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Phase 4 > Oncology > Flashcards

Oncology Flashcards

1
Q

what type of cancer is most commonly associated with superior vena cava obstruction?

A

lung cancer - most common

also lymphoma

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2
Q

what are 6 causes of superior vena cava obstruction?

A

malignancy - non-small cell lung cancer, lymphoma, metastatic seminoma, Kaposi’s sarcoma, breast cancer

Aortic aneurysm
Mediastinal fibrosis
goitre
SVC thrombosis

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3
Q

what are 4 complications of superior vena cava syndrome?

A

laryngeal oedema and airway obstruction
cerebral oedema - neuro signs
Low cardiac output and hypotension
PE - if due to thrombus

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4
Q

what are 8 symptoms of superior vena cava syndrome?

A

SOB - may be exacerbated lying down
Swelling of face, neck and arms , may have conjunctival/periorbital oedema
Chest pain
Headache - worse in morning
Visual disturbance
Pulseless jugular vein distension
collateral vein development - late sign
compressive symptoms - stridor, dysphagia, hoarse voice

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5
Q

what investigations can be done for superior vena cava syndrome?

A

CXR - mass or widened mediastinum
CT thorax with contrast
MRI chest
US doppler of upper extremities
Venography
Biopsy

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6
Q

what is the management of superior vena cava syndrome?

A

PCI stenting if emergency
Radio/chemotherapy and corticosteroids if malignant
Tumor removal
Thrombolysis if due to thrombus

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7
Q

how common is lung cancer?

A

3rd most common in UK

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8
Q

what is.the most common type of lung cancer?

A

non-small cell adenocarcinoma

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9
Q

what are 3 types of non-small cell lung cancer?

A

adenocarcinoma
squamous cell carcinoma
large cell carcinoma

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10
Q

what is mesothelioma?

A

lung malignancy affecting meothelial cells of pleura linked to asbestos inhalation. Poor prognosis

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11
Q

what are 9 presentations of lung cancer?

A

SOB
cough
Haemoptysis
finger clubbing
recurrent pneumonia
weight loss
lymphadenopathy
Hoarse voice - especially pancoast tumoour
SVC syndrome

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12
Q

what is dysplasia?

A

the presence of abnormal cells in a tissue

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13
Q

what is special about small cell lung cancers?

A

have neuroendocrine differentiation and release neuroendocrine hormones with a wide range of paraneoplastic associations

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14
Q

what is a pancoast tumour?

A

a type of lung cancer located at the lung apex that can lead to shoulder pain and Horner’s syndrome (ptosis, miosis, anhydrosis)

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15
Q

what are 5 paraneoplastic syndromes that can be caused by lung cancer?

A

Hypercalcaemia due to production of PTH peptide

Cushings - due to ectopic ACTH production

SIADH leading to hyponatraemia

Lamber-eaton myasthenic syndrome - caused by antibodies against small cell lung cancer

Clubbing

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16
Q

how can small cell lung cancer cause Lamber-eaton myasthenic syndrome ?

A

due to antibodies against small cell lung cancer which target and damage voltage gated calcium chennels on presynaptic terminals of motor neurones leading to weakness in proximal muscles. Can also affect intraocular, levator and pharyngeal muscles causing diplopia, ptosis, slurred speech and dysphagia

may also have dry mouth, blurred vision, impotence, dizziness due to autonomic dysfunction

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17
Q

what sign can be used to assess for superior vena cava syndrome?

A

Pemberton’s sign

raising hands over head causes facial congestion and cyanosis

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18
Q

what are 5 investigations for lung cancer?

A

CXR - hilar enlargement, peripheral opacity, u/l pleural effusion, collapse

Staging contrast CT
PET-CT
Brochoscopy
Histological diagnosis - brochoscopy biopsy or percutaneous biopsy

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19
Q

what is the management of non-small cell lung cancer?

A

Radiotherapy
Surgery - mediastinoscopy prior as CT does not always show mediastinal lymph node involvement - often lobectomy.

Poor response to chemo

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20
Q

what are 8 contrindications to surgery in non-small cell lung cancer?

A

general health
Stage IIIb or IV
FEV1<1.5L
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction

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21
Q

what is the management of small cell lung cancer?

A

limited spread - 4-6 cycles of cisplatin based chemo +/- radiotherapy

Extensive mets - platinum based combo chemo + radiotherapy

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22
Q

where is lung cancer likely to metastasise to?

A

Brain
bone
liver

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23
Q

what is the normal size of the abdominal aorta?

A

<1.5cm women
<1.7cm men

> 50 years

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24
Q

when does screening for AAA take place?

A

males aged 65

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25
Q

what happens to AAAs 3-4.4cm?

A

small aneurysm - rescan every 12 months

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26
Q

what happens to AAA <3cm?

A

normal no action needed

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27
Q

what happens to AAAs 4.5-5.4cm?

A

medium aneurysm - rescan every 3 months

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28
Q

what happens to AAAs >5.5cm?

A

large aneurysm - refer 2ww to vascular for probable intervention

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29
Q

what puts an AAA at high rupture risk?

A

symptomatic
diameter >5.5cm
Rapidly enlarging >1cm a year

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30
Q

what is the management of AAA?

A

elective endovascular repair (EVAR) or open repair

EVAR - stent placed in abdominal aorta via femoral artery to prevent blood collecting in aneurysm

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31
Q

what are 4 presentations of AAA rupture?

A

Pain in back or loin - abdo pain radiating through to back

Cardiovascular failure - tachy, hypotensive (shock), poorly responsive to fluids

Distal ischaemia - if haematoma in aneurysmal cavity can embolise and cause distal artery occlusion

Death

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32
Q

what investigations should be done for ruptured AAA?

A

USS - quick diagnostic test to rule out AAA

CT angio - gold standard

Bloods
- FBC
- U+E - due to contrast needed for endovascular procedure
- coag screen
- group, save and cross match for surgery

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33
Q

what are the 2 types of repair for rupture AAA?

A

open surgical repair - using midline laparotomy for direct visualisation

Endovascular aneurysm repair (EVAR)

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34
Q

what are 7 complications of ruptured AAA?

A

renal failure
MI
bowel ischaemia
limb ischaemia
graft infection
abdominal compartment syndrome - more common in open surgery
endo leak of blood around aneurysm graft causing enlargement of aneurysm - only with EVAR

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35
Q

what is the usual size for the thoracic aorta?

A

ascending <4.5cm
descending <3.5cm

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36
Q

what is a false aneurysm?

A

usually de to trauma such as RTC, when intima and media rupture and there is dilation of vessel with blood only being contained within adventitia whereas true aneurysm has dilation of all layers of vessel

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37
Q

what are 6 presentations of throacic abdominal aneurysm?

A

chest/back pain
trachea or L bronchus compression - cough, SOB, stridor
Phrenic nerve compression - hiccups
Oesophageal compression - dysphagea
Recurrent laryngeal nerve compression - hoarse voice

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38
Q

what part of the pancreas is usually affected in pancreatic cancer?

A

the head

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39
Q

what are 6 symptoms of pancreatic cancer?

A

Painless jaundice
Palpable gallbladder
Non-specific - anorexia, wt loss, epigastric pain
Steatorrhea
Diabetes
Atypical back pain

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40
Q

what is Whipple’s resection?

A

Pancreaticoduodenectomy for pancreatic cancer

For resectable lesions of the head of the pancreas

Removal of
Head of pancreas
pylorus of stomach
duodenum
gall bladder
bile duct
relevant lymph nodes

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41
Q

What is the most common type of pancreatic cancer?

A

Adenocarcinoma

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42
Q

what is the serum tumour marker for pancreatic cancer?

A

Ca 19-9

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43
Q

what procedure is used for tumours in the body/tail of the pancreas?

A

distal pancreatectomy

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44
Q

what are 4 non-modifiable risk factors for pancreatic cancer?

A

Age >60
Male
Afro-Caribbean or Ashkenazi Jewish heritage
Fhx - BRACA 2 mutations, FAMMM syndrome

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45
Q

what are 6 modifiable risk factors for pancreatic cancer?

A

Smoking
Diet - red and processed meats
BMI and inactivity
Alcohol
Chronic pancreatitis
Diabetes

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46
Q

when should an urgent CT for pancreatic cancer be done?

A

> 60 years and weight loss plus;
Diarrhoea
Back pain
Abdo Pain
Nausea
Vomiting
Constipation
New onset diabetes

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47
Q

What is the TNM staging for pancreatic cancer?

A

Tis - carcinoma in situ
T1 - <2cm confined to pancreas
T2 - >2cm confined to pancreas
T3 - local invasion not into blood vessels or nerves
T4 - local invasion of blood vessels and nerves

N0 - no regional lymph nodes
N1 - regional lymph nodes involved

M0 - No distant mets
M1 - distant mets

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48
Q

What are 4 surgeries for pancreatic cancer?

A

Total pancreatectomy
distal pancreatectomy
Modified whipple
Whipple procedure

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49
Q

what are 5 palliative options for pancreatic cancer?

A

Stents to relieve biliary obstruction
Surgery to improve symptoms
palliative chemo
palliative radiotherapy
EOL care

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50
Q

what scan is used for staging pancreatic cancer?

A

CT TAP

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51
Q

what chemo can be used in metastatic pancreatic cancer treatment?

A

1 - FOLFIRINOX

Fluorouracil
Leucovorin
Ieinotectan
Oxaliplatin

2 - Oxaliplatin based chemo

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52
Q

where are the 3 most common sites of pancreatic metastasis?

A

Liver
Lungs
Peritoneum

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53
Q

what is Courvoisiers law?

A

For pancreatic cancer

Palpable gallbladder + jaundice is unlikely to be gallstones

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54
Q

what is Trousseau’s sign of malignancy?

A

For pancreatic cancer

migratory thrombophlebitis as a sign of malignancy

Blood vessel inflammation with an associated thrombus which reoccur in different locations over time

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55
Q

what may be seen on radiology in pancreatic cancer?

A

Double duct sign - dilation of both common bile duct and pancreatic ducts commonly due to carcinoma of head of pancreas

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56
Q

what chemo can be used as an adjuvant in pancreatic cancer?

A

Gemcitabine
+ Capecitabine

6 cycles after resection

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57
Q

what is the most common type of gastric cancer?

A

adenocarcinoma

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58
Q

where in the world is gastric cancer most common?

A

Japan

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59
Q

what are 7 manifestations of gastric cancer?

A

Dyspepsia/indigestion
Epigastric pain
Early satiety or postprandial fullness
Wt loss
Anaemia
Nausea and vomiting
GI bleeds
Epigastric mass

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60
Q

what are 3 differentials for gastric cancer?

A

peptic ulcer
oesophageal stricture
achalasia

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61
Q

what are 6 risk factors for gastric cancer?

A

H. Pylori infection
Smoking
High salt intake
genetics
Smoked/preserved foods
Pernicious anaemia and atrophic gastritis

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62
Q

when should you refer for upper GI endoscopy when suspecting gastric/oesophageal cancer?

A

Dysphagia
55+ weight loss +
- Upper abdo pain
- Reflux
- Dyspepsia

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63
Q

When should you refer non-urgently to gastro for ?gastric/oesophageal cancer >55 years?

A

Tx resistant dyspepsia
Upper abdo pain with low Hb

raised platelets with
- nausea
- vomiting
- wt loss
- refluc
- dyspepsia
- upper abdo pain

Nausea + vom with
- wt loss
- reflux
- dyspepsia
- upper abdo pain

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64
Q

what are is the 1st line investigation for gastric cancer?

A

Gastric endoscopy with biopsy

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65
Q

What are 2 surgeries for gastric cancer?

A

Partial gastrectomy
Total gastrectomy

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66
Q

what 2 targeted therapies can be used in gastric cancer?

A

Anti-HER2 therapy - transtuzumab, pertuzumab
Anti-VEGF therapies

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67
Q

what is the 5 year survival rate of pancreatic cancer?

A

5%

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68
Q

what are 4 complications of gastric cancer?

A

obstruction
bleeding`
perforation
mets

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69
Q

What are 3 locations for gastric metastasis?

A

Liver
Lymph nodes - virchow’s node
Ovaries - Krukenberg tumours

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70
Q

what are 3 signs associated with gastric cancer?

A

Acanthosis nigricans
Trousseau’s cancer syndrome - migratory thrombophlebitis
Leser-Trelat sign - rapid increase in number of seborrheic keratoses

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71
Q

what can be seen histologically in gastric cancer?

A

signet ring cells - large vacuole of mucin displacing nucleus

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72
Q

what is dumping syndrome?

A

Associated with gastrectomy

Early - 30 mins after meal fluid moves into intestine due to high osmotic load resulting in dizziness and palpitations

Late - 2 hour after meal, glucose rapidly absorbed into intestine causing reactive hyperinsulinemia and subsequent hypoglycaemia

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73
Q

what are the 2 main types of oesophageal cancer?

A

Adenocarcinoma - most common UK - GORD

Squamous cell carcinoma - Most common developing word (smoking)

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74
Q

what are 4 risk factors for oesophageal cancer?

A

Barrett’s oesophagus
Male
Smoker
Achalasia

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75
Q

where are oesophageal adenocarcinomas found?

A

Lower third of oesophagus - near gastroesophageal junction

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76
Q

where are squamous cell oesophageal carcinomas found?

A

Upper 2/3rds of oesophagus

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77
Q

what are 6 presentations of oesophageal cancer?

A

Dysphagia (solids then liquids)
Odynophagia - Pain on swallowing
Weight loss
Hoarse voice/cough
Retrosternal pain/dyscomfort
lymphadenopathy

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78
Q

what are 4 investigations for oesophageal cancer?

A

Upper GI endoscopy with biopsy - gold
CT chest abdomen and pelvis for staging
Endoscopic US for locoregional staging
Barium swallow

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79
Q

what are 3 differentials for oesophageal cancer?

A

benign stricture
achalasia
Barrett’s oesophagus

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80
Q

what is the management of oesophageal cancer?

A

Surgical resectio - Oesophgectomy
Endoscopic mucosal resection

Chemo - platinin based

Radiotherapy

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81
Q

what is the most common type of surgical resection in oesophageal cancer?

A

Ivor Lewis type oesophagectomy

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82
Q

what are 3 complications of oesophageal cancer?

A

Post-resection acid reflux
trachea-oesophageal fistula
Anastamotic leak - due to surgery

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83
Q

What is Barrett’s oesophagus?

A

a change (metaplasia) in the normal squamous epithelium of the oesophagus to specialised intestinal epithelium

stratified squamous to simple columnar

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84
Q

what is the change in epithelium in Barrett’s oesophagus?

A

Stratified squamous TO
Simple columnar

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85
Q

what are 4 causes for Barrett’s oesophagus?

A

GORD
Lower oesophageal sphincter hypotension
hiatus hernia
gastric acid hypersecretion

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86
Q

what are 3 risk factors for Barrett’s oesophagus?

A

GORD
smoking
obesity
male

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87
Q

what is the pathophysiology of Barrett’s oesophagus?

A

Reduced lower oesophageal sphincter muscle tone => increased relaxation allowing reflux of gastric acid through the LOS => damage to squamous mucosa and eventual metaplasia to columnar cells

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88
Q

what are 4 clinical presentations of Barrett’s oesophagus?

A

heartburn
regurgitation
dysphasia
SOB/wheezing and belching

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89
Q

what is the investigation for Barrett’s oesophagus?

A

Upper Gi endoscopy + biopsy = gold

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90
Q

what are 3 differentials for Barrett’s oesophagus?

A

osephagitis
GORD
oesophageal carcinoma

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91
Q

what is the management of Barrett’s oesophagus?

A

1 - High dose PPIs - omeprazole 40mg OD, Lansoprazole 30mg BD

1 - Lifestyle changes

Radio frequency ablation

repeat endoscopic surveillance every 5 years without dysplasia, every 6 months with dysplasia

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92
Q

what are 3 complications of Barrett’s oesophagus?

A

oesophageal adenocarcinoma
oesophageal strictures
quality of life deficit

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93
Q

what is Zollinger-Ellison syndrome?

A

Rare condition where duodenal/pancreatic tumour secretes excess gastrin (gastrinomas) leading to excess acid secretion in stomach

This causes severe dyspepsia, diarrhoea and peptic ulcers

Gastrinomas are associated with multiple endocrine neoplasia 1 (MEN1).

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94
Q

what are 8 clinical features of breast cancer?

A

hard, irregular, painless, fixed lumps
lumps tethered to skin or chest wall
nipple retraction
skin dimpling - peau d’orange
nipple discharge
rash, crusting or scaling around nipple
change in shape/size of breast
auxillary lymphadenopathy

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95
Q

What is triple assessment of breast lumps?

A

clinical assessment - Hx and exam

Imaging - USS, mamography

histology - fine needle/core biopsy

each scored 1-5 from normal to malignant

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96
Q

what is phyllodes tumour?

A

can be benign or malignant breast lumps
rapidly growing painless breast lumps

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97
Q

what is the most common type of breast cancer?

A

invasive ductal carcinoma

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98
Q

What are 6 risk factors for breast cancer?

A

Female
increased oestrogen exposure - OCP and HRT
more dense breast tissue
obestiy
smoking
FHx

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99
Q

What chromosome is BRACA1 on?

A

chromosome 17

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100
Q

what cancers does BRACA1 increase risk of?

A

breast - 70% BY 80yo
ovarian - 50%
prostate and bowel

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101
Q

what chromosome is BRACA2 on?

A

chromosome 13

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102
Q

what is ductal carcinoma in situ?

A

pre-cancerous or cancerous epithelial cells of breast ducts
localised
good prognosis

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103
Q

what is lobular carcinoma in situ?

A

precancerous
usually asymptomatic and undetectable on mammogram
increased risk of invasive breast cancer in future
often managed with close managing

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104
Q

what is invasive ductal carcinoma?

A

originates in cells of breast ducts
80% of invasive breast cancers
seen on mamograms

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105
Q

what is invasive lobular carcinoma?

A

10% of invasive breast cancers
from breast lobules
not always visible on mammograms

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106
Q

what is inflammatory breast cancer?

A

1-3% of breast cancer
similar to breast abscess or mastitis
swollen, warm, tender breat with peau d’orange
doesnt respond to antibiotics
worse prognosis

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107
Q

what is pagets disease of the nipple?

A

loosk like eczema of nipple
erythematous, scaly rash
indicates breast cancer of niple
may be DCIS or invasive breast cancer
requires biopsy, staging and treatment

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108
Q

when is breast cancer screening offered?

A

aged 50-70 every 3 years mammogram

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109
Q

what medications can be used as chemoprevention of breast cancer in those with high risk?

A

tamoxifen - premenopause
anastrozole - postmenopausal

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110
Q

what are 4 investigations for breast cancer?

A

mammogram
biopsy and histology
breast MRI
breast ultrasound

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111
Q

what are 2 investigations needed of confirmed breast cancer?

A

hormone receptor testing - oestrogen and progesterone receptor status
HER2 testing

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112
Q

what medication can be used in HER2 positive breast cancer?

A

trastuzamab (herceptin)

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113
Q

what is the usual management for breast cacinoma in situ?

A

lumpectomy + radiotherapy

tamoxifen/aromatase inhibitors can be used in high risk patients

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114
Q

what is pagets disease of the breast?

A

eczema like changes to skin of nipple and areola - sign of breast cancer
dark scaly rash - often sore and inflamed

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115
Q

What causes peau d’orange?

A

blocked lymphatic drainage causes superficial oedema with sweat ducts making small dimples

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116
Q

what type of tumour can cause gynacomastia due to oestrogen secretion?

A

leydig cell tumour - testicular cancer

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117
Q

What is the first line medication for oestrogen receptor +ve breast cancer if premenopausal women?

A

tamoxifen - 5 years

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118
Q

What is the first line medication for oestrogen receptor +ve breast cancer in post-menopausal women?

A

Aromatase inhibitors
e.g. anastrozole

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119
Q

What medication is used in HEr2 +ve breast cancer?

A

Trastuzamab
3 weekly injections for a year after surgery

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120
Q

What is the most common types of vulval cancer?

A

squamous cell carcinoma - 90%

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121
Q

what are 5 risk factors for vulval cancer?

A

advanced age (>75)
immunosuppression
HPV
lichen sclerosis
Vulval intraepithelial neoplasia

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122
Q

what is the premalignant form of vulval cancer?

A

vulval intraepithelial neoplasia

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123
Q

what type of vulval intraepithelial neoplasia is associated with younger people?

A

high grade squamous intraepithelial lesion - associated w/ HPV infection

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124
Q

What type of vulval intraepithelial neoplasia is associated with older people?

A

differentiated VIN associated w/ liches sclerosis

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125
Q

what are 6 presentations of vulval cancer?

A

vulval lump
ulceration
bleeding
pain
itching
lymphadenopathy of the groin

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126
Q

what are the management options for VIN?

A

Watch and wait
Wide local excision
Imiquimod cream
laser ablation

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127
Q

what are 4 management options for vulval cancer?

A

Surgery - wide local excision or vulvectomy
Radiotherapy
Chemotherapy - platinum based
Biologics - anti-EGFR monoclonal antibodies

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128
Q

what are 6 presentations of vaginal cancer?

A

Lump in vagina
Ulcer and skin changes in/around vagina
Bleeding post menopause/post coital
Smelly/bloodstained discharge
Intermenstrual bleeding
Itch

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129
Q

what are 4 risk factors for vaginal cancer?

A

HPV infection
Hx of cervical/endometrial cancers
>75 years
AID/immunosuppression

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130
Q

What is the most common type of cervical cancer?

A

Squamous cell carcinoma

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131
Q

what is the second most common type of cervical cancer?

A

adenocarcinoma

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132
Q

What is the most common cause of cervical cancer?

A

Human papilloma virus (HPV)

16 and 18 most commonly

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133
Q

what cancers is HPV associated with?

A

Cervical
Anal
Valval
Vagina
Penile
Mouth and throat

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134
Q

what 2 strains of HPV are responsible for 70% of cervical cancers?

A

16 and18

135
Q

How does HPV promote cancers?

A

Inhibits tumour suppressor genes (P53 and pRb)

136
Q

What are 6 risk factors for cervical cancer?

A

increased risk of catching HPV
non-engagement with screening
smoking
HIV
COCP >5 years
family history

137
Q

what increases your risk of catching HPV? (5)

A

early sexual activity
Increased number of sexual partners
sex work
not using condoms

138
Q

what are 4 cervical appearances that may suggest cancer?

A

ulceration
inflammation
bleeding
visible tumour

139
Q

what are 4 presentations of cervical cancer?

A

abnormal vaginal bleeding - intermenstrual, postcoital, post menopausal
vaginal discharge
pelvic pain
dyspareunia (painful sex)

140
Q

what is the premalignant form of cervical cancer?

A

cervical intraepithelial neoplasia (CIN)

141
Q

How is CIN diagnosed?

A

colposcopy

142
Q

what is CIN I?

A

mild dysplasia affecting 1/3rd thickness of epithelial layer - likely to return to normal without treatment

143
Q

what is CIN II?

A

moderate dysplasia affecting 2/4rds of thickness of epithelial layer - likely to progress to cancer if untreated

144
Q

what is CIN III?

A

severe dysplasia very likely to progress to cancer

145
Q

when does cervical screening take place?

A

every 3 years 25-49
Every 5 years 50-64

146
Q

what is the staging used for cervical cancer?

A

FIGO staging

147
Q

what are the 4 stages of cervical cancer?

A

1 - confined to cervix (1A <7mm, 1B >7mm)
2 - invades uterus or upper 2/3rds of vagina
3 - invades pelvic wall or lower 1/3rd of vagina
4 - invades bladder, rectum or beyond pelvis

148
Q

what biopsy techniques are used for cervical cancer?

A

large loop excision or punch biopsy during colposcopy

cone biopsy - also Tx of v early stage cervical Ca

149
Q

what is the management of CIN or early stage 1A cervical cancer?

A

LLETZ or cone biopsy if wanting to maintain fertility

Gold standard is hysterectomy +/- lymph node biopsy

150
Q

what is the management of stage 1B and above cervical cancer?

A

Radical hysterectomy and removal of local lymph nodes, chemo and radiotherapy

151
Q

What MAB can be used in cervical cancer treatment?

A

Bevacizumab - target vascular endothelial growth factor A

152
Q

what are 6 complications of cervical cancer?

A

Hydronephrosis - due to tumour invasion

Prem birth - post come biopsy
Ureteral fistula - post radical hysterectomy
Radiation proctitis/cystitis
Radiation burns
Lymphoedema

153
Q

what type of cancer is 80% of endometrial cancer?

A

adenocarcinoma

154
Q

which hormone stimulates the growth of endometrial cancer?

A

oestrogen

155
Q

what is the precancerous version of endometrial cancer?

A

endometrial hyperplasia

156
Q

what are 9 risk factors for endometrial cancer?

A

increased age
earlier onset of menstruation
late menopause
oestrogen only hormone replacement
no/few pregnancies
obesity
PCOS
Tamoxifen
Diabetes T2

157
Q

what are 4 protective factors for endometrial cancer?

A

COCP
MIrena coil
Increased pregnancies
smoking

158
Q

what are 7 presentations of endometrial cancer?

A

post menopausal bleeding
postcoital and instermenstrual bleeding
menorrhagia
Abnormal discharge
haematuria
anaemia
raised platelets

159
Q

what is the referral criteria for endometrial cancer?

A

2ww - Postmenopausal bleeding

Urgent TV US - >55 with unexplained vaginal discharge, visible haematuria with raised platelets, anaemia or elevated glucose

160
Q

what are 3 investigations for endometrial cancer?

A

TV USS for endometrial thickness
pipelle biopsy - highly sensitive
hysteroscopy with endometrial biopsy

161
Q

what is a normal endometrial thickness post menopause?

A

<4mm

> 5mm warrants biopsy

162
Q

what is the management of endometrial hyperplasia?

A

High dose progestogens and repeat sampling in 3-4 months

If atypia - hysterectomy

163
Q

What are the stages of endometrial cancer?

A

1 - confined to uterus
2 - invades cervix
3 - invades ovaries, fallopian tubes, vagina or lymph nodes
4 - invades bladder, rectum or beyond pelvis

164
Q

What is the treatment for endometrial cancer?

A

total or radical hysterectomy with bilateral salpingo-oophorectomy

Radial hyterectomy
radiotherapy
chemo
progesterone tx

165
Q

what are 4 complications of management of endometrial cancer?

A

Bowel changes - due to radiotherapy
Urinary changes
Lymphoedema
Neutropenic sepsis

166
Q

what is the most common type of ovarian cancer?

A

Epithelial cell tumours

include serous tumours, endometrioid carcinomas, clear cell tumours, mucinous tumours, undifferentiated tumours

167
Q

what are ovarian germ cell tumours?

A

also called dermoid cysts

Teratomas containing skin, teeth, hair, bone - associated with ovarian torsion

168
Q

what markers can ovarian germ cell tumours cause to be raised?

A

alpha-fetoprotein
human chorionic gonadotrophin

169
Q

what are sex cord stromal tumours?

A

rare benign or malignant tumours that arise from stroma or sex cords

sertoli-leydig tumours
granulosa cell tumours

170
Q

what is the name of an ovarian tumour metastasised from the GI tract?

A

Krukenberg tumours

have classic signet ring cells on histology

171
Q

what are 6 risk factors for ovarian cancer?

A

Age (highest incidence >60)
BRACA1 and 2 genes (FHx)
Increased number of ovulations
obesity
smoking
recurrent use of clomifene

172
Q

what factors increase the number of ovulations (and therefore ovarian cancer risk)?

A

early onset periods
late menopause
no pregnancies

173
Q

what are 3 protective factors for ovarian cancer?

A

combined oral contraceptive pill
breastfeeding
pregnancy

174
Q

what are 8 presentations of ovarian cancer?

A

abdominal bloating
early satiety/loss of apetite
pelvic/hip and groin pain
urinary symptoms
weight loss
abdominal/pelvic masses
ascites

175
Q

what is the referral criterial for ovarian cancer?

A

2ww - Acites, pelvic mass, abdominal mass

176
Q

what is the tumour marker for ovarian cancer?

A

CA125

177
Q

what are 3 tumour markers for rarer ovarian germ cell tumours?

A

alpha-fetoprotein
HCG
lactate dehydrogenase

178
Q

what are 6 non-cancer causes of a raised CA125?

A

Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy

179
Q

what is the staging of ovarian cancer?

A

FIGO

1 - confined to ovary
2 - spread past ovaries but in pelvis
3 - spread past pelvis but in abdomen
4 - distant metastasis

180
Q

what are 5 complications of ovarian cancer?

A

Ascites
Bowel obstruction
chronic pain
VTE
Hyperthyroidism due to ovarian teratoma - struma ovarii containing thyroid tissue

181
Q

what are the side effects of tamoxifen and aromatase inhibitors?

A

hot flushes
nausea
vaginal bleeding
thrombosis
endometrial cancer

182
Q

what medication can be used in pre-menopausal woman with ovarian sensitive breast cancer?

A

GNFR inhibitors

183
Q

what is the name of 3 HER2 receptor blocker medications?

A

trastuzumab
pretuzumab
Neratinib

184
Q

what medications can be used in tripple negative breast cancer?

A

immunomodulators

185
Q

what medications can be used in braca1 and 2 cancers?

A

PARP inhibitors

186
Q

what other than ovarian cancer can cause a raised Ca125?

A

adenomyosis
ascites
endometriosis
menstruation
breast cancer
ovarian torsion
endometrial cancer
liver disease
metastatic lung cancer

187
Q

What is the most common type of bladder cancer?

A

Transitional cell carcinoma

188
Q

what are the 2 different types of transitional cell carcinoma?

A

Papillary - majority - superficial and often non-invasive

Flat - lie flat against bladder tissue, more prone to invasion

189
Q

what are 4 risk factors for bladder cancer?

A

Increased age
smoking
Aromatic amines - dye and rubber workers
Polycyclic aromatic hydrocarbons - aluminium, coal, roofing
Schistosomiasis

190
Q

what kind of cancer does schistosomiasis cause?

A

Squamous cell carcinoma of bladder - common in egypt

191
Q

what are 5 clinical manifestations of bladder cancer?

A

Painless haematuria
LUTS - frequency
Systemic symptoms
Anaemia
suprapubic masses

192
Q

when should a patient with suspected bladder cancer be referred for a 2ww?

A

> 45 with unexplained visible haematuria - without uti/after treatment

> 60 with microscopic haematuria PLUS dysuria or raised WBCs

consider in >60 with recurrent persistent unexplained UTIs

193
Q

what are 3 investigations for bladder cancer?

A

Primary - urinalysis, bloods

flexible cystoscopy + biopsy - GOLD

CTTAP/MRI - for staging

194
Q

what T staging is non-muscle invasive bladder cancer?

A

T in situ - T1

195
Q

What T staging is muscle invasive bladder cancer?

A

T2-4

196
Q

what is the management for non-muscle invasive bladder cancer?

A

Transurethral resection of bladder tumour (TURBT)
PLUS
Intravesical mitomycin C

May have multiple doses if higher risk

197
Q

what is the management of muscle invasive bladder cancer?

A

Radical cystectomy
Radical radiotherapy

with neoadjuvant chemo (cisplatin)

198
Q

what are the options for urine drainage after cystectomy?

A

Urostomy with ileal conduit
Continent urinary diversion
neobladder reconstruction
Ureterosigmoidostomy

199
Q

what are 5 complications of bladder cancer?

A

haematuria
UTIs
obstructive uropathy

Treatment related:
Surgery complications
Cystectomy related issues
Radiation cystitis

200
Q

what is cancer grading?

A

histological - how differentiated from original tissue is it?

201
Q

what is cancer staging?

A

size and metastasis

202
Q

where are most prostate cancers situated?

A

Peripheral zone of prostate gland

203
Q

what is the most common cancer of men?

A

prostate cancer

204
Q

what are 5 risk factors for prostate cancer?

A

older age
FHx - BRACA2, HOXB13
Black African or Caribbean
Anabolic steroids

205
Q

what are 5 manifestations of prostate cancer?

A

LUTS
Haematuria or Haematospermia
Mets symptoms - bone pain, wt loss, cauda equina
Erectile dysfunction
Urinary retention

206
Q

what is the referral criterial for prostate cancer?

A

Malignant feeling on DRE
High PSA

PSA and DRE in men with
any LUTS
Erectile dysfunction
Haematuria

207
Q

what is the 1st line investigation for prostate cancer

A

Multiparametric MRI

Then transrectal US guided biopsy to confirm if likely cancer

208
Q

what are 5 risks of prostate biopsy?

A

Pain
Bleeding
Infection
urinary retention
erectile dysfunction

209
Q

what scan can be used to look for bony mets?

A

isotope bone scan

210
Q

what scale is used to report prostate cancer on multiparametric MIR?

A

Likert scale

offer biopsy >3

211
Q

what is the management of low-medium risk prostate cancer?

A

Active surveillance
Radical prostatectomy
Radical radiotherapy or brachytherapy (radioactive seeding) +/- anti-androgen therapy (flutamide)

212
Q

what is the management of high risk prostate cancer?

A

Radical prostatectomy
Radical radiotherapy PLUS anti-androgen therapy
Radical radiotherapy with brachytherapy
Docetaxel chemotherapy PLUS anti-androgen therapy

213
Q

what can be an alternative to medical anti-androgen therapy?

A

bilateral orchidectomy

214
Q

what is the chemotherapy agent used in prostate cancer?

A

Docetaxel

215
Q

what are 5 side effects of hormone therapy in prostate cancer?

A

Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis

216
Q

what anti-androgen therapies can be given in prostate cancer?

A

GnRH agonists - Goserelin

GnRH antagonists - Degarelix

Biclutamide - non steroidal anti-androgen

Cyproterone acetate - steroidal anti-androgen

Abiraterone - androgen synthesis inhibitor

217
Q

how does the male gonadal axis work?

A

Hypothalamus secretes GnRH
GnRH promotes release of LH and FSH from anterior pituitary
LH stimulates Leydig cells to produce testosterone
FSH stimulates Sertoli cells to produce androgen binding globulin and inhibin
Negative feed back

218
Q

what is removed in radical prostatesctomy?

A

Prostate
seminal vesicles
Amupulla
vas deferens

lymph nodes if involved

219
Q

what are 3 complications of prostate cancer?

A

radiation/surgery induced erectile dysfunction
urinary strictures
gynaecomastia

220
Q

what grading is used in prostate cancer?

A

Gleason scale - based off biopsy histology - higher number = worse prognosis

221
Q

what is a low risk gleason score?

A

<6

222
Q

what is an intermediate risk gleason score?

A

7

223
Q

what is a high risk gleason score?

A

> 8

224
Q

what are the 4 red flags for kidney cancer?

A

loin pain
haematuria
masses
metastatic disease symptoms

225
Q

what is the most common malignancy in young males?

A

testicular cancer

226
Q

what are 5 risk factors for testicular cancer?

A

FHx
Undescended testes
Male infertility
Increased height
Kleinfelter’s syndrome

227
Q

what are the 2 different types of testicular cancer?

A

Seminomas
non-seminomas - usually teratomas

228
Q

where does testicular cancer usually spread to?

A

lung
liver
bones - back
lymph nodes - chest, pelvis, neck

229
Q

what are 4 manifestations of testicular cancer?

A

Usually painless lump on testicle
Occasionally testicular pain
Systemic symptoms

Gynaecomastia - due to leydig cell tumour

230
Q

what are 3 investigations for testicular cancer?

A

1 - testicular doppler ultrasound

Tumour markers
CT TAP - for staging

231
Q

what are 3 tumour markers in testicular cancer?

A

Alpha fetoprotein - raised in teratomas
bHCG - teratomas and seminomas
Lactate dehydrogenase - non-specific

232
Q

what is the royal marsden staging of testicular cancer?

A

1 - isolated to testicle
2 - spread to retroperitoneal lymph nodes
3 - spread to lymph nodes above diaphragm
4 - metastasised to other organs

233
Q

what is the staging system for testicular cancer?

A

Royal marsden staging system

234
Q

what is the management of testicular cancer?

A

Radical orchidectomy

Platinum based chemo - carboplatin
retroperitoneal
radiotherapy
Sperm banking

235
Q

what are 6 side effects of testicular cancer treatment?

A

Infertility
Hypogonadism
Peripheral neuropathy
Hearing loss
Liver, kidney or cardiac damage
increased risk of future cancer

236
Q
A
237
Q

what genetic condition can give rise to renal cell carcinoma?

A

Von Hippel-Lindau syndrome

238
Q

what is the gold standard investigation for renal cell carcinoma?

A

CT abdomen/pelvis with contrast

239
Q

what is the most common site of metastasis for kidney cancer?

A

lung - cannonball metasteses

240
Q

what is the treatment for metastatic kidney cancer?

A

molecular therapy - sunitinib

241
Q

what is Wilms’ tumour?

A

a specific type of tumour affecting the kidney in children, typically under the age of 5 years

242
Q

what do renal adenocarcinomas cause that isn’t seen in other renal cancers?

A

musucuria - mucus in urine

243
Q

what is the treatment for muscle invasive bladder cancer?

A

radical cystectomy with chemo

radical radiotherapy

244
Q

what is the inheritance of Von Hippel Lindau disease?

A

autosomal dominant

245
Q

what is Von Hippel Lindau disease?

A

rare autosomal dominant disorder caused by mutation in tumour suppressor gene leading to cysts and benign tumours in various parts of body => eyes, CNS, kidneys, adrenals, pancreas

246
Q

what is the primary cause of death in patients with Von Hippel Lindau disease?

A

renal cell carcinoma

247
Q

what is a key feature of a testicular seminoma?

A

secretes ALP

248
Q

what is a key feature of a testicular teratoma?

A

many different cells

249
Q

what is a key feature of a testicular choriocarcinoma?

A

secretes hCG

250
Q

what is a key feature of a testicular endodermal yolk sac tumour?

A

Alph fetoprotein

251
Q

what are the criteria for the 2 week wait for bladder cancer?

A

45+ with unexplained visible haematuria without UTI

60+ with unexplained non-visible haematuria and either dysuria or a raised WCC

252
Q

what percentage of men with raised PSA will not have prostate cancer?

A

specificity = 30%

253
Q

what percentage of men with normal PSA will have prostate cancer?

A

sensitivity = 94%

254
Q

when would you refer someone with UTIs for a bladder cancer review?

A

60+ with recurrent/persistent UTIs

255
Q

what is the most common type of renal cell carcinoma?

A

clear cell carcinoma

256
Q

what are 2 risk factors for small intestine cancer?

A

coeliac disease

Crohn’s disease

257
Q

what staging is used in colorectal cancer?

A

Duke’s staging

258
Q

what 3 inherited conditions can cause colorectal cancer?

A

familial adenomatous polypososis
Hereditary non-polyposis colon cancer
Peutz-Jeghers syndrome

259
Q

what is the inheritance pattern for FAP and HNPCC?

A

autosomal dominant

260
Q

what part of the colon is most affected in familial adenomatous polyposis?

A

left colon and rectum

261
Q

what part of the colon is most affected in Hereditary non-polyposis colon cancer?

A

right colon

262
Q

what are 4 risk factors for colorectal cancer?

A

increased age
red and processed meats
low dietary fibre
hereditary conditions

263
Q

what are 5 presentations of R sided colorectal cancer?

A

often asymptomatic

iron deficiency anaemia 
progressive change in bowel habit
large bowel obstruction 
weight loss and fatigue 
abdo discomfort
264
Q

what are 5 presentations of L sided colorectal cancer?

A 
rectal mass 
progressive change in bowel habit 
abdo discomfort
large bowel obstruction
weight loss and fatigue
265
Q

what are 3 investigations for colorectal cancer?

A

colonoscopy and biospy - gold
FBC and U+E
fecal occult blood test

266
Q

what is the most common primary liver cancer?

A

hepatocellular carcinoma

267
Q

what can cause liver adenomas?

A

anabolic steroids, oral contraceptive pill, pregnancy

268
Q

What are 4 presentations of neoplastic spinal cord compression?

A

Back pain - earliest/most common
Lower limb weaakness
Sensory changes
neurological signs - upper if above L1, lower if below L1

269
Q

what is neoplastic back pain like?

A

severe unremitting progressive
Mechanical
Aggravated by straining
Night pain
Localised tenderness
Claudication

270
Q

what investigation should be done for neoplastic spinal cord compression?

A

MRI WHOLE SPINE

within 24h of presentation

271
Q

what 6 cancers commonly metastasize to bone?

A

BLT with Ketchup Please (M)

Breast
Lung
Thyroid

Kidney
Prostate

Myeloma

272
Q

where are the most common sites of bony metastases?

A

Descending order

Spine
Pelvis
Ribs
Skull
Long bones

273
Q

what are 4 features of bony mets?

A

Bone pain
Pathological fractures
Hypercalcaemia
Raised Alk Phos

274
Q

what is the management of neoplastic spinal cord compression?

A

Immobilisation

High dose Dexamethasone - 16mg OD

Surgery and radiotherapy

Analgesia and VTE prophylaxis

275
Q

what are 4 complications of neoplastic spinal cord compression?

A

Permanent paralysis
Bladder and bowel incontinence
Pressure ulcers
DVT

276
Q

what are 4 x-ray signs of bone cancer and what cancers do they demonstrate?

A

Soap/double bubble lesions - Giant cell

Sunburst - osteosarcoma

Onion skin - Ewing sarcoma

Moth-eaten - chondrosarcoma

277
Q

when does osteosarcoma usually present?

A

10-20 year olds

278
Q

what is the most common bone to be affected by osteosarcoma?

A

femur

tibia and humorous also common

279
Q

what are 6 symptoms of bone cancer?

A

persistent bone pain
pain worse at night - disturb or wake from sleep
bone swelling
palpable mass
restricted joint movement
low grade fever

280
Q

what can be seen on LFTs that suggest bone tumour?

A

raised ALP

281
Q

what are 2 complications of bone tumours?

A

pathological fractures
metastasis

282
Q

what is the 1st line investigation for bone tumour?

A

urgent (in 48 hours) x-ray and specialist assesment

283
Q

what is the most common bone cancer in children?

A

osteosarcoma

284
Q

what is the second most common bone cancer in children?

A

ewing sarcoma

285
Q

what are 3 benign bone tumours?

A

Osteoma
Osteochondroma - exotosis
Giant cell tumour

286
Q

what are 3 malignant bone tumours?

A

Osteosarcoma
Ewing’s sarcoma
Chondrosarcoma

287
Q

what is an osteoma?

A

benign bone tumour
Overgrowth of bone - most typical in skull

288
Q

what condition is osteoma associated with?

A

Gardner’s syndrome - variant of familial adenomatous polyposis (FAP)

289
Q

what is the most common benign bone tumour?

A

osteochondroma

cause cartilage capped bony projections on external surface of bone

290
Q

where do giant cell tumours most commonly occur?

A

Epiphysis of long bones

291
Q

what can be seen on x-ray in giant cell tumours?

A

soap/double bubble appearance

292
Q

where does osteosarcoma most commonly occur?

A

long bones prior to epiphyseal closure

Most in femur, some tibia and humerus

293
Q

what can be seen on x-ray in osteosarcoma?

A

Codman triangle - periosteal elevation

Sunburst appearance

294
Q

what other cancer is osteosarcoma associated with?

A

retinoblastoma

295
Q

where does Ewing’s sarcoma most commonly occur?

A

pelvis and long bones

tends to cause severe pain

296
Q

what is seen on x-ray in ewing sarcoma?

A

onion skin appearance

297
Q

what is a chondrosarcoma?

A

malignant tumour of cartilage - mostly affecting axial skeleton

more common in middle age

298
Q

what is the 1st line chemo in osteosarcoma?

A

cisplatin
doxorubicin
methotrexate
ifosfamidew

299
Q

what scans are good for diagnosing bone mets?

A

bone scintigraphy scan

300
Q

what monoclonal antibody can be used to slow the progress of bone mets?

A

Denosumab

301
Q

what is the most common type of cholangiocarcinoma?

A

Adenocarcinoma

302
Q

where is the most common site of cholangiocarcinoma?

A

Perihilar region - where R and L hepatic duct joint to become common HD

303
Q

what are 2 risk factors for cholangiocarcinoma?

A

Primary Sclerosing Cholangitis

Liver flukes (Parasites)

304
Q

what is the presentation of cholangiocarcinoma?

A

Obstructive jaundice - pale stools, dark urine, itch
Unexplained wt loss
RUQ pain
Palpable gallbladder
Hepatomegaly

305
Q

what is Courvoisier’s law?

A

A palpable gallbladder PLUS jaundice is unlikely to be gallstones

Pancreatic cancer /cholangiocarcinoma/gallbladder cancer more likely

306
Q

what tumour marker may be raised in cholangiocarcinoma?

A

CA 19-9

307
Q

what are 3 management options for cholangiocarcinoma?

A

bile ductectomy - small cances
Partial hepatectomy
Whipple procedure (pancreaticoduodenectoym)

Stenting, chemo

308
Q

what is the most common primary liver cancer?

A

Hepatocellular carcinoma

309
Q

what are 5 risk factors for hepatocellular carcinoma?

A

Alcoholic liver disease
NAFLD
Hepatitis B
Hepatitis C
Primary sclerosing cholangitis

310
Q

what is the tumour marker for hepatocellular carcinoma?

A

Alpha fetoprotein

311
Q

what is the presentation of liver tumours?

A

wt loss
abdo pain
anorexia
nausea and vom
jaundice
Pruritus
RUQ mass

312
Q

what is the 1st line imaging in liver cancer?

A

Liver US

313
Q

what are 2 common benign tumours of the liver?

A

Haemangioma
Focal nodular hyperplasia - more common in women on the COCP

314
Q

what is the management of HCC?

A

Resection
Liver transplant

Radiofrequency ablation
Microwave ablation
Transarterial chemoembolization
radiotherapy
Targeted drugs

315
Q

what are 5 cancers that are likely to metastasise to the lungs?

A

Breast
Colorectal
Renal
Bladder
Prostate

316
Q

what are 4 processes that allow metastases?

A

Epithelial to mesenchymal transition - allows tumours to invade surrounding tissues and migrate to distant sites
Angiogenesis - allows tumours to access circulatory system for dissemination
Immune evasion - tumour cells evade immune surveillance
Molecular alterations - changes in gene expression

317
Q

what are 5 cancers that metastasise to brain?

A

Lung - most common
Breast
Bowel
Skin - melanoma
Kidney

318
Q

what is the most common primary brain tumour in adults?

A

Glioblastoma

319
Q

what do glioblastomas appear like on imaging?

A

Solid tumour with central necrosis and contrast enhancing rim
Associated vasogenic oedema

320
Q

what is the management of glioblastoma?

A

Surgical
Post op chemo and/or radiotherapy

Dexamethasone treats oedema

321
Q

what is the second most common brain tumour of adults?

A

meningioma

322
Q

are meningiomas benign or malignant?

A

Usually benign but can lead to raised ICP and mass effect

323
Q

where do meningiomas arise from?

A

Arachnoid cap of meninges - typically located next to the dura and cause compression rather than invasion symptoms

324
Q

what is the most common primary brain tumour in children?

A

Pilocytic astrocytoma

325
Q

what is seen histologically in pilocytic astrocytomas?

A

Rosenthal fibres
(corkskrew eosinophilic bundles)

326
Q

what is a particularly aggressive paediatric brain tumour?

A

Medulloblastoma - in infratentorial compartment

327
Q

what is the histology of medullobastomas?

A

Small blue cells
Rosette pattern of cells
many miotic figures

328
Q

what type of benign slow growing brain tumour is common in the frontal lobes?

A

Oligodendroma

329
Q

what is the histological appearance of an oligodendroma?

A

calcifications with fried egg appearance

330
Q

what condition are hemangioblastomas associated with?

A

von Hippel Lindau syndrome

331
Q

what is the most common paediatric supratentorial tumour?

A

Craniopharyngioma

332
Q

what is a Craniopharyngioma derived from?

A

remnants of rathke’s pouch in the sellar region

common in children but can also present in adults

333
Q

what are 8 features of raised intracranial pressure?

A

constant headache - worse at night, on waking, coughing, straining, bending forwards
Vomiting
Papilledema
Altered mental state
visual field defects
seizures
unilateral ptosis
III and VI CN palsies

334
Q

how does papilledema present on fundoscopy?

A

Blurring of optic disc margin
elevated optic disc
Loss of venous pulsation
Engorged retinal veins
haemorrhages around optic disc
Paton’s lines - creases/folds in retina around optic disc

Phase 4 (22 decks)

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