CSIM solid organ malignancy Flashcards
what is the grading system for cytological samples?
C1 - C5 where 5 is definite malignancy
what is icterus?
jaundice in the scelera
which abdo organs move on respiration?
basically all of them
not so much bowel
cancer patient with confusion- what additional investigations should you always do?
LP - check for cancer cells in the fluid
calcium - bone cancer
why do you need to check clotting in cancer patients?
risk of bleeding in biopsy
what kind of anaemia in cancer?
normocytic or micro if there is an associated iron deficency
what is serum protein electrophoresis? when is it used?
measures specific proteins in the blood to help identify some diseases
looking for diseases that chuck out loads of protein (e.g. anti bodies) like myeloma
role of calcium in confusion ? how to investigate?
raised calcium causes confusion
need corrected calcium
what is B HCG diagnostic of?
CONTEXT:
germ cell cancer
molar pregnancy
what is corrected calcium and ionized calcium?
ionized - unbound ‘free’ calcium
corrected - takes into account the amount bound to albumin as well as the free atoms
what is the advantage of a colonoscopy over non invasive imaging techniques?
can do a biopsy too
what is PTT?
AKA APTT
activated partial thromboplastin time - measures the intrinsic clotting pathway
what is the tumour marker for colon cancer?
carcinoembryonic antigen
effect on MCV in suspected GI malignancy? why
decreased
chronic gi bleed -> iron deficiency
what is performance status?
scale from 1 - 5 where 1 is normal and 4 is bed bound (5 is dead)
when does breast cancer metastasize?
when grown to 1cm
what is transcoelomic spread
a route of tumour metastasis across a body cavity, such as the pleural, pericardial, or peritoneal cavity.
modes of cancer spread
lymph
local
transceolomic
blood
what nodes do testes / ovarian cancer spread to?
para-aortic
what nodes do genital tract cancers spread to?
femoral / inguinal
what are the 3 steps in the approach to carcinoma of unknown origin?
- search for primary site
- rule out potentially curable / treatable tumours
- characterise the pathology then treat
what is the biggest environmental factor in cancer predisposition?
diet
what % of lung cancers are associated with smoking?
90%
adenocarcinomas arent that strongly associated
how does smoking affect organs other than the lungs?
absorption of chemicals into other parts of the body leads to chronic inflammation
which lung is more likely to be effected by mesothelioma?
the right
right main bronchus is more vertical and these particles follow gravity
how does radiation lead to cancer?
high-frequency radiation dislodges electrons therefore damaging molecular structure
what % of cancer is caused by ionizing radiation?
5%
how does xeroderma pigmentsum predispose you to cancer?
minimal UV exposure will cause mutation
what viruses causes HCC?
HBV HCV
world wide most common cause of HCC?
HBV
here it is alcohol and therefore cirrhosis
what causes kaposi sarcoma?
HHV8
what hormonal causes of breast cancer are there?
anything that heightens exposure to estrogen:
- low parity
- late age of first birth
- early menarche and late menopause
- increased breast density
effect of post menopause estrogen Tx on endometrial cancer?
increases risk if given without progesterone
how do viruses cause cancer?
chronic inflammation
what is the difference between a germ line and a somatic mutation?
germ line - mutation that effects every cell in the body including all the gametes
somatic- only in that one cell
what characterizes li-fraumeni syndrome?
- pre-menopausal breast cancer
- childhood sarcoma
- brain tumours
- leukaemia
- lymphoma
- adrenocortico carcinoma
what is the defect in li-fraumeni syndrome?
germ line mutation in the p53 gene on chromosome 17p
clinical sign in the eye for retinoblastoma?
white pupil reflex
what are the clinical features of multiple endocrine neoplasia. inheritance?
mucosal nueromas on the tongue
medullary carcinoma of the thyroid
marfanoid features
skin pigmentation
autosomal dominant condition
what is lead time bias in relation to cancer screening?
in a screening programme you will detect cancer earlier therefore the survival time from detection is spuriously long in relation to those who didnt undergo screening
sens. and spec. of CA125?
high sensitivity
low specificity
why is the prevalence of lung cancer less than the incidence?
most people die very quickly after dignosis
why do some lung cancer patients get dysphagia?
tumour pressing on the oesophaus
why do some lung cancer patients get a hoarse voice?
pressing on the laryngeal nerve
this is very bad for prognosis
which lymph nodes does lung cancer typically drain to?
supraclavicular
axilla
which vessel can become compressed in lung cancer and constitutes a medical / oncological emergency?
sup. vena cava
signs of SVC obstruction
dilated / tortuous vessels of upper chest (nipples)
oedema of the face / neck / arms with distended veins
congested mucous membranes
what is Pancoasts syndrome?
apical malignant neoplasm in the lung leads to:
- Horners syndrome
- shoulder pain
- oedema secondary to vessel compression
what happens to trachea in pleural effusion?
normally nothing as fluid will be at base of lung
can shift it if MASSIE effusion
what is the role of sputum cytology in lung cancer ix?
not very useful but can hep rule out non-cancerous causes
what is the role of CT thorax in lung cancer?
used to assess size, spread, invasion and lymph node involvement
what further investigations are always done in SCC
CT head
CT upper abdo
to check for spread else where
what is the most important factor when considering treatment?
performance status
what does LDH tell you about cancer?
NOT an indication of cancer risk but high LDH suggests rapid growth of cancer cells so is a prognostic factor
why does LDH increase with cancer growth
cancer cells need increased glycolysis
cancer cells use anaerobic method of metabolism even when oxygen is sufficient
most common presentaion of brain mets?
headaches
also get cognitive dysfunction, neuro deficit and seizures
which lung cancer can present with large amounts of pink frothy sputum?
bronchoalveolar carcinoma
what supportive treatment is useful in brain mets?
steroids to reduce oedema
anti convulsants
why can you get a raised calcium in cancer?
tumour producing PTH-rP leads to increased calcium
presentation of hypercalcaemia
rapid onset confusion, nausea / vomming, dehydration
why is gynecomastia a feature of cancer?
in germ cell cancers (testes, ovaries) the tumour can produce gonadatrophins
which lung cancer can cavitate?
squamous cell - can get a fluid level
which lung cancer gets multiple bilateral pulmonary nodules?
bronchoalveolar carcinoma
how does SCC look on CXR?
large, bulky central mass with hilar and mediastinal adenopathy
what type of cancer is a biopsy often not necessary in ?
germ cell cancers
what is the most common cancer in teenagers / young adults?
testicular germ cell in men
germ cell cancers are generally very rare
what happens to testicularsize in germ cell cancer?
noramlly gets larger
can get smaller
where is there pain in testicualr cancer?
testes (20%)
back (10%) due to para aortic lymphadenopathy
why get gynaecomastia in germ cell cancer?
beta - HCG
what tumour markers do you want to look for in testicular cancer?
AFP
B-HCG
LDH
why raised LDH in tumour growth?
it is an intra cellular enzyme that is released on tumour necrosis so goes up with chemotherapy
what imaging in testicular cancer?
USS
CT
what three things combine to be diagnostic for testicular cancer
testicular mass
raised B-HCG
AFP
this is one scenario where tumour markers are diagnostic of cancer
what drug can give a false positive in B-HCG test?
regular cannabis use
what gives false positive in AFP?
alcohol abuse
what imaging is done after the histological diagnosis in germ cell cancer?
contrast CT chest, abdo and pelvis within 3 weeks
what would prompt you to do CT head in germ cell cancer?
multiple lung mets
very high HCG (>10,000)
how can HCG tell you about brain mets?
if CSF HCG > serum HCG then must be cancer in brain
if CSF HCG < serum HCG then it is seeping in from the blood
what is tumour lysis syndrome? why does it happen
oncological emergency -> AKI, DIC, cardiac arrest
hyperuraemia
hyperkalaemia
hypOcalcaemia
hyperphosphataemia
when there is a large amount of tumour cell death (due to treatment) the products of this can be toxic to the liver
when is tumour lysis syndrome often seen and why?
large volume and sensitive tumours: germ cell sarcoma burketts lymphoma leukaemia
when should contralateral teste be biopsied?
if < 30 yo
if small
how are suspected residual masses investigated?
PET at least 2 weeks after end of chemo
what must considered before biopsy of testes?
sperm banking
effect of multiple pregnancies on ovarian cancer?
reduced
effect of taking the mini pill on ovarian cancer?
none,
taking the COC for 10 years reduces it though
why do animal fats increase ovarian cancer?
animals are fed oestrogen to make them fatter
in a somatic mutation which cells have a mutation?
only the tumour cells
why do 2/3 of ovarian cancer patients present late (stage 3 or 4)
early stage is asymptomatic
signs symptoms of ovarian cancer?
bowel - distention, bloating, constipation, pain, loss of appetite
kidney - recurrent UTI, hydronephrosis secondary to ureteric obstruction, loin pain, renal failure
pleural effusion
constitutional
what tumour markers are you looking for in ovarian cancer?
CEA
CA-125
in younger women:
AFP
B-HCG
LDH
why can throtoxicosis be confused with ovarian cancer
non-specific symptoms
raised CA-125 in BOTH
ALWAYS BIOPSY
how is ovarian cancer diagnosed?
histopathological study following exploratory laparotomy
what is the first line imaging in ovarian cancer?
USS
generally speaking, which advanced imaging techniques are good for the pelvis / abdo?
MRI good for pelvis
CT good for the abdo
how is CT used in ovarian cancer?
in advanced disease it is used to assess extent of spread
how is the Risk of Malignancy calculated for pelvic masses?
uss x menopause status x CA-125
what are the most likely sources of malignant cells in the ascites?
any visceral site of carcinoma but most likely to be epithelial
what three things cause CA-125 to be raised?
inflammation
infection
infarction
how does draining ascites reduce CA-125?
extra cellular fluid acts as a reservoir
what kind of investigation is best for diagnosing cancer/
anything that allows a biopsy
how is CA-125 useful in ovarian cancer?
a rise of 25% indicates progression of the cancer
doubling almost confirms a relapse
what is the origin or most ovarian cancers?
90% epithelial
what are the complications of local invasion in ovarian cancer?
lymphoedema
vaginal discharge
bowel obstruction
ascites
what are the non-metastatic complications of ovarian cancer?
pulmonary emboli
dermatomyositis
what is dermatomyositis? how does it present?
inflammation of the skin and underlying muscle tissue
proximal myopathy skin changes systemic: cardio-pulmonary retinopathy arthralgias
how is malignant hypertension treated?
usually with paracentesis
tx revolving around reducing Na retention DO NOT work e.g. loop diuretics, salt restriction etc
three blood tests that indicate dermatomyositis
aldolase
LDH
CK
all raised
how is imaging used in malignant ascites?
USS, CT or MRI used to guid drainage
what is the most common site for breast cancer?
left breast
upper out quadrant or retro areolar region
what are the risk factors for breast cancer associated with oestrogen?
early menarche / late menopause
nulliparous / late (>35) pregnancy
OCP
HRT
how often is a hereditary predisposition indicated in breast cancer?
10% of cases
what re the three most common breast cancer genes?
BRCA 1
BRCA 2
p53 (Li Fraumeni)
what are the characteristics associated with BRCA breast cancer?
worse histology
early onset
more likely to be bi-lateral
most common ways breast cancer presents?
lump in up to 75%
Pagets disease
mammograpic findings on screening
what is Pagets disease?
associated with intraductal carcinoma
involves terminal ductuals of the breast (may be invasive)
how does pagets disease present?
eczematoid change in nipple
where might there be lymphadenopathy in breast cancer?
neck and axilla
3 most common distant mets in breast cancer?
bone lung liver
recommendation for self breast check?
monthly from 20 yo
how is a cystic mass investigated?
fine needle aspiration- this should result in full resolution
USS - to determine weather it is solid or cystic
biopsy - only if the fluid is bloody or is not resolved after FNA
how common is cystic carcinoma of the breast?
rare - < 1% of breast cancer
investigations in solid mass in breast?
mammography - of both breasts
FNA
core biopsy
what is the disadvantage of FNA in breast cancer?
small chance of false positive findings
up to 25% chance of false negative findings
advantage of core biopsy in breast cancer?
can assess architecture as well as cytology
4 ways to investigate a non palpable breast lump?
MRI
wire excision
US guided core biopsy
stereotactic guided core biopsy
stereotactic = precisely positioning patient
is CA 15.3 used in breast cancer screening? why?
no, low sensitivity for early disease
what is the use of CA 15.3 in breast cancer?
rising levels in follow up are associated with relapse
most common type of breast cancer?
70% are invasive ductal carcinoma
what are the three components of breast cancer triple assessment?
exam
imaging
needle biopsy
4 things on a mammogram that indicate malignancy?
microcalcification
mass
distorted architecture
asymmetry
non metastatic complication of breast cancer?
hypercalaemia
what are the complications of local invasion in breast cancer?
ascites / pleural effusion
lymphoedema
most common distant mets in breast cancer
bone liver lung brain
spinal cord compression
best investigation for suspected spinal cord compression?
MRI
will see compression but not the associated bone destruction
bone is invisible to MRI
what clinical finding indicates cord compression?
bi lateral UMN signs
who gets further investigations into mets in breast cancer? and what are these?
t > 5cm
n > 3
clinical suspicion
CXR
bone scan
USS
when are CT / MRI used in looking for mets in breast cancer?
if there is still clinical suspicion AFTER CXR, bone scan and USS
which type of breast cancer does tamoxifen reduce the risk of?
oestrogen receptive+ tumours
disadvantages of tamoxifen?
increased DVT and PE risk
increased incidence of endometrial cancer
no over all increase in survival
what do aromatase inhibitors do and how are they used in cancer?
stop production of oestrogen in post menopausal women
used to treat early stage of ER+ breast cancer
