Oncology Flashcards
Describe the main types of skin carcinoma
- basal cell carcinoma: usually presents as raised, smooth, pearly bump on the sun-exposed skin of head neck or shoulders, ulceration and telangiectasia may also feature
- squamous cell carcinoma: common presents as a red scaling thickened patch over sun-exposed skin. More malignant than BCC but less common
- malignant melanoma: the least common but most malignant usually presents as an asymmetrical area with irregular border and colour variation from shades of brown to black. Though some more aggressive melanomas called amelanotic appear pink, red of fleshy. Tend to be larger than 6mm and evolve over time.
Describe Ewing’s sarcoma and its treatment
Malignant round-cell tumour of long bones (typically diaphysis) and limb girdles that present in adolescents. Radiographs show bone destruction, concentric layers of new bone formation (onion ring sign). Typically those with it have a t11:22 chromosomal translocation.
Treatment:
Chemotherapy, surgery and radiotherapy are required. The key adverse factor is metastatic disease at diagnosis taking 5 year survival from 55% to 22%
What is the difference between adjuvant and neoadjuvant?
Adjuvant therapy is therapy that is given in addition to the main therapy to reduce the risk of recurrence e.g. post surgical chemo or radiotherapy.
Neoadjuvant therapy in contrast is given before main treatment and is needed to help ‘cure’. For example systemic therapy given before removal of breast, or therapy given to shrink tumours before surgery
Describe TNM staging.
T describes extent of tumour. 1 being small tumour with minimal invasion and 4 being large tumour with extensive invasion.
N describes degree of spread to regional lymph nodes. 0 means tumour cells absent, 1 shows spread to regionally lymph nodes increasing through to 3 depending on the distance of those lymph nodes
M is for the presence of metastases and is either 0 or 1
Describe Breast Carcinoma, the types, its risk factors, investigations, and treatment
Most common type of cancer. Affects 1 in 8 women. 60-70% of breast cancers are oestrogen receptor +ve conveying better prognosis. around 30% over-express HER2 (growth factor receptor gene) associated with aggressive disease and poorer prognosis.
Types:
- Non-invasive Ductal Carcinoma In-Situ (DCIS) is premalignant and seen as micro-calcification on mammography.
- Non-invasive lobular CIS is rarer and tends to be multifocal, picked up less through conventional radiology, MRI is more sensitive.
- Invasive ductal carcinoma is most common (70%) whereas invasive lobular carcinoma accounts for 10-15%.
Risk factors: Family history, age, uninterrupted oestrogen exposure,1st pregnancy after 30yrs, early menarche, late menopause, HRT, Obesity, BRCA genes, not breastfeeding, previous cancer.
Investigations: all lumps undergo Triple assessment:
- Clinical examination - Ductal carcinomas most commonly present as lumps in the upper outer quadrant of the breast.
- Radiology - ultrasound for 40 and under (due to increased breast density mammography is less reliable), mammography and ultrasound for 40 and older
- Histology/cytology (FNA or core biopsy, US-guided core biopsy best for new lumps)
Treatment:
- Surgery - wide local excision or mastectomy +/- breast reconstruction, + axillary node sampling/surgical clearance or sentinel node biopsy.
- Radiotherapy - recommended for all patients with invasive disease post wide local excision. Axillary radiotherapy may be used if lymph nodes +ve on sampling and surgical clearance not performed
- Chemotherapy - adjuvant chemotherapy improve survival. Neoadjuvant to allow breast-conserving surgery
- Endocrine agents - Tamoxifen for oestrogen receptor +ve tumours in pre and perimenopausal women. anastrozole an aromatase inhibitor targeting peripheral oestrogen synthesis may be used in post-menopausal women.
Describe Phaeochromocytoma, its symptoms, tests, and treatment,.
Rare catecholamine-producing tumour. They arise from sympathetic paraganglia cells, which are collections of chromaffin cells. They are usually found in the adrenal medulla, rarely they may be found by the aortic bifurcation. Follow a rule of 10%, 10% maligant, 10% extra-adrenal, 10% bilateral, 10% familial.
Symptoms: Classic triad is episodic headache, sweating and tachycardia
Tests: WCC raised, plasma + 3 x 24h urine collectuon for free metadrenaline and normetadrenaline +/- clonidine supprestion test if borderline. Localisation with abdominal CT/MRI
Treatment:
- Surgery - alpha-blockade (phenoxybenzamine) pre-op, consult anaethestist.
- If emergency principle is combined alpha and beta blockade, start with alpha as unopposed beta blockade can worsen hypertension.
Describe adrenocortical carcinoma, its symptoms, investigations, and treatment
An aggresive cancer originating in the cortex (steroid-hormone producing tissue) of the adrenal. Bimodal distribution by age clustering in children under 5 and adults 30-40yrs.
Symptoms: Early signs include abdominal fullness + pain. If functional, many hormonal syndromes can occur including Cushing’s syndrome, Conn Syndrome, virilization and feminization. Most commonly presents as Cushing’s + Virilzation due to glucocorticoid and androgen overproduction.
Investigations: BM (raised glucose in cushing’s), 24h urine collection, CT scan.
Treatment: Surgical excision if local, if metastatic chemotherapy. palliative radiotherapy.
Describe immune checkpoint blockade in cancer therapy.
A new potential treatment target for cancer, immunologic checkpoint blockade with antibodies that target cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) and the programmed cell death protein 1 (PD-1) have demonstrated promise in a variety of malignancies.
Antibodies for these targets (Ipilimumab for CTLA-4 and Pembrolizumab for PD-1) prevent down-regulation of T-cells allowing the natural immune response to be boosted in fighting cancer.
Describe Advanced Care Planning.
All patients reaching the end of their life should be offered the opportunity (but not feel obliged) to plan ahead. ACP is a process of discussions between a patient and professionals regarding their future care, decisions and wishes can be documented in the following ways and the patient should be informed of these measures:
- Advanced statement - documentation of patients preferences and wishes.
- Advanced Decision - legally binding, made when patient has capacity to be used if they no longer have capacity regarding refusal of specific treatments in specific situations.
- Lasting Power of Attorney - may be given by the patient to a nominated patient which grants that person legal responsibility for making decisions regarding the patients health.
- The setting of end of life care should also be discussed as well as including religious and cultural views.
When dealing with patients ask yourself would you be surprised if this patient were to die in the next 2 years? If yes think about discussing the above with a patient.
Describe Liver metastases, common primary sites, symptoms,
The commonest liver tumour are secondary (metastatic) e.g. from breast, bronchus (lung), or the GI tract.
Symptoms: Fever, malaise, weight loss, RUQ pain (due to liver capsule stretch), jaundice and ascites are later signs.
Management: often palliative prognosis is usually less than 6 months.
Describe renal cell carcinoma, its features, tests, and management
Accounts for 90% of renal cancers, arising from the proximal renal tubular epithelium. Mean age 55yrs. Twice as common in men.
Features: Haematuria, loin pain, abdominal mass, anorexia, malaise, weight loss, pyrexia of unknown origin, 25% metastasise at presentation to bone, liver, or lung.
Tests: Raised BP due to increased renin secretion, FBC shows polycythaemia due to increased erythropoietin secretion. Imaging - US, CT/MRI, CXR may show Cannon-ball metastases.
Management: Radical nephrectomy, generally radio and chemo resistant. Biological therapies targeting angiogenesis e.g. sunitinub, sorafenib may be effective. For patients with multiple poor-risk factors temsirolimus (inhibits mTOR) improves survival compared to interferon
Describe colorectal carcinoma, its presentation, tests and management
3rd most common cancer mostly in those over 60yrs old. Predisposing factors include, polyps, IBD, FAP and HNPCC, smoking, alcohol, low fibre high red + processed meat diet.
Presentation: depends on site:
- left-sided = bleeding/mucus PR, altered bowel habit or obstruction, tenesmus, mass PR
- right-sided = weight loss, anaemia, abdominal pain, obstruction less likely.
- Either may present with abdominal mass, perforation, haemorrhage, fistula.
Tests: FBC shows microcytic anaemia, FOB +ve, sigmoidoscopy/colonoscopy. LFT + CT for metastatic spread to liver, lung, bone
Management:
- Surgery aims to cure. Right hemicolectomy for caecal, ascending or proximal transverse colon tumours. Left hemicolectomy for tumours in distal transverse or descending colon. Sigmoid colectomy for sigmoid tumours. Anterior resection for low sigmoid or high rectal tumours. Abdomino-perineal resection for tumours low in the rectum.
- Radiotherapy most often used in palliation of colonic cancer occasionally neo-adjuvantly to allow resection. Adjuvant only used in rectal tumours with high risk of recurrence.
- Chemotherapy is used adjuvantly the standard is FOLFOX regimen (5-FU, folinic acid and oxaliplatin). Biological therapies e.g. anti-VEGF improves survival when added to combination therapy in advanced disease.
What are some commonly used tumour markers?
Alpha-fetoprotein (aFP) - germ cell/testicular and HCC
Calcitonin - Medullary thyroid
CA-125 - Ovarian (raised in many other diseases)
CA 19-9 - Pancreatic
CA 15-3 - Breast
Carcinoembryonic antigen (CEA) - Colorectal
Describe gastric carcinoma, its risk factors, presentation, tests, and management.
Carcinoma of the stomach
Risk factors: H Pylori, Low Vitamin C, FHx, High Sodium diet, Japanese, Gastric Surgery, Pernicious Anaemia, Smoking.
Presentation: often non-specific, dyspepsia (for more than 1 month and age over 50 years demands investigation), weight loss, vomiting, dysphagia, anaemia. Signs of late stage disease include virchow’s node, epigastric mass, hepatomegaly, jaundice, ascites, acanthosis nigricans.
Tests: gastroscopy + multiple ulcer edge biopsies. Aim to biopsy all ulcers as even malignant ulcers may appear to heal on drug treatment. CT/MRI helps staging.
Treatment: Surgical resection. Combination chemotherapy increases survival in advanced disease (epirubicin, cisplatin, 5-FU). Targeted therapies have increasing role eg. trastuzumab for HER-2 +ve tumours.
Describe oesophageal carcinoma, its risk factors, presentation, red flag, tests, and treatment
More common in men, risk factors include diet low in vit A+C, alcohol excess, smoking, plummer-vinson syndrome, obesity, nitrosamine exposure (Fish is high in nitrosamines), barrets oesophagus. 20% occur in the upper part, 50% in the middle and 30% in the lower part. They may be squamous cell (proximal) or adenocarcinomas (distal).
Risk Factors: Smoking, Alcohol, GORD, Barrett’s oesophagus, Achalsia, Plummer-Vinson Syndrome, Nitrosamines, Coeliac disease, scleroderma.
Presentation: progressive dysphagia, weight loss, retrosternal chest pain. Signs from upper third include hoarseness, cough.
Red Flags: dysphagia, 55 and over with weight loss and any of the following upper abdominal pain, dyspepsia.
Tests: OGD with biopsy. CT for staging
Treatment: oesophagectomy for local disease. If surgery not applicable, chemoradiotherapy is recomended. Palliative therapy aims to restore swallowing with chemo/radiotherapy.
Describe Spinal Cord Compression, its causes, symptoms, investigation, and management.
An oncological emergency, urgent treatment is required to preserve neurological function.
Causes: Typically extradural metastases.
Symptoms: Back pain, weakness or sensory loss with a root distribution (or a sensory level), bowel and bladder dysfunction.
Investigations: urgent MRI of whole spine.
Management:
- Dexamethasone 16mg/24h PO.
- Palliative radiotherapy is the commonest treatment.
- Discuss with neurosurgeon and clinical oncologist immediately.
Describe SVC obstruction with airway compromise, its causes, symptoms, investigations, and management.
It is an oncological emergency only if there is tracheal compression with airway compromise otherwise there is time to plan optimal treatment.
Causes: Malignancy accounts for more than 90% of SVCO, 3/4 of which are lung cancer. Rarer causes include mediastinal enlargement (germ cell tumour), thymus malignancy, mediastinal lymphadenopathy, (e.g. lymphoma), thrombotic disorders, thrombus around IV central line.
Symptoms: Dyspnoea, orthopnoea, plethora/cyanosis, swollen face and arm, cough, headache, and engorged veins.
Investigations: Pemberton’s test (lifting the arms over hte head for more than a minute causes facial plethora/cyanosis, raised JVP, and inspiratory stridor) Urgent contrast enhanced CT.
Management:
- get a tissue diagnosis if the cause is unknown e.g. biopsy of peripheral lymph node
- Give oral dexamethasone 8-16mg/24h.
- Consider balloon venoplasty and SVC stenting as this provides the most rapid relief of symptoms.
Describe malignancy associated hypercalcaemia, its causes, symptoms, and management.
An oncological emergency, affects 10-20% of patients with cancer and 40% of those with myeloma. Very poor prognostic sign.
Causes: Lytic bone mets, myeloma, production of osteoclast activating factor or PTH-like hormones by the tumour.
Symptoms: Lethargy, anorexia, nausea, polydipsia, polyuria, constipation, dehydration, confusion, weakness. Most obvious is corrected serum Ca greater than 3mmol/L
Management: Involves rehydration followed by IV bisphosphonate (or calcitonin if resistant). Maintenance with bisphosphonates, treat underlying malignancy.
Describe Raised Intracranial pressure, its symptoms, investigations, and management
It is an oncological emergency, due to either primary CNS tumour or mets.
Symptoms: Headache (often worse in the morning, when coughing or bending over), nausea, vomiting, papilloedema, fits, focal neurological signs.
Investigations: Urgent CT/MRI is important to diagnose an expanding mass, cystic degeneration, haemorrhage within a tumour, cerebral oedema, or hydrocephalus as the management of these scenarios are different.
Treatment: Dexamethasone 8-16mg/24h PO, radiotherapy and surgery as appropriate depending on cause. Mannitol may be tried for symptom relief of cerebral oedema though not based on strong evidence.
Describe lung cancer, its symptoms, tests, and management.
35% are squamous cell (CXR may show central cavitating lesion aka coin lesion), 27% adenocarcinoma, 20% small cell, 10% large cell. Main division is into small cell (SCLC) and non-small cell (NSCLC).
Symptoms: Cough (80%), haemoptysis (70%), dyspnoea (60%), chest pain (40%), recurrent or slowly resolving pneumonia, lethargy, anorexia, weightloss. Lymphadenopathy, recurrent laryngeal nerve palsy (mediastinal lymph nodeS), Horner’s syndrome (pancoasts tumour), ACTH from small cell leading to cushings
Tests: cytology of sputum, CXR. fine needle aspirations or biopsy and CT staging. Bronchoscopy to assess tumour.
Treatment:
- NSCLC - excision is the treatment of choice for peripheral tumours, without mets. Curative radiotherapy is an alternative if respiratory reserve is poor. Chemo + Radio for more advanced tumours.
- SCLC - may respond to chemo but invariably relapse, consider palliation radiotherapy for bronchial obstruction, SVC obstruction
Describe PSA, its normal range, causes of raised PSA,
Prostate Specific Antigen is a tumour marker that may be raised in a number of scenarios
Normal Range: 40-49yrs = 2.5, 50-59yrs = 3.5, 60-69yrs = 4.5, 70+yrs = 6.5
Causes of raised PSA:
- BPH (usually less than 10ng/mL)
- Prostate cancer (65% greater than 10ng/ml)
- BMI greater than 25
- Afro-carribeans
- Taller men
- Recent ejaculation
- Prostatitis
- Recent rectal examination
If PSA is greater than 10ng/mL think prostate cancer. Finasteride can half PSA so double for representative value of prostate
What are the conversion of some common opiod medications?
Codeine phosphate 60mg PO = Morphine 6mg PO
Tramadol 100mg PO = Morphine 20mg PO
Oxycodone 5mg PO = Morphine 10mg PO
Morphine 5mg IV/SC = Morphine 10mg PO
Diamorphine 5mg IV/SC = Morphine 15mg PO
Oxycodone 5mg IV/SC = Morphine 20mg PO
Alfentanil 1mg IV/SC = Morphine 30mg PO
