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Surgery > Malignancy > Flashcards

Malignancy Flashcards

1
Q

What are the MC cancers

A

Breast and prostate

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2
Q

What is the leading cause of cancer death

A

Lung cancer (5th MC in Aus, 2nd MC worldwide)

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3
Q

Classify lung cancers

A

Small cell lung cancer

Non small cell lung cancer
- SCC
- Adenocarcinoma
- Bronchial Carcinoid
- Large cell cancer
- Large neuroendocine cell

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4
Q

Describe SCLC

A

Highly aggressive malignant cancer of lung epithelium composed of small blue undifferentiated/anaplastic neuroendocrine Kulchitsky cells with secretory granules that release chromogranin A, synaptophysin, neuron-specific enolase and CD56

No resemblance to glandular or squamous epithelium

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5
Q

Where is SCLC usually located

A

Centrally

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6
Q

Who does SCLC typically affect

A

M > F
Smokers

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7
Q

What are the paraneoplastic effects of SCLC

A

ACTH –> Cushing syndrome
ADH –> SIADH

Anti-VGCC antibodies –> Lambert-Eaton syndrome presenting with proximal muscle weakness that worsens with rest and improves with use

Anti-neuron antibodies –> peripheral neuropathy/encephalitis/subacute cerebellar degeneration

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8
Q

What is the prognosis of SCLC

A

Poor
Average survival ~ 11mo
Early mets

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9
Q

What are the pathological findings of SCLC

A

Cells with irregular borders, scant cytoplasm, hyperchromatic nuclei (salt and pepper pattern), high mitoses, widespread necrosis

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10
Q

Who is affected by lung adenocarcinoma

A

F > M
Non-smokers

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11
Q

What is the most common type of lung cancer

A

Adenocarcinoma

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12
Q

What gene mutations are associated with lung adenocarcinoma

A

EGFR
KRAS
AKT

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13
Q

What is lung adenocarcinoma

A

Malignant proliferation of glandular/mucin+ epithelium of lung

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14
Q

What is the precursor for lung adenocarcinoma

A

Atypical adenomatous hyperplasia

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15
Q

Describe atypical adenomatous hyperplasia

A

Dysplastic cuboidal pneumocytes lining alveoli often with interstitial fibrosis

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16
Q

Describe the progression of atypical adenomatous hyperplasia

A

Dysplastic cuboidal pneumocytes lining alveoli often with interstitial fibrosis

Progresses to adenocarcinoma in situ/lepcidic adenocarcinoma/bronchoalveolar variant involving proliferation of tall columnar cells along alveolar septa and existing walls
- lepcific growth only: no parenchymal, pleural, stromal, or vascular infiltration

Progresses to invasive adenocarcinoma

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17
Q

What does lung adenocarcinoma in situ look like on CXR

A

Pneumonia

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18
Q

How do mucin secreting tumours spread in lungs

A

Aerogenously –> satellite tumours in other parts of lung parenchyma are seeded via spread of cancer cells through airways

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19
Q

Where is lung adenocaricnoma usually located

A

Peripherally

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20
Q

Tumour marker for lung adenocarcinoma

A

Thyroid transcription factor I

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21
Q

Paraneoplastic effects of lung adenocarcinoma

A

May secrete TGFB-1 resulting in ECM deposition –> clubbing and hypertrophic osteoarthropathy

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22
Q

Where is lung SCC usually located

A

centrally

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23
Q

Paraneoplastic effects of lung SCC

A

PTHrP secretion –> hypercalcaemia

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24
Q

Who does lung SCC usually affect

A

M > F
Smokers

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25
Q

Describe macroscopic morphology and growth of lung SCC

A

Large firm mass of malignant squamous cells
- can be exophytic and protrude into lumen of bronchi –> obstruction –> collapse –> post-obstructive pneumonia
- can infiltrate through bronchial wall into mediastinum/up to carina
- can grow along broad front as a cauliflower-like mass and compress lung parenchyma

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26
Q

Pathological findings of lung SCC

A

Keratinising (keratin pearls) or non-keratinising
Intercellular bridges
Focal haemorrhage and necrosis

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27
Q

Progression and precursor for lung SCC

A

Begins as squamous metaplasia –> dysplasia –> squamous cell carcinoma in situ –> invasive SCC

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28
Q

What is a bronchial carcinoid tumour

A

Polypoid mass in bronchus composed of blue well-differentiated neuroendocrine cells arranged in nests that secrete chromogranin A and synaptophysin

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29
Q

Describe the functional consequences/activity of bronchial carcinoid tumour

A

LG tumour

May secrete serotonin and bradykinin resulting in carcinoid syndrome characterised by
- wheezing
- cutaneous flushing
- diarrhoea
- tricuspid/pulmonary regurgitation
- pellagra: B3/niacin deficiency manifesting as diarrhoea, dermatitis, glossitis, dementia, death

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30
Q

What is a urine marker of bronchial carcinoma

A

5HIAA in urine

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31
Q

What is a Pancoast tumour

A

A tumour in the superior sulcus/apex of the lung producing Pancoast syndrome due to mass effect and compression of surrounding structures

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32
Q

Describe Pancoast syndrome

A

Brachial plexus: ipsilateral shoulder/axilla pain –> somatosensory deficits and weakness/atrophy of ipsilateral hand

SVC: impaired drainage of blood from head, upper extremities and neck resulting in facial plethora, jugular venous distension, and upper extremity oedema

Brachiocephalic artery: unilateral oedema of ipsilateral arm and face

RLN: hoarseness

Phrenic nerve: hemidiaphragm paralysis (elevated on CXR)

Stellate/cervical ganglion: Horner’s syndrome

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33
Q

What is a risk of SVC compression

A

RICP –> aneurysm/ICH

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34
Q

Describe what structures might be damaged and how for Horner’s syndrome to occur

A

Sympathetic chain

HYPOTHALAMUS –> BRAINSTEM –> CILIOSPINAL CENTRE (C8-T2): brainstem stroke, pontine haemorrhage, MS, meningitis

CILIOSPINAL CENTRE –> STELLATE GANGLION –> SUPERIOR CERVICAL GANGLION: Pancoast tumour, lymphadenopathy, aortic dissection, common carotid dissection, cervical rib fracture

SUPERIOR CERVICAL GANGLION –> ICA AND OPTHALMIC NERVE –> IRIS DILATOR MUSCLE: cluster headache, ICA dissection, HZV, tumour, cavernous sinus

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35
Q

What is mesotheioma and how does it occur

A

Cancer of pleura (or other mesothelial membranes e.g., peritoneum, pericardium)
Asbestosis –> 20-30year latency

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36
Q

How does mesthothelioma present and how is it Dx

A

Severe pleuritic chest pain and dyspnoea
Pleural effusion recurrent (may be hemorrhagic)
Severe pleural thickening

Dx with cytology of pleural fluid

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37
Q

What is the prognosis of mesothelioma

A

Death within 10mo

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38
Q

What is lymphangitis carcinomatosis

A

Spread of cancer along lymphatics presenting with a reticular pattern on imaging

39
Q

Risk factors for lung cancer

A

Tobacco smoking (related to pack years) –> arsenic, polycyclic aromatic hydrocarbons, carcinogens
Passive smoking

Air pollution
Radon (soil and basements/enclosed spaces) and uranium
Chromium, nickel, silica, coal tar
Asbestosis
Previous radiation

FHx/genetics
Chronic inflammation/infection
Scarring
Intersititial fibrosis

40
Q

Pathogenesis of lung cancer in relation to smoking

A

Smoking: carcinogens inhaled in cigarette smoke produce DNA-adducts (DNA segments attached to carcinogen) –> DNA can be repaired, cell with DNA adduct can undergo apoptosis or the DNA-adduct can persist/be repaired incorrectly resulting in a DNA mutation

Mutations accumulate overtime resulting in cell cycle progression/uncontrollable proliferation and cancer esp. if mutations occur in TSGs and oncogenes

41
Q

Describe the mechanisms of lung cancer spread

A

Local: peribronchiolar, stromal, mediastinal, pleural, parenchymal

LNs: hilar, peribronchiolar, mediastinal

Intracoloemic: pleural

Haematogenous: adrenals, liver, bone, brain

42
Q

What cancers are likely to metastasise to lungs and how do they appear

A

Colon
Breast
RCC
Bladder
Prostate

Multiple peripheral canon-ball lesions

43
Q

Non-Small Cell Carcinoma Staging (AJCC System(

A

Tumour: Size and extension
- T2 –> main bronchus involvement without carina, visceral pleura, lobar collapse
- T3 –> chest wall, parietal pleura, lung collapse, satellite nodules in same lobe
- T4 –> mediastinum, carina, diaphragm, great vessels, trachea, oesophagus, vertebral bodies, satellite nodules in different lobe of same lung

Nodes
- N1. Ipsilateral hilar and/or peribronchiolar and intrapulmonary nodes
- N2. Ipsilateral mediastinal and/or subcarinal
- N3. Contralateral hilar and mediastinal or ipsilateral/contralateral supraclavicular/scalenes

Metastasis: adrenals, liver, bone, brain

44
Q

Small Cell Carcinoma Staging

A

AJCCC system or
- Limited: contained to ipsilateral hemithorax
- Extensive: beyond ipsilateral hemithorax

45
Q

Classify the clinical features of lung cancer

A

Pulmonary
Constitutional
Metastatic
Paraneoplastic
Invasive

46
Q

Outline the pulmonary clinical features of lung cancer

A

Asymptomatic/insidious onset due to high lung reserve and no parenchymal pain fibres

Cough –> irritation from obstruction

Dyspnoea
- Reduced lung capacity/surface area for gas exchange
- Pneumonia
- COPD exacerbation
- Collapse/effusion/pneumothorax
- Lymphangitis carcinomatosis
- Anaemia
- Anxiety/depression
- Weakness of respiratory muscles (cachexia)
- URT obstruction
- SVC obstruction
- Chest wall infiltration
- Hemidiaphragm paralysis
- Pericardial effusion

Hemoptysis: invasion into BVs
Wheeze: obstruction
Recurrent infection: post-obstructive collapse and infection
Collapse from obstruction (reduced breath sounds, dullness to percussion, reduced chest expansion)
Pleural effusion (stony dullness; pleural involvement: usually peripheral cancers)
Chest pain (usually peripheral cancers –> parietal pleura)

47
Q

Constitutional and metastatic clinical features of lung cancer

A

Constitutional: weakness, weight loss, fever

Metastatic
- Brain: seizures, FNDs, headache, RICP
- Liver: asymptomatic but possible cholestatic Sx, ascites, portal HTN
- Bone: pathological fractures, bone pain, hypercalcemia, high ALP
- Adrenals: asymptomatic

48
Q

Invasive clinical features of lung cancers

A

As per Pancoast +
- Oesophagus –> dysphagia
- Post-obstructive infection
- Pleural effusion if pleural involvement

49
Q

Paraneoplastic features of lung cancers

A

PTHrP, ACTH, ADH, anti-VGCC Ab (Lambert-Eaton Syndrome), antineuronal Ab, TGFB1 (clubbing and hypertrophic osteoarthropathy/swelling in joints and long bones), carcinoid syndrome
Calcitonin –> hypocalcemia
hCG –> gynecomastia (large cell and poorly differentiated adenocarcinoma)

50
Q

Investigations lung cancer

A

CXR/CT chest –> coin lesion (+/- hilar lymphadenopathy, collapse if bronchial compression, pleural effusion if pleural involvement, hemidiaphragmatic elevation if phrenic nerve involvement)

Tissue diagnosis
- Sputum cytology
- Central lesion: biopsy via bronchoscopy: cytology
- Peripheral lesion: biopsy via CT-guided transthoracic needle aspiration –> cytology (can do via bronchoscopy or US-guided endobronchial biopsy if contraindicated)
Risks = pneumothorax, haemothorax, air embolism, seeding

Staging:
- CT or CT/PET
- LN/metastasis biopsy
- Pleurocentesis for cytology if involved

Driver gene ID for Tx (esp. PDL1 and EGFR)

51
Q

Mx of lung cancer

A

Surgical lobectomy/pneumonectomy if fissure/close to hilum

SACT: chemo, immunotherapy, radiotherapy

Targeted e.g., EGFR inhibitors

Supportive

SLCLC includes polychemotherapy, radiation and prophylactic IC radiation due to high rate of brain mets

52
Q

Aetiology of hepatocellular carcinoma

A

HBV, HCV
Cirrhosis (NAFLD, alcoholic cirrhosis, hep viruses, haemochromatosis)
Fungal aflatoxin
Androgenic steroids
Weak association with OCP

M > F

53
Q

Pathology of hepatocellular carcinoma

A

Single tumour or multiple nodules
Composed of cells resembling hepatocytes

54
Q

Where does HCC met to

A

Via hepatic or portal veins (haematogenous) to LNs, bones, lungs

55
Q

Ix for HCC

A

FBC, LFT, UEC, AFP

USS (filling defects)

CT with contrast: ID HCC but hard to confirm Dx in lesions < 1cm (MRI can help)
- hypervascularity of nodule
- lack of portal vein washout

USS-guided tumour biopsy: used less frequently now due to imaging quality and risk of seeding

56
Q

Mx of HCC

A

Surgical resection
- isolated lesions < 5cm diameter
- up to 3 lesions < 3cm diameter
Risk of recurrence
Alternative: trans-arterial embolisation/radiofrequency ablation –> prolongs survival but less successfully than surgery

Liver transplantation = only opportunity for cure but limited

Non-resectionable: sorafenib prolongs survival

57
Q

Risk factors in CRC

A

Increasing age

FHx of colon cancer/polyps
Inherited cancer syndromes: FAP, Peutz Jegher, Turcot, Gardner, NPCC

Colorectal polyps (esp. adenomatous and serrated)
Chronic IBD
DM
Acromegaly

Obesity
Animal fat and red meat consumption
Smoking

Abdominal radiotherapy

58
Q

Protective factors against CRC

A

Aspirin and NSAIDs
Exercise
Vegetables, garlic, milk, calcium consumption

59
Q

Pathophysiology/mutation pathways of development CRC

A

Progression from normal mucosa to invasive cancer involving accumulation of abnormalities in a number of critical growth-regulating genes

CHROMOSOMAL INSTABILITY PATHWAY (MCC)
APC mutations resulting in adenomas and progression to invasive CRC
(FAP)

MICROSATELLITE INSTABILITY PATHWAY
Inactivation of MMR genes –> ineffective DNA repair –> proximal colon CRCs
(HNPCC)

CPG ISLAND METHYLATOR PHENOTYPE
BRAF/KRAS mutations –> serrated polyps (esp. proximal colon) –> TSG and MMR mutations –> invasive CRC

60
Q

CRC locations by frequency

A

Sigmoid (25%)
Rectum (20%)
Caecum and transverse colon (~15%)
Ascending and descending colon (< 10%)

61
Q

How does CRC spread

A

Direct infiltration through bowel wall
Lymphatics and BVs with subsequent spread –> liver and lung

62
Q

What are signet ring cells

A

Malignant cells characterised by mucin filled cytoplasms and eccentric nuclei –> poor prognosis and mets

63
Q

Clinical features of CRC

A

Change in bowel habit: looser and more frequent stools
Rectal bleeding
Tenesemus
Rectal/abdominal mass palpable
IDA features

64
Q

How do tumours in caecum/right colon typically present

A

Asymptomatic/IDA
- polypoid

65
Q

How do tumours in sigmoid/left colon typically present

A

Obstruction/colicky pain
Haematochezia
- apple core/circumferential

66
Q

Ix for CRC

A

Screening of asymptomatic pt = FOBT

Dx
- Colonoscopy + biopsy
- CT colonography to visualise large bowel

Staging
- Endoanal USS and pelvic MRI for rectal cancer staging
- Chest, abdo, pelvic CT for local spread and mets
- PET for detection of occult mets/evaluation of suspicious lesions found on CT (MRI can also be used for this)

Recurrence
- Carcinoembryonic antigen (CEA)

67
Q

Rectal cancer Mx

A

Total mesorectal excision: removal of entire package of mesorectal tissue surrounding tumour –> low rectal anastamosis

Very low tumours within 5cm of anal margin –> abdominoperineal resection with permanent colostomy

Neoadjuvant radiotherapy

Local transanal surgery very occasionally used for early superficial rectal tumours

68
Q

CRC Mx

A

Segmental resection w/ removal of draining LNs as far as the root of the mesentery + restorative anastamosis

If obstructed: pre-operative decompression w/ endoscopic stenting to improve resection prognosis (elective vs emergency surgery)

Adjuvant chemo in stage III

Surgical/radiofrequency ablative Tx of liver and lung mets
+/- chemo +/- anti-EGFR agents

Radiotherapy cannot be used for colonic cancers proximal to rectum due to toxicity

69
Q

Risk factors for SCC of oesophagus

A

Tobacco smoking
High alcohol intake

Plummer-vinson syndrome
Achalasia
Corrosive strictures

Celiac disease
Breast cancer Tx with radiotehrapy

70
Q

Risk factors for oesophageal adenocarcinoma

A

Longstanding GORD
Barrett’s oesophagus

Age
Obesity
Tobacco smoking

Achalasia

Breast cancer Tx with radiotherapy

71
Q

Where do oesophageal squamous cell carcinomas vs adenocarcinomas occur

A

SCC: upper 2/3rds (mostly middle 3rd)
Adenocarcinoma: lower 1/3rd and at gastric cardia

72
Q

Epidemiology of oesophageal cancer

A

Adenocarcinoma:
- Western countries

SCC:
- Asia, Africa
- M > F

60-70yo

73
Q

Pathogenesis of oesophageal adenocarcinoma

A
  1. Chronic GORD
  2. Intestinal metaplasia/Barrett’s oesophagus = metaplastic transformation of squamous cell epithelium of oesophagus to non-ciliated columnar epithelium with goblet cells
  3. Dysplasia (LG –> HG)
  4. Malignant transformation
74
Q

Oesophageal carcinoma clinical features

A

Progressive, unrelenting dysphagia (solids –> liquids in weeks)
- oesophageal obstruction eventually results in difficulty swallowing saliva, coughing, and aspiration

Food impaction –> pain
Persistent pain from infiltration of adjacent structures

Weight loss, anorexia, lymphadenopathy

75
Q

How does oesophageal carcinoma spread

A

Local invasion into surrounding structures and LNs is more common than distant mets

76
Q

Investigations of oesophageal cancer

A

Diagnosis
- Endoscopy + biopsy
- Barium swallow can be useful when DDx for dysphagia include motility disorders e.g., achalasia

Staging
- CT thorax and upper abdomen
- Endoscopic USS (depth of tumour and infiltration and LN involvement) –> FNA aspiration of LNs
- Laparoscopy if tumour is at cardia to look for peritoneal and node mets
- PET to confirm distant mets suspected on CT

77
Q

Mx of oesophageal cancer

A

Surgery: resection only if tumour has not infiltrated outside oesophageal wall
+ neo-adjuvant and adjuvant Tx chemoradiotherapy for pts with stage 2b and 3 disease

Endoscopic mucosal resection may be used in early mucosal SCC (confined to superficial mucosa)

Palliative Tx:
- endoscopic dilatation (high perforation risk) + laser/brachytherapy or endoscopic stenting
- nutritional support

78
Q

Gastric cancer epidemiology

A

Peak: 50-70
M > F
Japan

79
Q

Risk factors gastric adenocarcinoma

A

Atrophic gastritis 2˚ to chronic H. pylori infection
- H. pylori –> acute gastritis –> chronic gastritis –> atrophic gastritis –> intestinal metaplasia –> dysplasia –> malignancy

Pernicious anaemia –> atrophic gastritis

Tobacco smoking

EBV

Nitrosamines, dietary nitrates, high salt intake

Genetics (e-cadherin mutations)
FHx

80
Q

Pathological types of gastric cancer

A

Intestinal = Type 1
- Well formed glandular structures (differentiated)
- Polypoid/ulcerated with heaped, rolled edges
- Intestinal metaplasia in surrounding mucosa (often with H. pylori and atrphic gastritis)
- MC in distal stomach

Diffuse = Type 2
- Poorly differentiated cells infiltrate gastric wall esp. at cardia
- Diffuse thickening/rigidity of wall = linitus plastica
- Assoc. with e. cadherin mutation and more likely in younger patients
- Signet ring cells
- Poor prognosis

81
Q

Clinical features gastric cancer

A

Asymptomatic –> often present with advanced disease

Sx of dyspepsia, epigastric pain, possibly relieved with food/antacids
- hard to differentiate from gastritis and PUD

Nausea, anorexia, weight loss

Dysphagia if fundic involvement

Anaemia from occult blood loss

81
Q

Clinical features gastric cancer

A

Asymptomatic –> often present with advanced disease

Sx of dyspepsia, epigastric pain, possibly relieved with food/antacids
- hard to differentiate from gastritis and PUD
Nausea, anorexia, weight loss
Dysphagia if fundus involvement

Palpable epigastric mass
Abdominal tenderness
Anaemia from occult blood loss

Liver mets: malignant ascites, jaundice
Bone, brain, lung Sx
Virchow’s node = palpable L supraclavicular LN

Dermatomyositis
Acanthosis nigricans
Lesser trelat: abrupt appearance of multiple seborrhoeic keratoses

82
Q

Ix of gastric cancer

A

Dx
- gastroscopy + 8-10 biopsies from suspicious lesions

Staging
- CT chest and abdomen
- Endoscopic USS
- Laparoscopy may be done in pts being considered for surgery to exclude serosal disease
- PET

83
Q

Mx of gastric cancer

A

Endoscopic mucosal resection or endoscopic submucosal dissection for early non-ulcerated mucosal lesions

Surgery (partial/total gastrectomy) + adjuvant cisplatin, 5-FU and radiotherapy

Palliation for advanced disease with
- chemo
- endoscopic stents/venting gastrostomy to relieve obstruction + octreotide to reduce secretions
- nutritional support (nasojejunal or gastrostomy tube or TPN)

84
Q

Pancreatic adenocarcinoma epidemiology

A

M > F
Mean age = 71

85
Q

MC type of pancreatic cancer

A

Adenocarcinoma

86
Q

Aetiology of pancreatic adenocarcinoma

A

Smoking
Excess alcohol
Excess coffee
Excess aspirin

DM
Chronic pancreatitis

PRSS1 genetic mutation

87
Q

Progression and precursors of pancreatic adenocarcinoma

A

Originates from pancreatic ductal epithelium

Pre-malignant lesions –> successive mutations:
- pancreatic intraepithelial neoplasia (MC)
- intraductal papillary mucinous neoplasms
- mucinous cystic neoplasia

88
Q

Clinical features of pancreatic adenocarcinoma

A

2/3rds = @ pancreatic head:
- abdominal pain (often radiating to back +/- partial relief by leaning forward)
- anorexia
- weight loss
- jaundice (early manifestation of pancreatic head/ampullary cancers) 2˚ to occlusion/compression of distal common bile duct
- pale stools, dark urine, pruritus
- malabsorption and steatorrhea
- Courvoisier sign
- palpable epigastric mass/central abdominal mass

New onset depressive Sx
Polyarthritis
Skin nodules
Trousseau syndrome

Liver mets –> hepatomegaly

89
Q

What is Trousseau syndrome

A

Superficial recurring migratory thrombophlebitis
Red, tender extremities
Assoc. with pancreatic cancer (10%)

90
Q

What is Courvoisier sign

A

Palpable gallbladder 2˚ obstructed CBD or cystic duct

91
Q

Dx of pancreatic adenocarcinoma

A

Transabdominal USS = initial imaging in majority of patients
- dilated intrahepatic bile ducts if bile duct obstruction
- mass in head of pancreas (less reliable if body/tail tumour due to overlying bowel gas)

CT with contrast confirm mass, LNs, and mets
- use dual phase pancreatic protocol CT scan if high index of suspicion for pancreatic cancer

Endoscopic USS: can help for small (<2cm) lesions which may be missed on CT and allows FNA cytology = essential before chemo

Tumour markers for monitoring: CA19-9
- progressive elevation over time suggests Dx
- monitor response to Tx

92
Q

Mx pancreatic adenocarcinoma

A

Pancreaticoduodenectomy (Whipple procedure): tumours of head and neck

Distal pancreatectomy (often laparoscopic): tumours of body and tail

Adjuvant and neoadjuvant chemo: flurouracil or gemcitabine

Palliation
- chemo
- opiates or coeliac axis block for pain
- nutritional support, enzyme supplementation, diabetes Mx
- endoscopic stenting for obstructive jaundice
- endoscopic stenting or surgical bypass for duodenal obstruction (tumour @ head/uncinate process of pancreas)

93
Q

Prognosis pancreatic adenocarcinoma

A

5 year survival rate = 3%

Surgery (17 decks)

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