Cancers Flashcards
(46 cards)
1
Q
Risk factors of lung cancer
A
asbestos scarring from eg. tb smoking air polution radon gas arsenic
2
Q
Presentation of lung cancer
A
- haemoptysis, pleuritic chest pain, SOB, unexplained cough for 3 weeks
- 10% weight loss in 6 months, night sweats, fevers, fatigue, anaemia (iron def)
- recurrent chest infections, not better with antibiotics
- hoarse voice = recurrent laryngeal nerve
- cachexia, clubbing, lymphadenopathy
3
Q
Investigations for lung cancer
A
- 1st line CXR (mass + raised hemidiaphragm from phrenic nerve)
- Endobronchial US guided bronchcoscpy for biopsy
- Serum calcium (raised if PTHrP from squamous)
- U&Es (na for siadh in small cell)
- FBC = anaemia
- LFTs
- pulse ox and ecg
- Contrast CT CAP (adrenals + liver for mets!)
- spirometry
4
Q
When would you refer suspected lung cancer? + areas of spread
A
Liver, adrenals, bone, brain spread
2ww cxr if >= 40 and 2 of the following (1 if ever smoked)…
cough/fatigue/sob/chest pain/anorexia/weight loss
OR >40 and 1 of the following…
recurrent chest infections/ finger clubbing/ >6 week lymphadenopathy/ chest signs consistent with lung cancer/ thrombocytosis
2ww cancer pathway if
- > = 40 and unexplained haemoptysis
- suspicious cxr
5
Q
Management of non small cell lung cancer
A
stage 1-3
- lobectomy (or wedge resection in reduced lung function)
- neo-adjuvant chemo
- adjuvant chemo and radio for stage 2 and 3
- or can use stereotactic ablative radiotherapy as curative therapy
stage 4
- immunotherapy, targeted therapy, chemotherapy
- palliative = chemo and radiotherapy for mets and symptoms
6
Q
Management of small cell lung cancer
A
surgery if it is local but most present as mets
so do palliative chemo
do prophylaxis cranial irradiation
7
Q
Complications of small cell lung cancer
A
- siadh
- lambert eaton syndrome
- cushings
8
Q
Complications of non-small cell lung cancer
A
- hypertrophic pulmonary osteoarthropathy = squamous and adeno
- PTHrP from squamous (hypercalcaemia)
most pancoast are non small cell
- horners if sympathetic compression
- hoarseness if recurrent laryngeal nerve compression
- svco
- arm pain from brachial plexus compression
- vagus nerve compression
9
Q
Risk factors for breast cancer (male too)
A
Male = gynaecomastia, klinefelters, BRCA1/2, fhx prostate cancer, cirrhosis, radiation
Female =
- nulliparity, never breastfed
- increased exposure to oestrogen (early menarche, late menopause, hrt (combined), cocp, obesity or high fat diet, first baby >30)
- fhx of relative <50 years old
- older age
- BRCA1,2
- p53 mutation
- chest radiation
10
Q
Presentation of breast cancer and some other differentials of breast lumps
A
- painless fixed hard lump in the breast
- skin changes like dimpling
- nipple discharge or bleeding
- nipple changes or inversion
- Pagets disease of the nipple (ductal carcinoma in situ)
- oedema or erythema or colour changes
- Ulceration is a late sign
- lump in the axilla
fibroadenomas, lipomas, phillodes tumours, fat necrosis
11
Q
When would your refer suspected breast lump?
A
> =30 2ww
unexplained lump in the breast or axilla
> =50 2ww
unexplained skin or unilateral nipple changes suggestive of malignancy (discharge, retraction, etc)
<= 30 Not urgent
unexplained breast lump
12
Q
What is the breast screening available?
A
47-73 every 3 years
Mammogram
also for those with brca1/2, fhx of first degree relative <50 years old, previous cancer
13
Q
How would you investigate breast cancer?
A
Triple assessment
- mammogram (<35 do US as there is thicker breast tissue)
- breast examination
- fine needle aspiration (cytology) or core needle biopsy (histology)
- CTCAP
- TNM staging
- Receptor status (her, oestrogen, progesterone)
- LFTs, U&Es, FBC
- bone scan
14
Q
What are the types of breast cancer?
A
Ductal carcinoma in situ
- microcalcifications on mammogram
- associated with pagets disease
Invasive ductal carcinoma
- invaded through basement membrane
Lobular carcinoma in situ
- may be no lump or discharge, hard to detect
- often multifocal and bilateral
Invasive lobular carcinoma
15
Q
How would you manage breast cancer?
A
Wide local excision or mastectomy
- can do neoadjuvant chemo to reduce tissue
- adjuvant chest wall radiation afterwards
- can do sentinel node biopsy or axillary node clearance if indicated
- adjuvant chemo improves survival
Advanced breast cancer
- chemo and radiotherapy +/- targeted therapies
- HER2 +ve = herceptin (tratuzumab)
- Oestrogen +ve = SERM tamoxifen for premenopausal, Aromatase inhibitor letrozole or anostrozole for post menopausal
- If triple negative = chemo with platinum and anthracycline
16
Q
Where does breast cancer spread?
A
lungs, liver, bones
17
Q
What are some risk factors for colorectal cancer?
A
- low fibre
- high processed meat, high fats, alcohol, smoking
- IBD
- diabetes
- old, male
- familial adenomatous polyposis, HNPCC
18
Q
How does colorectal cancer present? (L,R,Rectal)
A
Sister Mary Joseph Nodule = lymphadenopathy
R = caecal
- faecal occult bleeding
- iron def anaemia/ fatigue
- appendicitis
- RIF mass and abdo pain
L = sigmoid
- colicky pain
- LIF mass
- tenesmus
- bowel changes (diarrhoea, mucus), obstruction etc
Rectal
- rectal mass
- tenesmus then persistent pain
- rectal bleeding
- if invades anal sphincter = incontinence
- can invade into sacral plexus = back pain
19
Q
When would you refer for suspected colorectal cancer?
A
- palpable rectal mass
- man with iron deficiency
- non menstruating woman with iron deficiency
- > 40 and unknown rectal bleeding or changes in bowel habit for >6 weeks
- > 50 and unknown rectal bleeding for >6 weeks
20
Q
How would you investigate for colorectal cancer?
A
- 1st line = flexi or rigid colonoscopy + biopsy
- barium enema if that was not possible
- Faecal Occult blood
- FBC, U&Es, LFTs
- Cea to monitor treatment
- CTCAP
- MRI for rectal cancers
21
Q
What is the colorectal screening system available?
A
60-75 every 2 years
faecal immunochemistry test
22
Q
How would you manage colorectal cancer?
A
Dukes Scale and TNM
Dukes A-C
- surgical resection (use laxatives before and prophylactic antibiotics after)
- emergency = hartmanns
- FOLFOX adjuvant chemo for B and C
Radiotherapy for rectal cancer +/- chemo
Obstruction = decompression colostomy or endoscopic stenting
23
Q
What are some risk factors for prostate cancer?
A
BRCA 2
fhx of prostate cancer, breast cancer, colorectal
Black, male, high bmi, old age
24
Q
How would prostate cancer present?
A
LUTS (hesitancy, resistance) ED, haematospermia haematuria lower back pain asymptomatic with a randomly raised PSA anorexia, weight loss, lethargy
25
When would you refer for prostate cancer?
Do a PSA and DRE for...
men with LUTS, haematuria, ED
Refer for 2ww if...
- PSA>=3 in a <70 year old
- PSA>5 in >70s
- abnormal DRE
26
What kinds of things can raise a PSA
Urinary retention, BPH, Chronic prostatitis, prostate cancer
Vigorous exercise, recent ejaculation
recent medical procedure like TURP or DRE or catheterisation
27
How would you investigate for prostate cancer?
- PSA
- free PSA (if free PSA<15% and PSA is high, suggestive of malignancy)
- DRE (BPH is smooth generally enlarged, chronic prostatitis is boggy and tender, cancer is craggy hard irregular nodular)
- 1st line is Multiparametric MRI of prostate (Linkerts scale if >=3 then do a biopsy too for TNM and Gleason staging)
- Used to be a Trans Rectal US Guided Biopsy (higher infection than trans perineal)
- FBC, U&Es (obstruction or hydronephrosis), LFTs
- Xray for osteosclerotic lesions, bone scan
- CT CAP
28
How would you manage prostate cancer
PSA<10, Gleason<=6, T1-T2a
- watchful waiting (dres, psa)
- active surveillance (dres, psa, biopsy)
- radical prostatectomy or curative external beam radiotherapy +/- brachytherapy
PSA 10-20, Gleason 7, T2b
- active surveillance
- radical prostatectomy or curative EBRT+/- brachy
PSA>20, Gleason 8-10, >=T2c
- radical prostatectomy or curative EBRT+/-brachy
- hormonal for mets
Hormonal
- LHRH agonists like goserelin (zolidex) but give androgen antagonist first to avoid testosterone spike
- or you could do an bilateral orchidectomy to block androgens
- Androgen receptor antagonists like Bicalutamide
Palliative
bisphosphonates and radiotherapy
29
What are some risk factors for myeloma?
- radiation
- long term hair dye exposure
- petrochemical industries or agriculture industry exposure
30
How would myeloma present?
CRABBI
Calcium is high
- osteoclast overactivity, results in bone pain and pathological fractures.
- stones, moans, bones, psychic groans, polydipsia etc.
Renal dysfunction
- nephrocalcinosis and nepholithiasis (hyperuricaemia) don't help
- light chains get deposited in renal tubules and cause damage
Anaemia
- pancytopaenia due to bone marrow overcrowding, stopping erythropoiesis
Bones
- bone pain due to osteoclast overactivity and bone marrow overcrowding
- Lytic lesions seen on xray
Bleeding
- pancytopaenia due to bone marrow overcrowding
Infections
- reduced production of normal immunoglobulins
31
When would you refer about myeloma?
do Ca2+, FBC, ESR, PV if >60 and...
unknown pathological fractures or unexplained back pain
do Bence Jones proteins or serum electrophoresis within 48 hours if >=60 and...
- unknown hypercalcaemia/leukopenia AND suspicious myeloma presentation
do Bence Jones proteins or serum electrophoresis within 48 hours for anyone if...
- PV and ESR were suspicious AND suspicious myeloma presentation
do 2ww myeloma if...
- Bence Jones and serum electrophoresis were suspicious for myeloma
32
How would you investigate for myeloma?
- FBC, U&Es, LFTs, Ca2+, PV, ESR, LDH
- Bone marrow aspiration and trephine biopsy = plasma infiltration of bone marrow
- Serum protein electrophoresis (monoclonal paraproteins) + Immunofixation (Iga or igg) = raised monoclonal IgG and IgA production
- Urine protein electrophoresis for Bence Jones proteins
- peripheral blood film = Rouleaux formation (due to increased paraproteins)
- Xray = lytic lesions like "raindrop skull"
- DEXA Bone scan
- Whole body MRI
33
What results are diagnostic for myeloma?
- monoclonal proteins present in serum or urine from electrophoresis
- monoclonal plasma cells in bone marrow >10%
- end organ damage eg. hypercalcaemia, lytic lesions, renal damage
34
How would you manage myeloma?
Stem cell transplant (autologous best but risk of neutropenic sepsis)
- Bortezomib + dexmethasone induction therapy
- monitor for 3 months after with electrophoresis and bloods
if relapse after initial therapy
- 1st line Bortezomib
- or repeat stem cell transplant
Symptom management
- anaemia = erythropoietin analogues, blood transfusions
- infection = influenza vaccine, prophylaxis antibiotics, immunoglobulin replacement therapy
- bone pain = bisphosphonates (+ppi), vit d, calcium
- lytic lesions already happened = kyphoplasty
- VTE prophylaxis
35
What are some risk factors for Hodgkins and Non-Hodgkins lymphoma?
both:
- HIV, EBV, Ra, sarcoidosis, autoimmune
- FHX
non-hodgkins specific:
- MALT = h pylori
- Hep B, C
- hx chemo or radio
- exposure to pesticides and trichloroethylene
- old age
36
How would a hodgkins and non-hodgkins lymphoma present? compare and differentiate
Hodgkins
- bimodal distribution (20s then 70s)
- painless asymmetrical lymphadenopathy non tender
- pain on drinking alcohol
- B symptoms prominent like weight loss, night sweats, fatigue, malaise
Non Hodgkins
- painless asymmetrical lymphadenopathy non tender
- B symptoms later on
- Extranodal presentations like hepatosplenomegaly, testicular enlargement, abdo pain, pancytopaenia, SOB
37
When would you refer for query lymphoma?
Hodgkins
- unexplained lymphadenopathy (consider B symptoms and alcohol pain)
Non Hodgkins
- unexplained lymphadenopathy or splenomegaly (consider B symptoms)
38
How would you investigate for hodgkins vs non hodgkins lymphoma?
Hodgkins
- FBC, U&Es, LFTs normal, LDH high, ESR high
- excisional Lymph node biopsy = Reed Sternberg Cells
- CXR = mediastinal widening
- CT CAP to stage
Non hodgkins
- FBC, U&Es, LFTs, LDH, ESR
- excisional Lymph node biopsy
- Urea breath test for H Pylori (MALT)
- Microscopy shows starry sky appearance (Burkitts)
- Bone marrow aspiration and trephine biopsy
- Immunophenotyping (B or T cells)
- Immunoglobulin tests (Igm or Igg)
- HIV test as it is a risk factor
- CT CAP to stage
39
How would you manage hodgkins and non hodgkins lymphoma?
Ann Arbor staging
```
Hodgkins:
ABVD Chemo (adriamycin, bleomycin, vinblastine, dascarbazine)
```
Non Hodgkins:
- Radiotherapy for localised disease
- Stem cell transplant
- CHOP Chemo + rituximab (monoclonal antibody) for high grade
- flu/pneumococcal vaccines
- prophylactic antibiotics for neutropenia
40
what are some risk factors for acute vs chronic leukaemia?
AML =
41
what are some risk factors for acute vs chronic leukaemia?
Acute:
radiation, benzene, genetic mutations like downs and klinefelters
```
Chronic:
Philadelphia chromosome (BRC-ABL), etc
```
42
how would ALL and AML present? how would CML and CLL present?
ALL = kids!
- lymphadenopathy, hepatosplenomegaly, testicular enlargement
- bone pain and bone marrow failure = pancytopaenia (petechiae, bleeding, bruising, infection, fatigue)
AML
- bone marrow failure and pancytopaenia signs
- violaceous skin lesions
CLL
- typically asymptomatic
- pancytopaenia
- painless lymphadenopathy more marked than CML
- very big hepatosplenomegaly
CML typically presents in chronic phase
- SOB (anaemia), dyspnoea, abdo discomfort, hepatosplenomegaly, lymphadenopathy
- gout due to increased purine breakdown
- bruising, bleeding, pallor, infection, fatigue
43
How would you investigate acute leukaemias and how would AML and ALL vary?
peripheral blood films =
- ALL = leukoblasts
- AML = Auer rods
FBC (low hb, low platelets, high wcc)
U&Es, LFTs, LDH, ESR
Bone marrow aspirate =
- low erythropoiesis and low megakaryocytes
- Flow Cytometry Immunophenotyping for myeloid or lymphoid
- Fluorescent Insitu Hybridisation for mutations like Jak2
ALL has mediastinal widening on CXR
44
How would you investigate chronic leukaemias and how would CML and CLL vary?
FBC = low rbc, low platelets, high wcc
(CLL wcc is very very high)
Blood film
- CLL = smudge cells or smear cells
- CML = neutrophilia with myeloid precursor like blasts
Bone marrow aspiration =
- CLL = high lymphocytic infiltration
- CML = increased cellularity
Immunophenotyping
Fluorescent insitu hybridisation =
- CLL = trisomy 12, 13q deletion, mutated IgVH
- CML = philadelphia chromosome (BRC-ABL)
Urate raised
45
How would you manage acute leukaemias?
Remission induction using chemo to destroy tumour= huge bone marrow hypoplasia
Then once haematopoesis is acheived, remission consolidation = huge bone marrow hypoplasia
After remission, watch for 3 years. then continue to watch ALL patients closely
AML = high risk are only give treatment if they have an HLA match for bone marrow transplant
ALL = need intrathecal chemo prophylaxis as soon as blasts are cleared from blood
Symptom management
- bleeding = prophylactic platelet transfusion (esp AML)
- fresh frozen plasma to maintain APTT and INR<1.5x normal
- cryoprecipitate to keep fibrinogen >1.5g/dl
- Norethisterone for women to avoid menorrhagia
- infection = Prophylactic antibiotics and handwashing education
- hyperuricaemia = prophylactic allopurinol, rasburicase, hydration
46
How would you manage chronic leukaemias?
CML = ph chromosome
- 1st line = Imatinib for chronic phase
- if no ph chromosome then interferon a
- SOKAL index for prognosis
CLL
- 1st line = Rituximab
- Rai or Binet staging systems
- watch for richters syndrome (EBV involved) --> NHL
