Oncology Flashcards
what type of cancer is most commonly associated with superior vena cava obstruction?
lung cancer - most common
also lymphoma
what are 6 causes of superior vena cava obstruction?
malignancy - non-small cell lung cancer, lymphoma, metastatic seminoma, Kaposi’s sarcoma, breast cancer
Aortic aneurysm
Mediastinal fibrosis
goitre
SVC thrombosis
what are 4 complications of superior vena cava syndrome?
laryngeal oedema and airway obstruction
cerebral oedema - neuro signs
Low cardiac output and hypotension
PE - if due to thrombus
what are 8 symptoms of superior vena cava syndrome?
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
what investigations can be done for superior vena cava syndrome?
CXR - mass or widened mediastinum
CT thorax with contrast
MRI chest
US doppler of upper extremities
Venography
Biopsy
what is the management of superior vena cava syndrome?
PCI stenting if emergency
Radio/chemotherapy and corticosteroids if malignant
Tumor removal
Thrombolysis if due to thrombus
how common is lung cancer?
3rd most common in UK
what is.the most common type of lung cancer?
non-small cell adenocarcinoma
what are 3 types of non-small cell lung cancer?
adenocarcinoma
squamous cell carcinoma
large cell carcinoma
what is mesothelioma?
lung malignancy affecting meothelial cells of pleura linked to asbestos inhalation. Poor prognosis
what are 9 presentations of lung cancer?
SOB
cough
Haemoptysis
finger clubbing
recurrent pneumonia
weight loss
lymphadenopathy
Hoarse voice - especially pancoast tumoour
SVC syndrome
what is dysplasia?
the presence of abnormal cells in a tissue
what is special about small cell lung cancers?
have neuroendocrine differentiation and release neuroendocrine hormones with a wide range of paraneoplastic associations
what is a pancoast tumour?
a type of lung cancer located at the lung apex that can lead to shoulder pain and Horner’s syndrome (ptosis, miosis, anhydrosis)
what are 5 paraneoplastic syndromes that can be caused by lung cancer?
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
how can small cell lung cancer cause Lamber-eaton myasthenic syndrome ?
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
what sign can be used to assess for superior vena cava syndrome?
Pemberton’s sign
raising hands over head causes facial congestion and cyanosis
what are 5 investigations for lung cancer?
CXR - hilar enlargement, peripheral opacity, u/l pleural effusion, collapse, focal lesion
Staging contrast CT
PET-CT
Brochoscopy
Histological diagnosis - brochoscopy biopsy or percutaneous biopsy
what is the management of non-small cell lung cancer?
Radiotherapy
Surgery - mediastinoscopy prior as CT does not always show mediastinal lymph node involvement - often lobectomy.
Poor response to chemo
what are 8 contrindications to surgery in non-small cell lung cancer?
general health
Stage IIIb or IV
FEV1<1.5L
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction
what is the management of small cell lung cancer?
limited spread - 4-6 cycles of cisplatin based chemo +/- radiotherapy
Extensive mets - platinum based combo chemo + radiotherapy
where is lung cancer likely to metastasise to?
Brain
bone
liver
what part of the pancreas is usually affected in pancreatic cancer?
the head
what are 6 symptoms of pancreatic cancer?
Painless jaundice
Palpable gallbladder
Non-specific - anorexia, wt loss, epigastric pain
Steatorrhea
Diabetes
Atypical back pain
what is Whipple’s resection?
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
What is the most common type of pancreatic cancer?
Adenocarcinoma
what is the serum tumour marker for pancreatic cancer?
Ca 19-9
what procedure is used for tumours in the body/tail of the pancreas?
distal pancreatectomy
what are 4 non-modifiable risk factors for pancreatic cancer?
Age >60
Male
Afro-Caribbean or Ashkenazi Jewish heritage
Fhx - BRACA 2 mutations, FAMMM syndrome
what are 6 modifiable risk factors for pancreatic cancer?
Smoking
Diet - red and processed meats
BMI and inactivity
Alcohol
Chronic pancreatitis
Diabetes
when should an urgent CT for pancreatic cancer be done?
> 60 years and weight loss plus;
Diarrhoea
Back pain
Abdo Pain
Nausea
Vomiting
Constipation
New onset diabetes
What is the TNM staging for pancreatic cancer?
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
What are 4 surgeries for pancreatic cancer?
Total pancreatectomy
distal pancreatectomy
Modified whipple
Whipple procedure
what are 5 palliative options for pancreatic cancer?
Stents to relieve biliary obstruction
Surgery to improve symptoms
palliative chemo
palliative radiotherapy
EOL care
what scan is used for staging pancreatic cancer?
CT TAP
what chemo can be used in metastatic pancreatic cancer treatment?
1 - FOLFIRINOX
Fluorouracil
Leucovorin
Ieinotectan
Oxaliplatin
2 - Oxaliplatin based chemo
where are the 3 most common sites of pancreatic metastasis?
Liver
Lungs
Peritoneum
what is Courvoisiers law?
For pancreatic cancer
Palpable gallbladder + jaundice is unlikely to be gallstones
what is Trousseau’s sign of malignancy?
For pancreatic cancer
migratory thrombophlebitis as a sign of malignancy
Blood vessel inflammation with an associated thrombus which reoccur in different locations over time
what may be seen on radiology in pancreatic cancer?
Double duct sign - dilation of both common bile duct and pancreatic ducts commonly due to carcinoma of head of pancreas
what chemo can be used as an adjuvant in pancreatic cancer?
Gemcitabine
+ Capecitabine
6 cycles after resection
what is the most common type of gastric cancer?
adenocarcinoma
where in the world is gastric cancer most common?
Japan
what are 7 manifestations of gastric cancer?
Dyspepsia/indigestion
Epigastric pain
Early satiety or postprandial fullness
Wt loss
Anaemia
Nausea and vomiting
GI bleeds
Epigastric mass
swelling of periumbilical lymph nodes causing protrusion of umbilicus - sister Mary joseph nodule
what are 3 differentials for gastric cancer?
peptic ulcer
oesophageal stricture
achalasia
what are 6 risk factors for gastric cancer?
H. Pylori infection
Smoking
High salt intake
genetics
Smoked/preserved foods
Pernicious anaemia and atrophic gastritis
when should you refer for upper GI endoscopy when suspecting gastric/oesophageal cancer?
Dysphagia
55+ weight loss +
- Upper abdo pain
- Reflux
- Dyspepsia
When should you refer non-urgently to gastro for ?gastric/oesophageal cancer >55 years?
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
what are is the 1st line investigation for gastric cancer?
Gastric endoscopy with biopsy
What are 2 surgeries for gastric cancer?
Partial gastrectomy
Total gastrectomy
what 2 targeted therapies can be used in gastric cancer?
Anti-HER2 therapy - transtuzumab, pertuzumab
Anti-VEGF therapies
what is the 5 year survival rate of pancreatic cancer?
5%
what are 4 complications of gastric cancer?
obstruction
bleeding`
perforation
mets
What are 3 locations for gastric metastasis?
Liver
Lymph nodes - virchow’s node
Ovaries - Krukenberg tumours
what are 3 signs associated with gastric cancer?
Acanthosis nigricans
Trousseau’s cancer syndrome - migratory thrombophlebitis
Leser-Trelat sign - rapid increase in number of seborrheic keratoses
what can be seen histologically in gastric cancer?
signet ring cells - large vacuole of mucin displacing nucleus
what is dumping syndrome?
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
what are the 2 main types of oesophageal cancer?
Adenocarcinoma - most common UK - GORD
Squamous cell carcinoma - Most common developing word (smoking)
what are 4 risk factors for oesophageal cancer?
Barrett’s oesophagus
Male
Smoker
Achalasia
where are oesophageal adenocarcinomas found?
Lower third of oesophagus - near gastroesophageal junction
where are squamous cell oesophageal carcinomas found?
Upper 2/3rds of oesophagus
what are 6 presentations of oesophageal cancer?
Dysphagia (solids then liquids)
Odynophagia - Pain on swallowing
Weight loss
Hoarse voice/cough
Retrosternal pain/dyscomfort
lymphadenopathy
what are 4 investigations for oesophageal cancer?
Upper GI endoscopy with biopsy - gold
CT chest abdomen and pelvis for staging
Endoscopic US for locoregional staging
Barium swallow
what are 3 differentials for oesophageal cancer?
benign stricture
achalasia
Barrett’s oesophagus
what is the management of oesophageal cancer?
Surgical resectio - Oesophgectomy
Endoscopic mucosal resection
Chemo - platinin based
Radiotherapy
what is the most common type of surgical resection in oesophageal cancer?
Ivor Lewis type oesophagectomy
what are 3 complications of oesophageal cancer?
Post-resection acid reflux
trachea-oesophageal fistula
Anastamotic leak - due to surgery
What is Barrett’s oesophagus?
a change (metaplasia) in the normal squamous epithelium of the oesophagus to specialised intestinal epithelium
stratified squamous to simple columnar
what is the change in epithelium in Barrett’s oesophagus?
Stratified squamous TO
Simple columnar
what are 4 causes for Barrett’s oesophagus?
GORD
Lower oesophageal sphincter hypotension
hiatus hernia
gastric acid hypersecretion
what are 3 risk factors for Barrett’s oesophagus?
GORD
smoking
obesity
male
what is the pathophysiology of Barrett’s oesophagus?
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
what are 4 clinical presentations of Barrett’s oesophagus?
heartburn
regurgitation
dysphasia
SOB/wheezing and belching
what is the investigation for Barrett’s oesophagus?
Upper Gi endoscopy + biopsy = gold
what are 3 differentials for Barrett’s oesophagus?
osephagitis
GORD
oesophageal carcinoma
what is the management of Barrett’s oesophagus?
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
what are 3 complications of Barrett’s oesophagus?
oesophageal adenocarcinoma
oesophageal strictures
quality of life deficit
what is Zollinger-Ellison syndrome?
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).
what are 8 clinical features of breast cancer?
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
How common is breast cancer in women?
1 in 8 in their lifetime
What is triple assessment of breast lumps?
clinical assessment - Hx and exam
Imaging - USS, mamography
histology - fine needle/core biopsy
each scored 1-5 from normal to malignant
what is phyllodes tumour?
can be benign or malignant breast lumps
rapidly growing painless breast lumps
can metastasize if malignant
what is the most common type of breast cancer?
invasive ductal carcinoma
What are 6 risk factors for breast cancer?
Female
increased oestrogen exposure - OCP and HRT, nulliparity, early menarche, late menopause
Not breast feeding
more dense breast tissue
obesity
smoking
FHx - BRACA, p53 gene mutations
What chromosome is BRACA1 on?
chromosome 17
what cancers does BRACA1 increase risk of?
breast - 70% BY 80yo
ovarian - 50%
prostate and bowel
what chromosome is BRACA2 on?
chromosome 13
what is the inheritance pattern of the BRACA genes?
Autosomal dominant
what is ductal carcinoma in situ?
pre-cancerous or cancerous epithelial cells of breast ducts
localised to single area
Potential to become invasive breast cancer
Generally good prognosis
what is lobular carcinoma in situ?
precancerous condition typically in pre-menopausal women
usually asymptomatic and undetectable on mammogram
increased risk of invasive breast cancer in future
often managed with close monitoring
what is invasive ductal carcinoma?
Most common
originates in cells of breast ducts
80% of invasive breast cancers
seen on mamograms
what is invasive lobular carcinoma?
10% of invasive breast cancers
from breast lobules
not always visible on mammograms
what is inflammatory breast cancer?
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
what is pagets disease of the nipple?
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
when is breast cancer screening offered?
aged 50-70 every 3 years mammogram
what are 4 criteria that may require referral to secondary care for high risk breast cancer screening?
1st degree relative with breast cancer <40 years
1st degree male relative with breast cancer
1st degree relative with bilateral breast cancer <50 years
2x 1st degree relatives with breast cancer
what medications can be used as chemoprevention of breast cancer in those with high risk?
tamoxifen - premenopause
anastrozole - postmenopausal
what surgeries can be done for prevention of breast cancer in high risk women?
Bilateral mastectomy
OR
Bilateral oophorectomy
what is the referral criteria for breast lumps?
2ww
- unexplained lump in breast/axilla >30 years
- unilateral nipple changes >50 years
- Skin changes suggestive of breast cancer
Non-urgent referral for unexplained breast lump <30 years
what are 4 investigations for breast cancer?
mammogram
biopsy and histology
breast MRI
breast ultrasound - younger women
how are lymph nodes assessed in breast cancer?
US of axilla and US guided biopsy of abnormal nodes
Sentinel lymph node biopsy used in surgery
what are 2 investigations needed of confirmed breast cancer?
hormone receptor testing - oestrogen and progesterone receptor status
HER2 testing
what medication can be used in HER2 positive breast cancer?
trastuzamab (herceptin)
what is the usual management for breast cacinoma in situ?
lumpectomy + radiotherapy
tamoxifen/aromatase inhibitors can be used in susceptible tumours
what are 3 risk factors of tamoxifen?
Increased risk endometrial cancer
Increased risk VTE
Menopausal symptoms
what is pagets disease of the breast?
eczema like changes to skin of nipple and areola - sign of breast cancer
dark scaly rash - often sore and inflamed
What causes peau d’orange?
blocked lymphatic drainage causes superficial oedema with sweat ducts making small dimples
what type of tumour can cause gynacomastia due to oestrogen secretion?
leydig cell tumour - testicular cancer
What is the first line medication for oestrogen receptor +ve breast cancer if premenopausal women?
tamoxifen
given for 5-10 years
what is the MOA of tamoxifen?
selective oestrogen receptor modulator
blocks oestrogen receptors in breast tissue and stimulates in uterus and bone - helps prevent osteoporosis but increases risk of endometrial cancer
What is the first line medication for oestrogen receptor +ve breast cancer in post-menopausal women?
Aromatase inhibitors
e.g. anastrozole
given for 5-10 years
What medication is used in HEr2 +ve breast cancer?
Trastuzamab
3 weekly injections for a year after surgery
2 - pertizumab, neratinib
what is one contraindication to trastuzumab?
cannot be given in Hx of heart disorders
what chemotherapy is used in breast cancer?
FEC-D
Fluorouracil
Epirubicin
Cyclophosphamide
Docetaxel
where does breast cancer most commonly metastasise to?
2Ls 2Bs
Lungs
Liver
Bones - most common
Brain
what is one complication of axillary lymph node clearance in breast cancer?
chronic lymphoedema
what is the management of chronic lymphoedema?
massage techniques
compression bandages
lymphoedema exercises to improve drainage
weight loss
good skin care
what are 5 side effects of breast radiotherapy?
general fatigue
local skin and tissue irritation and swelling
fibrosis of breast tissue
shrinking of breast tissue
long term skin colour changes
what is the follow up of breast cancer patients?
mammograms yearly for 5 years post clearance (or longer if under screening age)
what are 2 options for breast reconstruction after breast conserving surgery?
partial reconstruction
reduction and reshaping
what are the options for breast reconstruction after mastectomy?
breast implants
flap reconstruction - using latismus dorsi, rectus abdominis or just subcutaneous tissue but no muscle
What is the most common types of vulval cancer?
squamous cell carcinoma - 90%
what are 5 risk factors for vulval cancer?
advanced age (>75)
immunosuppression
HPV
lichen sclerosis
Vulval intraepithelial neoplasia
what is the premalignant form of vulval cancer?
vulval intraepithelial neoplasia
what type of vulval intraepithelial neoplasia is associated with younger people?
high grade squamous intraepithelial lesion - associated w/ HPV infection
What type of vulval intraepithelial neoplasia is associated with older people?
differentiated VIN associated w/ liches sclerosis
what are 6 presentations of vulval cancer?
vulval lump
ulceration
bleeding
pain
itching
lymphadenopathy of the groin
what are the management options for VIN?
Watch and wait
Wide local excision
Imiquimod cream
laser ablation
what are 4 management options for vulval cancer?
Surgery - wide local excision or vulvectomy
Radiotherapy
Chemotherapy - platinum based
Biologics - anti-EGFR monoclonal antibodies
what are 6 presentations of vaginal cancer?
Lump in vagina
Ulcer and skin changes in/around vagina
Bleeding post menopause/post coital
Smelly/bloodstained discharge
Intermenstrual bleeding
Itch
what are 4 risk factors for vaginal cancer?
HPV infection
Hx of cervical/endometrial cancers
>75 years
AID/immunosuppression
What is the most common type of cervical cancer?
Squamous cell carcinoma
what is the second most common type of cervical cancer?
adenocarcinoma
What is the most common cause of cervical cancer?
Human papilloma virus (HPV)
16 and 18 most commonly
what cancers is HPV associated with?
Cervical
Anal
Valval
Vagina
Penile
Mouth and throat
what 2 strains of HPV are responsible for 70% of cervical cancers?
16 and18
How does HPV promote cancers?
Inhibits tumour suppressor genes (P53 and pRb)
What are 6 risk factors for cervical cancer?
increased risk of catching HPV
non-engagement with screening
smoking
HIV
COCP >5 years
family history
what increases your risk of catching HPV? (5)
early sexual activity
Increased number of sexual partners
sex work
not using condoms
what are 4 cervical appearances that may suggest cancer?
ulceration
inflammation
bleeding
visible tumour
what are 4 presentations of cervical cancer?
abnormal vaginal bleeding - intermenstrual, postcoital, post menopausal
vaginal discharge
pelvic pain
dyspareunia (painful sex)
what is the premalignant form of cervical cancer?
cervical intraepithelial neoplasia (CIN)
How is CIN diagnosed?
colposcopy
what is CIN I?
mild dysplasia affecting 1/3rd thickness of epithelial layer - likely to return to normal without treatment
what is CIN II?
moderate dysplasia affecting 2/4rds of thickness of epithelial layer - likely to progress to cancer if untreated
what is CIN III?
severe dysplasia very likely to progress to cancer
when does cervical screening take place?
every 3 years 25-49
Every 5 years 50-64
what is the staging used for cervical cancer?
FIGO staging
what are the 4 stages of cervical cancer?
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
what biopsy techniques are used for cervical cancer?
large loop excision or punch biopsy during colposcopy
cone biopsy - also Tx of v early stage cervical Ca
what is the management of CIN or early stage 1A cervical cancer?
LLETZ or cone biopsy if wanting to maintain fertility
Gold standard is hysterectomy +/- lymph node biopsy
what is the management of stage 1B and above cervical cancer?
Radical hysterectomy and removal of local lymph nodes, chemo and radiotherapy
What MAB can be used in cervical cancer treatment?
Bevacizumab - target vascular endothelial growth factor A
what are 6 complications of cervical cancer?
Hydronephrosis - due to tumour invasion
Prem birth - post come biopsy
Ureteral fistula - post radical hysterectomy
Radiation proctitis/cystitis
Radiation burns
Lymphoedema
what type of cancer is 80% of endometrial cancer?
adenocarcinoma
which hormone stimulates the growth of endometrial cancer?
oestrogen
what is the precancerous version of endometrial cancer?
endometrial hyperplasia
what are 9 risk factors for endometrial cancer?
increased age
earlier onset of menstruation
late menopause
oestrogen only hormone replacement
no/few pregnancies
obesity
PCOS
Tamoxifen
Diabetes T2
what are 4 protective factors for endometrial cancer?
COCP
MIrena coil
Increased pregnancies
smoking
what are 7 presentations of endometrial cancer?
post menopausal bleeding
postcoital and instermenstrual bleeding
menorrhagia
Abnormal discharge
haematuria
anaemia
raised platelets
what is the referral criteria for endometrial cancer?
2ww - Postmenopausal bleeding
Urgent TV US - >55 with unexplained vaginal discharge, visible haematuria with raised platelets, anaemia or elevated glucose
what are 3 investigations for endometrial cancer?
TV USS for endometrial thickness
pipelle biopsy - highly sensitive
hysteroscopy with endometrial biopsy
what is a normal endometrial thickness post menopause?
<4mm
> 5mm warrants biopsy
what is the management of endometrial hyperplasia?
High dose progestogens and repeat sampling in 3-4 months
If atypia - hysterectomy
What are the stages of endometrial cancer?
1 - confined to uterus
2 - invades cervix
3 - invades ovaries, fallopian tubes, vagina or lymph nodes
4 - invades bladder, rectum or beyond pelvis
What is the treatment for endometrial cancer?
total or radical hysterectomy with bilateral salpingo-oophorectomy
Radial hyterectomy
radiotherapy
chemo
progesterone tx
what are 4 complications of management of endometrial cancer?
Bowel changes - due to radiotherapy
Urinary changes
Lymphoedema
Neutropenic sepsis
what is the most common type of ovarian cancer?
Epithelial cell tumours
include serous tumours, endometrioid carcinomas, clear cell tumours, mucinous tumours, undifferentiated tumours
what are ovarian germ cell tumours?
also called dermoid cysts
Teratomas containing skin, teeth, hair, bone - associated with ovarian torsion
what markers can ovarian germ cell tumours cause to be raised?
alpha-fetoprotein
human chorionic gonadotrophin
what are sex cord stromal tumours?
rare benign or malignant tumours that arise from stroma or sex cords
sertoli-leydig tumours
granulosa cell tumours
what is the name of an ovarian tumour metastasised from the GI tract?
Krukenberg tumours
have classic signet ring cells on histology
what are 6 risk factors for ovarian cancer?
Age (highest incidence >60)
BRACA1 and 2 genes (FHx)
Increased number of ovulations
obesity
smoking
recurrent use of clomifene
what factors increase the number of ovulations (and therefore ovarian cancer risk)?
early onset periods
late menopause
no pregnancies
what are 3 protective factors for ovarian cancer?
combined oral contraceptive pill
breastfeeding
pregnancy
what are 8 presentations of ovarian cancer?
abdominal bloating
early satiety/loss of apetite
pelvic/hip and groin pain
urinary symptoms
weight loss
abdominal/pelvic masses
ascites
what is the referral criterial for ovarian cancer?
2ww - Acites, pelvic mass, abdominal mass
what is the tumour marker for ovarian cancer?
CA125
what are 3 tumour markers for rarer ovarian germ cell tumours?
alpha-fetoprotein
HCG
lactate dehydrogenase
what are 6 non-cancer causes of a raised CA125?
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
what is the staging of ovarian cancer?
FIGO
1 - confined to ovary
2 - spread past ovaries but in pelvis
3 - spread past pelvis but in abdomen
4 - distant metastasis
what are 5 complications of ovarian cancer?
Ascites
Bowel obstruction
chronic pain
VTE
Hyperthyroidism due to ovarian teratoma - struma ovarii containing thyroid tissue
what are the side effects of tamoxifen and aromatase inhibitors?
hot flushes
nausea
vaginal bleeding
thrombosis
endometrial cancer
what medication can be used in pre-menopausal woman with ovarian sensitive breast cancer?
GNFR inhibitors
what is the name of 3 HER2 receptor blocker medications?
trastuzumab
pretuzumab
Neratinib
what medications can be used in tripple negative breast cancer?
immunomodulators
what medications can be used in braca1 and 2 cancers?
PARP inhibitors
what other than ovarian cancer can cause a raised Ca125?
adenomyosis
ascites
endometriosis
menstruation
breast cancer
ovarian torsion
endometrial cancer
liver disease
metastatic lung cancer
What is the most common type of bladder cancer?
Transitional cell carcinoma
what are the 2 different types of transitional cell carcinoma?
Papillary - majority - superficial and often non-invasive
Flat - lie flat against bladder tissue, more prone to invasion
what are 4 risk factors for bladder cancer?
Increased age
smoking
Aromatic amines - dye and rubber workers
Polycyclic aromatic hydrocarbons - aluminium, coal, roofing
Schistosomiasis
what kind of cancer does schistosomiasis cause?
Squamous cell carcinoma of bladder - common in egypt
what are 5 clinical manifestations of bladder cancer?
Painless haematuria
LUTS - frequency
Systemic symptoms
Anaemia
suprapubic masses
when should a patient with suspected bladder cancer be referred for a 2ww?
> 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
what are 3 investigations for bladder cancer?
Primary - urinalysis, bloods
flexible cystoscopy + biopsy - GOLD
CTTAP/MRI - for staging
what T staging is non-muscle invasive bladder cancer?
T in situ - T1
What T staging is muscle invasive bladder cancer?
T2-4
what is the management for non-muscle invasive bladder cancer?
Transurethral resection of bladder tumour (TURBT)
PLUS
Intravesical mitomycin C
May have multiple doses if higher risk
what is the management of muscle invasive bladder cancer?
Radical cystectomy
Radical radiotherapy
with neoadjuvant chemo (cisplatin)
what are the options for urine drainage after cystectomy?
Urostomy with ileal conduit
Continent urinary diversion
neobladder reconstruction
Ureterosigmoidostomy
what are 5 complications of bladder cancer?
haematuria
UTIs
obstructive uropathy
Treatment related:
Surgery complications
Cystectomy related issues
Radiation cystitis
what is cancer grading?
histological - how differentiated from original tissue is it?
what is cancer staging?
size and metastasis
where are most prostate cancers situated?
Peripheral zone of prostate gland
what is the most common cancer of men?
prostate cancer
what are 5 risk factors for prostate cancer?
older age
FHx - BRACA2, HOXB13
Black African or Caribbean
Anabolic steroids
what are 5 manifestations of prostate cancer?
LUTS
Haematuria or Haematospermia
Mets symptoms - bone pain, wt loss, cauda equina
Erectile dysfunction
Urinary retention
what is the referral criterial for prostate cancer?
Malignant feeling on DRE
High PSA
PSA and DRE in men with
any LUTS
Erectile dysfunction
Haematuria
what is the 1st line investigation for prostate cancer
Multiparametric MRI
Then transrectal US guided biopsy to confirm if likely cancer
what are 5 risks of prostate biopsy?
Pain
Bleeding
Infection
urinary retention
erectile dysfunction
what scan can be used to look for bony mets?
isotope bone scan
what scale is used to report prostate cancer on multiparametric MIR?
Likert scale
offer biopsy >3
what is the management of low-medium risk prostate cancer?
Active surveillance
Radical prostatectomy
Radical radiotherapy or brachytherapy (radioactive seeding) +/- anti-androgen therapy (flutamide)
what is the management of high risk prostate cancer?
Radical prostatectomy
Radical radiotherapy PLUS anti-androgen therapy
Radical radiotherapy with brachytherapy
Docetaxel chemotherapy PLUS anti-androgen therapy
what can be an alternative to medical anti-androgen therapy?
bilateral orchidectomy
what is the chemotherapy agent used in prostate cancer?
Docetaxel
what are 5 side effects of hormone therapy in prostate cancer?
Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis
what anti-androgen therapies can be given in prostate cancer?
GnRH agonists - Goserelin
GnRH antagonists - Degarelix
Biclutamide - non steroidal anti-androgen
Cyproterone acetate - steroidal anti-androgen
Abiraterone - androgen synthesis inhibitor
how does the male gonadal axis work?
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
what is removed in radical prostatesctomy?
Prostate
seminal vesicles
Amupulla
vas deferens
lymph nodes if involved
what are 3 complications of prostate cancer?
radiation/surgery induced erectile dysfunction
urinary strictures
gynaecomastia
what grading is used in prostate cancer?
Gleason scale - based off biopsy histology - higher number = worse prognosis
what is a low risk gleason score?
<6
what is an intermediate risk gleason score?
7
what is a high risk gleason score?
> 8
what are the 4 red flags for kidney cancer?
loin pain
haematuria
masses
metastatic disease symptoms
what is the most common malignancy in young males?
testicular cancer
what are 5 risk factors for testicular cancer?
FHx
Undescended testes
Male infertility
Increased height
Kleinfelter’s syndrome
what are the 2 different types of testicular cancer?
Seminomas
non-seminomas - usually teratomas
where does testicular cancer usually spread to?
lung
liver
bones - back
lymph nodes - chest, pelvis, neck
what are 4 manifestations of testicular cancer?
Usually painless lump on testicle
Occasionally testicular pain
Systemic symptoms
Gynaecomastia - due to leydig cell tumour
what are 3 investigations for testicular cancer?
1 - testicular doppler ultrasound
Tumour markers
CT TAP - for staging
what are 3 tumour markers in testicular cancer?
Alpha fetoprotein - raised in teratomas
bHCG - teratomas and seminomas
Lactate dehydrogenase - non-specific
what is the royal marsden staging of testicular cancer?
1 - isolated to testicle
2 - spread to retroperitoneal lymph nodes
3 - spread to lymph nodes above diaphragm
4 - metastasised to other organs
what is the staging system for testicular cancer?
Royal marsden staging system
what is the management of testicular cancer?
Radical orchidectomy
Platinum based chemo - carboplatin
retroperitoneal
radiotherapy
Sperm banking
what are 6 side effects of testicular cancer treatment?
Infertility
Hypogonadism
Peripheral neuropathy
Hearing loss
Liver, kidney or cardiac damage
increased risk of future cancer
what is the most common type of renal tumour?
renal cell carcinoma - type of adenocarcinoma arising from renal tubules
what is the classic triad of renal cell carcinoma presentation?
Haematuria
Flank/loin pain
Palpable mass
also non-specific cancer symptoms - wt loss, fatigue, anorexia, night sweats, pyrexia of unknown origins
Varicocele - mostly left sided
paraneoplastic syndromes
what are the 3 most common subtypes of renal cell carcinoma?
clear cell - most common
papillary
chromophobe
what are 6 risk factors for renal cell carcinoma?
smoking
obesity
hypertension
end stage renal failure
Von Hippel-Lindau disease
tuberous sclerosis
what is the 2ww guidance for renal cancer?
> 45 years with unexplained visible haematuria with or without UTI or persisting after tx of UTI
what genetic condition can give rise to renal cell carcinoma?
Von Hippel-Lindau syndrome
what is the gold standard investigation for renal cell carcinoma?
CT abdomen/pelvis with contrast
how does renal cancer usually spread?
to local tissues within gerota’s fascia then to renal vein then inferior vena cava
often spreads to lungs
what is the most common site of metastasis for kidney cancer?
lung - cannonball metasteses
what is the treatment for metastatic kidney cancer?
molecular therapy - sunitinib
what is Wilms’ tumour?
a specific type of tumour affecting the kidney in children, typically under the age of 5 years
what are 4 paraneoplastic features that are associated with renal cancer?
polycythaemia - due to secretion of EPO
Hypercalcaemia - due to secretion of PTH mimic (can also be due to bony mets)
HTN - due to increased renin, polycythaemia and physical compression
Stauffer’s syndrome - abnormal LFTs (raised ALT, AST, ALP and billi) without liver mets
what staging is used in renal cell carcinomas?
TNM
what specific number staging can be used in renal cell carcinoma?
1 - <7cm confined to kidney
2 - >7cm confined to kidney
3 - local spread to nearby tissues or veins but not beyond Gerota’s fascia
4 - spread beyond Gerota’s fascia including mets
what is the 1st line management of renal cancer?
tumour removal
Partial nephrectomy - for T1 tumour
radical nephrectomy - kidney + surrounding tissue + lymph nodes +/- adrenals
what is the non-surgical management of renal cancer?
arterial embolisation
percutaneous cryotherapy
radiofrequency ablation
chemotherapy and radiotherapy
Molecular therapy - sunitiniib and pazopanib
what do renal adenocarcinomas cause that isn’t seen in other renal cancers?
musucuria - mucus in urine
what is the treatment for muscle invasive bladder cancer?
radical cystectomy with chemo
what is the inheritance of Von Hippel Lindau disease?
autosomal dominant
what is Von Hippel Lindau disease?
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
what is the primary cause of death in patients with Von Hippel Lindau disease?
renal cell carcinoma
what is a key feature of a testicular seminoma?
secretes ALP
what is a key feature of a testicular teratoma?
many different cells
what is a key feature of a testicular choriocarcinoma?
secretes hCG
what is a key feature of a testicular endodermal yolk sac tumour?
Alph fetoprotein
what are the criteria for the 2 week wait for bladder cancer?
45+ with unexplained visible haematuria without UTI
60+ with unexplained non-visible haematuria and either dysuria or a raised WCC
what percentage of men with raised PSA will not have prostate cancer?
specificity = 30%
what percentage of men with normal PSA will have prostate cancer?
sensitivity = 94%
when would you refer someone with UTIs for a bladder cancer review?
60+ with recurrent/persistent UTIs
what is the most common type of renal cell carcinoma?
clear cell carcinoma
what are 9 risk factors for colorectal cancer?
FHx
Family adenomatous polyposis
IBD
Increased age
Diet - high in red and processed meat and low fibre
Obesity and sedentary lifestyle
smoking
alcohol
what are 6 red flags for colorectal cancer?
Change in bowel habit
unexplained weight loss
rectal bleeding
unexplained abdo pain
IDA
abdo/rectal mass on examination
what is the screening for bowel cancer?
Aged 60-74
At home FIT test every 2 years
increased screening if FAP, HNPCC or IBD
what is the tumour marker for colorectal cancer?
carcinoembryonic antigen (CEA)
what staging is used in colorectal cancer?
TNM
Prev. Duke’s classification
what is Dukes classification?
for colorectal cancer
A - confined to mucosa and part of muscle of bowel wall
B - extending through muscle of bowel wall
C - Lymph node involvement
D - metastatic disease
what is the TNM classification of colorectal cancers?
Tx - unable to assess size
T1 - submucosal involvement
T2 - involvement of muscularis propria
T3 - involvement of subserosa and serosa
T4 - spread through serosa and reaching other tissues or organs
Nx - unable to assess
N0 - No nodes
N1 - spread 1-3 nodes
N2 - spread to 3+ nodes
M0 - no mets
M1 - metastasis
what 3 inherited conditions can cause colorectal cancer?
familial adenomatous polypososis
Hereditary non-polyposis colon cancer - most common
Peutz-Jeghers syndrome
what other cancer is associated with hereditary non-polyposis colorectal carcinoma?
endometrial cancer
what is the Amsterdam criteria for screening for hereditary non-polyposis colorectal carcinoma?
at least 3 family members with colon cancer
span at least 2 generations
at least 1 case diagnosed <50 years
what is the inheritance pattern for FAP and HNPCC?
autosomal dominant
what part of the colon is most affected in familial adenomatous polyposis?
left colon and rectum
what part of the colon is most affected in Hereditary non-polyposis colorectal cancer?
right colon
what prophylactic surgery can be done for family adenomatous polyposis?
panproctocolectomy
what are 5 presentations of colorectal cancer?
iron deficiency anaemia
progressive change in bowel habit
large bowel obstruction
weight loss and fatigue
abdo discomfort
Rectal mass
what are 3 investigations for colorectal cancer?
OGD + colonoscopy and biopsy - gold
Faecal immunochemical test
CT colonography
what is removed in a right hemicolectomy?
caecum, ascending and proximal transverse colon
what is removed in a left hemicolectomy?
distal transverse and descending colon
what is removed in a high anterior resection?
removal of sigmoid colon
what is removed in a low anterior resection?
sigmoid colon
upper rectum
spares lower rectum and anus
what is removed in an abdominal perineal resection?
rectum and anus and suturing over anus - left with permanent colostomy
what is Hartmann’s procedure?
removal of rectosigmoid colon and creation of colostomy
rectal stump sutured closed
colostomy may be permanent or reversed
what are 12 complications of colorectal surgery?
bleeding, infection pain
damage to nerves, bladder, ureter or bowel
post-op ileus
anaesthetic risks
conversion to laparotomy
leakage or failure of anastomosis
requirement for stoma
failure to remove the tumour
change in bowel habit
VTE
Incisional hernia
intra-abdominal adhesions
what is low anterior resection syndrome?
urgency and frequency of bowel movements, faecal incontinence
difficulty controlling flatulence after low anterior resection
what is the most common primary liver cancer?
hepatocellular carcinoma
what can cause liver adenomas?
anabolic steroids, oral contraceptive pill, pregnancy
What are 4 presentations of neoplastic spinal cord compression?
Back pain - earliest/most common
Lower limb weaakness
Sensory changes
neurological signs - upper if above L1, lower if below L1
what is neoplastic back pain like?
severe unremitting progressive
Mechanical
Aggravated by straining
Night pain
Localised tenderness
Claudication
what investigation should be done for neoplastic spinal cord compression?
MRI WHOLE SPINE
within 24h of presentation
what 6 cancers commonly metastasize to bone?
BLT with Ketchup Please (M)
Breast
Lung
Thyroid
Kidney
Prostate
Myeloma
where are the most common sites of bony metastases?
Descending order
Spine
Pelvis
Ribs
Skull
Long bones
what are 4 features of bony mets?
Bone pain
Pathological fractures
Hypercalcaemia
Raised Alk Phos
what is the management of neoplastic spinal cord compression?
Immobilisation
High dose Dexamethasone - 16mg OD
Surgery and radiotherapy
Analgesia and VTE prophylaxis
what are 4 complications of neoplastic spinal cord compression?
Permanent paralysis
Bladder and bowel incontinence
Pressure ulcers
DVT
what are 4 x-ray signs of bone cancer and what cancers do they demonstrate?
Soap/double bubble lesions - Giant cell
Sunburst - osteosarcoma
Onion skin - Ewing sarcoma
Moth-eaten - chondrosarcoma
when does osteosarcoma usually present?
10-20 year olds
what is the most common bone to be affected by osteosarcoma?
femur
tibia and humorous also common
what are 6 symptoms of bone cancer?
persistent bone pain
pain worse at night - disturb or wake from sleep
bone swelling
palpable mass
restricted joint movement
low grade fever
what can be seen on LFTs that suggest bone tumour?
raised ALP
what are 2 complications of bone tumours?
pathological fractures
metastasis
what is the 1st line investigation for bone tumour?
urgent (in 48 hours) x-ray and specialist assesment
what is the most common bone cancer in children?
osteosarcoma
what is the second most common bone cancer in children?
ewing sarcoma
what are 3 benign bone tumours?
Osteoma
Osteochondroma - exotosis
Giant cell tumour
what are 3 malignant bone tumours?
Osteosarcoma
Ewing’s sarcoma
Chondrosarcoma
what is an osteoma?
benign bone tumour
Overgrowth of bone - most typical in skull
what condition is osteoma associated with?
Gardner’s syndrome - variant of familial adenomatous polyposis (FAP)
what is the most common benign bone tumour?
osteochondroma
cause cartilage capped bony projections on external surface of bone
where do giant cell tumours most commonly occur?
Epiphysis of long bones
what can be seen on x-ray in giant cell tumours?
soap/double bubble appearance
where does osteosarcoma most commonly occur?
long bones prior to epiphyseal closure
Most in femur, some tibia and humerus
what can be seen on x-ray in osteosarcoma?
Codman triangle - periosteal elevation
Sunburst appearance
what other cancer is osteosarcoma associated with?
retinoblastoma
where does Ewing’s sarcoma most commonly occur?
pelvis and long bones
tends to cause severe pain
what is seen on x-ray in ewing sarcoma?
onion skin appearance
what is a chondrosarcoma?
malignant tumour of cartilage - mostly affecting axial skeleton
more common in middle age
what is the 1st line chemo in osteosarcoma?
cisplatin
doxorubicin
methotrexate
ifosfamidew
what scans are good for diagnosing bone mets?
bone scintigraphy scan
what monoclonal antibody can be used to slow the progress of bone mets?
Denosumab
what is the most common type of cholangiocarcinoma?
Adenocarcinoma
where is the most common site of cholangiocarcinoma?
Perihilar region - where R and L hepatic duct joint to become common HD
what are 2 risk factors for cholangiocarcinoma?
Primary Sclerosing Cholangitis
Liver flukes (Parasites)
what is the presentation of cholangiocarcinoma?
Obstructive jaundice - pale stools, dark urine, itch
Unexplained wt loss
RUQ pain
Palpable gallbladder
Hepatomegaly
what is Courvoisier’s law?
A palpable gallbladder PLUS jaundice is unlikely to be gallstones
Pancreatic cancer /cholangiocarcinoma/gallbladder cancer more likely
what tumour marker may be raised in cholangiocarcinoma?
CA 19-9
what are 3 management options for cholangiocarcinoma?
bile ductectomy - small cances
Partial hepatectomy
Whipple procedure (pancreaticoduodenectoym)
Stenting, chemo
what is the most common primary liver cancer?
Hepatocellular carcinoma
what are 5 risk factors for hepatocellular carcinoma?
Alcoholic liver disease
NAFLD
Hepatitis B
Hepatitis C
Primary sclerosing cholangitis
what is the tumour marker for hepatocellular carcinoma?
Alpha fetoprotein
what is the presentation of liver tumours?
wt loss
abdo pain
anorexia
nausea and vom
jaundice
Pruritus
RUQ mass
what is the 1st line imaging in liver cancer?
Liver US
what are 2 common benign tumours of the liver?
Haemangioma
Focal nodular hyperplasia - more common in women on the COCP
what is the management of HCC?
Resection
Liver transplant
sorafenib - 1 for metastatic HCC
Radiofrequency ablation
Microwave ablation
Transarterial chemoembolization
radiotherapy
what are 5 cancers that are likely to metastasise to the lungs?
Breast
Colorectal
Renal
Bladder
Prostate
what are 4 processes that allow metastases?
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
what are 5 cancers that metastasise to brain?
Lung - most common
Breast
Bowel
Skin - melanoma
Kidney
what is the most common primary brain tumour in adults?
Glioblastoma
what do glioblastomas appear like on imaging?
Solid tumour with central necrosis and contrast enhancing rim
Associated vasogenic oedema
what is the management of glioblastoma?
Surgical
Post op chemo and/or radiotherapy
Dexamethasone treats oedema
what is the second most common brain tumour of adults?
meningioma
are meningiomas benign or malignant?
Usually benign but can lead to raised ICP and mass effect
where do meningiomas arise from?
Arachnoid cap of meninges - typically located next to the dura and cause compression rather than invasion symptoms
what is the most common primary brain tumour in children?
Pilocytic astrocytoma
what is seen histologically in pilocytic astrocytomas?
Rosenthal fibres
(corkskrew eosinophilic bundles)
what is a particularly aggressive paediatric brain tumour?
Medulloblastoma - in infratentorial compartment
what is the histology of medullobastomas?
Small blue cells
Rosette pattern of cells
many miotic figures
what type of benign slow growing brain tumour is common in the frontal lobes?
Oligodendroma
what is the histological appearance of an oligodendroma?
calcifications with fried egg appearance
what condition are hemangioblastomas associated with?
von Hippel Lindau syndrome
what is the most common paediatric supratentorial tumour?
Craniopharyngioma
what is a Craniopharyngioma derived from?
remnants of rathke’s pouch in the sellar region
common in children but can also present in adults
what are 8 features of raised intracranial pressure?
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
how does papilledema present on fundoscopy?
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
what causes hypercalcaemia of malignancy?
paraneoplastic secretion of parathyroid hormone related protein leading to increased bone resorption
may also be due to boney metastasis
what is the management of hypercalcaemia of malignancy?
hydration
bisphosphonates or denosumab - to inhibit osteoclastic activity
haemodialysis
