Cancer Detection, Prevention, and Treatment Flashcards by Liz Pennington

Ways to detect a tumor based on sensation

Breast Cancer: annual physical exam, monthly breast exam

Soft tissue sarcomas: may present with mass

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Does a mass alone tell you something is cancer?

Nope

Skin invasion overlying a mass is far more concerning for malignancy, though

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What are some clues that a mass could be causing obstruction?

Lung Carcinoma: endobronchial growth, causes stridor, collapsed lung, and SVCS (below)

Superior Vena Cava Syndrome: venous distension of neck, chest wall, facial edema and plethora, upper arm edema (Pemberton’s sign)

Abdominal and pelvic tumors: can compress GI, bladder, biliary system, vessels

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A tumor around the spinal cord can cause what sort of sudden emergency?

Spinal cord compression

may cause permanent paralysis or worse

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What are some examples of hemorrhage in tumors?

Hemorrhage can be a presenting sign in teh following

post-menopausal bleeding (always concerning for uterine cancer, do biopsy)

Less specific concerns: hematuria, hematochezia, hematemesis, hemoptysis

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What are some ways that hemorrhaging tumors can manifest (besides seeing it)

rapid enlargement of a tumor or compartment from the blood with significant associated pain

chronic bleeding leading to iron-deficient anemia

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What are some reasons that tumors cause irritation?

peritoneum and pleural spaces are easily irritated by tumor cells

can cause ascites (ovarian carcinoma)

can cause malignant pleural effusions (tumor irritating pleura)

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What are some approaches we can take as physicians to detect tumors?

History:

palpable/visible mass (pt will tell you about)

obstructive signs/sx

hemorrhage (pt will tell you)

Exam:

palpable/visible mass

indications of invasion

compression

effusions

Labs:

hemorrage

effusions

cancer markers

Rad:

all of the above

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Case Study:

62 y/o f pt with increasing fatigue, abdominal weight gain, increased gas/constipation

Exam: ascites, adnexal mass

Orders: Ca125 elevated, full body imaging, biopsy with surgery and removal of tumor

Dx: Ovarian Cancer

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How to stage cancer

T: Tumor size/invasion

N: lymph Node metastasis

M: other Metastasis/other considerations

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Different types of metastatic spread:

Lymphatic:

Hematogenous:

Transcoelomic:

Canalicular:

travels through lymph (typical of carcinomas)

travels through blood (typical of sarcomas, advanced carcinomas)

punches through serosa

travels through duct/lumen

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How does understanding the spread of cancers impact clinical care?

helps us know where to look for metastasis (check LN palpably or with rad.)

what types of sx of metastasis to look for

if a previous cancer diagnosis, how to order radiology in anticipation for metastasis

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Sentinel biopsies and LN dissections are done in which cancers?

Endometrial carcinoma spreads via lymph, where do you check for metastasis?’

Myometrial sarcoma would metastasize where?

Breast carcinoma and melanoma

LN!

Blood and can go to lungs and liver (common for sarcomas)

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Carcinomas need to be staged by looking at what?

What is the one exception?

Renal cell carcinoma (spreads hematogenously, even though it’s a carcinoma)

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What are some general metastatic cancer symptoms we should beware of?

fatigue, weight loss

bone pain/back pain

headache/neuropsych sx

obstruction/compression

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What is the Sister Mary Joseph nodule?

What is the Virchow node?

umbilical metastasis, typically from ovarian cancer

Supraclavicular LAD, typically left sided, associated with thoracic/abdominal carcinoma due to drainage of thoracic duct into subclavian vein in the supraclavicular region

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What is the difference between a primary and metastatic tumor?

primary:

solitary, no other cancer dx, unusual met location, typical demographic

metastatic:

multiple, history of other cancer, location typical for mets, unusual demographic

What kind of surveillance should be done in a pt with a prior diagnosis of cancer or in anticipation of metastasis?

depends on the cancer!

checking regional LN is most important, using radiology as appropriate

can use serum cancer markers as well

Ovarian:Ca125

Myeloma: B2 microglobulin

Medullary thyroid: Calcitonin

What does a late metastasis from a sarcoma present like?

lung metastasis from sarcoma can arise a decade later and pt’s may not even remember that they had a primary sarcoma (like a uterine leiomyosarcoma)

(it actually happens a lot that people forget diagnoses, esp if they were relatively easy, minor to treat)

What does late metastasis from breast cancer present like?

metastasis from breast carcinomas can arise decades later

back pain decades after definitive breast cancer can indicate osseous metastsis to the spine

What is the definition of paraneoplastic syndrome?

tumor secretes a substance (PTH-rP, ACTH)

tumor evokes eleboration of other factors (autoantibodies, cytokines)

Case Study:

68 yo m, smoker with acute AMS

exam: drowsy, confused, Ca elevated, Phos low, PTH low, PTH-rP is elevated

Dx: Humoral Hypercalcemia of Malignancy from squamous carcinomas of any site, likely lung in this case due to hx of smoking

Sx mediated by PTH-rP secretion from tumor

CT shows right hilar lung mass

Case Study

52 yo f, smoker, c/o lethargy and weakness

Exam: drowsy, irritable, normal BP, euvolemic, Na low, Osm low, urine Osm elevated

secretion of ADH signals renal receptors to retain free water, diluting serum osm and causing AMS

Dx: SIADH most often from small neuroendocrine carcinoma but can be from lung, GI and GU/ovarian carcinomas

Hers is from lung due to smoking history

Case Study

48 yo m, new onset HTN

Exam: low K, weight loss, muscle weakness

morning serum cortisol elevated

ACTH elevated

Dx: Cushing syndrome due to small cell carcinoma and ectopic ACTH

often neuroendocrine tumors, but can be lung, bronchial, pancreatic islet, medullary thyroid, or pheochromocytoma

What is Eaton-Lambert Myasthenic syndrome?

often associated with small cell malignancy assx with muscle weakness and dry mouth dz is mediated by antibodies to voltage gated Ca channels Dx via antibody and nerve stimulation testing

When is surgery for malignancy not indicated

metastatic disease removes the advantage of surgery leukemia/lymphoma can't really be surgical excised systemic therapy can be so effective that surgery isn't needed

Types of radiation therapy

external beam radiation intensity-modulated radiotherapy brachytherapy systemic radionucleotides

How does external beam radiation work? How does brachytherapy work?

linear accelerator delivers direct radiation beams to affected site very localized high-dose therapy delivered continuously for a prolonged time through implanted devices

What is an example of systemic radionucleotides?

I131 is used for thyroid cancer and noncancerous thyroid diseases the metabolism of iodine by neoplastic thyroid cells results in cellular ingestion of the killing radionucleotide

When do you use radiation therapy?

it is part of adjuvant and neoadjuvant therapy Use when surgery is contraindicated Use for palliative care (prevent spinal cord compression, ENT carcinoma to prevent suffocation, pelvic side wall to prevent pain)

When looking at systemic cancer therapy, what are the types and indications?

Hormone therapy: breast/prostate, can inhibit receptor Growth Factors: EGF, VEGF, can inhibit receptor Antigens: CD20 for B cell Lymphomas, can use Rituximab (antibody) Immune Checkpoints: PD1, CTLA, can use inhibitors

What is CAR-T therapy?

Chimeric antigen receptor therapy T cells are manipulated ex vivo to express a binding domain for a tumor associated antigen (customized) with a transmembrane domain and an intracellular signaling domain that intensifies the immune attack against the tumor cells

What are some indications for stem cell transplantation in cancers? Types of stem cell transplants

if therapy involves ablation of bone marrow such as hematopoietic neoplasms, or advanced solid tumors that need a lot of chemo allogenic (someone else) syngeneic (identical twin) autologous (self)

Screening and prevention for ovarian cancer

Ca125 (not specific, can be elevated for other reasons, or only elevated by the time tumor is too progressed) no real effective treatment Prevention: bilateral salpingo-oophorectomy, distal salpingectomy

Screening for prostate cancer

PSA, DRE PSA may be elevated for other reasons DRE typically identifies tumors after they are too advanced PSA may not be super effective, but can be offered and can indicate need for biopsy

Cervical cancer screening

Pap smear every 3 years (over 21 if hx of normal) treat pre-cancerous lesions with local excision and cryoablation before becomes invasive Prevent HPV infections with HPV vaccine

Breast cancer screening

recommendations vary, but mammograms are important! ACS and AAFP say to screen every other year at age 50-75 Encourage breast self-exams at early age with monthly frequency and educate pt on checking axilla, skin changes, and avoiding breast self-exams during menstrual cycle

BRCA1 and 2 genetic testing

indicated with family hx of breast/ovarian cancer in multiple relatives, relatives diagnosed at young age, and breast cancer in male relatives or if the pt was diagnosed before age 45

What happens if someone is BRCA positive?

prophylatic surgery with double mastectomy and bilateral salpingo-oophorectomy, hormone therapy and increased screening and self-exams

Endometrial cancer screening

Counsel people with uteruses to report any vaginal bleeding that occurs after menopause (one year without period)

colon cancer screening

ages 45-75 fecal immunochemical test annually guaiac based fecal occult blood test annually fecal DNA test every three years Colonoscopy every 10 years (maybe CY colonography every 5yrs)?

What is the benefit of a colonoscopy? How to prevent colon cancer?

ability to check pt's fr precancerous polyps and remove them before they invade smoking cessation, low dose CT annually for current smokers, those with 30 pack year history, and those who quit within the past 15 years