solid organ malignancy Flashcards
what tests can be be done on ascitic fluid in a patient suspected of cancer?
albumin cytology glucose LDH microscopy, culture, sensitivity pH
how can you tell that a distended abdomen is due to ascites?
everted umbilicus in a normally inverted one
in a patient that presents with confusion, what serum investigation do you want to do?
calcium BM LFTs U&Es FBC
difference between corrected calcium and ionised calcium and total calcium?
calcium binds to albumin in the blood. depending on albumin levels, measured calcium can be interpreted wrongly. always interprete corrected calcium as that accounts for albumin levels
what should be done for hypercalcaemia?
hydration IV saline
bisphoshonates
haloperidol can be used as an anti-emetic, t or f
t
how to find out normal range of ESR based on age?
(age + (10 if female))/2
what type of cancers would raised AFP and Beta HCG suggest?
germ cell cancer
what would MCV be in iron deficiency anaemia?
microcytic
what kind of MCV anaemia would u get in chronic gi bleed
microcytic anaemia
what types of screening programs are there in UK, and the ages
cervical - 25
breast - 50
colon - 60
what causes transudates
organ failure - heart, liver, kidney
what causes exudates
infection, inflammation, cancer
what is a carcinoma of unknown primary?
when cancer presents with symptoms from mets, before primary site is found
difference between carcinoma of unknown primary and primary tumours
early dissemination
more aggressive
unpredictable metastatic pattern
absence of symptoms from primary tumour
4 classifications of carcinoma of unknown primary by cytology
adenocarcinoma - well differentiated
adenocarcinoma - poor/undifferentiated
squamous cell carcioma
undifferentiated carcinoma
most common cytology of carcinoma of unknown primary
well-moderately differentiated adenocarcinoma
approach to carcinoma of unknown primary?
find primary
exclude curable cancers
characterise specific aetiology of symptoms
decide treatment aim - curative or palliative
where do carcinoma of unknown primary present commonly?
screening, of if over 75 years old, 40% present at A&E
symptoms of carcinoma of unknown primary
symptoms localised to mets, lumps, mass, obstruction, ulceration,
systemic symps - weight loss, fatigue, fever, paraneoplastic effects
common endocrine paraneoplastic effects of carcinoma of unknown primary
cushings due to ACTH
SIADH due to vasopressin
hypercalcaemia due to PTHrP
how to investigate carcinoma of unknown primary (standard)
full exam incld breast, rectal, pelvic, head/neck
FBC, biochem, LFTs, calcium, urinalysis, FOB
CXR, other Xrays
CT thorax, abdomen, pelvis
specialised tests in investigating carcinoma of unknown primary
endoscopes
biopsies
cancer markers
whole body PET-CT
what can immunohistochemistry identify in investigating carcinoma of unknown primary
neuroendocrine tumours lymphomas germ cell tumours melanomas sarcomas embryonal malignancies
how can cancers spread
locally
distanty thru blood, lymph, transcoelomic
common site of mets
lymph nodes
lung
bone
liver
which lymph nodes will thoracic cancers commonly spread to
supraclavicular and axilliary
which cancers more associated with spread to inguinal and femoral LNs
uterine, cervical, vulva, vagina
what is the median survival of CUP
6-9 months
what features indicate poorer prognostic
lymph node mets
more mets
males worse than female
performance status
what is the approach to treatment in CUP
treat for palliation, reducing symptoms, improving QOL. stop when no longer benefiting
what is the sequence of spread of lung cancer
circumferentially within lobe, along bronchus
lymphatic
haematogenous
what is the order of lymphatic spread in lung cancer
ipsilateral peribronchial hilar mediastinal contralateral hilar supraclavicular
what are the common haematogenous spread sites in lung cancer
bone
liver
brain
cytological classifications of lung cancer
small cell lung cancer adenocarcinoma squamous cell carcinoma large cell malignant mesothelioma adenocarcinoma in situ
what many % of lung cancers are small cell lung cancers
20%
where do SCLCs tend to be located?
large airways, proximal location
how do SCLCs tend to present
systemic symptoms
what kind of mets are SCLCs prone to
haematogenous routes - liver, bone, brain, adrenal glands
which kind of lung cancer is more prone to endocrine paraneoplastic syndromes
small cell
what types of lung cancer is smoking most associated with
squamous cell and SCLC
a lung cancer exhibiting cavitation and air fluid level on a CXR is most likely to be what kind of cancer?
squamous cell
what is the growth pattern of sqamous cell carcinoma like?
slow, local spread, late mets
adenocarcinomas are associated with smoking - T or F
F
what kind of cells do adenocarcinomas come from?
bronchial mucosal glands
where do adenocarcinomas tend to be located
periphery
where do adenocarcinomas tend to metastasise to first?
lymph nodes
what are the risk factors of lung cancer
smoking
family history
chemical exposure - asbestos, metals, formaldehyde
clinical features of lung cancer due to local spread
cough haemoptysis breathlessness finger clubbing recurrent chest infection
hoarseness
dysphagia
SVCO
Horner’s syndrome
how does superior vena cava obstruction present
swelling of face and neck
venous distension over upper thorax
breathlessness
what are other causes of SVCO other than malignancy
thrombosis
clinical features of lung cancer due to distant spread
bone metastasis
liver failure + liver symptoms
brain mets
leptomeningeal mets
what finger signs to look out for in suspected lung cancer
tar staining
finger clubbing
how can brain mets present
headaches
seizures
neurological deficits
cognitive dysfunction
what are some paraneoplastic syndromes seen in lung cancer
ACTH - cushings
PTHrP - hypercalcaemia
SIADH - ADH
dermatomyositis, acanthosis nigricans
how does dermatomyositis look like?
rash
systemic features of inflammation
what does a non-pulsatile JVP with facial swelling and venous distension indicate?
SVCO
what CXR signs can be seen in lung cancer?
pneumonia - consolidation
pleural effusion
pulmonary collapse
how to investigate lung cancer
bedside - full body examination including lymph nodes
bloods - FBC, LFTs, ABG, calcium, U&Es
imaging - CXR, CT chest/abdo, MRI, V/Q
specialised tests - LDH, tumour markers, biopsy, lymph node sampling, pleural tap + cytology, PET/CT
how to stage lung cancer?
PET CT
what is LDH a marker of?
cell necrosis, raised in cancer
what kind of cancer will commonly show on CXR - large peripheral mass?
large cell
what kind of cancer will commonly show on CXR - central mass with hilar or mediastinal lymphadenopathy
small cell
what radiological findings can be seen in adenocarcinoma?
peripheral mass, solitary nodule, pleural effusion
what kind of lung cancers tend to be more centrall located?
small cell
squamous cell
what kind of lung cancers tend to be more peripherally located
adenocarcinoma
large cell
why is staging done when investigating lung cancer?
to determine spread, prognosis and intent of treatment
why would a cancer patient present with constipation, confusion and renal failure?
possibly hypercalcaemia. due to PTHrP endocrine paraneoplastic syndrome
treatment for hypercalcaemia?
rehydration IV saline
bisphosphonates
a known cancer patient presents with thirst, polyuria and confusion. what might be going on and how to find out?
hypercalcaemia
SIADH - hyponatraemia
U&Es and calcium test.
how can cancer cause neurological symptoms?
brain mets
spinal cord compression
bilateral upper motor neurone signs is until proven otherwise?
spinal cord compression
symptoms of spinal cord compression?
vertebral pain
sensory or motor changes below level of compression
sphincter dysfunction
cauda equina symptoms
where is spinal cord compression due to malignancy most likely?
thoracic spine
investigation for suspected spinal cord compression?
urgent MRI
how does magnesium affect calcium levels?
low magnesium causes hypocalcaemia due to inhibition of PTH.
what are some complications of cancer treatment?
neutropenic sepsis
tumour lysis syndrome
what is neutropenic sepsis?
fever or sepsis with neutropenia (<0.5 x 10^9/L)
why are cancer patients prone to neutropenic sepsis?
due to chemotherapy/radiotherapy and immunosuppression or malignant infiltration of the bone marrow itself
how to investigate neutropenic sepsis?
swab peripheral and central sites, including any venous/arterial lines
treatment for neutropenic sepsis
empirical broadspectrum antibiotics e.g. tazocin + meropenam, or metronidazole
paracetamol is a good adjunct for treating neutropenic sepsis - T or F
false, should not give paracetamol in neutropenic sepsis as it can mask on going fevers
what additional nursing actions must be taken in someone with neutropenic sepsis?
positive pressure room
barrier nursing
what causes tumour lysis syndrome?
sudden destruction of large numbers of tumour cells
and the consequential metabolic disturbance
what biochemical disturbance does tumour lysis syndrome cause?
hyperkalaemia
hyperphosphataemia
hypocalcaemia
high uric acid
what will tumour lysis syndrome cause?
renal failure
electrolyte imbalance - neurological and neuromuscular, cardiac conduction
what causes renal failure in tumour lysis syndrome
high uric acid, precipitation of phosphate and calcium
what can trigger tumour lysis syndrome?
chemotherapy
spontaenous due to tumour ischaemia
what kind of cancers are prone to tumour lysis syndrome
lymphoma
leukaemia
metastatic germ cell tumours
what are germ cell cancers?
testicular or ovarian
what are 2 classifications of germ cell cancer
seminiomas - uniform cells of sheets and cords
non-seminomatous germ cell tumours
what are examples of
non-seminomatous germ cell tumours
mature teratoma teratocarcinoma embryonal tumour yolk sac tumour choriocarcinoma
what will AFP and bHCG be like in NSGCTs
raised in 75% of cases
risk factors of germ cell tumours
genetics testicular maldescent klinfelters turner's infertility down's syndrome
2 peak age groups for testicular cancer
25-35 and 55-65
describe the spread characteristics of seminomas
slow, predictable lymphatic spread - para-aortic, then pelvic then mediastinal
haematogenous mets is common in seminomas T or F
F
describe the spread characteristics of non-seminoma tumours
similar to seminomas but less predictable, more haematogenous spread to lungs, possibly liver/brain/bone
symptoms of testicular cancer
often painless swelling/enlargement
with decreased testicular size
some will have scrotal pain
some will present with gynaecomastia, and back aches
and systemic symptoms of cancer and/or mets
what is the pain in testicular cancer often described as?
‘dragging sensation’
why is there gynaecomastia in testicular cancer?
raised HCG
what causes back ache in testicular cancer
para-aortic lymphatic spread
what are some metastatic symptoms in testicular cancer
dyspnea/cough from lungs
ureteric obstruction
SVCO
Investigations in suspected testicular cancer
examination
bloods - rule out inflammation of gonads
imaging - cxr, USS, CT
biopsy
what is the characteristic CXR finding in metstatic testicular cancer
‘cannon-ball’ mass in the lungs
what are AFP, bHCG and LDH used in testicular cancer
commonly raised, but can also present without rise.
can be good marker of surveillance and monitoring of response to treatment
LDH is marker of necrosis and,
when can tumour markers be almost diagnostic
when highly raised in the right clinical context, symptoms and patient demographics.
which type of germ call cancers are will more frequently have raised AFP and HCG
NSCGTs
what else can raise AFP alone?
HCC, alcoholics
what drug can raise HCG?
cannabis
what is the use of staging investigations in testicular cancer?
find spread, determine treatment method
when is radiological staging done?
after histological diagnosis
3 weeks after surgery
CT brain if multiple lung mets and/or HCG >10k
what else can cause testicular mass
benign epididymal mass
epididymo/orchitis
lymphoma/leukaemia infiltrate
management of testicular cancer
orchidectomy
when to biopsy contralateral testis?
if also shrunken, or <30 years old
what should be offered to the patient before orichedectomy
sperm storage
what are the options for stage 1 seminoma post-orchidectomy? what are the indications for each?
surveillance if <4cm and no rete testis involvement
radiotherapy
1x carboplatin
what is the disadvantage of radiotherapy after orchidectomy?
radiotherapy is carcinogenic itself which might cause another cancer 10-20 years later
what organ function should be assessed before commencing carboplatin?
kidney
NSGCTs have a higher relapse rate than seminomas - T or F
T
most common site of relapse in NSCGTs
abdominal nodes
post-orchidectomy, treatment is not commenced if biomarkers are up, but no imaging evidence of relapse is found. T or F
F, treat even if just biomarkers increase
how long should NSGCTs be followed up for post-orchidectomy
5 years
what is the chemotherapy offered in metastatic germ cell tumour
BEP - bleomycin, etoposide and cisplatin
what is a possible complication of bleomycin. especially in older patients
pneumonitis, lung fibrosis
what are the side effects of cisplatin
renal impairment neuropathy high tone hearing loss vomiting vascular toxicity
how will fertility be impacted in testicular cancer
most will have decreased smart count
what are 2 non-metastatic complications of testicular cancer
tumour lysis syndrome
pulmonary emboli
what are the adverse consequences of tumour lysis syndrome
renal failure
cardiac arrhythmias/arrest
disseminated intravascular coagulation
what serum biomarker is an early indicator of possible tumour lysis syndrome
LDH, or rising potassium
what prophylaxis can be given for tumour lysis syndrome, what does it do?
allopurinol - reduces uric acid
what drugs should be avoided in possible tumour lysis syndrome?
ACEI, spironolactone, NSAIDs
what is abnormal Ecadherin function associated with?
highly metastatic
where in the breast is breast cancer more common?
upper outer quadrant and retroareolar.
what are some histological classifications of breast cancer
invasive ductal carcionma - 70%
invasive lobular carcinoma - rest of maglinant cases
ductal carcinoma in situ (DCIS) - pre malignant stage
loblular carcinoma in situ - pre malignant, increased malignant risk
inflammatory breast cancer
what is inflammatory breast cancer?
invasive malignancy with inflammatory state. highly aggressive, poor prognosis, PMN infiltrates, frequently triple hormone receptor negative.
examples of inheritable genetic mutations that increase breast cancer risk
brca 1 brca 2
p53 (li fraumeni)
characteristic of breast cancer due to familial inheritance
usually younger onset bilateral frequently hormone-negative risk of other cancers familial clusters of different types of associated cancers
risk factors for dveloping breast cancer
age fmhx/cancer hx previous breast disease estrogen exposure - endogenous or exogenous (cocp/hrt/nulliparity/late menopause/early menarche) radiation obesity alcohol
symptoms of breast cancer
breast lump that persist thru menstrual cycle breast pain inflammatory signs (systemic or local) retracted nipple skin changes nipple discharge (bloody) pagets disease of breast
how does pagets disease of the breast look like?
erythematous inflammation over skin of breast, eczematous, bloody discharge, breast mass, often with invasive component
signs of breast cancer
neck/axilla lymphadenopathy
nipple discharge/retraction
breast skin change - peu d orange, erythema, nodules, ulceration, asymmetry, skin thickening
signs of metastasis
most common sites of metastasis in breast cancer?
bone - 70%
lung - 60%
liver - 55%
pleura, adrenals, skin brain
what is CA15.3 and how can it be used in breast cancer investigation
not very specific or sensitive marker of cancer.
raised in majority of late stage metastatic breast cancer
often rises in recurrence
no value in screening/diagnosis/staging
what does triple assessment in breast cancer involve?
clinical exam
mammography
FNA - core or mammtome biopsy
what does cytology C1 to 5 mean?
1 is insufficient cells 2 is normal 3 is abnormal but likely benign 4 is suspicious 5 is malignant
what are some signs of cancer on mammography
asymmetry
microcalcification
architectural cahnges
mass
what investigations to do in cystic mass?
ultrasound - determine if cystic
FNA - should resolve
if purely cystic
biopsy if bloody aspirate, or recurrence/non-resolving
what investigations to do in solid mass?
mammography
FNA + cytology
biopsy - core or biopsy
how is core biopsy done?
18 guage needle
what investigations to do in non-palpable mass?
wire excision biopsy
sterotactic guided core biopsy
ultrasound guided core biopsy
breast MRI
what form of breast imaging is preferred in younger women?
MRI, less ionising radiation
what is the benefit of hormone receptor testing breast cancer?
if tumour is hormone receptor positive, can use drugs that target that receptr e.g. herceptin on HER receptor, or tamoxifen on estrogen receptor
when should staging be done in breast cancer?
if tumour is >5 cm
or 3 or more papable nodes
or on clinical suspicion
how is staging done in breast cancer
cxr
uss
bone scan
ct/mri
management options in breast cancer?
mastectomy - partial or complete, with node clearance or sentinal biopsy
radiotherapy
chemotherapy
hormone therapy
when is radiotherapy mandatory in management of breast cancer
if mastectomy was partial
when can hormone therapy be used
postmenopausal
hormone receptor positive cancer
what is the normal function of the BRCA1 gene?
tumour suppressor, DNA repair
median age of diagnosis for ovarian cancer?
63
risk factors of ovarian cancer
family history gene mutation nulliparity ovulation inducing drugs talcum powder obesity early menarche, late menopause
proctective factors against ovarian cancer
having children
COCP
lactation
pregnancy
2 classifications of ovarian histology types
epithelial and non epithelial
most common epithelial ovarian cancer type
serous - from fallopian tube epithelium
e.g. of non epithelial ovarian tumour
sex cords
germ cell
sarcoma/carcinosarcomas
describe the typical pattenr of spread in ovarian cancer
local organs
peritoneal cavity
lymphatics
blood
clinical features of ovarian cancer
many asymptomatic bloating, fullness ascites pelvic mass urinary/bowel symptoms abnormal menses
what kind of presentations in ovarian cancer are more indicative of malignancy
rapid growth
ascites
advanced age
bilateral masses
ovaries in patients with ovarian cancer are very commonly enlarged - T or F
F, can be normal sized
how does ovarian cancer cause kidney problems?
ureteric obstruction leading to hydronephrosis, haematuria, uti, loin pain, renal failure
what is stage 1 2 3 4 in ovarian cancer staging
1 - in ovaries
2- local organs
3-abdominal
4-distant organs
investigations required in suspected ovarian cancer
bloods, fbc, u&e, lfts, calcium, tfts,
cxr
uss
CT
tumour markers
what tumour marker is commonly used in assessing ovarian cancer risk
CA-125
how is ovarian cancer diagnosed?
exploratory laparotomy with biopsy with peritoneal washing and cytology
what is assessed in risk of malignancy index of cancer
menopausal status
ultrasound features
level of ca125
what is the RMI cut off for referral to gynae oncologist
200
how is CA125 interpreted?
not diagnostic, but the higher its raised, the more likely it is to be cancer.
how is ovarian cancer managed?
surgery
chemo
radio
how is ovarian cancer monitored?
using ca125 and USS
complications of ovarian cancer - local invasion, metastatic, non-metastatic
lymphodema vaginal discharge bowel obstruction malignant ascites pleural effusion
metastasis - lung, liver, bone, brain
dermatomyositis
pulmonary embolus
what is dermatomyositis
inflammatory myopathy, associated with cancers, can be a warning sign of relapse
features of dermatomyositis
proximal myopathy
skin changed - erythematous papules
systemic features - arthalgia, retinopathy, cardiopulmonary features
how to diagnose dermatomyositis
clinical picture “gottrons patches”
serum - CK, LDH, aldolase, autoantibodies
EMG studies
muscle biopsy
how to investigate malignant ascites?
examination
LFTs (albumin)
ultrasound
tap and cytology
what 3 broad things can raise CA125?
inflammation
infection
infarction
what does TTF1 tumour factor mean and what does a negative reading mean?
thyroid transcription factor. if negative, can rule out lung cancer
what does a positive CEA suggest?
GI malignancy
if a PSA is over 500, what is the most likely diagnosis
prostate cancer
what syndrome is characterised by polypopsis, osteomas, fibromas and sebaceous cysts
Gardner’s syndrome
what is the diagnosis criteria for Li fraumeni syndrome?
- sarcoma <45 years old
- FDR with any cancer <45
- FDR or SDR with any cancer <45 or sarcoma any age
what cancers are most associated with li fraumeni syndrome
breast, sarcomas (soft tissue and bone), brain tumours, leukaemia, lymphoma, adrenocortical carcinoma
what cancers are most associated with HNPCC
colorectal, endometrial, stomach,
what cancers are most associated with FAP
colorectal, duodenum, stomach
type of lung cancer with the worst prognosis
small cell lung cancer
most common type of lung cancer
adenocarcinoma
what are these tumor markers associated with
AFP CA125 CA15-3 CA19-9 CEA b-HCG
AFP - NSGCT, HCC CA125 - ovarieas CA15-3 - breast CA19-9 pancreas, ovaries CEA - colorectal b-HCG - choriocarcinoma
