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SURGERY > Cancer > Flashcards

Cancer Flashcards

1
Q

What are the 2 different types of oesophageal cancer and how does oesophageal cancer present?

A
  1. Adenocarcinoma (80%) - arises from Barrett’s
  2. SCC (15%) - unrelated to barrett’s, due to smoking, alcohol, hot beverages, low fibre
  • Dysphagia
  • Odynophagia
  • Weight loss
  • Hoarse voice
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2
Q

What is the diagnostic investigations for oesophageal cancer?

A

Oesophagogastroduodenoscopy (OGD) with biopsy

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3
Q

How does the prognosis differ between oesophageal cancer and stomach cancer?

A
  • 5yr survival for oesophageal cancer is only 5%

- 5yr survival for stomach cancer is 0% with no treatment, if detected early 60% are cured

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4
Q

What are the clinical symptoms of stomach cancer? What is a relative differential and how is it diagnosed?

A
  • Vague abdominal pain
  • Early satiety
  • Dyspepsia
  • Nausea and vomiting
  • Cancer B symptoms + anorexia
  • Anaemia (can be pernicious)
  • Epigastric mass/tenderness
    DDx: PUD
    Diagnosed with endoscopy + biopsy + cytology
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5
Q

What are the two different types of pancreatic endocrine tumours?

A 
Acinar cell carcinoma 
Arise from the pancreatic islets:
1. Functioning
- Insulinoma
- Glucagon
- Gastrinoma (ZE syndrome)
2. Non-functioning
- Usually asymptomatic, tend to become malignant
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6
Q

What is the most common type of exocrine pancreatic tumour? Where does it usually arise?

A

Pancreatic ductal adenocarcinoma (secretes mucous)

- Head of pancreas

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7
Q

How does pancreatic cancer present?

A
  • Painless jaundice, palpable gall bladder (rare)
  • Vague abdo pain
  • Weight loss, fatigue
  • Steatorrhoea
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8
Q

How does pancreatic cancer appear on imaging? What other investigations are required?

A 
CT - fat stranding
X-ray - calcification
U/S - dilated ducts, mass
FBC - anaemia, coags (poor vit K absorption)
LFTs - obstructive
EUC - severity
Ca19-9 pancreatic cancer marker
ERCP for biopsy and imaging
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9
Q

What procedure is required for pancreatic cancer?

A

Whipple’s procedure

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10
Q

What is the pneumonic for staging the severity of pancreatitis?

A 
P O2
A ge
N eutrophilia 
C alcium (LOW)
R enal (high urea)
E nzymes (LFTs, amylase and lipase)
A lbumin is low
S ugar is high
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11
Q

What are the important differential diagnoses to rule out when considering pancreatitis?

A
  • Perforated PUD (high amylase can be due to systemic absorption of pancreatic enzymes in abdo cavity)
  • Aortic dissection (CT scan to look for intimal flap)
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12
Q

What are some complications of acute pancreatitis?

A 
LOCAL:
- Pancreatic psuedocyst (Unilocular collection of fluid and necrotic debris, rich in pancreatic enzymes)
- Abscess formation
- Fistula
- Biliary obstruction
SYSTEMIC:
- Sepsis
- ARDs
- Renal failure
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13
Q

What are some risk factors for developing testicular cancer?

A
  • Cryptorchidism (undescended testes)
  • FHx
  • Infantile hernia
  • Trauma
  • Occupational?
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14
Q

What are some differentials for scrotal swellings and how will you differentiate between them?

A
  • Testicular cancer
  • Testicular torsion
  • Hydrocele
  • Varicocele
  • Epididimo-orchitis
  • Spermatocele (epididymal cyst)
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15
Q

What are the layers of the scrotum?

A 
Skin
Dartos muscle
External spermadic fascia
Cremaster muscle
Internal spermadic vascia
Tunica vaginalis
Tunica albuginea
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16
Q

What are some important blood tests for testicular cancer?

A

b-HCG and alpha-fetoprotein

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17
Q

What is the function of the prostate gland?

A
  • Produces alkaline fluid to make up 30% of seminal fluid

- Aids in the motility and survival of semen and the genetic material

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18
Q

What are the common clinical findings of prostate cancer?

A
  • Painless, asymptomatic
  • LUTS symptoms
  • Bone pain from mets
  • Cough from mets
  • DRE: hard, irregular, nodular, asymmetrical
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19
Q

What are the important cut off levels for PSA?

A 
3, 5.5, 10
<3 - do nothing
3-5.5 - redo in 1-3mo
>5.5 - repeat test, then biopsy
>10 - probably cancer - biopsy
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20
Q

Explain the pros and cons of PSA screening for prostate cancer

A

PROS: sensitive, allows early diagnosis BUT does not alter mortality
CONS: very non-specific
- Increases with BPH, prostatitis, cancer
- generates unnecessary fear, leads to unnecessary treatment

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21
Q

What are the 3 signs of paraneoplastic syndrome in kidney cancer?

A

HTN: Renin production
Polycythaemia: EPO production
Hypercalcaemia: Ectopic PTH production

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22
Q

How does renal cancer commonly present? What investigations are required?

A
  1. Painless haematuria, usually frank
  2. Palpable mass
  3. Flank/loin pain (only in 7-10% cases)
    25% have metastases on presentation
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23
Q

What are the three different types of renal cell carcinoma? What are the characteristics of each?

A

Clear cell RCC (most common): from PCT, solid, cystic, vascular, Gold/orange colour
Papillary cell RCC: from PCT, solid, NON-haemorrhagic, necrosis, cysts
Chromophobe RCC: from collecting duct, Solid, tan coloured

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24
Q

What is the most common kidney cancer occurring in children?

A

Wilm’s tumour (nephroblastoma)

  • Arises from embryonic mesodermal tissue
  • 4th most common childhood cancer
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25
Q

What cancers give osteosclerotic and osteolytic lesions?

A 
Sclerotic = prostate
Lytic = breast
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26
Q

What investigations are required with prostate cancer?

A 
Diagnostic is prostate biopsy
- required for Gleason score
Transrectal U/S guided needle core biopsy
PSA
FBC, LFTs, EUCs - remember mets
Bone scan, PET scan for mets
CXR - mets
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27
Q

What is the Gleason score? What does it entail?

A

Evaluates the prognosis of men with prostate cancer by staging the cancer which guides treatment
- Involves looking at histopathology of prostate sample, 2 most common cell types = 2 numbers!
How much do these cells resemble normal prostatic tissue:
- Most common cell pattern = first grade
- Second most common cell pattern = second grade
○ Score (grade 1 + grade 2)
I.e. 8 (3+5) is better than 8(5+3)

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28
Q

What are the treatment options for localised prostate cancer (T1/T2)?

A

Localised prostate cancer (T1/T2)

  • Treatment depends on life expectancy and patient choice
  • Conservative: active monitoring & watchful waiting, track PSA, do another biopsy if concerned
  • Radical prostatectomy
  • Radiotherapy: external beam and brachytherapy
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29
Q

What are the different types of bladder cancer?

A

Transitional cell (urothelial) - most common
Squamous cell
Adenocarcinoma
Mixed

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30
Q

How does bladder cancer present?

A

Haematuria (macro or micro), usually painless
~65 years
Can have some urinary symptoms (frequency, dysuria, urgency)

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31
Q

What are risk factors for bladder cancer?

A

Smoking, alcohol, age
Exposure to chemicals / radiation
Chronic infection
History of indwelling foreign body

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32
Q

What investigations are required with suspected bladder cancer?

A

Urinalysis - haematuria, proteinuria more likely GN
MCU - RBCs and morphology
Urine cytology - look for malignant cells
FBC, coags, LFTs, EUCs, CMP - renal function should be normal
Cancer markers - Ca-125?
Pelvic ultrasound if non-glomerular from above tests
X-ray, DEXA scan if worried about mets

33
Q

What does a low specific gravity on urinalysis indicate?

A

Poor concentrating ability of kidney

- Probably an intrinsic renal disease

34
Q

How do you distinguish extra-glomerular from golmerular haematuria?

A

EXTRA

  • Red/pink colour
  • Clots may be present
  • Usually no protein
  • Normal shaped - extrinsic source (stones, cancer, obstruction, infection)

GLOM

  • Red/smoky brown colour
  • No clots
  • Proteinuria
  • Dysmorphic RBC forming casts - glomerulonephritis (intrinsic renal disease)
35
Q

Describe Dukes criteria for staging CRC

A

A: submucosa and muscle layer
B: breached muscle layer and bowel wall
C: spread to pericolic, then mesenteric lymph nodes
D: distant mets

36
Q

Describe the T (from TNM) staging for CRC

A

T1: invades to submucosa
T2: through to muscularis propria
T3: through to subserosa, non-peritonised perirectal tissues
T4: invades other surrounding structures, perforates visceral peritoneum

37
Q

What are the genetic mutations present in FAP and Lynch syndrome respectively?

A

FAP

Lynch

38
Q

What is the role of CEA in CRC treatment?

A

Carcinogenic embryogenic antigen

  • Monitor this level after treatment - tracks progression
  • Elevates if cancer is coming back
39
Q

What are the parameters that determine whether a colostomy bag is required post CRC surgery?

A
  • Depends on blood supply and length of tube
  • Decreased blood supply can lead to scarring
  • Not enough tube
40
Q

What are the surgery management options for T1/T2 and T3/T4 CRCs?

A

T1/T2 - straight to surgery

T3/T4 - pre-op chemo and radio to shrink tumour first, then think about surgery

41
Q

Compare the pros/cons for CRC screening methods

A

FOBT
- Cons: Sensitive but not specific - leads to many false positives, misses some cancers, need colonoscopy anyway
- Pros: non-invasive, no prep required, low cost, no risks of perforation etc.
Colonoscopy
- Cons: invasive, requires anaesthetic, misses flat lesions, requires ++prep, risk of bleeding/perforation
- Pros: easily visualised entire rectum/colon, can biopsy at same time
CT Colonography
- Cons: requires ++prep, miss small polyps, need colonoscopy anyway if find anything, radiation exposure, not covered by medicare
- Pros: minimally invasive, can visualise whole colon, don’t need sedation

42
Q

Who is sent FOBT in the mail?

A

50, 55, 60, 64, 65, 70, 72, 74

43
Q

Compare and contrast osteosarcoma and Ewing’s sarcoma

A

Osteosarcoma: metaphysis prior to epiphyseal closure,

  • Usually distal femur, proximal tibia
  • Older children, most common, males>females
  • ‘Sunburst’ appearance on x-ray (spicules of new bone)
  • Associated with retinoblastoma, Paget’s disease of the bone and radiotherapy

Ewings: diaphysis

  • Usually mid-proximal femur, also pelvis
  • Younger children, less common
  • Destructive lesion on x-ray
44
Q

What is the most common benign bone tumour?

A

Osteochondroma

45
Q

What investigations do you do to detect hepatocellular carcinoma?

A

a-fetoprotein

Liver U/S

46
Q

What is the most common type of testicular cancer?

A

Seminoma

47
Q

What are the features of a seminoma testicular cancer?

A

Homogenous and painless mass with the absence of haemorrhage. On histology, findings include large cells in lobules with clear cytoplasm ‘fried egg appearance’.
Metastasises late, responds to radiotherapy and has an excellent prognosis.

48
Q

What kind of testicular cancer is this?
Homogenous and painless mass with the absence of haemorrhage. On histology, findings include large cells in lobules with clear cytoplasm ‘fried egg appearance’.

A

Seminoma

49
Q

Would you biopsy a testicular tumour?

A

NUP - high risk of seeding the scrotum. Instead, investigations include a scrotal ultrasound and blood tests for tumour markers. Treatment is radical orchiectomy as most testicular tumours are malignant

50
Q

Where does prostate metastasise to most frequently?

A

Metastasis commonly involves the lumbar spine in late stages of the cancer creating osteoblastic lesions on the bone. It presents as lower back pain. Serum alkaline phosphatase (ALP) will be raised as well as prostatic specific antigen (PSA).

51
Q

Which area of the prostate does cancer usually begin?

A

Posterior lobe and on the periphery. This is why it is often asymptomatic as it does not compress the urethra producing no urinary symptoms at an early stage. The prostate is located anterior to the rectum. Thus, on digital rectal exam (DRE), a mass can be felt as the posterior and peripheral region is affected.

52
Q

What is the most common testicular cancer in young boys? What are the features?

A

Yolk sac tumour
An elevated AFP and Schiller Duval bodies on histo (resemble glomerulus) are important features to differentiate from the other types of testicular tumours.

53
Q

What are the risk factors for developing germ cell tumours of the testes?

A

Klinefelter syndrome or cryptorchidism.
Cryptorchidism is the failure of the testicle to descend into the scrotum.
Klinefelter syndrome: a chromosomal abnormality (47 XXY) leading to dysgenesis of seminiferous tubules causing testicular atrophy, gynecomastia, infertility and eunuchoid body shape.

54
Q

What are the different kinds of non-seminoma testicular cancers?

A 
Embryoma - very malignant
Teratoma - more mature embryoma
Chondrocarcinoma (produces bHCG)
Mixed seminoma and non-seminoma
Yolk sac tumour (produces AFP)
55
Q

Describe the staging system for lymphoma

A

Stage 1: 1 LN site only
Stage 2: 2 LN sites, on same side of diaphragm
Stage 3: LN involvement on both sides of diaphragm
Stage 4: Disseminated disease involving one or more extralymphatic organs

56
Q

What are some risk factors for developing lymphoma?

A
  • EBV infection
  • Immune deficiency
  • Infectious mononucleosis
  • Lymphoma or leukaemia in first degree relatives
57
Q

What are the indications for lymph node biopsy in context of lymphadenopathy?

A

• Significant enlargement >2cm
• Persists for >4 weeks
• Progressive increase in size
- Choosing the LN: Peripheral are preferable (easily accessed, highly diagnostic yield), can use CT-guided core biopsy needles for non-accessible LNs
- Supraclavicular = NHL in 75-90% cases
- Cervical/axillary = NHL in 60-70% cases
- Inguinal = NHL in 30-40% cases

58
Q

What investigations are required if you suspect lymphoma?

A 
Diagnosis: excisional LN biopsy
FBC with WCC differentiation
Blood film (hodgkin vs. NH)
Bone marrow aspirate and biopsy
LDH/ALP - tumour marker, staging
Whole body CT/PET - staging
CXR - mediastinal lymphadenopathy
59
Q

What are the long term complications of lymphoma and how are these investigated in follow up?

A

Complications: secondary malignancies (leukaemia, lung, breast, thyroid, myelodysplastic)
Side effects of long term treatment: cancer, cardiac disease, endocrine dysfunction (TFT, fertility), lung damage (radio), hyposplenism, psych
Follow up:
- TFT and clinical exam of thyroid yearly (thyroid cancer and hypothyroidism)
- FBC yearly (myelodysplastic syndromes, leukaemia)
- Mammography yearly (breast cancer)

60
Q

What are the common side effects of chemotherapy and radiotherapy?

A 
- Acute
	○ Nausea and vomiting
	○ Malaise
	○ Febrile neutropaenia
	○ Alopecia
- Chronic
	○ Sterility 
	○ Cardiac damage (rare)
- Psychosocial issues
61
Q

What are the long term side effects of lymphoma therapy?

A 
○ Cancer 
○ Cardiac disease
○ Endocrine dysfunction (hypothyroidism, sterility)
○ Psychological trauma
○ Lung damage (secondary to radiation)
○ Dental caries
○ Hyposplenism
62
Q

What does the C stand for in TNM staging?

A

Staging performed using clinical methods e.g. examination, imaging, etc.

63
Q

What does the P stand for in TNM staging?

A

Staging performed by pathologist using resected specimen

64
Q

What does the Y stand for in TNM staging?

A

Analysis following cancer treatment (e.g. radio, chemo)

65
Q

What does the R stand for in TNM staging?
Describe difference in RX, R0, R1, R2
RX - residual tumour could not be assessed
R0 - no residual tumour
R1 - microscopic residual tumour
R2 - macroscopic residual tumour

A

Presence / absence of any residual tumour after treatment

RX - residual tumour could not be assessed
R0 - no residual tumour
R1 - microscopic residual tumour
R2 - macroscopic residual tumour

66
Q

What are the different types of melanoma?

A
  1. Superficial spreading (most common 70%)
  2. Nodular (15%, papule or nodule)
  3. Lentigomaligna (old people)
  4. Acral letiginous (fingernails)
67
Q

Describe the appearance of BCC

A 
Superficial:
'Non-healing scabs'
Think pink/red plaque, scaly
Nodular:
Papules with telangiectasias
Flesh coloured with pearly rolled borders
Sometimes with central ulceration
Very slow growing
68
Q

Describe the appearance of SCC

A 
Usually occurs on sun-damaged skin
Hyperkeratotic, crusted, indurated, may ulcerate
Erythematous papule or plaque
'Non-healing scabs'
Grow over time
69
Q

What are some risk factors for skin cancer

A 
Fair skinned and hair and eyes
Lots of freckles
UV radiation (damaged p53) and sun exposure
FHx
Past hx of other skin cancers
70
Q

What are the margins for SCC, MCC, melanoma removal?

A

BCC 3-6mm
SCC 4-6mm
2cm for melanoma also deep

71
Q

What are the treatment options for RCC?

A
  • Partial or total nephrectomy depending on the tumour size, for confined disease
  • Alpha-interferon and interleukin-2: reduce tumour size, treat metatases
  • Receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib)
72
Q

What are normal PSA values for different ages?

A 
Normal PSA levels
40-49 <2
50-59 <3
60-69 <4
>70yrs 5.5
73
Q

How does Gleason score correlate with prognosis of prostate cancer?

A

Gleason score assesses level of differentiation, how much do the cancerous tissues look like normal prostate tissue?
6 is the lowest score indicative of malignancy (3+3)
Low-grade <6 (T1/T2): Grow and spread slowly
Intermediate grade 7: Intermediate rate of growth and spread
High grade 8-10: Aggressive, spread and grow quickly

74
Q

What are some other tests looking at PSA that may be helpful in differentiating prostate malignancy?

A

Free to total PSA ratio: <25%= unlikely to be cancer
PSA doubling time (PSA-DT): >1 year - likely to be cancer but confined to prostate, <9mo - likely to be metastatic disease

75
Q

What are the treatment options for localised advanced prostate cancer (T3/T4)

A

Localised advanced prostate cancer (T3/T4)

  • Hormonal therapy: see below
  • Radical prostatectomy
  • Radiotherapy: external beam and brachytherapy
76
Q

What are the treatment options for metastatic prostate cancer?

A

Metastatic prostate cancer disease - hormonal therapy

  • Synthetic GnRH agonist (testosterone antagonist) - palliative management, reduces prostate growth factors
    e. g. Goserelin (Zoladex)- cover initially with anti-androgen to prevent rise in testosterone
  • Anti-androgen
    e. g. cyproterone acetate - prevents DHT binding from intracytoplasmic protein complexes
  • Orchidectomy
77
Q

What are the treatment options for Hodgkin’s lymphoma?

A

• Early disease (stage 1-2) without adverse prognostic factors
- CHEMO: ABVD (Adriamycin, Bleomycin, Vinblastine, Dacarbazine)
- Radio
• With adverse factors: longer courses of chemo and radio
• Extensive disease (stage 3-4): CHEMO alone - ABVD

78
Q

What are the treatment options for low grade Non-Hodgkin’s lymphoma?

A 
Follicular lymphoma (20% all NHL)
○ Stage 1-2 
- Involved field radio - small change of cure + combo chemo + monoclonal antibody (ritixumab)
○ Stage 3-4
- Symptomatic disease
- Rituximab for induction and maintenance
- wide field radio
- combo chemo
79
Q

What are the treatment options for aggressive Non-Hodgkin’s lymphoma?

A

Diffuse large B-cell lymphoma (50% all lymphomas, 35% all NHL)
• Stage 1-2
- Radio
- Rituximab
- Short course chemo - CHOP (Cyclophosphamide, hydroxy…, oncovin, prednisolone)
• Stage 3-4
- Rituximab
- Longer course chemo
- Radiotherapy
* Rituximab cannot be used in T-cell lymphoma

SURGERY (5 decks)

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