Cancer Detection, Prevention, and Treatment Flashcards
Ways to detect a tumor based on sensation
Breast Cancer: annual physical exam, monthly breast exam
Soft tissue sarcomas: may present with mass
Does a mass alone tell you something is cancer?
Nope
Skin invasion overlying a mass is far more concerning for malignancy, though
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
A tumor around the spinal cord can cause what sort of sudden emergency?
Spinal cord compression
may cause permanent paralysis or worse
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
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
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)
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
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
How to stage cancer
T: Tumor size/invasion
N: lymph Node metastasis
M: other Metastasis/other considerations
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
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
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)
Carcinomas need to be staged by looking at what?
What is the one exception?
LN
Renal cell carcinoma (spreads hematogenously, even though it’s a carcinoma)
What are some general metastatic cancer symptoms we should beware of?
fatigue, weight loss
bone pain/back pain
headache/neuropsych sx
obstruction/compression
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
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 lung 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
