CCC - 'the big 4' Flashcards
What is the chance of a woman getting breast cancer?
1/8
What is the current 10 year survival rate in the UK for breast cancer?
80%
What are the risk factors for breast cancer? (6)
Age BRCA1 (breast and ovarian) BRCA2 OCP and hormone replacement therapy Obesity - fat cells start to produce insulin Alcohol Ionising radiation - lots of X rays
What is the most common cell type of breast cancer?
Infiltrative/invasive DUCTAL CARCINOMA
What is the second most common cell type of breast cancer and what is a key feature?
Lobular carcinoma, commonly multicentric tumours
What is the most common presentation in breast cancer?
Breast mass
What are changes to the breast (not a lump) that can be indicative of cancer?
Indentation peau d'orange retracted nipple nipple discharge skin erosion redness/heat
What are the features of inflammatory breast cancer?
Can progress very quickly
Looks like cellulitis
Can present with axillary lymphadenopathy
In the context of breast cancer what would regional lymphadonopathy be indicative of?
Metastatic disease
Where does breast cancer most commonly spread to?
Bone (most common)
Brain
Lungs
Liver
If seen at GP and suspect breast cancer what is the next step?
2 week referral
What makes up a ‘triple assessment’ of breast cancer?
- Clinical assessment - full history and exam
- Bilateral mammography - to identify multicentric tumours or synchronous primaries in the opposite breast
- Targeted ultrasound (+biopsy) of symtomatic area or area of mammographic abnormality
(Patients also have USS of axillary and biopsy if any suspicious nodes)
What imagery should be done for suspected disseminated disease in breast cancer patients?
Isotopic bone scan
Liver imaging - USS or CT
In diagnosing breast cancer when is MRI used? (3)
If there is a discrepancy in between clinical exam, mammogram and USS findings
OR
Breast density prevents accurate mammogram
OR
Histology suggests lobular
What is the TMN staging for breast cancer?
T0 noprimary tumour T1 invasive tumour <2cm T2 Tumour between 2 nnd 5cm T3 Tumour >5cm T4 skin involvement
NO - no lymph nodess
N1 - mobile axillary nodes
N2 - fixed axilliary nodes
N3 Internal mammary nodes
M0 - no mets
M1 - mets
What are the stages of breast cancer?
Stage 0: Tis, N0, M0 Stage I: T1, N0, M0 Stage II: T2/3, N0, M0 or T0/1/2, N1, M0 Stage III: T or N > stage II, M0 Stage IV: Any T, Any N, M1
What is the normal first line choice treatment for breast cancer?
Surgery
What are the types of surgery possible in breast cancer?
Mastectomy
OR
Conservative surgery (wide local excision) with post op radiotherapy
When would neoadjuvant chemotherapy be offered pre surgery in breast cancer patients?
- Surgery not possible due to the size of tumour
- To allow for breast conservation
- Her2 positive or triple negative breast cancer (ER, PR and Her 2 negative) as high response rates are possible
How are the axillary nodes assessed in breast cancer and when is axillary clearance warranted?
- Assessment of axillary nodes at same time as breast surgery
- If initial assessment shows evidence of metastatic involvement the patient will have axillary clearance
- If no evidence of metastatic involvement of the lymph nodes - patient has sentinel node biopsy
- Sentinel nodes are located by injecting tracer material during the surgery
- Sentinel nodes are removed and analysed - if positive then patient will go on to have axillary clearance or radiotherapy to the axillae
When selecting adjuvant systemic therapy for breast cancer - what factors are important to consider?
- Hormone receptor status (oestrogen receptor status)
- HER-2 receptor status
- menopausal status
- Nodal involvement
- Performance status
What tools can be used to assess benefit of chemotherapy in breast cancer?
Oncotype DX test
Adjuvant online
What are the benefits of chemotherapy in breast cancer?
Reduces annular risk of recurrence by 28%
Reduces mortality by 16%
NB effect is greater in women less than 50
NB Use of adjuvant chemo is based on risk/benefit assessment
When can Trastuzamab be used in breast cancer?
When the cancer over expresses the target epithelial growth factort HER-2
Effective in metastatic and localised disease
Give the logistics of giving Trastuzamab (2)
Given for 12 months in adjuvant setting
Can affect cardiac function so need a MUGA scan regularly
What 2 endocrine therapies for breast cancer and when do you give them?
Tamoxifen - PREMENOPAUSAL WOMEN who have tumours which are ER/PR positive
Aromatase inhibitors e.g. anastrazole for POST MENOPAUSAL WOMEN
What are the features of Tamoxifen?
Reduces risk of recurrence and risk of death
Give for 5 years
Complciations - Increased thrombotic complications and increased risk of endometrial cancer
What are the features of Aromotase inhibitors?
Fewer vascular and malignant complications than Tamoxifen
More problems with oseteroporosis
What is the role of radiotherapy in breast cancer? (3)
- Following conservative surgery
- Local chest wall radiotherapy - following mastectomy if high risk recurrence:
a. deep resection margin involvement
b. large primary tumours >4cm
c. multiple axillary lymph nodes
d. wide spread lymphovasular tumour permeation
What is he standard radiotherapy treatment routine for breast cancer?
Monday - Friday for 3 weeks
Additional week for under 50s and close surgical margins
What is the management for metastatic disease in breast cancer?
Depends on state of disease, hormone, HER2 receptor status and patients symptoms, preferences and performance status
If stage 4 after assessment - surgery = not part of treatment except for palliation
Can do endocrine/chemo/radiotherapy
Radiotherapy - palliation of locally recurrent disease and controlling symptoms such as bony mets
What are the endocrine options in metastatic breast cancer?
- Tamoxifen
- Aromotase inhibitors
- Ovarian ablation - in pre menopausal women
How can ovarian ablation be achieved in pre menopausal women who have metastatic breat cancer? (4)
- Surgically
- Radiotherapy induced
- LHRH antagonists
- Gonadotrophin releasing hormone antagonists
What factors of patients with metastatic breast cancer suggest a higher response to endocrine therapy? (3) (Just to recognise for an MCQ)
- The dominant site of disease (highest in women with disease in soft tissue, less in those with bone metastases and less again in those with visceral metastases). This may simply reflect ER status
- An objective response to prior endocrine treatment.
- Greater duration of previous disease free interval.
Before undergoing endocrine treatment for breast cancer what test is important to do?
Obviously hormone receptor status but
DEXA scan
(plus further reccomendations e.g. Vit D, Calcium supplements, bisphosphanates
What are the 3 differentials for breast lump (not cancer)?
Fibrocystic changes - lumpiness, thickening, swelling on period, free moving, smooth, well defined
Fibroadenomas - solid, round, moves, younger woemn
Duct papilloma - small benign tumpur that forms in a milk duct, can cause bloody discharge
How common is colorectal cancer?
4th most common cancer
What are the risk factors for colorectal cancer?
Diet - high in red meat, low in fibre
IBD - definitely UC, CD = controversial
Familial conditions:
a) hereditary non polyposis colonc cancer (HNPCC) (mutations in DNA mismatch repair genes)
b) familial adematous polyposis (FAP) (APC gene - 5q21-22)
c) Gardners syndrome (subtype of FAP)
What gene is faulty in FAP?
APC gene
Where are the most common sitres of colorectal cancer? (3 sites and their percentages)
- Rectum 40%
- Sigmoid 20%
- Caecum 6%
What is the main histological type of colorectal cancer?
90% is adenocarcinoma (mucinous or signet ring)
Rare = squamous cell carcinoma or adenosquamous carcinoma
Describe the development (steps) of adenocarcinoma in colorectal cancer?
normal epithelium > hyperproliferative epithelium > benign adenomas -> invasive carcinoma
NB FAP produces lots of benign adenomas therefore increasing risk of developing invasive carcinoma
What is the presentation of colorectal cancer? (5)
Altered bowel habit Weight loss Rectal bleeding Vague abdomen pain More discrete tumours (RHS colon and caecum) may present with IDA
What is the breast screening programme?
Mammography every 3 years after age of 50-70
What imaging/investigations are done for colorectal cancer and what role do they have? (5)
- Rectal examination (PR) - can feel 75% of rectal lesions
- Direct visualisation - rigid sigmoidoscopy/colonoscopy/proctoscopy (can also biospy)
- CT - provides staging and useful for bowel evaluation
- CT colonography - CT with inflate bowel - can help see synchronous polyps when cant do colonoscopy
- Measurement of tumour marker CEA - not diagnostic but can be used to monitor progression (carcinoembryonic antigen)
What is the staging for colorectal cancer?
T0 - no evidence of tumour T1 Sub mucosal invasion T2 Muscularis propia invasion T3 Into peri colic tisssues T4 Invades visceral peritoneum/adjacent organ or structure
N0 no nodes
N1 1-3 nodes
N2 4+ nodes
M0 no met M1 distant met M1a met just one site M1b - 2 or more sites M1c - peritoneal spread
What is the named staging for colorectal cancer?
Dukes Staging
A invasion into but not through bowel wall
B Invasion through bowel wall but not nodes
C Lymph node involvement
D Distant mets
Age below 40 = bad prognostic factor - biologically more aggressive tumour
What is the role of surgery in the treatment of colorectal cancer?
Radical resectin = usual treatment
Early stage colroecta cancer is usually cured by surgery
Can also have surgery in advanced disease e.g. resection of liver mets in addition to the primary tumour might be helful
Can also do further resection if recurrents to improve survival rate - makes sense
What is the role of radiotherapy in the treatment of colorectal cancer?
Used in rectal but not colon cancer as too much movement
Pre op for high risk rectal carcinomas before resection (cases selected on MRI basis)
Local recurrences can be palliated with radiotherpay
Metastatic disease may also respond to palliative radiotherapy
What is the role of adjuvant chemo for colorectal cancer?
For higher risk colorectal cancers
eg Dueks stage C - 6 months increases survival from 40%-60%
Newer drugs such as Oxaliplatin and Irinotecan are now in standard use
What is the current screening for colorectal cancer?
Faecal occult blood testing of average-risk populations
(with follow up colonoscopy for positive cases) has demonstrated a reduction of mortality between 15-18%. programme.
A+ fact about current issues in colorectal cancer ?
Agents acting through angiogenic mechanisms such as bevacizumab, and agents acting on epithelial growth factor receptors such as cetuximab can be effective when added to chemotherapy in advanced disease and their place in standard treatment regimens is being determined by research and the National Institute Health and Clinical Excellence (NICE).
How common is lung cancer?
3rd most common cancer in UK
Only 10% of people who are diagnosed with lung cancer liver >5 years
What are the different types of lung cancer?
Non small cell lung cancer - adenocarcionma and squamous cell carcinoma
Small cell carcinoma
What are the features of non small cell lung cancers?
- Doubling time from 60 days
2. Localised disease can be treated (and potentially cured) with localised treatment
What are the features of small cell lung cancer? (4)
- Doubling time from 8 days (highly aggressive and fast growing)
- Assume microcscopic mets even if only signs of localised disease (thus need chemo) = met early
- Neoplastic syndromes
- Orgininate in kulchistsky cells
What are the risk factors for lung cancer?
SMOKING age COPD Genetic predisposition Radiation exposure/industrial exposures
What are the symptoms of lung cancer?
Tumour, Mets, Nodal spread
TUMOUR
breathlessness, cough, haemoptysis, recurrent chest infections, wheeze/stridor, dysphagia, palpitations/abnormal heart rhythms
METS
Local (M1a) - lung and pleura
Distant (M1b) - Liver, bone, adrenals (can cause abnormal Na), skin, brain
Due to NODAL spread
SVC obstruction
Hoarse voice - pressing on recurrent laryngeal cancer
Dysphagia/neck lump/mediastinal lymphadenopathy
What are the investigations for lung cancer? (7)
- CXR - 95% lung cancers can be seen on Xray
- CT chest/abdomen - extent of local and distant disease
- PET scan - for patients with operable disease, checks for distant mets which may not have been seen in CT
- Bronchoscopy - view bronchial tree and biopsy (+endobronchial ultrasound - can biopsy lymph nodes within mediastinum)
- Trans thoracic biospy - another biopsy method
- Tumour markers - NSE (neuron specific endolase) and LDH lactate dehydrogenase) - not routinely used
- Pulmonary functioning anad cardiopulmonary testing
What is the management of small cell lung cancer?
Chemo = mainstay
If diagnosis appears to be limited stage = radical radiotherapy and chemo
If more extensive = chemo and maybe consolidation thoracic radiotherapy (if good response to chemo)
Prophylactic cranial irradiation - patient with limited disease and extensive disease who resepond well to chemo
How does small cell lung cancer respond to chemo?
Very well but most patients relapse with cehmo resistnat disease withing 12 months of chemo
NB so receptive to cehmo can use chemo to treat metastatic spinal cord compression in SCLC
What are the advantages and disadvantages of prophylactic cranial irradiation?
Reduces risk of brain mets and improves survival
BUT memory impariment, functional defecit and dementia
What is the prognosis for SCLC? (with and without treatment)
With treatment = 6-12 months
Without treatment - 2-4 months
What role does surgery have in NSCLC?
30% suitable
Stage 1 or 2 can be managed with asurgical resection
Normally followed with adjuvant chemo (adjuvant radiotherapy if positive margins)
What is a contraidication for surgery in NSCLC for most surgeon?
Mediastinal involvement
What is the role of radiotherapy in NSCLC?
If not suitable for surgery often used
SPECIAL RADIOTHERAPY available
CHART = continuus hyperfractionated accelerate radiotherapy - 3xday for 12 days
SABR = sterotatic ablative body radiotherapy (SABR) = for peripheral lung tumours
Often concurrent chemo and radio
What is the role of chemotherapy in NSCLC?
Lots of detail wanted
Mainstay for treatment if metastatic disease or locally advanced disease
Adenocarcinoma - test for mutations in ALK or EGFR - if positive - tyrosine kindase inhibitors = targeted therapy
Immunotherpay - Pembrolizumab - high PDL1 expression can be used before or after chemo
What is the prognosis of NSCLC?
Without treatment 3-6m
With treatment 1y
With targeted therapy 2y
Where do the tumours of lung cancer normally arise from?
Endothelium of large/medium bronchi - rarely from actual lung parenchyma
What are the paraneoplastic syndromes and which type of lung cancer are they associated with? (3)
- SIADH - kidneys dont clear free water = euvolaemic hyponatraemia
- Cushings - increased ACTH thus increased corisol thus weight gain, fatigue, weight gain, fatigue, red face, excess hair, increased BP, Diabetes
- Lambert-eaton syndrome - decreased ACH - weakness, dropping eyelid, swallowing problems
What are the features of squamous cell carcinoma?
Type of non small cell lung cancer
Centrally located
CLosely linked to smoking
Can secrete PTH related hormone - hypercalcaemia
What are the features of adenocarcinoma?
Type of non small cell lung cancer
Peripherally located
Most common lung cancer in non smokers
Has ALK and EGFR mutations (if does can use tyrosine kinase inhibitors)
What are the features of large cell carcinoma?
Type of non small cell lung cancer
Less differentiated than other NSCLCs
Metastasises earlier
What is the function of the prostate?
Make seminal fluid which is stored in the seminal vesicles
What is the most common histology type of prostate cancer? And where does prostate cancer orignate from compared to BPH?
90% = ADENOCARCINOMA
Develop in the posterior or peripheral part of the glandular tissue of the prostate
BPH - orginated from the centre ot he glandular tissue
What is the presentation of prostate cancer?
- Asymptomatic - picked up on PR or PSA test
- LUTS- frequency, hesitancy, dribbling, urgency, weak flow, long time micturating
- Impotence
- Metastatic presentaton - bone pain, anaemia, pathological fracture MSCC
What would you feel on PR for textbook prostate cancer?
Enlarged, hard, craggy gland/nodule
Eventually - obliteration of the median sulcus
What are the initial investigations for prostate cancer? (2)
- PSA
2. PR exam
What investigations would be undertaken by the Urology Oncolology team (3)
- Transrectal US biopsy - to confirm diagnosis
- MRI - if radical treatment is appropriate
- Bone isotope scan if metastatic disease suspected
When do you not need to do a trans rectal US guided biopsy n suspected prostate cancer?
PSA >100 and positive bone scan
Explain the Gleason Grading system
Scores tumpurs from 2-10 on basis of histological patterns of two main areas
Scored 1-5 (5=worse)
Explain the TMN staging system for prostate cancer
T1: Clinically unapparent tumour not palpable nor visible by imaging
T2: Tumour confined within prostate
T3: Tumour extends through the prostate capsule
T3a: Extracapsular extension (unilateral or bilateral)
T3b: Tumour invades seminal vesicle(s)
T4: Tumour is fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall
N0 No regional lymph node involvement.
N1 Regional lymph node involvement
M0: No distant metastasis M1: Distant metastasis M1a: Non-regional lymph node(s) M1b: Bone(s) M1c: Other or multiple site(s) with or without bone disease
What are the 5 components of possible management options for prostate cancer?
- Observation
- Surgery
- Radiotherapy
- Hormonal therapy
- Chemo
What is the observation/watch and weight management method for prostate cancer and wh ois it is appropriate in?
Best for patients with asymptomatic disease confined to the prostate or those with life expectancy <10 years
What is the role of surgery in the management of prostate cancer?
Pateints with localised disease T2 or less - can be treated with a RADICAL PROSTATECTOMY
Can also be used for trans urethral resections to relieve prostatic symptoms or urinary obstruction in some men
What are the potential complications of surgical treatment for prostate cancer?
Lasting impotence and incontinence
What is the role of radiotherapy in the treatment for prostate cancer?
- Alternative to surgery in T1 or T2 patients where PSA = low suggesting no occult mets
- Adjuvantly after surgery if concern of residual disease
- Palliative radiotherapy - palliate the primary tumour/ mets
When radiotherapy is used for palliative care in prostate cancer after TURPs, how long should you wait post TURP and why?
6 weeks to avoid stricture formation
What are the different ways radiotherapy can be given for prostate cancer?
- External beam radiation
- Brachytherapy
NB can use a combo
What are the side effects of radiotherapy treatment in prostate cancer treatment?
Dysuria Rectal bleeding Diarrhoea Impotence Incontinence
What is the role of hormonal treatment in prostate cancer?
Hormonal treatments are used for the treatment of advanced disease or in conjunction with radiotherapy for loalised disease
What are the different types of hormonal treatment in prostate cancer? (5) And, in brief, how do they work?
- LHRH agonist - interferes with release of gonadotrophins and thus reduces level of testosterone (SE of tumour flare on initiation)
- Gonadotrophin releaseing hormone antagonist (self explantory) can give when tumour flare
- Oestrogen therapy - oestrogen inhibits GnRH production (negative feedback loop)
- Anti androgens - compete with androgen sites for androgen receptor
- Bilateral orchidectomy - bit budget - used in countries with low resource level
What are the main side effects for each of the hormonal treatments for prostate cancer?
- LHRH agonist - tumour flare, impotence, loss libido (long term - increased cardiac risk and osteoporosis)
- Gonadotrophin releasing hormone antagonist - none given
- Oestrogen therapy - loss libido, impotence, gynaecomastia, MI, stroke, PE
- Anti androgens - none given
- Bilateral orchidectomy - risks of surgery eg infection
How can a tumour flare be avoided when using LHRH agonists?
Can be avoided by short-term concomitant anti-androgen therapy.
What is the Cancer research UK grading of lung cancer?
Grade 1
The cells look very like normal cells. They tend to be slow growing and are less likely to spread than higher grade cancer cells. They are called low grade.
Grade 2
The cells look more abnormal and are more likely to spread. This grade is also called moderately well differentiated or moderate grade.
Grades 3 and 4
The cells look very abnormal and not like normal cells. They tend to grow quickly and are more likely to spread. They are called poorly differentiated or high grade.
What is the TMN staging for lung cancer?
T1 cancer in lung
T2 cancer between 3-5cm
T3 cancer between 5-7cm
T4 cancer bigger than 7cm
N0
N1 in lung/hilar nodes
N2 mediastinal nodes
N3 opposite side of chest/collar bone/top of lung nodes
M0
M1a cancer in both lungs
M1b single area of cancer outside chest in organ or node
M1c more than one area of cancer in one or several organs
