Solid malignancy Flashcards
What are the RF of prostate cancer?
- Increasing age
- FH
- African heritage
- BRCA2 gene mutation
What are the CF of prostate cancer?
LUTS
Asymptomatic - raised PSA
Bone pain - mets
Ejaculatory sx eg. blood in semen - rare
What are the ix into prostate cancer?
DRE
PSA - poor ix, mets unlikely if <10
MRI prostate/pelvis - often pre biopsy to decide technique, also if no suspicious areas don’t need biopsy
Biopsy - transperineal most commonly, for Gleason grading
What are some common causes of raised PSA?
Prostate cancer
UTI - dip
Prostatitis
Enlarged rpostate eg. BPH
Acute urinary retention
What factors influence treatment of prostate cancer?
Age
DRE - staging - localised, locally adv or advanced
PSA
Biopsies - Gleason grade
MRI - nodes or mets ? and bone scan
What is the treatment of metastatic prostate cancer?
Hormones - enzalutamide = androgen R antagonist, GnRH agonist or bilat orchidectomy
Palliation - single dose RT for bone pain, bisphosphonates
What is the treatment for locally advanced prostate cancer?
Radical radiotherapy w adjuvant hormones
External beam RT? Procitis is complication
Brachytherapy - seeds inside ?
What is the treatment for localised prostate cancer?
Active surveillance
Curative - radical prostatectomy, RT, incontinence or erectile dysfunc r the complications
Palliative - deferred hormones, watchful waiting
What are the differential diagnosis for haematuria?
Cancer - RCC, TCC bladder, prostate cancer
Stones
Infection and inflam
BPH
Glomerular eg. nephritic syndrome
What are the ix into haematuria?
Flexible cystoscopy
USS of kidney
Urine cytology
What is the presentation of testicular cancer?
Painless lump in the body of the testis - 2WW. Most are germ cell tumours - hx of undescended testis
What are the ix into testicular cancer? How do you treat?
Urgent USS of scrotum
Tumour markers - aFP, hCG, LDH
Treat - inguinal orchidectomy
What are the RF of bladder cancer? TCC
Smoking
Occupational exposure - rubber or plastics manufacture, handling crude oil, carbon, painting, mechanics, hairdressers
Male more than women
What are the ix into bladder cancer? How is it treated?
Cystoscopy - treat w TURBT
Can sometimes give single intravesical dose of chemo eg. mitomycin
High risk - intravesical BCG to create immune response
Mets - cisplatin based chemo
Biologicals
What is the treatment of upper tract TCC?
Nephro ureterectomy
What are the RF of RCC
Male and white
Smoking
Obesity
Dialysis
What is the presentation of RCC?
Haematuria
Incidental finding on imaging
Palpable mass - vv rare
What is the treatment of RCC?
Surveillance
Excision - partial or radical nephrectomy
Mets - palliative, biologicals and targeted therapies
What are sx of lung cancer?
Unexplained cough >3w
Haemoptysis
SOB
Hoarse, dysphagia
Chest pain, wheeze
B sx
What are some signs of lung cancer?
SVC obstruction
DVT
Clubbing
Horner’s syndrome
Where does lung cancer met to most commonly?
Other lung or other lung lobe
Liver, brain, bone, adrenal glands
What are the ix into lung cancer?
Biopsy + histology
Bloods - FBC (infection, anaemia), U+E (contrast CT), Ca (bone profile, paraneoplastic syndrome), LFTs (tests and mets), INR (tests)
CXR - hilar enlargement, pleural effusion, collapse, opacity
Staging - CT thorax, abdo, pelvis w contrast
What are the options for biopsy in lung cancer?
US guided neck node core for cytology - least invasive
Nothing in the neck - bronchoscopy = EBUS
CT biopsy if peripheral mass
Sputum sample for cytology
Pleural effusion - thoracoscopy
What are the ix into malignant pleural effusion?
Bloods - FBC, U+E, CRP, INR, LFT
US guided diagnostic aspirate - protein, LDH, cytology, microbiology
-ve cytology - medical thoracoscopy
If you have pleural effusion in lung cancer normally have non curative treatment.
What is Light’s criteria?
Transudate = protein <0.5, LDH <0.6
Causes - congestive HF, hypoalbuminaemia - cirrhosis, nephrotic syndrome
Exudate = protein >0.5, LDH >0.6
Causes - malignancy, PE, infection, autoimmune
What is done w incidental lung nodules?
5mm + = follow up
8mm + = active intervention
20mm + = cancer clinic
What are the different types of lung cancer?
80% Non small cell lung cancer - SCC, large cell, adenocarcinoma 40%
20% small cell lung cancer - linked with smoking
What is the treatment of hypercalcaemia?
> 3 = treat
IV fluids - see if reduces Ca
Pamidronate one off reduces Ca
What is WHO performance status?
0 - fully active w/o restriction
1 - restricted in physically strenuous activity, able to carry out light work
2 - capable of self care but can’t work
3 - limited self care, seated/bed >50% time
4 - completely bed bound
5 - dead
Where does prostate cancer most affect?
Peripheral zone
What are some risks of prostate biopsy?
Pain
False -ve - miss cancerous area
Bleeding in stools, urine and semen
Infection
Urinary retention
Erectile dysfunc
What are the RF of lung cancer?
Smoking and second hand smoke
Prev lung disease
Asbesto or radon exposure
FH
What is the management of NSCLC?
1st line = surgery = lobectomy, segmentectomy or wedge resection if isolated disease, curative
RT can be curative if early disease
Adjuvant chemo after surgery or palliative
What is the management of SCLC?
Chemo (cisplatin based) and RT - much worse prognosis than NSCLC
What are the ix prior to surgery for NSCLC?
LFT - determine the type of surgery and can predict post op lung func
What are the extrapulm manifestations of lung cancer?
RLN palsy
Phrenic nerve palsy = SOB
SVCO
Paraneoplastic syndrome - SIADH and Cushing’s syndrome = SCLC, hypercalcaemia = SCC
Limbic encephalitis
Lambert Easton syndrome
Horner’s = pancoast tumour
What is referral guidance for lung cancer?
2WW referral:
- Suggestive CXR and unexplained haemoptysis >40
- Recurrent chest infection or clubbing or supraclav LA >40
- >40 and have smoked w sx of lung cancer
What staging is used for lung cancer?
TMN
What is the prognosis for lung cancer?
Biggest cause of cancer related death in UK
1 year survival ~40%, 5 year survival ~16%
What are some differentials for breast lumps?
- Breast cancer
- Fibroadenoma
- Fibrocystic breast changes
- Breast cysts
- Fat necrosis
- Lipoma
- Galactocele
- Phyllodes tumour
What are the RF of breast cancer?
- Female
- Increase O exposure eg. COCP, HRT, long time w periods
- Glandular breast tissue
- Obesity and smoking
- FH
What hereditary syndromes predispose someone to breast cancer?
BRCA 1 - 60-80% risk breast cancer
BRCA 2 - 45-70% risk breast cancer
Also increase risk of breast cancer in men
What are the types of breast cancer?
Ductal or lobular carcinoma in situ - pre cancerous or cancerous cells not breached the BM, can spread
Invasive ductal (most common) or lobular carcinoma
Inflam breast cancer
Paget’s disease of the nipple
What is inflam breast cancer?
~1-3% of breast cancers
Looks like breast abscess or mastitis - swollen, warm, ternder breast w pitting skin = peau d’orange
Doesn’t respond to abx
Worst prognosis
What is Paget’s disease of the nipple?
Erythematous scaly rash - looks like eczema of the nipple
Indicates breast cancer involving the nipple
What screening is there for breast cancer?
50-71 years old women, transmen and transwomen on HRT have a mammogram
Satisfactory - no evidence of breast cancer
Abnormal - need further ix
Unclear - need further ix
What are the CF of breast cancer?
Asymptomatic
Lump - irregular, hard/firm, fixed
Breast pain
Change to skin appearance, pitting, tethering
Nipple inversion or discharge
Features of mets
What is triple assessment in breast cancer?
- Hx and exam
- Imaging - mammogram and US
- Biopsy - FNA or core biopsy
What are the other ix into breast cancer?
CXR
MRI breast
CT chest abdo pelvis w contrast
±CT brain
±Liver USS
±Bone scan
±PET/CT
What is the tumour marker for breast cancer?
Ca 15-3
What receptors are there in breast cancer?
Oestrogen
Progesterone
HER2 - can have herceptin, ab that blocks HER2 pathway
What is the screening for breast cancer?
Normal pt - mammogram every 3 years for women aged 50-70
High risk pt - annual mammogram for high risk pt
Can have chemoprevention, genetic counselling and pre test counselling, bilat mastectomy or oophorectomy also
What pt are at high risk of breast cancer?
1st degree relative w breast cancer <40 years
1st degree male relative w breast cancer
1st degree relative w bilat breast cancer <50 years
x2 1st degree relatives w breast cancer
What chemoprevention is offered for high risk women?
Tamoxifen - pre menopausal
Anastrozole - post menopausal
What surgery options are there in breast cancer?
- Tumour removal - breast conserving surgery or mastectomy w breast recon
- Axillary clearance
What are the hormone treatments used in breast cancer?
- Tamoxifen - pre menopausal
- Aromatase inhib - post menopausal eg. letrozole
Both block O production, given for 5-10 years in women w O R +ve breast cancer
What targeted treatments are used in breast cancer?
HER2 R targetters - herceptin, perjeta
What are the RF of colorectal cancer?
FH
FAP and HNPCC/Lynch syndrome
IBD
Increased age
Diet w lots of red meat, processed meat and not much fibre
Obesity and sedentary lifestyle
Smoke and alcohol
What are the red flags for bowel cancer?
Change in bowel habit
Unexplained weight loss
Rectal bleeding
Unexplained abdo pain
Fe def anaemia
Mass
What is the 2WW criteria for cancer referral?
> 40 years w abdo pain and unexplained weight loss
50 years unexplained rectal bleed
60 years w change in bowel habit or Fe def anaemia
What is bowel cancer screening?
FIT - faecal immunochemical test in 60-74 years every 2 years
Tests for human Hb in stool, +ve - colonoscopy
What are the ix into bowel cancer?
Colonoscopy - gold standard, can biopsy
Sigmoidoscopy - when only rectal bleeding
CT colonography
CT AP thorax w contrast - staging
CEA = tumour marker
What is the management of bowel cancer?
Surgical resection - w stoma or anastomosis formation
Chemo
RT
Palliative care
What are the different surgeries in bowel cancer?
R hemicolectomy - caecum, ascending and proximal transverse colon
L hemicolectomy - distal transverse and descending colon
High ant resection - remove simoid colon
Low ant resection - remove sigmoid colon and upper rectum
APR - removes rectum and anus
Hartmann’s - emergency, remove recto sigmoid colon and colostomy formation
What are the complications of bowel cancer surgery?
Bleed, infection, pain, VTE
Damage to neighbouring structures
Post op ileus
Anaesthetic risks
Failure of anastomosis, need stoma
Failure to remove tumour
Adhesions
Incisional hernias
What is low ant resection syndrome?
Urgency and freq of bowel movements
Faecal incontinence
Difficulty controlling flatulence
What are some tumour markers?
CEA - bowel cancer
Ca 125 - ovarian cancer
Ca 19-9 - pancreatic cancer
Ca 15-3 - breast cancer
AFP - hepatocellular and testicular
PSA - prostate
What is the most common type of head and neck cancer and where is it?
SCC
Nasal cavity
Paranasal sinuses
Mouth
Salivary glands
Pharynx
Larynx
What are the RF of head and neck cancer?
Smoke
Chewing tobacco or betel leaves
Alcohol
HPV
EBV
What are the red flags of head and neck cancer?
Lump in mouth or lip
Unexplained ulceration of mouth >3 weeks
Erythroplakia
Erythroleukoplakia
Persistent neck lump
Unexplained hoarse voice
Unexplained thyroid lump
What is the treatment of head and neck cancer?
Chemo, RT, surgery, palliation
Cetuximab
What are the RF of BCC?
Long term UV exposure
Prev BCC
UVA therapy for psoriasis
Skin type 1
Immunosuppression
Genetic syndromes - xeroderma pigmentosa
What are the CF of BCC?
In areas of the body that get lots of sunlight - head, neck, hands, ears
Small slow growing lesions
Raised pearly edges
Telangiectasia
ASymptomatic
What are the ix into SCC and BCC?
Dermatoscope examination
Excision biopsy
What is the management of BCC?
Imiquimod cream
5 flurouracil cream
Cryotherapy, curettage
Excision - margins 3-5 mm ±skin graft
Can do Mohs’ micrographic surgery
What prevention advice is given for skin cancer?
Avoid sunbeds
Use SPF50 all year
Protective clothing - hats etc, sit in shade
What are the RF of SCC?
Prolonged UV exposure
Chronic wounds and inflam
Immunosuppression
Pre malignant conditions eg. AK, Bowen’s disease
Smoking
What are the CF of SCC?
Nodular, indurate, keratinised
Ulcerated
Bleeding/itchy
Growing quickly
Sun exposed sites
What is Bowen’s disease?
Growth of cancerous cells confined to outer layer of skin - SCC in situ
Small red scaly lesion, normally flat and treated w topicals
What is the management of SCC?
Excision
Low risk - 4mm margin
High risk - 6mm
v high risk - 10mm
Which areas are most commonly affected by melanoma and where does it met to?
Trunk and legs
Mets - every tissue and organ in body ! can met to anywhere
What are the RF of melanoma?
UV exposure
Genetic mutations
Premalignant lesions
Prev melanoma
Age
Caucasian
>50 naevi
Sunbeds
Type 1 and 2 skin
What are the CF of melanoma?
New naevus or change to existing mole
Bleed/ulcer
Asymmetrical
Irreg border
Uneven colour
Diameter >6mm
Evolving lesion
LN involvement
What are the ix into melanoma?
Excision biopsy to diagnose
Staging CT CAP - TNM
What can help to determine met risk in melanoma?
Breslow thickness
