBD
  3. 2nd most common cause of cancer death in west; 60-65yrs age of dx
  4. 20% will present as emergency with pain and distention due to large bowel obstruction and haemorrhage/peritonitis due to perf. Depends on size and location:
    1. Left colon and rectum = change in bowel habit, rectal bleeding (blood/mucus with stools), tenesmus
    2. Right colon = later presentation, anaemia syx (lethargy), weight loss, non specific malaise, lower abdo pain (rare)
  5. Anaemia, abdo mass, if metastatic = hepatomegaly, ascites; low lying rectal may be felt on DRE
  6. Bloods = FBC (anaemia), LFTs, tumour markers (CEA); Stools FOBT as screening test; endoscopy can be used to biopsy tumour; double contrast barium enema (apple core strictures), contrast CT for Duke’s staging
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6
Q

Gastric cancer

  1. Definition
  2. Explain aetiology/risk factors
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Cancer of stomach, usually adenocarcinoma; rarer forms = lymphoma, leiomyosarcoma, stromal tumours
  2. Unknown, env and genetics; RF = smoked and processed foods, smoking, alcohol, H. pylori infection, atrophic gastritis, pernicious anaemia, partial gastrectomy, gastric polyps
  3. Common cause of cancer death; highest incidence in Japan, 6th most common in UK; >50yrs
  4. Asyx early, early satiety, epigastric discomfort, systemic syx = weight loss, anorexia, n/v; dysphagia, syx of metastases (ascites and jaundice)
  5. Epigastric mass, abdo tenderness, ascites, sx of anaemia, virchow’s node, sister Mary Joseph’s nodule (metastatic node on umbilicus), Krukenberg’s tumour (ovarian mets)
  6. Upper GI endoscopy; bloods = FBC (anaemia), LFTs; CT/MRI for staging, endoscopic USS - assess depth of gastric invasion and LN involvment
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7
Q

Hepatocellular carcinoma

  1. Definition
  2. Explain aetiology/risk factors
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Primary malignancy of liver parenchyma
  2. Chronic liver damage (alcoholic liver disease, hep c, autoimmune disease), metabolic disease (haemochromatosis), aflatoxins (cereals contaminated with fungi)
  3. Common, 1-2% of malignancies, less common than liver metastases, high incidence in hep b/c endemic regions
  4. Syx of malignancy = malaise, weight loss, loss of appetite; hx of exposure to carcinogens = high alcohol intake, hep b/c (sexual activity, IV drug use), abdo distention, jaundice
  5. Sx of malignancy = cachexia, lymphadenopathy; hepatomegaly, jaundice, ascites, bruit over liver
  6. Bloods = FBC, ESR, LFTs, Clotting, alpha-fetoprotein (tumour marker), hepatitis serology; imaging = abdo USS, CT/MRI gold standard for staging; histology/cytology = ascitic tap sent for cyto analysis; staging = CT scan
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8
Q

Lung Cancer

  1. Definition
  2. Aetiology/Risk Factors
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Primary malignant neoplasm of the lung; Small cell lung cancer (20%) and Non-small cell lung cancer (80%)
  2. Smoking, asbestos exposure, other occupational exposure (polycyclic hydrocarbons, nickle, radon); atmospheric pollution
  3. Most common FATAL cancer in the west, 3x more common in MALES
  4. Asyx, 1ry cancer = cough, haemoptysis, chest pain, recurrent pneumonia; due to local invasion = brachial plexus invasion has shoulder and arm pain, left recurrent laryngeal nerve has hoarse voice and bovine cough, dysphage, arrhythmias, horner’s syndrome; due to metastatic disease/paraneoplastic phenomenon = weight loss, fatigue, fractures, bone pain
  5. no sx, fixed monophonic wheeze, signs of lobar collapse/pleural effusion, sx of metastases
  6. Dx = CXR, sputum cytology, bronchoscopy with brushings/biospy, CT/US-guided percutaneous biopsy, LN biopsy; Staging = CT/MRI of head, chest and abdomen; Bloods = FBC, U&Es, Ca (hyper is common), ALP (raised with bone mets), LFTs; Pre-op = ABG, pulm function tests
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9
Q

Mesothelioma

  1. Definition
  2. Aetiology/Risk Factors
  3. Epidemiology
  4. Presenting Syx and Presenting Sx
  5. Investigations
A
  1. Aggressive tumour of the mesothelial cells, usually occurring in the pleura (90%), but also in other sites such as peritoneum, pericardium and testes
  2. Strongly related to asbestos exposure
  3. Rare, more common in elderly; asbestos exposure in 70-80%, latent period between exposure and mesothelioma can be up to 50yrs
  4. Most common = SOB, Chest pain (dull, diffuse and progressive), weight loss, occasionally palpable chest wall mass, fatigue, fever, night sweat, clubbing (asbestosis), sx of mets
  5. CXR/CT (show pleural effusion, maybe = pleural mass and rib destruction), MRI, PET, Pleural fluid sent for cytological analysis and may be blood stained, pleural biopsy
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10
Q

Neutropenic sepsis

  1. Definition
  2. Aetiology/Risk Factors
  3. Epidemiology
  4. Presenting Syx and Presenting Sx
  5. Investigations
A
  1. Development of sepsis in a patient with neutropenia -> Dx = temp >38, neutrophil count <0.5 x 10^9/L; can also have without fever due to meds/steroids
  2. Incidental = congenital (ethnic variation, cyclical neutropenia in children = VERY RARE), acquired (decreased/ineffective neutrophil production = bone marrow infiltration, aplastic anaemia, B12/folate deficiency, chemo/radiotherapy; accelerated turnover = fety’s syndrome, hypersplenism, malaria; others = toxoplasmosis, dengue fever) and Febrile neutropenia = temp >38.5 or 2 consecutive above 38 for 2hrs and absolute neutrophil count <0.5 x10^9 /L
  3. Most common in pts with cytotoxic chemo
  4. Hx for = high risk features: active cancer, recent chemo, use of immunosuppressants or immunosuppressive illness; CKD; recent blood products; intravascular devices; Exam = sx of infection may be minimal, pyrexia, features of infective endocarditis, lymphadenopathy, skin rashes
  5. FBC (neutrophil level), Blood cultures (sepsis), others = blood film, D-dimer, U&Es, creatinine, LFTs
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11
Q

Oesophageal cancer

  1. Defintion
  2. Aetiology/Risk Factors
  3. Epidemiology
  4. Presenting syx
  5. Presenting Sx
  6. Investigation
A
  1. Malignant tumour arising in the oesophagus -> squamous cell carcinoma and adenocarcinoma
  2. SCC = alcohol, tumour, plummer-vinson syndrome, achalasia, scleroderma, coeliac disease, nutritional deficiencies, dietary toxins; adenocarcinoma = GORD, Barrett’s oesophagus
  3. 3x more common in males, 8th most common, scc more common in developing countries, adenocarrcinoma more in western world
  4. asyx, progressive dysphagia (initially worse for solids), regurgitation, cough, choking after food, voice hoarseness, odynophagia (painful swallowing), weight loss, fatigue (IDA)
  5. No sx, metastatic disease may cause = supraclavicular lymphadenopathy, hepatomegaly, hoarseness, sx of bronchopulm involvement
  6. Endoscopy (brushings and biopsy), imaging (barium swallow and CXR), staging (CT chest and abdo), other (bronchoscopy, Lung FT, ABGs)
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12
Q

Pancreatic cancer

  1. Defintion
  2. Aetiology/Risk Factors
  3. Epidemiology
  4. Presenting syx
  5. Presenting Sx
  6. Investigation
A
  1. Malignancy arising from the exocrine or endocrine tissues of the pancreas
  2. UNKOWN, 5-10% hereditary (MEN, HNPCC, FAR, VHLS) RF = age, smoking, DM, chronic pancreatitis, dietary (low intake of fresh fruit and veg)
  3. Increasing incidence, 2x more common in males, 60-80yrs peak
  4. Non-specific, anorexia, malaise, nausea, epigastric pain, weight loss, DM, jaundice
  5. Weight loss, epigastric tenderness/mass, jaundice/palpable gallbladder (courvoisier’s law), metastatic spread = hepatomegaly, Trousseau’s sx of malignancy = superficial thrombophlebitis
  6. Bloods = CA19-9, CEA is elevated, obstructive jaundice = high bilirubin/ALP/deranged clotting; imaging = USS, CT w/out guided biopsy, MRI/MRCP, ERCP (may allow biopsy bile, cytology and stenting)
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13
Q

Prostate cancer

  1. Defintion
  2. Aetiology/Risk Factors
  3. Epidemiology
  4. Presenting syx
  5. Presenting Sx
  6. Investigation
A
  1. Primary malignant neoplasm of the prostate gland
  2. Unknown, RF = age, afro-caribbean, FHx, Dietary factors, occupational exposure to cadmium
  3. Common, 2nd most common cause of male cancer
  4. Asyx, Lower UT obstruction = frequency, hesitancy, poor stream, terminal dribbling, nocturia; Metastatic spread = bone pain, cord compression, paraneoplastic syndromes, systemic syx: malaise, anorexia, weight loss
  5. Assymetrical hard nodular prostate, loss of midline sulcus
  6. Bloods = FBC, U+Es, PSA (not very specific), acid phosphatase, LFTs, bone profile; CT/MRI for local invasion/LN involvement; transrectal US and needle biopsy; isotope bone scan
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14
Q

Renal Cell Cancer

  1. Defintion
  2. Aetiology/Risk Factors
  3. Epidemiology
  4. Presenting syx
  5. Presenting Sx
  6. Investigation
A
  1. Primary malignancy of the kidneys
  2. Renal clear cell carcinoma (80%) of unknown cause, papillary carcinoma (10%) of unknown cause, transitional cell carcinoma (10%) occur at renal pelvis; RF =
    1. associated with inherited conditions such as mutation in VHL protein (causes headaches, balance issues, dizziness, limb weakness, vision problems, high BP),
    2. tuberous sclerosis (rare genetic disease causing benign tumours to grow in the brain and other organs),
    3. PCKD,
    4. familial renal cell cancer,
    5. smoking,
    6. chronic dialysis;
    7. can cause abnormal LFTs in absence of liver mets = STRAUFFER’S SYNDROME
  3. Uncommon, 3% of adult malignancies, peak 40-60yrs
  4. RCC = late presentation, asyx in 90%, haematuria, flank pain, abdominal mass; Transitional cell carcinoma = presents earlier with haematuria; systemic sx of malignancy = weight loss, malaise, paraneoplastic syndromes (fever, hyperca, polycythaemia)
  5. Palpable renal mass, HTN, plethora, anaemia, LHS tumour can obstruct left testicular vein as it joins the left renal vein causing LHS varicocoele
  6. Urinalysis (haematuria, cytology), Bloods (FBC, U&Es, Ca, LFTs, High ESR (75%)), abdo USS (best first line), CT/MRI for staging
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15
Q

Testicular cancer

  1. Defintion
  2. Aetiology/Risk Factors
  3. Epidemiology
  4. Presenting syx
  5. Presenting Sx
  6. Investigation
A
  1. Malignant tumour of the testes.
    1. Types:
      1. Seminomas - 50%
      2. Non-seminomatous germ cell tumours/teratomas - 30%
      3. Rare: gonadal stromal tumours and NHL
  2. Unknown
    1. RF: maldescended testes, ectopic testes, atrophic testes
  3. Uncommon, 1% of male malignancies, common age of onset: 18-35yrs
  4. Swelling or discomfort of the testes, backache due to paraaortic LN enlargement; lung mets -> SOB, haemoptysis
  5. Painless, hard testicular mass; 2ry hydrocoele, lymphadenopathy, gynaecomastia
  6. Bloods: FBC, U+E, LFTs, Tumours (alpha-fetoprotein, beta-HCG, LDH
    1. Urine pregnancy test - +ve if tumour produces b-HCG
    2. CXR for lung mets
    3. Testicular USS: visualisation, associated hydrocoele
    4. CT abdo and thorax: allows staging -> royal marsden hospital staging
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16
Q

Tumour Lysis Syndrome

  1. Defintion
  2. Aetiology/Risk Factors
  3. Epidemiology
  4. Presenting syx
  5. Presenting Sx
  6. Investigation
A
  1. Group of metabolic abnormalities that can occur as a complication during treatment of cancer where large amounts of tumour cells are lysed at the same time by treatment, releasing their contents into the bloodstream
  2. Sudden lysis of many tumour cells, releasing toxic contents into blood, most commonly after tx of lymphomas and leukaemias; RF are characteristics of = tumour (high cell turnover rate, rapid growth rate, high tumour bulk), pt (baseline serum creatinine, renal insufficiency, dehydration), chemo (chemo-sensitivity - lymphoma has higher risk)
  3. Occurs in pts with poorly differentiated lymphoma and leukaemias
  4. Hyperkalaemia = Arrhythmias, severe muscle weakness and paralysis; hyperphosphataemia = Acute kidney failure (crystals (CaPO4) in kidney parenchyma); hypocalcaemia = Tetany, parkinsonism, myopathy, sudden mental incapacity; hyperuricaemia = gout; lactic acidosis
  5. Check levels of metabolites = Potassium, phosphate, Calcium, uric acid; monitor for syx = increased serum creatinine, arrhythmia, seizure
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17
Q

Definition

Bladder cancer

A

Malignancy of bladder cells - most transitional cell carcinomas but rarely may be squamous cell carcinomas associated with chronic inflammation

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18
Q

S+S

Bladder cancer

A
  1. Painless microscopic haematuria, irritative/storage syx (freq, urgency, nocturia), recurrent UTIs, and rarely, ureteral obstruction
  2. No sx often, bimanual examination may be part of disease staging
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19
Q

investigations

Bladder cancer

A
  1. Cytoscopy for visualisation, biopsy or removal,
  2. USS,
  3. IV radiography,
  4. CT/MRI for staging
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20
Q

Definition

Breast cancer

A
  1. Malignancy of breast tissue - invasive ductal carcinoma
  2. Genetics (BRCA-1/BRCA-2), environmental factors,
  3. RF = age, prolonged exposure to oestrogen (nulliparity - not having kids, early menarche, late menopause, obesity, COCP, HRT), FHx of breast cancer
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21
Q

S+S

Breast cancer

A
  1. Breast lump (painless), changes in breat shape, nipple discharge (bloody?), axillary lump,
  2. syx of malignancy = weight loss, bone pain, paraneoplastic syndrome
  3. Breast lump (firm, irregular, fixed to surrounding structures), peau d’orange, skin tethering, fixed to chest wall, skin ulceration, nipple inversion,
  4. Paget’s disease of the nipple (eczema-like hardening of the nipple - ductal carcinoma in situ infiltrating the nipple
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22
Q

Investigations

Breast Cancer

A
  1. Triple assessment =
    1. clinical assessment,
    2. imaging = US (<35) OR mammogram (>35),
    3. tissue diagnosis = fine needle aspiration OR core biopsy;
  2. Sentinel LN biopsy (radioactive tracer injected into tumour, ID sentinel LN and then biopsy node for spread);
  3. staging = CXR, liver US, CT (brain/thorax);
  4. bloods = FBC, U&Es, Ca, bone profile, LFTs, ESR
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23
Q

Definition

Cholangiocarcinoma

A

1ry adenocarcinoma of the biliary tree

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24
Q

S+S

Cholangiocarcinoma

A
  1. Obstructive jaundice syx = yellow sclera, pale stools, dark urine, pruritus;
  2. abdo pain/fullness
  3. systemic syx of malignancy = weight loss, malaise, anorexia
  4. Jaundice,
  5. palpable gallbladder (courvoisier’s law - jaundice + palpable gallbladder (non-tender) is unlikely to be gallstones),
  6. epigastric/RUQ mass,
  7. may be hepatomegaly
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25
Q

Investigations

Cholangiocarcinoma

A
  1. Bloods = FBC, U+Es, LFTs (high ALP and GGT),
  2. clotting screen,
  3. tumour markers (CA19-9 is marker of pancreatic cancer and cholangiocarcinoma);
  4. endoscopy;
  5. USS, CT, MRI,
  6. Bone scan for staging
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26
Q

Definition

CNS tumour

A
  1. Tumours of CNS ->
    1. high grade = tumour grows rapidly and aggressively: glioma and glioblastoma multiforme, primary cerebral lymphoma, medulloblastoma;
    2. VS Low grade = tumour grows slowly and may/not be successfully treated: menangioma, acoustic neuroma, neurofibroma, pit tumour, craniopharyngeoma, pineal tumour.
  2. Brain metastases arise commonly from = lung, breast, stomach, prostate, thyroid, colorectal
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27
Q

S+S

CNS tumour

A
  1. Presentation depends on size and location of tumour;
  2. headache worse in morning and when lying down,
  3. nausea and vomiting,
  4. seizures,
  5. progressive focal neurological deficits,
  6. cognitive and behavioural syx,
  7. papilloedema
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28
Q

Definition

Colorectal cancer

A
  1. Malignant adenocarcinoma of large bowel,
  2. 60% rectum and sigmoid,
  3. 30% desc colon,
  4. 10% rest of colon
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29
Q

S+S

Colorectal cancer

A
  1. 20% will present as emergency with pain and distention due to large bowel obstruction and haemorrhage/peritonitis due to perf. Depends on size and location:
  2. Left colon and rectum = change in bowel habit, rectal bleeding (blood/mucus with stools), tenesmus
  3. Right colon = later presentation, anaemia syx (lethargy), weight loss, non specific malaise, lower abdo pain (rare)
  4. Anaemia,
  5. abdo mass,
  6. if metastatic = hepatomegaly, ascites;
  7. low lying rectal may be felt on DRE
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30
Q

Investigations

Colorectal cancer

A
  1. Bloods = FBC (anaemia), LFTs, tumour markers (CEA);
  2. Stools FOBT as screening test;
  3. endoscopy can be used to biopsy tumour;
  4. double contrast barium enema (apple core strictures),
  5. contrast CT for Duke’s staging
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31
Q

Definition

Gastric cancer

A

Cancer of stomach, usually adenocarcinoma;

rarer forms = lymphoma, leiomyosarcoma, stromal tumours

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32
Q

S+S

Gastric cancer

A
  1. Asyx early,
  2. early satiety,
  3. epigastric discomfort,
  4. systemic syx = weight loss, anorexia, n/v;
  5. dysphagia, syx of metastases (ascites and jaundice)
  6. Epigastric mass,
  7. abdo tenderness,
  8. ascites,
  9. sx of anaemia,
  10. virchow’s node,
  11. sister Mary Joseph’s nodule (metastatic node on umbilicus),
  12. Krukenberg’s tumour (ovarian mets)
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33
Q

Investigations

Gastric cancer

A
  1. Upper GI endoscopy;
  2. bloods = FBC (anaemia), LFTs;
  3. CT/MRI for staging,
  4. endoscopic USS - assess depth of gastric invasion and LN involvment
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34
Q

Definition

Hepatocellular carcinoma

A

1ry malignancy of liver parenchyma

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35
Q

S+S

Hepatocellular carcinoma

A
  1. malaise,
  2. weight loss,
  3. loss of appetite;
  4. hx of exposure to carcinogens = high alcohol intake, hep b/c (sexual activity, IV drug use),
  5. abdo distention, ascites
  6. jaundice
  7. cachexia,
  8. lymphadenopathy;
  9. hepatomegaly, bruit over liver
36
Q

Investigations

Hepatocellular carcinoma

A
  1. Bloods = FBC, ESR, LFTs, Clotting, alpha-fetoprotein (tumour marker), hepatitis serology;
  2. imaging = abdo USS, CT/MRI gold standard for staging;
  3. histology/cytology = ascitic tap sent for cyto analysis;
  4. staging = CT scan
37
Q

Definition

Lung cancer

A

Primary malignant neoplasm of the lung;

Small cell lung cancer (20%) and Non-small cell lung cancer (80%)

38
Q

S+S

Lung cancer

A
  1. Asyx,
  2. 1ry cancer =
    1. cough,
    2. haemoptysis,
    3. chest pain,
    4. recurrent pneumonia;
  3. due to local invasion =
    1. brachial plexus invasion has shoulder and arm pain,
    2. left recurrent laryngeal nerve has hoarse voice and bovine cough,
    3. dysphagia,
    4. arrhythmias,
    5. horner’s syndrome;
  4. due to metastatic disease/paraneoplastic phenomenon =
    1. weight loss,
    2. fatigue,
    3. fractures,
    4. bone pain
  5. no sx,
  6. fixed monophonic wheeze,
  7. signs of lobar collapse/pleural effusion,
  8. sx of metastases
39
Q

Investigations

Lung cancer

A
  1. Dx = CXR, sputum cytology, bronchoscopy with brushings/biospy, CT/US-guided percutaneous biopsy, LN biopsy;
  2. Staging = CT/MRI of head, chest and abdomen;
  3. Bloods = FBC, U&Es, Ca (hyper is common), ALP (raised with bone mets), LFTs;
  4. Pre-op = ABG, pulm function tests
40
Q

Definition

Mesothelioma

A

Aggressive tumour of the mesothelial cells, usually occurring in the pleura (90%), but also in other sites such as peritoneum, pericardium and testes

More common in elderly; asbestos exposure (latent for 50yrs)

41
Q

S+S

Mesothelioma

A
  1. Most common = SOB,
  2. Chest pain (dull, diffuse and progressive),
  3. weight loss,
  4. occasionally palpable chest wall mass,
  5. fatigue,
  6. fever,
  7. night sweats,
  8. clubbing (asbestosis),
  9. sx of mets
42
Q

Investigations

Mesotheliomas

A
  1. CXR/CT (show pleural effusion, maybe = pleural mass and rib destruction),
  2. MRI,
  3. PET,
  4. Pleural fluid sent for cytological analysis and may be blood stained,
  5. pleural biopsy
43
Q

Definition

Neutropenic sepsis

A
  1. Development of sepsis in a patient with neutropenia -> Dx = temp >38, neutrophil count <0.5 x 10^9/L;
    1. can also have without fever due to meds/steroids
  2. Incidental =
    1. congenital (ethnic variation, cyclical neutropenia in children = VERY RARE),
    2. acquired (decreased/ineffective neutrophil production = bone marrow infiltration, aplastic anaemia, B12/folate deficiency, chemo/radiotherapy; accelerated turnover = fety’s syndrome, hypersplenism, malaria; others = toxoplasmosis, dengue fever)
  3. Febrile neutropenia = temp >38.5 or 2 consecutive above 38 for 2hrs and absolute neutrophil count <0.5 x10^9 /L
44
Q

S+S

Neutropenic sepsis

A
  1. Hx for = high risk features: active cancer, recent chemo, use of immunosuppressants or immunosuppressive illness;
  2. CKD;
  3. recent blood products;
  4. intravascular devices;
  5. Exam = sx of infection may be minimal, pyrexia, features of infective endocarditis, lymphadenopathy, skin rashes
45
Q

Investigations

Neutropenic sepsis

A
  1. FBC (neutrophil level),
  2. Blood cultures (sepsis),
  3. others = blood film, D-dimer, U&Es, creatinine, LFTs
46
Q

Definition

Oesophageal cancer

A
  1. Malignant tumour arising in the oesophagus -> squamous cell carcinoma and adenocarcinoma
  2. SCC = alcohol, tumour, plummer-vinson syndrome, achalasia, scleroderma, coeliac disease, nutritional deficiencies, dietary toxins;
  3. adenocarcinoma = GORD, Barrett’s oesophagus
47
Q

S+S

Oesophageal cancer

A
  1. asyx,
  2. progressive dysphagia (initially worse for solids),
  3. regurgitation,
  4. cough,
  5. choking after food,
  6. voice hoarseness,
  7. odynophagia (painful swallowing),
  8. weight loss,
  9. fatigue (IDA)
  10. No sx,
  11. metastatic disease may cause = supraclavicular lymphadenopathy, hepatomegaly, hoarseness, sx of bronchopulm involvement
48
Q

Investigations

Oesophageal cancer

A
  1. Endoscopy (brushings and biopsy),
  2. imaging (barium swallow and CXR),
  3. staging (CT chest and abdo),
  4. other (bronchoscopy, Lung FT, ABGs)
49
Q

Definition

Pancreatic cancer

A

Malignancy arising from the exocrine or endocrine tissues of the pancreas

50
Q

S+S

Pancreatic cancer

A
  1. Non-specific,
  2. anorexia,
  3. malaise,
  4. nausea,
  5. epigastric pain,
  6. weight loss,
  7. DM,
  8. jaundice
  9. Weight loss,
  10. epigastric tenderness/mass,
  11. jaundice/palpable gallbladder (courvoisier’s law),
  12. metastatic spread = hepatomegaly,
  13. Trousseau’s sx of malignancy = superficial thrombophlebitis
51
Q

Investigation

Pancreatic cancer

A
  1. Bloods = CA19-9, CEA is elevated,
  2. obstructive jaundice = high bilirubin/ALP/deranged clotting;
  3. imaging = USS, CT w/out guided biopsy, MRI/MRCP, ERCP (may allow biopsy bile, cytology and stenting)
52
Q

Definition

Prostate cancer

A

Primary malignant neoplasm of the prostate gland

53
Q

S+S

Prostate cancer

A
  1. Asyx,
  2. Lower UT obstruction = frequency, hesitancy, poor stream, terminal dribbling, nocturia;
  3. Metastatic spread = bone pain, cord compression, paraneoplastic syndromes,
  4. systemic syx: malaise, anorexia, weight loss
  5. Assymetrical hard nodular prostate, loss of midline sulcus
54
Q

Investigations

Prostate cancer

A
  1. Bloods = FBC, U+Es, PSA (not very specific), acid phosphatase, LFTs, bone profile;
  2. CT/MRI for local invasion/LN involvement;
  3. transrectal US and needle biopsy;
  4. isotope bone scan
55
Q

Definitions

Renal cell cancer

A
  1. Primary malignancy of the kidneys
  2. Renal clear cell carcinoma (80%) of unknown cause, papillary carcinoma (10%) of unknown cause, transitional cell carcinoma (10%) occur at renal pelvis;
  3. RF =
    1. associated with inherited conditions such as mutation in VHL protein (causes headaches, balance issues, dizziness, limb weakness, vision problems, high BP),
    2. tuberous sclerosis (rare genetic disease causing benign tumours to grow in the brain and other organs),
    3. PCKD,
    4. familial renal cell cancer,
    5. smoking,
    6. chronic dialysis;
    7. can cause abnormal LFTs in absence of liver mets = STRAUFFER’S SYNDROME
56
Q

S+S

Renal cell cancer

A
  1. RCC = late presentation, asyx in 90%, haematuria, flank pain, abdominal mass;
  2. Transitional cell carcinoma = presents earlier with haematuria;
  3. systemic sx of malignancy = weight loss, malaise, paraneoplastic syndromes (fever, hyperca, polycythaemia)
  4. Palpable renal mass,
  5. HTN,
  6. plethora,
  7. anaemia,
  8. LHS tumour can obstruct left testicular vein as it joins the left renal vein causing LHS varicocoele
57
Q

Investigations

Renal cell cancer

A
  1. Urinalysis (haematuria, cytology),
  2. Bloods (FBC, U&Es, Ca, LFTs, High ESR (75%)),
  3. abdo USS (best first line),
  4. CT/MRI for staging
58
Q

Definition

Testicular cancer

A
  1. Malignant tumour of the testes.
    1. Types:
    2. Seminomas - 50%
    3. Non-seminomatous germ cell tumours/teratomas - 30%
    4. Rare: gonadal stromal tumours and NHL
59
Q

S+S

Testicular cancer

A
  1. Swelling or discomfort of the testes,
  2. backache due to paraaortic LN enlargement;
  3. lung mets -> SOB, haemoptysis
  4. Painless, hard testicular mass;
  5. 2ry hydrocoele,
  6. lymphadenopathy,
  7. gynaecomastia
60
Q

Investigations

Testicular cancer

A
  1. Bloods: FBC, U+E, LFTs, Tumours (alpha-fetoprotein, beta-HCG, LDH
  2. Urine pregnancy test - +ve if tumour produces b-HCG
  3. CXR for lung mets
  4. Testicular USS: visualisation, associated hydrocoele
  5. CT abdo and thorax: allows staging -> royal marsden hospital staging
61
Q

Definition

Tumour Lysis Syndrome

A
  1. Group of metabolic abnormalities that can occur as a complication during treatment of cancer where large amounts of tumour cells are lysed at the same time by treatment, releasing their contents into the bloodstream
  2. Sudden lysis of many tumour cells, releasing toxic contents into blood, most commonly after tx of lymphomas and leukaemias;
  3. RF are characteristics of = tumour (high cell turnover rate, rapid growth rate, high tumour bulk), pt (baseline serum creatinine, renal insufficiency, dehydration), chemo (chemo-sensitivity - lymphoma has higher risk)
62
Q

S+S

Tumour Lysis Syndrome

A
  1. Hyperkalaemia = Arrhythmias, severe muscle weakness and paralysis;
  2. hyperphosphataemia = Acute kidney failure (crystals (CaPO4) in kidney parenchyma);
  3. hypocalcaemia = Tetany, parkinsonism, myopathy, sudden mental incapacity;
  4. hyperuricaemia = gout; lactic acidosis
63
Q

Definition

Wilm’s tumour

A
  1. Wilms’ tumour (a.k.a. nephroblastoma) is the commonest intra-abdominal tumour in children, rarely occuring in adults.
  2. It is a malignant tumour derived from embryonic mesodermal tissues.
  3. Patients present with a loin mass, weight loss, anorexia and fever.
  4. Although the tumour is rapidly growing an behaves aggressively, it has an 80% survival rate at 5 years.
64
Q

Definition

Kaposi’s sarcoma

A
  1. Kaposi’s sarcoma is a malignant tumour of the vascular endothelium consisting of spindle cells and small blood vessels
  2. It is very rare in patients without HIV infection or those who are immunosuppressed.
  3. It gives rise to multiple lesions in the skin that appear like purple bruises and are not painful to touch.
  4. In about 40% of cases (such as this one) there is gastrointestinal involvement
65
Q

Definition

Pancoast tumour

A
  1. Pancoast tumours are lung tumours located at the apex of the lung.
  2. They typically extend to involve the sympathetic ganglion resulting in ipsilateral Horner’s syndrome (ptosis, meiosis, anhydrosis).
  3. In some cases, the lower roots of the brachial plexus are also involved, resulting in pain and weakness in the muscles of the arm and hand, specifically in the T1 distribution.
66
Q

Definition

Burkitt’s lymphoma

A
  1. Burkitt’s lymhpoma is a high-grade B-cell lymphoma endemic in some parts of Africa.
  2. It frequently involves the jaw and is most often seen in African children with previous EBV infection (there is a strong association between the two)
  3. Other associations include chronic malarial infection and translocation of chromosome 8 on the c-myc gene with chromosome 14.
67
Q

Definition

Brodie’s tumour

A
  1. Brodie’s tumour (a.k.a. phyllodes tumour) are rare tumours of the fibroepithelial stroma of the breast.
  2. The history of a rapidly growing mass that distorts the shape of the breast points towards this disease.
  3. Most of these tumours are benign and the prognosis after surgery is excellent.
68
Q

Tumour marker

CA 15-3

A
  1. High Ca 15-3 levels suggest metastatic breast disease.
  2. However, it has poor sensitivity and is therefore not used as a screening procedure to detect breast carcinoma.
  3. This tumour marker has recently been superseded by Ca 27-29, which is claimed to be more sensitive and specific.
  4. However, CA 27-29 lacks predictive value in the earliest stages of breast cancer and thus has no role in screening for or diagnosing the malignancy.
69
Q

Tumour marker

CA 19-9

A
  1. Ca 19-9 is used to confirm the diagnosis of malignant pancreatic tumours, differentiating them from chronic pancreatitis.
  2. However, it should not be used as a stand-alone diagnostic tool, rather as an adjunct to CT, U/S and ERCP.
  3. It is also used for monitoring the response to therapy. Levels can also be elevated in hepatbiliary disease, but it is not used in this setting.
70
Q

Tumour marker

PSA

A
  1. Prostate-specific antigen (PSA) is used as a screening test, a diagnostic test, a measure of treatment success and a marker of recurrence.
  2. It has replaced the use of prostatic acid phosphatate.
  3. However, PSA lacks the required specificity as it is raised in patients without prostatic cancer (i.e. a high false positive rate).
  4. Therefore, it should be used alongside other methods of investigation, and not by itself, to make a diagnosis.
71
Q

Tumour marker

CEA

A
  1. Although carcinoembryonic antigen (CEA) lacks the sensitivity and specificity to be a diagnostic test for colorectal cancer,
  2. it has found a valuable application in the detection of recurrence of malignant disease following treatment.
72
Q

Tumour marker

alpha-Fetoprotein

A
73
Q

Definition

Superior Vena Cava Obstruction

A
  1. This occurs when the SVC is subjected to pressure from a tumour in the superior mediastinum or from thrombosis.
  2. The most common cause is lymph node metastases from bronchial carcinoma.
  3. The main clinical features are due to venous congestion, and there may even be stridor due to obstruction of the trachea or main bronchi.
  4. Initial treatment is with oral dexamethasone to reduce oedema around the tumour followed by long-term radiotherapy/chemotherarpy.
74
Q

Features of tumour lysis syndrome

A
  1. Tumour lysis syndrome usually occurs in patients undergoing chemotherapy for lymphoproliferative malignancies, who have just initiated treatment.
  2. Lysis of tumour cells leads to the release of large amounts of potassium, phosphate and uric acid into the circulation.
  3. The excess phosphate binds to calcium, leading to hypocalcaemia and its clinical features.
  4. Patients are also at risk of developing acute renal failure due to the deposition of uric acid and calcium phosphate crystals in the renal tubules.
75
Q

Which malignancy is associated with:

Coeliac disease

A

T cell lymphoma and small bowel adenocarcinoma

76
Q

Which malignancy is associated with:

Pernicious anaemia

A

Gastric carcinoma

77
Q

Which malignancy is associated with:

Unprotected sexual intercourse with several promiscuous partners

A

Cervical cancer - transmission of HPV types

78
Q

Which malignancy is associated with:

Rubber industry

A

Bladder cancer

79
Q

Which malignancy is associated with:

previous Hep C infection

A

Hepatocellular carcinoma following development of cirrhosis

80
Q

Definition

Waldenstrom’s macroglobulinaemia

A
  1. lymphoproliferative disorder of B cells, which take on a lymphoplasmacytoid appearance.
  2. It is characterised by the production of immunoglobulin M (IgM), which gives rise to the clinical features of hypervisosity (nosebleeds, blurred vision, retinal haemorrhage etc.)
81
Q

Classic Presentations of:

Gastric carcinoma

A
  1. Troisier’s sign is the finding of a palpable solid lymph node located in the left supraclavicular fossa (known as Virchow’s node).
  2. It is commonly associated with gastric malignancy.
82
Q

Classic presentation of

Renal cell carcinoma

A

Erythrocytosis:

Erythropoietin is produced in the kidney and renal cell carcinoma may lead to increased production as a paraneoplastic syndrome. This causes a a secondary polycythaemia.

83
Q

Classic presentation of:

Small cell lung carcinoma

A
  1. Eaton-Lambert syndrome: is a myasthenic syndrome characterised by impaired release of acetylcholine due to autoantibodies to presynaptic voltage-gated calcium channels.
  2. description is of a patient with absent tendon reflexes and muscle weakness that improved after repeated contraction (much to the amazement of the examining doctors colleagues!).
  3. Eaton-Lambert syndrome is associated with small cell lung carcinoma in 60% of cases.
84
Q

Classic presentation of

Medullary thyroid carcinoma

A
  1. Medullary thyroid carcinoma are uncommon and arise from the parafollicular cells of the thyroid.
  2. These tumours produce calctionin and elevated levels are diagnostic.
  3. They may occasionally present with hypocalcaemia and tetany as a result of this.
85
Q

Classic presentation of

Glucagonoma

A
  1. Necrolytic migratory erythema:
  2. This rash is characteristic of glucagonoma and is also known as ‘glucagonoma syndrome’.
  3. It is characterised by the spread of erythematous blisters across the lower abdomen, buttocks, perineum and groin.
86
Q

Classic presentation of:

Insulinoma

A
  1. Insulimonas present with spontaneous episodes of hypoglycaemia, especially when fasting and exercising.
  2. Most insulinomas are benign and small tumours, but may cause significant metabolic effects.

Year 3 (13 decks)

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