Cancers Flashcards
Risk factors of lung cancer
asbestos scarring from eg. tb smoking air polution radon gas arsenic
Presentation of lung cancer
- haemoptysis, pleuritic chest pain, SOB, unexplained cough for 3 weeks
- 10% weight loss in 6 months, night sweats, fevers, fatigue, anaemia (iron def)
- recurrent chest infections, not better with antibiotics
- hoarse voice = recurrent laryngeal nerve
- cachexia, clubbing, lymphadenopathy
Investigations for lung cancer
- 1st line CXR (mass + raised hemidiaphragm from phrenic nerve)
- Endobronchial US guided bronchcoscpy for biopsy
- Serum calcium (raised if PTHrP from squamous)
- U&Es (na for siadh in small cell)
- FBC = anaemia
- LFTs
- pulse ox and ecg
- Contrast CT CAP (adrenals + liver for mets!)
- spirometry
When would you refer suspected lung cancer? + areas of spread
Liver, adrenals, bone, brain spread
2ww cxr if >= 40 and 2 of the following (1 if ever smoked)…
cough/fatigue/sob/chest pain/anorexia/weight loss
OR >40 and 1 of the following…
recurrent chest infections/ finger clubbing/ >6 week lymphadenopathy/ chest signs consistent with lung cancer/ thrombocytosis
2ww cancer pathway if
- > = 40 and unexplained haemoptysis
- suspicious cxr
Management of non small cell lung cancer
stage 1-3
- lobectomy (or wedge resection in reduced lung function)
- neo-adjuvant chemo
- adjuvant chemo and radio for stage 2 and 3
- or can use stereotactic ablative radiotherapy as curative therapy
stage 4
- immunotherapy, targeted therapy, chemotherapy
- palliative = chemo and radiotherapy for mets and symptoms
Management of small cell lung cancer
surgery if it is local but most present as mets
so do palliative chemo
do prophylaxis cranial irradiation
Complications of small cell lung cancer
- siadh
- lambert eaton syndrome
- cushings
Complications of non-small cell lung cancer
- hypertrophic pulmonary osteoarthropathy = squamous and adeno
- PTHrP from squamous (hypercalcaemia)
most pancoast are non small cell
- horners if sympathetic compression
- hoarseness if recurrent laryngeal nerve compression
- svco
- arm pain from brachial plexus compression
- vagus nerve compression
Risk factors for breast cancer (male too)
Male = gynaecomastia, klinefelters, BRCA1/2, fhx prostate cancer, cirrhosis, radiation
Female =
- nulliparity, never breastfed
- increased exposure to oestrogen (early menarche, late menopause, hrt (combined), cocp, obesity or high fat diet, first baby >30)
- fhx of relative <50 years old
- older age
- BRCA1,2
- p53 mutation
- chest radiation
Presentation of breast cancer and some other differentials of breast lumps
- painless fixed hard lump in the breast
- skin changes like dimpling
- nipple discharge or bleeding
- nipple changes or inversion
- Pagets disease of the nipple (ductal carcinoma in situ)
- oedema or erythema or colour changes
- Ulceration is a late sign
- lump in the axilla
fibroadenomas, lipomas, phillodes tumours, fat necrosis
When would your refer suspected breast lump?
> =30 2ww
unexplained lump in the breast or axilla
> =50 2ww
unexplained skin or unilateral nipple changes suggestive of malignancy (discharge, retraction, etc)
<= 30 Not urgent
unexplained breast lump
What is the breast screening available?
47-73 every 3 years
Mammogram
also for those with brca1/2, fhx of first degree relative <50 years old, previous cancer
How would you investigate breast cancer?
Triple assessment
- mammogram (<35 do US as there is thicker breast tissue)
- breast examination
- fine needle aspiration (cytology) or core needle biopsy (histology)
- CTCAP
- TNM staging
- Receptor status (her, oestrogen, progesterone)
- LFTs, U&Es, FBC
- bone scan
What are the types of breast cancer?
Ductal carcinoma in situ
- microcalcifications on mammogram
- associated with pagets disease
Invasive ductal carcinoma
- invaded through basement membrane
Lobular carcinoma in situ
- may be no lump or discharge, hard to detect
- often multifocal and bilateral
Invasive lobular carcinoma
How would you manage breast cancer?
Wide local excision or mastectomy
- can do neoadjuvant chemo to reduce tissue
- adjuvant chest wall radiation afterwards
- can do sentinel node biopsy or axillary node clearance if indicated
- adjuvant chemo improves survival
Advanced breast cancer
- chemo and radiotherapy +/- targeted therapies
- HER2 +ve = herceptin (tratuzumab)
- Oestrogen +ve = SERM tamoxifen for premenopausal, Aromatase inhibitor letrozole or anostrozole for post menopausal
- If triple negative = chemo with platinum and anthracycline
Where does breast cancer spread?
lungs, liver, bones
What are some risk factors for colorectal cancer?
- low fibre
- high processed meat, high fats, alcohol, smoking
- IBD
- diabetes
- old, male
- familial adenomatous polyposis, HNPCC
How does colorectal cancer present? (L,R,Rectal)
Sister Mary Joseph Nodule = lymphadenopathy
R = caecal
- faecal occult bleeding
- iron def anaemia/ fatigue
- appendicitis
- RIF mass and abdo pain
L = sigmoid
- colicky pain
- LIF mass
- tenesmus
- bowel changes (diarrhoea, mucus), obstruction etc
Rectal
- rectal mass
- tenesmus then persistent pain
- rectal bleeding
- if invades anal sphincter = incontinence
- can invade into sacral plexus = back pain
When would you refer for suspected colorectal cancer?
- palpable rectal mass
- man with iron deficiency
- non menstruating woman with iron deficiency
- > 40 and unknown rectal bleeding or changes in bowel habit for >6 weeks
- > 50 and unknown rectal bleeding for >6 weeks
How would you investigate for colorectal cancer?
- 1st line = flexi or rigid colonoscopy + biopsy
- barium enema if that was not possible
- Faecal Occult blood
- FBC, U&Es, LFTs
- Cea to monitor treatment
- CTCAP
- MRI for rectal cancers
What is the colorectal screening system available?
60-75 every 2 years
faecal immunochemistry test
How would you manage colorectal cancer?
Dukes Scale and TNM
Dukes A-C
- surgical resection (use laxatives before and prophylactic antibiotics after)
- emergency = hartmanns
- FOLFOX adjuvant chemo for B and C
Radiotherapy for rectal cancer +/- chemo
Obstruction = decompression colostomy or endoscopic stenting
What are some risk factors for prostate cancer?
BRCA 2
fhx of prostate cancer, breast cancer, colorectal
Black, male, high bmi, old age
How would prostate cancer present?
LUTS (hesitancy, resistance) ED, haematospermia haematuria lower back pain asymptomatic with a randomly raised PSA anorexia, weight loss, lethargy
When would you refer for prostate cancer?
Do a PSA and DRE for…
men with LUTS, haematuria, ED
Refer for 2ww if…
- PSA>=3 in a <70 year old
- PSA>5 in >70s
- abnormal DRE
What kinds of things can raise a PSA
Urinary retention, BPH, Chronic prostatitis, prostate cancer
Vigorous exercise, recent ejaculation
recent medical procedure like TURP or DRE or catheterisation
How would you investigate for prostate cancer?
- PSA
- free PSA (if free PSA<15% and PSA is high, suggestive of malignancy)
- DRE (BPH is smooth generally enlarged, chronic prostatitis is boggy and tender, cancer is craggy hard irregular nodular)
- 1st line is Multiparametric MRI of prostate (Linkerts scale if >=3 then do a biopsy too for TNM and Gleason staging)
- Used to be a Trans Rectal US Guided Biopsy (higher infection than trans perineal)
- FBC, U&Es (obstruction or hydronephrosis), LFTs
- Xray for osteosclerotic lesions, bone scan
- CT CAP
How would you manage prostate cancer
PSA<10, Gleason<=6, T1-T2a
- watchful waiting (dres, psa)
- active surveillance (dres, psa, biopsy)
- radical prostatectomy or curative external beam radiotherapy +/- brachytherapy
PSA 10-20, Gleason 7, T2b
- active surveillance
- radical prostatectomy or curative EBRT+/- brachy
PSA>20, Gleason 8-10, >=T2c
- radical prostatectomy or curative EBRT+/-brachy
- hormonal for mets
Hormonal
- LHRH agonists like goserelin (zolidex) but give androgen antagonist first to avoid testosterone spike
- or you could do an bilateral orchidectomy to block androgens
- Androgen receptor antagonists like Bicalutamide
Palliative
bisphosphonates and radiotherapy
What are some risk factors for myeloma?
- radiation
- long term hair dye exposure
- petrochemical industries or agriculture industry exposure
How would myeloma present?
CRABBI
Calcium is high
- osteoclast overactivity, results in bone pain and pathological fractures.
- stones, moans, bones, psychic groans, polydipsia etc.
Renal dysfunction
- nephrocalcinosis and nepholithiasis (hyperuricaemia) don’t help
- light chains get deposited in renal tubules and cause damage
Anaemia
- pancytopaenia due to bone marrow overcrowding, stopping erythropoiesis
Bones
- bone pain due to osteoclast overactivity and bone marrow overcrowding
- Lytic lesions seen on xray
Bleeding
- pancytopaenia due to bone marrow overcrowding
Infections
- reduced production of normal immunoglobulins
When would you refer about myeloma?
do Ca2+, FBC, ESR, PV if >60 and…
unknown pathological fractures or unexplained back pain
do Bence Jones proteins or serum electrophoresis within 48 hours if >=60 and…
- unknown hypercalcaemia/leukopenia AND suspicious myeloma presentation
do Bence Jones proteins or serum electrophoresis within 48 hours for anyone if…
- PV and ESR were suspicious AND suspicious myeloma presentation
do 2ww myeloma if…
- Bence Jones and serum electrophoresis were suspicious for myeloma
How would you investigate for myeloma?
- FBC, U&Es, LFTs, Ca2+, PV, ESR, LDH
- Bone marrow aspiration and trephine biopsy = plasma infiltration of bone marrow
- Serum protein electrophoresis (monoclonal paraproteins) + Immunofixation (Iga or igg) = raised monoclonal IgG and IgA production
- Urine protein electrophoresis for Bence Jones proteins
- peripheral blood film = Rouleaux formation (due to increased paraproteins)
- Xray = lytic lesions like “raindrop skull”
- DEXA Bone scan
- Whole body MRI
What results are diagnostic for myeloma?
- monoclonal proteins present in serum or urine from electrophoresis
- monoclonal plasma cells in bone marrow >10%
- end organ damage eg. hypercalcaemia, lytic lesions, renal damage
How would you manage myeloma?
Stem cell transplant (autologous best but risk of neutropenic sepsis)
- Bortezomib + dexmethasone induction therapy
- monitor for 3 months after with electrophoresis and bloods
if relapse after initial therapy
- 1st line Bortezomib
- or repeat stem cell transplant
Symptom management
- anaemia = erythropoietin analogues, blood transfusions
- infection = influenza vaccine, prophylaxis antibiotics, immunoglobulin replacement therapy
- bone pain = bisphosphonates (+ppi), vit d, calcium
- lytic lesions already happened = kyphoplasty
- VTE prophylaxis
What are some risk factors for Hodgkins and Non-Hodgkins lymphoma?
both:
- HIV, EBV, Ra, sarcoidosis, autoimmune
- FHX
non-hodgkins specific:
- MALT = h pylori
- Hep B, C
- hx chemo or radio
- exposure to pesticides and trichloroethylene
- old age
How would a hodgkins and non-hodgkins lymphoma present? compare and differentiate
Hodgkins
- bimodal distribution (20s then 70s)
- painless asymmetrical lymphadenopathy non tender
- pain on drinking alcohol
- B symptoms prominent like weight loss, night sweats, fatigue, malaise
Non Hodgkins
- painless asymmetrical lymphadenopathy non tender
- B symptoms later on
- Extranodal presentations like hepatosplenomegaly, testicular enlargement, abdo pain, pancytopaenia, SOB
When would you refer for query lymphoma?
Hodgkins
- unexplained lymphadenopathy (consider B symptoms and alcohol pain)
Non Hodgkins
- unexplained lymphadenopathy or splenomegaly (consider B symptoms)
How would you investigate for hodgkins vs non hodgkins lymphoma?
Hodgkins
- FBC, U&Es, LFTs normal, LDH high, ESR high
- excisional Lymph node biopsy = Reed Sternberg Cells
- CXR = mediastinal widening
- CT CAP to stage
Non hodgkins
- FBC, U&Es, LFTs, LDH, ESR
- excisional Lymph node biopsy
- Urea breath test for H Pylori (MALT)
- Microscopy shows starry sky appearance (Burkitts)
- Bone marrow aspiration and trephine biopsy
- Immunophenotyping (B or T cells)
- Immunoglobulin tests (Igm or Igg)
- HIV test as it is a risk factor
- CT CAP to stage
How would you manage hodgkins and non hodgkins lymphoma?
Ann Arbor staging
Hodgkins: ABVD Chemo (adriamycin, bleomycin, vinblastine, dascarbazine)
Non Hodgkins:
- Radiotherapy for localised disease
- Stem cell transplant
- CHOP Chemo + rituximab (monoclonal antibody) for high grade
- flu/pneumococcal vaccines
- prophylactic antibiotics for neutropenia
what are some risk factors for acute vs chronic leukaemia?
AML =
what are some risk factors for acute vs chronic leukaemia?
Acute:
radiation, benzene, genetic mutations like downs and klinefelters
Chronic: Philadelphia chromosome (BRC-ABL), etc
how would ALL and AML present? how would CML and CLL present?
ALL = kids!
- lymphadenopathy, hepatosplenomegaly, testicular enlargement
- bone pain and bone marrow failure = pancytopaenia (petechiae, bleeding, bruising, infection, fatigue)
AML
- bone marrow failure and pancytopaenia signs
- violaceous skin lesions
CLL
- typically asymptomatic
- pancytopaenia
- painless lymphadenopathy more marked than CML
- very big hepatosplenomegaly
CML typically presents in chronic phase
- SOB (anaemia), dyspnoea, abdo discomfort, hepatosplenomegaly, lymphadenopathy
- gout due to increased purine breakdown
- bruising, bleeding, pallor, infection, fatigue
How would you investigate acute leukaemias and how would AML and ALL vary?
peripheral blood films =
- ALL = leukoblasts
- AML = Auer rods
FBC (low hb, low platelets, high wcc)
U&Es, LFTs, LDH, ESR
Bone marrow aspirate =
- low erythropoiesis and low megakaryocytes
- Flow Cytometry Immunophenotyping for myeloid or lymphoid
- Fluorescent Insitu Hybridisation for mutations like Jak2
ALL has mediastinal widening on CXR
How would you investigate chronic leukaemias and how would CML and CLL vary?
FBC = low rbc, low platelets, high wcc
(CLL wcc is very very high)
Blood film
- CLL = smudge cells or smear cells
- CML = neutrophilia with myeloid precursor like blasts
Bone marrow aspiration =
- CLL = high lymphocytic infiltration
- CML = increased cellularity
Immunophenotyping
Fluorescent insitu hybridisation =
- CLL = trisomy 12, 13q deletion, mutated IgVH
- CML = philadelphia chromosome (BRC-ABL)
Urate raised
How would you manage acute leukaemias?
Remission induction using chemo to destroy tumour= huge bone marrow hypoplasia
Then once haematopoesis is acheived, remission consolidation = huge bone marrow hypoplasia
After remission, watch for 3 years. then continue to watch ALL patients closely
AML = high risk are only give treatment if they have an HLA match for bone marrow transplant
ALL = need intrathecal chemo prophylaxis as soon as blasts are cleared from blood
Symptom management
- bleeding = prophylactic platelet transfusion (esp AML)
- fresh frozen plasma to maintain APTT and INR<1.5x normal
- cryoprecipitate to keep fibrinogen >1.5g/dl
- Norethisterone for women to avoid menorrhagia
- infection = Prophylactic antibiotics and handwashing education
- hyperuricaemia = prophylactic allopurinol, rasburicase, hydration
How would you manage chronic leukaemias?
CML = ph chromosome
- 1st line = Imatinib for chronic phase
- if no ph chromosome then interferon a
- SOKAL index for prognosis
CLL
- 1st line = Rituximab
- Rai or Binet staging systems
- watch for richters syndrome (EBV involved) –> NHL
