module 3: neoplasms

Question 1

what are the two main characteristics of tissue growth and repair?

Answer 1

1. cell proliferation
2. cell differentiation

Question 2

what is cell proliferation?

Answer 2

new cells replacing old ones

Question 3

what is cell differentiation?

Answer 3

cells acquiring the characteristics of the tissue that they make up

Question 4

what happens to cell proliferation and differentiation in neoplasia?

Answer 4

one or both of these characteristics are lost

Question 5

describe benign tumors

Answer 5

• not problematic until cause local issue
• have lost the ability to control proliferation BUT:
  
  • growth is slow, may come to a stop
  • made of fairly well-differentiated cells and well-organized stroma
  • do not invade beyond their capsule
  • no metastasis
• generally named for the tissues from which they arise
• can still be a problem if the growth interferes with function of surrounding tissue or inappropriately produced hormones

Question 6

describe malignant tumors

Answer 6

• AKA cancer
• loss of differentiation (anaplasia) and tissue organization
• cells are different sizes and shapes (pleomorphic)
• lack of a capsule = invasion of nearby blood vessels, lymphatics, and surrounding structures
• most deadly = the ability to spread far beyond the tissue of origin (metastasize)
• carcinoma = from epithelial tissue
• sarcoma = from mesenchymal tissue
• lymphomas = from lymphatic tissue
• leukemias = from blood-forming cells
• solid or hematologic tumours

Question 7

Define metastasis

Answer 7

cells take over good things from tissue

• spread far beyond the tissue of origin

Question 8

Despite losing control of proliferation, there are characteristics of benign tumors that distinguish them from malignant growth. Describe these 4 features

Answer 8

1. growth is usually slow and may come to a stop
2. made of fairly well-differentiated cells and well-organized stroma
3. do not invade beyond their capsule
4. no metastasis

Question 9

Can benign tumors still cause problems? How?

Answer 9

yes, if the growth interferes with the function of surrounding tissue or inappropriately produces hormones

Question 10

Describe 4 characteristics of malignant tumors

Answer 10

1. loss of control of growth
2. anaplasia = loss of differentiation
3. can invade local tissues
4. can metastasize = spread beyond the tissue of origin

Question 11

what is anaplasia?

Answer 11

loss of differentiation

Question 12

what is pleomorphic?

Answer 12

cells are different sizes and shapes

Question 13

How are benign tumors named compared to malignant tumors?

Answer 13

benign generally named for the tissue from which they arise, with suffix “oma”

malignant tumors are named for cell type from which they originate with

Question 14

What does “adeno-” at the beginning of a name mean? From what tissues do lymphomas originate from? Leukemias?

Answer 14

• “adeno-” = pertaining to a gland
• lymphomas originate from lymphatic tissue
• leukemias are cancers of blood forming cells

Question 15

Describe the two categories of malignant neoplasms

Answer 15

1. solid tumors (initially confined to specific tissue/organ)
2. hematologic tumors (cells normally found in blood/lymph)

Question 16

Most human cancers are derived from which tissues?

Answer 16

epithelial tissue

Question 17

Describe “carcinoma in situ”. Where can this occur?

Answer 17

• a growth with malignant characteristics in epithelial tissue that has not (yet) invaded local tissue.. technically not malignant
  
  • hard to decide either to treat or watch it
  • can remain stable, become malignant, or regress
• occurs:
  
  • breast
  • cervix
  • skin
  • stomach

Question 18

what are eight cancer cell characteristics?

Answer 18

1. genetic instability
2. the cell must become independent of external growth signals
3. loss of contact inhibition
4. decrease in cell adhesion
5. loss of anchorage dependence
6. production of unusual antigens
7. able to divide without limit
8. altered metabolism, increasing anaerobic respiration

Question 19

describe genetic instability

Answer 19

a high frequency of mutations in cancer cells

Question 20

describe how the cell must become independent of external growth signals

Answer 20

• able to make their own signals
• don’t need any signals
• extremely sensitive to growth factors

Question 21

describe loss of contact inhibition

Answer 21

normal cell usually stop growing once they come in contact with each other, but cancer cells will keep on growing and pile up on top of each other

Question 22

describe a decrease in cell adhesion

Answer 22

normal cells have membrane structures that allow them to stick together

cancer cells lack that ability= can more easily be shed from a tumour = increase chance of metastasis

Question 23

describe loss of anchorage dependence

Answer 23

cancer cells can survive and grow under conditions that normal cells can’t

Question 24

describe the production of unusual antigens

Answer 24

there is a production of wonky markers and it is harder to control those cells

Question 25

describe the ability to divide without limit (immortal)

Answer 25

* telomeres are ends of chromosomes that get shorter each cell division, until. the cell can't divide anymore * cancer cells have an enzyme called telomerase = lengthen telomeres = cells divide without a limit and immune system thinks it's ok

Question 26

describe an altered metabolism, increasing anaerobic respiration

Answer 26

cancer cells do not undergo very much cell respiration = don't need a lot of o2, goes throuh anaerobic resperation

Question 27

Explain why cancer cells require such high levels of glucose

Answer 27

because they use mainly anaerobic respiration (glycolysis) = normal tissue starts to die off

Question 28

How do we use this characteristic (high levels of glucose) to detect cancer cells in the body?

Answer 28

use a fluorescent compound that is taken up by cells in the same way as glucose, but can't be metabolized * accumulates in cells that would take up a lot of glucose

Question 29

What is metastasis?

Answer 29

* metastasis: the spread of cancer cells from the original site to distant organs and tissues

Question 30

Describe the local growth of benign tumors

Answer 30

* local spread = helped by enzymes made by the cancer cells that break down cells and connective tissue of surroundings (crablike extensions) * benign = pushed on surrounding connective tissue to form a capsule around the growth

Question 31

describe the difference in the local growth of malignant tumors to explain why malignant tumors metastasize

Answer 31

malignant tumors = cells that grow uncontrollably and spread locally and/or to distant sites * because they are not in a capsule and they have lost their cell proliferation & differentiation

Question 32

Carcinomas spread through \_\_\_\_\_\_\_\_\_\_\_\_\_\_, while sarcomas spread through the \_\_\_\_\_\_\_\_\_\_\_\_\_\_.

Answer 32

* lymph * blood

Question 33

describe the spread of carcinomas

Answer 33

* through lymph * the tumor cells lodge first in the initial lymph node that drains the area (AKA sentinel node) * goes through the lymphatic system - drains through node where cancerous cell shows up * examination od these nodes can show if metastasis has occured

Question 34

describe the spread of sarcomas

Answer 34

* spread through blood * the organ that is next in the vascular pathway is most likely affected * OR organ that supplies a similar environment as the tissue containing the original tumor

Question 35

Describe the steps in metastasis

Answer 35

must evolve characteristics needed to metastasize 1. initially invade the **interstitial spaces** of local tissue 2. if carried by lymphatic drainage, go to primary or sentinel **lymph nodes** 3. enter the **venous system** as lymph drains into left and right **subclavian veins** 4. must evade the **innate immune** system 5. secrete **proteolytic enzymes** to penetrate tissues from blood vessels (vice versa) 6. once **“seeded”** release cytokines and growth factors that control invaded tissue functions 1. stimulates their growth and proliferation 2. cancer must develop ability to perforn angiogenesis

Question 36

what are seven possible local effects of a tumor?

Answer 36

1. compression 2. obstruction 3. infarction 4. hemorrhage 5. rupture 6. effusions 7. effects are usually combined and relate to symptoms

Question 37

describe a compression local effect of tumors

Answer 37

loss of function, sensation * ex: brain tumor, headaches, local nerve compression

Question 38

describe an obstruction local effect of tumors

Answer 38

growth is blocking the way * ex: blockage to airways, gut

Question 39

describe an infarction local effect of tumors

Answer 39

obstruction of blood vessels * casing local necrosis of tissues * ex: blood in stool from colorectal cancer

Question 40

describe a hemorrhage local effect of tumors

Answer 40

severe bleeding out of blood vessel * ex: intestine, lungs

Question 41

describe a rupture local effect of tumors

Answer 41

perforation * ex: gut, ovary

Question 42

describe an effusion local effect of tumors

Answer 42

inappropriate amounts of fluid in pleural, pericardial, or peritoneal spaces may occur

Question 43

what are the nine systemic effects of cancer?

Answer 43

1. paraneoplastic syndromes 2. pain 3. fatigue 4. cachexia 5. anemia 6. leukopenia and thrombocytopenia 7. infection 8. GI tract 9. hair and skin

Question 44

Describe the paraneoplastic syndromes systemic effects of cancer, including how cancer and/or the treatment can be the cause of the problem

Answer 44

* often due to treatments * symptoms caused from the tumor, but not coming from the tumor itself * ex: hormone production (excess) * pituitary tumors overproduce hormones from endocrine gland

Question 45

Describe the paraneoplastic syndromes systemic effects of cancer, including how cancer and/or the treatment can be the cause of the problem

Answer 45

* often due to treatments * symptoms caused from the tumor, but not coming from the tumor itself * ex: hormone production (excess) * pituitary tumors overproduce hormones from the endocrine gland

Question 46

Describe pain as a systemic effect of cancer, including how cancer and/or the treatment can be the cause of the problem

Answer 46

* not always at the site of the tumor * little or none in early stages, can be strong in later stages * can result from pressure, stretching, inflammation

Question 47

Describe fatigue as a systemic effect of cancer, including how cancer and/or the treatment can be the cause of the problem

Answer 47

* not relieved by sleep or rest * may be due to sleep disturbances, carious biochemical changes, nutrition, etc. * mechanism not fully understood

Question 48

Describe cachexia as a systemic effect of cancer, including how the cancer and/or the treatment can be the cause of the problem

Answer 48

* loss of body mass due to metabolic disturbances caused by a disease and cannot be reversed nutritionally * caused by altered metabolism that leads to inefficient use of energy * compounded by side-effects of cancer: depression, anorexia, loss of sense of taste

Question 49

Describe how anemia is a systemic effect of cancer, including how the cancer and/or the treatment can be the cause of the problem

Answer 49

* caused by chronic bleeding, or leukemia, malnutrition, chemotherapy, and malignancy in blood-forming organs

Question 50

Describe the leukopenia and thrombocytopenia systemic effect of cancer, including how the cancer and/or the treatment can be the cause of the problem

Answer 50

* rapidly dividing cells being killed = compromised immune system * caused by tumor invasion of bone marrow, chemotherapy, or radiation therapy

Question 51

Describe the infection systemic effect of cancer, including how the cancer and/or the treatment can be the cause of the problem

Answer 51

* losing WBC * most significant cause of complications and death * due to loss of immune cells * causes increased risk from surgery, poor tissue perfusion, indwelling devices

Question 52

Describe the GI tract systemic effect of cancer, including how the cancer and/or the treatment can be the cause of the problem

Answer 52

* destroys the lining of GI tract * relies on rapidly multiplying tissue which is the type of tissue affected by chemotherapy and radiation therapy * treatments can cause oral ulcers, malnutrition, and infection * nausea also effect of therapeutic agent on nervous system

Question 53

Describe the hair and skin systemic effect of cancer, including how the cancer and/or the treatment can be the cause of the problem

Answer 53

also due to rapidly growing tissue being affected by therapeutic agents

Question 54

What is the multistep theory of carcinogenesis?

Answer 54

1. initiation 1. exposure to a carcinogenic agent 2. irreversible mutations to the genome 3. may be very small doses. overtime 4. cells in mitosis or meiosis most susceptible 2. promotion 1. cytokines and growth factors begin to induce cell proliferation (division) 3. progression 1. tumor cells eventually acquire all the characteristics needed to invade and metastasize to other tissues

Question 55

What is the effect of age on the development of cancer (why is cancer more prevalent with age

Answer 55

* rate of cancer increases dramatically with age due to the accumulation of small changes in genetic material (mutations) that occur over a lifetime

Question 56

Name the 2 types of growth controlling genes that when altered, may cause cancer.

Answer 56

1. proto-oncogenes 2. tumor-suppressor genes

Question 57

describe proto-oncogenes and include an example

Answer 57

* genes that in their normal non-mutant state code for proteins that cause the cell to divide (stimulates cell growth) * if one is mutated, it causes an increase of growth rate (growing more than it should) = oncogenes * ex: breast cancer

Question 58

describe tumor-suppressor genes and give an example

Answer 58

* genes that suppress the growth * only need one copy to be sufficient * if both are mutated, then there will be an effect * ex: BRCA1 gene in breast cancer

Question 59

Why is the alteration of tumor-suppressing genes said to be recessive in effect?

Answer 59

both copies of the gene must be altered in order for this to have an effect

Question 60

Describe and give an example of two other factors that could contribute to the development of cancer.

Answer 60

1. changes in the control mechanisms that govern which genes are expressed 1. labeling right on DNA so it can't be transcribed = not able to produce those proteins 2. changes in metabolic pathways inside the cell 1. can't fix mutation you want to fix 2. proteins damaged = DNA not checked = damage cells

Question 61

what are the causative factors of cancer?

Answer 61

1. inflammation 2. viral 3. bacterial 4. environmental/lifestyle interactions 5. heredity 6. age 7. chemical carcinogens 8. low strength (solar) radiation and high strength (nuclear) radiation

Question 62

how does inflammation cause cancer?

Answer 62

* get possible rupture of neutrophils/enzymes = increase of mutations * immune cells produce oxidative species = damage to cells around you and more likely for mutations

Question 63

how does viral (viruses) cause cancer?

Answer 63

* up to 80% of liver cancer are associated with chronic hepatitis by HBV/HBC * all cervical cancer is caused by infection with specific subtypes of HPV * EBV virus infects B cells and stimulates their growth

Question 64

how does bacteria cause cancer?

Answer 64

* chronic infection with **helicobacter pylori** (causes ulcers in the stomach sometimes) has been linked to gastric carcinoma * infection is asymptomatic, but the prolonged chronic inflammation can lead to the development of cancer

Question 65

what is carcinogenesis?

Answer 65

when normal cells become cancer cells

Question 66

Describe the use of tumor markers in the detection of cancer.

Answer 66

* substances being produced in excess because of benign and malignant cells can be found on tumor cells, in blood, spinal fluid, or urine * if detect high amount of the marker, it can indicate the type of cancer * can get false positives and negatives

Question 67

Describe the 3 uses of cytology/histology in the detection of cancer.

Answer 67

1. papanicolau (pap) test: examining the secretion can reveal abnormal cells 1. if you have area of body where creating secretions around a tumor, it can contain cells of the tumor since the cells are easily shed 2. biopsy: taking a chunk of tissue to make slides to look for abnormal cells under a microscope 3. immunohistochemistry = **the best to check the type of cancer** 1. take biopsy and apply antibodies to bind to antigens/surface marker to see it show up depending on marker you're looking for

Question 68

Describe the use of imaging in the detection of cancer.

Answer 68

* endoscopic (to get biopsy) * ultrasound * x-rays * CT scan (computerized tomography) = many x-rays taken from different angles to produce 3D image * MRI (magnetic resonance imaging) = uses magnetic field to provide more soft tissue detail * PET (position emission): check for high metabolic rate where you naturally should not have

Question 69

Differentiate between the following **imaging** techniques; CT, MRI and PET scans.

Answer 69

* CT (computerized tomography) = many x-rays taken from different angles to produce a 3D image * MRI (magnetic resonance imaging) = uses a magnetific field to provide more soft tissue detail * PET (position emission) = uses biologically active molecule attached to a tracer to show metabolically active tissue

Question 70

Differentiate between the grading and staging classifications of a cancer

Answer 70

* grading = according to cellular characteristics * staging = according to spread

Question 71

Describe the basis of grading a tumour

Answer 71

* portion of the tumor is obtained through a biopsy * closer the tumor cells resemble normal tissue, the lower the grade

Question 72

Describe the 4 stage system of classifying cancer

Answer 72

includes size and spread of the disease stage 1: confined to origin stage 2: local invasive stage 3: spread to local lymph nodes stage 4: spread to distant sites

Question 73

Describe WHO’s TNM system

Answer 73

describes tumor size, lymph node involvement and extent of metastasis T = tumor size N = lymph nodes involver M = metastasis

Question 74

Name the 3 main treatments for cancer

Answer 74

1. chemotherapy 2. radiation therapy 3. surgery

Question 75

describe chemotherapy

Answer 75

* giving a drug to target cells based on what they look like * given in combination to kill as many cancer cells as possible and reducing side effecrs * can be given alone (induction), or in combination with surgery * adjuvent = after surgery to hopefully kill the cells that fluffed off/spread * neoadjuvant = before surgery to reduce tumor size

Question 76

describe radiation therapy

Answer 76

* using radiation to target cells, DNA damage to eliminate the dividing cells * most effective on cells that are rapidly renewing * can be through an external beam, or by placing small radioactive capsules in the affected area

Question 77

describe surgery for cancer maintenance/removal

Answer 77

* often definitive treatment for localized tumors * may be used prophylactically (preventative surgery) * precautions include * obtaining enough tissue for biopsies * avoiding spread of cancerous cells during operation * esablishing staging information

Question 78

Why are chemotherapeutic agents often given as “cocktails”?

Answer 78

to decrease the amount given of any one drug (reducing side effects) and increasing attack on cancer cells

Question 79

Describe induction, adjuvant and neoadjuvant chemotherapies.

Answer 79

* induction: chemo given alone * adjuvant: chemo given after surgery to hopefully kill cells that fluffed off * neoadjuvant: chemo given before surgery to reduce tumor size

Question 80

What is brachytherapy?

Answer 80

placing small radioactive capsules in the affected area

Question 81

What are three uses for surgery other than complete removal of the tumour?

Answer 81

1. obtaining enough tissue for biopsies, or to ensure all tumor has been removed 2. avoiding spread of cancerous cells during operation 3. establishing staging information by observin and sampling local lymph tissue

Question 82

How does the type of cancer usually found in children differ in origin from that of adults?

Answer 82

most are noth of epithelial origin: leukemia, brain, sarcoma

Question 83

When are childhood cancers usually diagnosed?

Answer 83

during peak times of physical growth and maturation

Question 84

Why can childhood cancers be difficult to diagnose early?

Answer 84

having symptoms that are typical to other diseases (cold, flu, etc.)

Question 85

What is the most widely used treatment for childhood cancers? Why?

Answer 85

* chemotherapy * children better tolerate side effects and the type of tumors respond better to chemotherapy

Question 86

Mr. Chow (68 yrs) visits his doctor, complaining of a chronic cough that has recently become significantly worse (at times even producing some blood) and is now accompanied by a shortness of breath with moderate exercise (climbing stairs). In addition, his voice has lately become increasingly hoarse, although his throat is not sore. He admits to a history of cigarette smoking (since the age of 16). Auscultation of his lungs reveals a wheezing sound in the left upper lobe when he breathes in. Sputum samples reveal the presence of highly aplastic and pleomorphic cells. A CT scan of his chest area shows a 4 cm mass in a medial area of the left upper lobe, as well as enlarged ipsilateral hilar nodes, both ipsilateral and contralateral mediastinal nodes and finally, thickened areas on the outside of the tracheal wall. Subsequent biopsies show abnormal squamous cells present in the mass in the lung, and lymph nodes, and in tissue from the thickened area of the trachea. A thorough neurological exam showed normal reflexes, with no evidence of deficits in memory, cognition or co-ordination. 1. What is the most likely diagnosis of Mr. Chow’s condition? (Be as specific as you can – the handout is a good source for this answer.) Explain your choice using descriptions of any abnormal cell types and their location.

Answer 86

Squamous cell carcinoma - sputum shows aplastic and pleomorphic cells - Spread to hilar lymph nodes - Abnormal squamous cells present in masses

Question 87

Mr. Chow (68 yrs) visits his doctor, complaining of a chronic cough that has recently become significantly worse (at times even producing some blood) and is now accompanied by a shortness of breath with moderate exercise (climbing stairs). In addition, his voice has lately become increasingly hoarse, although his throat is not sore. He admits to a history of cigarette smoking (since the age of 16). Auscultation of his lungs reveals a wheezing sound in the left upper lobe when he breathes in. Sputum samples reveal the presence of highly aplastic and pleomorphic cells. A CT scan of his chest area shows a 4 cm mass in a medial area of the left upper lobe, as well as enlarged ipsilateral hilar nodes, both ipsilateral and contralateral mediastinal nodes and finally, thickened areas on the outside of the tracheal wall. Subsequent biopsies show abnormal squamous cells present in the mass in the lung, and lymph nodes, and in tissue from the thickened area of the trachea. A thorough neurological exam showed normal reflexes, with no evidence of deficits in memory, cognition or co-ordination. Based on your diagnosis, account for the signs/symptoms that caused him to see his doctor

Answer 87

Chronic cough – airway irritation and obstruction Blood – lesion erodes blood vessels Wheezing – obstruction of airway Hoarse voice – involvement of laryngeal nerve Shortness of breath – also obstruction of airway

Question 88

Is Mr. Chow’s tumor a carcinoma in situ? Why/why not?

Answer 88

No, because it has spread to local lymph nodes (know what ipsilateral and contralateral, hilar and mediastinal mean).

Question 89

Mr. Chow (68 yrs) visits his doctor, complaining of a chronic cough that has recently become significantly worse (at times even producing some blood) and is now accompanied by a shortness of breath with moderate exercise (climbing stairs). In addition, his voice has lately become increasingly hoarse, although his throat is not sore. He admits to a history of cigarette smoking (since the age of 16). Auscultation of his lungs reveals a wheezing sound in the left upper lobe when he breathes in. Sputum samples reveal the presence of highly aplastic and pleomorphic cells. A CT scan of his chest area shows a 4 cm mass in a medial area of the left upper lobe, as well as enlarged ipsilateral hilar nodes, both ipsilateral and contralateral mediastinal nodes and finally, thickened areas on the outside of the tracheal wall. Subsequent biopsies show abnormal squamous cells present in the mass in the lung, and lymph nodes, and in tissue from the thickened area of the trachea. A thorough neurological exam showed normal reflexes, with no evidence of deficits in memory, cognition or co-ordination. . What factor(s) in his case (i.e., personal information) indicates a greater risk of this type of cancer, and how would this increase his risk of cancer?

Answer 89

Smoking = increased exposure to carcinogens Age = increase in number of mutations Men = more common in men (unknown why)

Question 90

Mr. Chow (68 yrs) visits his doctor, complaining of a chronic cough that has recently become significantly worse (at times even producing some blood) and is now accompanied by a shortness of breath with moderate exercise (climbing stairs). In addition, his voice has lately become increasingly hoarse, although his throat is not sore. He admits to a history of cigarette smoking (since the age of 16). Auscultation of his lungs reveals a wheezing sound in the left upper lobe when he breathes in. Sputum samples reveal the presence of highly aplastic and pleomorphic cells. A CT scan of his chest area shows a 4 cm mass in a medial area of the left upper lobe, as well as enlarged ipsilateral hilar nodes, both ipsilateral and contralateral mediastinal nodes and finally, thickened areas on the outside of the tracheal wall. Subsequent biopsies show abnormal squamous cells present in the mass in the lung, and lymph nodes, and in tissue from the thickened area of the trachea. A thorough neurological exam showed normal reflexes, with no evidence of deficits in memory, cognition or co-ordination. If it is decided that Mr. Chow’s treatment will be chemotherapy followed by surgery, what term would apply to the chemotherapy? Why would it be given prior to the surgery?

Answer 90

Neoadjuvant – to decrease size of tumour

Question 91

Mr. Chow (68 yrs) visits his doctor, complaining of a chronic cough that has recently become significantly worse (at times even producing some blood) and is now accompanied by a shortness of breath with moderate exercise (climbing stairs). In addition, his voice has lately become increasingly hoarse, although his throat is not sore. He admits to a history of cigarette smoking (since the age of 16). Auscultation of his lungs reveals a wheezing sound in the left upper lobe when he breathes in. Sputum samples reveal the presence of highly aplastic and pleomorphic cells. A CT scan of his chest area shows a 4 cm mass in a medial area of the left upper lobe, as well as enlarged ipsilateral hilar nodes, both ipsilateral and contralateral mediastinal nodes and finally, thickened areas on the outside of the tracheal wall. Subsequent biopsies show abnormal squamous cells present in the mass in the lung, and lymph nodes, and in tissue from the thickened area of the trachea. A thorough neurological exam showed normal reflexes, with no evidence of deficits in memory, cognition or co-ordination. If chemotherapy was used after the surgery, what term would apply to the chemotherapy? Why would it be given after the surgery?

Answer 91

Adjuvant – to kill any remaining cells (around the tumour, or metastasized cells)

Question 92

If Mr. Chow is not healthy enough to withstand the trauma of surgery, what treatment is likely to be used?

Answer 92

radiation

Question 93

Mr. Chow (68 yrs) visits his doctor, complaining of a chronic cough that has recently become significantly worse (at times even producing some blood) and is now accompanied by a shortness of breath with moderate exercise (climbing stairs). In addition, his voice has lately become increasingly hoarse, although his throat is not sore. He admits to a history of cigarette smoking (since the age of 16). Auscultation of his lungs reveals a wheezing sound in the left upper lobe when he breathes in. Sputum samples reveal the presence of highly aplastic and pleomorphic cells. A CT scan of his chest area shows a 4 cm mass in a medial area of the left upper lobe, as well as enlarged ipsilateral hilar nodes, both ipsilateral and contralateral mediastinal nodes and finally, thickened areas on the outside of the tracheal wall. Subsequent biopsies show abnormal squamous cells present in the mass in the lung, and lymph nodes, and in tissue from the thickened area of the trachea. A thorough neurological exam showed normal reflexes, with no evidence of deficits in memory, cognition or co-ordination. Identify and explain several iatrogenic manifestations that Mr. Chow may experience.

Answer 93

Due to chemotherapy: Anemia, leukopenia and thrombocytopenia GI tract (ulcers) Hair loss and dry skin Nausea Increased infection due to loss of WBC and medical treatment

Question 94

Mr. Chow (68 yrs) visits his doctor, complaining of a chronic cough that has recently become significantly worse (at times even producing some blood) and is now accompanied by a shortness of breath with moderate exercise (climbing stairs). In addition, his voice has lately become increasingly hoarse, although his throat is not sore. He admits to a history of cigarette smoking (since the age of 16). Auscultation of his lungs reveals a wheezing sound in the left upper lobe when he breathes in. Sputum samples reveal the presence of highly aplastic and pleomorphic cells. A CT scan of his chest area shows a 4 cm mass in a medial area of the left upper lobe, as well as enlarged ipsilateral hilar nodes, both ipsilateral and contralateral mediastinal nodes and finally, thickened areas on the outside of the tracheal wall. Subsequent biopsies show abnormal squamous cells present in the mass in the lung, and lymph nodes, and in tissue from the thickened area of the trachea. A thorough neurological exam showed normal reflexes, with no evidence of deficits in memory, cognition or co-ordination. What would be a likely explanation if Mr. Chow also experiences ongoing constipation and the development of kidney stones?

Answer 94

Paraneoplastic effect – tumour releases a parathyroid like peptide that increases calcium in blood, which can cause: - kidney stones - have quieting effect on smooth muscles of GI tract, causing constipation.

Question 95

Mr. Chow (68 yrs) visits his doctor, complaining of a chronic cough that has recently become significantly worse (at times even producing some blood) and is now accompanied by a shortness of breath with moderate exercise (climbing stairs). In addition, his voice has lately become increasingly hoarse, although his throat is not sore. He admits to a history of cigarette smoking (since the age of 16). Auscultation of his lungs reveals a wheezing sound in the left upper lobe when he breathes in. Sputum samples reveal the presence of highly aplastic and pleomorphic cells. A CT scan of his chest area shows a 4 cm mass in a medial area of the left upper lobe, as well as enlarged ipsilateral hilar nodes, both ipsilateral and contralateral mediastinal nodes and finally, thickened areas on the outside of the tracheal wall. Subsequent biopsies show abnormal squamous cells present in the mass in the lung, and lymph nodes, and in tissue from the thickened area of the trachea. A thorough neurological exam showed normal reflexes, with no evidence of deficits in memory, cognition or co-ordination. Why was a neurological examination performed on Mr. Chow?

Answer 95

To check for metastasis to the brain

Question 96

Ms. Peters, (40 yrs) visits her doctor, complaining of weakness, fatigue and unexplainable weight loss, with the added misery of chronic constipation. A laboratory work-up reveals a hematocrit of 25%, a hemoglobin value of 7.6 g/dL, a RBC count of 3.5 million/cubic mm, and a WBC count of 5200 cells/cubic mm. She denied heavy menstrual flow, so was tested for fecal occult blood, which yielded a positive result. A colonoscopy was performed, which revealed a 5 cm mass in the ascending colon. A biopsy of the mass revealed an adenocarcinoma with ulceration. Surgery was performed to remove the mass – the pathology report showed that the tumour had penetrated the through the width of the wall of the colon and perforated the visceral peritoneum. Nearby lymph nodes that were biopsied showed involvement of 3 local nodes. A serum CEA level of 16 ng/ml was observed after surgery. Ms. Peters underwent several cycles of chemotherapy, which resulted in a serum CEA value of 3.5 ng/ml. Abdominal and chest CT scans were negative at that point. Describe the differences in the histology of the tumour, if it had been assessed as an adenoma (rather than an adenocarcinoma).

Answer 96

Adenoma – benign, well differentiated cells and well organized Adenocarcinoma – malignant Pleomorphic – different sizes and shapes Anaplastic – not differentiated

Question 97

Ms. Peters, (40 yrs) visits her doctor, complaining of weakness, fatigue and unexplainable weight loss, with the added misery of chronic constipation. A laboratory work-up reveals a hematocrit of 25%, a hemoglobin value of 7.6 g/dL, a RBC count of 3.5 million/cubic mm, and a WBC count of 5200 cells/cubic mm. She denied heavy menstrual flow, so was tested for fecal occult blood, which yielded a positive result. A colonoscopy was performed, which revealed a 5 cm mass in the ascending colon. A biopsy of the mass revealed an adenocarcinoma with ulceration. Surgery was performed to remove the mass – the pathology report showed that the tumour had penetrated the through the width of the wall of the colon and perforated the visceral peritoneum. Nearby lymph nodes that were biopsied showed involvement of 3 local nodes. A serum CEA level of 16 ng/ml was observed after surgery. Ms. Peters underwent several cycles of chemotherapy, which resulted in a serum CEA value of 3.5 ng/ml. Abdominal and chest CT scans were negative at that point List three other characteristics of an adenocarcinoma that would differentiate it from a benign tumor.

Answer 97

1. growth would be more rapid 2. no capsule, so can invade local tissue 3. can metastasize

Question 98

Ms. Peters, (40 yrs) visits her doctor, complaining of weakness, fatigue and unexplainable weight loss, with the added misery of chronic constipation. A laboratory work-up reveals a hematocrit of 25%, a hemoglobin value of 7.6 g/dL, a RBC count of 3.5 million/cubic mm, and a WBC count of 5200 cells/cubic mm. She denied heavy menstrual flow, so was tested for fecal occult blood, which yielded a positive result. A colonoscopy was performed, which revealed a 5 cm mass in the ascending colon. A biopsy of the mass revealed an adenocarcinoma with ulceration. Surgery was performed to remove the mass – the pathology report showed that the tumour had penetrated the through the width of the wall of the colon and perforated the visceral peritoneum. Nearby lymph nodes that were biopsied showed involvement of 3 local nodes. A serum CEA level of 16 ng/ml was observed after surgery. Ms. Peters underwent several cycles of chemotherapy, which resulted in a serum CEA value of 3.5 ng/ml. Abdominal and chest CT scans were negative at that point Explain Ms. Peters’ feelings of weakness and fatigue, supporting your explanation with the lab values obtained.

Answer 98

Due to anemia – decreased hematocrit, decreased hemoglobin, decreased RBC

Question 99

Ms. Peters, (40 yrs) visits her doctor, complaining of weakness, fatigue and unexplainable weight loss, with the added misery of chronic constipation. A laboratory work-up reveals a hematocrit of 25%, a hemoglobin value of 7.6 g/dL, a RBC count of 3.5 million/cubic mm, and a WBC count of 5200 cells/cubic mm. She denied heavy menstrual flow, so was tested for fecal occult blood, which yielded a positive result. A colonoscopy was performed, which revealed a 5 cm mass in the ascending colon. A biopsy of the mass revealed an adenocarcinoma with ulceration. Surgery was performed to remove the mass – the pathology report showed that the tumour had penetrated the through the width of the wall of the colon and perforated the visceral peritoneum. Nearby lymph nodes that were biopsied showed involvement of 3 local nodes. A serum CEA level of 16 ng/ml was observed after surgery. Ms. Peters underwent several cycles of chemotherapy, which resulted in a serum CEA value of 3.5 ng/ml. Abdominal and chest CT scans were negative at that point Why was she asked about a heavy menstrual flow?

Answer 99

could be the cause of the anemia

Question 100

Ms. Peters, (40 yrs) visits her doctor, complaining of weakness, fatigue and unexplainable weight loss, with the added misery of chronic constipation. A laboratory work-up reveals a hematocrit of 25%, a hemoglobin value of 7.6 g/dL, a RBC count of 3.5 million/cubic mm, and a WBC count of 5200 cells/cubic mm. She denied heavy menstrual flow, so was tested for fecal occult blood, which yielded a positive result. A colonoscopy was performed, which revealed a 5 cm mass in the ascending colon. A biopsy of the mass revealed an adenocarcinoma with ulceration. Surgery was performed to remove the mass – the pathology report showed that the tumour had penetrated the through the width of the wall of the colon and perforated the visceral peritoneum. Nearby lymph nodes that were biopsied showed involvement of 3 local nodes. A serum CEA level of 16 ng/ml was observed after surgery. Ms. Peters underwent several cycles of chemotherapy, which resulted in a serum CEA value of 3.5 ng/ml. Abdominal and chest CT scans were negative at that point What does “fecal occult blood” mean? Why did the positive fecal occult blood result in Ms. Peters undergoing a colonoscopy? How does the result of the colonoscopy explain her initial clinical manifestations (including the constipation)?

Answer 100

* Fecal occult blood means blood that can’t be seen in the feces. * If this is positive, she is bleeding somewhere in the lower GI tract, and this may be due to a tumour. (Hmmm…. Would this cause anemia and tiredness?) * Anemia due to loss of blood because of the tumour. * Constipation due to obstruction of tract by tumour * Loss of weight due to cachexia

Question 101

Ms. Peters, (40 yrs) visits her doctor, complaining of weakness, fatigue and unexplainable weight loss, with the added misery of chronic constipation. A laboratory work-up reveals a hematocrit of 25%, a hemoglobin value of 7.6 g/dL, a RBC count of 3.5 million/cubic mm, and a WBC count of 5200 cells/cubic mm. She denied heavy menstrual flow, so was tested for fecal occult blood, which yielded a positive result. A colonoscopy was performed, which revealed a 5 cm mass in the ascending colon. A biopsy of the mass revealed an adenocarcinoma with ulceration. Surgery was performed to remove the mass – the pathology report showed that the tumour had penetrated the through the width of the wall of the colon and perforated the visceral peritoneum. Nearby lymph nodes that were biopsied showed involvement of 3 local nodes. A serum CEA level of 16 ng/ml was observed after surgery. Ms. Peters underwent several cycles of chemotherapy, which resulted in a serum CEA value of 3.5 ng/ml. Abdominal and chest CT scans were negative at that point What is the significance of the serum CEA level? What would a subsequent rise in this value possibly indicate?

Answer 101

CEA is a tumour marker that increases with colorectal cancer. This decreased after surgery and removal of the tumour. If it goes up again, the tumour has returned.

Question 102

Ms. Peters, (40 yrs) visits her doctor, complaining of weakness, fatigue and unexplainable weight loss, with the added misery of chronic constipation. A laboratory work-up reveals a hematocrit of 25%, a hemoglobin value of 7.6 g/dL, a RBC count of 3.5 million/cubic mm, and a WBC count of 5200 cells/cubic mm. She denied heavy menstrual flow, so was tested for fecal occult blood, which yielded a positive result. A colonoscopy was performed, which revealed a 5 cm mass in the ascending colon. A biopsy of the mass revealed an adenocarcinoma with ulceration. Surgery was performed to remove the mass – the pathology report showed that the tumour had penetrated the through the width of the wall of the colon and perforated the visceral peritoneum. Nearby lymph nodes that were biopsied showed involvement of 3 local nodes. A serum CEA level of 16 ng/ml was observed after surgery. Ms. Peters underwent several cycles of chemotherapy, which resulted in a serum CEA value of 3.5 ng/ml. Abdominal and chest CT scans were negative at that point If Ms. Peters’ condition was specifically identified as a type of cancer for which higher risk runs in families, identify what type of gene might likely be involved, and explain the mechanism that lies behind the inheritance effect.

Answer 102

* Tumour suppressor gene – slows down the rate of cell division * Recessive effect – need to have a mutation in both copies for loss of protection. If are born (inherit) one defective copy, more likely to get cancer (only need one mutation). * This increases the risk, but getting cancer is still not for sure.