Solid organ malignancy 2.61-68 Flashcards
Extent of surgery in breast cancer?
Does not improve survival due to micrometastases; does improve symptoms related to local invasion. Do “lumpectomy” instead if possible.
Transcoelomic spread of ovarian cancer?
Spreads up right paracolic gutter, over surface of liver, down omentum.
Why do metastases from gastrointestinal cancers often appear in the liver?
Hepatic portal vein!
Lymphatic drainage of ovaries/testes?
Paraaortic nodes
Lymphatic drainage of scrotal/vulval/penile cancers?
Inguinal nodes
L’dopathy above SCF?
ENT!
Axillary and supraclavicular nodes?
All of thorax ie stomach, breast, lung.
Clinical presentation of cancer (1): Direct?
Mass effect (pressure, pain, palpable), obstruction of conduit (air, blood, bile), ulceration of serosal (organ) or mucosal (epithelial) surfaces e.g. IDA in GI bleed.
Clinical presentation of cancer (2): Other?
- Metastatic (effusions [microscopic inflammation], organomegaly)
- Asymptomatic (screening/Ix)
- Non-metastatic effects (fever, weight loss, paraneoplastic).
Two types of paraneoplastic phenomena?
- Humoral. e.g. ACTH/ADH; actively secreted so will improve once cancer treated.
- Immunological e.g. tumour Ag leads to new Ab formed; get cross-reactivity that may persist one cancer treated e.g. Lambert-Eaton syndrome
What is CUP?
Unique entity where a primary tumour is able to metastasize before the primary site becomes large enough to be identified
Differences between CUP and known primary tumours?
Early disseminsation, unpredictable metastasis, more aggressive, absence of symptoms due to primary.
Most common primary sites in CUP?
Lung, pancreas, gynae, GI.
Best approach to CUP?
Limited diagnostic approach designed to identify patients with good prognostic features; cheaper, faster, make use of MDT! Communication key!
Assessment in CUP?
Thorough exam, basic bloods, FoB, CT thorax/abdomen/pelvis. Only do endoscopy on basis of symptoms/signs. In men, can do serial PSA/AFP/BHCG to exclude treatable/curable cancers, and teste exam. Women need breast exam, mammogram, probably gynae exam. Whole body PET-CT can help with management. do family history!
Median survival in CUP?
6-9 months so don’t over investigate! This includes curable GCT/lymphoma so survival is torrid for some patients. Consider cost of time, burden of investigation, what investigation will actually add
Prognostic factors in CUP?
LN involvement (except SCF), performance status (key; comorbidity ie renal/hepatic impairment can be overcome; fitness CANNOT), weight loss >10%, serum markers (particularly LDH), males do worse, poorly differentiated cancer
Approach to CUP?
Search for primary (exam and image), rule out potentially curable/treatable tumours (GCT/lymphomas etc), characterise specific clinicopathological entity and split into favourable and unfavourable subsets and treat accordingly (curative and palliative INTENT)
Two oddly specific subtypes of patients who can do well with CUP? Do not miss!
1) patients with predominantly nodal metastases of poorly differentiated carcinomas
2) women with peritoneal carcinomatosis of a serous type adenocarcinoma
Main lifestyle factor for cancer mortality?
Diet (35%) then tobacco, then patterns of reproduction, then alcohol
Main community based factors for cancer mortality?
Infections (e.g. HPV), workplace, natural physical exposures, human made pollution, medicines/procedures, consumer products.
Tobacco and carcinogenesis?
90% of lung cancer attributable to tobacco. Due to inflammation of bronchial mucosa. Also carcinogens affect oropharynx, oesophagus, pancreas, bladder, RCC, AML.
What does smoking lower the cancer risk for?
Endometrial
Asbestos and mesothelioma?
Only need low exposure, but higher increases risk. More likely to be right-sided. Eventually obliterates visceral and parietal pleura.
PFTs in mesothelioma?
Restrictive
How does ionising radiation cause cancer?
High frequency, dislodges electrons, damages tissue. Lower frequencies e.g. electromagnetic radiation, radio waves are not associated with cancer. Spreading dose out over longer duration decreases risk.
Tissues most sensitive to ionising radiation?
Bone marrow, thyroid, breast (so be wary in treating mediastinal lymphoma in young women due to high chance of secondary breast malignancy)
What does ionising radiation include?
Cosmic rays, X-rays, gamma rays, A/B particles
UV radiation and carcinogenesis?
UVC and most of UV-B absorbed in ozone; some UV-B (and tiny proportion of UV-A) can be carcinogenic, but only for skin. Incidence lower in groups with more melanin, higher incidence at warmer latitudes. Heavy and intermittent burning as a child has particular risk.
Xeroderma pigmentosum?
AR defect with defective NER enzymes. Get photosensitivity, pigmentation changes, premature skin aging and high incidence of skin cancer (all types) as early as 3-4. Means that every exposure to UV causes lasting DNA damage; normally this is repaired.
What cancer is EBV linked to?
Burkitt’s lymphoma
What cancers is HHV-8 linked to?
Kaposi’s sarcoma, Castleman’s disease, primary effusion lymphoma
Which HPV strains are linked to cancer?
16, 18, 31, 45
Problem with vaccinating against cerival cancer?
Any remaining cancers are likely to be extremely aggressive and difficult to treat
Why polcythaemia in HCC?
Activation of fetal genes e.g. AFP/epo
Hormones and breast cancer?
Early menarche, late menopause, nulliparity, late age at first birth (and breast density) because have heightened exposure. COC does not increase risk directly! HRT does if >55 years old, >10 years
Hormones and endometrial cancer?
Post menopausal risk is increased greatly by HRT if it doesn’t contain progesterone too
Ovarian cancer and hormones?
Increased risk with nulliparity, early menarche and late menopause; COC protective (reduces number of ovulations)
Parasites and cancer?
Schistosoma haematobium can cause bladder cancer; bilharzia can cause bladder cancer, chronic cystitis.
Roughly how much cancer is heritable?
10%
Where may mutations be found in familial cancer syndromes?
Oncogenes (myc, HER-2, K-ras), TS genes (p52, BRCA1/2), DNA mismatch repair genes, genomic instability genes, dominant transforming genes (MEN2A), polymorphic carcinogen metabolising genes (CYP)
Hereditary breast cancer?
Only comprises 5% overall cases. Male beast cancer is mostly due to BRCA-2 mutations
What is Li-Fraumeni syndrome?
Rare; germline p53 mutation; AD; penetrance of 50% at 50. Characterised by premenopausal breast cancer, and childhood sarcoma, brain tumours, leukaemia and lymphoma, adrenocortical carcinoma
RR with breast cancer types?
First degree relative affected = RR 1.7; first degree relative with bilateral, premenopausal = RR 9
MEN 2b?
Mucosal neuromas of tongue, medullary cancer of thyroid, marfanoid, skin pigmented. May get neuromas elsewhere, + phaeo and parathyroid tumours. AD. RET oncogene.
NF-1?
AD. 100% penetrance; variable expression. Axillary freckling, cafe-au-lait macules. Pigmented hamartomas of iris (Lisch nodules in NF1, not NF2); phaeochromocytoma, optic glioma, acoustic neuroma, astrocytoma, meningioma, neurofibrosarcoma.
Acoustic neuromas in NF?
Rare in NF-1, but unilateral; uni or bilateral in NF2
Down’s syndrome and cancer?
Increased risk of AML
Paget’s disease of the bone?
Get bowing of legs, “sabre tibia”. ALP used as marker of disease activity. Get excessive bone breakdown and resorption with abnormal remodelling. Increased risk of osteosarcoma and fractures; must identify if fractures are benign or not.
Considerations in screening programmes?
Is it curable if diagnosed early, sensitivity (more important than specificity), is it common, frequency, what demographic, disadvantages of screening e.g. stigma, discomfort, fear.
How does Peutz-Jeghers increase cancer risk?
Get entirely benign hamartomous polyps of gut; no malignant potential but increase surface area dramatically so get increased CRC
Evaluating cancer screening programmes?
Screening uptake rate, recall rate of screened pop (TP + FP), biopsy rate, cancer detection rate, rate of interval cancers, incidence rate in non-attendees, deaths from cancers
Lead time bias in cancer screening?
Detect tumours at earlier stage so survival post-diagnosis seems to improve
Length time bias in cancer screening?
At start of screening programme, detect lots of patients with indolent disease (because prevalence of slow growing tumours is higher, even if incidence of faster growing is higher) so get illusory survival benefit in screened cohort
Breast cancer screening?
25% reduction in mortality. Women offered are 50-65, three yearly. Most interval cancers are in third year; should it be 2 yearly?
CRC screening?
Population testing of over 50s with FOB reduces deaths; sigmoidoscopy also effective. Different in FAP/HNPCC families (need surveillance colonoscopy)
PSA screening?
No RCTs have shown survival benefit or optimal therapy for early cancer; low benefit because tend to “die with” it
CIN screening?
Works due to clear prodrome. Has reduced SCC incidence; not good for CGIN.
Cancer prevention: vaccines?
HBV for HCC; HIV?; HPV for CIN. Social opposition because of fears of sexualising children
Cancer prevention: pharma? Review
NSAIDs, tamoxifen, vit A analogies, deltanoids, finasteride??
Why are germ cell tumours so sensitive to chemotherapy?
They are rapidly growing i.e. very short doubling
Peak incidence of testicular germ cell tumours?
25-35, 55-65.
Why are the adverse effects associated with chemotherapy particularly pertinent in GCC?
The survival is so good therefore “less important” factors like fertility must be considered
How do testicular germ cell tumours commonly present?
Lump in scrotum (may be detected incidentally after trauma), increase/decrease in teste size, scrotal pain, dragging sensation; can present with hydrocoele or gynaecomastia (if producing sex hormones), or non-specific back ache
Presenting with advanced disease in germ cell tumours?
Weight loss, fatigue, dyspnoea (mets/PE), ureteric obstruction (if retroperitoneal), SVC obstruction (mediastinal mass). May only take weeks for this to occur!
Investigating TGCTs?
Tumour markers (this is the rare case where they can be diagnostic), scrotal US, CT (thorax/abdomen/pelvis) for staging; may be performed after orchidectomy to assess residual disease.
“Morning sickness” in TGCT?
Rate of increase of BHCG
GCTs and tumour markers?
Not all germ cell tumours produce tumour markers, and if they are not produced at the start they will probably never be useful
Role of tumour markers in GCT?
- Can be diagnostic e.g. lump/US findings with raised AFP/BHCG is sufficient often
- Prognostic (higher is worse prognosis)
- Surveillance; marker relapse can precede clinical relapse by months
B-HCG and thyroid?
Very high BHCG can cause thyrotoxicity (acts as “on” switch for metabolism in pregnancy)
GCTs and HCG?
Produced by 100% of choriocarcinomas, 15% seminomas, and 75% of NSGCTs
Who may get FP in BHCG?
Regular cannabis users
AFP?
Physiologically synthesised in foetal yolk sac, liver and intestine
AFP and tumours?
Can be diagnostic of HCC along with hypoechoic lesion. 75% of NSGCTs.
Elevations in AFP?
Grossly in HCC and GCTs; slightly in other GI cancer and non-malignant liver disease
AFP T1/2?
Longer than BHCG, so takes longer to decrease after chemotherapy/surgery
AFP increase paradox?
Can be increased just after chemotherapy/necrosis of tumour; patient must be aware of this
LDH?
Non-diagnostic; marker of tumour bulk. Associated with necrosis i.e. seen in rapidly growing tumours and therefore is a predictor of TLS
When to do markers in TGCT?
Pre-orchidectomy, 24 hours post-surgery, then weekly until normalise. Good to assess residual disease.
Markers indicating no residual disease in GCT?
HCG normalises after 24 hours; AFP in 4-6 days.
Pre-op investigations in GCT/
Bilateral testicular ultrasound, CT chest/CXR, tumour markers
Differentials of “cannonball mets”?
Renal cell carcinoma, melanoma, osteosarcoma, choriocarcinoma, testicular cancer, metastatic adenocarcinoma. Only testicular and choriocarcinoma have a good prognosis.
Differentials for testicular mass?
Testicular cancer, benign epididymal mass, epidydimo-orchitis/orchitis, leukaemia/lymphoma infiltrate.
Risk factors for testicular cancer?
Genetics, testicular maldescent (orchidolpexy only reduces risk), XXY, trisomy 21
FP in AFP?
Alcohol abusers
Two types of TGCTs?
- Seminoma. Sheets and cord of relatively uniform cells which resemble primitive germ cells.
- NSGCTs. Umbrella term; can differentiate along embryonic and extraembryonic lines hence variety of appearances and spread.
NSGCT can be further divided to?
Mature teratoma, teratocarcinoma, yolk sac, choriocarcinoma, embryonal
What are the rete testis?
Tubules carrying sperm from seminiferous tubules to the efferent ducts
Local spread of seminoma and NSGCT?
Both to rete testis; this indicates higher risk of nodal involvement
Lymphatic spread of seminoma and NSGCT?
- Seminoma is highly predictable; goes to paraaortic, then pelvic, then mediastinal
- NSGCT. Less predictable, and may skip nodal junctions
Haematogenous spread of seminoma and NSGCT?
- This route is uncommon for seminomas.
2. NSGCT often to lungs, rarely to liver/brain/bone. Indicates poorer prognosis.
Poor prognosis for seminoma and NSGCT?
No such thing for seminoma! For NSGCT, associated with extrapulmonary visceral metastases, LDH >10* ULN etc.
What differentiates good risk and intermediate risk for seminoma?
Presence of extrapulmonary visceral mets.
How to stage in GCT?
Have histology, then contrast enhanced CT chest/abdo/pelvis; then have CT within 3 weeks of surgery to identify residual disease. Get CT brain if have multiple lung mets or HCG >10,000!
Complications of disease spread in GCT?
- Local (get SVC obstruction, pleural effusion, ureteric obstruction)
- Metastatic (lung, liver, brain, LNs)
- Non-metastatic (TLS, PE)
Biochemical features of TLS?
Hyperuricaemia, hyperkalaemia, hyperphosphataemia, hypocalcaemia. Caused by sudden death of tumour cells; can have secondary problems if pre-formed hormones are released e.g. phaeochromocytoma.
Complications of TLS?
Acute renal failure (hyperuricaemia and urate nephropathy), cardiac arrest/arrhythmia, DIC (cell death, activation of coag. cascades, intramuscular haemolysis (gives high LDH)
Prevention of TLS?
Expected (as usually follow chemotherapy), so can prepare with hydration, allopurinol, alkalinisation of urine.
Drugs to avoid in TLS?
ACEI/ARB, K+ sparing diuretics, NSAIDs, high potassium diet (chocolate, bananas)
Predisposing factors to TLS?
Large volume, SENSITIVE, tumours (Burkitt’s, NHL, leukaemia, germ cell, neuroblastoma, sarcoma); high LDH is a clue. Renal impairment (be wary of lymphomatous involvement of the kidney), male, <25.
Precipitants for TLS?
Cytotoxic chemotherapy, radiotherapy, steroid therapy, immune modifiers, surgery +/- anaesthesia, or DE NOVO argh!!
Managment of TLS?
Electrolye control with diet, diuretics, hydration etc., haemodialysis, allopurinol (inhibits uric acid formation by inhibiting xanthine oxidase), recombinant urate oxidase (converts uric acid into allantoins).
Problem with giving allopurinol or other xanthine oxidase inhibitors in TLS?
Can get accumulation of xanthine, which is itself nephrotoxic
Definitive management of early GCT?
Surgery (orchidectomy), consider biopsy of contralateral testis AFTER SPERM STORAGE. Remember to offer prosthesis! (better psych outcomes)
Options for patients with stage 1 seminoma (i.e. no residual disease after surgery)?
17% relapse; best therefore just to do surveillance on all.
Which has higher relapse rate, seminoma or NSGCT?
NSGCT, by some way.
How is surveillance done in NSGCT?
Monthly clinics for first year, with CXR/markers/exam, and CT @ 3 and 12 months. Then seen bimonthly in second year.
Management of metastatic GCT?
Still maintain a good prognosis; treat quickly and aggressively, and monitor Cx. Need to minimise treatment-related toxicity!
Bleomycin for metastatic GCT?
Risk of fatal pneumonitis; may wish to avoid in old patients, or those with renal impairment. Need PFTs before every cycle.
Cisplatin for metastatic GCT?
Renal impairment common (need to keep hydration), highly emetogenic, severe vascular toxicity (MI/CVA) possibly related to vascular spasm
Detecting residual tumour in GCT?
CT/PET-CT
Complications of therapy in GCT?
TLS, fertility (also a concern in women as harder to store but more likely to retain function), secondary malignancy! (especially with radiotherapy), pulmonary fibrosis (bleomycin), CVD risk (cisplatin), psychosocial. Need to be hyperaware of secondary malignancy etc. because survival rates are so good; it is not enough to “just survive”.
Fertility issues in GCT?
50% of men with testicular tumours will have low sperm count; therefore all who are receiving chemotherapy or radiotherapy should have sperm stored. May also be concern if remove the one working testicle. If sperm count is normal before therapy, 2/3 will be normal after. May be possible to do testicular-saving surgery rather than radical orchidectomy. Women often become amenorrhoeic, though fertility may return before periods do!
Cardiovascular related mortality in GCT?
May now begin to decrease as mediastinal radiotherapy less common. Still a problem with HTN after nephrotoxic chemo (particularly cisplatin). Lowest in surveillance, higher in chemo alone, highest if received radiotherapy. Latency period of 5-8 years. Advised not to smoke.
Secondary malignancy in GCT?
Risk of haematological cancer (5 years latency) after chemo, and solid organ cancer at/near radiological field. Greatest risk in under 30s. Smoking independently increases risk of 2ndary malignancy.
Psychosexual issues post GCT?
Anxiety and depression, sexual dysfunction, body image, relationship issues, gender issues. Mix of chemotherapy damage and psychological trauma of facing cancer.
Which lung cancers are most associated with smoking?
SCC and SCLC
Natural history of carcinoma of the bronchus?
Spread is circumferential and longitudinal along branch of bronchus, frequently involving regional lymphatics, and can spread in blood to virtually anywhere
LN involvement in Ca bronchus?
Peribronchial and hilar nodes ipsilaterally, then mediastinal nodes, then contralateral hilar, and supraclavicular nodes.
Presentation of lung cancer?
Some will be asymptomatic and found incidentally.
- Intrathoracic sc (cough, SOB, chest pain, haemoptysis, recurrent infections)
- Dysphagia from extrnsinc compression, SVC obstruction (mediastinal mass)
- Hoarse voice from invastion of RLN; indicates that cancer is inoperable so is significant finding.
- Extrathoracic symptoms e.g. anaemia, weight loss, malaise, lethargy
Finger clubbing is most associated with what lung cancer?
Squamous
What is Horner’s syndrome?
Miosis, enopthalmos, ptosis and anhidrosis (if lesion i pre-ganglionic)
What are most Pancoast’s tumours?
SCC or adenocarcinoma
What is Pancoast syndrome?
Shoulder pain, radicular pain in T1 distribution, Horner’s syndrome (sympathetic chain begins at T1?). Due to tumour, usually NSCLC in apex of lung invading surrounding soft tissues.
Some non-metastatic manifestations of lung cancer?
- Haem e.g. anaemia
- Neuromuscular e.g. LES
- Cutaneous e.g. acanthosis nigricans
- Ectopic hormone produciton e.g. PTH-RP causing hypercalcaemia
Signs of SVC obstruction?
Facial plethora, distended neck and chest veins (in distribution of SVC drainage) facial swelling, shortness of breath, cough/hoarseness/syncope. 90% have malignant cause; can be compression/invasion/thrombosis. May be aggravated by bending/stooping, improves after standing all day. Elevated JVP with absent waveform! Prognosis depends on cause e.g. may disappear with lymphoma. CXR should help with diagnosis; most common finding is widened mediastinum; may be normal CXR so CT better.
Clinical signs of pleural effusion?
Reduced expansion, tachypnoea, dull (stony dull) to percussion, mediastinum away/normal (more prominent with apex than trachea due to gravity), breath sounds absent or diminished, TVF decreased or absent (UNLIKE IN CONSOLIDATION). Bronchial breathing over level of effusion (aegophony), whispering pectoriloquy, may have pleural rub above fluid