✅ Oncology Flashcards
Lymphadenopathy
The location of the lymphadenopathy can be a helpful predictor of the likelihood of a pathologic versus benign cause. Specifically, whereas mediastinal, supraclavicular, and abdominal lymphadenopathy have a greater likelihood of a pathologic cause, cervical, axillary, and inguinal lymphadenopathy have a greater likelihood of a benign cause.
Size can be a helpful predictor of whether lymphadenopathy is benign or pathological, lymph nodes <2 cm frequently are from benign causes, and those ≥2 cm are more likely to be associated with a pathological cause.
Most infectious and immunologic causes of lymphadenopathy resolve within 2 weeks, and persistence for less than 2 weeks is reassuring for a benign cause of lymphadenopathy. If a benign cause of lymphadenopathy is suspected, an observation period of at least 4 weeks is considered appropriate before pursuing additional diagnostic studies.
SPREAD
Squamous cell carcinoma in a cervical lymph node, especially in a smoker, likely has a mucosal head and neck primary site and requires examination of the laryngopharyngeal mucosa.
Abdominal malignancies (eg, stomach, pancreas, colon, ovaries) can spread via the thoracic duct to the left supraclavicular lymph nodes (Virchow node)—an ominous sign. Most of these abdominal malignancies are adenocarcinomas.
Breast cancer commonly affects the axillary and internal mammary lymph nodes.
HCC typically metastasizes to the lungs, portal vein, and portal lymph nodes.
Thyroid cancer metastasizes to cervical nodes. Cancers are papillary,
Gastrointestinal malignancies, such as colorectal or pancreatic cancer, are the most frequent source of liver metastases as their venous drainage is through the portal system directly to the liver. Lung, breast, and skin cancers (melanoma) often also spread to the liver. The liver is a common site of metastatic disease due to its dual blood supply (systemic and portal) and hepatic sinusoidal fenestrations allowing for easier metastatic deposition. Multiple hepatic nodules are typically seen in metastatic disease; however, solitary lesions are not uncommon.
Cyclophosphamide
An alkylating agent frequently used as an immunosuppressant in systemic lupus erythematosus, vasculitis and certain cancers. Regarding SLE, cyclophosphamide is reserved for patients with significant renal or central nervous system problems. Unfortunately, cyclophosphamide has many side effects. Serious side effects include acute hemorrhagic cystitis, bladder carcinoma, sterility, and myelosuppression. Hemorrhagic cystitis and bladder cancer are caused by acrolein, a bladder-toxic metabolite of cyclophosphamide. Drinking plenty of fluids, voiding frequently, and taking MESNA are all helpful in preventing these complications.
CHEMO
Neoadjuvant therapy is defined as treatment given before the standard therapy for a particular disease. This would be the case in this patient if the radiation therapy was given before the radical prostatectomy was done.
Adjuvant therapy is defined as treatment given in addition to standard therapy. This would be the case in this patient if the radiation therapy was given at the same time as the radical prostatectomy.
Induction therapy is an initial dose of treatment to rapidly kill tumor cells and send the patient into remission (<5% tumor burden). A typical example is induction chemotherapy for acute leukemia.
Consolidation therapy is typically given after induction therapy with multidrug regimens to further reduce tumor burden. An example is multidrug therapy after induction therapy for acute leukemia.
Maintenance therapy is usually given after induction and consolidation therapies (or initial standard therapy) to kill any residual tumor cells and keep the patient in remission. An example is daily antiandrogen therapy for prostate cancer.
Salvage therapy is defined as a form of treatment for a disease when a standard treatment fails.
LUNG
SVC syndrome: Tumors that may cause SVC syndrome include small-cell carcinoma of the lung, squamous cell carcinoma of the lung, lymphoma, and mediastinal tumors like thymomas and germ cell tumors.
Pancoast syndrome (superior sulcus tumor) is a complication of lung cancer when it extends into the apex. Patients have compression of the C8, T1, and T2 nerves and often complain of arm and shoulder pain.
Superior pulmonary sulcus (SPS) tumor (Pancoast tumor)
Usually a malignant lung neoplasm (most commonly squamous cell carcinoma or adenocarcinoma).
Typical lung cancer symptoms include cough, hemoptysis, dyspnea, chest pain, decreased appetite, and weight loss, but tumors located in the SPS often present with shoulder pain as the initial symptom due to invasion of the brachial plexus or adjacent structures. The pain may also radiate up to the head and neck or down the ipsilateral arm in the ulnar nerve distribution, and weakness and atrophy of the medial hand muscles may occur. Horner syndrome is also common and occurs due to tumor invasion of the paravertebral sympathetic chain and inferior cervical ganglion. Initial evaluation includes chest imaging (eg, x-ray of the chest) to evaluate for lung mass.
Squamous Cell Carcinoma
increased thirst, and easy fatigability) and laboratory studies are consistent with hypercalcemia, which is usually associated with the abovementioned carcinoma (remember: sCa++mous).
Hypercalcemia usually result from the effects of parathyroid hormone-related protein (PTHrP), which is similar in nature to PTH in the receptor-binding area. Binding to PTH receptor results in increased calcium resorption from the bones and increased renal calcium resorption in the distal tubule. Furthermore, hypercalcemia in such settings may result from metastatic involvement of the bone and usually develops as a late complication of the cancer; thus, its appearance has very serious implications.
Adenocarcinoma
Adenocarcinoma is usually a peripheral lesion that is usually not associated with hypercalcemia. It is typically associated with hypertrophic pulmonary osteoarthropathy.
Small Cell Carcinoma
Small cell carcinoma of the lung usually causes other paraneoplastic syndromes such as ACTH productionand SIADH.
PROSTATE
Prostate Cancer
Benign prostatic hyperplasia (BPH)
Acute prostatitis
Metastatic Skeletal Disease:
Osteomyelitis
Paget disease
Other cancers
Prostate Cancer
Hx: Early prostate cancer usually is asymptomatic, although some patients may present with hematospermia, painful ejaculation, or symptoms of bladder outlet obstruction, such as urinary hesitancy and frequency. Patients with metastatic disease may present with bone pain, back pain, weight loss, or fatigue.
The American College of Physicians also recommends against screening individuals at average risk unless a patient expresses a desire to pursue testing following a discussion of the potential risks and benefits of screening. If pursued, screening should not be performed before age 50 years, after age 69 years, or if the life expectancy is <10 to 15 years.
Dx: Any abnormality on digital rectal examination requires biopsy, regardless of serum PSA level. Serum PSA values >4.0 ng/mL (4 µg/L) generally are considered abnormal. Because the PSA value rises very slowly over time, an increase of >0.75 ng/mL (0.75 µg/L) in 1 year, regardless of the initial value, is considered abnormal.
Refer any patient with an abnormal PSA value for transrectal ultrasound-guided prostate biopsy. This outpatient procedure usually consists of six to twelve random needle biopsies. umors detected on these biopsies are further classified according to their histology, using the Gleason score. In the Gleason histologic scoring system, tumors are graded from 1 to 5 based on the degree of glandular differentiation and structural architecture, with 1 being the most and 5 being the least differentiated. The resulting Gleason score (up to 10) reflects the biological characteristics of the tumor and correlates well with tumor behavior, with lower scores (2, 3, or 4) being considered well-differentiated or low-grade cancers, and higher scores (8, 9, or 10) representing poorly differentiated or high-grade cancers.
Patients with stage I cancer have low-risk disease limited to the prostate. Stage II disease is also limited to the prostate but has features that increase the risk for spread. Stage III disease is locally advanced outside of the prostatic capsule, and stage IV disease has positive regional lymph node involvement or distant metastases. Patients with Gleason score >7, serum PSA level >10 ng/mL (10 µg/L), large tumors, or the presence of bone pain may require a bone scan and/or abdominal and pelvic computed tomography (CT) to evaluate for metastatic disease.
Bone alkaline phosphatase
Not used in diagnosing prostate cancer. Elevated levels in patients with prostate cancer suggest bone metastases.
Transrectal ultrasonography
Transrectal ultrasonography has a PPV of 7%-34% and an NPV of 85%. The test is used to guide prostate biopsies; it is not used to screen for or stage prostate cancer.
Prostate biopsy
Biopsy is the only way to definitively diagnose prostate cancer.
CBC
Metastatic cancer to the bone marrow is common and can result in anemia.
Abdominal and pelvic CT
CT is helpful in evaluating for pelvic or retroperitoneal lymph node metastases or bone metastases. Bone or lymph node metastases are rare in men with serum PSA levels <20 ng/mL (20 µg/L), especially if the Gleason score is <8.
Bone scan
Bone is the most common site of metastatic prostate cancer, and bone scans are useful for detection. Osteoarthritis, other degenerative changes, trauma or fracture, osteomyelitis, and Paget disease also can result in increased uptake on bone scans. Ambiguous bone scan results often lead to additional bone imaging studies (radiography, CT, MRI). A biopsy is performed for ambiguous radiologic imaging results.
Tx: Radical prostatectomy usually is reserved for patients with at least a 10-year life expectancy.
Radiation therapy can be delivered using external beam radiation or by implanting radioactive “seeds” around the prostate (brachytherapy).
Prostate cancers are dependent on testosterone for growth; thus, androgen deprivation therapy (ADT) often is used with other therapies to treat higher-risk localized cancers and is the primary therapy in patients with local treatment failures (defined by a rise in serum PSA level after surgery or radiation therapy).
Benign prostatic hyperplasia (BPH)
BPH is characterized by symptoms of urinary outflow obstruction (nocturia, urinary urgency and hesitancy) and may result in elevated serum PSA levels. Prostate cancer and BPH can coexist, but there is no causal association between the diseases. BPH results in a generalized and symmetric enlargement of the prostate, whereas prostate cancer may manifest as a palpable lump, induration, or asymmetric enlargement. Biopsy distinguishes between the two entities.
Acute prostatitis
Acute prostatitis can result in elevated serum PSA levels but also fever, chills, dysuria, pelvic or perineal pain, and possible obstructive symptoms (dribbling, hesitancy, anuria). DRE reveals edematous and tender prostate. Urine shows pyuria and positive urine culture.
Osteomyelitis
Osteomyelitis results in increased uptake on bone scans and can be confused with metastatic disease. Osteomyelitis is not associated with an elevated serum PSA level, and metastatic prostate cancer in the context of a normal PSA level is very unusual. Metastatic prostate cancer tends to be multifocal, whereas osteomyelitis tends to be unifocal. Prostate cancer and osteomyelitis have very different appearances on CT and MRI scans.
Paget disease
Paget disease of the bone can look like sclerotic bone metastases. Paget disease is not associated with an elevated serum PSA level.
Other cancers
Many other cancers spread to the pelvic and retroperitoneal lymph nodes and the bones, including bladder cancer, colorectal cancer, testicular cancer, renal cell carcinoma, carcinoma of the ureter and renal pelvis, and penile cancer. Prostate cancer can generally be distinguished from other malignancies on the basis of histopathologic examination of biopsy specimens and presence of elevated serum PSA level.
👄 Leukoplakia
Leukoplakia is a reactive precancerous lesion (white mucosal lesion) that represents hyperplasia of the squamous epithelium.
Although leukoplakia is often a benign, asymptomatic condition, evolving oral leukoplakia that is nonhomogeneous and friable (eg, tasting blood) is concerning for squamous cell carcinoma, especially in a patient who uses smokeless tobacco.
Most cancers of the head and neck arise from squamous epithelial cells that undergo stepwise, premalignant changes (ie, hyperplasia to dysplasia to carcinoma). Lesions may initially manifest in the oral cavity as hyperplastic or dysplastic white (leukoplakia) or red (erythroplakia) patches (which is likely what was noted on the patient’s initial biopsy). Because these lesions are at risk of malignant transformation, patients require counseling regarding risk reduction (eg, tobacco chewing cessation), regular examination of the oral cavity, and rebiopsy if changes (eg, thickness, firmness) are seen.
If biopsy results are cancerous, regional metastatic spread to the cervical lymph nodes is highly likely; therefore, a CT scan of the neck with contrast should also be obtained, both to evaluate the extent of invasion and characterize the metastatic nodal spread.
Ddx:
Aphthous stomatitis refers to localized, shallow, painful ulcers with a gray base. Recurrent aphthous stomatitis is the most common cause of oral ulcers.
Oral candidiasis, or thrush, occurs in patients with diabetes, immunodeficiency states, and use of antibiotics or inhaled glucocorticoids.
Gingivostomatitis. It can present with multiple vesicular lesions with an erythematous and inflammatory base and erythematous border within the oral cavity and perioral area.
