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Fundamentals 3- Heme > Clinical Presentation of a Patient with Cancer > Flashcards

Clinical Presentation of a Patient with Cancer Flashcards

1
Q

What are the 4 defining characteristics of cancers?

A
  1. Clonality- arise from a single cell with genetic alteration and proliferation
  2. Autonomy- not regulated by normal biochemical and physical environment signals
  3. Anaplasia- malignant cells do not mature or differentiate properly
  4. Metastasis- malignant cells can be released from the primary tumor and spread/ continue growing
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2
Q

What are the 3 “B symptoms” not SPECIFIC but more common for lymphoma?

A
  1. fever without obvious infection
  2. night sweats
  3. Weight loss
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3
Q

What are 3 generalized symptoms associated with cancer?

A
  1. unusual fatigue
  2. obvious loss of appetite
  3. loss of taste for food
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4
Q

What are 5 localizing symptoms for cancer?

A
  1. change in bowel/bladder habits
  2. rectal bleeding or hematuria
  3. persistent cough
  4. palpable lump or mass
  5. painless jaundice
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5
Q

If you have positive findings when taking a patient history for cancer, what 4 questions should you follow up with?

A
  1. Duration
  2. Quality of pain - sharp, pleuritic, positional
  3. Exacerbating/ ameliorating factors
  4. progressive, constant, intermittent symptoms
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6
Q

What cancers have a family history?

A 
Breast
Ovarian
Colon
Uterine
Melanoma
Neurofibromatosis, endocrine neoplasia
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7
Q

What four factors would you look for specifically in a social history when considering cancerous symptoms?

A
  1. Tobacco
  2. Alcohol
  3. IV drug use/sexual promiscuity with immunocompromised state
  4. transplant historys
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8
Q

When doing a physical exam, what systems do you want to pay special attention to?

A
  1. lymphadenopathy and organomegaly
  2. rectal/prostate
  3. skin lesions and rashes
  4. heart and lung
  5. palpable masses
  6. neurologic abnormalities
  7. general appearance (functional status, treatment options)
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9
Q

Malignancies produce symptoms in what 2 general way?

A
  1. Mass Effect- occupying space disrupts the surrounding tissues with or without invasion
  2. Paraneoplastic syndromes- Metabolic derangement and release of hormones/biologically active agents
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10
Q

What are the mass effect symptoms of a brain tumor?

How do brain tumors metastasize?

A
  1. headache, seizure, neurologic and CN deficits, altered mental status, herniation (presents with stroke like symptoms but can be differentiated from stroke with CT scan or level of acuteness)
  2. Brain tumors metastasize to other areas of the brain or are locally recurring. Ependymoblastomas, medulloblastomas and primitive neuroectodermal tumors can seed the neural axis.
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11
Q

What are the mass effects of lung tumors?

A
  1. Diminished O2 exchange
  2. invasion into vessels can cause hemorrhage and fill alveoli
  3. Airway obstruction
  4. cause SVC or locally invade mediastinum (heart, aorta, esophagus
  5. cause Horner’s syndrome by invasion into sympathetic ganglion
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12
Q

What organs do lung tumors metastasize to?

To what 2 local lymph nodes?

A 
Pleura
lung
bone 
brain
pericardium
liver
adrenal 
*vascular drainage to other organs
*lymphatics to bronchoarterial vessels to hilar and mediastinal nodes
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13
Q

What is the mass effect of GI tumors?

A
  1. Slow oozing bleeding –>Fe deficiency
  2. Obstructed bowel or perforate
  3. Pancreas/Liver tumors obstruct causing hepatic cholestasis and parenchymal destruction
  4. Fistulas
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14
Q

What is the mass effect of GU tumors?

A
  1. Bleeding
  2. Obstruction
  3. Renal failure
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15
Q

What are the mass effects of bone marrow tumors?

A
  1. crowd out normal progenitors leading to anemia, thrombocytopenia, leukopenia
  2. Increased bleeding risk
  3. increased risk of infection
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16
Q

What are the two “space occupying” tumors in the marrow?

A
  1. Primary tumors- leukemia

2. Metastatic- prostate cancer

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17
Q

What is the mass effect of bone cancers?

What is the major type of bone weakening cancer?

A

Weakened bone that can be broken by minor stresses

Multiple myeloma

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18
Q

What are the mass effects of liver cancer?

A
  1. biliary obstruction (jaundice)
  2. parenchymal destruction
  3. Coagulopathies (because clotting factors are made in the liver)
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19
Q

What are mass effects of muscle and connective tissue cancer?

A

Sarcomas lead to local destruction and spread to liver, lungs, and brain

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20
Q

What are the mass effects of lymphatic tumors?

A

local invasion and obstruction leading to the same problems as bone marrow “mass effects”
Anemia, thrombocytopenia, leukopenia

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21
Q

Where does the pancreas metastasize to?

What is the lymphatic and venous drainage of pancreatic cancers?

A

lung
liver
bone
serosal seeding

Lymphatics: local nodes and portal venous circulation

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22
Q

Where do colong cancers metastasize?

What are the lymphatic and venous drainage sites?

A

Liver
Lungs
Bone
Serousal seeding (same as pancreas)

Lymphatics: intramural lymphatics to pericolic and intermediate nodes
Venous: mesenteric and periaortic nodes

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23
Q

Where does breast cancer metastasize?

What are the lymphatic and venous drainage?

A 
skin
chest wall
axilla
lungs
brain 
liver

Lymphatics: axillary nodes and internal mammary nodes

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24
Q

What are two types of intradural extramedullary tumors?

A

Scwhannoma

meningioma

25
Q

What are two intradural intramedullary tumors?

A

astrocytoma

ependymoma

26
Q

What are two examples of extradural spinal cord tumors?

A

chordoma

metastases

27
Q

What type of lymphoma has predictable contiguous spread?

A

Hodgkin’s lymphoma

non-hodgkins has unpredictable spread

28
Q

Where is the primary infection for most lymphomas?

Where do they metastasize?

A

They are primary nodal tumors.

They metastasize to the liver, spleen and marrow

29
Q

Where do plasma cell neoplasms commonly cause disease?
What is overproduced by them?
What are the 3 major metabolic effects of a plasma cell neoplasm?

A

They cause nodal and marrow disease

They overproduce immunoglobins (IgG>IgA>IgM>IgD=IgE

Metabolic effects:

  1. Hypercalcemia
  2. renal failure
  3. infections
30
Q

What are the 3 main types of plasma cell neoplasms?

A
  1. multiple myeloma
  2. plasmacytoma
  3. Waldenstrom’s macroglobulinemia
31
Q

What is Waldenstrom’s macroglobulinemia?

A

Plasma cell neoplasm characterized by IgM pentamer overproduction.
It lead to:
Hyperviscosity of the blood
Heavy liver, spleen and lymph node infiltrate

32
Q

What makes a leukemia chronic vs. acute?

A

Chronic is mature cells and acute is immature cells (blasts)

Acute has a worse outcome because the cells are less differentiated

33
Q

What is SVC syndrome?

A

low pressure syndrome providing drainage for head and neck, upper extremities and thorax to SVC gets obstructed by:
Lung or breast cancer or lymphoma
and causes collateral venous formation:
1. azygous, internal mammary

34
Q

What are the symptoms of SVC syndrome?

A 
Dyspnea
Facial swelling
Arm swelling
Cough
Plethora (excess blood)
Cyanosis
35
Q

What is Horner’s syndrome?

A

High apical tumor of the lung disrupts the sympathetic chain and causes:
myosis (constricted pupil)
Anhydrosis (inability to sweat)
mild ptosis (droopy eye)

36
Q

Where is the location of tumor normally in spinal cord compression?

A

Tumor extends from vertebral bone metastasis or paraspinous tumor through the foramina

37
Q

How does a patient with spinal cord compression present?

A

Pain, weakness, paresthesia (numbness), bowel and bladder dysfunction

38
Q

What types of cancers cause lactic acidosis as their metabolic effects?
What classification of lactic acidosis is it?

A
  1. leukemias
  2. lymphomas
  3. extensive liver metastases

It is type B lactic acidosis from overproduction of pyruvate (not poor perfusion which is type A)

39
Q

Hypocalcemia occurs as part of _____________ syndrome.
What is the mechanism that causes the hypocalcemia?
What two cancers is this common in?

A

Tumor lysis syndrome- from very large tumors or in response to chemotherapy
Ca levels drop due to binding with phosphate released by dying cancer cells.
Common in leukemia and lymphoma

40
Q

What ectopic hormones are produced by cancers?

A
  1. ACTH
  2. Vasopressin
  3. Calcitonin
  4. PTH
  5. 1,25 (diOH) Vitamin D
  6. Erythropoietin
41
Q

What is the number one metabolic emergency in cancer patients?
How do these patients present?

A 
Hypercalcemia.
These patients present with:
dehydration
nausea/vomiting
weakness
Confusion
Coma 
Seizure
42
Q

What happens to serum calcium, phosphorus and urinary cAMP in patients with primary hyperparathyroidism?

A

Ca increase
Phosphorus decreases
urinary cAMP increases

43
Q

What are the five major causes of hypercalcemia in cancer patients?

A
  1. Humoral hypercalcemia in malignancy
  2. Osteolytic hypercalcemia
  3. Metastases
  4. Immobilization
  5. Volume depletion
44
Q

What happens in humoral hypercalcemia of malignancy?
What are the 3 tumor locations that can cause this type of hypercalcemia?
What are the 3 hormones released?

A

the primary tumor produces hormones released into circulation which indirectly releases Ca from bone without metastases.

Breast, non-small cell lung, head and neck

PTH-RP (parathyroid hormone related protein
PTH
Vit D3

45
Q

What is local osteolytic Hypercalcemia?
What type of cancer causes this?
What is the released product?

A

Tumors occuring in bone release cytokines to act locally and release Ca from the bone with metastasis.
Multiple myeloma

IL1, IL6, 1,25 (diOH) Vitamin D

46
Q

What is the clinical presentation of Dermatomyositis?

What type of cancers is it associated with?
How is it diagnosed?

A
  1. inflammatory myelopathy with proximal muscle weakness
  2. erythema on eyelids (Heliotrope rash)
  3. telangiectasia (Gottron’s Papules) on knuckles, chest and face

It is associated with breast, lung, GI or ovary cancer.

Diagnosis by EMG/NCV (electromyogram/nerve conduction velocity)

47
Q

What is Eaton-Lambert syndrome?
What cancer usually underlies it?
How is it diagnoses?

A

Proximal muscle weakness where Ab are made against presynaptic cleft Ca channels decreasing Ach release

Small cell cancer of the lung
Diagnosed by EMG/NCV (electromyogram/nerve conduction velocity)

48
Q

Investigative studies to diagnose cancer fall into 3 categories. What are they?

A
  1. Radiologic studies
  2. Lab studies
  3. Invasive procedures
49
Q

What are the five scans for radiologic imaging? What areas of the body does each image?

A
  1. CT- chest, abdomen, brain
  2. plain films- lungs and bone
  3. MRI- spinal cord and brain
  4. Mammography - breasts
  5. Sonography- abdomen and pelvis
50
Q

What 6 pieces of info about the tumor can be described using radiologic study?

A
  1. size
  2. location
  3. relationship to adjacent structures
  4. solid v. cystic
  5. vascularity
  6. How to best biospy/resect
51
Q

What are the four invasive procedures used to assess the tumor?

A
  1. Endoscopic techniques- bronchoscopy, colonoscopy, esophagastroduodenoscopy, laryngoscopy
  2. FNA
  3. bone marrow biopsy
  4. excisional biopsy- especially for lymphoma
52
Q

What stain helps identify:

  1. glycogen
  2. catecholamines in neuroendocrine tumors
  3. glandular differentiation in adenocarcinomas
A
  1. PAS stain
  2. silver stain
  3. mucin stains
53
Q

What cell do the following antibodies help identify in immunohistochemistry?

  1. keratin
  2. vimentin
  3. LAC
  4. L-26
  5. UCHL1
  6. S-100
  7. EMA
  8. CEA
  9. HCG,AFP
A
  1. epithelial cells (carcinomas)
  2. mesenchymal cells (sarcoma, melanoma)
  3. leukocytes
  4. B-cells
  5. T-cells
  6. Melanocytes
  7. Epithelial
  8. Adenocarcinomas (colon breast, GI cancer)
  9. germ cell cancers
54
Q

What is the distinction between clinical stage and pathological stage?
Which is more accurate?

A 
Clinical stage is based on:
1. physical exam
2. radiologic studies
Pathological stage is based on:
1. surgical findings
2. histologic findings

Pathological stage is more accurate

55
Q

Which is a worse prognosis:
T3NOMO or T1N1MO?
Why?

A

T1N1M0 is worse because N+ disease is generally worse than N- disease regardless the T stage

56
Q 
What is meant by:
Tx
T0
Tis
T1,2,3,4
A

Tx= primary tumor cannot be assessed
T0= no evidence of primary tumor
Tis= cancer in situ
T1,2,3,4 increasing size and local extent

57
Q

What is meany by:
Nx
N0
N1,2,3

A 
Nx= regional lymph node cannot be assessed
N0 = no spread to regional lymph 
N123 = increasing involvement of regional lymph nodes
58
Q

What is meant by:
Mx
M0
M1

A 
Mx= cannot be assessed 
M0= no distant metastasis
M1= distant metastasis

Fundamentals 3- Heme (19 decks)

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