The Big 4 Cancers Flashcards
colorectal: how common? (2) risk factors? (6) mutations? (1) pathogenesis? (1) is colon or rectal more common? (1)
- 1 in 20
- 4th most common (10-15% all malignancies)
- men
- old age
- diet: animal fat/ low fibre
- Western countries
- IBD; UC (Crohns more controversial)
- familial association ~10%; FAP, HNPCC, APC
- APC mutations are associated with the development of benign adenomas whereas the progression to invasive carcinoma requires further mutations e.g. p53, DCC and RAS
- from well-demarcated polyp –> tumours
- colon 1.5* more common than rectal
mortality is decreasing due to better screening; reduced mortality between 15-18%
colorectal:
where are they located? (3)
- 1/3 in rectum
- 1/3 on left side
- 1/3 in remainer of colon
Future of treatments:
Agents acting through angiogenic mechanisms such as bevacizumab, and agents acting on epithelial growth factor receptors such as cetuximab can be effective when added to chemotherapy in advanced disease and their place in standard treatment regimens is being determined by research and the National Institute Health and Clinical Excellence (NICE).
colorectal caner:
red flags? (6)
- rectal bleeding
- change in bowel habit
- mucous PR
- anorexia
- weight loss
- abdo pain
rectal bleeding:
prevalence in UK? (1)
causes? (6)
~50% have it at some point, ~3% of all consultations
quite a COMMON symptom! lots of causes..
- cancer
- anal fissure
- trauma
- anticoagulants
- gastroenteritis/ IBD
- haemorrhoids
colorectal cancer:
examination signs? (4)
- abdo mass
- signs of anaemia
- mass on rectal exam
- weight loss
colorectal cancer: routes to presentation? (4)
1) URGENT SUSPECTED CANCER REFERRAL:
- straight to test if ‘fit’= colonoscopy/ flex sig OR colorectal surgeon review in 14 days
if cancer diagnosed should start treatment within 62 days
2) EMERGENCY PRESENTATION
- 1:5 have red flat symptoms
- present with obstruction, perforation, bleeding, abdo pain
3) NORMAL OUTPATIENT REFERRAL
4) SCREENING ~10% of cancers
- every 2 years 60-74 years old
- FIT Faecal immunochemical testing
- one sample
- FOB Faecal Occult Blood: used to require 3 samples
Positive: treat as urgent suspected cancer
Bowel screening scope (sigmoidoscopy) at 55: one off to detect left sided polyps
colorectal cancer: reoccurance risk more common in rectal or colon? (1) how to prevent reoccurance in: colon? (2) rectal? (4) what is Hartmans? (1)
- more common in RECTAL cancer
COLON
Surgery + consider neoadjuvant chemo
(hemicolectomy/ anterior resection)
(giving chemo before and after surgery is better than just after)
RECTAL
- consider neoadjuvant treatment:
low risk= surgery
medium risk= radiotherapy, anterior resection
high risk= radiotherapy+chemotherapy, APER (anteriorperitoneal resection), Hartmanns
Hartmans= Surgery involves removing the affected section of the bowel and creating an alternative path for faeces to be passed. i.e. colostomy
Essentially: the rectal is very susceptible to RADIOTHERAPY
what is DPD testing?
don’t need to know this
- patients receiving 5FU chemotherapy tests for DPD enzyme deficiency (heterozygous)
patients who have the deficiency have a v severe reaction to the chemotherapy as unable to metabolism it
colorectal cancer:
follow-up investigations? (3)
- specialist-nurse led
- telephone-based
investigations:
- CEA 6-monthly
- CT 18 months, 3 years, 5 years
- colonoscopy within 12 months, 3 years post last one
lung cancer:
prevalence? (1)
prognosis? (2)
- 13% of all cancers, 21% of all deaths
- 3rd most common in UK
- usually presents at advanced stages (stage IV)
- outcomes poor (5% 10 yr survival) but improving (3-5%)
mortality higher in men than women
lung cancer: risk factors (7)
- deprivation
- smoking
- male
- genetic predisoposition
- history of COPD
- industrial exposure to asbestos, chromium, arsenic and iron oxide
- exposure to radiation
lung cancer:
subtypes? (4)
histology (1)
why is it important to identify which subtype? (1)
NSCLC and SCLC: 50% adenocarcinoma 30% squamous cell carcinoma 15% small-cell carcinoma 5% large cell carcinoma It is not clear whether these distinct tumours arise from different cell types or from a single common progenitor which then differentiates to produce different tumour types.
- arise from epithelium of bronchi usually, only rarely from lung parenchyma itself
- important to differentiate type as different clinical features and management
adenocarcinoma is the most common for NON-smokers, but smoking is still a risk factor for ALL TYPES
lung cancer:
presentation in early (2) and late disease (8)
Early disease:
- cough
- breathless
(very non-specific symptoms!)
Advanced disease:
- haemoptysis
- chest pain
- weight loss
- bone pain
- RUQ pain
- headaches/ nausea/ neurological
- stridor (emergancy)
- recurrent chest infections
- Horners syndrome if affect sympathetic chain (Pancoast’s)
- SVCO
- recurrent laryngel nerve palsy
haemoptysis is very central cancers… either means its spread lots already or centrally placed –> surgery not appropriate
lung cancer non-specific symptoms–> often an incidental finding!
Specific histologies may be associated with a particular pattern of presentation. For instance, clubbing is more frequent with squamous cell carcinoma. Sputum production may be excessive in bronchio-alveolar carcinoma.
lung cancer:
localized treatment? (2)
systemic treatment (3)
- surgery
- radiotherapy: curative/ palliative
- chemotherapy
- immunotherapy
- targeted therapy (biologics)
Pancoast tumour:
symptoms? (4)
what type of cancer often are they? (1)
where? (1)
- ptosis
- meiosis (pupil)
- anhidrosis
- pain in R arm
- weakness small muscles of R hand
- NSCLC
- lung apex
Why is it important to know
performance status? (1)
co-morbidities? (1)
smoking - why quit after lung cancer diagnosis? (3)
- performance status lets you work our how aggressive you can be with the treatment/ how well someone is despite the cancer
- some drugs are contraindicated in co-morbidities
+ SMOKING MAKES CHEMO AND RADIO LESS EFFECTIVE
+ chemo side effects worse,
+ increases risk of recurrence:
- smoking makes the level of oxygen in your blood drop –> radiotherapy less effective
- tobacco smoke has chemicals in it that can reduce the levels of some chemotherapy drugs, making them less effective
histology of small cell lung cancer (5)
- small and oval cells
- scanty cytoplasm
- fine granular neoplasm
- absent nucleoli
- frequent mitosis
- dense neurosecretory granules
What is a paraneoplastic syndrome? (1)
What paraneoplastic syndromes does each lung cancer causes:
- SCLC? (5)
- squamous cell? (3)
- adenocarcinoma? (2)
- large cell/ NSCLC? (2)
- group of disorders where cancer causes an abnormal immune response
(can affect endocrine, dermatologic, haematologic and rheumatologic systems) - small cell lung carcinoma SCLC
(has lots because it is a NEUROENDOCRINE subtype of cancer compared to the others)
1- ectopic ACTH–> crushing
2- SIADH –>hyponataemia
3- Eaton-Lambert Syndrome (similar to myasthania), NSCLC causes ~50% of cases
4- SVC syndrome (2nd most common cause after NSCLC)
5- carcinoid–> flushing and diarrhoea
1- PTHrp–> hyperCa2+
2- Horners–> ptosis, miosis, anhydrosis
3- Pancoasts–> 1st/2ns thoracic nerve–> shoulder pain–> ulner nerve pain
1- pulmonary osteoarthropathy–> pain in hands/legs
2- marantic endocarditis
1- SVC syndrome (most common cause)
2- gynaecomastia
treatment small lung cell carcinoma (SCLC)? (2)
SCLC is the RUBBISH one :( presents late..
1- CHEMOTHERAPY mainstay, responds well normally
2- radiotherapy to chest and brain
- often too late for surgery
only give radiotherapy to the brain in this circumstance and in childhood cancers (leukemia that might have gone to brain) (not normal!) –> can lead to short term memory loss and brain cancer (!!)
What are oncogene addicted tumours?
lung cancers
- targeted therapies have significantly improved outcomes
lung cancer:
which type is…
highly aggressive/ rapid? (1)
associated with paraneoplasic syndromes? (1)
often found centrally close to bronchi? (1)
often peripheral+non-smokers? (1)
previous asbestos exposure? (1)
less differentiated than other NSCLCs and tend to metastasis early? (1)
associated with mutations in EGFR and ALK?
- SCLC; often metastasised already and inoperable prior to diagnosis. responsive to chemo but relapse quickly. Poor prognosis.
- SCLC
- squamous cell carcinoma: central, close to bronchi, closely linked to cigarette smoking. Squamous cell cancers can also secrete PTH relate peptide (PTHrp) which can lead to malignancy-related hypercalcaemia
- adenocarcinomas; often in women
- adenocarcinoma
- large cell carcinoma
- adenocarcinoma (mutations)
other types of lung cancers include carcinoid, mesothelioma, sarcoma, and lymphoma.
lung cancer:
investigations (7)
- CXR
- CT chest and upper abdomen
- PET scan
- bronchoscopy
- other biopsy techniques
- tumour markers
- pulmonary function tests
- cadiopulmonary exercise testing
lung cancer: when to do CT? (1) use of PET? (1) bronchoscopy? (1) other biopsy techniques? (1) tumour markers? (2)
What are the uses of:
pulmonary fuction tests? (1)
cardiopulmonary exercise testing? (1)
- local/distant disease, principally in the lungs, mediastinum, pleura, liver and adrenal glands, can do brain too
- operable disease to check for distant metastases which may not be picked up on CT
- fibre-optic or rigid bronchoscopy allows visualisation of the bronchial tree, tumour biopsy and bronchial washings to be taken. Endo-bronchial Ultrasound (EBUS) can be used to biopsy lymph nodes within the mediastinum.
- trans-thoracic biopsy under radiological guidance is sometimes required for the biopsy of peripheral lung tumours, or distant metastatic disease e.g. liver metastases.
- neuron specific enolase (NSE) and lactate dehydrogenase (LDH) may provide useful indications of tumour activity. These are not routinely used.
- PFTs are important for assessing underlying lung disease / function –> show fitness for treatment
- to assess fitness pre-surgery to see if safe
lung cancer:
- management of SCLC (2)
- in which patients is prognosis better? (2)
- how does treatment vary to NSCLC? (1)
- which cancers cause SVCO? (4)
- is surgery done in SCLC? (1)
- what to tell patients ask if smoking caused their cancer? (1)
- what to tell them to do next? (1)
PALLIATIVE…
- if appears “limited stage” at diagnosis (i.e. encompassable within a high dose radiotherapy field) then radical radiotherapy + chemotherapy
- prophylactic cranial irradiation used with limited disease and those in extensive who respond to chemo
~80% of patients with SCLC will respond to combination chemotherapy (with complete response rates approaching 50%) but most relapse then die rapidly
- Eaten-Lambert syndrome concurrently because often discovered earlier
- high performance status
Very CHEMO AND RADIOSENSITIVE
—> complications such as SVCO and MSCC = treat with chemotherapy rather than radiotherapy (in contrast to NSCLC!)
1st = NSCLC 2nd= SCLC 3rd= non-Hodgkin’s lymphoma 4rd= breast/ thymic/ mediastinal germ cell tumours
- SCLC = considered a systemic disease at presentation –> surgery inappropriate in many cases
(often occurs by accident i.e. it’s resected and they realize it’s SCLC) - no evidence of improved outcome
- if they ask, say yes, smoking will have contributed but there are many other factors too such as genetics and bad luck
- stop smoking now.. it will reduce treatment side effects, improve the efficacy of treatment and decrease chance of recurrence
three uses for radiotherapy in SCLC? (3)
prognosis SCLC? (2)
prognostic factors (4)
remember SCLC is the awful one!!
1- treat primary tumor (concurrent with chemo)
2- prophylactic cranial irradiation (but can –> memory impairment, functional deficit and dementia) :(
3- palliative
- without treatment: 2-4months
- with treatment: 6-12 months
- extent of disease at presentation
- number of metastatic sites
- performance status, degree of weight loss
- biochemical abnormalities (elevated LDH or low sodium or albumin)
Patients with limited disease, a good performance status, and favourable biochemistry have a small but real chance of long-term survival (10-15%). Patients with extensive disease who are less fit are rarely cured but can obtain good palliation from chemotherapy.
management of NSCLC:
surgery? (3)
radiotherapy?
- possibility of cure
- mediastinal involvement is contraindication
- ~30% of NSCLC are suitable for surgery
- 3-5% mortality from pneumonectomy –> lobectomy/wedge resections recommended
In general:
SCLC= worse prognosis= metastasis at presentation= no surgery so have to use chemo/radio (the neoplastic one)
non-SCLC= better prognosis= surgery then chemo
Use of radiotherapy alone is complicated and not necessary to learn but interesting:
Giving radiotherapy at the same time as chemotherapy (concurrent chemo-radiotherapy) may also improve outcomes compared to giving chemotherapy first followed by radiotherapy (sequential chemo-radiotherapy). This is usually used in patients with Stage II-III disease.
Increasingly, early NSCLC located more peripherally in the lungs is treated by stereotactic ablative body radiotherapy (SABR). This delivers a small number (≤5) of very large doses of radiotherapy to a small, highly conformal volume around the lung tumour. This technique has rates of tumour control that are comparable to surgery and can be used in many patients who would not be fit enough for surgery.
