Solid Organ Malignancy Flashcards
1
Q
How large does a tumour have to be to be palpable?
A
Usually >1cm
2
Q
How large does a tumour have to be to be palpable?
A
Usually >1cm
3
Q
Describe what is meant by a paraneoplastic effect of cancer?
A
A set of signs and symptoms that is the consequence of cancer in the body BUT unlike mass effect or metastases is not due to the local presence of cancer cells. Para-neoplastic effects are humoral mediated (e.g. by hormones or cytokines) that are secreted by the cancer cell or by an immune response against the tumour.
4
Q
List the 4 ways in which cancer can spread
A
LOCAL invasion
DISTANT - via blood, lymphatics or transcolaemic
5
Q
Describe the 2 week rule
A
It should be no more than 2 weeks from presentation to GP to the time of seeing a specialist
6
Q
Describe the 31 day rule
A
Primary treatment must start within 31 days of agreeing treatment plan with the patient
7
Q
Describe the 62 day rule
A
Primary treatment must start within 62 days of the original referral from the GP
8
Q
Define the term Carcinoma of Unknown Primary
A
Detection of one or more sites of metastatic tumour for which investigations have failed to identify a primary site
9
Q
List some of the features that make CUP different from known primary tumours
A
Early Dissemination
Unpredictable metastatic pattern
Greater Aggressiveness
Absence of symptoms due to primary tumour
10
Q
How common are CUP, list some epidemiological statistics
A
Up to 5% of all cancers
7th most frequent form of cancer
4th most common cause of cancer death in both sexes
Median age of presentation 60 years
11
Q
How common is it to identify the primary site following investigation
A
12
Q
What primary sites are commonly indicated in CUP cases?
A
Lung
Pancreas
GI
Gynaecological
13
Q
Describe what is meant by a paraneoplastic effect of cancer?
A
A set of signs and symptoms that is the consequence of cancer in the body BUT unlike mass effect or metastases is not due to the local presence of cancer cells. Para-neoplastic effects are humoral mediated (e.g. by hormones or cytokines) that are secreted by the cancer cell or by an immune response against the tumour.
14
Q
List the 4 ways in which cancer can spread
A
LOCAL invasion
DISTANT - via blood, lymphatics or transcolaemic
15
Q
Describe the 2 week rule
A
It should be no more than 2 weeks from presentation to GP to the time of seeing a specialist
16
Q
Describe the 31 day rule
A
Primary treatment must start within 31 days of agreeing treatment plan with the patient
17
Q
Describe the 62 day rule
A
Primary treatment must start within 62 days of the original referral from the GP
18
Q
Define the term Carcinoma of Unknown Primary
A
Detection of one or more sites of metastatic tumour for which investigations have failed to identify a primary site
19
Q
List some of the features that make CUP different from known primary tumours
A
Early Dissemination
Unpredictable metastatic pattern
Greater Aggressiveness
Absence of symptoms due to primary tumour
20
Q
How common are CUP, list some epidemiological statistics
A
Up to 5% of all cancers
7th most frequent form of cancer
4th most common cause of cancer death in both sexes
Median age of presentation 60 years
21
Q
How common is it to identify the primary site following investigation
A
22
Q
What primary sites are commonly indicated in CUP cases?
A
Lung
Pancreas
GI
Gynaecological
23
Q
What are the 4 major sub types of CUP on light microscopy and how common are each of them?
A
Well/moderately differentiated adenocarcinoma (50%)
Poorly/undifferentiated adenocarcinoma (30%)
Squamous Cell Carcinoma (15%)
Undifferentiated Carcinoma (5%)
N.B. also carcinomas with neuroendocrine differentiation = RARE
24
Q
List some of the initial and further investigations you may consider in a patient with CUP.
A
INITIAL
Full History and Examination (including head, neck, rectal, pelvis, breast and LN areas), FBC, Serum Biochemistry, LFTs, Urinalysis, FOB test.
FURTHER (patient dependent)
CXR, CT (chest, abdo, pelvis), Symptom directed endoscopy, plain film imaging of bone pain sites, tumour markers, mammogram (in women with adenocarcinoma histology), biopsy for histology, whole body PET-CT
25
What is the median life expectancy of someone who presents with CUP
6-9 months
26
List some of the poor prognostic factors in patients who present with CUP
```
Poorly differentiated adenocarcinoma, SCC, or neuroendocrine
LN involvement
No of metastatic sites
Male sex
Performance status (less fit do worse)
Weight loss (>10% do worse)
Serum markers like alk phos, LDH
```
27
List the stepwise approach to dealing with patients with CUP
1 - search for a primary site
2 - rule out potentially treatable or curable tumours
3 - characterize specific clinicopathological entity and treat the patient
Favourable subsets - curative intent
Unfavourable subsets - palliative intent
28
Describe the grading system for cytological samples?
```
C1 = inadequate sample
C2 = normal breast cells
C3 = cells abnormal but more likely to be benign
C4 = highly suspicious of cancer
C5 = cancer cells present
```
29
If malignant cells are found in ascites - where are the cancer cells likely to have come from?
Breast, lung, colon, stomach, pancreas, liver, biliary tree, ovary, endometrium and the peritoneum
30
List the advantages of doing each of these tests on ascitic fluid
albumin, amylase, cytology, glucose, lactate dehydrogenase, MCS, pH
Albumin - can work out SAAG, tells you if its exudative or transudative (e.g. in >1.1 indicates portal hypertension rather than malignant cause)
Amylase - tell you if pancreas is involved
Glucose - if low bacteria or cancer cells using it up
LDH - marker for high cell turnover - cancer
MSC - if looking for bacterial cuases of ascites e.g. SBP
pH - looking for lactic acidosis
31
Describe the condition xeroderma pigementosum
AUTOSOMAL RECESSIVE
Patients have defect in nucleotide excision repair (NER) pathway, that normally would repair DNA damage
This exposes them to UV induced malignancies
First malignant tumours develop as early as the 4th year.
Life expectancy around 20 years.
32
What components make up cachexia?
anorexia, weight loss, muscle wasting, anaemia, and lack of energy
Likely to be anorexia combined with metabolic derangement in cancer patients
33
What could the cause of pruritis be in a cancer patient?
```
Obstructive Jaundice
Uraemia
Hodgkin's Disease
Allergy
Dermatitis
Neuropathy
Drug reaction (often with opiates)
```
34
What could the cause of jaundice be in a cancer patient?
```
Widespread parenchymal liver metastases
Solitary parenchymal liver met near porta hepatis
LN met near porta hepatis
Drug reaction
Viral Infection
```
35
Describe how you tell if a fluid is an exudate or a transudate?
You compare the protein the fluid to that in the serum - it is always a relative measurement
More protein in fluid = exudate
More protein in serum = transudate
36
What cancers commonly spread to brain?
```
Bone
Bronchus
Breast
Melanoma
Kidney
Prostate
```
37
Describe the three steps of carcinogenesis.
INITIATION
Replication of cells where repair of chemically induced DNA damage has failed, irreversible once DNA damage has occurred. Mutation is then passed on to all daughter cells.
PROMOTION
Once a cell has been mutated by an initiator, it is susceptible to the effects of promoters. These compounds promote the proliferation of the cell, giving rise to a large number of daughter cells containing the mutation created by the initiator. Promoters have no effect when the organism in question has not been previously exposed to an initiator
PROGRESSION
Is the stepwise transformation of a benign tumor to a neoplasm and to malignancy. Progression is associated with a karyotypic change since virtually all tumors that advance are aneuploid. This karyotypic change is coupled with an increased growth rate, invasiveness, metastasis and an alteration in biochemistry and morphology
38
What cancers are particularly associated with exposure to tobacco smoke and its carcinogens?
LUNG (90% lung cancers directly attributable to smoking)
Oropharyngeal
Oesophageal
Bladder
39
What tissues are particularly susceptible to the effects of ionising radiation?
Bone Marrow, Thyroid and Breast
40
How does ionising radiation and non-ionisng radiation cause cellular damage?
IONISING
Displaces electrons from atoms resulting in an ion pair
NON-IONISING
Does not yield an ion pair, but still excites electrons, leading to DNA damage
41
Describe the cancers associated with each of the MEN syndromes
MEN1 (3Ps) - parathyroid tumours, pancreatic tumoours and phaeochromocytoma
MEN2a (2PsM) - phaeochromocytoma, parathyroid and medullary thyroid cancers
MEN2b (P2Ms) - phaochromocytoma, medullary thyroid cancer and muscosal neuromas - also marfanoid features
42
Describe the condition xeroderma pigementosum
AUTOSOMAL RECESSIVE
Patients have defect in nucleotide excision repair (NER) pathway, that normally would repair DNA damage
This exposes them to UV induced malignancies
First malignant tumours develop as early as the 4th year.
43
What caners are associated with infection of Epstein Barr Virus?
```
Nasopharyngeal Cancer
Burkitts Lymphoma
Hodgkin Lymphoma
Occasioanlly stomach cancer
EBV-related cancers are more common in Africa and parts of Southeast Asia. Overall, very few people who are infected with the virus will develop cancer.
```
44
What cancer is associated with HHV-8 infection?
Kaposi's Sarcoma
45
What cancer is associated with infection of schistosoma haematobium?
Squamous cell bladder cancer
46
What cancer is associated with infection of schistosoma japonicum?
Colorectal cancer
| Liver cancer
47
What is the association between breast cancer and oestrogen?
Risk is increased by increased exposure to endogenous oestrogens
e.g. low parity, late age at first birth, early menarche, late menopause
48
Apart from breast and ovarian, what other cancers are you at increased risk of with a BRCA1 and BRCA2 mutation?
BRCA 1
Fallopian tube, peritoneal, prostate and pancreatic cancer
BRCA 2
Prostate, Pancreatic, Fanconi anaemia
49
What is the relationship between ovarian cancer and hormones?
INCREASED OVULATIONS = INCREASED RISK OF OVARIAN CANCER
so COCP is protective (only if taken >10 years)
also having children, fewer ovulation's i.e late menarche and early menopause are protective.
50
Describe the difference between familial cancers and hereditary cancers.
FAMILIAL CANCERS
Cancers that present as clusters within families
HEREDITARY CANCERS
Are those familial cancers for which a specific inheritance pattern has been identified.
51
What name is Li-Fraumeni syndrome also known by, what cancers is it associated with and what gene is involved?
TP53 gene
| Also known as SBLA syndrome - sarcoma, breast, leukemia and adrenal gland.
52
Describe the cancers associated with each of the MEN syndromes
MEN1 (3Ps) - parathyroid tumours, pancreatic tumoours and phaeochromocytoma
MEN2 (2PsM) - phaeochromocytoma, parathyroid and medullary thyroid cancers
MEN3 (P2Ms) - phaochromocytoma, medullary thyroid cancer and muscosal neuromas
53
Describe the tumours associated with Neurofibromatosis Type 1 and Type 2
Type 1 = Neurofibromas
| Type 2 - Schwannomas (especially on vestibular nerve)
54
What are the suspicious mammographic features to look out for?
Microcalcifications
| Increase in soft tissue density
55
Describe mammographic screening programme in the UK
Women ages 50-65 years are offered one view mammographic screening every 3 years
56
Describe the UK colorectal cancer screening programme
FOB home test kit sent out every 2 years to men and women between the ages of 60-74. They can be requested after this.
57
Describe the cervical cancer screening programme in the UK
Women aged 25-49 offered smear test every 3 years
Women aged 50-64 offered smear test every 5 years
Abnormal smears should be followed up by colposcopy and biopsy
58
Describe the breast screening offered to women with a TP53 mutation and a BRCA1/BRCA2 mutation
TP53 - MRI screening from 20-49 years
BRCA1/BRCA2 - MRI 30-49 years, mammography 50-69 years
DO NOT OFFER MAMMOGRAPHY TO WOMEN UNDER 30 YEARS WITH ANY MUTATION
59
Apart from breast and ovarian, what other cancers are you at increased risk of with a BRCA1 and BRCA2 mutation?
BRCA 1
Fallopian tube, peritoneal, prostate and pancreatic cancer
BRCA 2
Prostate, Pancreatic, Fanconi anaemia
60
What histological types of lung cancer are most strongly associated with smoking?
Squamous Cell
| Small Cell
61
Describe the symptoms and signs you might hear of in a patient with SVCO?
SYMPTOMS
SOB, facial swelling, head fullness, cough, arm swelling, chest pain
SIGNS
Venous distension of neck, venous distension of chest wall, facial oedema, cyanosis, plethora of face, oedema of arms
62
Describe some of the complications of a Pancoast Tumour (apical lung tumour)?
HORNERS SYNDROME
ptosis, meiosis and anhydrosis on one side of the face due to invasion of the sympathetic ganglion
HOARSE VOICE
Due to invasion of the recurrent laryngeal nerve
THORACIC OUTLET SYNDROME
Tumour invades brachial plexus causes shoulder tip, arm and hand pain and weakness
63
Describe how testicular germ cell tumours can present
Most present with painless, solid unilateral mass in scrotum
Scrotal pain in 20% - dragging sensation
Non specific back pain 10%
Gynaecomastia (7%) due to high circulating hCG levels
Hydrocoele
Advanced disease - may present with weight loss, fatigue, and metastatic dependent symptoms.
64
Describe the two types of testicular germ cell tumours
SEMINOMA (dysgerminoma in ovary)
75% present with disease confined to testes or ovary
Spread is by lymphatics and predictable
Slow growth
No reliable tumour marker - hCG elevated in up to 25% of cases
NON-SEMINOMA
Disease spread occurs early - by lymphatics AND haematogenous spread - commonly to lungs, rarely to liver, brain and bone - signifies poor prognosis.
AFP and hCG tumour markers are elevated in 75%
65
Describe the role of tumour markers in germ cell tumours.
They can be DIAGNOSTIC in the right context i.e. a young male with a testicular mass
They can be PROGNOSTIC e.g LDH as a measure of tumour bulk
They are also essential in SURVEILLANCE, serum markers should be measured pre-orchidectomy, 24 hours post orchidectomy, weekly thereafter until normal
N.B. there is an absence of residual disease if normalise hCG in 24 hours and AFP in 4-6 days.
66
What sign on CXR should make you examine the testes in any young male?
Cannonball lung
67
Other than tumour markers, what other investigation should be done in a young male presenting with a testicular mass?
Testicular Ultrasound
| Imaging for Staging - often performed after orchidectomy.
68
What are the differential diagnoses of a testicular mass?
Benign Epididymal Mass - relatively common
Epididymo-Orchitis (if not resolved in 3 weeks should be referred)
Lymphoma/Leukaemic Infiltrate
69
Describe the follow up for testicular germ cell tumours
STAGE 1 SEMINOMA - 17% relapse
Reduced with adjuvant radiotherapy and single dose carboplatin chemotherapy
STAGE 1 NON-SEMINOMA
Relapse rate = 80% in first year, but high chance of cure with chemo
See in clinic monthly for 1 year, the bimonthly, then 3 monthly and then 6 monthly until 5 years. clinical examination and serum markers every visit, CT scan at 3 and 12 months and CXR every month for the first year.
70
Which chemotherapy agent used to treat germ tell testicular tumours is associated with pulmonary fibrosis?
Bleomycin
71
Describe the biochemical disturbances seen in tumour lysis syndrome
HYPERkalaemia
HYPERuricaemia
HYPERphosphataemia
HYPOcalcaemia
72
What are the rsik factors for getting tumour lysis syndrome?
Large volume chemo-sensitive tumour
e.g. lymphomas, leukemia's, germ cell tumours
Renal Impairment
Male
73
Describe some of the complications associated with treatment of germ cell tumours.
FERTILITY
50% will have low sperm count, all men who require chemo or radiotherapy should be offered sperm storage
CARDIOVASCULAR RISK
May decrease as mediastinal therapy now infrequent, however hypertension as a result of nephrotoxic chemotherapy remains a risk factor, patients should be advised not to smoke and GP informed of their increased cardiovascular risk
SECONDARY MALIGNANCY
Hematological malignancy after chemo (5yr latency)
Sold Organ Malignancy near radiotherapy site (15 yr latency)
PSYCHOSEXUAL ISSUES
Sexual dysfunction.body image, relationship issues, gemder issues, anxiety and depression
74
What are the indications for the contralateral testes being biopsied?
Decrease in testicular size
| Aged
75
What is a woman's lifetime risk of breast cancer?
1 in 9
76
In men presenting with breast cancer, what genetic mutation are they likely to have?
BRCA2
77
What is the approximate 5 year survival rate from breast cancer in the UK?
Approx 80% of women are alive and disease free at 5 years
78
Why is obesity a risk factor for the development of breast cancer?
Oestrogen is synthesized in brown adipose tissue
79
List some of the features of BRCA associated breast cancer?
Younger age at onset
Frequent bilateral occurence
Worse histological features e.g. more aneuploidy, higehr grade, higher proliferation indices and a higher proportion are hormone receptor negative
80
Discuss the different pathological types of breast cancer
Invasive Ductal Carcinoma (70%)
Invasive Lobular Carcinoma (most of remaining cases)
DCIS
LCIS
81
List the common sites of breast cancer metastatses
Bone 70%, Lung 60%, Liver 55%, Pleura 40%, Adrenals 35%, Skin 30%, Brain 20%
82
Describe Pagets Disease of Nipple
Excema like rash on breast, around nipple, areola area
Associated with underlying malignancy in around 50% of cases
Usually ductal carcinoma involving terminal ducts on breast
83
What would you expect to see on FNA of a cyst?
Non- Bloody Fluid
| Cyst should completely resolve after FNA
84
When should biopsy of a suspected cyst be considered?
If the fluid contains blood
If it does not completely resolve after FNA
If the cyst recurs after repeated aspirations
N.B. cystic carcinoma accounts for
85
Describe the steps in evaluating a solid mass
```
Refer to breast clinic
Triple assessment
1) Clinical Examination
2) Mammography
3) FNA or core biopsy if lump is found
```
86
Describe the different types of ways you can assess a breast lump and what they tell you?
FNA
allows for cytological examination only
Core Biopsy
can look at architectural as well as cellular characteristics
Excisional Biopsy
Involves excision of whole breast lump, it definitively establishes the diagnosis
87
how can you test for prescence of HER-2 receptors?
Immunohistochemistry
| FISH
88
List some cancers that commonly metastasise to the brain
breast, lung melanoma and colon (also CUP)
89
How would you confirm the diagnosis of leptomeningeal metastasis and how would you treat it?
Would find cancer cells in the CSF on lumbar puncture
| Treat with intrathecal chemotherapy
90
Describe what patients are recomended to undergo staging and what staging investigations are used?
Tumour > 5cm
>3 palpable lymph nodes
All should have CXR, US liver and bone scan
CT/MRI used if their is clinical suspiscion of mets
91
What drug can be taken as chemoprevention for breast cancer and how does it work?
Tamoxifen
Acts as an oestrogen antagonist via its active metabolite in the breast, so effects of endogenous oestrogen in breast is reduced
(as increases oestrogen increases risk of breast cancer)
Only prevents ER+ tumours
92
What problems are associated with using Tamoxifen as chemoprevention?
2.53 x more endometrial cancers
| Increased risk of DVT and PE
93
In patients with a positive BRCA mutation, when would breast cancer surveillance start?
5 years before onset in first degree relative
| annual clinical breast exam and MRI
94
Describe the aetiology of ovarian cancer
5-10% are from inherited defects
Increased number of ovulations increases cancer risk e.g. low parity and infertility, ovulation inducing drugs, HRT for >10 years
Note family Hx has the largest impact on relative risk
95
Describe the presenting features of ovarian cancer
Insidious onset - asymptomatic
Tumour may be 10-12 cm before impinging on adjacent organs and producing symptoms of urinary frequency and rectal pressure
Advanced disease vague IBS type picture with abdo discomfort, bloating, altered bowel habit, N&V, backache and weight loss
+constitutional symptoms of fatigue and anorexia
70% of women present with stage3/4 disease
Kindey - hydronephrosis secondary to ureteric obstruction, heamuturia, recurrent UTI, loin pain and renal failure may be presenting symptoms
Or pleural effusion causing breathlessness
96
How is the diagnosis of ovarian cancer usually made?
Histopathological study following exploratory laparotomy.
surgery should debulk tumour volume and provide sample for diagnosis
the stage of the disease can only be determined by surgery.
97
What score on RMI needs referral to a gynae oncologist?
>200
98
Describe the debulking surgery done in ovarian cancer
Total hysterectomy with BSO with omentectomy and LN resection
