Cancer Flashcards
(88 cards)
1
Q
Breast cancer epidemiology
A
- second leading cause of cancer mortality in women (1st is lung ca)
- 1/7 women in Canada diagnosed with breast ca in their lifetime
- 1/35 women will die from breast ca
2
Q
Breast cancer risk factors
A
-BRCA gene
[BRCA1 lifetime Ca risk - breast 72%, ovarian 39%]
[BRCA2 lifetime ca risk - breast 69%, ovarian 11-17%)
-Gender (99% female)
-Age (new dx of ca 80% >50 years old, 28% > 70 years old
- Prior history of breast cancer, prior breast biopsy
- 1st degree relative with breast cancer (risk increases by 2x) or relative with BRCA gene
- Unopposed estrogen (nulliparity, first pregnancy >30 years old, menarche <12, menopause >55, NOT breastfeeding, >5yr HRT)
- Radiation exposure (ex: Mantle radiation in Hodgkin’s lymphoma)
- Hx benign breast disease: Moderate/florid hyperplasia (increase 2x), atypical hyperplasia (increase 4x), sclerosing adenosis (increase 1.5x), Papilloma (increase 1.5x)
MODIFIABLE
Things that will lower risk
- Decreasing weight and increasing activity
- Decreasing alcohol
- Decreasing hormone exposure
- Early pregnancy
- Breastfeeding
3
Q
Regular risk screening mammogram guidelines
A
- From age 50 - 69 every 2 to 3 years
- Age 70 - 74 is based on patient preference (risk of radiation exposure, pain, anxiety, false +ve, extra imaging and biopsies)
-No breast exams or self breast exam of average risk patient - Consider yearly mammogram if 45+ with dense breast or hx of atypical hyperplasia
4
Q
Breast cancer screening guidelines in high risk patients
A
- Age 30 - 69 annual mammography/MRI (can start at age 25)
Who is considered high risk?
- Known BRCA 1/2 carrier
- 1st degree relative BRCA 1/2 carrier
- Chest radiation <30 year old and at least 8 years ago
- >25% risk IBIS/BOADICEA
5
Q
Genetic screening in breast cancer
A
- BRCA1/2 for patients under 50 dx with breast ca
- especially under age 35
- ovarian ca
- bilateral breast ca
- breast + ovarian ca in same patient
- multiple breast ca on same family side
- male with breast ca
- Ashkenazi Jewish
6
Q
Special population considerations in breast cancer
A
- Try to decrease emotional and physical discomfort if gender diverse
- Trans women on 5 years or more of cross-sex hormone - screen per guideline
- Trans men without chest reconstruction - screen per guideline
- Trans men with bilateral mastectomy do NOT need screening
7
Q
Prevention in high-risk patients
[Breast cancer]
A
- Mastectomy + salpingo-oophorectomy decrease risk of breast ca
- MRI picks up extra ca than mammogram + US though mammogram still better for DCIS
8
Q
Types of breast cancer
A
- Ductal carcinoma in situ (DCIS)
> Proliferation of malignant ductal epithelial
> 80% non-palpable - detected by screening - Lobar carcinoma in situ (LCIS)
> Neoplastic - contained within breast lobule
> Non-palpable, not on mammography, usually found on biopsy - Infiltrative ductal carcinoma (8-15%), 20% bilateral
> Originates from lobular epithelium, hard to detect - Paget’s disease (1-3%): Ductal ca invades nipple with eczema
- Inflammatory carcinoma (1-4%)
> Ductal carcinoma that invades dermal lymphatics
> Most aggressive form - erythema, edema, warm, tender
> peau d’orange indicates advance disease (IIIb - IV)
Pathology indicates estrogen receptor (ER) - progesterone receptor (PR) status, human epidermal growth factor receptor 2 (HER2) status
9
Q
Treatment for breast cancer
(chart)
A
BCS = breast conserving surgery
10
Q
Endocrine therapy for estrogen or progesterone receptor +
A
- Premenopausal: tx with tamoxifen +/- ovarian suppression (leuprolide or goserelin)
- Postmenopausal: tx with tamoxifen or aromarase inhibitor x 5years or 2 - 3 years of tamoxifen THEN aromatase inhibitor to complete 5 years
- The NHS PREDICT Tool helps with treatment choice
- HER2+ benefits from tratsuzumab and pertuzumab
11
Q
Complications and complications of treatment
[Breast cancer]
A
- Hypercalcemia (usually secondary to osteoclastic resorption, not always associated with bone mets)
- Poor prognosis, median survival 3-4 months S+S: N/V, constipation, abdo pain, dehydration, confusion
- Tx: hydration IVF NS, IV denosumab (preferred) or bisphosphonate (pamidronate or zoledronate), consider corticosteroids, calcitonin (if severe, ex: serum calcium >14mg/dl)
-
Mets: Bone > lungs > liver > brain
1. tx: bone mets: opioid, NSAID, steroid, bisphosphonate, radiation -
Meds: Estrogen: VTE
1. Estrogen antagonists: hot flashes, vaginal dryness, fatty liver, VTE, endometrial Ca
2. Progestins: weight gain, nausea, fluid retention
3. Aromatase inhibitors: somnolesence, skin rash, arthralgia, OP, HTN, elevated lipids, vaginal dryness/dyspareunia - Sx: Lymphedema (early physio decreases risk), cellulitis, phantom pain
- Radiation: weakness/paresthesia, pulmonary/cardiac fibrosis
- Chemo: Premature ovarian failure, dilated cardiomyopathy, MI, arrhythmia, secondary cancers, cognitive dysfunction
12
Q
Follow-up
[Breast cancer]
A
- No MRI, bloodwork (CBC, LFTs, tumor markers) cardiac image
13
Q
Long term effects
[Breast cancer]
A
Refer for genetic screen if applicable
- osteoporosis: baseline BMD if postmenopausal or on aromatase inhibitor/GNRH
- Menopausal symptoms: offer SSRI, SNRI, gabapentin + lifestyle modification for vasomotor, consider CBT + activity
- Assess an tx: lipids, cognitive concerns, mood, fatigue (NO methylphenidate), pain (acupuinture & activity), secual health (non-hormonal lubricants), lymphedema, infertility, body image
- If on aromatase inhibitor or GNRH: Q2yr BMD & Q1yr lipids
- Monitor for side effects from tx above (complications card)
14
Q
Epidemiology of cervical cancer
A
- Lifetime prevalance of HPV infection is 80%
- 90% of HPV infection spontaneously cleared in 6-18 months
- Lifetime probablity of developing cerevical cancer 1 in 150 (without screening 1 in 28), peak age of diagnosis 50s year old
15
Q
Etiology
[Cervical cancer]
A
- Human papillomavirus - transmitted through intimate sexual contact
- Usually asymptomatic, usually naturally resolves in <2years
16
Q
Risk factors for cervical cancer
A
- Secual activity at a young age (<20)
- Multiple partners
- Having a partner with a number of previous intimate contacts
- Smoking (weakens the immune system)
- Long term OCP
- Giving birth to multiple children
- Immunosuppressed
> Patient living with HIV/AIDS
> On long-term (continuous/frequent interval) immunosuppressants
> Organ transplant recipients (solid organ or allogenic stem cell)
> People with congenital immunodeficiency
17
Q
Protective factors
[cervical cancer]
A
- Routine Pap
- HPV immunizations (grade 8 to age 45, even if already sexually active)
18
Q
Signs and symptoms
[cervical cancer]
A
- Abnormal vaginal bleeding
- Bleeding or spotting between regular menstrual periods
- Bleeding/pain after sex
- Menstrual periods lasting longer and heavier than before
- Bleeding after menopause
- More discharge than normal
- Pain in pelvis/back
19
Q
Screening in cervical cancer
A
> Take steps to decrease emotion/physical discomfort for gender diverse patient
- CTFPHC + OCSP: Q3yr for women starting at age 25 if they have ever been secually active (intercourse, digital, oral with a partner of either gender)
- <20yr old (NO screening (strong recommendation
- 20-24yr old (NO screening (weak recommendation)
- if immunocompromised, start screening at age 21
- Basically, screen from age 25 to 39 Q3yrs
- >70, no screening if 3 successive negatives in 10 years
20
Q
Screening special populations
[cervical cancer]
A
- Immunocompromised (ex: HIV) - annual screening starting at age 21
- Systemic Lupus Erythematosus - annual screening at age 21
- Total hysterectomy:
> if sx benign, no hx of dysplasia/HPV - no screening
> if hx of HSIL, AIS or cancer - annual vault smear for life - Subtotal hysterectomy with cervix intact - routine screening
- Pregnant - same screening as non-pregnant, ASCUS and LSIL found in pregnancy - do not repeat until after 6 months post-partum
- Patients on androgens (ex: trans men with a cervix), screen as above and notehormones on req - androgen causes changes that mimic dysplasia
- Patients with neo cervix (ex: trans women) do not need cervical screening
- Hx of HSIL/CIN - annual screening
HPV testing ?not yet funded age 30-65
- HPV DNA testing Q5years after first negative
- If HPV DNA test positive
> cytology: if negative, repeat HPV testing in 1 year, then Q5yrs if negative
> > If positive cytology or repeat HPV + refer to colposcopy
- If 2 or more normal test in past 10 years, can stop screening at age 65
21
Q
Approach to abnormal cytopathology
[cervical cancer]
A
- Transformation zone: Paps lacking T zone continue regular interval (unless suspicious of abn), repeated samples lacking T-zone may require further investigations
- unsatisfactory sample: repeat in 3 months
-
Atrophy: it requires action only if clinically indicated (eg: for symptoms or for re-evaluation of a patient’s cytology)
-Benign endometrial cells:
> premenopausal + asymptomatic - routine screen
> post menopausal - investigations including endometrial biopsy
> any woman with abnormal vaginal bleeding - investigations including endometrial biopsy - ASCUS/LSIL: Repeat in 12 months, & if greater than or equal to ASCUS, refer to colposcopy, if normal, repeat in 12 months. If second test is normal, resume Q3yr test. If second test is greater than or equal to ASCUS, refer to coloposcopy
-
ASC-H, HSIL, AGC, AIS - refer to colposcopy
> Atypical squamous cells cannot exclude HSIL (ASC-H) –> Consider biopsy
> Abnormal glandular (AGC)/ Endocervical/ Endometrial cells - endometrial biopsy
> High grade squamous intraepithelial lesion (HSIL) - biopsy
22
Q
Managing Histological abnormalities
[Cervical cancer]
A
- Excisional procedure, cone biopsy, LEEP, laser excision
- CIN 1/LSIL observe with repeat in 12 months, consider excisional biopsy
- CIN 2/HSIL and <25 yr old: colposcopy Q6months up to 24 months before considering treatment
- CIN3/ HSIL and <25 yr old: excisional procedure, if positive margins, repeat colposcopy
- CIN 3/HSIL and 25 or >25 yr old excisional procedure if positive margins, repeat colposcopy
- Adenocarcinoma in situ (AIS) excisional procedure or type 3 transformation zone excision
23
Q
Cytology tree cervical cancer
A
24
Q
Discharge from colposcopy tree
A
25
Epidemiology of colorectal cancer
- 2nd leading cause of cancer related death
- 3rd most common diagnosed cancer
- Lifetime risk 1/14 for men and 1/17 for women
- 5 year survival 60%
- Most arise from adenomatous polyp (30% of pts >50 have adenomatous polyps)
26
Risk factors
[Colon cancer]
- Age (90% >50yrs old)
- IBD, polyps
- High fat diet
- Excessive caloric/alcohol intake
- Obesity
- Sedentary life
- Smoking
- Vitamin E increases risk of polyps
- Family history
> One 1st degree relative = 9%
> One 1st degree relative <45 y/o = 15%
> Two 1st degree relatives = 16%
## Footnote
Some evidence NSAI + ASA reduce risk but s/e outweights benefits. some evidence statins reduce risk
27
Signs, symptoms, labwork
[Colorectal cancer]
**Symptoms**
- rectal bleeding, blood in the stool (dark blood mixed in with stool)
- change in bowel habits (diarrhea/constipation/urgency, incontinence, incomplete emptying), narrow stool
- absences of perianal symptoms
- Persistent bloating, feelings of fullness, cramps, steady abdo pain
- weakness, fatigue, anorexia, vomiting, weight loss
- Hx of polyps
**Signs**
- Rectal mass (DRE), abdominal mass
- Signs of anemia
- Weight loss
**Labwork**
- Anemia (if microcytic anemia - order ferritin)
- Hgb males 110 or less, Hgb menopausal women less than 100
28
Positive predictive value based on symptoms
[Colorectal cancer]
29
Colorectal cancer screening for **average risk** patients
- 50 - 74 yr old, includes patients with 2nd degree relative with colon cancer, 1st degree relative with non-advance adenoma, no family hx ca, no hx of polyps, no IBD, no signs or symptoms of colorectal Ca
- NO screening for patients 75 and older
- *Either of the following*
- FOBT/FIT Q2yrs (no medication restriction (ex: ASA/NSAID/iron))
> Positive results followed up by a colonoscopy
> FIT sens 81.5%, spec 95%, false positive 88 of 1000
- Sigmoidoscopy q10years
> Do **NOT** use **colonoscopy** for screening of avg risk patients
30
Colorectal cancer screening for **increased risk patients**
- *1 or more FDR with colon cancer*
> 1st line: screen with colonoscopy age 40 - 50 y/o or 10 yrs younger than the age relative was dx, wichever is earlier. Screen Q5-10 yrs
> 2nd line: screen with FIT age 40-50 y/o or 10 yrs younger than the age relative was dx, wichever is earlier. Screen Q1-2yrs
> If 2 or more FDR with colon ca: screen with colonoscopy Q5yrs starting at 40
- *1 FDR with known advanced adenoma*: screen with colonoscopy Q5-10yrs or FIT q1-2 yrs, start age 40-50 y/o or 10 years younger than FDR
- *IBD*: Colonoscopy 8 - 10 yrs after pancolitis or 12- 15 yrs after left sided colitis done Q1-2yrs
- *FAP*: Genetic counselling, flexibile sigmoidoscopy Q1-2 yrs starting at age 10-12
- *HNPCC (Lynch syndrome)*: Genetic counselling, colonoscopy q1-2yrs start at age 20 or 10 years earlier than family case
## Footnote
First degree relative (FDR) = parent, sibling, child
31
Potential investigations
[Colorectal cancer]
- **FOBT (gFOBT or FIT)
> Single test - sens 13-25%, spec 80-95%
> Repeated test - sens 50%, spec 96-98%
> ARR 2.7/1000 screened, NNS 377 for 18 years to prvent 1 death
> FIT false positive = 5.5 -12%, false negative = 0.02 -0.13%
-**Sigmoid** ARR 1.2/1000 screened, NNS 850 for 11yr: prevent 1 death
> Perf 0/001%, bleed (minor 0.05%, major 0.09%), death 0.015%
- **Barium** sensitivity 48 - 85%, spec 85%
- **Colonoscopy** sensitivity 90%, spec 99%
> Perf 0.06%, minor bleed 0.3%, major bleed 0.1% and death 0.035%
- **CT colonography** sens 96%, spec 48-85% (depending on polyp size)
32
Referrals time frame
[Colorectal cancer]
- Urgent referral seen in 2 weeks: mass
- Semi-urgen referral seen in 4 weeks: iron deficiency anemia or rectal bleeding, >60 years old, hx of polyps, fam hx
- Otherwise... treat signs and symptoms, monitor for resolution in 6w, if persists then refer, if due for FOBT --> order
- STAGING: CT CAP
33
Surveillance after abnormal colonoscopy in average risk person
34
Treatment and complications
[colorectal cancer]
- **Surgery**: infection, anastomosis breakdown, bleeding, adhesions
> Frequent +/- urgent bowel movements, gas +/- bloating, incisional hernia, increase risk of bowel obstruction
-**Chemotherapy**: Premature ovarian failure, dilated cardiomyopathy, secondary cancers, cognitive dysfunction
-**Biologics** (Avastin, Erbitux, Vectibix, Cediranib): peripheral neuropathy
-**Radiation**: weakness/paresthesia, CAD, valvular disease, skin changes, rectal ulcerations/bleeding, anal dysfunction (incontinence), bowel obstruction, infertility, sexual dysfunction
-**Immunotherapy**: bone pain, fatigue, fever, rash, bleeding, clots
## Footnote
Mets to liver, lung, peritoneum
35
Colorectal cancer follow-up care and surveillance
- **Medical f/u** (hx, px, health promotion), q6month x3yr
- **Carcinoembryonic antigen (CEA)** q6mo x5yr (optional)
- **Imaging (CT CAP)**: 1 and 3 years
- **Colonoscopy** 6-12 monthsafter surgery and then every 5 years as long as cscope is normal (Sigmoidoscopy is an option for rectal cancer who are at high risk of recurrence at an interval of less than 5yrs)
- **NO evidence for**: CBC, FIT/FOBT
- **Physical**: assess for complications (previous card)
- **Psychosocial**: mental health, cognitive s/e, challenged with body =/- self image, return to work, gfinancial challenges
36
Leukemia
- General definition
- Epidemiology
- Uncontrolled proliferation of hematopoietic stem cells in bone marrow
- 1 in 70 persons develop leukemia in their lifetime
37
Leukemia
risk factors
- Down syndrome + neurofibromatosis
- Ionizin radiation: medical radiation worker, radiation therapy, 2 or m ore CTs
- Exposure to benzene
- Household pesticides
- Obesity
38
Leukemia signs and symptoms
(children, adult, acute, chronic)
***ACUTE***
- **Children:** (Usually ALL) fever, lethargy, bleeding, MSK symptoms (usually spine + long bones), enlarged liver/spleen, lmphadenopathy
- **Adults**: (Usually AML) fever, fatigue, weight loss, anemia related symptoms (SOB, CP), thrombocytopenia related symptoms (bruising, nosebleeds, heavy menstruation), can have enlarged liver/spleen
***CHRONIC*** (almost exclusively adults)
- Often asymptomatic (50% CLL and 20% CML are picked up indidentally with marked leukocytosis), less common to have constitutional symptoms, often have enlarged liver/spleen
39
Initial investigations
[leukemia]
- CBC (WBC >11x10^9) (acute lukemias can also have leukopenia usually with anemia + thrombocytopenia)
> Approach to leukocytosis (based on predominant type)
>> Monocyte - chronic infection like TB
>> Eosinophile - allergic reaction, parasite
>> Lymphocyte - EBV, CMV, pertussis, TB
>> Basophil - viral infection, inflammation
>>>>> Order a **peripheral smear** IFL leukocytosis despite management, WBC >20x10^9, associated anemia/ thrombocytopenia/ thrombocytosis, enlarged liver / spleen/ lymph nodes. unexplained constitutional symptoms
>>>>> If smear shows increased hematopoietic precursor cells or marked (>50%) increase in lymphocytes - refer for possible leukemia
- LFTs, Cr, lytes, coagulation studies
- If febrile or ill: look for infection (ex: urinalysis, urine culture, blood culture, CXR)
40
Follow-up investigations
[leukemia]
- Bone marrow aspirate and biopsy
- Cytogenetics, molecular genetics, flow cytometry
> Radiology: dental survey, CT chest + abdomen
>> Sperm preservation in men (according to patient preference)
>> Serum pregnancy test in females
41
Treatment
[leukemia]
- Chemotherapy, radiation, monoclonal antibodies, stem cell transplantation
42
Definition of acute myeleogenous leukemia (AML)
Blast cells on peripheral smear or bone marrow aspirate.
Auer rods on peripheral smear
43
Epidemiology of AML
- Usually adults, median age at diagnosis 67 years old
- Mortality 4 - 6 per 100,000
44
Signs and symptoms
[AML]
-Fever, fatigue, weigh loss, bleeding, bruising
- Hepatomegaly + lymphadenopathy (rare)
45
Prognosis for AML
- 5yr survival rate: <50 y/o = 55%, >50 y/o = 14%
- Prognosis governed by AML subtype
- Favourable: Acute promyelocytic + myelomonocytic leukemia
- Intermediate: Normal karyotype AML
- Poor: AML with complex karyotype
46
Diagnostic work-up [AML]
and Follow-up investigations
-CBC with differential: often WBC >100x10^9
>WHO 2016 criteria: 20% or more blasts in marrow or peripheral blood
**Follow up investigations**
- Serum uric acid, LDH have prognostic relevance
- Blood group and HLA type of patient and family (for potential stem cell transplant)
47
Surveillance [AML]
- CBC Q1-2 months x 3yrs, then Q 3-6 months x5yrs
- Echo + ecg q2yrs
48
Definition of acute lymphocytic leukemia (ALL)
- Blast cells on peripheral or bone marrow aspirate
49
ALL epidemiology
- Children and young adults --> 53% of cases occur in patients under 20
50
Signs and symptoms [ALL]
- Constitutional symptoms, fever, lethargy, dizziness
- Bleeding, bruising, MSK pain/dysfunction
- Hepatosplenomegaly + lymphadenopathy (~20% of patients)
51
Investigations [ALL]
- CBC with peripheral smear with blast cells + bone marrow biopsy
- Lytes, renal and liver function, amylase, lipase, INR, echo
52
Prognosis [ALL]
- 5 yr survival rate: under 50 y/o = 75%
- Over 50 y/o = 25%
53
Surveillance [ALL]
- Monthly bloodwork for the first 2 years, then Q3months until 5yrs
- Annual CBC, Cr, lytes, urea, calcium, magnesium, phosphorus, TSH, urinalysis
- Echo + ECG Q3-5 years if pretreatment abnormalities or signs/symptoms of heart failure
- Routine eye/dental
54
**Chronic Myelogenous Leukemia (CML)**
* Definition
* Epidemiology
* Signs and symptoms
* Prognosis
* Investigations
* Management
* Surveillance
**Definition**
Philadelphia chromosome
**Epidemiology**
Usually adults
**Signs and symptoms**
20% asymptomatic
Splenomegaly
**Prognosis**
5 yr survival <50 yo = 84%, >50 yo = 48%
**Investigations**
Often WBC >100x10^9
**Management**
Early stage chronic leukemias (no anemia, thrombocytopenia, < 3 nodal involvement) can often be monitored without treatment
**Surveillance**
CBC q3months
55
Chronic lymphocytic leukemia (CLL)
* Definition
* Epidemiology
* Signs and symptoms
* Prognosis
* Management
* Surveillance
**Definition**
* Clonal expansion of at least 5000 B lymphocytes (ex: 5x10^9/L) in the peripheral blood
**Epidemiology**
* Older adults --> 85% of cases occurs in pts >65 yo
**Signs and symptoms**
* 50% asymptomatic
* Hepatosplenomegaly + lymphadenopathy
**Prognosis**
* 5ye survival rate: <50 yo = 94%, >50 yo = 83%
* Median survival (yrs) Stage 0 (11)
* Stage I (8)
* Stage II (5)
* Stage III-IV (2-4)
* Consider using the IPS-E (international prognostic score) for asymptomatic early stage CLL
**Management**
* Early stage chronic leukemias (no anemia, thrombocytopenia, < 3 nodal involvement) can often be monitored without treatment
* Monoclonal antibodies, chemotherapy (eg: rituximab, venetoclax), radiation, transplant
**Surveillance**
* Untreated
> Routine/period history, physical, CBC (no guide on frequency)
> Flu shot annually, pneumococcal vaccine q5yrs
> Avoid live vaccine
* Treated
> Refer to cardiologist for baseline evaluation
> Resting and stress echo
56
Lung cancer epidemiology and prognosis
* most common cause of cancer death in Canada
* Often diagnosed at late stage --> poor prognosis
* Average age at diagnosis is 68-70
Prognosis: 5 year survival 13% for males and 19% for females
57
Lung cancer risk factors
* Current or previous smoking of tobacco using cigarettes, vaping, cigars, dry pipe or water pipe or exposure to second-hand smoke
* Previous exposure to asbestos or to other known carcinogens (radon, chromium, nickel)
* Occupational exposure to dust or microscopic particles (ex: wood dust, silica, diesel engine emissions, or chlorinated solvents)
* Occupations (miners, painters, iron/steel workers, bricklayers, welders)
* Personal or family history of cancer (especially lung, head and neck)
* History of COPD, asthma, pulmonary fibrosis
* Infections (TB, HPV 16/18 of the respiratory tract, previous pneumonia, HIV)
* Environmental (burning of coal and/or biomass, unventilated cooking over high heat, air pollution, low socioeconomic status, high caffeine)
* Other underlying health issues (SLE, RA, systemic sclerosis, DM, periodontal disease, increased abdominal obesity, dyslipidemia)
58
Lung cancer signs and symptoms
59
Bloodwork with suspected lung cancer diagnosis
* CBC, ALP, AST, ALT, calcium, albumin, lytes, urea, Cr
* Staging --> CT chest, abdo, pelvis + bone scan + CT/MRI brain
60
Lung cancer
Pathology
61
Lung cancer
Screening
* 55-74 yo & high risk (current smoker or within past 15 yr & 30 or more pack years) *Screen with a low dose CT every year for 3 consecutive years*
62
Pulmonary nodules
* **Suspicious:** >8mm, irregular border, eccentric calcifications, spiculated
* **Benign features:** old granulomas, peri-fissural lymph node, clear vascular pattern or a hamartoma or arteriovenous malformation
63
Lung cancer treatment
* **Non-small cell lung (NSCLC)**: sx resection for stage I-II, chemo and radiation for stage III, palliative care stage IV. Genetic immunotherapy
* **Small cell lung cancer (SCLC)**: chemo & radiation, usually palliative
64
Lung cancer signs and symptoms flow tree
page 6
65
[Oncologic emergencies]
**Hemorrhage/Bleeding**
* General management
> Transfuse packed red blood cells
> Correct coagulopathy with fresh frozen plasma +/- platelets
* Disseminated intravascular coagulation (DIC)
> Anticoagulants
> Treat underlying malignancy
* Gross hemoptysis
> Protect airway, place in lateral decubitis on bleeding side if known
> Correct coagulopathies
> Suppress cough as needed
> Nebulized tranexamic acid 500mg TID
* GI bleed
> Control vomiting/retching
> If gastric/duodenal source --> pantoprazole infusion (80mg bolus then 8mg/hr)
> If esophageal variceal --> octreotide infusion
* Hematuria
> If light (pink/cranberry/transparent), limited tiny clots and not in retention --> hydrate to dilute and refer to outpatient urology
> If heavy bleed or large clots or tretention --> 3 way foley with manual irrigation. Call urology first if recent radical prostatectomy (within 30 days)
66
[Oncologic emergencies]
**Seizure/ change in LOC from brain mets**
* Desamethasone 10mg IV followed by 4-8mg/ dose q6hr IV or PO
* Short acting benzo to halt seizure (midazolam 2mg or lorazepam 1mg IB)
* Anticonvulsant - phenytoin 15mg/kg followed by 300mg/day
67
[Oncologic emergencies]
* **Malignant airway obstruction**
* **Superior Vena Cava Obstruction**
* **Spinal cord compression**
**Malignant airway obstruction**
* Desamethasone (10mg IV followed by 4-8mg/ dose q6hr IV or PO) ASAP
* Heliox: if stridor and is not hypoxemic
**Superior Vena Cava Obstruction**
* Desamethasone (10mg IV followed by 4-8mg/ dose q6hr IV or PO)
**Spinal cord compression**
* Desamethasone (10mg IV followed by 4-8mg/ dose q6hr IV or PO)
68
[Oncologic emergencies]
Management of Febrile Neutropenia
* Panculture (blood/urine)
* Immediate broad-spectrum antibiotics, eg: pip/taz 4.5g IV Q 8hrs or cefepime monotherapy 2g IV Q8hrs
69
[Oncologic emergencies]
Hypercalcemia (malignancy associated)
- signs and symptoms
- treatment
* Usually secondary to osteoclastic resorption *not always associated with bone mets
* Poor prognosis median survival 3 - 4 months
*** S+S**: N/V, constipation, abdominal pain, dehydration, confusion
**Treatment**
* Fluid resuscitation with IV N.Saline (250- 500ml/hr)
* IV denosumab (preferred) or bisphosphonates (pamidronate 15-90mg over 1-2 hours OR zoledronate 4mg over 15-30 mins)
* If severe (serum calcium >14mg/dl) add calcitonin (IM/SC 4-8 units/kg Q6hrs x2 days)
* Consider corticosteroids
70
[Oncologic emergencies]
Syndrome of Inappropriate Anti-diuretic Hormone Secretion - Severe hyponatremia
**Acute duration**
* Fluid restriction (1L or less per day)
* Hyponatremic encephalopathy: administer IV hypertonic saline (100ml 3% IV over 10 minutes with 1-2 repeat boluses as neede dto increase plasma sodium by 4-6mEq/L)
**Chronic Duration**
* Restrict fluids (1L or less per day). If no change after 24-48 hours: consider furosemide (20-40mg IV or 20-80mg orally daily) OR demeclocycline (600-1200mg/day orally in 3 or 4 divided doses)
71
[Oncologic emergencies]
Non-emergent complications
**Cancer related lymphedema**
* Epidemiology and risk factors: Varies based on cancer type and treatment. Common in breast cancer patients and those with melanoma, sarcoma, or gynecologic/genitourinary cancers. Other risks include trauma, obesity, venous insufficiency, DVT, and cellulitis
* Diagnosis: based of history and physical examination. Early detection is crucial to minimize disease progression.
* Kety history elements: include medical, surgical and oscial history, and assessment for lymphedema and swelling-associated conditions
* Physical examination: Involves dermatologic exam, pitting test, Stemmer sign, vascular examination, and limb volume difference measurement
* Management: Involves decongestive lymphatic therapy, comprisin volume reduction and maintenance phases. Includes compression therapy, healthy lifestyle habits, and risk reduction strategies
72
Prostate cancer epidemiology
* Lifetime probability of developing prostate cancer is 1 in 7 (most prevalent cancer in men)
* 75% of prostate cancers in males between 60-85
* Mean age of diagnosis 72 year old
* Probability of dying from is 1 in 27 (3rd leading cause of death)
* 5 year survival is 96%
73
# [Prostate cancer]
Risk factors
* Urban african americans
* Family history (1st degree relative = 2x risk, 1st + 2nd degree relative = 9x risk)
* Increased dietary fat = 2x risk
* Cigarette smoking
NOT ASSOCIATED RISK FACTORS
* BPH
* Vasectomy
* Frequency of sexual activity/ejaculation
PREVENTION
* No evidence for selenium supplementation, vitamin E
74
# [Prostate cancer]
Anatomy/Location of malignancy
* 60-70% peripheral zone
* 10-20% transitional zone
* 5-10% central
75
# [Prostate cancer]
Signs and symptoms
* Usually asymptomatic
* Lower urinary tract symptoms (LUTS) *less common
>> Storage + voiding
>> Incontinence
* Lower back pain (metastasis)
* DRE: hard irregular nodule or diffuse dense induration involving one or both lobes
> Significant false positive (yearly DRE = 1 in 6 men after 4 years)
76
# [Prostate cancer]
* Recommended PSA Screening interval per CUA (Canadian Urology Association)
* Interpretation of PSA Values
* Age-varying threshold
77
Prostate cancer screening
78
Prostate cancer investigations
79
# Prostate cancer
* Prevention
* Spread
* Grading and prognosis
**Prevention**
* No evidence for selenium or Vitamin E supplementation for prevention of prostate Ca
**Spread**
* Local
* Lymphatic (obturator > iliac > presacral/para-aortic)
* Hematogenous
**Grading and Prognosis**
* Gleason score (aka "Grade Group")
>> 1-4 = well defferentiated
>> 5 - 6 = moderately differentiated
>> 8 - 10 = poorly differentiated
* Use PCPT prostate cancer risk calculator (PCPT-RC) or RSPC prostate cancer risk calculator (ERSPC-RC) to assess for clinically significant disease
* Use PREDICT Prostate as a prognostic model
80
Prostate cancer management and complications
81
# Upper Gastrointestinal Cancer
* General Prevention
* General Folllow-up
**General Prevention**
* discontinuing tobacco exposure
* decrease alcohol intake
* Maintaining healthy weight
* increase consumption of fruits and vegetables
**General follow-up**
* Endoscopic surveillance - per recommendation of specialist
* Radiation/surgery - may need referral for dilation if patient has stricture
* Lab work
* Nutritional - patients with distal/total gastrectomy need monitoring of B12 and iron deficiency
82
# Upper Gastrointestinal Cancer
**Bile duct cancer**
* Risk factors
* Screening
* DIagnosis
* Management
* **Risk factors:**
>> IBD, Primary sclerosing cholangitis, congenital choledochal cysts
>> Exposure to toxins (dioxin, asbestos, nitrosamines, thorotrast)
* **Screening:** Currently no screening guidelines
* **Diagnosis:** expedited abdominal imaging (US/CT)
* **Management:** Surgery for resection. Can consider palliative chemotherapy
83
# Upper Gastrointestinal Cancer
Gastrointestinal stromal tumor
**Management**
* Treatment dependant on stage of tumor and risk factors
* Standard treatmeant is surgical resection
* Chemotherapy may also be an option
* Palliative radiation may be of benefit in unresectable disease
84
# Upper Gastrointestinal Cancer
Gastrointestinal lymphoma
* Management
* Follow-up
**Management**
* Management dependant on stage of disease
* Resection only recommended for definitive diagnosis or to control complication of hemorrhage and perforation
* Antibiotics for H. pylori
**Follow-up**
* Influenza vaccine annually
* Pneumococcal vaccine at time of diagnosis (if it can be given 2 weeks before treatment)
* Tetanus q10yr
* Men-C, Men Quad, HiB - all 3 at least 2 weeks before splenectomy or as soon as possible after splenectomy, repeat Men Quad q5years
* *NEVER GIVE MMR + Yellow fever*
* Varicella + zostavax - at time of diagnosis (2 weeks prior to treatment) otherwise 6 months after completion fo treatment
85
# Upper Gastrointestinal Cancer
Neuroendocrine tumor
* **Risk factors:** Hereditary (MEN 1, von Hippel-Lindau disease, NF-1, TSC)
* **Management:** Resection. If unresectable, consider palliative debulking for palliation
86
# Upper Gastrointestinal Cancer
Esophagel cancer
* Epidemiology
* Risk factors
* Signs and symptoms (alarm symptoms)
* Prevention
* Screening
* Diagnosis
* Investigations
* Management
* **Epidemiology:** Incidence low (6.5 cases per 100,000)
* **Risk Factors:** 50years old or older
>> Chronic GERD
>> Smoking, Alcohol consumption
>> Elevated BMI, Intra-abdominal distribution of body fat
* **Signs and symptoms (alarm symptoms)**
>> (progressive) difficulty swallowing
>> Pain on swallowing
>> Food obstruction
>> Early satiety
>> Persistent vomiting
>> Unexplained weight loss
>> Hematemesis/ melena
>> Iron deficiency anemia
* **Prevention**
>> No mortality benefit for screening EDG for chronic GERD
>> Treat Barrett's esophagus with regular surveillance endoscopy and consider long term PPIs
* **Screening:** Currently no screening guidelines
***Diagnosis**
>> Endoscopy. Upper GI series if endoscopy not available
>> Urgent referral: any alarm symptoms
>> *Consider referral*: if 55 years or older and persistent/progressive heartburn
>> >Persistent/progressive abdominal pain
>> *No referral*: 55 years or younger with dyspepsia and NO alarm symptoms
* **Investigations** (in addition to endoscopy)
>> CEA, CA 19-9 --> baseline tumor markers
>> CT chest, abdo, pelvis --> local involvement + distant mets
* **Management**
>> Referral to thoracic surgeon, medical/radiation oncologist
>> PPI to reduce symptoms and heal erosive esophagitis
>> Surgically unresectable or metastatic disease is incurable and palliative measures are appropriate
87
# Upper Gastrointestinal Cancer
Pancreatic Cancer
* Epidemiology
* Risk factors
* Signs and symptoms (alarm symptoms)
* Screening
* Diagnosis
* Investigations
* Management
**Epidemiology:** Incidence low (12.55 cases per 100,000)
**Risk factors**
* Smoking
* Chronic pancreatitis, DM, Obesity
* Possibly H. pylori infection
* Hereditary risks (family history, BRCA, p16 mutation, lynch syndrome, Peutz-Jeghers syndrome)
**Signs and Symptoms (alarm symptoms)**
* Painless jaundice (although can have abdo pain)
* Fatigue, anorexia, weight loss, dull epigastric pain, early satiety
* Abdo/back pain or weight loss are late signs
**Screening:** do NOT screen avg risk pts. Consider MRI & endoscopic US screen for high risk pts starting at age 50 or 10 yrs before relative dx and done q1yr. High risk defines as:
* 2 or more relatives with pancreatic Ca, at least 1 FDR
* Genetic syndrome with increased risk (eg: Lynch, BRCA 1/2, PALB2. ATM)
**Diagnosis** pancreatic protocol CT if pancreatic abnormality/concerning cyst ot obstructive jaundice & suspected CA (PRIOR to drainage)
**Investigations:** CBC, Cr, LFTs, Ca 19-9
**Management:** Chemotherapy (FOLFIRINOX) & surgical resection (Whipple). Offer nutritional intervention (pancreatin)
88
# Upper Gastrointestinal Cancer
**Gastric Cancer**
* Epidemiology
* Risk factors
* Signs and symptoms (alarm symptoms)
* Prevention
* Screening
* Diagnosis
* Investigations
* Management
**Epidemiology:** Incidence low (8.16 per 100,000)
**Risk Factors**
* Family history of stomach cancer (especially 1o)
* Gastric polyps excluding fundic gland and inflammatory/hyperplastic polyps
* Birth in country where gastric cancer is common (ex: Japan, Korea, CHina)
* Previous partial gastrectomy
* H. Pylori
* Intestinal metaplasia
**Signs and Symptoms (alarm symptoms)**
* (progressive) difficulty swallowing
* Pain on swallowing
* Food obstruction
* Early satiety
* Persistent vomiting
* Unexplained weight loss
* Hematemesis/melena
* Iron deficiency anemia
**Prevention**
* Treat H. pylori infections with antibiotics and antacids
* low salt diet
* decrease smoked or pickled foods
* supplementation for >7 years with garlic (extract and oil) & vitamins (C, E, selenium) in pts who are high risk for gastric Ca
**Screening:** Currently no screening guidelines
**Diagnosis**
* Endoscopy. Upper GI series if endoscopy not available
* *Urgent referral:* any alarm symptoms
* *Consider referral*: if 55 years or older and persistent/progressive heartburn
>> Persistent/progressive abdominal pain
* *No referral*: 55 years or younger with dyspepsia and NO alarm symptoms
**Investigations** (in addition to endoscopy)
* CEA, CA 19-9 --> baseline tumor markers
* CT chest, abdo, pelvis --> local involvement + distant mets
**Management**
* Relapse is high, referral to multidisciplinary team is recommended
* In metastatic disease, palliative resection or bypass of the primary tumor is reserved for significant bleeding or obstruction (can also consider radiation)
