Quiz 3 Flashcards
Most common cancer in women, 1 in 8 women will get this
29-30% of new cancers in women
2017: 255,180 new cases (over 252,000 females, 24-2,500 males)
African American women more likely to present with regional/distant disease than white women
Family member with bilateral disease or diagnosed premenopause increases risk
Left most common
Treated with tangents, IMRT, or hybrid of both; usually chemo first
Stop using birth control
Rare to other breast (mets 0.5-1%) but 1-2 times more likely to develop new tumor in contralateral breast
Ovaries, spleen, and stomach
TNM staging
Breast cancer
10 risk factors of breast cancer
Gender: female increases risk
Early menarche
Increased age of birth of first child
Late menopause over 50-55 years old
Use of exogenous hormones: birth control increases risk with prolonged use over 5 years
History of atypical hyperplasia
Family history
Radiation exposure: avoid wedge because of scatter
Increasing age and history of breast cancer
Obesity/high fatty diets: fat cells produce estrogen
Menarche
Menstration
Benign breast disease proliferates and turn malignant
Atypical hyperplasia
___-___% of breast cancer occurs from altered genes
BRCA 1 & 2 mutations account for ___-___% of breast cancer
1 first degree relative with disease increases risk, 2 _______ risk
5-10%
5-6%
Triples
Protein promotes growth of breast cancer, 1 in 5 cancers have this more aggressive mutation
Human epidermal growth factor receptor 2 (HER2)
6 signs and symptoms of breast cancer
Most common sign of early benign disease: non-painful, mobile mass; malignant: firm, nontender, irregular, non-movable and fixed mass
Skin dimpling
Nipple retraction
Erythema coincides with peau d’orange
Nipple discharge
Enlarged axillary/supraclavicular (scv) LN
Dimpling on the skin commonly mistaken as infection, 50% have lump or mass
Clinical/pathological diagnosis, can be lymphatic
Peau d’orange/inflammatory
Upper outer breast cancer = \_\_\_% Upper inner = \_\_\_% Central = \_\_\_% Lower outer = \_\_\_% Lower inner = \_\_\_%
Upper outer breast cancer = 50% Upper inner = 15% Central = 17% Lower outer = 11% Lower inner = 6%
7 diagnostic methods for breast cancer
Mammogram Biopsy: fine needle; guided biopsy (mammotome/stereotactic biopsy) for deep tumor Breast self examinations (BSE) Clinical self exam (CBE) Digital radiography MRI defines extent of disease PET for staging
When is it recommended for patients 40-44 years old, 45-54 years old, and 55 or older to get a mammogram?
40-44: patient’s choice
45-54: yearly
55: every 2 years
Excision of tumor with small margin of normal tissue around it; with LN dissection and RT, gets as good a result as mastectomy
Excisional, remove mass in breast
Lumpectomy
Median age of diagnosis of breast cancer
61
8 histologic types of breast cancers
Invasive/infiltrating ductal Infiltrating lobular Medullary: 5-7% Tubular Mucinous Comedo Paget's disease Inflammatory/peau d'orange
70-80% of breast cancers; in ducts
Squamous, angiosarcoma, etc.
Invasive/infiltrating ductal
10-15% of breast cancers, second most common in glands that secrete milk
Infiltrating lobular
Uncommon disease of nipple
Paget’s disease
Average doubling time of breast cancer
60-90 days, but can be as fast as 15 days or up to 600 days
LN involvement in ___-___% of breast cancers
40-60%
Lateral lesions usually go to _______ or _______ LNs
Medial lesions usually go to _______, _______, or _______ LNs
Lateral lesions usually go to axillary or supraclavicular LNs
Medial lesions usually go to internal mammary, mediastinal, or supraclavicular LNs
Biopsy first LNs that receive drainage from tumor; if disease present, complete biopsy
Sentinel node biopsy
5 year survival of stage 1, 2, 3, and 4 breast cancer
1: 99%
2: 84%
3: 65%
4: less than 26%
60% estrogen receptor (ER) status; slower-growing, better prognosis
Usually postmenopausal
Use tamoxifen
ER positive
Anti-estrogen therapy, 60% response rate for ER positive
Standard adjuvant therapy for ER positive patients
Tamoxifen
More aggressive, postmenopausal women
ER negative
More aggressive and dividing breast cancer
Elevated S phase
Malignant cellular proliferation has not extended through basement membrane into surrounding tissue
Carcinoma in situ for breast cancer
Examine DNA count/microscopic particles to see amount of DNA
Flow cytometry
Unusual number of chromosomes, more aggressive
Aneuploid
3 surgical options for breast cancer
Lumpectomy
Axillary node dissection
Modified radical mastectomy
Removes all breast tissue and axillary node dissection; remove breast, LNs, and sentinel node biopsy
Modified radical mastectomy
4 things post-mastectomy radiation is recommended for
Patients with tumors over 5 cm
Skin or chest involvement
Positive surgical margins
Over 4 positive LNs
Intact breast and removed breast typical dose
Intact: 4680 cGy and 1400 cGy boost = 6080 cGy
Removed: 5040 cGy and 1000 cGy = 6040 cGy (initial dose higher because we don’t have to worry about cosmesis)
Chemo given to patients before surgery, have locally advanced or inflammatory breast cancer
Get tumor shrinkage, node negative less than 1 cm
Neoadjuvant
Chemo given after primary treatment, recommended for all with positive LNs
Adjuvant
3 side effects of tamoxifen
Increase calcium bone uptake (decrease osteoporosis)
Decrease cholesterol and heart disease
Increase risk of uterine tumors
7 common chemo drugs for breast cancer
Doxorubicin Epirubicin Paclitaxal Docetaxal 5FU Cyclophosphamide Methotrexate
2 factors for breast cancer patients to receive bone marrow transplant (BMT), have shown prolonged survival but still investigational
No mets
4 or less positive LNs
8 common sites of breast cancer mets (most to least common)
LN 40-76% Bone 71% Lung 69% Liver 65% Pleura 51% Adrenals 49% Skin 30% Brain
5 labs for breast cancer
CAAD Elevated CA 15-3 Serum liver function studies Bone scans Chest x-ray
5 things patients and families can suffer from
Depression Impaired marital relationships Lowered self-esteem Developmental delays in children Behavioral problems with adolescents
6% of all cancers, 8% of all cancer deaths
Third most common cancer for both genders, second leading cause of cancer deaths
Rate 50 times higher for people over 60-79 years old, environmental
Higher incidence in African Americans
Equal in men and women, rectal higher in men
Lower in people who have a lot of vegetables in diet, high fiber; 5 servings of fruit and vegetables a day
Direct extension most common, LN and blood, and implantation and seeding
Neoadjuvant chemo before surgery, 5FU radiosensitizes and enhances leucovorin
Colorectal cancer (CRC)
Median age of diagnosis of CRC
60-65 years old
Most common histology of CRC
Adenocarcinoma (90%) arises from constantly-secreting
65%, 25%, less than 10%, and less than 5% of anal cancers
65%: squamous
25%: transitional
Less than 10%: adenocarcinoma
Less than 5%: miscellaneous
9 contributing factors to CRC
Alcohol, especially beer Tobacco History of colon cancer Sedentary employment: inactive GYN radiation Inflammatory bowel disease (ex: Crohn's, etc.) Polyposis Family history Irritation of anal canal
3 irritations of anal canal
Condyloma
Rectal intercourse
Fistulas, tears/fissures, abscesses, hemorrhoids, etc.
Anal warts
Condyloma
Grade identifies adenocarcinoma: ___% of disease is well-differentiated, ___% moderately differentiated, and ___% poorly differentiated
10% of disease is well-differentiated
70% moderately differentiated
20% poorly differentiated
5 year survival for stage I, II, IIIA-C, and IV CRC
I: 93%
II: 85%
IIIA-C: 83-44%
IV: 8%
6 signs and symptoms of right/ascending colon disease
Abdominal pain Melena Weakness due to anemia, common Obstruction uncommon Palpable abdominal mass Anorexia
Bleeding dark or mahogany red
Melena
3 signs and symptoms of transverse colon disease
Blood in stool
Change in bowel pattern
Potential bowel obstruction
12 signs and symptoms of left/descending colon disease
Colicky pain Bleeding red mixed with stool Obstruction common Weakness due to anemia, uncommon Nausea and vomiting Constipation alternating with diarrhea Decreased caliber of stool Tenesmus Fatigue Anorexia Failure to thrive Right upper quadrant (RUQ) pain (common hepatic duct leads to liver mets)
Caliber
Size
Feeling you have to go to the bathroom due to narrowing, ineffective and painful straining during a bowel movement (BM)
Tenesmus
9 signs and symptoms of rectal disease
Steady pain Bleeding bright red, coating stool Change in bowel movements Pencil stools Rectal urgency Fecal incontinence Spasmodic contractions Peineal and buttock pain Tenesmus
4 signs and symptoms of anal disease
Bleeding
Pain
Sensation of a mass
Severe anal itching
6 signs and symptoms of CRC
Change in bowel habitus Blood in stool Abdominal pain Anorexia Flatulence Indigestion
3 late signs and symptoms of CRC
Weight loss
Fatigue
Decline in general health
CRC percent in descending and sigmoid, ascending, and transverse colon
Descending and sigmoid: 52%
Ascending: 32%
Transverse: 16%
Glycoprotein elevates with CRC
Carcinoembryonic antigen (CEA)
3 common sites of mets for colon
Liver: venous drainage through colon
Lungs
Peritoneum
Colon cancer goes through bowel wall and sheds into bowel cavity
Peritoneal seeding
Common mets site of rectal disease
Lung: venous drainage through hemorrhoidal veins
3 common sites of mets for anus
Liver
Lungs
Inguinal nodes
4 complications due to CRC
Bowel perforation
Obstruction of surrounding genitourinary organs
Hemorrhage
Liver failure
Start screening for CRC at ___ years old, high risk at ___-___ years
50
40-45
6 ways CRC is diagnosed with no symptoms
Fecal occult blood test (FOBT) Fecal immunochemical test (FIT) Flex sigmoidoscopy Double contrast barium enema (BE) Colonoscopy Digital rectal examination (DRE)
Sample for blood in stool at home in clean container and spread on card
False positives with red meat, iron, tomatoes, etc.; false negatives with low fiber diet 72 hours before test
Fecal occult blood test (FOBT)
Sample for blood in stool at home with long-handled brush smeared on card, no dietary restrictions
Fecal immunochemical test (FIT)
How often should FOBT and FIT, flex sigmoidoscopy, BE, and virtual CT, colonoscopy, and DRE be done?
FOBT and FIT: annually
Flex sigmoidoscopy, BE, and virtual CT: every 5 years
Colonoscopy: every 10 years
DRE: not recommended as only test
6 diagnostic workups for CRC
H&P: palpate abdomen, breast, and rectum
CBC, liver function test, coagulation profile, CEA, etc.
Endoscopic examination: flex-sig, colonoscopy, biopsy
Transrectal ultrasound for staging
Double contrast BE (noninvasive)
Diagnostic studies: CT chest, abdomen, and pelvis; MRI for soft tissue of abdomen and pelvis
4 ways high fiber diet protects colon
Decreasing transient time in intestine
Diluting carcinogens in stool
Altering pH in colon
Decreasing ammonia concentrations in intestine
_______ is primary treatment of CRC, over _______ of patients can be cured with surgical resection
Surgery, half
Treatment of choice for anal disease because of sphincter
Chemo and RT
5 ways colostomy is managed
Clean the peristomal skin with soap and water, don’t submerge self down to stoma
Apply disposable pouch over the stoma
Empty the pouch when it’s 1/3 full of stool and/or flatus
Change the pouch every 4-7 days if there’s no leakage
Adequate fluids, no nuts or seeds, avoid beans, cabbage, and brussel sprouts (flatulence), avoid heavy lifting and pulling, etc.
3 pre-op RT indications for CRC
Reduce bulky rectal cancers
Improve rate of resectability
Eradicate microscopic disease
Advantage of pre-op RT for CRC
Better blood flow
4 post-op RT indications for CRC
Prevent local recurrence in stage B or C rectal cancers
Remove remaining disease if positive surgical margins
Disease invades other organs
Palliatively to decrease painful mets or control bleeding
About ___% of CRC patients require surgical colostomy, every patient after this surgery require colostomy to rest area
15%
8 CRC related complications from RT
Skin irritation: erythema, dry or moist desquamation, and hyperpigmentation Proctitis Nausea/vomiting Diarrhea Bone changes: obstruction, fibrosis, adhesions, and fistulas Sexual dysfunction Myelosuppression Fatigue
Inflammation of rectal lining
Proctitis
Inflammation of bladder
Cystitis
About ___% of CRC patients die of mets due to left behind disease, chemo important
50%
2 CRC chemo regimens
FOLFOX
FOLFIRI
FOLFOX
5FU, leucovorin, and oxaliplatin
FOLFIRI
5FU, leucovorin, and irinotecan
Secrete/produce hormones directly into the bloodstream for transport throughout the body
Endocrine glands
Excessive secretion of hormones directly into the bloodstream for transport throughout the body
2017: 59250 new cases, 3010 deaths
Endocrine neoplasms
6 common endocrine tumors
Pituitary/master gland Thyroid Parathyroid Adrenal glands: benign or malignant Pancreatic/silent killer Carcinoid: slow-growing, surgery is treatment of choice
Four posterior to thyroid, controls calcium
Parathyroid
Secretes large amounts of hormones but not endocrine gland, 90% in intestines
Slower growing but have mets potential
Arises from cells
Most common site: appendix
Carcinoid tumors
7 hormones secreted by pituitary gland
Growth Prolactin Thyroid stimulating Follicle stimulating Luteinizing Melanocyte stimulating Adrenocorticotropic
Controls body growth
Growth hormone
Initiates milk production
Prolactin
Controls thyroid gland
Thyroid stimulating hormone
Stimulates egg and sperm production
Follicle stimulating hormone
Stimulates other sexual and reproductive activity
Luteinizing hormone
Hormone that relates to skin pigmentation
Melanocyte stimulating hormone
Influences the action of the adrenal cortex
Adrenocorticotropic hormone
Cell that produces growth hormone and prolactin
Acidophils
Cell that produces thyroid stimulating, follicle stimulating, luteinizing, melanocyte stimulating and adrenocorticotropic hormones
Basophils
4 pituitary tumors
Growth hormone
Prolactinomas
Corticotropin (ACTH)-producing tumors
Gonadotropin-producing tumors
2 syndromes with growth hormone tumors
Gigantism is kids
Acromegaly in adults
Enlarged extremities and organs
Acromegaly
3 syndromes with prolactinomas
Galactorrhea
Amenorrhea
Impotence
Abnormal milk discharge, men and infants can develop milk
Galactorrhea
Cessation of menstration
Amenorrhea
Inability to get erection
Impotence
Syndrome with corticotropin (ACTH)-producing tumors
Cushings disease
10 clinical features of cushings disease
Central obesity Facial plethora Moon face Buffalo hump Purple striae Easy bruising Muscle weakness Emotional lability Hypertension Diabetes mellitus
Oversecretion of cortisol
Corticotropin (ACTH)-producing tumors
Stress hormone
Cortisol
Excessive abdominal fat around center of body/stomach area
Central obesity
Excess of blood in face
Facial plethora
Face develops rounded appearance due to fat deposits on side of face
Moon face
Excess deposit of fat localized on the back of the neck
Buffalo hump
“Stretch marks”
Purple striae
Rapidly changing mood
Emotional lability
High blood pressure (BP)
Hypertension
Body’s ability to produce or respond to insulin reduced
Diabetes mellitus
Syndrome with gonadotropin-producing tumors
Reduction of absence of hormone secretion or other physiological activity of the gonads (testes or ovaries), don’t have enough sex hormone to testes or ovaries
Hypogonadism
Usually benign histologically and rarely metastasize
Can invade local structures such as optic nerves, cavernous sinus, CNS, cervical LNs, liver, and bone
Severe headaches, visual defects, vascular thrombosis, and hydrocephalus
Surgery treatment of choice, incision through nose/sphenoid bone; large invasive tumors: surgery and radiation (SRS)
Prolactinomas: medications
Pituitary tumor
7 primary tumors that metastasize to pituitary
Breast Lung Kidney Prostate Liver Pancreas Nasopharynx
2 types of thyroid cancers
Follicular cells
Parafollicular cells
Synthesize thyroid hormones
Follicular cells
3 histologies of follicular cell tumors
Papillary 70%
Follicular 15%
Anaplastic 0.5-1.5%
Produce calcitonin for calcium and bone metabolism
Medullary carcinomas develop from these cells, 5-8%
Parafollicular cells
Painless thyroid mass
Diagnosis: fine-needle aspiration biopsy
Good prognosis
2017: 56870 new cases, 2010 deaths
Thyroid cancers
4 symptoms that suggest thyroid tumor is malignant
Size greater than 3 cm
Rock-hard consistency
Lymphadenopathy
Hoarseness due to vocal cord paralysis
Papillary and follicular cure rate and 10 year survival and medullary 10 year survival
Papillary: cure rate over 90%, 95% 10 year survival
Follicular: cure rate over 90%, 90% 10 year survival
Medullary: 75% 10 year survival
More invasive follicular disease, loss of differentiation
Patients die within 6 months-1 year of diagnosis
Anaplastic
Treatment for papillary and follicular thyroid disease
Near total thyroidectomy and daily suppression therapy; I131 treatment, stop L-thyroxine (LT4) 4-6 weeks before
LT4
Thyroid hormone replacement
L-thyroxine (LT4)
Treatment for medullary thyroid carcinoma
Total thyroidectomy and suppression therapy
Treatment for anaplastic thyroid carcinoma
Total thyroidectomy, suppression therapy, and sometimes EBRT and doxorubicin chemo
Neck mass with lymphadenopathy, hypercalcemia
Elevated levels of parathyroid hormone (PTH), need tissue sample to confirm
Treat with aggressive neck dissection, chemo and RT rarely help
Parathyroid carcinoma
5 and 10 year survival of parathyroid carcinoma
5: 88%
10: 49%
2 parts of adrenal gland
Adrenal cortex
Adrenal medulla
Outer part of adrenal gland that produces steroid hormones
Tumors produce excessive cortisol, testosterone, and aldosterone; large amounts of cortisol leads to cushings
Adrenal cortex
Inner part of adrenal gland that makes catecholamines
Adrenal medulla
Controls potassium and sodium in blood
Aldosterone
Manifestations of adrenal tumors if producing aldosterone (2), androgen (2), pheochromocytomas (4), and nonsecreting tumors (2)
Aldosterone: hypertension and hypokalemia
Androgen: virilization in women, asymptomatic in men
Pheochromocytomas: hypertension, sweating, palpitations, and irregular heartbeat
Nonsecreting: pain or weight loss
Deficiency of potassium in blood
Hypokalemia
Masculine secondary sex; changes: deep voice, balding, facial hair, etc.
Virilization
2 treatments of adrenal tumors
Surgery for nearly all hormone secreted tumors and nonsecreting tumors over 6 cm; good prognosis for benign tumors, better in younger patients and smaller localized disease: complete resection and nonfunctioning/nonsecreting
Chemo with mitotane (adrenal hormone) in malignant tumors, RT not effective
5 year survival for stage 1 & 2, 3, and 4 adrenal tumors
1 & 2: 65%
3: 40%
4: 10%
Endocrine system cells
Islet
Digestive enzymes
Exocrine
3 hormones produced by pancreas
Insulin
Glucagon
Somatostatin
Causes body to take up glucose/sugar
Insulin
Liver converts glycogen to glucose
Glucagon
Controls release of insulin/glucagon
Somatostatin
3 common types of pancreatic islet tumors
Gastrinoma
Insulinoma
Glucagonoma
Islet tumor that produces gastrin
Gastrinoma
Gastric acid usually created in stomach
Gastrin
Produce excessive amounts of insulin
Insulinoma
Produce excessive amounts of glucagon
Glucagonoma
2 symptoms of pancreatic tumors caused by excessive amounts of gastrin
Multiple or recurrent peptic ulcers
Zollinger-Ellison syndrome
Chronic watery diarrhea
Zollinger-Ellison syndrome
4 symptoms of pancreatic tumors caused by excessive amounts of insulin
Hypoglycemia
Confusion
Convulsions
Coma
___% of gastrinomas are malignant and ___% benign; true for all other pancreatic tumors except for insulinomas where ___% are malignant and ___% are benign
80%, 20%
20%, 80%
Can palpate gallbladder due to obstruction of pancreas
Courvoisier’s sign
4 treatments of islet cell tumors
Surgical resection treatment of choice: whipple procedure
Small meals help with hypoglycemia
Administration of some medications, ex: for ulcers
Chemo: doxorubicin or 5FU and other agents
Remove head of pancreas, distal stomach, duodenum, common bile duct, and gallbladder, and vagotomy
Whipple procedure
Remove vagus nerve for pain
Vagotomy
Symptoms of cutaneous flushing, diarrhea, and wheezing
May develop fibrosis of right heart valves, endocardium, pleura, peritoneum, and retroperitoneum
Advanced carcinoid tumors, mets
Carcinoid syndrome
