Quiz 4 Flashcards
Second most common cancer in men and women, leading cause of cancer death in men and women second to heart disease
17% alive in 5 years
Lung cancer
8 risk factors of lung cancer
Cigarette smoking most common Radon second most common Air pollution Asbestos Previous TB Genetic predisposition Occupational respiratory carcinogens Nutritional factors: diets with fruits and vegetables protect against lung cancer, vitamin A helps prevent it
If people stopped smoking, cancer death would decrease by what percent?
25%
___% of all cancer deaths and ___% of all lung cancer deaths are associated with smoking
35%, 85%
9 symptoms of lung cancer
Cough/change in cough most common Hemoptysis Dyspnea Wheezing due to blocked airway Weight loss Fatigue Chest or shoulder pain associated with pancoast tumor at apex of lung Recurring pneumonia or bronchitis; if pneumonia not cleared up in 2 months, suspect lung cancer Stridor
Blood in spetum
Hemoptysis
Difficulty breathing
Dyspnea
High-pitched, wheezing sound caused by disrupted airflow
Stridor
8 systemic symptoms of lung cancer
Syndrome of inappropriate antidiuretic hormone (SIADH) Hypercalcemia Cushing's Facial swelling from SVC syndrome Anorexia Headaches and seizures from brain mets Pleural effusions Hoarseness
6 late symptoms of lung cancer
Pain from bone mets Anorexia CNS system changes due to brain mets Dysphagia Weight loss Paraneoplastic syndrome
Syndrome caused by small cell lung disease that affects nervous system (NS)
Horner’s syndrome
2 symptoms of Horner’s syndrome
Ptosis
Miosis
Drooping of upper eyelid
Ptosis
Constricted pupil
Miosis
More common with lung cancers, degenerative disorder where patient’s immune system T cells start fighting/attacking normal cells
Paraneoplastic syndrome
Cancer fighting antibodies
T cells
9 ways to diagnose lung cancer
History and physical (H&P) Complete blood count (CBC) Chest x-ray (CXR), CT, MRI, and PET Sputum cytology Fiberoptic examination Fine needle aspiration LN biopsy Mediastinoscopy, thoracoscopy, or thoracotomy Endobronchial US (EBUS)
Routine CXR often detects _______ lung cancer
Asymptomatic
___-___ of all pulmonary nodules are malignant
1/3-1/2
Examine upper chest wall between and in front of lungs with small incision
Mediastinoscopy
Incision inside patient to see inside of chest wall
Thoracoscopy
Open chest wall to biopsy/remove part of nodule for diagnosis
Thoracotomy
Bronchoscope inserted in trachea with US probe on end of it to examine LN and biopsy can be US-guided
Endobronchial US (EBUS)
2 major histologies of lung cancer
Non-small cell lung cancer (NSCLC)/non oat cell
Small/oat cell
___-___ of lung cancers are NSCLC, and ___-___% are small cell
80-85%, 10-15%
3 types and percentage of NSCLC
Adenocarcinoma: 40%
Squamous cell: 30%
Large cell: 10-15%
Most common NSCLC, women and younger people
Adenocarcinoma
More aggressive and shorter doubling time makes this lung cancer more sensitive to radiation and initially greater response but becomes aggressive again
Commonly goes to brain, about 10%
Prophylactic brain irradiation when symptoms arise, whole brain when patient in remission
Only about 10-15% survive 3 years
More systemic and advances so quickly, surgery not usually an option unless it’s caught early
90% relapse and die
Small/oat cell (SCLC)
Doubling time of NSCLC and small cell lung cancer
NSCLC: 90 days
Small: 45 days
Staging system of NSCLC and small cell lung cancer
NSCLC: TNM
Small: bimodal staging system
Which type of lung cancer is more radiosensitive and why?
Small cell due to rapid division
3 things radiation is used for in the treatment of lung cancer
Cure non-surgical candidates with NSCLC
Sterilize tumors preoperatively and treat LNs
Palliation by shrinking tumors
3 oncologic emergencies associated with lung cancer, need to treat quickly
Superior vena cava (SVC) syndrome
Airway obstruction: mediastinal tumor pressing against airway
Spinal cord compression from spinal mets
Most common emergency with lung cancer, usually advanced disease; causes cerebral edema, dizziness, etc. and can lead to death if untreated
Superior vena cava (SVC) syndrome
Tumor that has caused rib destruction and nerve root involvement (C7-T1), area located near the brachial plexus, thoracic vessels, and vertebral bodies
Primary location: apex of lung
Severe shoulder and arm pain (brachial plexus)
RT, neoadjuvant chemo, and possible rib resection (decreases QOL); pain management medication for arm and shoulder pain
Most common point of spread: brain mets
Pancoast tumor syndrome
6 prognostic factors of lung cancer
Weight loss greater than 10 pounds in 6 months is a poor indication of health
Size of tumor
Mets
Gender: women do better than men
Age: under 60-70 year olds do better, over 60-70 have poor response
Performance status
Average SCLC survival
9-11 months
4 common mets sites of lung cancer
Liver
Adrenals
Bone
Brain
Rare neoplasm caused by asbestos most commonly involves pleura but can also involve peritoneum
Shipyards, pipefitters, and brake repairs
No effective treatment: intrapleural chemo, RT, and surgery
Cisplatin gave 9 month survival; now: pemetrexed and cisplatin give longer survival
Mesothelioma
Decrease in mental function, confusion
Organic brain syndrome
Lung cancer screening method
No cost effective method; CT scans between 55-74 year olds who’ve smoked/had 30 pack years of 30 pack years in past and quit within 15 years
Initial then next based on what’s seen on CT
Symptoms don’t appear until disease has progressed by more likely in smokers than normal population
Smoked one pack of cigarettes daily for 30 years
30 pack years
Malignant tumor originating from melanocytes most commonly found in basal layer of epidermis
Unpredictable and deadly
Can be in any place that has melanocytes/pigment cells; ex: retina or iris
Symptoms include a mole that changes in size, elevation, color, surface, surroundings, and sensation
Malignant melanoma
7 risk factors of malignant melanoma
More than 20 congenital nevi/large number of moles
Family history of melanoma
History of severe sunburning: child having 2-3 severe burns
Light/sensitive skin type I and II, blue, gray, or green eyes, and blonde or red hair; inability to tan
Dysplastic nevus syndrome (DVS)
History of acute and intermittent exposure to sun or ultraviolet light
Personal history of melanoma
6 skin types (lower number increases risk)
I. Never tans, always burns, fair or red hairs, and many freckles
II. Burns easily, sometimes tans, freckles, and fair hair
III. Burns moderately; tans easily and rarely burns
IV. Burns minimally; always tans and very rarely burns
V. Rarely burns and brown skin
6. Never burns and black skin
Clinically atypical moles precursor to melanoma
Dysplastic nevus syndrome (DVS)
6 histologies of malignant melanoma
Superficial spreading Nodular melanomas Lentigo maligna Acral lentiginous Uveal melanoma (rare) Mucosal lentigines, desmoplastic melanoma, and varicose/warty type lesions less common
Most common melanoma histology, 70% of all cutaneous melanomas
More common in women than men, 40-50 year olds are the most commonly diagnosed age group
Variegated in color with areas appearing blue, black, gray, white, or pink; irregular pigmented plaque with areas of regression and notched borders, horizontal or radial extension
May appear scaly and crusty and itch
Increasingly more common in young adults
Superficial spreading
Small tan/brown/black, dark type of freckle that doesn’t fade
Appears as a large, flat, irregular lesion resembling a stain
Located o n face and neck of elderly, severely suntanned whites
Lentigo maligna/lentigo malignant melanoma
Extremities, relating to or affecting peripheral parts
Acral
Pigmented middle layer of eye
Uvea
Light brown spots on mucosal surface
Mucosal lentigines
Infiltrating melanoma with an abundance of fibrous matrix
Desmoplastic melanoma
Patchy, different within itself
Veriegated
Colorless, lacks pigment
Amelanotic
Common sites of superficial spreading melanoma in men and women
Men: trunk/back
Women: lower extremities
4 common sites of lentigo maligna melanoma
Face
Neck
Trunk
Dorsum of hands
3 common sites of nodular melanoma
Trunk
Head
Neck
4 common sites of acral-lentiginous melanoma
Palms of hands
Soles of feet
Nailbeds
Mucous membranes
For deep skin lesions, excision through underlying fat; helps see tumor depth
Punch type biopsy
ABCDE approach to early detection of melanoma
A: asymmetry in shape, color, and appearance; melanoma lesions are typically irregular shaped
B: bleeding or borders that are notched, uneven, ragged, or irregular
C: color of mole variegated blues, grays, pinks, reds, browns, varying shades of black, etc.
D: diameter of 6 mm or greater suspicious in any direction or change in size, growing
E: evolving/changing or elevation
Mole is raised or has uneven surface
Elevation
6 preventative measures of melanoma
Avoid peak time of intense UV radiation exposure at 10AM-4PM, UV radiation damages skin cells
Use sunscreen with minimum SPF 15
Wear protective clothing
Avoid tanning booths
Do regular self examinations of skin several times a year or at least annually for life and US anything suspicious
Can stay outside 15 minutes longer than you normally would without burning
SPF 15
7 common sites of melanoma mets
Regional LN most common Lungs second most common Skin Subcutaneous tissue just beneath skin Liver commonly with ocular melanoma Brain Bone
With melanoma mets, __________ elevated when cells are being damaged
Lactase dehydronaise
LNs commonly involved with melanoma, isotope/dye to identify first place of drainage from disease for patients with lesions over 1 mm deep
Sentinel node mapping
4 melanoma treatments
Surgery recurrence rates same for wide and small excision
Chemo (dacarbazine [DTIC]), immunotherapy, and targeted therapy
Radiation mainly for palliation for CNS or bone mets; 50% skin response, not cure
Alpha interferon
Indication for post surgical adjuvant therapy in patients with melanomas over 4 mm in thickness and after LN dissection
Length of the therapy is about 1 year, 5 days a week; subcutaneous injection that can be done by patient or family
Biotherapy stimulates the body’s immune system to recognize and fight cancer
Alpha interferon
Numbness due to nerve damage
Parethesia
Damage from toxin
Ototoxicity
5 year survival for localized melanoma, regional mets, and distant mets
Localized: 97%
Regional: 59%
Distant: 15-20%
Melanoma follow-up for years 1-3, 4 and 5, and after 5 years
Years 1-3: every 3-4 months
4&5: every 6 months
After 5 years: annually
Number one cancer in men besides skin because of early detection by prostate specific antigen (PSA), about 20% of patients have normal PSA
Third leading cause of cancer deaths in men; lung first and colon second
Urethra runs through this gland and when it’s enlarged it doesn’t allow men to urinate
Late symptom: pain from bone mets
Prostate cancer
5 risk factors of prostate cancer
Increasing age over 50 years old African American Family Dietary fat Genetics: BRCA 1&2 genetic mutations and lynch syndrome
Median age of diagnosis of prostate cancer
66 years
African Americans have ___% higher risk of being diagnosed with prostate cancer at an earlier age and more aggressive; have higher incidence and _______ the mortality rate
Asians have lowest incidence
50%, double
Having 1 or 2 first degree relatives (dad or brother) with prostate cancer increases the patient’s risk by how much?
1: 3x
2: 9x
What is the prostate cancer screening recommendation by the American Cancer Society (ACS) and the Urological Association?
ACS: digital rectal examination (DRE) and PSA annually for over 50 year olds for individual at normal risk and have a high life expectancy over 10 years, high risk individuals should start at 40 years old
Urological: over 50 years old annual PSA and DRE
Protein produced by prostate
For positive disease use US guided rectal biopsy to see if it’s malignant
Prostate specific antigen (PSA)
Normal and abnormal PSA range
Normal: 0-4 ng/ml
Abnormal: 4 or higher
5 reasons PSA can give false negative (irritants)
Prostatitis Cystoscopy Prostatic hypertrophy Transurethral resection of prostate (TURP) Needle biopsy
Inflammation of prostate gland
Prostatitis
Enlarged prostate
Prostatic hypertrophy
Part of prostate removed
Transurethral resection of prostate (TURP)
A system of grading prostate cancer tissue based on how it looks under a microscope, 2-10
Grade
Gleason score (GS)
PSA _______ with age
Increases
PSA range for ages 40-49, 50-59, 60-69, and 70-79
40-49: 0-2.5
50-59: 0-3.5
60-69: 0-4.5
70-79: 0-6.5
7 signs and symptoms of prostate cancer similar to urinary obstruction
Nocturia Hesitancy Straining to void Urgency and frequency Dysuria Feeling of incomplete voiding Hematuria or hematospermia
Excessive urination at night
Nocturia
Blood in semen
Hematospermia
5, 10, and 15-year relative survival rate of prostate cancer
5: 99%
10: 98%
15: 96%
5 year survival for stage 1-3 prostate cancer and distant mets
1-3: 100%
Mets: 31.9%
2 parts of obtaining a GS
1st number from primary histology/grade
2nd from highest grade
Formula to evaluate risk of seminal vesicle (SV) involvement with prostate cancer
(GS-6)10 + PSA
If evaluation of SV and LN involvement is over ___%, treat them
15%
Formula to evaluate risk of LN involvement with prostate cancer
2/3(GS-6)10 + PSA
Low risk for involvement of SV from calculation, PSA, and GS
Calc: 15% or less
PSA: 10 or less
GS: 6 or less
High risk for involvement of SV from calculation, PSA, and GS
Calc: over 15%
PSA: over 10
GS: over 6
Why don’t we want to treat the SVs?
They’re close to rectum
4 treatments of prostate cancer
Surgery
Radiation
Hormone
Chemo not curative
Removal of entire prostate, SVs, and a portion of the bladder neck through perineal or retropubic area
Radical prostatectomy
Between scrotum and anus
Perineal area
8 problems that can be caused by radical prostatectomy
Atelectasis Wound infection Bleeding Edema of penis if LN dissection included Edema of lower extremities Deep vein thrombosis (DVT) Stress incontinence and incontinence (5%) Impotence
Bladder leaks urine during physical activity or exertion.
Stress incontinence
Airless/collapsed lung, usually from anesthesia after radical prostatectomy and can lead to PE
Atelectasis
What percent of men are potent after bilateral and single nerve sparing surgery?
Bilateral: 68%
Single: less
5 times radiation is used for prostate cancer
Any stage from I-III Organ confined disease Patients that are a poor surgical risk Positive margins: adjuvant Alone or in conjunction with hormonal therapy
When are seed implants used for prostate cancer?
10 or less PSA/advanced disease
3 brachytherapy sources for prostate cancer
Iodine-125 seeds
Palladium seeds
Iridium catheter
3 types of EBRT for prostate cancer
5-7 field IMRT or VMAT
4 field for LNs
Protons
Prostate EBRT dose
74-81.6 Gy
7 side effects of prostate irradiation, brachytherapy effects more intense than EBRT
Cystitis Diarrhea Incontinence Lymphedema Impotence: 30-50%, will resolve Fecal and urinary urgency PSA decreases when treatment ends
Blocks testosterone production for patients with symptomatic, metastatic disease and mainly palliative
Medically or orchiectomy
$100-$20,000
Hormonal therapy
Removal of testes
Orchiectomy
5 side effects of prostate hormonal therapy
Hot flashes Weight gain Loss of bone density Gynecomastia Impotence
Abnormally large mammary glands
Gynecomastia
4 treatments for impotence from prostate hormonal therapy
Implants
Drugs
Injections
Vacuums
3 treatments for hot flashes from prostate hormonal therapy
Megace
Vitamin E
Clonidine patches for hypertension
Oral steroid hormone most effective in treating hot flashes from prostate hormonal therapy
Megace
2 RT treatments for prostate bone mets
Teletherapy palliative radiation to local area
Strontium-89 or samarium-153 IV for excessive bone mets
Follows calcium route in bones and treats from inside out
40-80% response rate
Only 1 injection
Beta emitter like electrons and positrons from nuclei
IV for excessive bone mets
Strontium-89
Second most common histology of malignant melanoma often resembles a “blood blister”
Appears as a symmetric, raised, dome-shaped lesion with vertical growth patterns
Blue-black in color but can be amelanotic
Nodular melanoma
Usually flat, irregular melanoma with an average diameter of 3 cm
Blue or black discoloration or a tan or brown stain occurs on palms and soles or under nailbeds
Acral lentiginous melanoma
Present at birth and result from a proliferation of benign melanocytes in the dermis, epidermis, or both
Congenital nevi
5 semirigid penile protheses
Simple Hinged Malleable Positionable Mechanically activated
GS with sharply circumscribed aggregate of small, closely packed, uniform glands
1
GS with greater variation in glandular size, more stroma between glands, and more infiltrative magins
2
GS with further variation in glandular size, glands more widely disperse in stroma, and distinctly infiltrative margins with loss of circumpscription
3
GS with “fused gland” pattern and infiltration of prostatic stroma
4
Irregular masses of neoplastic glands coalescing and branching
“Fused gland” pattern
GS with diffusely infiltrating tumor cells with only occasional gland formation
5
