Oncology Flashcards
1
Q
types of thyroid cancer
A
Papillary Follicular Medullary Lymphoma Anaplastic
2
Q
Papillary thyroid cancer
A
young patients
spread - lymph nodes and lung (jugulo-diagastric node metastasis - lateral aberrant thyroid)
Rx - total thyroidectomy +/- node excision +/- radioiodine
3
Q
Follicular thyroid cancer
A
middle ages
spreads early via blood –> bone and lungs
well differentiated
Rx - total thyroidectomy + T4 suppression + radioiodine ablation
4
Q
Medullary thyroid cancer
A
sporadic or part of MEN syndrome
may produce calcitonin –> used as a tumour marker
do not concentrate iodine
Phaeochromocytoma screen pre-op
Rx –> thyroidectomy + node excision. Consider external beam radiotherapy.
5
Q
Thyroid Lymphoma
A
may present with stridor or dysphagia
Do full staging before treatment (chemoradiotherapy)
Assess histology for mucosa-associated lymphoid tissue (MALT –> good prognosis)
6
Q
Anaplastic thyroid cancer
A
elderly
poor response to treatment
try excision and radiotherapy
7
Q
Oropharyngeal carcinoma
A
Advanced at presentation –> 20% node +ve at presentation
men more than women
- smoker with sore throat and sensation of a lump
8
Q
Oropharyngeal carcinoma
risk factors
A
Pipe smoking
Chewing tabacco
High Risk HPV type 16
9
Q
Oropharyngeal carcinoma
Rx
A
Surgery and radiotherapy
10
Q
Signs and symptoms of
Head & neck squamous cell carcinomas
A
- neck pain/ lump
- hoarse voice >6 weeks
- sore throat > 6 weeks
- mouth bleeding
- mouth numbness
- sore tongue
- painless ulcers
- patches in the mouth
- ear ache/ effusion
- lumps (lip/ mouth/ gum)
- speech change
- dysphagia
11
Q
leukoplakia
A
white vulval patches due to skin thickening and hypertrophy
- itchy
- biospy
Rx –> topical corticosteroids, psoralens + UV phototherapy, methotrexate, ciclosporin
12
Q
Malignant bone disease
A
Rare primary, common secondary (prostate, thyroid, lung, kidney, breast)
13
Q
Bone sarcoma presentation
A
non-mechanical bone or joint pain
bone pain at night
bony swellings
pathological fractures
14
Q
Osteoscarcoma
A
- typically adolescents
- metaphyses of long bones - esp around the knee
- secondaries in bone affected by Pagets Disease or after irradiation
- -> present with pain before mass
- post amputation recurrence –> micrometastises
15
Q
Osteosarcoma imaging
A
bone destruction and new bone formation --> sun-ray spiculation periosteal elevation (Codman's triangle)
16
Q
Ewings Sarcoma
A
malignant round cell tumour of long bones (diaphysis) and limb girdles
presents in adolescence
17
Q
Ewings Sarcoma Imaging
A
Bone destruction
New bone formation in concentric layers –> onion ring sign
periosteal elevation
18
Q
Ewings sarcoma treatment
A
chemo
radiotherapy
surgery
19
Q
Chrondrosarcoma
A
associated with pain or lump axial skeleton in middle age de novo pop-corn calcification on X-ray Excision is best management
20
Q
Osteochondroma
A
BENIGN
- proximal femur, knee or proximal humerus
- painful mass associated with trauma
- seen on X-Ray as a bony spur arising from the cortex, ointing away from the joint
Remove if causing problems
21
Q
Osteiod Osteoma
A
BENIGN - painful benign bone lesion - long bones and spine of males 10-25 -local cortical sclerois on x-r with central radiolucent nidus relieved by ibuprofen CT biopsy and radio frequency ablation
22
Q
Chondroma
A
BENIGN
- cartilaginous tumours
- bone surfaces or within the medulla
- causes local swelling or fracture
- exclude malignancy
23
Q
Define sarcoma
A
malignant neoplasm arising from mesenchymal cells
- Soft tissue cancers
- Primary bone cancers
- GI stomal cell tumours
24
Q
Define carcinoma
A
epithelial cells and frequently cause breast, bowel and lung cancers
25
Soft tissue sarcomas
originate from fat, muscle, --> painless enlarging mass
RF --> neurofibromatosis type 1 and previous radiotherapy
Rx--> excision with wide margins and radiotherapy
26
Lymphadenopathy
| reactive causes
infective
- bacterial (pyogenic, TB, brucella, syphilis)
- Viral (EBV, HIV, CMV, infectious hepatitis)
- toxoplasmosis, trypanosoiasis
Non-infective
- sarcoidosis, amyloidosis, berylliosis, connective tissue disease, dermatological or drugs (phenytoin)
27
Lymphadenopathy
Infiltrative causes
Benign histiocytosis
Malignant -->
haematological --> lymphoma, leukamia: ALL, CLL, AML
metastatic carcinoma from breast, lung bowel, prostate, kidney or head & neck cancers
28
Causes of mediastinal masses
- mediastinal fat
- retrosternal thyroid
- unfolded aorta or aortic aneurysm
- lymph node enlargement (sarcoidosis, lymphoma, mets, TB)
- tumour --> thyoma, teratoma
- cysts --> bronchogenic, pericardial
- paravertebral mass (TB)
29
Normal aortic lumps on the L border
1. Aortic knuckle
2. Pulmonary outflow tract
3. Left ventricle
Mediastinum moves towards collapsed lung and away from processes that add volume (effusion)
30
glandular epithelieum
benign - adenoma
| malignant - adenocarcinoma
31
Squamous epithelium
benign - squamous papilloma
| malignant - squamous cell carcinoma
32
transitional epithelium
benign - transitional papilloma
| malignant - transitional cell carcinoma
33
melatocytes
benign= naevus
| malignant - malignant melanoma
34
striated muscle
benign - rhabdomyoma
| malignant - rhabdomyosarcoma
35
Smooth muscle
benign - leiomyoma
| malignant - leiomyosarcoma
36
fat
lipoma
| liposarcoma
37
nerve sheath
neurofibroma
| neurofibrosarcoma
38
Lymphocytes
lymphoma
39
Glial cells
glioma
40
metaplasia
change in a cell type from one fully differentiated pattern to another fully differentiated pattern
e.g barretts oesophagus
41
dysplasia
epithelial cells with a disorder of maturation most common on the cervix
- division of cells above normally proliferative basal cell layer
- loss of polarity of the nucleus
- lack of differentiation
42
carcinoma in situ
severe degree of dysplasia with no discernible differentiation in cells between base and top of epithelium
no evidence of stromal invasion
43
microinvasive carcinoma
tumours that have invaded through the basal membrane but only into surrounding stroma
44
invasive carcinoma
any tumour that has invaded substantially through the basement membrane - able to gain access to lymphovascular channels and metastasize to distant sites
45
metastasis
spread and growth of tumour to site distant from origin
- tumour cells travel in the blood or lymphatic systems, or across a body cavity such as the pleura, peritoneum or meninges
46
process of metastasis
1. detachment
2. invasion through basement membrane
3. invasion through connective tissues
4. invasion into blood vessels/ lymphatics
5. survival in blood vessel/ lymphatic channel - opportunity for host immune recognition
6. extravasion
7. Growth at the distant site
47
proto-oncogenes
overactivity of these genes leads to development of cancer
| e.g Ras genes
48
tumour suppressor genes
underactivity of these genes lead to the development of cancer
e.g. retinoblastoma
49
mutator phenotype
cells with early loss of DNA damage detection and repair mechanisms
e.g. hereditary non-polyposis colorectal cancer
50
P53
present in over 50% of human cancers
mutations acquired during lifetime
controls transcription of other genes that control transcription, mediate apoptosis and arrest the cell cycle
non-functional p53 proteins lead to progressive accumulation of DNA damage in successive generations of cells
51
APC
Adenomatous polyposis coli gene
lost in 80% of sporadic colorectal cancers
individuals with 1 deleted APC develop hundreds of adenomas in by 20yo inevitably develop Colorectal Ca
52
DNA binding chemotherapy
alkylating agents
direct alteration of DNA by alkylating agents or platinum complexes
antiproliferative drugs that bind via alkyl groups to DNA
e.g. cyclophosphamide
53
anti-metabolite chemotherapy
block synthesis of purines and pyrimidines, essential for DNA synthesis
interfere with normal cellular metabolism of nucleic acids
e.g. methotrexate, 5-fluorouracil
54
anti-microtubule chemotherapy
interferes with mitosis
55
topoisomerase chemotherapy
inhibition leads to DNA damage
56
Bone marrow side effects of chemotherapy
neutropenia
infection
thrombocytopenia
anaemia
57
GI side effects of chemotherapy
nausea
vomiting
diarrhoea
mouth ulcers
58
skin side effects of chemotherapy
hair loss
59
gonad side effects of chemotherapy
infertility
60
anti-microtubule side effects of chemotherapy
peripheraly nerve damage
61
Anthracycline side effects of chemotherapy
cardiomyopathy
62
Side effects of radiotherapy
GI tract
mucosal ulceration
| --> sore mouth, diarrhoea
63
Side effects of radiotherapy
Skin
erythema and desquamation (similar to sun burn)
64
Side effects of radiotherapy
bone marrow
myelosuppression
- WCC --> platelets --> RBC
65
Side effects of radiotherapy
Gonads
fall in sperm count
ovarian failure
66
Late effects of radiotherapy
- lung fibrosis
| - spinal cord damage - myelitis
67
oxygen effect of radiotherapy
hypoxia causes resistance to radiation and abnormal vasculature of cancer can produce hypoxic areas within the cancer- potential to cause failure to eradicate cancer with radiotherapy
68
Principles of combination chemotherapy
each drug should
- single agent activity in that tumour type
- different mechanism of activity
- non-overlapping toxicity
- action on a different part of the cell cycle
- different mechanisms of resitance
69
Causes of Spinal Cord Compression
- extradural metastatases
- extension of tumour from a vertebral body
- direct extension of the tumour
- crush fracture
70
Signs and symptoms of spinal cord compression
back pain
weakness or sensory loss with a root distribution or sensory level
bowel and bladder dysfunction
low threshold for patients with known cancer and new onset back pain
71
Investigation of spinal cord compression
urgent MRI
72
Management of Spinal Cord Compression
- Dexamethasone 16mg/ 24hrs PO
| - >3/12 to live - urgent radiotherapy, significantly longer - spinal reconstruction may be appropriate
73
SVCO
- not an emergency unless there is tracheal obstruction with airway compromise
74
Causes of SVCO
- maligancy (90% of cases, 3/4 from lung cancer)
- mediastinal enlargement (germ cell tumour)
- thymus maligancy
- mediastinal lymphadenopathy (lymphoma)
- thrombotic disorders - Behcets or nephrotic syndromes
- thrombus around IV central line
- hamartoma
75
Signs and symptoms of SVCO
```
dyspnoea
orthopnoea
plethora/ cyanosis
swollen face and arm
cough
headache
engorged veins
```
76
SVCO - Pemberton's test
Lifting the arms above the head >1 min
- facial plethora/ cyanosis
- non-pulsatile increase in JVP
- inspiratory stridor
77
SVCO
| investigation
urgent contrast enhanced CT
78
Management of SVCO
tissue diagnosis of cause
oral dexamethasone (8-16mg)
consider ballon venoplasty and SVC stenting
79
Malignancy associated hypercalcaemia
poor prognostic sign
80
Causes of Malignancy associated hypercalcaemia
lytic bone metastases
production of osteoclast activating factor
production of PTH- like hormones
81
Symptomsof Malignancy associated hypercalcaemia
lethargy, anorexia, naeusea, polydipsia, polyuria, constipation, dehydration, confusion, weakness
82
Acute management of malignancy associated hypercalaemia
- rehydration
| - IV bisphosphonates (or calcitonin if resistant)
83
Tumour lysis syndrome
rapid cell death on starting chemotherapy for rapidly proliferating leukaemia, lymphoma, myeloma and some germ cell tumours
- ->
- rise in serum urate, potassium and phosphate
--> precipitating renal failure
84
Preventing tumour lysis syndrome
- hydration and allopurinol started before chemotherapy
| - haemodialysis may be needed in renal failure
85
Neutropenic Sepsis
neutrophils <0.5 x109/L
- full barrier nursing
- avoid IM injections
- look for infection - mouth, axilla, perinuem, IVI site
- check FBC, platelets, INR, LFTs, LDH, CRP, blood/urine/sputum/stool cultures
86
Testitcular tumours
commonest malignancy in men aged 15-44
- seminoma
- non-seminomatous germ cell tumour
- mixed germ cell tumour
- lymphoma
87
Signs of testicular tumour
typically painless testis lump found after trauma/infection+/- haematospermia
- secondary hydrocele
- pain
- dyspnoea (lung mets)
- abdominal mass
- effects of secreted hormones
88
Risk factors for testicular tumours
undescended testis
infant hernia
infertility
89
Staging testicular tumours
1. No evidence of metastasis
2. Infradiaphragmatic node involvement (spread by para-aortic not inguinal nodes)
3. Supradiaphragmatic node involvement
4. Lung involvement (haematogenous)
90
histology of lung tumours
```
35% squamous cell
27% adenocarcinoma
20% small (oat) cell
10% large cell
rare- alveolar cell carcinoma
```
Clinically most important difference between Small Cell (SCLC) and non-small cell (NSCLC)
91
Symptoms of Lung Ca
```
Cough
Haemoptysis
Dyspnoea
Chest pain
Recurrent/ slow resolving pneumonia
lethargy
anorexia
weight loss
```
92
Signs of Lung Ca
```
Cachexia
anaemia
clubbing
HPOA (hypertrophic osteoarthopathy) - causes wrist pain
supraclavicular nodes
axillary nodes
```
Chest signs:
- none
- consolidation
- collapse
- pleural effusion
Mets
-bony tenderness
hepatomegaly
confusion/ fits /focal CNS signs
93
Complications of Lung Ca
local
```
recurrent laryngeal nerve palsy
phrenic nerve palsy
SVC obstruction
Horners syndrome (Pancoast's tumour)
rib erosion
pericarditis
AF
```
94
Complication of Lung Ca
Metastasis
```
brain
bone - bone pain, anaemia, Ca2+ increases
liver
adrenals - Addisons
Endocrine - ectopic hormone excretion
```
95
Complications of Lung CA
- non metastatic neurology
```
confusion
fits
cerebellar syndrome
proximal myopathy
neuropathy
polymyositis
```
96
Non-small cell lung cancers
Treatments
excision
curative radiotherapy
Chemoradiotherapy for more advanced disease
platinum based mono-clonal antibodies targetting epidermal growth factor receptors
97
Small cell lung cancers
nearly always disseminated at presentation
| - may respond to chemotherapy but invariably relapse
98
Palliative treatment in lung Ca
radiotherapy for bronchial obstruction, SVCO, haemoptysis, bone pain and cerebral mets
SVC setents
Endobronchial therapy - tracheal stenting, cryotherapy, laser, brachytherapy
pleural drainage/ pleurodesis
99
Liver tumours
most commonly secondaries from breast, bronchus or GI tract
100
Symptoms of liver tumours
```
fever
malaise
anorexia
weight loss
RUQ pain --> liver capsule stretch
jaundice (late)
rupture --> intraperitoneal haemorrhage
```
101
Signs of liver tumours
hepatomegaly
signs of chronic liver disease (Leuconychia (white nails), Clubbing, Palmar erythema, Hyperdynamic circulation, Duypetren’s contracture, Spider naevi, Xanthelasma, Gynaecomastia, Atrophic testes, Loss of body hair, Parotid enlargement, Hepatomegaly)
evidence of decompensation - jaundice, ascites
102
Liver metastasis
signify advanced disease
treatment and prognosis depend on primary
chemo may be effective (lymphomas)
excision of small, solitary tumors
103
hepatocellular carcinoma
primary hepatocyte neoplasia
104
Signs and symptoms of HCC
fatigue, reduced appetite, RUQ pain, weight loss, jaundice, ascites, haemobilia
105
Causes of HCC
```
HBV
HCV
AIH (autoimmune hepatitis)
cirrhosis
NAFLD
aflatoxin
Clonorchis sinesis
anabolic steroids
```
106
Treatment of HCC
resect solitary tumours
liver transplant
percutaneous ablation
tumour embolisation
107
Prevention of HCC
HBV vaccination
| No needle sharing
108
Choloangiocarcinoma
10% of liver primaries
109
Causes of Choloangiocarcinoma
```
flukes
biliary cysts
Caroli's disease
HBV
HVC
DM
biliary enteric surgery
```
110
Symtoms of Choloangiocarcinoma
```
Fever
Abdominal pain +/- ascites
Malaise
Increasing bilirubin
very high alkaline phosphate
```
111
Management of Choloangiocarcinoma
70% unsuited to surgery
76% recur
post op complications - liver failures, bile leak & GI bleed
112
MEN Syndrome
functioning hormone producing tumours in multiple organs
inherited AD
- MEN 1 & 2 --> Neurofibromatosis, Von Hippel-Lindau and Peutz-Jeghers
