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Stage 4 HD > Oncology > Flashcards

Oncology Flashcards

1
Q

Things to report on when explaining the characteristics of a neck lump

A

-Bilateral or unilateral
-Single or multiple
-Site / Size / Shape / Surface / Edge
-Tender to palpate
-Fixation to superficial tissues or tethered (role skin over top)
-Consistency (Hard/soft/rubbery/ Fluctuance (ABSCESS)
-Pulsatility (Bruity – can hear blood flowing through)
-Temperature – warm = INFLAMMATION
-Transilluminability
-Change in overlying skin
-Draining lymph node enlargement
-Well or poorly defined
-Other symptoms (eg. palsy), duration

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2
Q

Causes of neck lumps

A

-Congenital (eg. cysts)
-Vascular
-Infective (sialadenitis, mumps, lymphadenitis, lymphadenopathy, abscess, cellulitis, TB, pharyngitis, syphylis, Lyme disease, glandular fever)
-Autoimmune (sjogren’s)
-Metabolic (goitre)
-Inflammatory (sarcoidosis)
-Neoplastic (lymphoma, leukaemia, metastases, skin cancer, benign tumour)
-Lipoma, neurofibroma, aneurysm

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3
Q

What is characteristic of a thyroid lump. List types of thyroid lumps

A

moves up when swallowing
-Goitre
-Benign, or malignant tumour
-Thyroglossal duct cyst
-Thyroid lymph node

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4
Q

Characteristics of a malignant neoplasm, opposed to benign

A

-Lump is Firm, fixed, immobile
-painless (not necessarily)
-Progressively growing
-Tethering of overlying skin
-Poorly defined borders, non-homogenous
- invasion of local structures (otherwise it is benign)
-cause necrosis
-can metastasise to distal sites via lymphatics, vessels,
-will keep growing, limitless replicative potential, can form its own blood supply (angiogenesis), potential nerve damage

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5
Q

Causes of acute lymphadenitis and chronic lymphadenopathy

A

-Acute Lymphadenitis infection– lasts <2 weeks. secondary to sore throat/ pericoronitis/ ear infection etc.
-Chronic Lymphadenopathy -Lastslonger. Infective (glandular fever, TB, HIV, measles, EBV) Autoimmune (lupus, RA).
Cancers (lymphoma, leukemia).

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6
Q

Explain these different types of congenital cysts: 1) Thyroglossal, 2) Sublingual dermoid, 3) cystic hygroma, 4) branchial

A

1) along tract where thyroid gland started embryologically from base of tongue at foramen cecum, down midline of neck
2) midline higher than thyroglossal cyst. Occurs at point of fusion with epithelium
3) lump in babies due to blockage in lymphatic system
4) Proliferation of residual remnants of second branchial cleft which should have been obliterated during development. Can become infected. Unilateral in young pt

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7
Q

What is Troisier’s sign. What metastasis does it usually represent

A

-Lump in Posterior triangle of neck.
-Enlarged supraclavicular lymph node (known as a Virchow node)
-Usually represents metastasis from GI cancer

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8
Q

Factors affecting the prognosis of oral cancer

A

-Site – FOM/ lateral border of tonue – BAD PLACES TO GET IT. Hard to excise
-Size – bigger is worse
-Differentiation and biological behaviour of neoplasm
-Immune response of host
-Existence and extent of metastases
-Response to treatment – depends on type of cancer and human response
-HPV related have better prognosis

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9
Q

List premalignancies

A

leukoplakia (3-6%)
erythroplakia
lichen planus (low risk)
Submucosa fibrosis

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10
Q

What types of cancer are increasing: head and neck cancers, oral SCC, oropharyngeal SCC, HPV+ oropharyngeal, HPV- oropharyngeal, laryngeal SCC

A

-Head and neck increasing
-Oropharyngeal increasing, with HPV positive increasing and HPV negative decreasing.
-Oral SCC increasing
- Laryngeal SCC decreasing

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11
Q

7 ENT warning signs for head and neck cancer

A
  1. Change in mole or new skin lesion
  2. Non-healing mouth ulcer
  3. Change in denture fit
  4. Hoarseness
  5. Persistent throat/ear pain
  6. Neck lump
  7. Unilateral nasal obstruction or bleeding
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12
Q

Characteristics for HPV positive oropharyngeal SCC

A

-usually affects younger patients
-has better prognosis
-affects non-keratinising tissue
-usually presents with neck lump first
-Incidence increasing
-p16 biomarker or DNA detection

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13
Q

Describe these terms: neoplasm, tumour, cancer, carcinoma

A

-Neoplasm= new growth, abnormal mass of tissue. Benign or malignant
-Tumour= swelling
-Cancer= malignant neoplasm
-Carcinoma= malignant epithelial cancer

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14
Q

Cells involved in papilloma, adenoma, fibromas, lipoma, osteoma, carcinomas, sarcomas. Which are benign and malignant

A

-Papilloma= benign squamous epithelial cells
-Adenoma=benign glandular epithelial tissue
-Fibroma= benign mesenchymal fibrous tissue
-Lipoma= benign mesenchymal fat
-Osteoma= benign mesenchymal bone

-Carcinomas= any malignant epithelial neoplasm (eg.SCC, adenocarcinoma)
-Sarcomas= any malignant mesenchymal neoplasm (eg.osteosarcoma, fibrosarcoma)

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15
Q

Most common sites for oral cancer

A

tongue (25%), then tonsils

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16
Q

Common symptoms for oropharyngeal cancer. Risk factors

A

-Affects base of tongue, soft palate, tonsils.
-Oral lesion/ ulcer/ white path/ red patch
-Neck lump – spread to lymph nodes: immobile, firm, fixed, painless
-Persistent sore throat or earache (referred from glossopharyngeal nerve branching to middle ear)
-Dysphagia or odynophagia (difficulty or pain swallowing)
-Trismus
-stridor [wheezing breathing in]
-nasty smell
-bleeding

-Persistent Hoarseness >3 weeks (= laryngeal cancer)

-Causes: Smoking, alcohol, HPV infection

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17
Q

Warning signs for cancer (non-oral signs)

A

-Weight loss
-loss of appetite
-nutritional deficiency
-fever
-cough

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18
Q

Treatment options for oral, oropharyngeal and laryngeal SCC

A

-oral =local incision. Radiotherapy if not successful
-Oropharyngeal= transoral robotic or transoral laser microsurgery with or without radiotherapy +/- chemotherapy. Deck dissection if lymph node involvement
-Laryngeal: incision/radiotherapy/laryngectomy

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19
Q

Explain the TNM Staging classification

A

-Tumour size
1 = <2cm
2= <4cm
3= >4cm
4= infiltrating deep structures

-Nodal involvement
0= none
1=single, mobile, small <3cm, without extra nodal extension
2=multiple, mobile 3-6cm, without extra nodal extension
3=fixed nodes >6cm with or without extra nodal extension

-Metastases
0= no
1=yes

These 3 parts come together to stage the disease (I-IV). M1 will always be stage IV
Staging= amount of cancer
Grading= microscopic appearance of the cells

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20
Q

What is TNM 8 classification

A

introduced for HPV related diseases, to reflect the high prognosis of HPV associated oropharyngeal cancer

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21
Q

Survival percentage for 1) HPV oropharyngeal and 2) HPV negative oropharyngeal cancer after 5 years

A

1) >85%
2) 50%

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22
Q

Oral side effects of head and neck radiotherapy

A

-Xerostomia= Taste dysfunction, difficulty swallowing, infections, mucositis, ulcers, lip cracking, caries, hypersensitivity
-Perio disease (reduced repair, Xerostomia)
-trismus ( fibrosis)
- risk of osteoradionecrosis
-Poor OH due to soreness
-Caries occurs in weird areas
-Craniofacial defects if during growth

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23
Q

Explain osteoradionecrosis and how to manage

A

-increased risk of bone necrosis after tooth extraction due to decreased blood supply and poor healing to mandible due to endarteritis obliterans.
-these patients are at HIGH RISK FOREVER. so extract teeth before
-if unavoidable: atraumatic, no vasoconstictor, prophylaxis, remove sharp bone, potential soft tissue flap

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24
Q

Oral side effects of chemotherapy

A

-Infections and bleeding due to PANCYTOPENIA – red/white cells & platelets REDUCED
-Ulcers and mucositis
-Lip cracking
-Xerostomia
-Delayed/abnormal development in child/ pregnant woman
-Candida, herpetic infection

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25
Q

Managing Oral side effects of chemoradiotherapy

A

-Stabalise oral health before radiotherapy due to increased risk of infection and osteoradionecrosis. Extract any teeth prior to tx. Prevention
-Use sponges or gauze soaked in CHX
-Difflam mouthwash (aqueous)
-Advise analgesics, oral cooling methods, lidocaine lollypops
-mucosal lubrication (olive oil around teeth)
-Saliva stimulants
-Toothpaste prescription, OHI
-Avoid hard bristle brush, strong flavoured toothpaste, spicy food
-Jaw exercises
-For ulcers-topical folic acid
-Manage increased risk of infection (candida, viral) and bleeding
-Follow-up (xerostomia can be long term, and FBC abnormal months-years after chemo)

26
Q

What is mucositis. The WHO scale

A

-Widespread inflammed erythema with erosions and ulcers on mucosa. Soreness, bleeding, painful. Due to xerostomia, chemo, radiotherapy

-WHO Mucositis Scale
1. Soreness / Erythema
2. Erythema & Ulcers / Able to eat solids
3. Ulcers / Requires liquid diet
4. Oral intake not possible = HOSPITALISED. Need tube feeding

27
Q

NICE guidelines for suspected oral and laryngeal cancer referral

A

Send to OMFS or ENT
Urgent 2 weeks if a suspected cancer:
-persistent unexplained hoarseness if > 45 years old
-unexplained neck lump
-unexplained ulceration in the oral cavity lasting > 3 weeks.
-a lump on the lip or oral cavity
-has a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia

28
Q

Objectives for oral cancer surgery

A

-Excise entire primary neoplastic lesion with a CLEAR MARGIN (cut around normal tissue)
-Remove margin of adjacent normal tissue in anticipation of microscopic spread (selective neck dissection to remove draining lymph nodes)
-Remove potential channels of metastasis e.g. lymphatics, nerves
-Promote rapid healing and rapid restoration of function (reconstruction, rehabilitation, psychological and social)

29
Q

When FNA cytology and core biopsy is used

A

FNA=thin needle to collect cells from fluid filled mass
-for cysts
-it won’t pick up cancerous cells on the wall of a cyst

-Core= gets tissue using needle. Helpful for viral investigation (HPV, EBV) Common for breast tissue

30
Q

Difference between curative and palliative cancer treatment. Different factors to consider when deciding tx

A

-Curative – aim is to cure you of disease
-Palliative = in elderly patients, less extensive treatment, aim to prolong life, decrease symptoms, reduce burden of disease, not curing them

-Consider age, life expectancy, general health, medical facilities available, patient’s wishes
-Type, site, extent of cancer
-Evidence

31
Q

Mechanism of chemotherapy

A

-Metastatic disease can only be cured by systemic treatment as Surgery alone cannot cure widespread disease
-inhibits cell proliferation and tumor multiplication, thus avoiding invasion and metastasis. But toxic effects as also affects normal cells.
-Also a DXT adjunct as increases effectiveness of radiotherapy
-Oral, IM, intrathecal but IV most common

32
Q

Toxic effects of chemotherapy

A

-LOCAL TOXICITY – tissue destruction if accidentally injected out of vessel
-BONE MARROW TOXICITY – reduced blood cells (Pancytopenia) = increased bleeding, infection
-GI TOXICITY – nausea and vomiting
-Hair loss after 18-21 days

-Long-term toxicity: Carcinogenesis = long-term alkylating agents can lead to ACUTE LEUKAEMIA
-Gonadal damage = infertility

33
Q

What is the normal platelet value. When should you avoid dental treatment in primary care

A

-normal value is 150-400 x109 per litre
-absolute cut off for dental treatment is <50
-Best if >100 in primary care for extra caution

34
Q

Give 2 examples of head and neck immunotherapy drugs

A

nivolumab and pemobrolizumab

Help the immune system attack cancer cells

but limited use in SCC of head and neck

35
Q

What is the use of radiotherapy in cancer treatment and its mechanism

A

-curative or palliative tx
-Induction, Neoadjuvant or adjuvant tx
-destroys cancer cells with localised high doses of high energy radiation.
-Targets DNA cells, Displaces an electron from its orbital path, creates an unstable ion, causes cell death if double strand break
-External beam or internal methods

36
Q

Advantages of using internal radiation over external. Give examples

A

-Specific radiation to tumour tissue, Less collateral damage, Higher doses possible
-Radioactive iodine (131I) used for thyroid carcinoma
-Injectable radioactive phosphorus (32P) for bone marrow cancer
-Brachytherapy seeds planted in prostate

37
Q

How is Sievert different to Grays

A

-Sievert considers biological quality/ radiosensitivity of the tissue unlike the Gray

-Gy= radiation-absorbed dose
-Sv= dose equivalent. Equal to Gray times a quality factor. Takes into consideration the biological effectiveness of the radiation. Different for different tissues

38
Q

Which tissues have high, moderate and low radio sensitivity

A

-High=bone marrow, gonad, gut mucosa, lymphatic tissue, eye lens
-Medium=liver, kidney, lung, skin, breast, gut wall, oral nervous tissue
-Low=Bone, connective tissue, muscle

39
Q

Acute and chronic effects of ionising radiation

A

-Acute= radiation sickness, death, skin erythema
-Chronic= tiredness, nausea, lost appetite, hair loss, cataracts, infertility, obliterative endarteritis (causing decreased blood supply, poor healing, necrosis), damage to foetus, radiation-induced malignancy

40
Q

What doses of radiation causes death. Compare this to a PA

A

-0.0002 Gy for a PA
>50Gy death in a few hours
5-10Gy death within a week

41
Q

What is the treatment regime for radiotherapy for oral cancers

A

5 days for 6 weeks
days off require tissues to heal

42
Q

What is resective, neck dissection and reconstructive cancer surgery

A

-Ressective= incising the primary tumour with scalpel or laser, with clear margins
-Neck dissection= remove diseased lymph nodes
-Reconstructive= restoring function and form with grafts or flaps

43
Q

Why is mouth very good at healing

A

good blood supply, high cell turnover, saliva

44
Q

What reconstrive surgery types can be done in the mouth after cancer incision

A

-Buccal fat pad
-Tongue flap – U shaped flap on dorsum of tongue and stitch onto palatal defect
-Pharyngeal wall
-Skin graft from different sites
-Nasolabial flat
-Complex skin flap
-Regional cutaneous flap
-Microvascular tissue transfer (eg.radial forearm free flap)
-Mycocutaneous pedicles flaps

45
Q

What is the most common cause of neck lumps

A

Infective - soft lumps

46
Q

Which are likely to be bilateral or unilateral neck swellings: syphylis, TB, lymphoma, developmental cysts, bacterial sialadenitis, Mumps, sialosis, pleomorphic adenoma, Warthin’s tumour

A

-TB, syphylis=bilateral
-Lymphoma=unilateral, single lump
-Developmental =unilateral
-Bacterial sialdenitis= unilateral
-Mumps= bilateral
-Sialosis= bilateral
-Pleomorphic adenoma= unilateral
-Warthin’s tumour= bilateral

47
Q

Diagnosing neck lumps

A

-History
-Examine neck lump
-Examine oral cavity and head and neck region
-Referral to OMFS or ENT
-Primary site biopsy
-Neck lump biopsy =FNA or core biopsy
-Imaging: MRI, CT, PET-CT

48
Q

Who is part of the MDT team for oral and oropharyngeal cancer. Their roles

A

-OMFS + ENT surgeons
-Head and neck radiologists (diagnose scans), pathologists (diagnoses under microscope), oncologists (radiotherapy, chemo)
-dietician, clinical nurse specialist (gives info, supports), Speech and language therapist (communication and swallowing problems)
-sometimes dental team

-Multidisciplinary approach for managing head and neck cancer

49
Q

What will a rubbery neck lump likely be

A

lymphoma

50
Q

Breast cancer: risk factors, types, symptoms, diagnosis, treatment

A

-age, race, genetic (BRCA1 or 2 mutation), ovarian cancer history, oestrogen exposure (pill, HRT), obesity, alcohol
-Types: Ductal or Lobular Carcinoma (either in situ or invasive), Inflammatory
-new lumps, thickening in breast under the arm, nipple tenderness, discharge, physical change, skin irritation or changes, warm/red/swollen breast. Sometimes asymptomatic
-Mammography, US, MRI, FNA cytology or core biopsy, blood test
-Masectomy, excision, radiotherapy, chemo, hormone therapy, targeted therapy

51
Q

Lung cancer: risk factors, common types, presentation, diagnosis

A

-smoking, former smoking, passive smoking, pollution, asbestos, occupational exposures
-Adenocarcinoma, SCC, small cell, large cell
-persistent cough getting worse, haemoptysis, chest pain, SOB, wheezing, hoarseness, respiratory infections
-CT scan, bronchosoppy, biopsy

52
Q

Smoking cessation interventions

A

-Behavioural = Very Brief Advice, full social support, Hypnotherapy, acupuncture, let family and friends know etc.

-Pharmacological
 “as part of an abstinence contingent treatment”
 Nicotine replacement therapy (patches, sprays)
 Varenicline (Champix)
o Unlicensed (anxiolytics, antidepressants etc.)

53
Q

Explain the staging (1-4) of cancers

A

1=not spread
2=small +/- spread to lymph nodes within tissue
3=spread to lymph nodes outside tissue
4=spread to distant sites

54
Q

What organs are classes in urological cancers. Presentation

A

-Kidney
-Ureter
-Bladder
-Prostate
-Testicular

-blood in urine (haematuria), urgency to pee, poor stream of pee, weak pee

55
Q

Prostate cancer: risk factors, types, treatment

A

-age, family history, obesity, race
-adenocarcinoma most common, transitional, SCC, small cell
-surgery, radiation, brachytherapy (internal radiotherapy), cryotherapy, hormone therapy, chemo

56
Q

What is the most common cancer in men

A

prostate cancer (1 in 6 will get it in their lifetime)

57
Q

Kidney cancer: risk factors, treatment

A

-male, age, smoking, obesity, on dialysis, genetics, family history, hypertension, thyroid cancer
-Surgery, cryotherapy, immunotherapy. Don’t respond well to chemo and radiotherapy so less common

58
Q

What is Wilm’s tumour

A

malignant nephroblastoma in kidney, occurring in children (peak 2 years)
spreads to lymph nodes and via the renal vein to the lungs

59
Q

The use of bisphosphonates

A

-Anti-resorptive. Promote osteoclast apoptosis

-Osteoporosis, Paget’s disease
-used in breast cancer to reduce risk of spreading to bone
-prevent osteoporosis in patients taking hormone therapy
-treat hypercalcamia (high level of Ca in blood)

60
Q

Differential diagnosis for a pre-auricular lump

A

-large skin cyst
-lipoma/ benign fatty tumour
-Parotid salivary gland = parotid lump
-Sarcoma

61
Q

Kaposi’s sarcoma - causes, oral appearance

A

-Common in advanced immunosupression
-HHV8, HIV
-Red/ purple macule that progress to plaques or nodules which may ulcerate

62
Q

Role of a maxfax surgeon

A

-treating misaligned jaws
-removing oral, head and neck cancer, cysts
-reconstructive surgery
-implants
-removing impacted teeth
-treating TMD, cleft lip and palate, facial trauma

Stage 4 HD (6 decks)

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