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4 CSIM2 > solid organ malignancy > Flashcards

solid organ malignancy Flashcards

1
Q

what tests can be be done on ascitic fluid in a patient suspected of cancer?

A 
albumin
cytology
glucose
LDH
microscopy, culture, sensitivity
pH
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2
Q

how can you tell that a distended abdomen is due to ascites?

A

everted umbilicus in a normally inverted one

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3
Q

in a patient that presents with confusion, what serum investigation do you want to do?

A 
calcium
BM
LFTs
U&Es
FBC
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4
Q

difference between corrected calcium and ionised calcium and total calcium?

A

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

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5
Q

what should be done for hypercalcaemia?

A

hydration IV saline

bisphoshonates

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6
Q

haloperidol can be used as an anti-emetic, t or f

A

t

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7
Q

how to find out normal range of ESR based on age?

A

(age + (10 if female))/2

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8
Q

what type of cancers would raised AFP and Beta HCG suggest?

A

germ cell cancer

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9
Q

what would MCV be in iron deficiency anaemia?

A

microcytic

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10
Q

what kind of MCV anaemia would u get in chronic gi bleed

A

microcytic anaemia

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11
Q

what types of screening programs are there in UK, and the ages

A

cervical - 25
breast - 50
colon - 60

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12
Q

what causes transudates

A

organ failure - heart, liver, kidney

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13
Q

what causes exudates

A

infection, inflammation, cancer

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14
Q

what is a carcinoma of unknown primary?

A

when cancer presents with symptoms from mets, before primary site is found

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15
Q

difference between carcinoma of unknown primary and primary tumours

A

early dissemination
more aggressive
unpredictable metastatic pattern
absence of symptoms from primary tumour

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16
Q

4 classifications of carcinoma of unknown primary by cytology

A

adenocarcinoma - well differentiated
adenocarcinoma - poor/undifferentiated
squamous cell carcioma
undifferentiated carcinoma

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17
Q

most common cytology of carcinoma of unknown primary

A

well-moderately differentiated adenocarcinoma

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18
Q

approach to carcinoma of unknown primary?

A

find primary

exclude curable cancers

characterise specific aetiology of symptoms
decide treatment aim - curative or palliative

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19
Q

where do carcinoma of unknown primary present commonly?

A

screening, of if over 75 years old, 40% present at A&E

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20
Q

symptoms of carcinoma of unknown primary

A

symptoms localised to mets, lumps, mass, obstruction, ulceration,

systemic symps - weight loss, fatigue, fever, paraneoplastic effects

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21
Q

common endocrine paraneoplastic effects of carcinoma of unknown primary

A

cushings due to ACTH
SIADH due to vasopressin
hypercalcaemia due to PTHrP

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22
Q

how to investigate carcinoma of unknown primary (standard)

A

full exam incld breast, rectal, pelvic, head/neck

FBC, biochem, LFTs, calcium, urinalysis, FOB

CXR, other Xrays
CT thorax, abdomen, pelvis

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23
Q

specialised tests in investigating carcinoma of unknown primary

A

endoscopes
biopsies
cancer markers
whole body PET-CT

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24
Q

what can immunohistochemistry identify in investigating carcinoma of unknown primary

A 
neuroendocrine tumours
lymphomas
germ cell tumours
melanomas
sarcomas
embryonal malignancies
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25
Q

how can cancers spread

A

locally

distanty thru blood, lymph, transcoelomic

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26
Q

common site of mets

A

lymph nodes
lung
bone
liver

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27
Q

which lymph nodes will thoracic cancers commonly spread to

A

supraclavicular and axilliary

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28
Q

which cancers more associated with spread to inguinal and femoral LNs

A

uterine, cervical, vulva, vagina

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29
Q

what is the median survival of CUP

A

6-9 months

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30
Q

what features indicate poorer prognostic

A

lymph node mets
more mets
males worse than female
performance status

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31
Q

what is the approach to treatment in CUP

A

treat for palliation, reducing symptoms, improving QOL. stop when no longer benefiting

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32
Q

what is the sequence of spread of lung cancer

A

circumferentially within lobe, along bronchus

lymphatic

haematogenous

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33
Q

what is the order of lymphatic spread in lung cancer

A 
ipsilateral peribronchial
hilar
mediastinal
contralateral hilar
supraclavicular
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34
Q

what are the common haematogenous spread sites in lung cancer

A

bone
liver
brain

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35
Q

cytological classifications of lung cancer

A 
small cell lung cancer
adenocarcinoma
squamous cell carcinoma
large cell 
malignant mesothelioma
adenocarcinoma in situ
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36
Q

what many % of lung cancers are small cell lung cancers

A

20%

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37
Q

where do SCLCs tend to be located?

A

large airways, proximal location

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38
Q

how do SCLCs tend to present

A

systemic symptoms

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39
Q

what kind of mets are SCLCs prone to

A

haematogenous routes - liver, bone, brain, adrenal glands

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40
Q

which kind of lung cancer is more prone to endocrine paraneoplastic syndromes

A

small cell

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41
Q

what types of lung cancer is smoking most associated with

A

squamous cell and SCLC

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42
Q

a lung cancer exhibiting cavitation and air fluid level on a CXR is most likely to be what kind of cancer?

A

squamous cell

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43
Q

what is the growth pattern of sqamous cell carcinoma like?

A

slow, local spread, late mets

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44
Q

adenocarcinomas are associated with smoking - T or F

A

F

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45
Q

what kind of cells do adenocarcinomas come from?

A

bronchial mucosal glands

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46
Q

where do adenocarcinomas tend to be located

A

periphery

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47
Q

where do adenocarcinomas tend to metastasise to first?

A

lymph nodes

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48
Q

what are the risk factors of lung cancer

A

smoking
family history
chemical exposure - asbestos, metals, formaldehyde

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49
Q

clinical features of lung cancer due to local spread

A 
cough
haemoptysis
breathlessness
finger clubbing
recurrent chest infection

hoarseness
dysphagia
SVCO
Horner’s syndrome

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50
Q

how does superior vena cava obstruction present

A

swelling of face and neck
venous distension over upper thorax
breathlessness

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51
Q

what are other causes of SVCO other than malignancy

A

thrombosis

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52
Q

clinical features of lung cancer due to distant spread

A

bone metastasis
liver failure + liver symptoms
brain mets
leptomeningeal mets

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53
Q

what finger signs to look out for in suspected lung cancer

A

tar staining

finger clubbing

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54
Q

how can brain mets present

A

headaches
seizures
neurological deficits
cognitive dysfunction

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55
Q

what are some paraneoplastic syndromes seen in lung cancer

A

ACTH - cushings
PTHrP - hypercalcaemia
SIADH - ADH
dermatomyositis, acanthosis nigricans

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56
Q

how does dermatomyositis look like?

A

rash

systemic features of inflammation

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57
Q

what does a non-pulsatile JVP with facial swelling and venous distension indicate?

A

SVCO

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58
Q

what CXR signs can be seen in lung cancer?

A

pneumonia - consolidation
pleural effusion
pulmonary collapse

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59
Q

how to investigate lung cancer

A

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

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60
Q

how to stage lung cancer?

A

PET CT

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61
Q

what is LDH a marker of?

A

cell necrosis, raised in cancer

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62
Q

what kind of cancer will commonly show on CXR - large peripheral mass?

A

large cell

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63
Q

what kind of cancer will commonly show on CXR - central mass with hilar or mediastinal lymphadenopathy

A

small cell

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64
Q

what radiological findings can be seen in adenocarcinoma?

A

peripheral mass, solitary nodule, pleural effusion

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65
Q

what kind of lung cancers tend to be more centrall located?

A

small cell

squamous cell

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66
Q

what kind of lung cancers tend to be more peripherally located

A

adenocarcinoma

large cell

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67
Q

why is staging done when investigating lung cancer?

A

to determine spread, prognosis and intent of treatment

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68
Q

why would a cancer patient present with constipation, confusion and renal failure?

A

possibly hypercalcaemia. due to PTHrP endocrine paraneoplastic syndrome

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69
Q

treatment for hypercalcaemia?

A

rehydration IV saline

bisphosphonates

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70
Q

a known cancer patient presents with thirst, polyuria and confusion. what might be going on and how to find out?

A

hypercalcaemia
SIADH - hyponatraemia

U&Es and calcium test.

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71
Q

how can cancer cause neurological symptoms?

A

brain mets

spinal cord compression

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72
Q

bilateral upper motor neurone signs is until proven otherwise?

A

spinal cord compression

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73
Q

symptoms of spinal cord compression?

A

vertebral pain
sensory or motor changes below level of compression
sphincter dysfunction
cauda equina symptoms

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74
Q

where is spinal cord compression due to malignancy most likely?

A

thoracic spine

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75
Q

investigation for suspected spinal cord compression?

A

urgent MRI

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76
Q

how does magnesium affect calcium levels?

A

low magnesium causes hypocalcaemia due to inhibition of PTH.

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77
Q

what are some complications of cancer treatment?

A

neutropenic sepsis

tumour lysis syndrome

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78
Q

what is neutropenic sepsis?

A

fever or sepsis with neutropenia (<0.5 x 10^9/L)

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79
Q

why are cancer patients prone to neutropenic sepsis?

A

due to chemotherapy/radiotherapy and immunosuppression or malignant infiltration of the bone marrow itself

80
Q

how to investigate neutropenic sepsis?

A

swab peripheral and central sites, including any venous/arterial lines

81
Q

treatment for neutropenic sepsis

A

empirical broadspectrum antibiotics e.g. tazocin + meropenam, or metronidazole

82
Q

paracetamol is a good adjunct for treating neutropenic sepsis - T or F

A

false, should not give paracetamol in neutropenic sepsis as it can mask on going fevers

83
Q

what additional nursing actions must be taken in someone with neutropenic sepsis?

A

positive pressure room

barrier nursing

84
Q

what causes tumour lysis syndrome?

A

sudden destruction of large numbers of tumour cells

and the consequential metabolic disturbance

85
Q

what biochemical disturbance does tumour lysis syndrome cause?

A

hyperkalaemia
hyperphosphataemia
hypocalcaemia
high uric acid

86
Q

what will tumour lysis syndrome cause?

A

renal failure

electrolyte imbalance - neurological and neuromuscular, cardiac conduction

87
Q

what causes renal failure in tumour lysis syndrome

A

high uric acid, precipitation of phosphate and calcium

88
Q

what can trigger tumour lysis syndrome?

A

chemotherapy

spontaenous due to tumour ischaemia

89
Q

what kind of cancers are prone to tumour lysis syndrome

A

lymphoma
leukaemia
metastatic germ cell tumours

90
Q

what are germ cell cancers?

A

testicular or ovarian

91
Q

what are 2 classifications of germ cell cancer

A

seminiomas - uniform cells of sheets and cords

non-seminomatous germ cell tumours

92
Q

what are examples of

non-seminomatous germ cell tumours

A 
mature teratoma
teratocarcinoma
embryonal tumour
yolk sac tumour
choriocarcinoma
93
Q

what will AFP and bHCG be like in NSGCTs

A

raised in 75% of cases

94
Q

risk factors of germ cell tumours

A 
genetics
testicular maldescent
klinfelters
turner's 
infertility
down's syndrome
95
Q

2 peak age groups for testicular cancer

A

25-35 and 55-65

96
Q

describe the spread characteristics of seminomas

A

slow, predictable lymphatic spread - para-aortic, then pelvic then mediastinal

97
Q

haematogenous mets is common in seminomas T or F

A

F

98
Q

describe the spread characteristics of non-seminoma tumours

A

similar to seminomas but less predictable, more haematogenous spread to lungs, possibly liver/brain/bone

99
Q

symptoms of testicular cancer

A

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

100
Q

what is the pain in testicular cancer often described as?

A

‘dragging sensation’

101
Q

why is there gynaecomastia in testicular cancer?

A

raised HCG

102
Q

what causes back ache in testicular cancer

A

para-aortic lymphatic spread

103
Q

what are some metastatic symptoms in testicular cancer

A

dyspnea/cough from lungs
ureteric obstruction
SVCO

104
Q

Investigations in suspected testicular cancer

A

examination
bloods - rule out inflammation of gonads
imaging - cxr, USS, CT
biopsy

105
Q

what is the characteristic CXR finding in metstatic testicular cancer

A

‘cannon-ball’ mass in the lungs

106
Q

what are AFP, bHCG and LDH used in testicular cancer

A

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,

107
Q

when can tumour markers be almost diagnostic

A

when highly raised in the right clinical context, symptoms and patient demographics.

108
Q

which type of germ call cancers are will more frequently have raised AFP and HCG

A

NSCGTs

109
Q

what else can raise AFP alone?

A

HCC, alcoholics

110
Q

what drug can raise HCG?

A

cannabis

111
Q

what is the use of staging investigations in testicular cancer?

A

find spread, determine treatment method

112
Q

when is radiological staging done?

A

after histological diagnosis

3 weeks after surgery

CT brain if multiple lung mets and/or HCG >10k

113
Q

what else can cause testicular mass

A

benign epididymal mass
epididymo/orchitis
lymphoma/leukaemia infiltrate

114
Q

management of testicular cancer

A

orchidectomy

115
Q

when to biopsy contralateral testis?

A

if also shrunken, or <30 years old

116
Q

what should be offered to the patient before orichedectomy

A

sperm storage

117
Q

what are the options for stage 1 seminoma post-orchidectomy? what are the indications for each?

A

surveillance if <4cm and no rete testis involvement

radiotherapy
1x carboplatin

118
Q

what is the disadvantage of radiotherapy after orchidectomy?

A

radiotherapy is carcinogenic itself which might cause another cancer 10-20 years later

119
Q

what organ function should be assessed before commencing carboplatin?

A

kidney

120
Q

NSGCTs have a higher relapse rate than seminomas - T or F

A

T

121
Q

most common site of relapse in NSCGTs

A

abdominal nodes

122
Q

post-orchidectomy, treatment is not commenced if biomarkers are up, but no imaging evidence of relapse is found. T or F

A

F, treat even if just biomarkers increase

123
Q

how long should NSGCTs be followed up for post-orchidectomy

A

5 years

124
Q

what is the chemotherapy offered in metastatic germ cell tumour

A

BEP - bleomycin, etoposide and cisplatin

125
Q

what is a possible complication of bleomycin. especially in older patients

A

pneumonitis, lung fibrosis

126
Q

what are the side effects of cisplatin

A 
renal impairment
neuropathy
high tone hearing loss
vomiting
vascular toxicity
127
Q

how will fertility be impacted in testicular cancer

A

most will have decreased smart count

128
Q

what are 2 non-metastatic complications of testicular cancer

A

tumour lysis syndrome

pulmonary emboli

129
Q

what are the adverse consequences of tumour lysis syndrome

A

renal failure
cardiac arrhythmias/arrest
disseminated intravascular coagulation

130
Q

what serum biomarker is an early indicator of possible tumour lysis syndrome

A

LDH, or rising potassium

131
Q

what prophylaxis can be given for tumour lysis syndrome, what does it do?

A

allopurinol - reduces uric acid

132
Q

what drugs should be avoided in possible tumour lysis syndrome?

A

ACEI, spironolactone, NSAIDs

133
Q

what is abnormal Ecadherin function associated with?

A

highly metastatic

134
Q

where in the breast is breast cancer more common?

A

upper outer quadrant and retroareolar.

135
Q

what are some histological classifications of breast cancer

A

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

136
Q

what is inflammatory breast cancer?

A

invasive malignancy with inflammatory state. highly aggressive, poor prognosis, PMN infiltrates, frequently triple hormone receptor negative.

137
Q

examples of inheritable genetic mutations that increase breast cancer risk

A

brca 1 brca 2

p53 (li fraumeni)

138
Q

characteristic of breast cancer due to familial inheritance

A 
usually younger onset
bilateral
frequently hormone-negative
risk of other cancers
familial clusters of different types of associated cancers
139
Q

risk factors for dveloping breast cancer

A 
age
fmhx/cancer hx
previous breast disease
estrogen exposure - endogenous or exogenous (cocp/hrt/nulliparity/late menopause/early menarche)
radiation
obesity
alcohol
140
Q

symptoms of breast cancer

A 
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
141
Q

how does pagets disease of the breast look like?

A

erythematous inflammation over skin of breast, eczematous, bloody discharge, breast mass, often with invasive component

142
Q

signs of breast cancer

A

neck/axilla lymphadenopathy
nipple discharge/retraction
breast skin change - peu d orange, erythema, nodules, ulceration, asymmetry, skin thickening
signs of metastasis

143
Q

most common sites of metastasis in breast cancer?

A

bone - 70%
lung - 60%
liver - 55%
pleura, adrenals, skin brain

144
Q

what is CA15.3 and how can it be used in breast cancer investigation

A

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

145
Q

what does triple assessment in breast cancer involve?

A

clinical exam
mammography
FNA - core or mammtome biopsy

146
Q

what does cytology C1 to 5 mean?

A 
1 is insufficient cells
2 is normal
3 is abnormal but likely benign
4 is suspicious
5 is malignant
147
Q

what are some signs of cancer on mammography

A

asymmetry
microcalcification
architectural cahnges
mass

148
Q

what investigations to do in cystic mass?

A

ultrasound - determine if cystic
FNA - should resolve
if purely cystic
biopsy if bloody aspirate, or recurrence/non-resolving

149
Q

what investigations to do in solid mass?

A

mammography
FNA + cytology
biopsy - core or biopsy

150
Q

how is core biopsy done?

A

18 guage needle

151
Q

what investigations to do in non-palpable mass?

A

wire excision biopsy
sterotactic guided core biopsy
ultrasound guided core biopsy
breast MRI

152
Q

what form of breast imaging is preferred in younger women?

A

MRI, less ionising radiation

153
Q

what is the benefit of hormone receptor testing breast cancer?

A

if tumour is hormone receptor positive, can use drugs that target that receptr e.g. herceptin on HER receptor, or tamoxifen on estrogen receptor

154
Q

when should staging be done in breast cancer?

A

if tumour is >5 cm
or 3 or more papable nodes
or on clinical suspicion

155
Q

how is staging done in breast cancer

A

cxr
uss
bone scan
ct/mri

156
Q

management options in breast cancer?

A

mastectomy - partial or complete, with node clearance or sentinal biopsy
radiotherapy
chemotherapy
hormone therapy

157
Q

when is radiotherapy mandatory in management of breast cancer

A

if mastectomy was partial

158
Q

when can hormone therapy be used

A

postmenopausal

hormone receptor positive cancer

159
Q

what is the normal function of the BRCA1 gene?

A

tumour suppressor, DNA repair

160
Q

median age of diagnosis for ovarian cancer?

A

63

161
Q

risk factors of ovarian cancer

A 
family history
gene mutation
nulliparity
ovulation inducing drugs
talcum powder
obesity
early menarche, late menopause
162
Q

proctective factors against ovarian cancer

A

having children
COCP
lactation
pregnancy

163
Q

2 classifications of ovarian histology types

A

epithelial and non epithelial

164
Q

most common epithelial ovarian cancer type

A

serous - from fallopian tube epithelium

165
Q

e.g. of non epithelial ovarian tumour

A

sex cords
germ cell
sarcoma/carcinosarcomas

166
Q

describe the typical pattenr of spread in ovarian cancer

A

local organs
peritoneal cavity
lymphatics
blood

167
Q

clinical features of ovarian cancer

A 
many asymptomatic
bloating, fullness
ascites
pelvic mass
urinary/bowel symptoms
abnormal menses
168
Q

what kind of presentations in ovarian cancer are more indicative of malignancy

A

rapid growth
ascites
advanced age
bilateral masses

169
Q

ovaries in patients with ovarian cancer are very commonly enlarged - T or F

A

F, can be normal sized

170
Q

how does ovarian cancer cause kidney problems?

A

ureteric obstruction leading to hydronephrosis, haematuria, uti, loin pain, renal failure

171
Q

what is stage 1 2 3 4 in ovarian cancer staging

A

1 - in ovaries
2- local organs
3-abdominal
4-distant organs

172
Q

investigations required in suspected ovarian cancer

A

bloods, fbc, u&e, lfts, calcium, tfts,

cxr
uss
CT

tumour markers

173
Q

what tumour marker is commonly used in assessing ovarian cancer risk

A

CA-125

174
Q

how is ovarian cancer diagnosed?

A

exploratory laparotomy with biopsy with peritoneal washing and cytology

175
Q

what is assessed in risk of malignancy index of cancer

A

menopausal status
ultrasound features
level of ca125

176
Q

what is the RMI cut off for referral to gynae oncologist

A

200

177
Q

how is CA125 interpreted?

A

not diagnostic, but the higher its raised, the more likely it is to be cancer.

178
Q

how is ovarian cancer managed?

A

surgery
chemo
radio

179
Q

how is ovarian cancer monitored?

A

using ca125 and USS

180
Q

complications of ovarian cancer - local invasion, metastatic, non-metastatic

A 
lymphodema
vaginal discharge
bowel obstruction
malignant ascites
pleural effusion

metastasis - lung, liver, bone, brain

dermatomyositis
pulmonary embolus

181
Q

what is dermatomyositis

A

inflammatory myopathy, associated with cancers, can be a warning sign of relapse

182
Q

features of dermatomyositis

A

proximal myopathy
skin changed - erythematous papules

systemic features - arthalgia, retinopathy, cardiopulmonary features

183
Q

how to diagnose dermatomyositis

A

clinical picture “gottrons patches”

serum - CK, LDH, aldolase, autoantibodies

EMG studies

muscle biopsy

184
Q

how to investigate malignant ascites?

A

examination
LFTs (albumin)
ultrasound
tap and cytology

185
Q

what 3 broad things can raise CA125?

A

inflammation
infection
infarction

186
Q

what does TTF1 tumour factor mean and what does a negative reading mean?

A

thyroid transcription factor. if negative, can rule out lung cancer

187
Q

what does a positive CEA suggest?

A

GI malignancy

188
Q

if a PSA is over 500, what is the most likely diagnosis

A

prostate cancer

189
Q

what syndrome is characterised by polypopsis, osteomas, fibromas and sebaceous cysts

A

Gardner’s syndrome

190
Q

what is the diagnosis criteria for Li fraumeni syndrome?

A
  1. sarcoma <45 years old
  2. FDR with any cancer <45
  3. FDR or SDR with any cancer <45 or sarcoma any age
191
Q

what cancers are most associated with li fraumeni syndrome

A

breast, sarcomas (soft tissue and bone), brain tumours, leukaemia, lymphoma, adrenocortical carcinoma

192
Q

what cancers are most associated with HNPCC

A

colorectal, endometrial, stomach,

193
Q

what cancers are most associated with FAP

A

colorectal, duodenum, stomach

194
Q

type of lung cancer with the worst prognosis

A

small cell lung cancer

195
Q

most common type of lung cancer

A

adenocarcinoma

196
Q

what are these tumor markers associated with

AFP
CA125
CA15-3
CA19-9
CEA
b-HCG
A 
AFP - NSGCT, HCC
CA125 - ovarieas
CA15-3 - breast
CA19-9 pancreas, ovaries
CEA - colorectal
b-HCG - choriocarcinoma

4 CSIM2 (11 decks)

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