Oncology Flashcards
What is multiple myeloma?
A neoplasm of the bone marrow plasma cells
Peak incidence for multiple myeloma?
60-70 years old
What are the clinical features of multiple myeloma?
Bone disease - osteoporosis, osteolytic lesions (rain-drop skull x-ray with black drops in the skull) Lethargy Hypercalcaemia Renal failure Amyloidosis Infection
Investigations for multiple myeloma?
Monoclonal proteins (IgG or IgA) in the serum and urine (Bence Jones proteins)
Increased plasma cells in the bone marrow
Skeletal survey for bone lesions (however we now use full body MRI)
X-ray - rain drop skull
Why is hypercalcaemia a feature in myeloma?
Due to increased osteoclastic bone resorption caused by local cytokines (Il-1, TNF) released by myeloma cells
Impaired renal function
Unexplained petechiae and hepatomegaly indicate?
Could indicate leukaemia
Refer for immediate assessment
What is Burkitt’s lymphoma associated with?
Epstein-Barr virus
What condition are thymoma’s commonly seen in?
Myasthenia gravis
What genes can predispose women to breast cancer?
BRCA1
BRCA2
These account for 10% of breast cancers
Risk factors for breast cancer
Prolonged oestrogen exposure (early menarche, late menopause, nulliparity)
HRT
Histology in breast cancer
Invasive ductal carcinoma (70%)
Invasive lobular carcinoma (30%)
Clinical presentation of breast cancer
Mass that is present throughout menstrual cycle
Nipple discharge (10%)
Pain (7%)
40% have axillary node disease
Common metastases sites breast cancer
Bone (70%)
Lung (60%)
Liver (55%)
Pleura (40%)
What is Paget’s disease of the nipple?
A rare form of breast cancer usually affecting the ducts of the nipple
Eczematous skin changes to the nipple/areola
Staging for breast cancer
TMN
Treatment of breast cancer
Spans from observation to prophylactic bilateral mastectomy
Axillary nodal excision as well
Adjuvant radiotherapy
Adjuvant hormonal therapy (if ER+ receptor expressed) - tamoxifen
Adjuvant chemotherapy (trastuzumab for HER2)
Prevention of breast cancer in high risk patients
Tamoxifen
Breast cancer screening
Mammographic screening (age 50-70, 2-3 yearly)
Types of lung cancer
Small cell lung cancer (20%)
Non-small cell lung cancer (80%)
Types of non-small cell lung cancer
Squamous (35%)
Adenocarcinoma (30%)
Large cell (10%)
Features of small cell lung cancer
Usually central
Arise from APUD cells (amine, precurosr uptake and decarboxylase cells)
Association with ectopic ADH and ACTH
Labert-Eaton syndrome - antibodies to calcium channels causing myasthenia gravis like syndrome
What features are caused by ectopic hormone production in small cell cancer?
ADH > hyponatraemia
ACTH > Cushing’s syndrome
ACTH > bilateral adrenal hyperplasia and thus high cortisol/hypokalaemic alkalosis
How do we manage small cell lung cancer
Chemotherapy generally (due to likelihood of metastatic disease) Etoposide or cisplatin
Median survival is 14 months
Squamous cell lung cancer
Normally central
Associated with PTH related protein secretion - causing hypercalcaemia
Finger clubbing
HPOA
Adenocarcinoma lung cancer
Typically peripheral - most common type in non-smokers
Gynaecomastia
HPOA
Large cell lung cancer
Peripheral
Anaplastic (poorly differentiated)
May secrete beta hCG
Non-small cell lung cancers
Develop from the epithelial cells anywhere from the central bronchi to the terminal alveoli
Non-small cell cancer treatment
Stages IIIa and less - complete surgical excision
Stages IIIb and IV - carboplatin or cisplatin
Investigating lung cancers
X-ray
CT - Ix of choice
Bronchoscopy - can allow biopsy
PET scanning - non-small cell cancers to determine viability of surgery
Surgery contraindications in lung cancer
Stage IIIb or IV (metastases) FEV1 <1.5L Malignant pleural effusion Tumour near hilum Vocal cord paralysis SVC obstruction
Superior vena cava obstruction
Oncological emergency commonly associated with lung cancer
SVC obstruction symptoms
Dyspnoea Swelling of face, neck, arms Headache Visual disturbance Pulseless jugular venous distension
Causes of SVC obstruction
Non-small cell cancers, lymphoma, breast cancer
Aortic aneurysm
Goitre
Management of SVC obstruction
Dexamethasone
Balloon venoplasty
Stenting
Lambert-Eaton syndrome
Associated with small cell lung cancer - an antibody against calcium channels
Repeated muscle contractions lead to increased muscle strength
Hyporeflexia
Autonomic symptoms: dry mouth, impotence, difficulty micturating
Ophthalmoplegia and ptosis not commonly seen
Mesothelioma
Aggressive tumour of the surface serosal cells of the pleura, peritoneal and pericardial cavities
Risk factors associated with mesothelioma
Asbestos (20-50 years before)
Smoking
Symptoms associated with mesothelioma
Cough
Dyspnoea
Non-pleuritic chest wall pain
Signs in mesothelioma
Usually there is dullness on one lung base + a pleural effusion seen on x-ray
Mesothelioma x-ray findings
Thickened, nodular, irregular mass
Pleural plaques
Tumour often encompasses the whole lung, but rarely seen bilaterally
Moderate-large pleural effusion unilaterally also
Colorectal cancer risk factors
Strong relation to age (>60) Diet: high calorie intake, red meat and alcohol intake Smoking Obesity Inflammatory bowel disease
What is HNPCC/lynch syndrome?
Hereditary non-polyposis colorectal cancer
Genetic syndrome of autosomal dominant pattern
Patients generally develop colorectal cancer in their 40s
What is FAP?
Familial adenomatous polyposis
An inherited autosomal dominant pattern genetic condition.
Patients develop benign polyps which can progress into cancerous lesions
Treatment for FAP
Prophylactic colectomy
Pathophysiology of colorectal cancer
70% are adenocarcinomas arising in the mucosa from benign adenomatous polyps
How do we stage colorectal cancer?
Duke’s staging:
A: tumour confined to mucosa
B: tumour has breached serosa
C: regional lymph nodes involved
D: Distant metastases present
Treatment of colorectal cancer
Surgical - usually hemicolectomy
Radiotherapy (sometimes before the surgery to reduce its size)
5-fluorouracil/irinotecan regimens
Prognosis of colorectal cancer
50% relapse within 2 years
Colorectal cancer locations
Rectal - 40%
Sigmoid - 30%
Transverse/ascending - 15% ea.
Colorectal cancer screening
60-74 year olds offer faecal immunochemical tests (FIT) every 2 years
If +ve result, colonoscopy
Two categories of lymphoma
Hodgkin’s
Non-hodgkin’s
Hodgkin’s lymphoma
Malignant proliferation of lymphocytes which accumulate in lymph nodes/other organs
M more affected than F
Peak incidence in 30s and 70s
Can be following EBV infection
Clinical features of Hodgkin’s lymphoma
Asymptomatic lymphadenopathy (usually above diaghram) Fever Night sweats Weight loss Alcohol pain Chronic pruritus
Pathophysiology of Hodgkin’s lymphoma
Nodular sclerosing (60%) Mixed cellularity (30%) Lymphocyte predominant (5%) Lymphocyte depleted (5%)
In what condition do you see Reed-Sternberg cells
Hodgkin’s lymphoma
These are giant cells found with light microscopy, usually derived from B lymphocytes
What might you find raised in Hodgkin’s lymphoma?
Eosinophils Lactate dehydrogenase (LDH)
Which form of Hodgkin’s lymphoma has the worst prognosis?
Lymphocyte depleted
How do we diagnose Hodgkin’s lymphoma
Biopsy of an enlarged lymph node (usually seeing Reed-Sternberg cells)
Treatment of Hodgkin’s lymphoma
Radiotherapy if stage I-IIa
Stages IIb-IV - chemotherapy
Stem cell transplantation sometimes
Chemo drugs for Hodgkin’s lymphoma
ABVD Adriamycin Bleomycin Vinblastine Dacarbazine
Non-Hodgkin’s lymphoma
Malignant proliferation of lymphocytes
Does NOT contain Reed-Sternberg cells
Risk factors for non-Hodgkin’s lymphoma
Elderly
Caucasian
History of viral infection (EBV)
FHx
Clinical features of non-Hodgkin’s lymphoma
Painless lymphadenopathy
Fever, weight loss, night sweats, lethargy
How can we differentiate between Hodgkin’s and non-Hodgkin’s lymphoma clinically?
Alcohol induced lymph node pain in Hodgkin’s lymphoma
B symptoms occur earlier in Hodgkin’s than in non-Hodgkin’s
Extra-nodal disease more common in non-Hodgkin’s
What are ‘B’ symptoms?
Constitutional symptoms, e.g.
Weight loss, night sweats, fevers
Investigations in non-Hodgkin’s lymphoma?
Excisional node biopsy
Staging system for non-Hodgkin’s lymphoma
Ann Arbor system
Ann Arbor system stages
Stage I - One node affected
Stage II - More than one node but same side of diaghram
Stage III - one node affected on either side of diaghram
Stage IV - extra-nodal involvement (e.g. spleen, bone marrow, CNS)
Management of non-Hodgkin’s lymphoma?
Radiotherapy for stage I
Stages II-IV:
Oral chlorambucil, IV cyclophosphamide, vincristine + prednisolone
Neutropenic sepsis
Commonly 7-14 days following chemotherapy
Defined as neutrophils <0.5 with temp >38 or other clinical symptoms of sepsis
How can we prevent neutropenic sepsis
We give fluoroquinolones if we are anticipating patient to get a <0.5 neutrophil count
Management of neutropenic sepsis
Give abx immediately (tazocin, piperacillin)
Vancomycin sometimes
What is Burkitt’s lymphoma?
A high grade B cell neoplasm
Two forms of Burkitt’s lymphoma?
Endemic (African) form: maxilla or mandible involvement
Sporadic: abdominal tumours (more common in patients with HIV)
Microscopy appearance in Burkitt’s lymphoma
Starry sky appearance - lymphocyte sheets interspersed with macrophages and dead apoptic tumour cells
Management of Burkitt’s lymphoma
Chemotherapy
Tumour lysis syndrome
A condition related to treatment of lymphomas and leukaemias, usually following chemotherapy
Breakdown of tumour cells releases chemical into the body
Electrolyte abnormalities with tumour lysis syndrome
Potassium high
Phosphate high
Calcium high
Uric acid high
How do we treat tumour lysis syndrome?
IV allopurinol given before chemotherapy
Fluids
Dialysis if kidney failure is bad and other therapy has not worked
Malignant spinal cord compression symptoms
Usually due to vertebral metastases, symptoms include:
Vertebral pain - esp. lying flat/coughing
Sensory changes two dermatomes below level
Motor weakness
Sphincter disturbance
Treatment of malignant spinal cord compression
High dose dexamethasone
Surgical decompression/radiotherapy
