4th Year > Cancers > Flashcards

Cancers Flashcards

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1
Q

Risk factors of lung cancer

A 
asbestos
scarring from eg. tb
smoking
air polution
radon gas
arsenic
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2
Q

Presentation of lung cancer

A
  • haemoptysis, pleuritic chest pain, SOB, unexplained cough for 3 weeks
  • 10% weight loss in 6 months, night sweats, fevers, fatigue, anaemia (iron def)
  • recurrent chest infections, not better with antibiotics
  • hoarse voice = recurrent laryngeal nerve
  • cachexia, clubbing, lymphadenopathy
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3
Q

Investigations for lung cancer

A
  • 1st line CXR (mass + raised hemidiaphragm from phrenic nerve)
  • Endobronchial US guided bronchcoscpy for biopsy
  • Serum calcium (raised if PTHrP from squamous)
  • U&Es (na for siadh in small cell)
  • FBC = anaemia
  • LFTs
  • pulse ox and ecg
  • Contrast CT CAP (adrenals + liver for mets!)
  • spirometry
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4
Q

When would you refer suspected lung cancer? + areas of spread

A

Liver, adrenals, bone, brain spread

2ww cxr if >= 40 and 2 of the following (1 if ever smoked)…
cough/fatigue/sob/chest pain/anorexia/weight loss

OR >40 and 1 of the following…
recurrent chest infections/ finger clubbing/ >6 week lymphadenopathy/ chest signs consistent with lung cancer/ thrombocytosis

2ww cancer pathway if

  • > = 40 and unexplained haemoptysis
  • suspicious cxr
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5
Q

Management of non small cell lung cancer

A

stage 1-3

  • lobectomy (or wedge resection in reduced lung function)
  • neo-adjuvant chemo
  • adjuvant chemo and radio for stage 2 and 3
  • or can use stereotactic ablative radiotherapy as curative therapy

stage 4

  • immunotherapy, targeted therapy, chemotherapy
  • palliative = chemo and radiotherapy for mets and symptoms
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6
Q

Management of small cell lung cancer

A

surgery if it is local but most present as mets
so do palliative chemo
do prophylaxis cranial irradiation

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7
Q

Complications of small cell lung cancer

A
  • siadh
  • lambert eaton syndrome
  • cushings
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8
Q

Complications of non-small cell lung cancer

A
  • hypertrophic pulmonary osteoarthropathy = squamous and adeno
  • PTHrP from squamous (hypercalcaemia)

most pancoast are non small cell

  • horners if sympathetic compression
  • hoarseness if recurrent laryngeal nerve compression
  • svco
  • arm pain from brachial plexus compression
  • vagus nerve compression
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9
Q

Risk factors for breast cancer (male too)

A

Male = gynaecomastia, klinefelters, BRCA1/2, fhx prostate cancer, cirrhosis, radiation

Female =

  • nulliparity, never breastfed
  • increased exposure to oestrogen (early menarche, late menopause, hrt (combined), cocp, obesity or high fat diet, first baby >30)
  • fhx of relative <50 years old
  • older age
  • BRCA1,2
  • p53 mutation
  • chest radiation
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10
Q

Presentation of breast cancer and some other differentials of breast lumps

A
  • painless fixed hard lump in the breast
  • skin changes like dimpling
  • nipple discharge or bleeding
  • nipple changes or inversion
  • Pagets disease of the nipple (ductal carcinoma in situ)
  • oedema or erythema or colour changes
  • Ulceration is a late sign
  • lump in the axilla

fibroadenomas, lipomas, phillodes tumours, fat necrosis

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11
Q

When would your refer suspected breast lump?

A

> =30 2ww
unexplained lump in the breast or axilla

> =50 2ww
unexplained skin or unilateral nipple changes suggestive of malignancy (discharge, retraction, etc)

<= 30 Not urgent
unexplained breast lump

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12
Q

What is the breast screening available?

A

47-73 every 3 years
Mammogram

also for those with brca1/2, fhx of first degree relative <50 years old, previous cancer

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13
Q

How would you investigate breast cancer?

A

Triple assessment

  • mammogram (<35 do US as there is thicker breast tissue)
  • breast examination
  • fine needle aspiration (cytology) or core needle biopsy (histology)
  • CTCAP
  • TNM staging
  • Receptor status (her, oestrogen, progesterone)
  • LFTs, U&Es, FBC
  • bone scan
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14
Q

What are the types of breast cancer?

A

Ductal carcinoma in situ

  • microcalcifications on mammogram
  • associated with pagets disease

Invasive ductal carcinoma
- invaded through basement membrane

Lobular carcinoma in situ

  • may be no lump or discharge, hard to detect
  • often multifocal and bilateral

Invasive lobular carcinoma

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15
Q

How would you manage breast cancer?

A

Wide local excision or mastectomy

  • can do neoadjuvant chemo to reduce tissue
  • adjuvant chest wall radiation afterwards
  • can do sentinel node biopsy or axillary node clearance if indicated
  • adjuvant chemo improves survival

Advanced breast cancer

  • chemo and radiotherapy +/- targeted therapies
  • HER2 +ve = herceptin (tratuzumab)
  • Oestrogen +ve = SERM tamoxifen for premenopausal, Aromatase inhibitor letrozole or anostrozole for post menopausal
  • If triple negative = chemo with platinum and anthracycline
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16
Q

Where does breast cancer spread?

A

lungs, liver, bones

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17
Q

What are some risk factors for colorectal cancer?

A
  • low fibre
  • high processed meat, high fats, alcohol, smoking
  • IBD
  • diabetes
  • old, male
  • familial adenomatous polyposis, HNPCC
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18
Q

How does colorectal cancer present? (L,R,Rectal)

A

Sister Mary Joseph Nodule = lymphadenopathy

R = caecal

  • faecal occult bleeding
  • iron def anaemia/ fatigue
  • appendicitis
  • RIF mass and abdo pain

L = sigmoid

  • colicky pain
  • LIF mass
  • tenesmus
  • bowel changes (diarrhoea, mucus), obstruction etc

Rectal

  • rectal mass
  • tenesmus then persistent pain
  • rectal bleeding
  • if invades anal sphincter = incontinence
  • can invade into sacral plexus = back pain
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19
Q

When would you refer for suspected colorectal cancer?

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A
  • palpable rectal mass
  • man with iron deficiency
  • non menstruating woman with iron deficiency
  • > 40 and unknown rectal bleeding or changes in bowel habit for >6 weeks
  • > 50 and unknown rectal bleeding for >6 weeks
20
Q

How would you investigate for colorectal cancer?

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A
  • 1st line = flexi or rigid colonoscopy + biopsy
  • barium enema if that was not possible
  • Faecal Occult blood
  • FBC, U&Es, LFTs
  • Cea to monitor treatment
  • CTCAP
  • MRI for rectal cancers
21
Q

What is the colorectal screening system available?

Study These Flashcards
A

60-75 every 2 years

faecal immunochemistry test

22
Q

How would you manage colorectal cancer?

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A

Dukes Scale and TNM

Dukes A-C

  • surgical resection (use laxatives before and prophylactic antibiotics after)
  • emergency = hartmanns
  • FOLFOX adjuvant chemo for B and C

Radiotherapy for rectal cancer +/- chemo

Obstruction = decompression colostomy or endoscopic stenting

23
Q

What are some risk factors for prostate cancer?

Study These Flashcards
A

BRCA 2
fhx of prostate cancer, breast cancer, colorectal
Black, male, high bmi, old age

24
Q

How would prostate cancer present?

Study These Flashcards
A 
LUTS (hesitancy, resistance)
ED, haematospermia
haematuria
lower back pain
asymptomatic with a randomly raised PSA
anorexia, weight loss, lethargy
25
When would you refer for prostate cancer?
Do a PSA and DRE for... men with LUTS, haematuria, ED Refer for 2ww if... - PSA>=3 in a <70 year old - PSA>5 in >70s - abnormal DRE
26
What kinds of things can raise a PSA
Urinary retention, BPH, Chronic prostatitis, prostate cancer Vigorous exercise, recent ejaculation recent medical procedure like TURP or DRE or catheterisation
27
How would you investigate for prostate cancer?
- PSA - free PSA (if free PSA<15% and PSA is high, suggestive of malignancy) - DRE (BPH is smooth generally enlarged, chronic prostatitis is boggy and tender, cancer is craggy hard irregular nodular) - 1st line is Multiparametric MRI of prostate (Linkerts scale if >=3 then do a biopsy too for TNM and Gleason staging) - Used to be a Trans Rectal US Guided Biopsy (higher infection than trans perineal) - FBC, U&Es (obstruction or hydronephrosis), LFTs - Xray for osteosclerotic lesions, bone scan - CT CAP
28
How would you manage prostate cancer
PSA<10, Gleason<=6, T1-T2a - watchful waiting (dres, psa) - active surveillance (dres, psa, biopsy) - radical prostatectomy or curative external beam radiotherapy +/- brachytherapy PSA 10-20, Gleason 7, T2b - active surveillance - radical prostatectomy or curative EBRT+/- brachy PSA>20, Gleason 8-10, >=T2c - radical prostatectomy or curative EBRT+/-brachy - hormonal for mets Hormonal - LHRH agonists like goserelin (zolidex) but give androgen antagonist first to avoid testosterone spike - or you could do an bilateral orchidectomy to block androgens - Androgen receptor antagonists like Bicalutamide Palliative bisphosphonates and radiotherapy
29
What are some risk factors for myeloma?
- radiation - long term hair dye exposure - petrochemical industries or agriculture industry exposure
30
How would myeloma present?
CRABBI Calcium is high - osteoclast overactivity, results in bone pain and pathological fractures. - stones, moans, bones, psychic groans, polydipsia etc. Renal dysfunction - nephrocalcinosis and nepholithiasis (hyperuricaemia) don't help - light chains get deposited in renal tubules and cause damage Anaemia - pancytopaenia due to bone marrow overcrowding, stopping erythropoiesis Bones - bone pain due to osteoclast overactivity and bone marrow overcrowding - Lytic lesions seen on xray Bleeding - pancytopaenia due to bone marrow overcrowding Infections - reduced production of normal immunoglobulins
31
When would you refer about myeloma?
do Ca2+, FBC, ESR, PV if >60 and... unknown pathological fractures or unexplained back pain do Bence Jones proteins or serum electrophoresis within 48 hours if >=60 and... - unknown hypercalcaemia/leukopenia AND suspicious myeloma presentation do Bence Jones proteins or serum electrophoresis within 48 hours for anyone if... - PV and ESR were suspicious AND suspicious myeloma presentation do 2ww myeloma if... - Bence Jones and serum electrophoresis were suspicious for myeloma
32
How would you investigate for myeloma?
- FBC, U&Es, LFTs, Ca2+, PV, ESR, LDH - Bone marrow aspiration and trephine biopsy = plasma infiltration of bone marrow - Serum protein electrophoresis (monoclonal paraproteins) + Immunofixation (Iga or igg) = raised monoclonal IgG and IgA production - Urine protein electrophoresis for Bence Jones proteins - peripheral blood film = Rouleaux formation (due to increased paraproteins) - Xray = lytic lesions like "raindrop skull" - DEXA Bone scan - Whole body MRI
33
What results are diagnostic for myeloma?
- monoclonal proteins present in serum or urine from electrophoresis - monoclonal plasma cells in bone marrow >10% - end organ damage eg. hypercalcaemia, lytic lesions, renal damage
34
How would you manage myeloma?
Stem cell transplant (autologous best but risk of neutropenic sepsis) - Bortezomib + dexmethasone induction therapy - monitor for 3 months after with electrophoresis and bloods if relapse after initial therapy - 1st line Bortezomib - or repeat stem cell transplant Symptom management - anaemia = erythropoietin analogues, blood transfusions - infection = influenza vaccine, prophylaxis antibiotics, immunoglobulin replacement therapy - bone pain = bisphosphonates (+ppi), vit d, calcium - lytic lesions already happened = kyphoplasty - VTE prophylaxis
35
What are some risk factors for Hodgkins and Non-Hodgkins lymphoma?
both: - HIV, EBV, Ra, sarcoidosis, autoimmune - FHX non-hodgkins specific: - MALT = h pylori - Hep B, C - hx chemo or radio - exposure to pesticides and trichloroethylene - old age
36
How would a hodgkins and non-hodgkins lymphoma present? compare and differentiate
Hodgkins - bimodal distribution (20s then 70s) - painless asymmetrical lymphadenopathy non tender - pain on drinking alcohol - B symptoms prominent like weight loss, night sweats, fatigue, malaise Non Hodgkins - painless asymmetrical lymphadenopathy non tender - B symptoms later on - Extranodal presentations like hepatosplenomegaly, testicular enlargement, abdo pain, pancytopaenia, SOB
37
When would you refer for query lymphoma?
Hodgkins - unexplained lymphadenopathy (consider B symptoms and alcohol pain) Non Hodgkins - unexplained lymphadenopathy or splenomegaly (consider B symptoms)
38
How would you investigate for hodgkins vs non hodgkins lymphoma?
Hodgkins - FBC, U&Es, LFTs normal, LDH high, ESR high - excisional Lymph node biopsy = Reed Sternberg Cells - CXR = mediastinal widening - CT CAP to stage Non hodgkins - FBC, U&Es, LFTs, LDH, ESR - excisional Lymph node biopsy - Urea breath test for H Pylori (MALT) - Microscopy shows starry sky appearance (Burkitts) - Bone marrow aspiration and trephine biopsy - Immunophenotyping (B or T cells) - Immunoglobulin tests (Igm or Igg) - HIV test as it is a risk factor - CT CAP to stage
39
How would you manage hodgkins and non hodgkins lymphoma?
Ann Arbor staging ``` Hodgkins: ABVD Chemo (adriamycin, bleomycin, vinblastine, dascarbazine) ``` Non Hodgkins: - Radiotherapy for localised disease - Stem cell transplant - CHOP Chemo + rituximab (monoclonal antibody) for high grade - flu/pneumococcal vaccines - prophylactic antibiotics for neutropenia
40
what are some risk factors for acute vs chronic leukaemia?
AML =
41
what are some risk factors for acute vs chronic leukaemia?
Acute: radiation, benzene, genetic mutations like downs and klinefelters ``` Chronic: Philadelphia chromosome (BRC-ABL), etc ```
42
how would ALL and AML present? how would CML and CLL present?
ALL = kids! - lymphadenopathy, hepatosplenomegaly, testicular enlargement - bone pain and bone marrow failure = pancytopaenia (petechiae, bleeding, bruising, infection, fatigue) AML - bone marrow failure and pancytopaenia signs - violaceous skin lesions CLL - typically asymptomatic - pancytopaenia - painless lymphadenopathy more marked than CML - very big hepatosplenomegaly CML typically presents in chronic phase - SOB (anaemia), dyspnoea, abdo discomfort, hepatosplenomegaly, lymphadenopathy - gout due to increased purine breakdown - bruising, bleeding, pallor, infection, fatigue
43
How would you investigate acute leukaemias and how would AML and ALL vary?
peripheral blood films = - ALL = leukoblasts - AML = Auer rods FBC (low hb, low platelets, high wcc) U&Es, LFTs, LDH, ESR Bone marrow aspirate = - low erythropoiesis and low megakaryocytes - Flow Cytometry Immunophenotyping for myeloid or lymphoid - Fluorescent Insitu Hybridisation for mutations like Jak2 ALL has mediastinal widening on CXR
44
How would you investigate chronic leukaemias and how would CML and CLL vary?
FBC = low rbc, low platelets, high wcc (CLL wcc is very very high) Blood film - CLL = smudge cells or smear cells - CML = neutrophilia with myeloid precursor like blasts Bone marrow aspiration = - CLL = high lymphocytic infiltration - CML = increased cellularity Immunophenotyping Fluorescent insitu hybridisation = - CLL = trisomy 12, 13q deletion, mutated IgVH - CML = philadelphia chromosome (BRC-ABL) Urate raised
45
How would you manage acute leukaemias?
Remission induction using chemo to destroy tumour= huge bone marrow hypoplasia Then once haematopoesis is acheived, remission consolidation = huge bone marrow hypoplasia After remission, watch for 3 years. then continue to watch ALL patients closely AML = high risk are only give treatment if they have an HLA match for bone marrow transplant ALL = need intrathecal chemo prophylaxis as soon as blasts are cleared from blood Symptom management - bleeding = prophylactic platelet transfusion (esp AML) - fresh frozen plasma to maintain APTT and INR<1.5x normal - cryoprecipitate to keep fibrinogen >1.5g/dl - Norethisterone for women to avoid menorrhagia - infection = Prophylactic antibiotics and handwashing education - hyperuricaemia = prophylactic allopurinol, rasburicase, hydration
46
How would you manage chronic leukaemias?
CML = ph chromosome - 1st line = Imatinib for chronic phase - if no ph chromosome then interferon a - SOKAL index for prognosis CLL - 1st line = Rituximab - Rai or Binet staging systems - watch for richters syndrome (EBV involved) --> NHL
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