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Sharon's phase 3b/4 > Cancer/oncology > Flashcards

Cancer/oncology Flashcards

1
Q

Cancers that most often spread to the brain

A
  • Lung
  • Breast
  • Renal cell carcinoma
  • Melanoma
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2
Q

Basal cell carcinoma (BCC)

A

Skin neoplasm associated with exposure to sunlight/UV rays

Can be locally invasive but rarely metastasises.

Typically associated with a history sun/UVexposure.

Characteristeristic appearance is raised, fleshy, pearly white papules with associated telangiectasias. Sometimes crusty and non-healing

Nodular basal cell carcinoma on the cheek
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3
Q

Investigations for BCC

A

1st line is biopsy for dermatohistopathology as it is diagnosed histological.

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4
Q

Management of BCC

A

Excision surgery with 4mm margin

Mohs surgery = tissue removed and examined under microscopy in real-time

Cryosurgery or radiotherapy if patient unsuitable for surgery

Advise sunscreen for prevention

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5
Q

Bladder cancer

A

Cancer arising from endothelial lining (urothelium)

Majority are superficial at presentation - not invading muscle layer

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6
Q

Types of bladder cancer

A
  • Transitional cell carcinoma (90%)
  • Squamous cell carcinoma (5% – higher in areas of schistosomiasis)
  • Others not mentioned
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7
Q

Risk factors of bladder cancer

A
  • Smoking
  • Age
  • Dye/rubber industaries previously (aromatic amines banned now)
  • Schistosomiasis = SCC

Typical presentation in exam: retired dye factory worker with painless haematuria - transitional cell carcinmoa

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8
Q

Presentation of bladder cancer

A

Painless haematuria = KEY!

NICE recommends 2WW for:
- >45 with unexplained visible haematuria, not/after UTI tx
- > 60 with microscopic haematuria AND dysuria or raised WBC on FBC

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9
Q

Diagnosis and staging for bladder cancer

A

Cytoscopy - camera through urethra to bladder

Staging: TNM staging

Non-muscle invasive:
- Tis/carcinoma in situ: only urothelium and flat
- Ta: only urothelium and projects into bladder
- T1: connective tissue invasion, no muscle invovlement

Invasive: T2 - 4 + any lymph node or metastasis

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10
Q

Treatment for bladder cancer

A
  • Managed by MDT
  • Transurethral resection of bladder tumour (TURBT) for non-muscle-invasive bladder cancer
  • AND intravesical chemo to reduce reoccurance
  • Intravesical BCG vaccine to stimulate immune system
  • Radial cytectomy - removal of bladder + urostomy with ileal conduit for urine drainage
  • Radiotherapy/chemo
The urologist removes a piece of ileum and connects this to the ureters, and makes a stroma in the abdo and into a urostomy bag
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11
Q

Gastric cancer

A

Most common in > 75, male: female 2:1, Japanese, Chinese

Most common is gastric adenocarcinoma, arises from glandular epithelium of the stomach lining

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12
Q

Risk factors for gastric cancer

A
  • Helicobacter pylori: triggers inflammation of mucosa > atrophy and intestinal metaplasia > dysplasia
  • Pernicious anaemia
  • Diet high in salt, salt-preserved foods
  • Smoking
  • Japanese, Chinese ethnicity
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13
Q

Clinical features of gastric cancer

A
  • Dyspepia
  • Abdo pain: vague epigastric
  • Weight loss and anorexia
  • N+V
  • Dysphagia if proximal stomach
  • Lymphatic spread: enlarged left supraclavicular lymph node (Virchow’s node)
  • Upper GI bleed is uncommon
  • Late signs: epigastric mass,hepatomegaly, jaundice, ascites (liver mets)
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14
Q

Investigations for gastric cancer

A

Diagnostic: oesophago-gastro-duodenoscopy (OGD) + biopsy: signet ring cells, more = worse prognosis

Staging: CT TAP to look for metastatic disease

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15
Q

Management for gastric cancer

A

Depends on extent and site
- Endoscopic mucosal resection
- Partial gastrectomy: distal tumours
- Total gastroectomy: proximal tumours
- Chemotherapy

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16
Q

Parathyroid axis and calcium regulation

A

4 parathyroid glands produce parathyroid hormone (PTH) in response to low calcium. PTH increases serum calcium by:

  • Bones: ↑ osteoclast number and activity
  • Kidneys: ↑ calcium reabsorption from urine
  • Intestines: ↑ vit D activity = ↑ calcium absorption from food

Calcitonin is a hormone released by parafollicular cells (C cells) in thyroid gland, reduces calcium levels

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17
Q

Hypercalcaemia of malignancy

A

Raised serum calcium

Most common in lung, breast and kidney cancer

Mechanisms by which cancer causes hypercalcaemia:

  • Parathyroid hormone-related protein (PTHrP) produced by tumour, which stimulates PTH recpetors
  • Bony metastases: ↑ osteoclast activitiy
  • Calcitriol (acitive form of vit D) released by tumour (particularly lymphomas)

Tx: IM/SC calcitonin

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18
Q

Leukaemia

A

Cancer of particular line of stem cells in the bone marrow, causing uncontrolled production of a specific type of blood cell

Types:

  • Acute myeloid leukaemia (rapidly progressing cancer of the myeloid cell line)
  • Acute lymphoblastic leukaemia (rapidly progressing cancer of the lymphoid cell line)
  • Chronic myeloid leukaemia (slowly progressing cancer of the myeloid cell line)
  • Chronic lymphocytic leukaemia (slowly progressing cancer of the lymphoid cell line)
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19
Q

Key differences of the leukaemia types for exams

A
  • ALL = most common in children, Down syndrome
  • CLL is associated with warm haemolytic anaemia, Richter’s transformation and smudge cells
  • CML has three phases, including a long chronic phase, Philadelphia chromosome
  • AML may result in a transformation from a myeloproliferative disorder, Auer rods
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20
Q

Pathophysiology of leukaemia

A

Genetic mutation in precursor cells in bone marrow > excess production of one type of WBC

Leads to underproduction of other cell types > pancytopenia (low RBC (anaemia), WBC (leukopenia) and platelets (thrombocytopenia))

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21
Q

Presentation of leukaemia

A

Non-specific

  • Fatigue
  • Fever
  • Pallor (anaemia)
  • Petechia/brusing (thrombocytopenia)
  • Abnormal bleeding
  • Lymphadenopathy
  • Hepatosplenomegaly
  • Failure to thrive (Children)
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22
Q

Diagnosis of leukaemia

A
  • NICE recommends FBC within 48 hours if leukaemia suspected
  • Children/young people with petechiae or hepatosplenomegaly = immediate specialist assessment
  • 1st line: FBC
  • Blood film
  • Diagnostic: bone marrow biopsy
  • CT staging
  • Lymph node biopsy if spread
  • Genetic test and immunophenotyping to guide tx
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23
Q

Overview of management of leukaemia

A
  • Oncology and haematology MDT
  • Chemo and targeted therapies
  • E.g. TKI (ibrutinib) and mAb (rituximab targets B cells)
  • Radiotherpy
  • Bone marrow transplant
  • Surgery
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24
Q

Complications of chemotherapy

A

Tumour lysis syndrome (massive levels of chemicals released when cells are destroyed by chemo)
- High uric acid (crystals in kidneys > AKI)
- Hyperkalaemia (cardiac arrhythmia)
- High phosphate causing low calcium

Tx: Good hydration and UO before chemo! Allopurinol to reduce uric acid

Others: failure to tx cancer, infections, neurotoxicity, infertility, cardiotoxicity, stunted growth in children

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25
Acute lymphoblastic leukaemia
Mutation of one type of lymphocyte precursor cells > acute proliferation of (usually) B-lymphocytes Most common in children < 5 or Down Syndrome, also older adults
26
Chronic lymphocytic leukaemia
- Slow proliferation of one type of well-differentiated lymphocyte, usually B-lymphocytes - Most common in > 60 - Mostly asymptomatic, but sometimes infections, anaemia, bleeding and weight loss - Can lead to warm autoimmune haemolytic anaemia - Smear/smudge cells on blood film
27
Chronic myeloid leukaemia
Three phases: - Chronic phase - asymptomatic, few years - Accelerated: abnormal blast cells 10 - 20%, anaemia, throbocytopenia and immunodeficiency - Blast phase: blast cells > 20%, severe symptoms and pancytopenia, often fatal
28
What chromosome abnormality is most associated with CML
- Philadelphia chromosome - Abnormal chromosome 22 caused by reciprocal translocation (swap) between section of chromosome 9 and 22 - Leads to abormal BCR-ABL1 gene segment, codes for abnormal tyrosine kinase > abnormal cell proliferation
29
Acute Myeloid Leukaemia
Any age, usualy presents from middle age Can result from myeloproliferative disorder trtansformation e.g. polycythaemia ruby vera Blast cells with Auer rods on blood fim and blood marrow biopsy (>50%)
30
Lymphoma
Cancer cells prolierating in the lymphocyte in the lymphatic system = lymphadenopathy - Hodgkin’s lymphoma (a specific disease) - Non-Hodgkin’s lymphoma (which includes all other types)
31
Hodgkin's lymphoma
- Bimodal age distribution: 20 - 25, 80 - RFs: HIV, Epstein-Barr virus - Autoimmune conditions e.g. RA - FHx
32
Non-Hodgkin Lymphoma
Includes many types - Diffuse large B cell lymphoma - rapidly growing painless mass in older patients - Burkitt lymphoma - EBV and HIV - MALT lymphoma - mucosa-associated lymphoid tissue Risk factors: HIV< EBV, H.pylori (MALT), pesticides, hepatitis B/C, FHx
33
Presentation of lymphoma
- Key = Lymphadenopathy - Non-tender, firm, rubbery - Hodgkin's lymphoma = lymph node pain after alcohol - B-symptoms: fever, weight loss, night sweats - Non-specific: fatigue, itching, cough, SOB, abdo pain, recurrent infections
34
Investigation for lymphoma
Gold standard: Lymph node biopsy = Reed sternberg cells (owl eyes) CT staging: Lugano Classification - Stage 1: one or one group of nodes - Stage 2: more than one node but same side of diaphragm - Stage 3: above and below diaphragm - Stage 4: widespread, non-lymphatic organs e.g. lungs, livers
35
Management of lymphoma
Hodgkin's lymphoma: curative chemo and radiotherapy NHL dependent on stage: watchful waiting, chemo, mAb (e.g. rituximab, targets B-cells), radiotherapy, stem cell transplantation
36
Malignant melanoma (passmed notes)
4 main subtypes, nodular is most aggressive, see table. There are other rare forms
37
Diagnostic criteria for melanoma
Major criteria: - Change in size - Change in shape - Change in colour Secondary features (minor criteria) - Diameter >=7mm - Inflammation - Oozing or bleeding - Altered sensation
38
Management of melanoma
- Excision biopsy, remove lesion completely and histopathological assessment - Once diagnosis confirmed, review report to see if further excision needed
39
Oesophageal cancer
40
Red flag features that suggest oesphageal cancer
- Dysphagia: most common = immediate 2WW - Anorexia + weight loss - Vomiting
41
Diagnosis of oesophageal cancer
- Upper GI endoscopy with biopsy is diagnostic - Local staging: endoscopic USS - Initial staging: CT TAP
42
Management of oesophageal cancer
- Operable disease (T1N0M0) = surgical resection - Adjuvant chemotherapy
43
Pancreatic cancer
Dx late and poor prognosis Most commonly adenocarcinomas, head of pancreas, grow large = block bile duct = obstructive jaundice
44
Presentation of pancreatic cancer
Painless obstrucitive jaundice = classic (ddx cholangiocarcinoma) - Yellow skin and sclera - Pale stools - Dark urine - Generalised itching 2WW criteria - > 40 + jaundice - > 60 with weight loss + additional symptom (diarrhoea, back pain, abdo pain, N+V, constipation, new diabetes) = direct access CT abdo ## Footnote New onset diabets or rapid worsening glycaemic control of T2DM despite meds and good lifestyle = suspect pancreatic cancer
45
Investigations for pancreatic cancer
- CT + biopsy for histology - Staging: CT TAP - Magnetic resonance cholangio-pancreatography (MRCP) to visulise biliary system - ERCP for stentt to relieve obstruction + biopsy
46
Mx of pancreatic cancer
- Hepatobiliary MDT meeting Surgery if small and isolated to head: - Total/distal pancreatectomy - Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure) - Radical pancreaticoduodenectomy (Whipple procedure) if not spread - Palliative care for most: stent/surgery to relieve obstruction, chemo/radio to improve symptoms
47
Squamous cell carcinoma of the skin
Common, metastases in 2 - 5% cases Risk factors: - Excessive exposure to sunlight - Actinic keratoses (pre-cancerous) and Bowen's disease (very early SCC) - Immunosuppression e.g. renal transplant, HIV - Smoking
48
Clinical features of skin SCC
- Usually on sun-exposed areas e.g. head/neck/ear - Rapidly expanding painless, ucerate nodules - May have cauliflower apperance - Bleeding
49
Management of skin SCC
Surgical excision - 4mm margins for lesions <20mm diameter - 6mm margins if lesion > 20mm - Mohs micrographic surgery if high-risk patient or comestically important area
50
Testicular cancer
- Arises from germ cells in the testes, they produce gametes (sperm) - Highest incidence 15 - 35yo - Seminomas and non-seminomas (mostly teratomas) - Risk factors: undescended testes, male infertility, FHx, increased height
51
Presentation of testicular cancer
Classically a painless testicular lump +/- pain - Non-tender - Arising from testicle - Hard - Irregular - Not fluctant and no transillumination - Gynaecomastia1 = Leydig cell tumour | 12% with gynaecosmatia = testicular tumour
52
Investigations and staging for testicular cancer
- 1st line: Scrotal USS Tumour markers - Alpha-fetoprotein = raised in teratoma (not in pure seminomas) - Beta-hCG = raised in both teratomas and seminomas Staging CT, Royal Marsden Staging System - Stage 1: isolated to the testicle - Stage 2: spread to the retroperitoneal lymph nodes - Stage 3: spread to the lymph nodes above the diaphragm - Stage 4: metastasised to other organs | Most common sites for testicular cancer to spread: LLLB ## Footnote Most common sites for testicular cancer to spread: LLLB, lymphatics, lungs, liver, brain
53
Management for testicular cancer
- Guided by MDT - Depends on grade and stage: - Surgery (radical orchidectomy) - Chemo - Radiotherapy - Sperm banking (infertility is side effect of tx) Prognosis is good if caught early, FU with monitoring tumour markers, CT and CXR
54
Prostate cancer
Most common cancer in men, slow-growing (most) > aggressive Depends on testosterone RFs: increasing age, FHx, Black Afrcan/Caribbean, anabolic
55
Clinical features of prostate cancer
Asymptomatic or LUTs e.g. hesitancy, frequency, weak flow, nocturia etc. (FUNI SHID) Other symptoms: haematuria, ED, advanced/metastasis (weight loss, bone pain or causa equina) ## Footnote FUNI: frequency, urgency, nocturia, intermittency (flow starts/stops) SHID: (poor) stream, hesitancy, incomplete empyting, dribbling (terminal)
56
Why is the PSA antigen test unreliable?
Non-specific, raised in BPH, UTIs, vigorus exercise (cycling), recent ejaculation False positive - 75% False negative - 15% Counselling patient on whether to have PSA test is common OSCE scenario
57
Investigations for prostate cancer
- Protate examination in digital rectal exam, cancerous prostate = firm, asymmetrical, craggy, loss of central sulcus = 2WW referral - 1st line: multiparametric MRI, Likert scale: 1 very low suspicion to 5 definite cancer - Diagnostic = prostate biopsy if Likert ≥ 3)
58
Gleason Grading System + TNM staging
For histology from prostate biopsies Two number, most prevalent + second most prevalent pattern on histology 6 = low risk 7 intermediate 8 or above = high risk T = tumour TX - unable to assesss size T1 = too small to be felt or seen on scans T2 = contained in prostate T3 = extend out of prostate T4 = spread to nearby organs N = node NX: unable to assess N0 = no nodal spread N1: lymph node spread M = metastasis M0/M1
59
Mx of prostate cancer
- Surveillance or watchful waiting in early prostate cancer - External beam radiotherapy directed at the prostate - Brachytherapy (radioactive metal seeds in prostate) - Hormone therapy (reduce testrosterone, androgen-receptor blocker e.g. bicalutamide) - Surgery - radical prostatectomy1 | 1 causes ED and urinary incontinence ## Footnote Hormone therapy SEs: hot flushes, sexual dysfunction, gynaeocomastia, fatigue, osteoporosis
60
61
Myeloma
- Cancer affecting plasma cells, B-lymphocytes that produce antibodies (IgA,G,M,D, E) - Antibodies made up of heavy and light chains - Paraproteins (M proteins) = abnormal antibodies/light chain - Multiple myeloma = myeloma in multiple bone marrow areas - Bence Jones protein = free light chains in urine
62
Clinical features of myeloma
CRAB - C – Calcium (elevated) - R – Renal failure - A – Anaemia - B – Bone lesions and bone pain
63
Complications from myeloma
- Anaemia - most common, cancerous plasma cells infiltrate BM = suppression of other cell lines = normocytic, normochromic anaemia, leukopenia, thrombocytopenia - Myeloma bone disease = increased osteoclast activity (skill, spine, long bines, ribs) - Renal disease (paraprotein deposits, hypercalcaemia, dehydration) - Hyperviscosity syndrome
64
RFs and presentation for myeloma
RFs: older, male, black, FHx, obesity Presentation: persistant bone pain, pathological fractures, fatigue, weight loss, fever, anaemia, hypercalcaemia, anaemia, renal impairment
65
Investigation for myeloma
- FBC (anaemia/leukopenia) - Calcium (raised) - ESR (raised) - Plasma viscosity (raised) - U+E (renal impairment - Serum protein electrophoresis (paraproteinaemia) - Serum-free light-chain assay (abnormal light chains) Urine protein electrophoresis (Bence-Jones protein) - DIagnostic: bone marrow assay - Whole body MRI/CT for bone lesions - X-ray: lytic lesions ("punched-out")
66
Management of myeloma
- MDT - Never cured, relapsing-remitting - Chemotherapy1 + stem cell transplant (autologous (own stem cells), allogenic (donor stem cells) - Myeloma bone disease: Bisphosphonates, radiotherapy, orthopaedic sugery | 1 Bortezomib (proteasome inhibitor), thalidomide, dexamethasone

Sharon's phase 3b/4 (15 decks)

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