Cancer Flashcards

Question

What are the signs of CNS tumours on physical examination?

Answer 1

Papilloedema / false localising signs (raised intracranial pressure)- bilateral hemianopia, anosmia, ophthalmoplegia Focal neurological deficits (visual field defects, dysphasia, agnosia, hemianopia, hemiparesis, ataxia, personality change)

Answer 2

CT-head: Usual initial investigation. MRI-brain: Higher sensitivity. Chest X-ray or CT (thorax, abdomen, pelvis): To determine if the lesion is secondary or primary. Blood: CRP, ESR, consider HIV screen, toxoplasma serology (consider hormone profile-pituitary) Brain biopsy: Type and grading (degree of differentiation of tumour) *Lumbar puncture: contraindication if there is evidence of raised intracranial pressure, may cause coning (herniation).

Answer 3

Cancers arising from the bile duct epithelium. These can be divided depending on their location in the biliary tree: intrahepatic or extrahepatic (perihilar and distal)

Answer 4

There is a close association between infection, inflammation, and malignancy

Answer 5

Age > 50 years Cholangitis Choledocholithiasis (gall stones) Structural disorders of the biliary tract e.g. bile duct adenoma Ulcerative colitis Primary sclerosis cholangitis (high association with UC) Non-specific cirrhosis, alcoholic liver disease HIV Hepatitis B and C

Answer 6

Slight male predominance Approximately 2/3rds of cholangiocarcinomas occur in patients between 50 and 70 years of age Highest rates in Thailand and South American Countries

Answer 7

``` Painless jaundice (90% of patients) Others which are less common: -Weight loss -Abdominal pain -Itchiness -Dark urine and pale stools (obstructive jaundice) ```

Answer 8

Jaundice Triad of: fever, jaundice and right upper quadrant pain (acute cholangitis- 10% of patients) Palpable gallbladder (RARE) Hepatomegaly (RARE)

Answer 9

Bloods: -Serum bilirubin: Conjugated bilirubin is elevated in obstructive jaundice -Serum alkaline phosphate: Suggests obstructive (or cholestatic) pattern of elevated LFTs, along with GGT, AST and ALT -Serum prothrombin time: increased in prolonged obstruction of the common bile or hepatic duct *Tumour marker: Ca 19-9- elevated in up to 85% of patients with cholangiocarcinoma Imaging: -Abdominal ultrasound*: intrahepatic cholangiocarcinoma may be seen as a mass lesion -Abdominal CT: intrahepatic mass lesion, dilated intrahepatic ducts, and localised lymphadenopathy -Abdominal MRI/angiography: staging tool/extent of tumour -*ERCP (Endoscopic Retrograde Cholangiopancreatography) : a filling defect or area of narrowing will be seen if a tumour is present- INVASIVE Others: MRCP (extent of duct involvement) Percuatneous transhepatic cathertisation (invasive procedure that is used when the tumour causes complete obstruction of the biliary tree)

Answer 10

Malignancy of the large bowel - the majority of colorectal cancers are adenocarcinomas derived from epithelial cells

Answer 11

Colorectal cancer represents a complex interaction of genetic and environmental factors: Genetic: next to age, FH is the most common risk factor *Family cancer syndromes: familial adenomatous polyposis (FAP) and Lynch syndrome Environmental: Obesity, high energy intake, and physical inactivity are synergistic risk factors (low fibre diet) Also: inflammatory bowel disease, acromegaly

Answer 12

Second most common cause of cancer death in the West | Average age at diagnosis 60–65 years.

Answer 13

Left-sided colon and rectum: - Change in bowel habit (increased frequency, looser stools) - Rectal bleeding or blood/mucous mixed in with stools - Rectal masses may also present as tenesmus (sensation of incomplete emptying after defecation) Right-sided colon: -Later presentation, with symptoms of anaemia, weight loss and non- specific malaise or, more rarely, lower abdominal pain Up to 20% of tumours will present as an emergency with pain and distension caused by large bowel obstruction, haemorrhage or peritonitis as a result of perforation

Answer 14

Anaemia may be only sign, particularly in right-sided lesions Abdominal mass, low-lying rectal tumours may be palpable on rectal examination Metastatic disease: Hepatomegaly, shifting dullness of ascites

Answer 15

Blood: FBC (for anaemia), LFT (often normal), tumour markers (CEA to monitor treatment response or disease recurrence) Stool: Occult or frank blood in stool (screening test) Endoscopy: -Sigmoidoscopy, colonoscopy: may see ulcerating or exophytic (growing outward) mucosal lesion that may narrow the bowel lumen -Allows visualization and biopsy. Polypectomy can also be performed if isolated small carcinoma in situ Barium contrast studies: Apple core stricture on barium enema Abdominal ultrasound scan for hepatic metastases Other staging investigations include: -CXR -CT: colonic wall thickening, enlarged lymph nodes, liver metastases, ascites, lung secondaries -MRI, endorectal ultrasound

Answer 16

Formation of a thrombus within the deep veins (most commonly of the calf or thigh) which may result in impaired venous blood flow and consequent leg swelling and pain

Answer 17

``` Oral contraceptive pill Surgery Prolonged immobility Long bone fractures Obesity Pregnancy Dehydration Smoking Polycythaemia Anti-phospholipid syndrome Thrombophilia disorders (e.g. protein C deficiency) Active malignancy ```

Answer 18

Venous stasis Vessel wall injury Blood hypercoagulability

Answer 19

Common, especially in hospitalised patients- yearly incidence of approximately 1 in every 1000 adults Long-term complications of DVT (venous insufficiency, ulceration) affect 0.5% population Incidence increases with age (increased medical co-morbidities, declining mobility, and perhaps age-related changes in coagulation)

Answer 20

Asymptomatic or lower limb swelling or tenderness | May present with signs/ symptoms of a pulmonary embolus (sudden onset dyspnoea, chest pain)

Answer 21

Examine for swelling, calf tenderness: Severe leg oedema (usually unilateral) Dilated superficial veins over foot and leg Cyanosis (phlegmasia cerulea dolens) is rare *Respiratory examination for signs of a pulmonary embolus (Sudden onset dyspnoea, cough, haemoptysis and pleuritic chest pain)

Answer 22

*Doppler ultrasound: gold standard -Good sensitivity for femoral veins; less sensitive for calf veins (reduced/absent spontaneous blood flow) Bloods: -D-dimers (fibrinogen degradation products) are sensitive but very non-specific and only useful as a negative predictor in low-risk patients -If indicated (e.g. recurrent episodes), a thrombophilia screen should be sent, prior to starting anticoagulation -FBC (platelet count prior to starting heparin) -U&E and clotting ECG, CXR and ABG: If there is suggestion that there might be PE

Answer 23

Lower limb trauma or surgery or immobilisation in a plaster cast (+1) Bedridden for >3 days or surgery within the last 4 weeks (+1) Tenderness along deep venous system (+1) Entire limb swollen (+1) Calf >3 cm bigger circumference; 10 cm below tibial tuberosity (+1) Pitting oedema (+1) Dilated collateral superficial veins (non-varicose) (+1) Malignancy (including treatment up to 6 months previously) (+1) Alternative diagnosis more likely than DVT (-2) Clinical probability of DVT: High >3 Moderate 1–2 Low <1

Answer 24

Anticoagulation: - Patients should be treated with heparin while awaiting therapeutic INR from warfarin anticoagulation - DVTs not extending above the knee treated with anticoagulation for 3 months, while those extending beyond the knee require anticoagulation for 6 months - Recurrent DVTs may require long-term warfarin* - If active anticoagulation is contraindicated and/or high risk of embolisation, placement of an IVC filter, e.g. Greenfield filter, by interventional radiology is indicated to prevent embolus to the lungs Prevention: - Use of graduated compression stockings - Mobilisation if possible (physical activity) - At-risk groups (immobilised hospital patients) should have prophylactic heparin, e.g. low molecular weight heparin if no contraindications

Answer 25

Of the disease: -Pulmonary embolus -Damage to vein valves and chronic venous insufficiency of the lower limb (post-thrombotic syndrome) *Rare: Venous infarction (phlegmasia cerulea dolens) Of the treatment: -Heparin-induced thrombocytopaenia -Bleeding

Answer 26

Depends on extent of DVT: - Below-knee DVTs lower risk of embolus - More proximal DVTs have higher risk of propagation and embolisation, which, if large, may be fatal

Answer 27

A neoplasm that can develop in any portion of the stomach and may spread to the lymph nodes and other organs, most commonly adenocarcinoma, more rarely lymphoma, leiomyosarcoma

Answer 28

Most cases are probably caused by environmental insults in genetically predisposed individuals that lead to mutation and subsequent unregulated cell growth Risk factors include: -Helicobacter pylori infection -Atrophic gastritis -Diet high in smoked, processed foods and nitrosamines -Smoking -Alcohol

Answer 29

Common cause of cancer death worldwide, with highest incidence in Asia, especially Japan Sixth most common cancer in UK (annual incidence is 15 in 100000) M: W is 􏰄2:1 Age>50 years *Cancer of the antrum/body is becoming less common, while that of the cardia and gastro- oesophageal junction is increasing

Answer 30

In the early phases, it is often asymptomatic Early satiety or epigastric discomfort Weight loss, anorexia, nausea and vomiting Haematemesis, melaena, symptoms of anaemia Dysphagia (tumours of the cardia) Symptoms of metastases, particularly abdominal swelling (ascites) or jaundice (liver involvement)

Answer 31

``` Physical examination may be normal Epigastric mass Abdominal tenderness Ascites Signs of anaemia Many eponymous signs: **Virchows node/Troisiers sign: Lymphadenopathy in left supraclavicular fossa Sister Mary Joseph node: Metastatic nodule on umbilicus Krukenbergs tumour: Ovarian metastases ```

Answer 32

*Upper gastrointestinal endoscopy with biopsy: ulcer or mass or mucosal changes Bloods: FBC (for anaemia), LFT CT/MRI: Staging of tumour and planning of surgery (metastatic lesions) Ultrasound of liver: Staging of tumour (metastatic lesions) Bone scan: Staging of tumour (metastatic lesions) Endoscopic ultrasound: Assesses depth of invasion and lymph node spread (determines clinical tumour (T) and node (N) stage) Laparoscopy: May be needed to determine if tumour is resectable

Answer 33

Primary malignancy of hepatocytes, usually occurring in a cirrhotic liver

Answer 34

- Chronic liver damage e.g. alcoholic liver disease, hepatitis B, hepatitis C, autoimmune disease - Metabolic disease e.g. haemochromatosis (inherited condition where iron levels accumulate) - Aflatoxins: Aspergillus flavus fungal toxin found on stored grains or biological weapons

Answer 35

Worldwide, HCC is the sixth most common cause of cancer and the second leading cause of cancer-related death Rare in West (1–2 in 100 000/year) Very common malignancy in areas where Hepatitis B and C are endemic, i.e. Asia and sub-Saharan Africa

Answer 36

``` Symptoms of malignancy: -Malaise -Weight loss -Loss of appetite Symptoms of chronic liver disease: -Abdominal distension -Jaundice -Right upper quadrant pain History of carcinogen exposure: -High alcohol intake -PMH of Hepatitis B or C or Aflatoxins ```

Answer 37

``` Signs of malignancy: -Cachexia -Lymphadenopathy Hepatomegaly: -Nodular (but may be smooth) Deep palpation may elicit tenderness *There may be bruit heard over the liver Signs of chronic liver disease: -Jaundice -Ascites -Palmar erythema Others: -Splenomegaly: indicative of portal hypertension secondary to cirrhosis of the liver -Decompensated cirrhosis- hepatic encephalopathy: asterixis, spider naevi ```

Answer 38

Blood: -*Raised AFP (tumour marker with high sensitivity): elevated in 60% of patients with HCC -Vitamin B12-binding protein is a marker of fibrolamellar hepatocellular carcinoma -LFT has poor specificity and sensitivity but may show biliary obstruction (elevated aminotransferases, alkaline phosphatase, and bilirubin; low albumin) -Prothrombin time: normal or elevated Abdominal ultrasound: -Poorly defined margins and coarse, irregular internal echoes -Not sensitive for tumours <1 cm Duplex scan of liver: -May be used to demonstrate large vessel invasion (e.g. into hepatic or portal veins) *CT (thorax, abdomen, pelvis) with contrast: -Typical hypervascular pattern -To define structural lesion and spread -Hepatic angiography: Using lipiodol (an iodized oil). Liver biopsy: -Confirms histology of tumour: well-differentiated to poorly differentiated hepatocytes with large multinucleated giant cells having central necrosis -Small risk of tumour seeding along biopsy tract Staging: -CXR -Radionuclide bone scan: "hot" spots- bone mets *Screening: AFP and abdominal ultrasound in at-risk individuals

Answer 39

Malignancy of primitive myeloid lineage WBCs (myeloblasts) with proliferation in the bone marrow and blood

Answer 40

1. Myeloblasts, arrest at an early stage of development, with varying cyto-genetic abnormalities (e.g. gene mutations and chromosome translocations) 2. Myeloblasts then undergo malignant transformation and proliferation, with subsequent replacement of normal marrow elements 3. Resulting in bone marrow failure

Answer 41

*Most common acute leukaemia in adults | Incidence increases with age.

Answer 42

Symptoms of bone marrow failure: -Anaemia (lethargy, dyspnoea) -Bleeding (thrombocytopaenia) or DIC(Disseminated intravascular coagulation-blood clots form throughout the body) -Opportunistic or recurrent infections Symptoms of tissue infiltration: -Gum swelling or bleeding -CNS involvement (headaches, nausea, diplopia-double vision): especially with particular variants

Answer 43

Signs of bone marrow failure: -Pallor -Cardiac flow murmur -Ecchymoses (discolouration of skin from bleeding underneath) -Bleeding -Opportunistic or recurrent infections (e.g. fever, mouth ulcers, skin infections, Pneumocytis Pneumonia- PCP) Signs of tissue infiltration: -Skin rashes -Gum hypertrophy -Deposits of leukaemic blasts may rarely be seen in the eye (chloroma), tongue and bone – in the latter may cause fractures

Answer 44

Bloods: -FBC (reduced Hb, reduced platelets, variable WCC) -Raised Uric acid -Raised LDH -Others: clotting studies, fibrinogen and D-dimers (when DIC is suspected) *Blood film: AML blasts may show cytoplasmic granules or Auer rods *Bone marrow aspirate or biopsy: -Hypercellular with >30 % blasts (immature cells) Immunophenotyping: Antibodies against surface antigens to classify lineage of abnormal clones Immunocytochemistry: Myeloblasts granules are positive [Cytogenetics: For diagnostic and prognostic information]

Answer 45

Malignancy of the bone marrow and blood characterized by the proliferation of lymphoblasts (primitive lymphoid cells)

Answer 46

1. Lymphoblasts, arrest at an early stage of development, with varying cytogenetic abnormalities (e.g. gene mutations and chromosome translocations) 2. Lymphoblasts then undergo malignant transformation and proliferation, with subsequent replacement of normal marrow elements 3. Resulting in bone marrow failure and infiltration into other tissues

Answer 47

Most common malignancy of childhood. The peak incidence occurs between 2 and 5 years of age Second peak in the elderly

Answer 48

Environmental: radiation, viruses Genetic: e.g. Down’s syndrome, neurofibromatosis type 1, increased risk in siblings

Answer 49

Symptoms of bone marrow failure: -Anaemia (fatigue, dyspnoea) -Bleeding (spontaneous bruising, bleeding gums, menorrhagia) -Opportunistic infections (bacterial, viral, fungal, protozoal) Symptoms of organ infiltration: -Tender bones -Enlarged lymph nodes -Mediastinal compression (in T-cell ALL) -Meningeal involvement (headache, visual disturbances, nausea)

Answer 50

``` Signs of bone marrow failure: Pallor -Bruising -Bleeding -Infection (e.g. fever, GI, skin, respiratory systems) Signs of organ infiltration: -Lymphadenopathy -Hepatosplenomegaly -Cranial nerve palsies -Retinal haemorrhage or papilloedema on fundoscopy -Leukaemic infiltration of the anterior chamber of the eye (mimics hypopyon) -Testicular swelling ```

Answer 51

Bloods: -FBC (normochromic normocytic anaemia, reduced platelets, variable WCC) -Raised uric acid, raised LDH, clotting screen Blood film: Lymphoblasts evident Bone marrow aspirate or trephine biopsy: -Hypercellular with >30 % lymphoblasts -Immunophenotyping: Using antibodies for cell surface antigens e.g. CD20 Lumbar puncture (and CSF analysis): For CNS involvement. CXR: May show mediastinal lymphadenopathy, thymic enlargement, lytic bone lesions Bone radiographs: Mottled appearance with ‘punched-out’ lesions (e.g. skull caused by leukaemic infiltration)

Answer 52

Morphologic classification(French–American–British classification): L1: Small lymphoblasts, scanty cytoplasm. L2: Larger, heterogenous lymphoblasts. L3: Large lymphoblasts with blue or vacuolated cytoplasm.

Answer 53

A malignant clonal disease characterized by proliferation of granulocyte precursors in the bone marrow and blood *distinguished from AML by its SLOWER progression

Answer 54

Malignant proliferation of stem cells. Three stages: 1. Relatively stable chronic phase of variable duration (average of 4–6 years) 2. Accelerated phase (3–9 months) 3. Acute leukaemia phase (blast transformation)

Answer 55

Incidence increases with age, mean 40–60 years | 4 times more common in males

Answer 56

Asymptomatic in up to 40–50 % and is diagnosed on routine blood count Hypermetabolic symptoms: Weight loss, malaise, sweating Bone marrow failure symptoms: Lethargy, dyspnoea, easy bruising, epistaxis (infection is rare) Others: -Abdominal discomfort and early satiety -Occasionally presents with gout or hyperviscosity symptoms (visual disturbance, headaches) -May present during blast crisis with symptoms of AML or ALL

Answer 57

Splenomegaly: Most common physical finding (90%) Signs of bone marrow failure: -Pallor -Cardiac flow murmur -Bleeding -Ecchymoses (discolouration of skin from bleeding underneath)

Answer 58

Bloods: -FBC: grossly raised WCC, low Hb, raised basophils /eosinophils/ neutrophils, variable platelets -Raised uric acid, low neutrophil alkaline phosphatase, high vitamin B12 and B12-binding protein Blood film: Shows immature granulocytes in peripheral blood Bone marrow aspirate or biopsy: Hypercellular with raised myeloid–erythroid ratio

Answer 59

Characterized by progressive accumulation of functionally incompetent lymphocytes, which are monoclonal in origin *There is an overlap between CLL and non- Hodgkin’s lymphomas

Answer 60

Malignant cells may accumulate as a result of their inability to undergo apoptosis (partly due to overexpression of BCL2 and Fas-inhibitory molecules)

Answer 61

90% are >50 years Men more than Women Rare in Asians

Answer 62

Asymptomatic: Up to 40–50 % diagnosed on routine blood count Systemic symptoms: -Lethargy, malaise, night sweats Symptoms of bone marrow failure: Recurrent infections (bacterial, viral, fungal), herpes zoster, easy bruising or bleeding (e.g. epistaxis)

Answer 63

Non-tender lymphadenopathy (often symmetrical) Hepatomegaly Splenomegaly Later stages: signs of bone marrow failure: -Pallor -Cardiac flow murmur -Purpura/ ecchymoses (discolouration of skin from bleeding underneath)

Answer 64

CLL may be associated with autoimmune phenomena: -Haemolytic anaemia (10 %) -Thrombocytopaenia or a combination of both (Evan’s syndrome) Bloods: -FBC: gross lymphocytosis, 5–300x109/L, anaemia, low platelets) -Anaemia may be due to bone marrow infiltration, hypersplenism or autoimmune haemolysis -Reduced serum immunoglobulins Blood film: -Small lymphocytes with thin rims of cytoplasm and smudge/smear cells Bone marrow aspirate or biopsy: -Lymphocytic replacement (25–95 %) of normal marrow elements Immunophenotyping shows the malignant cell to be a relatively mature B cell with weak surface expression of monoclonal IgM or IgD *CT (chest, abdomen, and pelvis): On the basis of the patient’s symptoms

Answer 65

A group of malignant epithelial tumours arising from cells lining the lower respiratory tract. Lung cancer is divided into 2 categories: -Non-small cell lung cancer (NSCLC) (80%) -Small cell lung cancer (15%)

Answer 66

1. adenocarcinoma 2. squamous cell carcinoma 3. large cell carcinoma

Answer 67

``` Cigarette smoking Environmental tobacco exposure Chronic obstructive pulmonary disease Family Hx Radon gas exposure ```

Answer 68

* Tobacco exposure continues to be the most important cause of lung cancer - 45% of NSCLC are adenocarcinomas, which tend to be located more peripherally in the lung - 25% to 30% of lung cancers are squamous cell carcinomas, which tend to involve the central airways - Large cell carcinomas, accounting for about 10% of lung cancers, are undifferentiated tumours without histological features typical of a squamous cell or adenocarcinoma and tend to arise centrally

Answer 69

The most common cause of cancer mortality worldwide NSCLC accounts for 80% of all lung cancer cases More common in men Median age of patients is 70 years (Less than 10% of cases are diagnosed below 50 years)

Answer 70

May be asymptomatic with radiographic abnormality found (5%) Due to primary: Cough, haemoptysis, chest pain, recurrent pneumonia Due to local invasion: e.g. brachial plexus (Pancoast tumour, in the apex of the lung) causing pain in the shoulder or arm, left recurrent laryngeal nerve (hoarseness and bovine cough), oesophagus (dysphagia), heart (palpitations/arrhythmias). Due to metastatic disease or paraneoplastic phenomena: Weight loss, fatigue, fits, bone pain or fractures, neuromyopathies

Answer 71

There may be no signs. Wheeze, rales, decreased breath sounds, and dullness to percussion Signs of collapse, consolidation or pleural effusion. Due to local invasion: -Superior vena cava compression (facial congestion, distension of neck veins, upper limb oedema) -Brachial plexus (wasting of the small muscles of the hand) -Sympathetic chain (Horners syndrome: pupillary miosis, ptosis and facial anhydrosis) PANCOAST TUMOUR Due to paraneoplastic phenomena: Hypertrophic osteoarthropathy: clubbing, painful swollen wrists/ankles (periosteal new bone formation) Due to metastases: Supraclavicular lymphadenopathy, hepatomegaly.

Answer 72

CXR: variable; may detect single or multiple pulmonary nodule(s), mass, pleural effusion, lung collapse, or mediastinal or hilar fullness Contrast enhanced CT of lower neck, thorax and upper abdomen: shows size, location and extent of primary tumour; evaluates for hilar and/or mediastinal lymphadenopathy and distant metastases Others: -Bronchoscopy: endobronchial lesions -Biopsy: malignant cells -Sampling of the mediastinal lymph nodes: spread -Thoracentesis: malignant cells within the pleural fluid -MRI/CT of brain: brain metastases -Bone scan: skeletal metastases -Bloods: may show anaemia, mildly elevated LFTs, hypercalcaemia (squamous cell carcinomas), Alk Phosphate (bone mets) -Contrast enhanced CT of liver and adrenals: metastatic lesions -ECG: cardiac disease/involvement (pre-operatively)

Answer 73

Cigarette smoking Environmental tobacco exposure Radon gas exposure Asbestos exposure (weak)

Answer 74

Tobacco exposure continues to be the most important cause of lung cancer and approximately 90% of lung cancer is directly attributable to smoking

Answer 75

SCLC comprises approximately 15-20% of lung cancers Incidence is decreasing (most likely due to number of smokers decreasing) Median age 65-70 years (over 50 years) Currently more common in men

Answer 76

May be asymptomatic with radiographical abnormality found Due to primary tumour: Cough, haemoptysis, dyspnoea, chest pain Due to metastatic disease: Weight loss, fatigue, bone pain Due to paraneoplastic syndromes: Weakness, lethargy, seizures, muscle fatiguability

Answer 77

May be no signs on auscultation of the chest Auscultation of the lungs may demonstrate: -Wheeze -Rales -Decreased breath sounds -Dullness to percussion -Signs of lobar collapse or pleural effusion Signs of metastases, e.g. supraclavicular lymphadenopathy or hepatomegaly Signs of paraneoplastic syndrome e.g. loss of muscle tone or weakness

Answer 78

Diagnosis: - Sputum cytology - Bronchoscopy with brushings and biopsy or percutaneous biopsy (malignant cells- may be within the pleural fluid) - Thoracoscopy - CXR:central mass, hilar lymphadenopathy, pleural effusion Staging: - CT of chest (massive lymphadenopathy and direct mediastinal invasion are common features of SCLC), abdomen, head - Isotope bone scan - MRI/CT of brain: brain metastases Other: - Lung function tests - Bloods: may show anaemia, mildly elevated LFTs, ADH secreting tumour? - may show hyponatraemia

Answer 79

Hodgkin’s lymphoma (􏰄15% of lymphomas) is diagnosed histo- pathologically by the presence of Reed–Sternberg cells (a mature cell of B-lymphoid lineage)

Answer 80

Neoplasms of lymphoid cells, originating in lymph nodes or other lymphoid tissues

Answer 81

Unknown- likely to be a result of an environmental trigger in a genetically susceptible individual *The presentation of HL (fevers, night sweats, lymphadenopathy) suggests an infectious aetiology- the EBV genome has been detected in 􏰄50% of Hodgkin’s lymphomas

Answer 82

Bimodal age distribution, with peaks 20–30 years and >50 years More common in males Annual European incidence is 2–5 in 100,000

Answer 83

``` Painless enlarging mass (most often in neck, occasionally in axilla or groin)- may become painful after alcohol ingestion ‘B’ symptoms: -Fevers >38􏰂C Night sweats Weight loss >10% body weight in last 6 months Other: -Pruritus -Cough -Dyspnoea -Chest pain/discomfort *with intrathoracic disease ```

Answer 84

Non-tender firm rubbery lymphadenopathy: -Cervical, axillary or inguinal Splenomegaly, occasionally hepatomegaly Skin excoriations (scratch marks) Signs of intrathoracic disease (e.g. pleural effusion, superior vena cava obstruction)

Answer 85

Bloods: -FBC: Anaemia of chronic disease, leucocytosis, raised neutrophils, raised eosinophils. Lymphopaenia (abnormal reduction) with advanced disease -Raised ESR and CRP -LFTs (raised LDH, raised transaminases if liver involved) *Lymph node biopsy: Hodgkin's cell can be a characteristic Reed-Sternberg cell Bone marrow aspirate and trephine biopsy: Involvement seen only in very advanced disease Imaging: -CXR: mediastinal mass, large mediastinal adenopathy -CT of thorax, abdomen and pelvis: may show enlarged lymph nodes and other sites of disease -Gallium scan, PET scans: involved sites appear bright

Answer 86

A diverse group consisting of 85% B cell, 15% T cell and NK cell forms, ranging from indolent (little/no pain) to aggressive disease and referred to as low, intermediate and high grades

Answer 87

Complex process involving the accumulation of multiple genetic lesions (activation of oncogenes by chromosomal translocations and inactivation of tumour suppressor genes by chromosomal deletions or mutations) The genome in certain lymphoma subtypes has been altered by the introduction of foreign genes via a number of oncogenic viruses: EBV has been detected in cases of Burkitt’s lymphoma and of AIDS- associated lymphomas

Answer 88

``` Radiotherapy Immunosuppressive agents Chemotherapy HIV, Hep B V, Hep C V Connective tissue diseases e.g. SLE Inherited and acquired immunodeficiency syndromes ```

Answer 89

Incidence increase with age More common in males More common in the West

Answer 90

``` Painless enlarging mass: Often in neck, axilla or groin Systemic symptoms (*less frequent than in Hodgkin’s): -Fever -Night sweats -Weight loss > 10 % body weight -Symptoms of hypercalcaemia. Symptoms related to organ involvement (*extranodal disease is more common in NHL than in Hodgkin’s lymphoma): -Skin rashes -Headache -Sore throat -Abdominal discomfort -Testicular swelling ```

Answer 91

``` Painless firm rubbery lymphadenopathy: Cervical, axillary or inguinal Oropharyngeal (Waldeyer’s ring of lymph nodes) involvement Skin rashes: -Mycosis fungoides (well-defined indurated scaly plaque-like lesions with raised ulcerated nodules caused by cutaneous T-cell lymphoma) and Sezary’s syndrome Abdominal mass Hepatosplenomegaly Signs of bone marrow involvement: -Anaemia, infections or purpura ```

Answer 92

Bloods: FBC (anaemia, neutropaenia and thrombocytopaenia if bone marrow involved) -U&Es, uric acid -Raised ESR and CRP, raised LDH, LFTs (elevated transaminases with liver involvement), Ca2+ (may be raised) -HIV, HBV and HCV serology (in select patients) Blood film: Lymphoma cells may be visible in some patients, nucleated red blood cells Lymph node biopsy: histopathologic evaluation Bone marrow aspiration and biopsy: important for staging Skin biopsy: useful for infiltration diagnosis Imaging: -PET scanning: increased uptake at involved sites -CT plus PET scanning is of particular value for evaluation of extranodal involvement (staging)

Answer 93

Haematological malignancy characterized by proliferation of plasma cells in the bone marrow resulting in bone lesions and production of a monoclonal immunoglobulin in the serum and/or urine

Answer 94

Unknown Genetic inheritance may play a role and/or a viral trigger Chromosomal aberrations are frequent, certain cytokines (e.g. IL-6) act as potent growth factors for plasma cell proliferation Multiple myeloma is associated with ionizing radiation, agricultural work or occupational chemical exposures (benzene)

Answer 95

Annual incidence is 4 in 100,000, peak incidence in 70-year-olds Afro- Caribbeans > white people > Asians

Answer 96

``` *May be diagnosed incidentally on routine blood tests Bone pain: -Often in back, ribs -Sudden and severe if caused by pathological fracture or vertebral collapse. Infections: Often recurrent General: -Tiredness -Thirst -Polyuria -Nausea -Constipation -Mental change (resulting from hypercalcaemia) Hyperviscocity: -Bleeding -Headaches -Visual disturbance ```

Answer 97

``` Pallor- anaemia Tachycardia Flow murmur Signs of heart failure Dehydration Purpura Hepatosplenomegaly Macroglossia Carpal tunnel syndrome Peripheral neuropathies ```

Answer 98

*Diagnostic test: serum/urine electrophoresis: Serum paraprotein (two-thirds IgG, one-third IgA) Bloods: -FBC (low Hb, normochromic normocytic) -Elevated ESR and CRP (CRP may be normal with elevated ESR)-extent of advanced disease -U&E (high creatinine, high Ca2+ in 45%), typically normal AlkPhos [renal impairment] Blood film: Rouleaux formation (stacks or aggregations of RBC) with bluish background (high protein) Skeletal survey- chest, pelvic or vertebral X-ray: Osteolytic lesions without surrounding sclerosis, osteopenia *Bone marrow aspirate an biopsy: monoclonal plasma cell infiltration

Answer 99

A potentially life-threatening complication of anti-cancer and other immunosuppressive drug treatment It is defined as a temperature of greater than 38°C or any symptoms and/or signs of sepsis, in a person with an absolute neutrophil count of 0.5 x 109/L or lower

Answer 100

A syndrome defined as life-threatening organ dysfunction due to a dysregulated host response to infection

Answer 101

The risk of clinically significant infection and sepsis increases as the neutrophil count decreases to less than 0.5 x 109/L

Answer 102

C: hyperCalcaemia R: renal failure A: anaemia B: bone lesions

Answer 103

It is a common complication of chemotherapy- often more common in patients with haematological malignancies than in patients with solid tumours Risk: greatest with the first treatment, also cumulative with ongoing cycles of therapy

Answer 104

Infants and people over 60 years of age are at higher risk Corticosteroids (additional immunosuppression) Co-morbidities: diabetes mellitus, liver disease, renal disease; poor nutritional status Full dose intensity chemotherapy Concurrent radiotherapy Prior episodes of neutropenia following chemotherapy

Answer 105

The most common life-threatening complication of cancer therapy Higher incidence in patients with heamatological malignancy

Answer 106

Symptoms or signs indicating possible infection: Dysuria Dyspnoea Diarrhoea Cough Nausea or vomiting Chills, shivers and/or a temperature greater than 38°C

Answer 107

``` Clinical features of possible sepsis: -Fever -Rigors -Tachycardia -Hypotension *people with sepsis may present with non-specific, non-localized clinical features: -general malaise -agitation -behavioural change In addition, neutropenia may cause changes in behaviour, mental state, or cognition which is independent from the onset of sepsis ```

Answer 108

Bloods: -FBC: absolute neutrophil count (ANC) <500 -U&Es: normal or elevated, indicator of renal dysfunction -LFTs: albumin <35 g/L (also a RF for neutropenic sepsis), total bilirubin and aminotransferases elevated Blood cultures: positive for pathogen CXR: infiltrates in pneumonia Others: -Stool and urine culture -Lumbar puncture: for patients with suspected CNS infection -Viral assay -CT of chest, abdomen and pelvis: infiltrates of pneumonia

Answer 109

Malignant tumour arising in the oesophageal mucosa. There are two major histological types: - Squamous cell carcinoma - Adenocarcinoma

Answer 110

Squamous cell carcinomas are more common in the mid-upper oesophagus Adenocarcinoma usually develops in the lower oesophagus or, increasingly, the gastro- oesophageal junction *Barrett's oesophagus (metaplasia of the mucosal lining of the distal oesophagus) is caused by long-standing gastro-oesophageal reflux, and is considered a pre-malignant condition for the development of adenocarcinoma

Answer 111

``` Male sex (7:1) Squamous cell carcinoma: -Alcohol -Tobacco -FH of oesophageal, stomach, oral or pharyngeal cancer -Certain nutritional deficiencies (vitamins, trace elements) -HPV infection -Achalasia Adenocarcinoma: -GORD -Barretts oesophagus -Obesity ```

Answer 112

Eighth most common malignancy (UK 7000–8000 per year) 3/4:1 male : female Worldwide squamous carcinoma is more common (95%) but in the West Adenocarcinoma is more common (65% cases in the UK)- INCIDENCE IS INCREASING Peak incidence 60–70 years

Answer 113

``` Early: symptomatic/symptoms of reflux Later: -Dysphagia, initially worse for solids -Regurgitation -Cough or choking after food -Pain on swallowing (odynophagia) -Weight loss, fatigue -Voice hoarseness (may indicate recurrent laryngeal nerve palsy) ```

Answer 114

No physical signs may be evident Signs of weight loss With metastatic disease there may be supraclavicular lymphadenopathy, hepatomegaly Respiratory signs may be due to aspiration or direct tracheobronchial involvement

Answer 115

Endoscopy: - *First test- Oesophagogastrodueodenoscopy (OGD) with biopsy: mucosal lesion; histology shows squamous carcinoma or adenocarcinoma - Early high-grade dysplasia and cancer detection is improved by endoscopic techniques such as narrow band imaging or magnification, staging Imaging: - Barium swallow- exclude differentials - CT (chest, abdomen, pelvis): size of primary tumour, local invasion, and presence or absence of metastases - PET: hyperactivity 'hot' spot, can detect previously occult distant metastases Other: - Bronchoscopy (if risk of trancheobronchial invasion) - Bone scan if symptoms of bony involvement - Laparoscopy and peritoneal washings * Careful cardiac and respiratory assessment if surgery planned

Answer 116

Malignancy arising from the exocrine or endocrine tissues of the pancreas Refers to primary pancreatic ductal adenocarcinoma, which accounts for >85% of all pancreatic neoplasms

Answer 117

Pancreatic cancer is a disease of older people, with a peak incidence in people 65 to 75 years of age The only consistently reported exogenous risk factor for pancreatic cancer is cigarette smoking 5-10% have a familial component Other risk factors(weak): -Obesity -Diabetes Mellitus -Dietary factors ( high in meats and fat, and low serum folate)

Answer 118

Increasing in incidence (8–12/100000), worldwide sixth cause of cancer deaths (poor prognosis) Peak age 60–80 years

Answer 119

``` Initial symptoms (often non-specific): -Anorexia -Malaise -Weight loss -Nausea Later symptoms: jaundice, epigastric pain ```

Answer 120

Signs of: -Weight loss -Epigastric tenderness -Mass Courvoisiers law: Jaundice and a painless palpable gallbladder - UNLIKELY TO BE GALLSTONES (rather carcinoma of the pancreas or the lower biliary tree) In patients with metastatic spread: there may be hepatomegaly Trousseaus sign is an associated superficial thrombophlebitis (sign in hypocalcaemia): increased risk of thromboembolic disease

Answer 121

Bloods: -Tumour marker CA19-9 can be elevated (specific, but not diagnostic) -If causing obstructive jaundice: bilirubin, alkaline phosphatase, and gamma glutamyl transpeptidase elevated Imaging: -*(without delay)Abdominal ultrasound: pancreatic mass, dilated bile ducts, liver metastases -Pancreatic protocol CT: may demonstrate a mass in the pancreas and the extent of local or distant spread -ERCP: ampullary tumour may be seen; all other pancreatic tumours are only detectable if there is pancreatic duct involvement, may allow biopsy/bile cytology with stenting -PET scan: may demonstrate a mass in the pancreas -MRI: detailed duct involvement -Endoscopic ultrasound: detect small tumours in the pancreas -Laparoscopy: useful in staging the disease (peritoneum, liver)

Answer 122

The proliferation of atypical, transformed epidermal keratinocytes in the skin with malignant behaviour

Answer 123

The incidence of non-melanoma skin tumours varies dramatically on: - Skin phototype or constitutive pigmentation - Cumulative sun exposure (geographic latitude) - Solar UV exposure (MAIN RF) - Ionising radiation - Burns - Hereditary skin conditions - Environmental toxins such as arsenic and tar - Human papillomavirus - Some immunocompromised states

Answer 124

Second most common cutaneous malignancy (20% of skin cancers) Often occurring in middle-aged and elderly light-skinned individuals Annual incidence is about 1/4,000 Male > female (2/3:1)

Answer 125

Skin lesion: - Ulcerated - Recurrent bleeding or non-healing - Growing * Marjolin ulcer presents in an area of previously traumatised, chronically inflamed or scarred skin

Answer 126

``` Variable appearance: -Ulcerated -Hyperkeratotic -Crusted or scaly -Non-healing lesion *often on sun-exposed areas Palpate for local lymphadenopathy- metastatic disease ```

Answer 127

Skin biopsy: Confirms malignancy (full thickness keratinocyte atypia) and distinguishes it from other skin lesions Fine-needle aspiration or lymph node biopsy: Only necessary if suspicion of metastasis Staging: CT and/or MRI, PET scanning: lymphadenopathy and/or visceral nodules Bloods: normal unless metastasis

Answer 128

The most common malignancy in young adult men (15 to 44 years of age), and highly curable when diagnosed early

Answer 129

All germ cell tumours are believed to start developing during fetal development and to progress through a non-invasive stage called intratubular germ cell neoplasia unclassified (carcinoma in situ).

Answer 130

1. Seminoma 55% (30–65yrs) 2. Non-seminomatous germ cell tumour, 33% (previously teratoma; 20–30yrs) 3. Mixed germ cell tumour 4. Lymphoma- most common in men > 50 (9-12%) * *Around 90–95% of testicular tumours are germ cell tumours, mainly teratomas and seminomas

Answer 131

- Cryptorchidism (undescended testis): relative risk of 2 to 17 times for malignancy, highest risk in abdominal and bilateral undescended testes. Seminoma (predominant type of tumour) - Gonadal dysgenesis: changes in the gonadotrophin feedback regulation - FH of testicular cancer - PMH of testicular cancer: risk of developing a second primary cancer in the contralateral testis - Testicular atrophy: Can be secondary to trauma, hormones, and viral orchitis (mainly at a younger age) - HIV infection - White ethnicity, aged 25-35 years

Answer 132

Testicular cancer accounts for 1% of all cancers, and less than 1% of all cancer death in males In the UK 1,400 men are diagnosed with testicular cancer every year, with the highest incidence in those aged 25–35 years White men have the highest incidence, compared with African and Asian men

Answer 133

Testicular mass (usually painless (>85%), 10% present with acute pain) Extratesticular manifestations: (5-10%) at the time of presentation. These include: -Bone pain (skeletal metastasis) -Lower extremity swelling (venous occlusion) -Supraclavicular lymph nodes -Symptoms and/or signs of hyperthyroidism -Gynaecomastia

Answer 134

Testicular mass: About 55% of cases occur on the right side. In up to 2% of cases, testicular cancer is bilateral Extratesticular manifestations: -Bone pain (skeletal metastasis) -Lower extremity swelling (venous occlusion) -Supraclavicular lymph nodes -Symptoms and/or signs of hyperthyroidism -Gynaecomastia

Answer 135

*Principal test (sensitivity 100%): Ultrasound of testis: testicular mass Bloods (tumour markers): -beta human chorionic gonadotrophin (B-hcg): >0.7 IU/L -alpha- fetoprotein (AFP): >25 microgram/L -lactate dehydrogenase (LDH): >25 U/L Imaging: CT abdomen and pelvis: enlarged retroperitoneal lymph nodes MRI: staging tool CXR: mediastinal and lung mass suggestive of metastasis Excision biopsy

Answer 136

The most common endocrinological malignancy and 4 types account for more than 98% of thyroid malignancies: - Papillary - Follicular - Anaplastic - Medullary

Answer 137

Genetic alterations are thought to underlie thyroid cancers (Family history is a strong RF) - Papillary: BRAF mutations - Follicular: PPAR gamma gene - Medullary: mutations in a tyrosine kinase receptor gene

Answer 138

The most common endocrinological malignancy, the rates of new thyroid cancer cases have been rising over the past few decades More common in women than in men Most likely to be diagnosed between the ages of 45 to 54 years

Answer 139

Neck lump Hoarseness Dyspnoea Dysphagia

Answer 140

Palpable thyroid nodule (most common in early adulthood) Tracheal deviation: enlarged goitre Cervical lymphadenopathy suggestive of neck metastasis

Answer 141

Initial screening test: TSH, often normal Ultrasound neck: micro-calcifications, a more-tall-than-wide shape, hypervascularity, marked hypoechogenicity, or irregular margins Fine needle biopsy: cytology of malignant features (variations in appearance), anapaestic (poorly differentiated) Laryngoscopy: paralysed vocal cord is highly suggestive of malignancy Others: -Free T3/T4: normal -Iodine thyroid scan/uptake: ordered for patients with overt or subclinical hyperthyroidism (Hot nodules: hyperfunctioning -almost always benign, cold nodule: hypofunctioning- most are benign but malignant nodules are also cold) -CT neck: lymphadenopathy -Serum calcitonin (parafollicular cells, opposes the action of parathyroid hormone): Normal is <10 nanograms/L, high in medullary cancer

Answer 142

A combination of metabolic and electrolyte abnormalities occurring spontaneously or following initiation of chemotherapy resulting in: -hyperkalaemia -hyperphosphataemia -secondary hypocalcaemia -hyperuricaemia -acute renal failure Characterised by rapid cell death (excessive cell lysis)

Answer 143

Appears in haematological malignancies characterised by a high proliferating rate, in particular non-Hodgkin's lymphoma, acute lymphocytic leukaemia, and acute myeloid leukaemia The risk of developing TLS is increased: -if the tumour consists of rapidly dividing cells -if the bulk of the disease is high -if response to treatment is good *Pre-existing renal impairment and/or dehydration are predisposing factors

Answer 144

Incidence of TLS is unknown- more prevalent in malignancies with high proliferating rates, tumour burden, and chemosensitivity Males and females of any age or ethnic group can be affected *Advanced age may increase the risk of developing TLS due to reduced glomerular filtration rate

Answer 145

``` Nausea and vomiting Diarrhoea Muscle weakness/ cramps Anorexia Lethargy Paraesthesia Oliguria/anuria/haematuria ```

Answer 146

Hypertension/ hypotension Lymphadenopathy Splenomegaly Peripheral oedema

Answer 147

Bloods: -Serum uric acid: >476 micromol/L (8 mg/dL) or a 25% increase -Serum phosphate: 25% increase -Serum Potassium: >6.0 mmol/L (6 mg/L) or 25% increase -Serum calcium: <1.75 mmol/L (7 mg/dL) or 25% decrease -Serum creatinine: >1.5 times upper limit of normal -Serum urea: elevated with acute renal failure -FBC: High levels of pretreatment WBC increase the likelihood of tumour lysis syndrome -Lactate dehydrogenase: elevated Urine pH: ≤5 Consider: ECG: arrhythmia with hyperkalaemia, hyperphosphataemia, or hypocalcaemia

Cancer Flashcards

(171 cards)