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Cancer care > Solid tumours > Flashcards

Solid tumours Flashcards

1
Q

What is the most common cancer?

A

Lung cancer

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2
Q

Where do lung cancers arise from?

A

Malignant epithelial cells

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3
Q

What is the prognosis of lung cancer?

A

Poor (5 year survival rate of 17%)

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4
Q

What are the two categories of lung cancer?

A

Non-small cell carcinoma (adenocarcinoma, squamous cell carcinoma, large cell carcinoma)

Small cell carcinoma

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5
Q

Where are adenocarcinomas found and what are their clinical features?

A

Peripherally (smaller airways)

More common in non-smokers and asian females

Metastasise early

Respond well to immunotherapy

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6
Q

What are the features of squamous cell carcinoma and where are they found?

A

Cenrally (in the bronchi)

More common in smokers

Secrete PTHrP = hypercalcaemia

Metastasise late (via lymph nodes)

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7
Q

What are the features of large cell carcinoma and where are they found?

A

Located peripherally and centrally

More common in smokers, metastasise early

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8
Q

What are the features of small cell carcinoma and where is it found?

A

Located centrally (poorly-differentiated)

More common in older smokers

Metastasise early

Secrete ACTH (cushing’s syndrome) and ADH (SIADH)

Associated with Lambert-Eaton syndrome

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9
Q

What are the risk factors for lung cancer?

A

Tobacco smoking

Air pollution (indoor and outdoor)

FH of cancer, especially lung cancer

Male sex

Radon gas (miners)

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10
Q

Which symptoms indicate lung cancer?

A

Unexplained cough 3 weeks (with / without haemoptysis)

Weight loss (>5% in last 6 months)

New onset dyspnoea

Pleuritic chest pain (tumour invade pleura)

Bone pain (mets - spine, pelvis, long bones)

Fatigue (anaemia of chronic disease)

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11
Q

What else to cover in history of lung cancer?

A

Family history (lung cancer in 1st degree relative - doubles risk of LC)

Smoking history (quantify in pack-years)

Occupation

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12
Q

What examination to perform for suspected lung cancer? Name some suggestive findings?

A

Full respiratory examination

Cachexia (increased resting energy expenditure and lipolysis)

Finger clubbing (unknown mechanism - may be due to increase in GH causing extracellular matric in nails to grow)

Dullness to percussion

Cervical lymphadenopathy (mets to lymphatic system)

Wheeze on auscultation (tumour blocks airway0

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13
Q

When to refer on 2WW for suspected lung cancer?

A

“Red flag symptoms”

X-ray findings suggestive of lung cancer

Over 40 and unexplained haemoptysis

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14
Q

What is a 2WW referral?

A

Hospital must see pt within 2 weeks of receiving the referral form

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15
Q

Which patients must recieve an urgent chest x-ray (within 2 weeks)?

A

Over 40 + 2 x (weight loss, appetite loss, cough, dyspnoea, chest pain, fatigue)

1 additional symptom if ever smoked

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16
Q

What are the differential diagnoses for lung cancer?

A

Tuberculosis

Mets to lungs from other sites

Sarcoidosis

Granulomatosis with polyangiitis (Wegener’s disease)

Non-Hodgkin’s lymphoma

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17
Q

What features are unique to TB?

A

Drenching night sweats

Positive sputum culture and microscopy

CXR: cavitating lesion / hilar lymphadenopathy

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18
Q

Which features are unique to mets to the lungs from other sites?

A

Symptoms of primary tumour (haematuria due to RCC)

CT head-abdo pelvis (shows primary tumour)

FDG-PET: increased uptake at primary tumour site

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19
Q

Which features are unique to sarcoidosis?

A

Enlarged parotids

Skin signs e.g. erythema nodosum and lupus pernio

Tissue biopsy: non-caseating granulomas

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20
Q

Which features are unique to granulomatosis with polyangiitis (Wegener’s disease)?

A

Saddle nose deformity

Positive cANCA

Urinalysis: haematuria, proteinuria, red cell casts

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21
Q

Which features are unique to Non-Hodgkin’s lymphoma?

A

Drenching night sweats

Hepatosplenomegaly

Positive lymph node biopsy (anti-CD20 strain)

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22
Q

What are some bedside investigations for lung cancer?

A

Pulse oximetry: aim for 94-98% ot 88-92% if patient has COPD

ECG: always pre-operatively

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23
Q

What are the lab investigations for lung cancer?

A

FBC (anaemia)

LFTs (raised ALP and GGT = hepatic mets raised ALP alone = bone mets)

U&E: for baseline before treatment (hyponatraemia = SIADH - small cell carcinoma)

Serum calcium: elevated with secretion of PTH-related protein (PTHrP) more common in squamous cell carcinoma

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24
Q

What imaging is required in lung cancer?

A

CXR - first line (opacities, pleural effusion, lung collapse)

CT chest-abdo-pelvis - confirm findings / look for mets

Bronchoscopy and biopsy - directly visualise tumour, biopsy taken (lung cancer subtype, and presence of targetable mutations e.g. EGFR) - essential for diagnosis

PET-CT (positron emission tomography CT) for staging

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25
Q

Which staging classification is first used for lung cancer?

A

TNM staging

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26
Q

What is stage 1-IV for lung cancer?

A

Stage I = One small tumour (<4cm) in one lung

Stage II = Larger tumour (>4cm) in nearby lymph nodes

Stage III = Spread to contralateral lymph nodes or grown into structures e.g. trachea

Stage IV = Spread to lymph nodes outside of chest or other organs (e.g. liver)

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27
Q

What is the treatment of non-small cell lung cancer?

A

Stage I-III

Sugery: lobectomy/pneumonectomy for intact lung function or wedge resection in patients with reduced function e.g. elderly, underlying respiratory conditions

Pre-op chemo

Post-op chemo and radiotherapy

Stage IV

Targeted therapies: target mutations which drive the pathogenesis of lung cancer

Immunotherapy: target immune checkpoints which prevent immune system from killing tumour cells

Chemotherapy: important for patients without mutations that can be targeted

Paliative care: including palliative radiotherapy for mets and symptom control

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28
Q

What targatable mutations exist in lung cancer?

A

EGFR

ALK

ROS1

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29
Q

What is the treatment of small cell lung cancer?

A

Chemotherapy and radiotherapy

Surgery: rare in small cell lung cancer (usually present with advanced disease)

Prophylactic cranial irradiation (as its associated with brain mets, radiotherapy is directed at brain)

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30
Q

What are some disease related complications of lung cancer?

A

Horners syndrome (due to pancoast tumour) in the lung apex infiltrating the brachial plexus - ptosis, miosis, anhidrosis, enophthalmos

SVC obstruction - tumour compresses SVC causing facial swelling and distended neck / chest veins

Paraneoplastic syndromes: e.g. SIADH and Lambert-Eaton syndrome

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31
Q

What are some treatment related complications for lung cancer?

A

Due to chemotherapy: alopecia, neutropaenia, bone marrow toxicity

Due to radiotherapy: mucositis, pneumonitis, oesophagitis

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32
Q

What is the most common malignancy affecting women in the UK?

A

Breast cancer

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33
Q

What are the risk factors for breast cancer?

A

Female gender

Age

FH (or personal history)

Genetic predispositions (e.g. BRCA1, BRCA 2)

Early menarche and late menopause

Nulliparity

Increased age of first pregnancy

Multiparity (risk increased in period after birth, then protective later in life)

COCP (still debated, effect likely minimal)

HRT

White ethnicity

Exposure to radiation

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34
Q

Where are BRCA1 and BRCA2 genes found respectively? What do they cause?

A

BRCA1 - mutation on chromosome 17

BRCA2 - mutation on chromosome 13

Increase risk of breast and ovarian cancer

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35
Q

Label the following:

A
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36
Q

What are the categories of breast cancer?

A

Carcinomas = Ductal or lobular (in situ or invasive - if penetrating basement membrane)

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37
Q

What is the most common invasive breast cancer?

A

Invasive ductal carcinoma

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38
Q

What are the molecular subtypes of breast cancer based on gene expression?

A

Luminal A

Luminal B

Basal

HER2

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39
Q

What age is breast cancer screening offered?

A

50 - 71 for women and transmen

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40
Q

Which imaging is used for breast cancer screening? What are the possible results?

A

Mammogram

Satisfactory: no evidence of breast cancer

Abnormal: abnormality detected and further investigations needed (25% with abnormal result with subsequently have breast cancer

Unclear: imaging is unclear / inadequate

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41
Q

How to deal with breast implants on mammography?

A

Eklund technique - way of obtaining images to optimise breast cancer detection

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42
Q

What are the clinical features of breast cancer?

A

Breast and/or axillary lump

  • Irregular
  • Hard / firm
  • Fixed to skin / muscle

Breast pain

Breast skin changes (change to normal appearance, skin tethering, oedema, peau d’orange)

Nipples: inversion, discharge (bloody), dilated veins

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43
Q

What are the potential features of mets?

A

Bone (bone pain)

Liver (malaise, jaundice)

Lung (SoB, cough)

Brain (confusion, seizures)

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44
Q

Who should be referred on 2WW for breast cancer?

A

30 and over with unexplained breast lump with/without pain

50 and over, with any of:

  • Dischage
  • Retraction
  • Other changes of concern
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45
Q

When else do NICE recommend a 2WW referral?

A

Skin changes suggestive of breast cancer

Aged 30 or over with unexplained lump in axilla

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46
Q

When to consider non-urgent referral in people aged under 30 for breast cancer?

A

Unexlained breast lump with / without pain

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47
Q

Where are suspected breast cancers reffered to?

A

‘One stop breast clinic’ for triple assessment

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48
Q

What are the three elements of the triple assessment?

A

History and exam (including FH)

Imaging

Over 40 = mammogram (soft tissue masses / microcalcifications)

Under 40 = Breast USS

Histopathology (depending on first 2 steps) - tissue / cellular sample may be taken

Fine needle aspiration (provisional same-day results)

Core biopsy (sometimes have to wait a few days)

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49
Q

Why are further investigations required for breast cancer?

A

Help stage disease and plan management

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50
Q

Which bloods are requested in suspected breast cancer?

A

RBC

Renal function

LFT

Bone profile

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51
Q

Which imaging is required in suspected breast cancer?

A

CXR

Breast tomosynthesis (uses mammography to produce 3-D representation of breast)

MRI breast (under guidance of MDT, used in pts with high risk FH / genetics / occult primary tumours / invasive cancers to guide treatment / assess tumour size for breast conserving surgery)

CT chest / abdo / pelvis: suspected advanced disease for visceral metastasis

CT brain: in symptomatic patients with neurological spread

Contrast enhanced liver USS: for suspected liver metastasis

Bone scan: spread to bones

PET/CT: not routine, use guided by breast MDT

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52
Q

Which receptor testing is done in breast cancer?

A

Oestrogen receptor (ER) status

Progesterone receptor (PR) status

Human epidermal growth receptor (HER2)

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53
Q

What assessment of axilla is done in breast cancer?

A

USS to assess axillary lymph nodes - can be sampled with ultrasound-guided needle sampling (for early invasive breast cancer)

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54
Q

What genetic testing should be performed for breast cancer?

A

Consideration for age / medical history / FH as to indication

If under 50 with triple-negative breast cancer testing for BRCA1 and BRCA2 should be offered

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55
Q

Who is involved in the management of breast cancer?

A

MDT

  • Breast surgeons
  • Plastic surgeons
  • Oncologists
  • Radiologists
  • Histopathologies
  • Specialist nurses
  • Palliative care
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56
Q

When can surgery be used for breast cancer and what is involved?

A

In early and locally advanced breast cancer

  • Breast conservation - wide local excision (whole breast radiotherapy after)
  • Mastectomy - for unfavourable tumour to breast ratio, where radiotherapy is contraindicated, multifocal tumours and recurrent

Along with sentineal lymph node biopsy (SLNB)

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57
Q

When is breast reconstruction performed?

A

At time of mastectomy or delayed as separate procedure

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58
Q

When is radiotherapy usually performed?

A

Key adjunct, reducing recurrence following breast conserving surgery

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59
Q

What are the local complications of radiotherapy?

A

Soreness

Fibrosis of breast tissue

Change in skin tone

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60
Q

What is the treatment after breast conservation surgery?

A

Radiotherapy

Partial breast radiotherapy / omitting radiotherapy (with very low risk of recurrence taking adjuvant endocrine theraoy)

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61
Q

What is the treatment after mastectomy?

A

Radiotherapy for:

  • node positive (macrometastases) invasive breast cancer or involved resection margins
  • node negative T3/T4 disease
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62
Q

When may chemotherapy be used for breast cancer?

A

To reduce risk of recurrence and improve survival

Neoadjuvant therapy (guided by MDT - reduce tumour size pre-operatively or with inflammatory breast cancer)

Adjuvant chemotherapy (usually contain a taxane and anthracycline)

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63
Q

Which biologic may be offered to HER2 positive breast cancers?

What are the side effects?

A

Trastuzumab (herceptin)

Also used for T1c / greater invasive disease

Monoclonal antibody which targets HER2 receptors

Significant cardiac based adverse effects, harmful in pregnancy and must be avoided for 7 months after treatment

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64
Q

Which patients are offered adjuvant endocrine therapy? What does treatment choice depend on?

A

Patients with ER / PR positive disease

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65
Q

What are the options for adjuvant endocrine therapies?

A

Tamoxifen (selective oestrogen receptor modulator) first line in men and pre-menopausal women (also for post-menopausal at low risk of disease reccurence / if aromatase inhibitors contra-indicated)

Aromatase inhibitors first line in post-menopausal women at high risk of disease recurrence (prevents peripgeral conversion of androgens to oestrogens - not effective in premenopausal women where oestrogens are primarily synthesised by ovaries)

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66
Q

What are the risks of tamoxifen?

A

Blood clots

Endometrial cancer

Osteoporosis

NOT TO BECOME PREGNANT WHILST ON TAMOXIFEN OR FOR 2 MONTHS AFTER

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67
Q

What is a side effect of aromatase inhibitor? e.g. anastrozole

A

Menopausal symptoms

Osteoporosis

MSK pain

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68
Q

When is endocrine therapy commenced?

A

After any adjuvant chemo (standard course is 5 years)

(neo-adjuvant endocrine therapy may be used - in the context of a clinical trial)

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69
Q

What may be considered for pre-menopausal women with ER +ve disease?

A

Ovarian function suppression (use guided by MDT)

GnRH analogue (e.g. goserelin)

Laparoscopic oophorectomy

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70
Q

What is the treatment aim in advanced metastatic cancer?

A

Prolong survival and improve quality of life

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71
Q

What is key in guiding treatment for advanced metastatic disease?

A

Receptor status (ER, PR, HER2)

Endocrine treatment with tamoxifen or anastrozole or targeted therapy with Herceptin

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72
Q

Is chemo advisable for metastatic breast cancer?

A
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73
Q

Which medications can be used to prevent lytic bone lesions and reduce bone pain / fracture?

A

Denosumab

Bisphosphonates

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74
Q

Where do colorectal cancers affect?

A

Beginning of colon

Caecum

End of rectum

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75
Q

How may colorectal cancer present?

A

Screening

Incidentally on imaging

Endoscopy

Change in bowel habit

Iron deficiency anaemia

Bowel obstruction

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76
Q

What are the risk factors of colorectal cancer?

A

Family history

Hereditary syndromes

Inflammatory bowel disease

Ethnicity

Radiotherapy

Obesity

Diabetes mellitus

Smoking

Dietary factors (data conflicting - red meates and processed foods increase risk, fibre is protective)

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77
Q

Which hereditary syndromes increase risk of CRC?

A

Lynch syndrome (HNPCC) = autosomal dominant, mutation to DNA mismatch repair gene, most common inherited cause

FAP = autosomal dominant, mutation to APC, a tumour suppressor

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78
Q

What is the pattern of CRC?

A

Sporadic (no FH / genetics) or inherited

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79
Q

What type of cancer are most CRC?

A

Adenocarcinomas

80
Q

What is the adenoma-carcinoma sequence?

A

Mutations = normal epithelium becomes adenomas progressively dysplastic and develop into carcinoma

81
Q

Where does CRC most commonly occur?

A

Rectum and sigmoid colon

82
Q

Why is there a screening programme for CRC?

A

Asymptomatic for much of it’s course

83
Q

Where does CRC metastasise to?

A

Liver (symptoms may lead to diagnosis)

Rectal cancers cause lung metastasis (due to direct haematogenous spread via the inferior rectal vein and IVC)

84
Q

What type of cancers are appendiceal cancers (often considered separately)? Where do they typically spread?

A

Carcinoids (1 in 3 are adenocarcinomas)

Spread into peritoneum

Presence of pseudomyxoma peritonei (if mucus producing) may be seen

85
Q

What are the clinical features of colorectal cancer?

A

Change in bowel habit

Anaemia (key indication for endoscopy)

Weight loss

86
Q

What are the symptoms of CRC?

A

Change in bowel habit

Weight loss

Malaise

Tenesmus

PR bleeding

Abdo pain

87
Q

What are the signs of CRC?

A

Pallor

Abnormal PR exam

Abdo mass

88
Q

What may suggest metastatic disease in CRC?

A

Hepatomegaly

Jaundice

Abdo pain

Lymphadenopathy

89
Q

Why may liver / lung mets occur in CRC?

A

Portal system = liver mets

Inferior rectal vein - IVC = lung mets

90
Q

How to right vs left sided CRC present differently?

A

Right = develops mass from dysplastic polyp (classically presents as iron-deficient anaemia)

Left = grow circumferentially causing ‘apple core’ appearance causing narrowing of lumen and symptoms of change in bowel habit / obstruction

91
Q

What are the aspects of the NHS screening programme?

A

(NOT OFFERED ANYMORE) Flexible sigmoidoscopy: Aged 55 invited for one-off screening with flexible sigmoidoscopy - if polyps found then completion colonoscopy will be organised (1% will be found with cancer)

Faecal immunochemical test (FIT) for those aged 60-74. After age of 75 people can request further test every two years (if abnormal then colonoscopy)

92
Q

If patient is indicated for coloscopy from referral - what may suggest review in colorectal clinic first?

A

Dementia

Learning difficulties

Physical impairments

On anticoagulation

Anal pathology

93
Q

When should patients be referred on 2WW for CRC?

A

Aged 40 and over with unexplained weight loss / abdo pain

Aged 50 or over with rectal bleeding

Aged 60 or over with:

Iron deficiency anaemia / changes in bowel habit

Tests show occult blood in faeces

Rectal / abdo mass

94
Q

When may a referral for a patient under 50 be considered for CRC?

A

Rectal bleeding and any of the following:

Abdo pain

Change in bowel habit

Weight loss

Iron-deficiency anaemia

95
Q

What is the gold standard for those with suspected CRC?

A

Colonoscopy

96
Q

What is a completion colonoscopy?

A

Reaching and visualising the terminal ileum (typically done with conscious sedation - or GA or CT pneumocolon)

97
Q

What are some potential complications of colonoscopy?

A

Perforation of the colon (increased risk in diverticular disease)

98
Q

What preparation is there for colonoscopy?

A

Bowel prep - specific diet and Moviprep

99
Q

Where does flexible sigmoidoscopy allow visualisation up to?

A

Splenic flexure

100
Q

How is a CT pneumocolon performed? What can be used if not tolerated?

A

Air insufflation via the rectum is needed (bowel prep also needed through less intensive preparation)

Plain CT abdo/pelvis

101
Q

What is the disadvantage of CT pneumocolon vs endoscopy?

A

No removal of polyps / biopsy of lesions

102
Q

Why may further investigations be required in CRC?

A

Assessment of distant spread and key-organ function to guide management

103
Q

Which bloods may be taken in CRC?

A

FBC

Serum iron, transferrin saturation, TIBC

Renal function

LFT

Clotting screen

104
Q

What tumour marker is there for CRC when is it used?

A

CEA (carcinoembryonic antigen) - monitor as a marker of recurrence

105
Q

Which imaging is used for CRC?

A

CT chest abdo pelvis (characterise disease burden / sites of metastatic spread)

MRI liver for liver mets

MRI rectum for better staging of rectal tumours

Endoanal USS for better stage rectal tumours

PET / CT not routine but may help with staging, prior to pelvic exenteration

106
Q

How is colorectal cancer staged?

A

TNM classification

107
Q

What are the management options for CRC?

A

Surgery

Endoscopic techniques

Radiotherapy

Systemic anti-cancer therapy

Palliative care

108
Q

Why is a stoma typically needed after surgery for CRC?

A

To protect the anastomosis (temporary with plan to reverse during second procedure)

Typically used in low anterior resection when anastomotic leak is more common

Typically reversed several months after primary operation

109
Q

What surgical options are there for rectal cancer?

A

Transanal excision

Endoscopic submucosal dissection

Total mesorectal excision

110
Q

What surgical options are there for colonic cancer?

A

Sigmoid colectomy

Right hemicolectomy

Left hemicolectomy

Subtotal colectomy

Total abdominal colectomy

111
Q

What are the complications from CRC surgery?

A

Infection (intra-abdominal, wound, urinary, chest)

Bleeding / haematomas

Blood clots (DVT/PE)

Damage to ureters during surgery

Anastomotic leak (commonly in operations with low rectal anastomosis - as such these are protected with look ileostomy)

112
Q

What are some risk factors for prostate cancer?

A

Age

Black ethnicity

Family history

Obesity

113
Q

What type of cancer is prostate cancer?

Where do the majority of prostate cancers arise?

A

Adenocarcinomas

Peripheral zone

114
Q

Label the following

A
115
Q

What are the clinical features of prostate cancer?

A

LUTS = nocturia, frequency, hesitancy, urgency, dribbling, overactive bladder, retention

Visible haematuria

Abnoral DRE (hard, nodular, enlarged, asymmetrical)

Symptoms of advanced disease(e.g. lower back pain, bone pain, weight loss, anorexia)

116
Q

When should DRE be considered in men?

A

LUTS (e.g. nocturia, frequency, hesitancy, urgency or retention)

Haematuria

Unexplained symptoms

Erectile dysfunction

Other reasons to be concerned of prostate cancer (e.g. elevated PSA)

117
Q

What is prostate specific antigen?

A

Protein produced by prostate epithelial cells

118
Q

What is the purpose of PSA in normal physiology?

A

Helps liquefy sperm

119
Q

What should men avoid before PSA?

A

UTI in last 6 weeks

Urological intervention in last 6 weeks

Ejaculation in previous 48 hours

Vigorous exercise in previous 48 hours

120
Q

When should PSA testing be performed?

A

Men over 50 who request it

121
Q

When should a 2WW referral be made for prostate cancer?

A

Abnormal prostate (feels malignant) on DRE

PSA level elevated above age-specific range

122
Q

What is the first line investigation in the diagnosis of prostate cancer?

A

Multiparametric MRI (with Likert score - 5-point score based on radiologists impression of scan)

123
Q

What further imaging may be used for prostate cancer?

A

Bone isotope scan

CT

Further MRI

For distant spread

124
Q

How is prostate cancer staged and graded?

A

TNM classification for staging

Gleason score for histological grade

125
Q

What are the management options for localised prostate cancer?

A

Active surveillance (not for high risk)

Radical prostatectomy

Radical radiotherapy

126
Q

What are the management options for locally advanced prostate cancer?

A

Radical prostatectomy

Radical chemotherapy (docetaxel chemo may be used)

127
Q

How may metastatic disease in prostate cancer be managed?

A

Docetaxel chemotherapy

Androgen depravation therapy (bilateral orchidectomy used as alternative)

128
Q

What are head and neck cancers?

A

Malignancies of oral cavity, pharynx, larynx, paranasal sinuses, nasal cavity or salivary glands

129
Q

What is the common cell type involved in H&N cancers?

A

Squamous cell epithelium (often called head and neck squamous cell carcinomas)

130
Q

What are the risk factors for HNSCCs?

A

Alcohol and tobacco use

HPV 16 (oropharyngeal cancer)

betel quid (oral cancer)

Occupational wood dust exposure (sinonasal cancer)

EBV infection (linked to nasopharyngeal cancer)

131
Q

What are the premalignant conditions of HNSCC?

A

Leukoplakia (white patches)

Erythroplakia (red patches)

Erythroleukoplakia (mixed red and white patches)

Oral lichen planus

Actinic cheilitis

132
Q

How do oral cavity cancers present?

A

A mass (typically painless) felt on the inner lip, tongue, floor of mouth or hard palate

Less commonly present with oral cavity bleeding, localised pain in oral cavity or jaw swelling

133
Q

How do pharyngeal cancers present?

A

Odynophagia

Dysphagia

Stertor

Referred otalgia

Nasopharngeal carcinoma can present initally with neck lump

134
Q

What is trotters syndrome?

A

Trial of clinical features suggestive of nasopharyngeal malignancy:

  • Unilateral conductive deafness (secondary to middle ear effusion)
  • Trigeminal neuralgia (secondary to perineural invasion)
  • Defective mobility of the soft palate
135
Q

How does laryngeal cancer present?

A

Hoarse voice

Stridor

Dysphagia

Persistent cough

Referred otalgia

136
Q

How are laryngeal cancers divided?

A

Glottis (present earlier and no lymphatic spread as no lymphatic drainage)

Supraglottis

Subglottis

137
Q

What are the investigations for HNSCC?

Investigations for those solely with lymphadenopathy?

A

Biopsy of lesion

Flexible nasal endoscopy (FNE) - if lesion seen then examination under anaesthesia and biopsy

Solely lymphadenopathy = ultrasound-guided fine needle aspiration (FNA)

138
Q

How are HNSCC staged?

A

CT scan of neck and chest (lung mets) for tumour extension, local invasion and cervical lymphadenopathy

PET-CT for tumours of unknown origin

MRI as it’s better in assessing oral cavity and oropharyngeal lesions

139
Q

When to refer for specialist centre for suspected HNSCC?

A

Patient presents with:

  • Laryngeal cancer (persistent unexplained hoarse voice, unexplained lump in neck)
  • Oral cancer (lump on lip or in oral cavity, erythroplakia / erythroleukoplakia, unceration in oral cavity > 3 weeks, unexplained lump in neck)
140
Q

What is the mainstay of treatment for HNSCCs?

A

Surgical resection +/- adjuvant radiotherapy or chemo or primary radiotherapy + / - adjuvant chemotherapy

141
Q

What is the management of small and large tumours of the oral cavity?

A

Small = wide local excision + / - neck dissection

Larger = surgical resection (flap reconstruction) / neck dissecrion / post op radio / chemotherapy

142
Q

What is the management of small tumours of the tonsil?

A

Surgical resection using laser or transoral robotic surgery +/- neck dissection or primary radiotherapy or both

143
Q

What is the management of small tumours of the tongue base?

A

Surgical ressection usuin transoral robotic surgery with neck dissection or primary radiotherapy or both

144
Q

What is the management of smaller tumours of the supraglottis?

A

Surgical resection using transoral laser microsurgery with bilateral neck dissecrion or primary radiotherapy

145
Q

What is the management of larger tumours of the supraglottis?

A

Laryngectomy with post-operative radiotherapy

146
Q

What are the complications following treatment for head and neck cancers?

A

Dysphagia (secondary to pharyngeal / oesophageal stricture)

Pharyngocutaneous fistula (following laryngectomy)

Injury to the accessory, vagus, hypoglossal or marginal mandibular nerves (following neck dissection) or chyle leak (following neck dissection)

Mucositis (early complication of radiotherapy) or xerostomia (complication of radiotherapy)

Chronic pain, persistent hoarse voice, hearing loss (following chemoradiotherapy)

147
Q

What is melanoma?

A

Cancerous growth of melanocytes

148
Q

What are the features suspicious of a melanoma?

A

ABCDE

Asymmetry

Border (irregular)

Colour alterations

Diamter > 6mm

Evolving lesion

149
Q

What are the risk factors for melanoma?

A

Exposure to UV light

Severe sun burn in childhood (e.g. blistering)

Immunosuppression

Multiple (>100) or giant (>20cm) naevi

Skin type (Fitzpatrick skin types I&II)

FH

Genetic mutations (e.g. CDK4, xeroderma pigmentosum)

150
Q

Who does melanoma typically affect?

A

Light-skinned populations

151
Q

What are melanocytes?

A

Specialised melanin-producing cells found in the basal epidermis (deepest layer of skin)

152
Q

What is the typical tumour progression in melanomas?

A

Benign naevus (typical mole) = controlled proliferation of melanocytes

Dysplastic naevus (atypical mole) = abnormal proliferation of melanocytes resulting in pre-malignant condition (atypical cellular structure

Radical growth phase = extend superficially and outwards initially

Vertical growth phase = malignant cells invade basement membrane and proliferate into dermis

Metastasis = spread to other areas of body (typically to regional lymph nodes first) may spread to other areas

153
Q

What are the clinical features of melanomas?

A

Pigmented lesion with irregular border and tendency to grow / change

154
Q

What is a dermascope?

A

Examination of a suspicious skin lesion with a dermascope (small, hand-held microscope)

155
Q

What is the first step after identifying a suspicious lesion?

A

Refer for excisional biopsy

156
Q

What is an excisional biopsy?

A

Suspicious lesion is excised with a margin of 1-2mm of healthy surrounding skin including a portion of subcut fat (ensuring full thickness of dermis sampled) - under local anaesthetic as a day case (care taken to not cause trauma as this can alter the histological grading)

157
Q

When is a punch or incisional biopsy (small sample of lesion taken) ?

A

Large lesions

Close proximity to vital structures (ears, eyes, nose)

158
Q

What are the five major histological subtypes of melanomas?

A
  • Sperficial spreading
  • Nodular
  • Lentigo maligna
  • Acral lentiginous
  • Desmoplastic melanoma
159
Q

What is amelanotic melanoma?

A

Malignant cells = little or no pigment (classically skin coloured) - any subtype can be amelanotic

160
Q

What is a superficial spreading melanoma?

A

Most common

Initial radial growth later changing to vertical growth (deep into the dermis)

161
Q

What is a nodular melanoma?

A

Seen at more advanced stage

Dark coloured

Grow rapidly

162
Q

What is lentigo maligna melanoma?

A

Occurs on elderly on chronically sun-exposed sites

Slow growing (good prognosis)

163
Q

What are acral lentiginous melanomas?

A

Melanomas occuring under nails or on palmar / plantar surfaces of hand and feet

Subungal lesions often mistaken for traumatic haematomas

164
Q

What are desmoplastic melanomas?

A

Rare form of melanomas characterised by abnormal deposits of collagen

165
Q

What can be used to classify the depth of melanoma invasion and / or give an indication of prognosis?

A

Clark level (use prognostic significance of depth of invasion, system is up for debate, not particularly used)

Breslow thickness

Ulceration

Mitotic index

166
Q

What is the breslow thickness?

A

Based on vertical thickness of the tumour in millimeters

Measured from the stratum granulosum of epidermis (if ulcerated then from the bottom of the ulceration)

Correlates strongly with mortality

167
Q

What is the mitotic index?

A

Indication of cell turnover (number of mitoses per mm2)

168
Q

What is the initial investigationsformelanomas?

A

Skin and lymph node examination

169
Q

How should a clinically suspicious lymph node be investigated in suspected melanomas?

A

Fine needle aspiration (FNA) and cytology

170
Q

When should a total body CT or PET-CT be used in melanomas?

A

Aggressive lesions (pT4, ulcerated, highmitotic index etc) or presence of known lymph node spread

171
Q

What marker can be used to risk stratify in melanomas?

A

LDH (lactate dehydrogenase - maker of cell turnover)

172
Q

What staging system is used for melanomas?

A

Americal joint committee on cacner (AJCC) system

173
Q

What are the management options for melanomas?

A

Surgical: wide local excision (down to muscular fascia), SLNB (under GA), lymph-adenectomy, electro-chemotherapy

Exision is the only treatment

174
Q

How is a sentinel lymph node biopsy performed?

A

Radio-labelled tracer injected at old biopsy scar - CT to locate ‘hot spots’

Blue dye injected into biopsy scar during operation - gamma probe locates ‘hot spots’ and correlates these

If positive then lymphadenectomy is performed - removal of all regional lymphatics

175
Q

What adjuvant therapy is given after surgical excision of a melanoma?

A

Chemotherapy

Radiotherapy

Immunotherapy

176
Q

Which skin cancer has the highest mortality?

A

Melanoma

177
Q

What is the commonest form of skin cancer?

A

Basal cell carcinoma

178
Q

What are the risk factors for BCC?

A

Exposure to UV light

Fitzpatrick skin types I&II (light skin, tans poorly)

Male

Genetics (mutations in PTCH, p53 or albinism, Gorlin’s syndrome, xeroderma pigmentosum)

Increasing age

Previous skin cancers

Immunosuppression (AIDS / transplantation)

179
Q

What is Gorlin-Golz syndrome?

A

Genetic condition inceraseing risk of developing BCCs

Autosomal dominant (mutation in PTCH1 gene)

Develop BCC in adolescence ot early adulthood

180
Q

What are the features of Gorlin-Golz syndrome?

A

Hyper-telorism

Palmar and plantar pits

Bifid ribs

Calcification of falx cerebri

181
Q

What are the clinical features of a typical nodular BCC?

A

TURP

T - Telangiectasia

U - Ulceration

R - Rolled edges

P - Pearly edge

182
Q

What is the treatment of BCC?

A

Surgical excision (3mm margin)

Topical imiquimod (immunotherapy - NOT if on head and neck)

Cyrotherapy for smaller, superficial, well defined lesions

183
Q

What are the risk factors for squamous cell carcinoma?

A

Smoking

Sun exposure

Premalignant lesions (actinic kertosis)

Age

Skin trauma

184
Q

How does SCC present?

A

Papule eroded at centre

Fleshy lesion

May be painful

Usually in sun-exposed area

185
Q

What are the treatment options of SCC?

A

Surgical excision with minimum 2mm margin

Topical cream (5-fluorouracil recommended treatment)

186
Q

What are the problems with topical immunotherapy cream?

A

Can cause scarring

No histological diagnosis

Never sure if its fully treated

187
Q

What are the features of seborrhoeic keratoses?

A

Crusty

Look ‘stuck on’ - like barnacles

Benign (if patient doesn’t like appearance / catch / itchy = reasonalble indication for removal)

Shave off or use curettage (burn off)

Mistaken for melanoma as often pigmented

188
Q

What are campbell de morgan spots?

A

red spots ocur over body with age

benign

raised / flat

189
Q

What is solar keratoses (aka actinic keratosis)?

A

Sun damaged skin

Pre cancerous - can turn into SCC

Red and scaly

Treated with cryotherapy / effufix (5-fluorouracil)

190
Q

What is a dermatofibroma?

A

Central scar like area with peripheral light brown network

Benign

Pinch and pulls inwards as its attached to underlying subcut tissue (moles push outwards)

191
Q

What is a congenital naevus?

A

“Cobblestone” pattern - develops early in life

192
Q

What is the term for mole?

A

Reticular naevi

193
Q

What are the side effects of surgery for lung cancer?

A

Shortness of breath
Pneumonia
Pain due to nerve damage
Problems with swimming (buoyancy) after pneumonectomy

194
Q

Why is staging in cancer important?

A

Guides treatment (trial eligibility)

Guides prognosis

195
Q

What are the pros and cons of PSA testing?

A

Pros
Picks up prostate cancer before symptoms
Can help pick up a fast-growing cancer at an early stage

Cons
Might have raised PSA and no cancer
1 in 7 men with normal PSA may have PSA
You might be diagnosed with a slow growing cancer, take treatment and suffer side effects

196
Q

Define the following terms:

Macule

Patch

Plaque

Papule

Nodule

Vesicle

Pustule

Bulla

A

Macule - flat lesion less than 1 cm, without elevation or depression

Patch - flat lesion greater than 1 cm, without elevation or depression

Plaque - flat, elevated lesion, usually greater than 1 cm

Papule - elevated, solid lesion less than 1 cm

Nodule - elevated, solid lesion greater than 1 cm

Vesicle - elevated, fluid-filled lesion, usually less than 1 cm

Pustule - elevated, pus-filled lesion, usually less than 1 cm

Bulla - elevated, fluid-filled lesion, usually greater than 1 cm

Cancer care (5 decks)

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