Solid tumours Flashcards
What is the most common cancer?
Lung cancer
Where do lung cancers arise from?
Malignant epithelial cells
What is the prognosis of lung cancer?
Poor (5 year survival rate of 17%)
What are the two categories of lung cancer?
Non-small cell carcinoma (adenocarcinoma, squamous cell carcinoma, large cell carcinoma)
Small cell carcinoma
Where are adenocarcinomas found and what are their clinical features?
Peripherally (smaller airways)
More common in non-smokers and asian females
Metastasise early
Respond well to immunotherapy
What are the features of squamous cell carcinoma and where are they found?
Cenrally (in the bronchi)
More common in smokers
Secrete PTHrP = hypercalcaemia
Metastasise late (via lymph nodes)
What are the features of large cell carcinoma and where are they found?
Located peripherally and centrally
More common in smokers, metastasise early
What are the features of small cell carcinoma and where is it found?
Located centrally (poorly-differentiated)
More common in older smokers
Metastasise early
Secrete ACTH (cushing’s syndrome) and ADH (SIADH)
Associated with Lambert-Eaton syndrome
What are the risk factors for lung cancer?
Tobacco smoking
Air pollution (indoor and outdoor)
FH of cancer, especially lung cancer
Male sex
Radon gas (miners)
Which symptoms indicate lung cancer?
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)
What else to cover in history of lung cancer?
Family history (lung cancer in 1st degree relative - doubles risk of LC)
Smoking history (quantify in pack-years)
Occupation
What examination to perform for suspected lung cancer? Name some suggestive findings?
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
When to refer on 2WW for suspected lung cancer?
“Red flag symptoms”
X-ray findings suggestive of lung cancer
Over 40 and unexplained haemoptysis
What is a 2WW referral?
Hospital must see pt within 2 weeks of receiving the referral form
Which patients must recieve an urgent chest x-ray (within 2 weeks)?
Over 40 + 2 x (weight loss, appetite loss, cough, dyspnoea, chest pain, fatigue)
1 additional symptom if ever smoked
What are the differential diagnoses for lung cancer?
Tuberculosis
Mets to lungs from other sites
Sarcoidosis
Granulomatosis with polyangiitis (Wegener’s disease)
Non-Hodgkin’s lymphoma
What features are unique to TB?
Drenching night sweats
Positive sputum culture and microscopy
CXR: cavitating lesion / hilar lymphadenopathy
Which features are unique to mets to the lungs from other sites?
Symptoms of primary tumour (haematuria due to RCC)
CT head-abdo pelvis (shows primary tumour)
FDG-PET: increased uptake at primary tumour site
Which features are unique to sarcoidosis?
Enlarged parotids
Skin signs e.g. erythema nodosum and lupus pernio
Tissue biopsy: non-caseating granulomas
Which features are unique to granulomatosis with polyangiitis (Wegener’s disease)?
Saddle nose deformity
Positive cANCA
Urinalysis: haematuria, proteinuria, red cell casts
Which features are unique to Non-Hodgkin’s lymphoma?
Drenching night sweats
Hepatosplenomegaly
Positive lymph node biopsy (anti-CD20 strain)
What are some bedside investigations for lung cancer?
Pulse oximetry: aim for 94-98% ot 88-92% if patient has COPD
ECG: always pre-operatively
What are the lab investigations for lung cancer?
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
What imaging is required in lung cancer?
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
Which staging classification is first used for lung cancer?
TNM staging
What is stage 1-IV for lung cancer?
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)
What is the treatment of non-small cell lung cancer?
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
What targatable mutations exist in lung cancer?
EGFR
ALK
ROS1
What is the treatment of small cell lung cancer?
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)
What are some disease related complications of lung cancer?
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
What are some treatment related complications for lung cancer?
Due to chemotherapy: alopecia, neutropaenia, bone marrow toxicity
Due to radiotherapy: mucositis, pneumonitis, oesophagitis
What is the most common malignancy affecting women in the UK?
Breast cancer
What are the risk factors for breast cancer?
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
Where are BRCA1 and BRCA2 genes found respectively? What do they cause?
BRCA1 - mutation on chromosome 17
BRCA2 - mutation on chromosome 13
Increase risk of breast and ovarian cancer
Label the following:
What are the categories of breast cancer?
Carcinomas = Ductal or lobular (in situ or invasive - if penetrating basement membrane)
What is the most common invasive breast cancer?
Invasive ductal carcinoma
What are the molecular subtypes of breast cancer based on gene expression?
Luminal A
Luminal B
Basal
HER2
What age is breast cancer screening offered?
50 - 71 for women and transmen
Which imaging is used for breast cancer screening? What are the possible results?
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
How to deal with breast implants on mammography?
Eklund technique - way of obtaining images to optimise breast cancer detection
What are the clinical features of breast cancer?
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
What are the potential features of mets?
Bone (bone pain)
Liver (malaise, jaundice)
Lung (SoB, cough)
Brain (confusion, seizures)
Who should be referred on 2WW for breast cancer?
30 and over with unexplained breast lump with/without pain
50 and over, with any of:
- Dischage
- Retraction
- Other changes of concern
When else do NICE recommend a 2WW referral?
Skin changes suggestive of breast cancer
Aged 30 or over with unexplained lump in axilla
When to consider non-urgent referral in people aged under 30 for breast cancer?
Unexlained breast lump with / without pain
Where are suspected breast cancers reffered to?
‘One stop breast clinic’ for triple assessment
What are the three elements of the triple assessment?
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)
Why are further investigations required for breast cancer?
Help stage disease and plan management
Which bloods are requested in suspected breast cancer?
RBC
Renal function
LFT
Bone profile
Which imaging is required in suspected breast cancer?
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
Which receptor testing is done in breast cancer?
Oestrogen receptor (ER) status
Progesterone receptor (PR) status
Human epidermal growth receptor (HER2)
What assessment of axilla is done in breast cancer?
USS to assess axillary lymph nodes - can be sampled with ultrasound-guided needle sampling (for early invasive breast cancer)
What genetic testing should be performed for breast cancer?
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
Who is involved in the management of breast cancer?
MDT
- Breast surgeons
- Plastic surgeons
- Oncologists
- Radiologists
- Histopathologies
- Specialist nurses
- Palliative care
When can surgery be used for breast cancer and what is involved?
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)
When is breast reconstruction performed?
At time of mastectomy or delayed as separate procedure
When is radiotherapy usually performed?
Key adjunct, reducing recurrence following breast conserving surgery
What are the local complications of radiotherapy?
Soreness
Fibrosis of breast tissue
Change in skin tone
What is the treatment after breast conservation surgery?
Radiotherapy
Partial breast radiotherapy / omitting radiotherapy (with very low risk of recurrence taking adjuvant endocrine theraoy)
What is the treatment after mastectomy?
Radiotherapy for:
- node positive (macrometastases) invasive breast cancer or involved resection margins
- node negative T3/T4 disease
When may chemotherapy be used for breast cancer?
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)
Which biologic may be offered to HER2 positive breast cancers?
What are the side effects?
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
Which patients are offered adjuvant endocrine therapy? What does treatment choice depend on?
Patients with ER / PR positive disease
What are the options for adjuvant endocrine therapies?
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)
What are the risks of tamoxifen?
Blood clots
Endometrial cancer
Osteoporosis
NOT TO BECOME PREGNANT WHILST ON TAMOXIFEN OR FOR 2 MONTHS AFTER
What is a side effect of aromatase inhibitor? e.g. anastrozole
Menopausal symptoms
Osteoporosis
MSK pain
When is endocrine therapy commenced?
After any adjuvant chemo (standard course is 5 years)
(neo-adjuvant endocrine therapy may be used - in the context of a clinical trial)
What may be considered for pre-menopausal women with ER +ve disease?
Ovarian function suppression (use guided by MDT)
GnRH analogue (e.g. goserelin)
Laparoscopic oophorectomy
What is the treatment aim in advanced metastatic cancer?
Prolong survival and improve quality of life
What is key in guiding treatment for advanced metastatic disease?
Receptor status (ER, PR, HER2)
Endocrine treatment with tamoxifen or anastrozole or targeted therapy with Herceptin
Is chemo advisable for metastatic breast cancer?
Which medications can be used to prevent lytic bone lesions and reduce bone pain / fracture?
Denosumab
Bisphosphonates
Where do colorectal cancers affect?
Beginning of colon
Caecum
End of rectum
How may colorectal cancer present?
Screening
Incidentally on imaging
Endoscopy
Change in bowel habit
Iron deficiency anaemia
Bowel obstruction
What are the risk factors of colorectal cancer?
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)
Which hereditary syndromes increase risk of CRC?
Lynch syndrome (HNPCC) = autosomal dominant, mutation to DNA mismatch repair gene, most common inherited cause
FAP = autosomal dominant, mutation to APC, a tumour suppressor
What is the pattern of CRC?
Sporadic (no FH / genetics) or inherited
What type of cancer are most CRC?
Adenocarcinomas
What is the adenoma-carcinoma sequence?
Mutations = normal epithelium becomes adenomas progressively dysplastic and develop into carcinoma
Where does CRC most commonly occur?
Rectum and sigmoid colon
Why is there a screening programme for CRC?
Asymptomatic for much of it’s course
Where does CRC metastasise to?
Liver (symptoms may lead to diagnosis)
Rectal cancers cause lung metastasis (due to direct haematogenous spread via the inferior rectal vein and IVC)
What type of cancers are appendiceal cancers (often considered separately)? Where do they typically spread?
Carcinoids (1 in 3 are adenocarcinomas)
Spread into peritoneum
Presence of pseudomyxoma peritonei (if mucus producing) may be seen
What are the clinical features of colorectal cancer?
Change in bowel habit
Anaemia (key indication for endoscopy)
Weight loss
What are the symptoms of CRC?
Change in bowel habit
Weight loss
Malaise
Tenesmus
PR bleeding
Abdo pain
What are the signs of CRC?
Pallor
Abnormal PR exam
Abdo mass
What may suggest metastatic disease in CRC?
Hepatomegaly
Jaundice
Abdo pain
Lymphadenopathy
Why may liver / lung mets occur in CRC?
Portal system = liver mets
Inferior rectal vein - IVC = lung mets
How to right vs left sided CRC present differently?
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
What are the aspects of the NHS screening programme?
(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)
If patient is indicated for coloscopy from referral - what may suggest review in colorectal clinic first?
Dementia
Learning difficulties
Physical impairments
On anticoagulation
Anal pathology
When should patients be referred on 2WW for CRC?
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
When may a referral for a patient under 50 be considered for CRC?
Rectal bleeding and any of the following:
Abdo pain
Change in bowel habit
Weight loss
Iron-deficiency anaemia
What is the gold standard for those with suspected CRC?
Colonoscopy
What is a completion colonoscopy?
Reaching and visualising the terminal ileum (typically done with conscious sedation - or GA or CT pneumocolon)
What are some potential complications of colonoscopy?
Perforation of the colon (increased risk in diverticular disease)
What preparation is there for colonoscopy?
Bowel prep - specific diet and Moviprep
Where does flexible sigmoidoscopy allow visualisation up to?
Splenic flexure
How is a CT pneumocolon performed? What can be used if not tolerated?
Air insufflation via the rectum is needed (bowel prep also needed through less intensive preparation)
Plain CT abdo/pelvis
What is the disadvantage of CT pneumocolon vs endoscopy?
No removal of polyps / biopsy of lesions
Why may further investigations be required in CRC?
Assessment of distant spread and key-organ function to guide management
Which bloods may be taken in CRC?
FBC
Serum iron, transferrin saturation, TIBC
Renal function
LFT
Clotting screen
What tumour marker is there for CRC when is it used?
CEA (carcinoembryonic antigen) - monitor as a marker of recurrence
Which imaging is used for CRC?
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
How is colorectal cancer staged?
TNM classification
What are the management options for CRC?
Surgery
Endoscopic techniques
Radiotherapy
Systemic anti-cancer therapy
Palliative care
Why is a stoma typically needed after surgery for CRC?
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
What surgical options are there for rectal cancer?
Transanal excision
Endoscopic submucosal dissection
Total mesorectal excision
What surgical options are there for colonic cancer?
Sigmoid colectomy
Right hemicolectomy
Left hemicolectomy
Subtotal colectomy
Total abdominal colectomy
What are the complications from CRC surgery?
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)
What are some risk factors for prostate cancer?
Age
Black ethnicity
Family history
Obesity
What type of cancer is prostate cancer?
Where do the majority of prostate cancers arise?
Adenocarcinomas
Peripheral zone
Label the following
What are the clinical features of prostate cancer?
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)
When should DRE be considered in men?
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)
What is prostate specific antigen?
Protein produced by prostate epithelial cells
What is the purpose of PSA in normal physiology?
Helps liquefy sperm
What should men avoid before PSA?
UTI in last 6 weeks
Urological intervention in last 6 weeks
Ejaculation in previous 48 hours
Vigorous exercise in previous 48 hours
When should PSA testing be performed?
Men over 50 who request it
When should a 2WW referral be made for prostate cancer?
Abnormal prostate (feels malignant) on DRE
PSA level elevated above age-specific range
What is the first line investigation in the diagnosis of prostate cancer?
Multiparametric MRI (with Likert score - 5-point score based on radiologists impression of scan)
What further imaging may be used for prostate cancer?
Bone isotope scan
CT
Further MRI
For distant spread
How is prostate cancer staged and graded?
TNM classification for staging
Gleason score for histological grade
What are the management options for localised prostate cancer?
Active surveillance (not for high risk)
Radical prostatectomy
Radical radiotherapy
What are the management options for locally advanced prostate cancer?
Radical prostatectomy
Radical chemotherapy (docetaxel chemo may be used)
How may metastatic disease in prostate cancer be managed?
Docetaxel chemotherapy
Androgen depravation therapy (bilateral orchidectomy used as alternative)
What are head and neck cancers?
Malignancies of oral cavity, pharynx, larynx, paranasal sinuses, nasal cavity or salivary glands
What is the common cell type involved in H&N cancers?
Squamous cell epithelium (often called head and neck squamous cell carcinomas)
What are the risk factors for HNSCCs?
Alcohol and tobacco use
HPV 16 (oropharyngeal cancer)
betel quid (oral cancer)
Occupational wood dust exposure (sinonasal cancer)
EBV infection (linked to nasopharyngeal cancer)
What are the premalignant conditions of HNSCC?
Leukoplakia (white patches)
Erythroplakia (red patches)
Erythroleukoplakia (mixed red and white patches)
Oral lichen planus
Actinic cheilitis
How do oral cavity cancers present?
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
How do pharyngeal cancers present?
Odynophagia
Dysphagia
Stertor
Referred otalgia
Nasopharngeal carcinoma can present initally with neck lump
What is trotters syndrome?
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
How does laryngeal cancer present?
Hoarse voice
Stridor
Dysphagia
Persistent cough
Referred otalgia
How are laryngeal cancers divided?
Glottis (present earlier and no lymphatic spread as no lymphatic drainage)
Supraglottis
Subglottis
What are the investigations for HNSCC?
Investigations for those solely with lymphadenopathy?
Biopsy of lesion
Flexible nasal endoscopy (FNE) - if lesion seen then examination under anaesthesia and biopsy
Solely lymphadenopathy = ultrasound-guided fine needle aspiration (FNA)
How are HNSCC staged?
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
When to refer for specialist centre for suspected HNSCC?
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)
What is the mainstay of treatment for HNSCCs?
Surgical resection +/- adjuvant radiotherapy or chemo or primary radiotherapy + / - adjuvant chemotherapy
What is the management of small and large tumours of the oral cavity?
Small = wide local excision + / - neck dissection
Larger = surgical resection (flap reconstruction) / neck dissecrion / post op radio / chemotherapy
What is the management of small tumours of the tonsil?
Surgical resection using laser or transoral robotic surgery +/- neck dissection or primary radiotherapy or both
What is the management of small tumours of the tongue base?
Surgical ressection usuin transoral robotic surgery with neck dissection or primary radiotherapy or both
What is the management of smaller tumours of the supraglottis?
Surgical resection using transoral laser microsurgery with bilateral neck dissecrion or primary radiotherapy
What is the management of larger tumours of the supraglottis?
Laryngectomy with post-operative radiotherapy
What are the complications following treatment for head and neck cancers?
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)
What is melanoma?
Cancerous growth of melanocytes
What are the features suspicious of a melanoma?
ABCDE
Asymmetry
Border (irregular)
Colour alterations
Diamter > 6mm
Evolving lesion
What are the risk factors for melanoma?
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)
Who does melanoma typically affect?
Light-skinned populations
What are melanocytes?
Specialised melanin-producing cells found in the basal epidermis (deepest layer of skin)
What is the typical tumour progression in melanomas?
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
What are the clinical features of melanomas?
Pigmented lesion with irregular border and tendency to grow / change
What is a dermascope?
Examination of a suspicious skin lesion with a dermascope (small, hand-held microscope)
What is the first step after identifying a suspicious lesion?
Refer for excisional biopsy
What is an excisional biopsy?
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)
When is a punch or incisional biopsy (small sample of lesion taken) ?
Large lesions
Close proximity to vital structures (ears, eyes, nose)
What are the five major histological subtypes of melanomas?
- Sperficial spreading
- Nodular
- Lentigo maligna
- Acral lentiginous
- Desmoplastic melanoma
What is amelanotic melanoma?
Malignant cells = little or no pigment (classically skin coloured) - any subtype can be amelanotic
What is a superficial spreading melanoma?
Most common
Initial radial growth later changing to vertical growth (deep into the dermis)
What is a nodular melanoma?
Seen at more advanced stage
Dark coloured
Grow rapidly
What is lentigo maligna melanoma?
Occurs on elderly on chronically sun-exposed sites
Slow growing (good prognosis)
What are acral lentiginous melanomas?
Melanomas occuring under nails or on palmar / plantar surfaces of hand and feet
Subungal lesions often mistaken for traumatic haematomas
What are desmoplastic melanomas?
Rare form of melanomas characterised by abnormal deposits of collagen
What can be used to classify the depth of melanoma invasion and / or give an indication of prognosis?
Clark level (use prognostic significance of depth of invasion, system is up for debate, not particularly used)
Breslow thickness
Ulceration
Mitotic index
What is the breslow thickness?
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
What is the mitotic index?
Indication of cell turnover (number of mitoses per mm2)
What is the initial investigationsformelanomas?
Skin and lymph node examination
How should a clinically suspicious lymph node be investigated in suspected melanomas?
Fine needle aspiration (FNA) and cytology
When should a total body CT or PET-CT be used in melanomas?
Aggressive lesions (pT4, ulcerated, highmitotic index etc) or presence of known lymph node spread
What marker can be used to risk stratify in melanomas?
LDH (lactate dehydrogenase - maker of cell turnover)
What staging system is used for melanomas?
Americal joint committee on cacner (AJCC) system
What are the management options for melanomas?
Surgical: wide local excision (down to muscular fascia), SLNB (under GA), lymph-adenectomy, electro-chemotherapy
Exision is the only treatment
How is a sentinel lymph node biopsy performed?
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
What adjuvant therapy is given after surgical excision of a melanoma?
Chemotherapy
Radiotherapy
Immunotherapy
Which skin cancer has the highest mortality?
Melanoma
What is the commonest form of skin cancer?
Basal cell carcinoma
What are the risk factors for BCC?
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)
What is Gorlin-Golz syndrome?
Genetic condition inceraseing risk of developing BCCs
Autosomal dominant (mutation in PTCH1 gene)
Develop BCC in adolescence ot early adulthood
What are the features of Gorlin-Golz syndrome?
Hyper-telorism
Palmar and plantar pits
Bifid ribs
Calcification of falx cerebri
What are the clinical features of a typical nodular BCC?
TURP
T - Telangiectasia
U - Ulceration
R - Rolled edges
P - Pearly edge
What is the treatment of BCC?
Surgical excision (3mm margin)
Topical imiquimod (immunotherapy - NOT if on head and neck)
Cyrotherapy for smaller, superficial, well defined lesions
What are the risk factors for squamous cell carcinoma?
Smoking
Sun exposure
Premalignant lesions (actinic kertosis)
Age
Skin trauma
How does SCC present?
Papule eroded at centre
Fleshy lesion
May be painful
Usually in sun-exposed area
What are the treatment options of SCC?
Surgical excision with minimum 2mm margin
Topical cream (5-fluorouracil recommended treatment)
What are the problems with topical immunotherapy cream?
Can cause scarring
No histological diagnosis
Never sure if its fully treated
What are the features of seborrhoeic keratoses?
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
What are campbell de morgan spots?
red spots ocur over body with age
benign
raised / flat
What is solar keratoses (aka actinic keratosis)?
Sun damaged skin
Pre cancerous - can turn into SCC
Red and scaly
Treated with cryotherapy / effufix (5-fluorouracil)
What is a dermatofibroma?
Central scar like area with peripheral light brown network
Benign
Pinch and pulls inwards as its attached to underlying subcut tissue (moles push outwards)
What is a congenital naevus?
“Cobblestone” pattern - develops early in life
What is the term for mole?
Reticular naevi
What are the side effects of surgery for lung cancer?
Shortness of breath
Pneumonia
Pain due to nerve damage
Problems with swimming (buoyancy) after pneumonectomy
Why is staging in cancer important?
Guides treatment (trial eligibility)
Guides prognosis
What are the pros and cons of PSA testing?
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
Define the following terms:
Macule
Patch
Plaque
Papule
Nodule
Vesicle
Pustule
Bulla
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
