Onc Ix Mx Flashcards
Basal cell carcinoma (most common type of cancer in the Western world)
Ix = Lesions are also known as rodent ulcers
Characterised by slow-growth and local invasion
Metastases are extremely rare.
The most common type is nodular BCC at sun-exposed sites
Initially a pearly, flesh-coloured papule with telangiectasia, may later ulcerate leaving a central ‘crater’
Mx = refer for surgery/cryo/radio/cream etc
Bladder cancer
‘painless haematuria’
Ix = biopsy, pelvic MRI + PET-CT
Needs referral to urology for investigations if suspected
Mx:
Superficial lesions = TURBT* in isolation.
Recurrences or higher grade/risk on histology = intravesical chemotherapy
Stage T2 disease = surgery (radical cystectomy and ileal conduit) or radical radiotherapy
*(transurethral resection of the bladder tumour)
Breast cancer
Ix:
USS (<35yo)
Mammogram (>35)
and mammogram 47-73, every 3 years
Triple assessment = history, scan, FNA/core biopsy*
Referral
2ww;
>30yo + unexplained lump in breast/axilla
>50yo + SLANT
<30yo + no pain = non-urgent referral
Assessed for Oe-Receptor+, P-Receptor+, HER-2
Mx:
HER-2 = trastuzumab (HERceptin)
Oe-R+ = pre/peri-menopause = tamoxifen, post = letrozole
Solitary nodule = Wide-local excision
post-excision of high risk cancer/Stage T3/t4 or >4 LN = Radio
Chemo is adjuvant pre-surgery
Axillary node clearance is indicated if there is any lymph node involvement
*Biopsy will show “atypical ductal hyperplasia”
Central nervous system (CNS) tumours
Ix = MRI
Mx = surgery
Resection of Gliomas is nearly always incomplete as they invade the brain tissue
Cholangiocarcinoma
Ix = LFTs (abnormal)
Incidental = USS
Suspected = CT
GS = ERCP!! then MRI for staging
Mx = remove
or chemo+stent is it’s non-resectable
Colorectal carcinoma
Ix (>55 and 60-74?)
It is currently thought there are three types of colon cancer:
sporadic (95%)
hereditary non-polyposis colorectal carcinoma (HNPCC, 5%)
familial adenomatous polyposis (FAP, <1%)
What are the amsterdam criteria for HNPCC?
Ix = sigmoid/colonoscopy
> 55yo = flexisig once
60-74 = FIT every 2 years
if either are +ve -> colonoscopy
Mx = surgery resection
The Amsterdam criteria are sometimes used to aid diagnosis of HNPCC;
- at least 3 family members with colon cancer
- the cases span at least two generations
- at least one case diagnosed before the age of 50 years
Gastric cancer
associated with acanthosis nigricans
Pernicious anaemia predisposes pt to developing gastric cancer
Ix = OGD (oesophago-gastro-duodenoscopy) + biopsy
signet ring cells may be seen in gastric cancer. (more=worse)
Staging: CT
Mx: surgeries;
endoscopic mucosal resection
partial/total gastrectomy
chemotherapy
Head & neck cancer (oral cavity, laryngeal,
Laryngeal cancer 2ww criteria:
>45yo + (persistent unexplained hoarseness) or
(an unexplained lump in the neck)
Oral cancer 2ww criteria:
Unexplained ulceration in the oral cavity lasting for more than 3 weeks
a persistent and unexplained lump in the neck, lip, oral cavity,
a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
Thyroid cancer 2ww criteria = unexplained lump in neck
Hepatocellular carcinoma
Accounts for 90% of liver tumours!
Ix:
USS + alpha-fetoprotein for high risk groups;
ie. Patients liver cirrhosis secondary to hepatitis B & C or Haemochromatosis or alcohol
Mx: surgery
early disease: surgical resection
liver transplantation
radiofrequency ablation
transarterial chemoembolisation
sorafenib: a multikinase inhibitor
Lung cancer
Gynaecomastia is associated with adenocarcinoma
IX: 1st = Chest X-Ray
Suspected = CT
Bronchoscopy (guided by USS) used for biopsy
PET scanning = to see if there’s enough neuroplastic tissue for 18-fluorodeoxygenase to work as a treatment
Bloods = raised platelets
2ww referral criteria:
> 40yo + (2symptoms, or 1symptom w smoking)
Cough, chest pain, SOB, appetite loss, WL, fatigue
> 40yo + 1 symptom of: clubbing, recurrent chest infection, lymphadenopathy, thrombocytosis)
Mx = surgery/chemo?
Neutropenic sepsis
most common cause = Staph epidermidis
Ix = 7-14 days post-chemo, neutrophil count < 0.5 * 109 + >38ºC or other signs of sepsis
after ab’s, send for blood cultures
Mx:
Immediate ab’s! (pip+taz) - given as soon as suspected (ie. 8days post chemo + pyrexic)
if still pyrexic after 48hrs, add (meropenem+vanc)
If this doesn’t work, consider fungal cause
prophylaxis for high-risk pt = fluroquinolone (floxacins e.g. cipro)
Oesophageal cancer
Most common oesophageal cancer?
Ix = Upper GI endoscopy with biopsy
Endoscopic-ultrasound = locoregional staging
CT CAP = initial staging
FDG-PET CT = occult metastases if metastases are not seen on the initial staging CT scans
Mx = Ivor-Lewis type oesophagectomy + adjuvant chemo
The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis resulting in mediastinitis
Most common = lower1/3rd = adenocarcinoma
upper2/3rds = scc
Pancreatic cancer
‘painless jaundice’
Ix =
ultrasound has a sensitivity of around 60-90%
high-resolution CT scanning is the investigation of choice if the diagnosis is suspected
imaging may demonstrate the ‘double duct’ sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts
Mx:
<20% suitable for surgery at diagnosis
Head of pancreas = a Whipple’s resection (pancreaticoduodenectomy)
Palliation = ERCP with stenting
SE’sWhipple’s = dumping syndrome and peptic ulcer disease
Prostate cancer
Ix = PSA, 1st = multi-parametric MRI
TRUS-guided biopsy is less used
Mx = localised = watch/remove/radiotherapy
advanced = hormonal, remove, radio,
metastatic = GnRH agonist (goserelin) + 3wks of antiandrogen
Renal cell carcinoma
Ix = CT-CAP
Mx = nephrectomy
Squamous cell carcinoma
(what 3 things does histology show for any carcinoma)
who gets urgent referral?
Histology for ANY carcinoma shows:
1. nuclear enlargement,
2. hyperchromasia
3. and pleomorphism
Squamous cell carcinomas are more common in patients who are immunosuppressed, and may present atypically and grow rapidly.
NICE therefore advises all patients who have received organ transplants are referred urgently to a dermatologist if they present with any new or growing skin lesions.
Testicular cancer
Ix: 1st = ultrasound
- a painless lump is the most common presenting symptom, some have pain
- hydrocele
- gynaecomastia (due to an increased oestrogen:androgen ratio)
germ-cell tumours → hCG → Leydig cell dysfunction → increases in both oestradiol and testosterone production, but rise in oestradiol is relatively greater than testosterone
leydig cell tumours → directly secrete more oestradiol and convert additional androgen precursors to oestrogens
Tumour markers for germ-cell tumour;
seminomas = hCG (in 20%)
non-seminomas = AFP/beta-hCG are elevated in 80-85%
LDH is elevated in around 40% of germ cell tumours
Mx:
Treatment depends on whether the tumour is a seminoma or a non-seminoma
orchidectomy
+ chemo if there’s lymph node involvement
chemotherapy and radiotherapy may be given depending on staging and tumour type
5yr survival-rate = >95%
Thyroid cancer
Thyroid cancer 2ww criteria = unexplained lump in neck
Tumour lysis syndrome
Ix: Also recent chemo (similar to neutropenic sepsis)
hyperkalaemia/phosphataemia, but hypocalcaemia
K>6, PO4>1.125, Ca<1.75 and uric acid>475
If suspicious, test for urate to confirm!
then 1 from: increased creatinine, arrhymthia or seizure
Mx: prophylaxis before/during chemotherapy
high-risk = IV (allopurinol + rasburicase)
low-risk = PO allopurinol
Parotid gland disease passmed
Hodgkin’s lymphoma
signs of poor prognosis:
- B-symptoms,
- increasing age,
- male sex,
- stage IV disease
- lymphocyte depleted subtype
Hodgkin’s lymphoma is a malignant proliferation of lymphocytes characterised by the presence of the Reed-Sternberg cell. It has a bimodal age distribution being most common in the third and seventh decades.
Ann-Arbor staging of Hodgkin’s lymphoma
I: single lymph node
II: 2 or more lymph nodes/regions on the same side of the diaphragm
III: nodes on both sides of the diaphragm
IV: spread beyond lymph nodes
Each stage may be subdivided into A or B
A = no systemic symptoms other than pruritus
B = weight loss > 10% in last 6 months, fever > 38c, night sweats (poor prognosis)
Management
chemotherapy is the mainstay of treatment. Two combinations may be used
ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine): considered the standard regime
BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone): alternative regime with better remission rates but higher toxicity
radiotherapy
combined modality therapy (CMT)
chemotherapy followed by radiotherapy
hematopoietic cell transplantation
may be used for relapsed or refractory classic Hodgkin lymphoma
How to tell the difference between breast issues?
Duct ectasia
Fat necrosis
fibroadenoma
fibrocystic disease
Duct ectasias – green/yellow discharge
Fat necrosis – usually following trauma/injury
d) fibroadenoma – smooth mobile
Fibrocystic disease – ill defined, lumpy, responsive to oestrogen
Which liver tumours are benign and which are malignant?
Benign primary liver tumours include: HALF!
H aemangiomas (most common);
A denomas;
L eiyomyomas.
F ibroma/ocal nodular
The malignant primary liver tumours include: carc/sarc/blastomas
- hepatocellular carcinoma (accounts for 90 per cent of primary liver
tumours); - cholangiocarcinoma;
- angiosarcoma (A);
- hepatoblastoma (D);
- fibrosarcoma (B);
- leiyomyosarcoma (E).
SCC vs BCC vs acitinic keratosis vs Keratoacanthoma
SCC = hyperkeratotic, ULCERATED (may be deep), expanding nodules
with everted edges. They are commonly seen on the back of the hands, face and trunk but may also appear on the edge of scars (e.g. burns scars). Immunosuppressed patients are at risk of developing SCCs.
Basal cell carcinomas (BCCs) are slow growing and initially present as reddishcoloured, DOME-SHAPED pearly nodules with a translucent surface and visible dilated surface capillaries. As the lesions expand, the central area
tends to ulcerate, leaving a rolled-edge appearance.
Actinic keratosis (C)
are characterized by SCALY, erythematous crusting lesions which tend to occur on the scalp, face and back of hands. They are very common lesions which arise secondary to prolonged sun exposure. Actinic keratoses have
the potential to transform into metastasizing squamous carcinoma.
Keratoacanthomas (D) are RAPIDLY GROWING, and usually self-healing,
epidermal nodules which possess pathological features indistinguishable
from early SCCs. Keratoacanthomas develop as solitary lesions on the face
and grow rapidly to a size of 2–3 cm in diameter. The nodule then develops
a necrotic centre and heals spontaneously leaving a PITTED SCAR appearance.
Hypercalcaemia mx in cancer pt’s
malignant and acute
malignant = IV fluids + bisphos (pamidronate)
acute = just fluids
Whats the WHO pain relief ladder?
Step 1 – Non-opioid analgesia, e.g. paracetamol, NSAIDs
Step 2 – Weak opioid analgesia, e.g. codeine, tramadol
Step 3 – Strong opioids, e.g. morphine, diamorphine, fentanyl
ie. if paracetamol doesn’t work then step up to give paracetamol + codeine
How do you calculate morphine breakthrough doseage?
Once a 24-hour requirement of morphine
is established, the dose can be given as a modified release preparation
(morphine sulphate tablets) in 2 divided doses.
A sixth of the total daily
morphine dose should be given as required (used a maximum of every 4
hours) for breakthrough pain.
So if the patient has used 60 mg of oral morphine solution in 24 hours. This can be divided into the 2 doses of 30 mg of modified release preparation of morphine given with 12-hour
intervals.
A sixth of the total daily dose of morphine for breakthrough
pain is 10 mg
So 60 mg would be 2 lots of 30mg plus 10mg as required
Carcinoid Tumours Px and Ix
Carcinoid tumours arise from enterochromaffin cells (APUD cells). They most commonly occur in the appendix, ileum or rectum but can occur
elsewhere, including other areas of the gastrointestinal tract, ovary, testis
or lung.
It is often difficult to histologically determine whether carcinoid
tumours are benign or malignant.
Carcinoid tumours of the
gastrointestinal tract are usually asymptomatic but may cause appendicitis,
intussusception or obstruction.
Carcinoid syndrome refers to carcinoid tumours with liver metastases.
These patients are usually symptomatic and
may present with spontaneous facial flushing, abdominal pain and watery diarrhoea. Fifty per cent of patients develop cardiac abnormalities, such as
tricuspid regurgitation or pulmonary stenosis. Symptoms are produced by the tumours secreting substances such as 5-hydroxytryptamine, bradykinin
and histamine.
Ix = radiological imaging of the liver metastases and 24-hour urine 5-hydroxyindoleacetic acid.
Non-hodgkins differentiators from hodgkins?
non is mostly elderly whereas HL is 30s and 70s
HL has Reed-sternberg owl eye cells
Lymphadenopathy in Hodgkin’s lymphoma can experience alcohol-induced pain in the node
‘B’ symptoms typically occur earlier in Hodgkin’s lymphoma and later in non-Hodgkin’s lymphoma
Extra-nodal disease is much more common in NHL than in HL
