Cancer Flashcards
(77 cards)
1
Q
What is Lymphoma?
A
- Group of blood cancers which develop from lymphocytes and tumours are mainly found in the lymph nodes
- Hodgkins (20%)
- Non-Hodgkins (80%)
- Diffuse B cell
- Burkitts
- Mantle cell
- Follicular
2
Q
Epidemiology of Hodgkins
A
- Bimodal age distribution : between 20-30 and >60
- M>F
- Associated with Epstein Barr Virus
3
Q
H&E of Hodgkins
A
- Asymmetrical lymphadenopathy
- Painful after alcohol
- Commonly mediastinal and cervical
- Firm and rubbery
- FLAWS
- Splenomegaly +/- Hepatomegaly
4
Q
Investigations for Hodgkins
A
- Lymph node biopsy : Reed-Sternberg cells (bi-nucleated ‘owl eyes’)
5
Q
Management of Hodgkins
A
- Chemotherapy
- Radiotherapy
- Stem cell transplant
Excellent prognosis especially in younger patients
6
Q
Epidemiology of Non-Hodgkins
A
- More common than Hodgkins
- 85% are B-cell, 15% T-cell or NK cell
- Associated with Epstein Barr Virus, HIV, SLE and Sjogren’s
- Incidence increase with age
7
Q
H&E of Non-Hodgkins
A
- Painless enlarging mass in neck, axilla or groin
- FLAWS (less common than Hodgkins)
- Organ involvement
- skin rashes
- Headache
- Hepatosplenomegaly (more common than Hodgkins)
8
Q
Investigations for Non-Hodgkins
A
- Lymph node biopsy : NO Reed-Sternberg cells
9
Q
Management of Non-Hodgkins
A
- Chemotherapy
- Radiotherapy
- Stem cell transplant
Excellent prognosis especially in younger patients
10
Q
Burkitt’s Lymphoma
A
- Strong association with EBV
- Translocation between chromosomes 8 and 14 = over expression of c-myc oncogene
- Rapidly enlarging lymph node in jaw
- Starry sky appearance under microscopy
11
Q
Investigations for Metastatic Disease for all patients
A
NICE recommends the following investigations:
- FBC, U&E, LFT, Calcium, Urinanalysis, LDH
- CXR
- CT CAP
- AFP and hCG
12
Q
Investigations for Metastatic Disease for specific patients
A
- Myeloma screen (if lytic bone lesions)
- Endoscopy (directed towards symptoms)
- PSA (men)
- CA 125 (women with peritoneal malignancy or ascites)
- Testicular US (men with germ cell tumours)
- Mammography (women with clinical or pathological features compatible with breast cancer)
13
Q
Management of Metastatic Disease
A
Involves a combination of:
Systemic therapies (chemo, targeted or immunotherapy)
Local treatments (surgery or radiation therapy)
Supportive care (pain management or palliative)
14
Q
Types of Prostate Cancer
A
95% Adenocarcinoma
In situ malignancy found in areas adjacent to cancer - multiple biopsies need to call true in situ disease
Often multifocal - 70% lie in peripheral zone
15
Q
Grading system for Prostate cancer
A
Gleason grading system
Two grades awarded 1 for most dominant grade (on scale of 1-5) and 2 for second most dominant grade (scale 1-5)
Two for added give Gleason score, where 2 is best prognosis and10 is worst
16
Q
Spread of Prostate Cancer
A
Lymphatic spread occurs first to the obturator nodes and local extra prostatic spread to the seminal vesicles is associated with distant disease
17
Q
H&E of Prostate Cancer
A
LUTS - storage and voiding symptoms (FUND HIPS)
- Frequency
- Urgency
- Nocturia
- Dysuria
- Hesitancy
- Incomplete voiding
- Poor Stream
Haematuria
Bone Pain (mets)
FLAWS
18
Q
Investigations for Prostate Cancer
A
- Urinanalysis
- DRE : asymmetrical hard nodular prostate and loss of midline sulcus
- PSA (non-specific)
- U&Es
- Transrectal US-guided needle biopsy
- Isotope bone scan for staging
19
Q
Management of Prostate Cancer for Localised (T1/T2)
A
- Active monitoring and watchful waiting if significant co-morbidities
- Radical prostatectomy (can cause ED)
- Radiotherapy (inc. risk of bladder, colon or rectal cancer)
20
Q
Management of Prostate Cancer Locally Advanced (T3/T4)
A
- Hormonal therapy
- Radical Prostatectomy
- Radiotherapy
21
Q
Management of Prostate Cancer Metastatic
A
- Hormonal/ anti-androgen therapy
- Bilateral orchidectomy
- Chemotherapy with docetaxel
22
Q
Hormonal/ anti-androgen Therapy for Prostate Cancer
A
- Synthetic GnRH agonist : Goserelin (Zoladex) = causes overstimulation so initially test rises for 2-3 weeks and then drops
- Synthetic GnRH antagonist : Degarelix = suppress test
- Bicalutamide : non-steroidal anti-androgen = blocks receptor
- Cyproterone acetate : steroidal anti-androgen = prevents DHT binding, less commonly used
- Abiraterone : androgen synthesis inhibitor = hormone-relapsed metastatic cancer, before chemo
23
Q
Courvoisier’s Law
A
painless jaundice and palpable gallbladder - indicative of pancreatic malignancy
24
Q
Causes of Pancreatic Cancer
A
75% in head of pancreas, mostly arising from exocrine tissue
MEN1 (multiple endocrine neoplasia) - pancreatic tumours arising from endocrine tissue
Often diagnosed late so poor prognosis
25
H&E of Pancreatic Cancer
- Painless jaundice
- Epigastric pain
- FLAWS
- Steatorrhea (loss of exocrine function)
- Diabetes (loss of endocrine function)
Exam
- Trousseau sign (migratory thrombophlebitis)
- Palpable GB
- Hepatomegaly if metastatic
26
RF for Pancreatic Cancer
- Age
- Obesity
- Smoking
- T2DM
- Chronic pancreatitis
27
Investigations for Pancreatic Cancer
- High resolution CT : 1st if high index of suspicion
- Endoscopic US or ERCP with biopsy is gold standard for diagnosis
- Bloods e.g. CA19-9 may be elevated in pancreatic cancer but not specific
28
Management of Pancreatic Cancer
Depends on stage of cancer, patients health and co-morbidities
- Surgical resection is mainstay treatment for early-stage
- chemo and radio for advanced disease
- Whipple’s resection (pancreaticoduodenectomy) + adjuvant chemo
- ERCP with stenting for late stage
- Palliative care
- 5 year survival < 10%
29
What is Leukaemia?
Blood cancers that begin with mutation of a bone marrow progenitor cell = presence of abnormal cells in blood
30
Types of Leukaemia
Acute Myeloid Leukaemia = AML
Acute Lymphoid Leukaemia = ALL
Chronic Myeloid Leukaemia = CML
Chronic Lymphoid Leukaemia = CLL
31
Acute vs Chronic Leukaemia
Acute = result of impaired cell differentiation, resulting in large numbers of malignant precursor cells in the bone marrow
Chronic = result of excessive proliferation of mature malignant cells, but cell differentiation is unaffected
32
Myeloid vs Lymphoid Leukaemia
Myeloid commonly arises from myeloid precursor cell, such as neutrophils
Lymphoid arises from lymphoid precursor such as B-cells
33
H&E of AML
Fever
Bone marrow failure
- Neutropenia = infections
- Anaemia = pallor
- Thrombocytopaenia = bleeding
Tissue infiltration
- Swollen gums = monocytic
- Hepatomegaly and splenomegaly
34
AML epidemiology
MC in adults
Associated with myelodysplastic disorders
RF include trisomy 21 and irradiation
35
Investigations for AML
FBC
- High WCC (blast cells), pancytopaenia
Bone marrow biopsy
- Auer rods (needle shaped cells)
- Myeloperoxidase
Down Syndrome
- Megokaryoblastic
36
Management of AML
Chemo
Supportive
- blood products
- infection prophylaxis
- allopurinol, fluids, electrolytes (prevent tumour lysis syndrome)
Bone marrow transplant
37
Prognosis of AML
Death occurs within 2 months without treatment
However still 20% 3-year survival if treated
38
Epidemiology of ALL
MC cancer in children
RF include trisomy 21 and neurofibramatosis
39
H&E of ALL
FLAWS
Bone marrow failure
- Neutropenia = infections
- Anaemia = pallor
- Thrombocytopaenia = bleeding
Tissue infiltration
- Lymphadenopathy
- Hepatosplenomegaly
- Tender bones
- Painless unilateral testicular swelling
40
Investigations for ALL
FBC
- high WCC (blasts), pancytopaenia
Bone marrow biopsy
- >20% lymphoblasts
Immunophenotyping
41
Management of ALL
Chemo
Supportive
- blood products
- infection prophylaxis
- allopurinol, fluids, electrolytes (prevent tumour lysis syndrome)
Allo-stem cell transplant
42
Prognosis of ALL
Children have 70-90% cure rate
43
Epidemiology of CML
MC in middle aged, M>F
Classically associated with Philadelphia chromosome (translocation between chromosomes 9 and 22) = BCR-ABL1 fusion gene = unregulated tyrosine kinase
44
H&E of CML
Can be asymptomatic
Massive splenomegaly
FLAWS
Bone marrow failure
- neutropenia = infections
- anaemia = pallor
- thrombocytopaenia = bleeding
Hyperviscosity
- neuro deficits, visual. changes and mucosal bleeding
45
Investigations for CML
FBC
- Pancytopaenia, elevated WCC, RAISED BASOPHILS
Bone marrow aspirate
- Hypercellular with a spectrum of immature and mature cells
PCR for BCR-ABL1 fusion gene
46
Management of CML
Tyrosine kinase inhibitors - Imatinib
Median survival 5-6 years
47
Epidemiology of CLL
MC in male patients over 60
Failure of apoptosis = inc. of non-functional lymphocytes (B cells)
48
H&E of CLL
Typically present asymptomatically but can get:
Symmetrical non-tender lymphadenopathy
Bone marrow failure
- neutropenia = infections
- anaemia = pallor
- thrombocytopenia = bleeding
FLAWS
Associated with autoimmunity
Can progress to lymphoma (Richter’s transformation)
49
Investigations for CLL
FBC
- High WCC >100, normal Hb and platelets
Low serum immunoglobulin
Blood film
- Smear and smudge cells
Immunophenotyping
50
Management of CLL
- Watchful waiting if slowly progressive
- Supportive treatment
- Rituximab
1/3 cases don’t progress, 1/3 progress slowly, 1/3 progress actively
51
What is Multiple Myeloma?
Type of cancer that affects plasma cells, which are responsible for producing antibodies
Arises due to genetic mutations which occur as B-lymphocytes differentiate into mature plasma cells
Builds up in bone marrow, crowding out healthy blood cells and causing bone pain, fractures, fatigue and kidney damage.
52
Epidemiology of Multiple Myeloma
Rare : accounts for 1% of cancers
MC diagnosed in older adults
Agricultural work, African descent
53
H&E of Multiple Myeloma
Median age of presentation : 70yo
CRABBI
Calcium - hypercalcaemia
Renal - light chain deposition in renal tubules = damage = dehydration and polydipsia
Anaemia - crowding suppresses EPO = fatigue and pallor
Bleeding - dec. platelets = bleeding and bruising
Bones - crowding = cytokine-mediated osteoclast activity = lysis
Infection - dec. immunoglobulin production = inc. risk of infection
54
Investigations for Multiple Myeloma
Bloods
- FBC = anaemia
- Blood film = rouleaux formation
- U&Es = renal failure
- Bone profile = hypercalcaemia
Raised Ca2+, normal or high phosphate, normal alkaline phosphate
Protein electrophoresis = raised monoclonal IgA/IgG in serum, in urine they are called Bence Jones proteins
Bone marrow aspiration = number of plasma cells > 30% = diagnosis
Imaging = whole body MRI, XR = ‘rain-drop’ skull
55
Management of Multiple Myeloma
Combination of Chemo, targeted therapy and supportive care
First-line = bortezomib, lenalidomide, daratumumab alone or in combo
Supportive care = bisphosphonate, blood transfusions, dialysis or transplant
56
What is Spinal Cord Compression and management?
Fractures/ vertebral collapse can compress the spinal cord due to multiple myeloma osteolytic fractures
Back pain, limb weakness/numbness, urinary/bowel incontinence
Diagnosed with whole body XR/MRI
Managed with analgesia and surgical decompression
57
Breast screening program NHS
Offered to women between the ages of 50-70 - mammogram every 3 years
After age of 70 women may still have mammograms but are encouraged to make their own appointments
58
H&E of Breast Cancer
- New irregular lumps in the breast or underarm
- Thickening or swelling of part of the breast
- Irritation or dimpling of skin
59
H&E of Paget’s Disease of Breast
Sign of underlying cancer, mostly invasive
- Itching or bruising
- Pain and sensitivity
- Flattening of nipple
- Yellow or bloody nipple discharge
- Unilateral
60
Referral for Breast Cancer
2WW
- 30 or older + unexplained breast lump w/ or w/o pain
- 50 or older + any symptoms in one nipple (discharge, retraction, other changes)
Consider 2WW
- Skin changes that suggest cancer
- 30 or older + unexplained lump in axilla
Non-2WW
- 30 or younger with unexplained breast lump w/ or w/o pain
61
Investigations for Breast Cancer
< 35yo : Ultrasound
> 35yo : Mammogram
Fine needle aspiration or biopsy
Invasive Ca receptor status
- ER : oestrogen receptor
- PR : progesterone receptor
- HER2
62
TNM staging for Breast Cancer
T
1 : 0-2cm
2 : 2-5cm
3 : >5cm
4 : Broken through skin or attached to chest wall
N
0 : Can’t feel nodes
1 : swollen nodes
2 : swollen and lumpy
3 : located near collarbone
M
0 : Cancer-free nodes
1 : Nodes show cancer or mets
63
Management of Breast Cancer
Is there axillary lymphadenopathy?
Yes - Axillary lymph node clearance
No - US and sentinel LN biopsy +/- clearance
64
Surgical management of Breast Cancer
Mastectomy
- Multifocal tumour
- Central tumour
- Large lesion in small breast
- DCIS > 4cm
Wide local excision
- Solitary lesion
- Peripheral tumour
- Small lesion in large breast
- DCIS < 4cm
Radio with mastectomy if T3/4 or >4 LN
Chemo
Offer reconstruction
65
Hormonal/ Biological Therapy for Breast Cancer
ER positive + pre/peri menopausal
- Tamoxifen
ER positive + post-menopausal
- Anastrazole or letrozole
HER2 positive
- Trastuzumab (Herceptin)
66
Types of Lung Cancer
SCLC (15% + carries worse prognosis)
NSCLC
- adenocarcinoma
- squamous
- large cell
- alveolar cell carcinoma
- bronchial adenoma
67
Features of Adenocarcinoma Lung Cancer
Peripheral, most common type of
Often seen in non-smokers
Gynaecomastia
Hypertrophic pulmonary osteoarthropathy
Lobar collapse on CXR indicates Bronchial obstruction
68
Features of Squamous Cell Lung Cancer
Central
Cavitating lesions are more common
Release PTHrP
Clubbing
Hyperthyroidism due to ectopic TSH
Hypertrophic pulmonary osteoarthropathy (HPOA)
69
Features of Large Cell Lung Cancer
Peripheral
70
Features of Alveolar Cell Lung Cancer
Not related to smoking
++ sputum
71
Features of Bronchial Cell Lung Cancer
Mostly carcinoid
72
H&E of Lung Cancer
- Persistant cough
- Haemoptysis
- Dyspnoea
- Chest pain
- FLAWS
- Hoarseness (pancoast compressing of recurrent laryngeal n.)
Exam
- Fixed, monophonic wheeze
- Supraclavicular lymphadenopathy or cervical
- Clubbing
73
Features of SCLC
Central
ADH - Low Na+
ACTH - Cushing’s + Bilateral adrenal hyperplasia
Lambert-Eaton Syndrome
74
Investigations for Lung Cancer
CXR first line
CT gold standard
Bronchoscopy and biopsy (Aided by endobronchial US)
PET scan (typically NSCLC) to see eligibility for curative treatment
Bloods - raised Platelets
75
Management of SCLC
- Usually metastatic by diagnosis
- Surgery in early stage
- Chemo and Radio
- Palliative in extensive
76
Management of NSCLC
- Medianstinoscopy prior to surgery
- Curative or palliative radiotherapy
- HOWEVER Poor response to chemo
77
Contraindications to Surgery for Lung Cancer
- Poor general health
- Stage IIIb or IV (mets present)
- FEV1 < 1.5L is general cut off point
- Malignant pleural effusion
- Tumour near hilum
- Vocal cord paralysis
- SVC obstruction
