Malignant disease Flashcards
What principles must a screening programme adhere to for it to be successful?
- the cancer being detected must be common enough for it to represent an important health problem.
- The natural history of the cancer should be know. So that people know the latent phase and when it will become symptomatic
- A test to be carried out and detect latent disease, that is specific and sensitive to cancer and safe and acceptable to the patient.
- early detection should lead to benefit in terms of cost of treatment and survival of the patient.
What are some examples of premalignant skin disease?
Actinic keratoses - dry and scaly patches of skin due to skin exposure
Bowen’s disease - aka SCC in situ. well demarcated erthymematous plaque
erythroplasia of Queyrat (penis) - Bowen’s disease of the penis
What are some examples of premalignant GI disease?
leukoplakia - white patches on the mucosa
Plummer - Vinson syndrome - difficultly swallowing, oesephageal webs and iron deficiency aneamia. increased risk of SCC
Barrett’s oesophagus
Villous adenomas and polyposis
IBD
Menetrier’s syndrome - massive overgrowth of mucous cells in the stomach, results in large gastric folds.
What are some examples of premalignant GU disease?
Leukoplakia of the bladder
Bilharzia
How should the symptoms of cancer be classified?
Symptoms from the primary tumour, the metastases and generalised systemic symptoms.
Please give some examples of symptoms causes by a primary tumour:
Palpable swelling:
Usually painless unless it starts to invade other structures.
Examples: breast, caecum and thyroid cancer
Obstruction. dysphagia in oesphageal cancer, obstructive jaundice in head of he pancreas, large bowel obstruction is colon cancer, vomiting in gastric outlet obstruction from gastric antrum cancer
Bleeding:
Overt - haematemesis, haemoptysis, haematuria, rectal bleeding
Occult - carcinoma of the stomach or caecum where anaemia occurs.
Compression or invasion of surrounding structures:
SVC obstruction
Back pain in retroperitoneal pancreatic cancer
inavsion of nerves - facial palsy in parotid gland, or recurrent lryngeal nerve palsy n anaplastic carcinoma of the thyroid
Please give some examples of symptoms caused by metastases:
Enlarged lymph nodes
Hepatomegaly
Jaundice
Ascites
Pathological fractures - breast, bronchus, thyroid, prostate, kidney
Pleural effusions
Fits, confusion, personality changes due to cerebral mets
What are the general manifestations of cancer?
Cachexia, pyrexia of unknown origin, hypertrophic pulmonary osteoarthropathy, thrombophlebitis migrans (pancreatic cancer)
How are malignancies staged?
Extent of the tumour (T)
Node status (N)
Presence of mets (M)
What is Dukes’ classfification?
Staging of colorectal cancer:
A - confined to bowel wall (80% 5 yr survival)
B - Through wall into surrounding tissue (60% 5 yr survival)
C - Lymph node involvement (30% 5 yr survival)
if distant mets are present 5 yr survival is only 5%
What is the grade of the tumour?
The histological appearance of the tumour - how much like the orginal cells it looks like.
Proportion of cells in mitosis, degree of differentiation, degree of nuclear polymorphism etc.
Tumour markers.
List them and what cancer they are specific for.
Alpha fetoprotein (AFP):
Increases in hepatocellular cancer and germ cell tumours.
Useful in monitoring mets and response to treatment.
Can be high in cirrhosis, hepatitis, and pregnancy
Carcinoembryonic antigen (CEA):
High in colon, pancreas and stomach cancer.
Can be high in IBD, and cirrhosis
Human chorionic gonadothrophin (hCG):
High is choriocarcinoma and hydatidiform moles, and testicular cancer.
Prostate specific antigen (PSA):
If PSA is 4-10 20-30% will have prostate cancer.
Can be high in BPH and prostatitis
CA 19-9:
High in GI malignancy - especially pancreas.
Can be high in pancreatitis, gall stones, cholecystitis, and cirrhosis
CA 125:
High in ovarian malignancy
Can be high in pregnancy, endometriosis, and cirrhosis, and other non ovarian malignancies
CA 15-3:
Mucin marker used in breast cancer assessment, used for prognosis as the higher the levels the higher cancer of recurrence.
What is Familial adenomatous polyposis and how is it managed?
Autosomal dominant condition - multiple polyps in the rectum and colon, that progress to malignancy if not treated at around 40 yrs.
Treated with subtotal colectomy and iliorectal anastomosis. regular survallience is needed for the duodenal and ampular as they can develop adenomas.
Where are the most common sites for colorectal cancer?
Rectum - 40%, sigmoid colon - 25%, descending colon - 5%, transverse colon - 10%, caecum and ascending colon - 20%.
What is the occurrence of synchronous and metachronous tumours?
2.5% synchronous - two cancers at the same time
1% metachronous - two cancers occurring at different times
What symptoms do people with bowel cancer present with?
Left sided - bleeding, altered bowel habit, obstruction
Right sided - anaemia, palpable mass, weight loss, abdominal pain.
Rectum - frequency of defecation, tenesmus,
How to colorectal cancers spread?
Local, lymphatic, by blood (liver, lung and bone) or transcoelomic.
What is more common? Adenocarcinoma or squamous cell carcinoma of the oesophagus?
Squamous cell - it occurs in the upper 2/3 of the oesophagus
Adenocarcinoma is increasing due to the increased GORD
What are the risk factors for squamous cell carcinoma of the oesophagus?
Smoking, alcohol, plummer-visons syndrome, achalasia, corrosive strictures, coeliac disease, tylosis (howel - evans syndrome) low vitamin A&C, nitrosamine exposure
What are the risk factors for adenocarcinoma of the oesophagus?
long standing heart burn, Barrett’s, smoking, obesity, increased age
How does oesophageal cancer spread?
Local into surrounding structures - trachea, lung, aorta
Lymphatic spread to nodes
Blood stream to liver and lung
What pathology is pancreatic cancer most likely to be and where in the pancreas is the tumour normally found?
Ductal adenocarcinoma
60% in pancreas head, 25% in the body and 15% in the tail,
What gene is associated with pancreatic cancer?
KRAS2 gene is mutated in 95% of cases
What are the risk factors for pancreatic cancer?
Smoking, alcohol, carcinogens, DM, chronic pancreatitis, ? high fat diet
Describe how patients with pancreatic cancer normally would present:
Painless jaundice if tumour in head of pancreas
Epigastric pain if tumour in the tail or body of pancreas
Anorexia, weight loss, new diabetes, acute pancreatitis
rarely: thrombophelbitis migrans (a vein in the arm becomes swollen and red, and then the same happens to a vein in the leg), hypercalcemia, marantic endocarditis (non bacterial), portal hypertension, nephrosis
What percentage of patients are suitable for surgery for pancreatic cancer?
What is the mean survival for pancreatic cancer?
Describe three of the cystic tumours of the pancreas:
75% of cysts in the pancreas are pseudocysts.
Serous cyst adenomas - multiple small cyst cavities, if they are over 5cm they can cause compression
Mucinous cyst adenomas - occur in 5th anf 6th decade. 20% are malignant on presentation
Intraductal papillary mucinous tumours - pancreatic cystic neoplasm, occurs more in men 60-70. transformation to malignancy is common.
What are the risk factors for gastric carcinoma?
Pernicious anaemia Blood group A H.Pylori Atrophic gastritis Adenomatous polyps lower social class smoking diet - high nitrate, high salt, pickling, low vitamin c nitrosamine exposure e.cadherin abnormalities
Describe the Borrmann classification of gastric tumours:
i) polypoid/ fungating
ii) excavating
iii) ulcerating and raised
iv) linitis plastica (leather bottle like uniform thickening of the stomach wall)
What investigations do women who present with a breath lump need to have done?
Triple assessment:
Clincal - hx and examination
Mammography or USS (if under 35yrs)
Fine needle aspiration or core biopsy
What are the risk factors for developing breast cancer?
oestrogen exposure (unopposed by progesterone) nulliparous women mutations in BRAC1 BRAC2 early menarche/ late menopause family history saturated dietary fats previous benign atypical hyperplasia
How is breast cancer staged?
Stage 1: confined to breast mobile
Stage 2: growth confined to breast mobile and ipsilateral nodes
Stage 3: tumour fixed to muscle (but not chest wall) ipsilateral nodes matted and may be fixed, skin involvement larger than tumour
Stage 4: Complete fixation of tumour to chest wall, distant mets
What is the sentinel node biopsy?
Blue dye is injected into the periareolar area or the tumour and the first node the dye reaches is detected (te sentinel node) this is then biopsied and sent to histology.
It decreases needlee axillary clearence as if the sentinel node is clear from mets then it is VV likely that they others are clear too.
What are the tumour markers used to plan additional treatments?
If patients are eostrogen +ve then using an ER blocker like tamoxifen can increase survival time
If tumours are HER2 +ve then herceptin can be used to reduce the micro metasases.
What are the 5 different types of thyroid cancer and their charcteristics?
- PAPILLARY
60% in young. Spreads to nodes and lungs - FOLLICULAR
What factors increase the chance of developing renal cell carcinoma?
Smoking Drinking coffee Exposure to cadmium, lead, asbestos, aromatic hydrocarbons, Dialysis von Hippel-Lindau disease Obesity Anatomical: horseshoe kidney, PKD
How to renal cell carcinomas normally present?
Normally an incidental finding on a CT for something else.
The classic triad is loin pain, mass and haemturia - only occurs in 10%
What is the staging system for renal cell carcinoma?
Robson staging: I - confined to kidney II- involves perinephric fat but not beyond Garota's fascia III- spread to renal vein IV - spread to adjacent/ distant organs
What are the associations with TCC of the bladder?
Smoking Aromatic amines (working in the rubber industry) Chronic cystitis Schistomsomiasis (for SCC) Pelvic irradiation
How does TCC spread?
Local to pelvic structures
Lymph to iliac and para-aortic nodes
Haematogenous to liver and lungs
Describe the stages of T in the TNM staging for TCC:
Tis carcinoma in situ Ta Tumour confined to epithelium T1 Tumour in lamina propria T2 Superficial muscle involved T3 Deep muscle involved T4 Invasion beyond bladder
What is the treatment of TCC of the bladder?
Tis/Ta/T1 - diathermy of the tumour or intravesical chemo
T2/T3 - radical cystectomy is the gold standard
What different types of testicular cancer are there?
Seminoma (30-65yrs)
Teratoma (20-30yrs)
Tumour of Sertoli or Leydig cells
Lymphoma
What are the risk factors for testicular cancer?
Age Cryptorchidism Race: more common in caucasians Previous testicular tumour FH Klinefelter's
How do testicular tumours spread?
Lymph - to the para aortic nodes NOT the ingunial
Haemtogenously to the lungs
How does prostate cancer spread?
Local - seminal vesicles, bladder and rectum
Via lymph
Haematogenously - sclerotic bone lesions)
What medication can be given to treat prostate cancer?
Gondaotrophinn releasing analogues, they at first stimulate and then inhibit the pituitary gonadotrophin.
What score is used for prognosis in prostate cancer?
Gleason score - is used to grade the tumours.
the higher the score the worse prognosis.
The pathologist looks at two areas and adds their score together 8-10 is a aggressive tumour, 5-7 intermediate, and 2-4 indolent.
What are the main causes of incontinence in men?
Enlargement of the prostate - chronic retention may cause urge incontinence
TURP or pelvic surgery
What are the main causes of incontinence in women?
Stress incontinence: leakage due to an incompetent sphincter when abdominal pressure increases.
Pelvic floor weakness, uterine prolapse is main cause
Urge/ overactive bladder: caused by detrusor instability from central inhibitory pathway malfunction or sensitisation of peripheral afferent terminals of the bladder, or a bladder muscle problem.
Need to check for organic brain problem (stroke, parkinsons, dementia) or urinary infection, diabetes, duretics, atrophic vaginitis, uretheritis,
What is a carcinoid tumour?
A tumour with origins of the enterchromaffin cells (neural crest) which are capable of making 5HT.
Where do carcinoid tumours present?
Appendix
Ileum
Rectum
(ovary, testis, bronchi)
then metastasize to the liver
What is carcinoid syndrome
When the carcinoid tumour is in the liver
Bronchoconstriction, paroxysmal flushing, diarrhoea, CCF, pulmonary fibrosis
What is a carcinoid crisis?
When a carcinoid tumour outgrows its blood supply and mediators flood out.
Life threatening vasodilatation, hypotension, tachycardia,, bronchoconstriction and hyperglycaemia
Treated with high dose octreotide and supportive measures
What is the proportion of different histology in lung cancer?
Squamous cell - most common
Adenocarcinoma - 27%
Small (oat) cell - 20%
Large cell- 10%.
Clinically most important distinction is small cell vs non small cell.
Where do Lung mets come from?
Kidney, prostate, breast, bone, GI, cervix, ovary
Whats better prognostically small cell or non small cell lung cancer?
Non small cell - can be excised if peripheral or have curative radiotherapy
Small cell are almost always dissemination on presentation.
Secrete hormones, and metastasise early.
Which hormones are produced by which lung cancer?
Small cell - ADH and ACTH resulting in SIADH and cushings
Squamous - PTH resulting in high Ca
What is a Krukenberg tumour?
A secondary tumour in the ovary from a GI primary, particularly the stomach
What are the risk factors for ovarian tumours?
The more ovulations the more at risk you are:
Late menopause, nullipara
COCP, breast feeding decrease the risk
What are the symptoms that suggest ovarian cancer?
Bloating and abdominal distension Early satiety Loss of appetite Unexplained weight loss Change in bowel habit Fatigue Onset of IBS >50yrs Urinary frequency or urgency Abdominal pain or pelvic pain
Very Vague!
How do patients with malignancy gets spinal cord compression?
- haematogoneous spread of the cancer to the spine and then extend into the epidural space
- direct invasion into the spinal canal by primary
What is the commonest site of spinal cord compression?
Thoracic spine - 60%
Lumbosacral - 30%
Cervical - 10%
But most patients have multiple levels of compression so need FULL MRI
What are the symptoms of spinal cord compression
Progressive back pain Pain increased by coughing or sneezing Progressive weakness of limbs Numbness and paraesthesia Loss of bladder and bowel function - DO NOT NEED TO WAIT FOR THIS May not have a sensory level
How do you treat spinal cord compression?
High dose steroids - 8mg dexamethasone BD (need to monitor BMS, give PPI and nystatin)
MRI spine within 24hrs
Keep flat on bed until images are discussed with the neurosurgeons
Radiotherapy - within 24hrs of MRI diagnosis,
Chemo is sensitive
Physiotherapy
What are the contraindications to surgery for spinal cord compression?
Multiple levels
Severe/ multiple co morbidities
Paralysis for > 24hrs
Life expectancy
What are the causes of superior vena cava obstruction?
Thrombosis
Direct invasion
Extrinsic compression of SVC - by primary tumour or lymph node mets
Which cancers more commonly cause SVC obstruction?
Lung cancer (small cell) Lymphomas Germ cell tumours Thymoma Mesothelioma Mets - from breast Ca
What are the symptoms and signs of SVC obstruction?
Symptoms: SOB Feeling of fullness in head and dizziness Swelling of face/ neck and upper limbs Headache/ chest pain Hoarse voice
Signs:
Pemberton’s sign - when you raise your arms it gets worse
Chest wall superficial venous distension
Distended neck veins
facial oedema
Plethora and cyanosis
Oedema of upper extremities
How do you treat SVC obstruction?
Symptom relief - high dose dexamethasone and then endovascular stent
Treat underlying malignancy
What causes malignant hypercalcaemia?
Bone mets - osteolysis releasing calcium
Parathyroid hormone related peptide secretion
What are the symptoms of hypercalcaemia?
Bones, stones, groans and psychic moans Nausea and vomiting, constipation, anxiety, depression, cognitive dysfunction Muscle weakness Arrhythmias - cardiac arrest Coma
How do you treat malignancy hypercalcaemia?
Rehydrate - 5L per day
Bisphosphonates
Stop any calcium supplements or thiazides
Which cancers most commonly cause brain mets that lead to raised ICP?
Lung
Breast
Melanoma, renal cell, testicular etc …..
What are the risk factors for hepatocellular carcinoma?
Viral hepatitis
Cirrhosis - alcohol, haemochromatosis, PBC
Parasites
Anabolic steroids
