JC Block C - Clinical Oncology Teaching Clinic I and II (all) Flashcards by Max Kam

Hallmarks of cancer

o Sustaining proliferative signaling
o Evading growth suppressors
o Activating invasion and metastasis
o Enabling replicative immortality
o Inducing angiogenesis
o Resisting cell death

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Reasons of growing cancer incidence

 Aging population (exposed to more risk factors; decreased immunity)

 Westernised lifestyle: high fatty intake, sedentary lifestyle without exercise

 Unfavourable habits: smoking, alcoholism, unprotected sun-tanning, unsafe sex (cervical cancer, HPV-associated oropharyngeal
cancer)

 Improved cancer screening

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5 leading behavioral and dietary risks of cancer development

High body mass index
Low fruit and vegetable intake
Lack of physical activity
Tobacco use (= most important risk factor for cancer)
Alcohol use

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Outline WHO’s Comprehensive cancer control strategy & action plan

Aims:
o Reduce cancer incidence and mortality
o Improve quality of life of cancer patients and their families

Plan:
o Prevention (e.g. HPV vaccine)
o Early detection (screen high-risk group)
o Diagnosis and treatment
o Rehabilitation
o Palliative care, survivorship:

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Incidence rate of cancer in HK

Mortality rate

1 in 4 men and 1 in 5 women will develop cancer before age of 75

Median age at diagnosis of cancer:
 68 years in men
 62 years in women

(~1/3) of all deaths
1 in 9 men and 1 in 15 women will die from cancer before age of 75

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Most common cancers in male and female in HK

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Cancers with increasing incidence rate in HK

o Female: breast, corpus uteri, pancreas

o Male: prostate, kidney (RCC), non-Hodgkin lymphoma, thyroid, pancreas

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Top 5 cancer in incidence and mortality rate in HK (both sex)

Incidence:
- Colorectal, Lung, Breast, Prostate, Liver

Mortality:
- Lung, colorectal, liver, breast, pancreas

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Effect of cancer growth

Local effects: 
o Mechanical (e.g. bone, spine collapse)
o Disturbance of functions:
 Anatomical (e.g. metastasis to humerus)
 Physiological
 Irritation/infiltration of nerves
 Hormonal disturbance

Systemic constitutional effects

Paraneoplastic manifestations

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List examples of paraneoplastic manifestations

 Dermatomyositis (e.g. breast, lung, NPC)

 Lambert-Eaton myasthenic syndrome (LEMS) (e.g. small cell lung cancer)

 Hypercalcaemia of malignancy (e.g. SCC lung, breast, lymphoma, prostate (sic))

 SIADH (e.g. small cell lung cancer (oat cell), breast, pancreatic)

 Cushingnoid features (etopic ACTH production) (e.g. small cell lung cancer)

 Hypoglycaemia (e.g. HCC)

 Polycythaemia (e.g. RCC: erythropoietin production)

 Vasculitis

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Causes of finger clubbing

 Respiratory system: CA lung, fibrosis, bronchiectasis, lung abscess

 Cardiovascular system: infective endocarditis, cyanotic heart disease

 GI: liver cirrhosis, inflammatory bowel disease

 Thyrotoxicosis (traditionally called pseudoclubbing) due to soft tissue proliferation

 Idiopathic

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Key presenting features of colorectal CA

 Per rectal bleeding
 Constipation/ change in bowel habit
 Tenesmus (= most specific: tumor in sigmoid/ rectum)
 Abdominal pain
 Abdominal distension: ascites, IO or liver met.
 Other local symptoms (e.g. hematochezia, passing mucus)

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Workup investigations for colorectal CA

 Proctoscopy/ colonoscopy – biopsy of lesion

 AXR: IO features

Proximal dilatation of bowel
Multiple air-fluid level
Perforation

 CT abdomen and pelvis (for staging, metastasis, complications)

Obstructing lesion (white solid arrow)/ mural thickening of rectosigmoid junction
Liver met.
Ascites

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Workup investigation for rectal CA

 Endorectal US (for local staging: depth of invasion)

 Pelvic MRI:
o Mural thickening
o Enlarged mesorectal lymph nodes

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Ddx colorectal cancer

Differential diagnoses – benign:
 Benign polyp (can be pre-malignant)
 Haemorrhoid
 Inflammatory bowel diseases
 Infective colitis
 Diverticulitis +/- abscess

 Adhesions
 Paralytic ileus

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Key presenting features of lung cancer

 Chronic cough, no regression

 Haemoptysis

 Shortness of breath, new wheezing, recurrent chest infection (tumor obstruction)

 Hoarseness

 Lower neck mass

(pleuritic chest pain)

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3 syndromes a/w lung cancer **

Superior vena cava syndrome* (SVCO)
 Dilated veins at neck and chest wall, facial & neck swelling (including lips), edematous arms and hands, dyspnea

Horner syndrome* (compression of sympathetic trunk usually at C7-T1)
 4 major features: partial ptosis, miosis, anhidrosis, enophthalmus

Pancoast syndrome (invades adjacent ribs & vertebrae)
- Brachial plexus:
o Severe pain at shoulder radiating toward axilla, scapula, ulnar aspect of hand
o Atrophy of small muscles of hand
- Cervical sympathetic nerves (Stellate ganglion): Horner’s syndrome

Paraneoplastic syndromes of lung cancer

 SIADH (hyponatremia)

 Cushing syndrome (ectopic ACTH production in small cell lung cancer)

 Lambert-Eaton syndrome* (production of IgG antibodies binding to voltage-gated Ca2+ channels):
o Proximal muscle weakness
o Autonomic disturbance

 Hypercalcaemia (PTHrP)

 Hypertrophic osteoarthropathy

 Cerebellar ataxia

 Peripheral neuropathy

Workup investigations for lung cancer

CXR

CT thorax

Sputum cytology, C/ST, AFB (if suspect carcinomatosis or TB)

Biopsy:
 CT or EBUS (endobronchial US) guided
 Bronchoscopy
 Mediastinoscopy

Staging Ix: TNM/ limited or extensive staging

Metastatic:
 CT/ MRI brain for distant metastasis
 PET-CT
 Blood tests: LFT, RFT (includes creatinine, urea, K+ , Na+), Ca2+, CEA (tumor marker for adenocarcinoma), LDH (prognosis)

Ddx lung cancer

Key features of breast cancer

 Breast lump, Fungating mass
 Skin changes (redness/ dimpling)
 Nipple retraction
 Nipple discharge
 Axillary/ neck swelling
 Upper limb – lymphedema due to LN met. or radiotherapy

 Signs of metastasis (bone, liver, lung, brain)

Workup investigations for breast cancer

 Mammogram/ USG
 MRI breast
 FNAC/ core biopsy

Ddx breast cancer

Prostate cancer

Key presenting features

Common presenting symptoms:
 Problem in passing urine (but seldom painful)
 Haematuria
 Haemaspermia
 Bone metastases: Bone pain, spinal cord compression, hypercalcemia S/S

Clinical signs:
 DRE: hard prostatic nodules, loss of middle sulcus
 Bony tenderness (cord compression in advanced cases)

Workup investigations for prostate cancer

 Tumour marker: PSA  MRI pelvis - Prostate cancer (e.g. involving peripheral, transition zone) - Extracapsular spread, e.g. invasion to seminal vesicles, neurovascular bundle, anterior wall of rectum - Lymph nodes  Transrectal ultrasound (TRUS) guided biopsy  MRI spine

Ddx prostate cancer

 Benign: benign prostate hyperplasia |  Malignant: direct invasion from bladder or rectum cancers

Liver cancer Key presenting features

Presentation  Abdominal distension (hepatomegaly, ascites)  Abdominal pain especially at RUQ  Jaundice, HE, Hypoglycaemia ``` Signs:  Jaundice  Signs of chronic liver diseases(clubbing, palmar erythema, Dupuytren’s contracture, flapping tremor, spider naevi, gynaecomastia, testicular atrophy)  Lower limb edema  Hepatomegaly – hard, irregular  Ascites  Splenomegaly ```

Workup investigations for liver cancer

 HBV and HCV serology  Tumor marker: alpha fetoprotein for HCC  Imaging: Ultrasound liver Triphasic CT scan – if hepatocellular carcinoma CT angiography MRI liver

Ddx HCC

NPC Risk factors

EBV infection genetic predisposition : HLA A2 + BW 46 Environmental factors: salted fish (nitrosamines), alcohol, poor oral hygiene

NPC Key presenting features

Neck mass (LN involvement) Nasal obstruction, bleeding, epistaxis, post-nasal drip, blood-stained saliva, discharge Aural (tinnitus, deafness, pain, discharge) due to blockage of Eustachian tube: Headache Cranial nerve palsy spread further up to cavernous sinus - Compress on CN III, IV, V1, V2, VI Dermatomyositis* (paraneoplastic)

Workup investigations for NPC

 Tumour marker: EBV-DNA, IgA anti-EBV  Nasopharyngoscopy & biopsy at fossa of Rosenmuller  MRI with gadolinium from skull base to clavicle, i.e. nasopharyngeal & cervical regions, and/or CT with contrast  FDG-PET/CT for systemic workup + supplement locoregional assessment

Prognosis of NPC

Prognosis – survival by stage (5-year):  I: 100% (very good)  II: 95% (very good)  III: 90% (regional LN; amenable to radical chemoirradiation)  IVA: 67%  IVB: 68%  IVC: 18%

General Constitutional and metastatic symptoms of all cancers

Modalities of pathological diagnosis of cancer

Modalities:  Cytology  Histopathology  Liquid-based biopsy (blood, pleural effusion, pericardial effusion) for circulating tumour cells or circulating tumour DNA  Biological and genetic characteristics: e.g. ER/ PR/ EGFR/ ALK...etc

Examples of hormonal therapy for cancer treatment Examples of immunotherapy

Hormonal: o Breast cancer: tamoxifen, aromatase inhibitors o Prostate cancer: abiraterone o Neuroendocrine tumors: octreotide Immuno: o Anti-PD-1: nivolumab, pembrolizumab, pidilizumab o Anti-PD-L1: atezolizumab, durvalumab, avelumab

Key presenting features of gastric cancer

Epigastric discomfort/ pain - “indigestion”, dyspepsia, early satiety Obstructive symptoms: vomiting, dysphagia  Melena, coffee ground vomiting  Systemic: anemia, weight loss

Workup investigations for gastric cancer

Endoscopy: OGD and biopsy CT abdomen and pelvis: metastasis, LN involvement, ascites, adnexal masses, complications e.g. GOO, Perforation Barium meal (e.g. nodular, markedly thickened folds)

Ddx gastric cancer

Skin cancer Key presenting features Most common types

Presenting symptoms:  Lump, nodules  Non-healing ulcer  Bleeding, pain (late stage) ``` Different histology:  Basal cell carcinoma  Squamous cell carcinoma  Merkel cell carcinoma  Cutaneous lymphoma  Kaposi’s sarcoma  Angiosarcoma  Dermatofibroma protuberans ```

Ddx skin cancer