Pathophysiology: Oncology Flashcards
Where do Oncogenes come from?
Proto-Oncogenes (important for normal cellular function) mutate into Oncogenes. Mutations can be genetic / inherited or due to toxins.
What do Oncogenes do?
Oncogenes cause abnormal cell growth - growth that can become out of control & doesn’t adhere to normal signals to stop.
Tumor Suppressor Gene
Gene that makes tumor suppressor protein. Mutations in these can lead to cancer. “Anti-Oncogene”
Hyperplasia
Increased number of cells
Dysplasia
Cells look abnormal but are not yet “cancer”; change from mature ell to cell with abnormalities in differentiation and maturation.
Metaplasia
Change from one type of mature cell to another type of mature cell that is found elsewhere.
Carcinoma In Situ
Group of abnormal cells that have not spread beyond their area of origin; Cancer Stage 0
Invasive Carcinoma
Cancer has spread beyond layer of tissue in which it was developed
Metastatic Carcinoma
Cancer has spread beyond its primary site
Hypertrophy
Enlargement due to increase in cell size
Neoplasia
Abnormal, uncontrolled growth of tissue; can be cancerous (malignant) or non-cancerous (benign)
Anaplasia
Cells that are not differentiated
Adjuvant
Treatment given in addition to the primary treatment, i.e. chemo in addition to surgery or hormone therapy in addition to surgery.
Neoadjuvant
Additional treatment given before the primary treatment. For example, radiation to treat a tumor before surgery.
Remission
Signs and symptoms of someone’s cancer are reduced or gone
Paraneoplastic Syndrome
Caused by the “remote” effects of cancer; caused by the hormonal and metabolic changes that cancer causes.
Where does cervical cancer spread?
Peritoneum
Where does breast cancer spread?
1 Bones, #2 Lungs
Where does colon cancer spread?
Liver
Where does lung cancer spread?
1 Brain, #2 Bones
What type of cancer rapidly goes to the brain?
Small cell lung cancer (also renal cell carcinoma & melanoma)
Where does prostate cancer go?
Bone
Where does testicular cancer go?
Lung
How do cancers spread?
Lymph, blood, local invasion, angiogenesis
Carcinoma
Cancer beginning in skin or tissue that cover organs
Sarcoma
Cancer of bone, cartilage, fat, muscle, blood vessels, connective tissue
Leukemia
Cancer in blood-forming tissue (marrow)
Lymphoma / Myeloma
Cancers of the immune system
Angiogenesis
Tumor lay down new blood vessels
“Two Hit Theory” of cancer
You have 2 genes… if you knock one out, you have a backup… when you knock both out - cancer.
What # of leading cause of death is cancer?
2nd
What factors are 30% of cancer deaths attributable to? (5)
High BMI, low fruit/veggie intake, low physical activity, tobacco use, alcohol
What are the 3 most common cancers in men?
- Prostate, 2. Lung, 3. Colorectal
Which 3 cancers kill the most men?
- Lung, 2. Prostate, 3. Colorectal
What are the 3 most common cancers in women?
- Breast, 2. Lung, 3. Colorectal
What 3 cancers kill the most women?
- Lung, 2. Breast, 3. Colorectal
What does TNM stand for?
Tumor, Nodes, Metastases
T in TNM.
Tumor (size, extent of invasion of primary tumor); T0=no tumor, TIS = in situ, T1-T4
N in TNM
Nodes (number and location of histologically involved regional lymph nodes); N0=no nodes, N1-N3
M in TNM
Metastases (Presence or absence of distant metastases); M0=no metastases, M1=yes distant metastases.
If a cancer has spread anywhere, what are you going to do to treat it?
You have to use systemic chemotherapy.
What are systemic cancer therapies?
Chemotherapy, hormonal therapy, targeted therapy
What does TX, NX, or MX mean
That component cannot be assessed
Example of Stage I Cancer (1)
T1-T2 tumors, N0
Examples of Stage II Cancer (2)
T-T2, N1 or T3, N0
Examples of Stage III Cancer (1)
T1-T3 with N1-N3
Example of Stage IV
Anything M1
Primary Prevention
REMOVING RISK FACTORS; risk factor modification.
What are examples of primary prevention?
Avoiding UV light, taking folic acid, weight management, avoiding tobacco.
What is Chemoprophylaxis?
Use of substances to reduce the risk of getting cancer or having it recur; used in groups who are at high risk for certain cancers.
What are examples of Chemoprophylaxis?
Aunt Susan taking Tomoxifen to keep Breast Ca from recurring; Someone who is BRCA1 positive taking Tomoxifen.
What form of Prevention is Chemoprophylaxis?
Primary
Secondary Prevention
Early detection and treatment; Identifies and treats individuals who are asymptomatic but have developed risk factors. “Pre-Clinical disease.”
Examples of Secondary Prevention
Pap smear in someone who is sexually active, cholesterol screening in someone with HTN.
Principles of Screening
Disease should have high mortality, early tx available, disease=common, tx inexpensive/non-invasive, high sens/spec
Oncogenic Viruses
HPV, HBV/HCV, HIV, EBV, Herpes
Ionizing Radiation
Radiology procedures (CT scans); high doses increase chemical activity in cells and can lead to cancer. EX someone gets Ca treated w/radiation - yrs later, get cancer somewhere else.
UV Light
Increases risk of cancer - sun, tanning booths
Cancer stages potentially treated by surgery
Stages I and II
Systemic Cancer Therapy
Use of cytotoxic drugs, hormones, antihormones, and biologic agents
Radiation works by:
Damaging DNA
What is the critical target of Radiation Therapy?
DNA
How can Radiation Therapy cause a secondary malignancy?
Radiation breaks DNA; DNA can repair itself BUT there can be mis-repairs & if you get another mis-repair 20 yrs later, then you can get a secondary cancer.
What type of death does Radiation cause? / When does death occur?
Clonogenic or Reproductive death; Occurs only when cell attempts to go through mitosis.
TD50/5 / goal?
Radiation dose that will produce complications for 50% of pop in 5 years / TD5/5
Acute Side Effects to Radiation
Occur during course of radiation: fatigue, skin (dry, red, itchy), alopecia, mucosa, anorexia
Sub Acute Side Effects of Radiation
Occur within next 6 months after; pneumonitis, veno-occlusive disease, SBO
Chronic Side Effects of Radiation
Persist for longer than 6 months, i.e. Bone growth loss, fibrosis of skin
Do you use radiation longer or shorter in the case of palliative care?
Shorter. You would want to decrease tumor size but cause as few other side effects as possible. You might treat longer & at higher dose if a CURE is possible.
Brachytherapy
Radiation given using sealed radioactive sources paced into cavities or tissues
Stereotactic Radiosurgery
Surgery to deliver very high dose to limited area; used on brain
Cushing Syndrome
Too much corticosteroid in the body b/c of pituitary secreting ACTH
What most frequently causes Cushing Syndrome?
Small cell lung cancer secreting ACTH.
Symptoms of Carcinoid Syndrome
Flushing, diarrhea, wheezing, hypotension
SIADH
Syndrome of Inappropriate Antidiuretic Hormone
What type of cancers (2) cause SIADH?
Small and non-small cell lung cancer
How does SIADH lead to hyponatremia?
ADH should be secreted when the body is dehydrated. Lung cancer can secrete it when unnecessary so the body hangs on to excess water. Lots of water: little solute = hyponatremia.
What is the most common paraneoplastic syndrome?
Hypercalcemia
Ectopic hormones / what cancer post frequently produces them?
Hormones produced by the cancer itself / small cell lung cancer
What syndrome is often observed before small cell lung cancer?
LEMS
What is LEMS
in Lambert Eaton Myasthenic Syndrome, antibodies damange calcium channel gates. Limited calcium enters nerve terminals, decreasing the amount of acetylcholine that is released. –> Muscle weakness
Trousseau’s Sign
Hypercoagulability (i.e DVT) being a sign of cancer
Cancers that cause too much clotting?
Lung and liver
Why might it hard to know if someone is neutropenic from chemo?
They might not have enough WBCs to present in the typical fashion with elevated WBCs indicating infection
Acute Tumor Lysis Syndrome causes (5)
Hyperkalemia, Hyperuricemia, Hyperphosphatemia, Hypocalcemia, Azotemia
What is happens in Tumor Lysis Syndrome?
As the tumor breaks up, potassium, uric acid and phosphate are dumped into the system circulation and can wreak havoc on the kidneys
Who is most at risk for Tumor Lysis Syndrome? (2)
1) People with leukemia, lymphoma (b/c tumors rapidly divide), or huge tumors, 2) After round 1 of chemo
What is spinal cord compression?
Metastases to vertebral bodies are compressing the spinal cord.
What most frequently causes spinal cord compression?
Lymphoma and Multiple Myeloma
What does spinal cord compression mimic / what differentiates the 2?
Degenerative Disc Disease / symptoms do not get worse or better depending upon patient’s position; specifically, pain gets worse recumbent & at night
How do you tx Spinal Cord Compression?
Treat immediately & before diagnosis. Give large dose of steroid and then get MRI.
“Bones, stones, moans, groans, psychiatric overtones” relates to?
Hypercalcemia
Symptoms of hypercalcemia?
Fatigue, anorexia, nausea, constipation, polyuria, polydypsia, weakness, lethargy, apathy, seizure, coma
What causes hypercalcemia? (3)
Increased mobilization from bone, increased renal tubular reabsorption, osteolysis
How do you treat hypercalcemia?
Tx the cancer, give Bisphosphonates to inhibit osteoclasts
Which types of cancer cause Superior Vena Cava Syndrome?
Lung cancers
What causes SVC Syndrome?
Tumor compressing spinal cord –> regurgitation of blood –> flushed face
What are symptoms of SVC Syndrome?
Flushed face, dyspnea, chest pain, syncope, cough, headache, venous distension, Horner’s Syndrome
What is Horner’s Syndrome? / What is it a sign of?
Drooping of the eyelid combined with constriction of that pupil / SVC Syndrome.
When is SVC considered a true emergency?
When tumor is blocking trachea.
Tumor Lysis Syndrome is also called:
Hyperuricemia
Treatments for each component of Tumor Lysis Syndrome? (4)
1) Hyperuricemia: meds to break up uric acid, 2) Urine alkalinization by giving bicarb, 3) Forced diuresis - give IV fluids and diuretics at the same time, 3)/4) Hyperkalemia/Hyperphosphatemia - give hypertonic glucose
Symptoms of a PE / Tx
Hemoptysis, syncope, dyspnea, chest pain / Antithrombolytics
Why is a low grade fever significant in a cancer patient?
Might be the only sign that they are going septic.
What is the most deadly cancer in men and women? / 5-year survival rate?
Lung cancer / 15%
What is the second most deadly cancer overall?
Colorectal cancer.
Second most deadly cancer in men?
Prostate Cancer
Second most deadly cancer in women?
Breast Cancer
Length-time bias in studies.
Studies are more likely to pick up slow-growing tumors then fast growing ones someone would have noticed on their own or died from
A-D, I Scale of US Preventive Services Task Force
A= highly recommend, b=partially recommend, c=some benefits, some drawbacks & they equal out, d=against, I=no recommendation either way
American Cancer Society Recommendations on Breast Cancer Screenings. (4)
1) Self exams starting in 20’s, 2) Clinical exams Q3yrs 20-40 then Q1yr, 3) Mammorgraphy Q1yr 40 and over, 4) high risk - get MRI
USPSTF Recommendations on Breast Cancer (3)
Self exams: I, Mammography 50-74 Q2yrs: B, Mammography before 50 based on high risk: C.
ACS recommendations on cervical cancer
1) Annual pap 3 years after sex or by age 21, 2) after age 30 & 3 nl paps, then Q2-3 yrs, 3) d/c after 70 if no abnormal results, 4) d/c after hysterectomy unless done as Ca tx
USPSTF recommendations on cervical cancer (2)
1) Screen sexually active women with a cervix - A recommendation, 2) Don’t screen after 65 if hx of normal paps - D
ACS and USPSTF recommendations on colorectal cancer
Fecal occult blood test / signoidoscopy or colonoscopy starting at 50 and going to 75 (“A”); USPSTF gives D to using aspirin/NSAIDs for prevention
ACS on lung cancer
no CXR, no sputum Cx
New USPSTF guideline on lung Ca
low dose CT for smokers and former smokers 55-80 with 30 pack yr Hx or who smoked for over 15 yrs.
ACS on prostate cancer (2)
1) Discuss DRE / PSA at age 50, 2) high risk men should consider PSA testing at 45 if relative has died of it
USPSTF on prostate cancer
D! No screening b/c of potential harm
ACS vs USPSTF on testicular cancer
ACS - yearly clinical exam, USPSTF - no screening
KPS Score
Karnofsky Performance Scale; score ranges 0-100 based on pt’s ability to perform ADLs; often need minimal score for enrollment in clinical trials
KPS score of 80/50/40/10
Can do all ADLs but with effort / All ADLs but with a ton of assistance / Disabled / Near death
What is meant by the “epidemic of survival?”
4% of the population, over 12 million people = cancer survivors
What percent of children survive cancer?
80%
Secondary condition of Hodgkin’s Lymphoma.
35% of girls with Hodgkin’s Lymphoma developed breast cancer by age 35.
Secondary malignancy of testicular cancer
w/radiation or chemo, much more likely to get cancer in other testicle later on
Secondary tumors of radiation
thyroid tumor, breast ca, GI tumors, melanoma
Most cancer survivors would rate their health as
good or excellent
Emphasis in ca tx used to be cure rate, now it’s
Quality of life
Legal / social issues assc w/survivorship
Ability to get insurance / loans / find employment
Primary care ramifications for Ca survivors
Primary care services UNDER-recommended (i.e.vision/hearing screening, flu vaccine, bone density/cholesterol screening).. even if someone had cancer in the past, their primary care goes to shit
