Oncology Flashcards
1
Q
What is radiotherapy?
A
A treatment method that uses high-energy radiation to kill or damage cancer cells.
2
Q
How does radiotherapy work to treat cancer?
A
It damages the DNA within cancer cells, preventing them from growing and dividing.
3
Q
What are the two main types of radiotherapy?
A
- External beam radiotherapy (EBRT)
- Brachytherapy
4
Q
What is external beam radiotherapy (EBRT)?
A
Delivers radiation from an external source to the tumour site, typically using a linear accelerator.
5
Q
What is brachytherapy?
A
Involves placing radioactive material directly inside or near the tumour.
6
Q
What is the advantage of brachytherapy?
A
Allows for high-dose radiation delivery to the tumour while minimising exposure to surrounding healthy tissue.
7
Q
What is 3D Conformal Radiotherapy (3DCRT)?
A
A technique that uses three-dimensional imaging to shape radiation beams to match the tumour’s shape.
8
Q
What are the advantages of 3D Conformal Radiotherapy (3DCRT)?
A
- More precise targeting of the tumour
- Minimises exposure to healthy tissues
- Reduces side effects
9
Q
What is Intensity-Modulated Radiotherapy (IMRT)?
A
A type of EBRT that modulates the intensity of radiation beams to conform to the tumour shape.
10
Q
How does IMRT improve treatment precision?
A
Delivers radiation from multiple angles with varying intensity, allowing higher doses to the tumour while sparing healthy tissues.
11
Q
What role does Image-Guided Radiotherapy (IGRT) play?
A
Enhances treatment accuracy by using imaging technologies to ensure precise targeting of the tumour.
12
Q
How does Stereotactic Radiosurgery (SRS) differ from conventional radiotherapy?
A
Delivers high doses of radiation with sub-millimetre precision in one or a few sessions.
13
Q
What type of tumors is SRS typically used for?
A
Small, well-defined tumors, such as those in the brain.
14
Q
What is proton therapy?
A
A radiotherapy technique that uses protons instead of X-rays.
15
Q
What is the Bragg peak in proton therapy?
A
A unique property where protons deliver the maximum dose at a specific depth, reducing exposure to healthy tissues.
16
Q
What steps are involved in the treatment planning process for radiotherapy?
A
- Imaging
- Target Volume Definition
- Dose Calculation
- Simulation
- Delivery
17
Q
What is Planning Target Volume (PTV)?
A
Includes the Clinical Target Volume (CTV) and an additional margin for tumor movement and positioning variations.
18
Q
How does adaptive radiotherapy differ from standard radiotherapy?
A
Adjusts the treatment plan based on changes in the tumour and patient anatomy during treatment.
19
Q
What are the benefits of adaptive radiotherapy?
A
- More precise targeting
- Reduces side effects
- Improves treatment effectiveness
20
Q
For which types of cancer is brachytherapy commonly used?
A
- Prostate cancer
- Cervical cancer
- Breast cancer
21
Q
What is the purpose of palliative radiotherapy?
A
To alleviate pain and improve the quality of life in advanced cancer patients.
22
Q
What role do fiducial markers play in radiotherapy?
A
Help guide and verify the precise targeting of radiation beams.
23
Q
What is the function of Cone Beam CT (CBCT) in radiotherapy?
A
Provides real-time, 3D imaging for precise positioning and verification.
24
Q
How is radiotherapy tailored for patients with low performance status?
A
Palliative and short-course radiotherapy regimens are used to minimize treatment burden.
25
What factors influence the choice of radiotherapy technique?
* Type and stage of cancer
* Tumor location and size
* Patient health status
* Previous treatments
* Patient preferences
26
What are common acute side effects of radiotherapy?
* Skin irritation
* Fatigue
* Nausea
* Localised pain
27
What are common long-term side effects of radiotherapy?
* Fibrosis
* Secondary cancers
* Organ-specific issues
28
How do radiotherapy teams minimize radiation exposure to healthy tissues?
Use advanced imaging, precise treatment planning, and techniques like IMRT and IGRT.
29
What are some emerging trends in radiotherapy?
* Proton therapy
* Adaptive radiotherapy
* Integration of artificial intelligence
* Novel imaging techniques
30
What are potential benefits of integrating artificial intelligence in radiotherapy?
* Improved treatment accuracy
* More personalised treatment.
* Enhanced decision-making
31
What are challenges of integrating artificial intelligence in radiotherapy?
* Data privacy concerns
* Need for extensive validation
* Integration into existing workflows
32
What are resection margins, and why are they important in surgical excision of a tumour or lesion?
Resection margins refer to the edges or borders of the tissue removed during the surgical excision of a tumour or lesion. They are crucial because they help determine whether the entire tumour has been removed or if residual cancerous or diseased cells remain.
33
How does the status of resection margins influence the likelihood of local recurrence?
The status of resection margins influences the likelihood of local recurrence because clear or negative margins indicate that the tumour has likely been completely removed, reducing the risk of recurrence. Positive margins suggest that some tumour cells may still be present, increasing the risk of recurrence.
34
What is the difference between negative (clear) margins and positive (involved) margins?
Negative (clear) margins mean no tumour cells are present at the edges of the removed tissue, indicating that the resection likely encompassed all the tumour cells. Positive (involved) margins mean tumour cells are present at or very close to the edge of the tissue, suggesting that cancerous tissue may still be in the body and may require further treatment.
35
What are close margins, and why might they be concerning?
Close margins mean tumour cells are close to, but not at, the edge of the resected tissue. This can be concerning because it might indicate a higher risk of recurrence and may prompt further treatment depending on the tumour type and clinical scenario.
36
Why is achieving negative margins particularly important in breast cancer surgery?
Achieving negative margins in breast cancer surgery is important to reduce the risk of recurrence. The margin size requirements may vary based on whether breast-conserving surgery or mastectomy was performed.
37
How do margin requirements differ between colorectal cancer and soft tissue sarcomas?
For colorectal cancer, negative radial margins are critical to lower recurrence risks. In soft tissue sarcomas, a 2-cm margin is generally recommended to reduce recurrence.
38
What is the purpose of intraoperative pathology (frozen section) in assessing resection margins?
Intraoperative pathology (frozen section) is used during surgery to quickly assess margins. If margins are positive, the surgeon may immediately resect additional tissue to achieve negative margins.
39
How does permanent pathology (final margin assessment) contribute to post-surgical treatment planning?
Permanent pathology (final margin assessment) involves a thorough microscopic examination of the resected specimen after surgery to confirm the margin status. This helps guide post-surgical treatment planning.
40
What are the typical margin size requirements for breast cancer and colorectal cancer?
For breast cancer, typically, no tumour cells should be on the inked margin surface. For colorectal cancer, margins of at least 5 cm are usually recommended to reduce recurrence.
41
Why might the required distance for a "clear" margin vary based on tumour type and location?
The required distance for a "clear" margin varies based on tumour type and location because different cancers have different patterns of spread and recurrence risks.
42
How do positive margins affect the need for additional treatments such as chemotherapy or radiation therapy?
Positive margins often necessitate additional treatments such as chemotherapy or radiation therapy to reduce the likelihood of recurrence.
43
Why is margin status considered a strong prognostic indicator?
Margin status is considered a strong prognostic indicator because it provides information about the completeness of tumour removal and the potential need for further treatment.
44
What is the most common type of prostate cancer, and from which cells does it originate?
he most common type of prostate cancer is adenocarcinoma, which originates from the gland cells that produce prostate fluid.
45
How do adenocarcinomas vary in their aggressiveness?
Adenocarcinomas can vary in their aggressiveness, with some growing very slowly and others more rapidly.
46
What type of prostate cancer originates from neuroendocrine cells and is known for its aggressive nature?
Small cell carcinoma originates from neuroendocrine cells and is known for its aggressive nature.
47
Why might small cell carcinoma not elevate PSA levels?
Small cell carcinoma might not elevate PSA levels because it behaves differently from typical prostate adenocarcinomas and does not produce PSA in significant amounts.
48
Where does transitional cell carcinoma typically start, and how does it spread to the prostate?
Transitional cell carcinoma typically starts in the bladder and spreads to the prostate.
49
Why is transitional cell carcinoma considered less common and more challenging to treat?
Transitional cell carcinoma is considered less common and more challenging to treat due to its origin in the bladder and its spread pattern, which can complicate treatment strategies.
50
What are the two types of neuroendocrine tumors mentioned, and how do they differ in terms of cell origin?
The two types of neuroendocrine tumors mentioned are small cell and large cell neuroendocrine carcinomas. They differ in terms of cell origin, with both arising from neuroendocrine cells but exhibiting different cellular characteristics.
51
What makes neuroendocrine tumors particularly aggressive?
Neuroendocrine tumors are particularly aggressive due to their rapid growth and tendency to spread quickly.
52
From which tissues do sarcomas originate in the prostate?
Sarcomas originate from the connective tissues of the prostate.
53
Why might sarcomas require different treatment strategies compared to adenocarcinomas?
Sarcomas might require different treatment strategies compared to adenocarcinomas because they arise from different tissue types and often exhibit more aggressive behavior.
54
What are the two initial assessments recommended by NICE for suspected prostate cancer?
The two initial assessments recommended by NICE are the Digital Rectal Examination (DRE) and the Prostate-Specific Antigen (PSA) test.
55
What imaging technique does NICE recommend as the first-line investigation for suspected clinically localised prostate cancer?
NICE recommends multiparametric MRI (mpMRI) as the first-line investigation for suspected clinically localised prostate cancer.
56
What type of biopsy is recommended if mpMRI results suggest the presence of cancer?
If mpMRI results suggest the presence of cancer, an MRI-targeted biopsy is recommended.
57
How are prostate cancer patients categorised into risk groups according to NICE guidelines?
Patients are categorised into risk groups (low, intermediate, high) based on:
PSA levels
Gleason score
The extent of cancer spread.
58
What scans are recommended for patients with high-risk or locally advanced prostate cancer to check for cancer spread?
For patients with high-risk or locally advanced prostate cancer, CT scans and bone scans are recommended to check for the spread of cancer to other parts of the body.
59
In what cases might genetic testing be recommended according to NICE guidelines?
Genetic testing may be recommended in certain cases to identify specific mutations that could influence treatment options and prognosis.
60
What does NICE emphasise regarding patient information and support?
NICE emphasises the importance of providing patients with clear, tailored information about their diagnosis and treatment options, along with decision aids and support from healthcare professionals to help patients make informed choices.
61
Name two performance status systems used in cancer patients.
ECOG (Eastern Cooperative Oncology Group)
Karnofsky
62
What cancers typically cause SVC syndrome?
Lung cancers.
Non-Hodgkin lymphoma is another potential cause.
63
Neutropenic sepsis typically occurs when the neutrophils count drops below ___________.
0.5*10^9/L
64
Risk factors for developing hepatocellular carcinoma.
Aflatoxins
Pyrrolizidines
Hepatitis (80% of cases globally)
Iron overload
Type 2 DM
NASH
Alpha-1-antitrypsin deficiency
Wilson’s disease
Haemophilia
65
Most common subtype of malignant melanoma.
Superficial spreading melanoma (60-70% of cases).
66
Suggest an important prognostic indicator in melanoma.
Breslow’s thickness.
67
What is the underlying pathophysiology of LEMS?
Autoantibodies against presynaptic voltage-gated calcium channels. These calcium channels are crucial for acetylcholine release.
68
Neutropenic sepsis drug of choice.
Piperacillin/tazobactam (Tazocin)
69
ECOG
- 0: Fully active, able to carry on all pre-disease performance without restriction.
- 1: Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature.
- 2: Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours.
- 3: Capable of only limited self-care; confined to bed or chair more than 50% of waking hours.
- 4: Completely disabled; cannot carry on any self-care; totally confined to bed or chair.
- 5: Dead.
70
Over 43,000 new lung cancers are diagnosed each year in the UK. A full time GP is likely to diagnose approximately one person with lung cancer each year. The 5-year survival is below __________.
10%
71
Test for SVC syndrome.
Pemberton test.
72
Where else can mesotheliomas arise, other than in the lungs?
Peritoneum.
Less commonly:
Pericardium
Tunica vaginalis
73
What imaging modality is most appropriate when initially investigating for mesothelioma?
Plain chest X-ray.
74
Complete: Mesothelioma is seen in both sexes, though currently _____ of new mesotheliomas occur in males.
85%
75
A chest X-ray suggests mesothelioma. What is the best course of action?
2-week-wait referral. Urgent.
76
Most common primary malignant brain tumour in adults.
Glioblastoma multiforme.
77
Most common primary brain tumour overall.
Meningioma.
78
Single ring-enhancing lesion in a patient with AIDs. What type of malignancy is this likely to be?
Primary CNS lymphoma.
79
What is the primary function of the mesothelium in the body?
The mesothelium acts as a protective barrier and provides a lubricated surface to reduce friction between moving organs and tissues.
80
Suggest chemotherapeutic agents that can be used in the treatment of mesothelioma.
Pemetrexed+cisplatin (or carboplatin).
Pemetrexed+cisplatin trade name=Alimta.
81
Alkylating agent mechanism of action.
Bifunctional Alkylation: The drug forms an irreversible bond between two base pairs in the DNA chain, causing cytotoxic effects that can destroy or poison the cell.
Monofunctional Alkylation: The drug reacts with just one strand of a base pair, separating it from its partner and eventually causing it and its attached sugar to break away from the DNA molecule
82
Tumour marker for HPV-associated cancer.
p16
83
Bone metastases treatments.
NSAIDs.
Radiotherapy for pain.
Bisphosphonates.
Denosumab.
83
Hypercalcaemia of malignancy causes.
Local osteolytic activity.
Elevated calcitriol.
Tumour secretes parathyroid hormone-related peptide.
84
Denosumab mechanism of action.
Denosumab is a monoclonal antibody used to treat conditions associated with bone loss, such as osteoporosis, bone metastases, and certain cancers. Its mechanism of action involves targeting the RANK/RANKL pathway, which plays a critical role in bone remodeling and resorption.
85
Calcium levels in hypercalcaemia.
Above 2.6 mmol/L.
86
Serum corrected calcium.
Serum corrected calcium is a calculation that adjusts measured total calcium levels in the blood to account for the amount of calcium bound to albumin.
87
Van Nuys Prognostic Index.
A numerical algorithm that helps predict the likelihood of a breast tumour recurring after the excision of ductal carcinoma in situ (DCIS).
88
In someone with hypercalcaemia, which other electrolytes should you check?
Magnesium
Phosphate
89
DCIS can be classified as stage ____ breast cancer.
0
90
Primary tool for detecting DCIS.
Mammography
91
For people having investigations for early and locally advanced invasive breast cancer:
>Perform pretreatment ultrasound evaluation of the axilla, and
>If abnormal lymph nodes are identified, perform ultrasound-guided needle sampling.
92
Should genetic testing for BRCA1 and BRCA2 mutations be offered to women under 50 years with triple-negative breast cancer, including those with no family history of breast or ovarian cancer?
Yes.
93
How is DCIS typically detected?
DCIS is often detected during a routine mammogram as part of breast cancer screening.
94
What are the common symptoms of DCIS?
Common symptoms include a breast lump and bloody nipple discharge, although DCIS often causes no symptoms.
95
What imaging technique is primarily used to diagnose DCIS?
Mammography is the primary imaging technique used to diagnose DCIS.
96
What are microcalcifications, and how are they related to DCIS?
Microcalcifications are tiny specks of calcium in the breast tissue that can be seen on a mammogram and are often an early sign of DCIS.
97
What additional diagnostic tests might be performed if a mammogram indicates an area of concern?
Additional diagnostic tests may include a breast ultrasound and a biopsy to further evaluate the area of concern.
98
What is breast-conserving surgery (lumpectomy), and how is it used to treat DCIS?
Breast-conserving surgery (lumpectomy) involves removing the DCIS along with a small margin of surrounding healthy tissue. It is often followed by radiation therapy to eliminate any remaining cancer cells.
99
When might a mastectomy be recommended for DCIS?
A mastectomy might be recommended if DCIS is widespread or if there are multiple areas of DCIS in the breast.
100
How does radiation therapy help in the treatment of DCIS?
Radiation therapy helps to destroy any remaining cancer cells in the breast after a lumpectomy.
101
Under what circumstances might hormone therapy be recommended for DCIS?
Hormone therapy might be recommended if the DCIS is hormone receptor-positive to reduce the risk of recurrence.
102
What is the general prognosis for someone diagnosed with DCIS?
The prognosis for DCIS is generally excellent, especially when detected and treated early.
103
Why is regular follow-up care important for patients treated for DCIS?
Regular follow-up care is important to monitor for any signs of recurrence and to ensure early detection if the cancer returns.
104
MRI of the breast is not routinely used as part of the preoperative assessment in women with DCIS or invasive breast cancer. Give some situations when it could be considered.
>If the extent of disease is not clear from clinical examination, mammography and ultrasound assessment for planning treatment.
>If accurate mammographic assessment is difficult because of breast density.
>To assess the tumour size if breast-conserving surgery is being considered for invasive lobular cancer.
105
Trastuzumab is used for which type of breast cancer?
HER2 receptor +
106
In addition to breast cancer, trastuzumab can also be used to treat which cancer?
Gastric cancer.
107
Mechanism of action of trastuzumab.
>Binding to HER2 receptors, blocking growth signals.
>Inhibiting cancer cell proliferation.
>Activating the immune system to destroy cancer cells through antibody-dependent cellular cytotoxicity (ADCC).
108
A 30-year-old patient presents with an unexplained axillary lump. What are the potential causes, and what should be the next steps in evaluation and diagnosis?
Urgent Referral: The patient should be referred to a specialist to check for breast cancer within 2 weeks.
Clinical Examination: A thorough clinical examination should be conducted to assess the lump and any other associated symptoms.
Diagnostic Tests: Further diagnostic tests such as imaging (e.g., mammography or ultrasound) and possibly a biopsy may be recommended depending on the clinical findings.
109
A 30-year-old patient presents with an unexplained breast lump, with or without pain. What type of referral does this presentation warrant?
Urgent (within 2 weeks).
110
What are the typical shapes and sizes of benign microcalcifications?
Benign microcalcifications are typically round or punctate and uniform in size. They often appear as larger, coarser, and well-defined.
111
How do malignant calcifications usually appear in terms of shape and size?
Malignant calcifications are often irregular, pleomorphic (varying shapes), and fine. They may appear as tiny, linear, or branching.
112
Describe the distribution pattern of benign calcifications.
Benign calcifications are usually scattered or diffuse, not following a specific pattern.
113
What distribution pattern is more likely to be associated with malignant calcifications?
Malignant calcifications tend to cluster tightly or follow a linear or segmental distribution, suggesting they are within a duct.
114
What are some benign patterns of calcifications?
Benign patterns include popcorn-like (involuting fibroadenomas), vascular (parallel tracks), and skin calcifications (lucent-centered).
115
What are some suspicious patterns of calcifications that may indicate malignancy?
Suspicious patterns include fine linear or fine linear branching, and pleomorphic patterns, which are more likely to be associated with ductal carcinoma in situ (DCIS) or invasive cancer.
116
What classification system do radiologists use to categorise findings on a mammogram?
Radiologists use the Breast Imaging Reporting and Data System (BI-RADS) to categorize findings.
117
What BI-RADS categories indicate the need for further investigation of calcifications?
Calcifications that are suspicious for malignancy are typically classified as BI-RADS 4 or 5.
118
What additional imaging technique can be used to better characterise calcifications on a mammogram?
Magnification views can be used to better characterise the calcifications and assess their morphology and distribution.
119
What is the purpose of a biopsy in the context of suspicious calcifications?
A biopsy is recommended to obtain a definitive diagnosis if the calcifications appear suspicious. This can be done using stereotactic or ultrasound-guided techniques.
120
Occupations with a high risk of asbestos exposure.
-Construction Workers
-Shipyard Workers
-Firefighters
-Industrial Workers
-Military Personnel
121
What is the primary cause of mesothelioma?
The primary cause of mesothelioma is exposure to asbestos. Asbestos fibers, when inhaled or ingested, can lodge in the mesothelium, leading to inflammation and genetic damage over time.
122
List the common symptoms of pleural mesothelioma.
Common symptoms of pleural mesothelioma include chest pain, painful coughing, shortness of breath, unusual lumps of tissue under the skin on the chest, and unexplained weight loss.
123
What are the common symptoms of peritoneal mesothelioma?
Common symptoms of peritoneal mesothelioma include abdominal pain, abdominal swelling, lumps in the abdomen, and unexplained weight loss.
124
Describe the diagnostic process for mesothelioma.
The diagnostic process for mesothelioma typically involves a physical examination, imaging tests (such as X-rays, CT scans, and MRIs), and a biopsy to confirm the presence of cancerous cells.
125
What are the main treatment options for mesothelioma?
The main treatment options for mesothelioma include surgery, chemotherapy, radiation therapy, immunotherapy, and targeted therapy. The choice of treatment depends on the stage and location of the cancer.
126
What is the prognosis for mesothelioma patients?
The prognosis for mesothelioma patients is generally poor, with an average survival time of 18-31 months with treatment. Factors such as the stage of the cancer, patient health, and response to treatment can affect the prognosis.
127
What are the different types of mesothelioma based on location?
The different types of mesothelioma based on location are pleural mesothelioma (lungs), peritoneal mesothelioma (abdomen), pericardial mesothelioma (heart), and mesothelioma of the tunica vaginalis testis (testicles).
128
What are the risk factors for developing mesothelioma?
Risk factors for developing mesothelioma include occupational exposure to asbestos, living with someone who works with asbestos, living in buildings with disturbed asbestos materials, and genetic predisposition.
129
Mr. Anderson, a 65-year-old male with a known history of metastatic prostate cancer, presents to the emergency department with severe lower back pain, tingling in his legs, and difficulty passing urine. He reports that the pain has been progressively worsening over the past two weeks and is now constant and severe, particularly when lying down.
Diagnosis: Neurological Examination:
Tone: Increased in both lower limbs.
Power: Decreased (3/5) in both legs.
Reflexes: Bilateral hyperreflexia and positive Babinski sign.
Sensation: Global loss of sensation below the level of L1.
Anal Tone: Decreased on digital rectal examination.
Spinal Examination:
Tenderness on palpation of the thoracic and lumbar spine.
What is the likely diagnosis and how should this patient's condition be managed?
These signs are consistent with spinal cord compression above the L1 level, likely due to metastatic disease. This is a medical emergency. Immediate steps include:
>Immobilisation.
>Imaging: Emergency MRI of the whole spine.
>Medications: Unless contraindicated (including significant suspicion of lymphoma), offer a loading dose of 16mg dexamethasone as soon as possible after assessment. 8mg twice daily thereafter.
If there are associated neurological features suggestive of spinal cord compression, seek immediate specialist advice.
>Referral: Urgent referral to neurosurgery for potential surgical intervention and activation of the metastatic spinal cord compression (MSCC) pathway
130
1) What imaging technique should be offered to people with obstructive jaundice and suspected pancreatic cancer before draining the bile duct?
2) If the diagnosis remains unclear after the initial imaging, what additional diagnostic methods should be offered?
A pancreatic protocol CT scan.
FDG-PET/CT and/or endoscopic ultrasound (EUS) with EUS-guided tissue sampling.
131
Under what conditions should a biliary brushing for cytology be taken?
A biliary brushing for cytology should be taken if endoscopic retrograde cholangiopancreatography (ERCP) is being used to relieve the biliary obstruction and there is no tissue diagnosis.
132
What imaging technique should be offered to people with pancreatic abnormalities but no jaundice?
A pancreatic protocol CT scan.
133
What scans should you offer to a patient with a pancreatic cyst?
Pancreatic protocol CT or magnetic resonance cholangiopancreatography (MRI/MRCP). If more information is needed after one of these tests, offer the other one.
Offer EUS if more information on the likelihood of malignancy is needed.
Consider fine-needle aspiration during EUS if more information is needed.
134
What high-risk features should prompt a referral for resection in people with pancreatic conditions?
Obstructive jaundice with cystic lesions in the head of the pancreas
Enhancing solid component in the cyst
A main pancreatic duct that is 10 mm diameter or larger
135
When performing fine-needle aspiration on a patient with a pancreatic cyst, what assay should be performed in addition to cytology if there is sufficient sample?
CEA
136
Main types of pancreatic malignancies..
Most common are exocrine tumours (primarily pancreatic ductal adenocarcinoma, originating in the ducts that carry digestive enzymes).
Pancreatic Neuroendocrine Tumours (PNETs): less common, arising from the hormone-producing islet cells.
137
Risk factors for pancreatic cancer.
>Age: older than 65.
>Smoking: significantly increases risk.
>Diabetes mellitus: particularly type 2 diabetes mellitus.
>Chronic pancreatitis
>Genetic predisposition: family history and certain genetic syndromes.
>Obesity.
138
Clinical presentation of pancreatic cancer.
Abdominal pain radiating to back, typically worsening after eating or lying down.
Jaundice
Unintentional weight loss.
Digestive symptoms: nausea, vomiting, steatorrhoea, and changes in bowel habits.
New-onset diabetes: particularly if it's hard to control.
139
Which dyes and chemicals have been linked to an increased risk of transitional cell carcinoma of the bladder?
1) Aromatic amines: Chemicals like 2-naphthylamine, beta-naphthylamine, and 4-chloro-o-toluidine.
2) Aniline dyes: Particularly those used in the textile industry.
3) Benzidine and its derivatives: Commonly used in dye production.
140
What are the risk factors for squamous cell carcinoma (SCC) of the bladder?
>Chronic bladder inflammation: Often due to repeated urinary infections or long-term use of urinary catheters.
>Schistosomiasis: A parasitic infection that causes chronic bladder inflammation, particularly in certain regions.
>Smoking: Tobacco use is a major risk factor for many types of bladder cancer, including SCC.
>Radiation exposure: Previous radiation treatments to the pelvic area can increase the risk.
>Foreign bodies: The presence of bladder stones or long-term catheter use can contribute to the development of SCC.
141
What is the role of BCG in bladder cancer management?
It is a key treatment for non-muscle invasive bladder cancer. It functions as a form of intravesical immunotherapy.
BCG works by stimulating the immune system to attack cancer cells, creating an inflammatory environment that helps the body recognize and destroy these cells. This treatment is particularly effective for early-stage bladder cancers, such as carcinoma in situ. It is often used after transurethral resection of bladder tumor (TURBT) to reduce the risk of recurrence.
Note: be aware of the contraindications of BCG instillations.
142
List four types of bladder cancer
>Urothelial (transitional cell) carcinoma.
>Squamous cell carcinoma.
>Adenocarcinoma
>Sarcoma
143
144
Why do men with prostate cancer typically have higher levels of PSA than those without prostate cancer?
Men with prostate cancer tend to have higher PSA levels because cancerous prostate cells produce more PSA than normal cells. This overproduction leads to an increase in the amount of PSA in the blood, which can be detected through a PSA test.
145
Does PSA increase or decrease with age?
PSA increases with age.
146
Age-specific NICE PSA thresholds for people with possible symptoms of prostate cancer.
Below 40: use clinical judgement.
40-49: more than 2.5
50-59: more than 3.5
60-69: more than 4.5
70-79: more than 6.5
Above 79: use clinical judgement.
147
What are the limitations and risks of PSA testing?
>False-negatives and false-positives.
>Unnecessary investigation.
>Unnecessary treatment.
>Anxiety.
148
A 65-year-old presents to his GP with complaints of painless gross haematuria that he has noticed intermittently over the past two months. He denies any dysuria, frequency, or urgency. He has a 40-pack-year smoking history. Physical examination is unremarkable. Urinalysis confirms the presence of red blood cells.
Based on the clinical presentation and initial findings, what is the most likely diagnosis, and what would be the most appropriate next step in the management of this patient?
Options:
A: UTI; prescribe antibiotics.
B: Nephrolithiasis; order a non-contrast CT scan of abdomen and pelvis.
C: Transitional cell carcinoma of the bladder; refer for cystoscopy and biopsy.
D: BPH; start alpha-blocker therapy.
C: Transitional cell carcinoma.
Refer for cystoscopy and biopsy.
149
Lynch syndrome (hereditary non-polyposis colorectal cancer)
Autosomal dominant.
Due to mutations in DNA mismatch repair genes.
Lifetime risk of colorectal cancer is up to 80%.
Increased risk of other ‘Lynch cancers’: endometrium, urinary tract, stomach, small intestine, hepatobiliary tract, and gastric.
150
Genes implicated in HNPCC.
MLH1
MSH2
MSH6
PMS2
EPCAM
151
EPCAM gene.
Endothelial cell adhesion molecule. Encodes the transmembrane glycoprotein that mediates Ca2+ independent homotypic cell-cell adhesion in epithelia.
152
Diagnostic criteria used to help doctors identify families which are likely to have Lynch syndrome.
Amsterdam criteria
https://fightlynch.org/physicians/physicians-screening-criteria/#:~:text=Amsterdam%20Criteria&text=Three%20affected%20relatives%20with%20colorectal,(FAP)%20should%20be%20excluded
153
Amsterdam Criteria
>3 or more relatives with an associated cancer.
>2 or more successive generations involved.
>At least 1 of the cancers diagnosed before age 50.
>1 should be a first-degree relative of the other two.
>FAP should be excluded in cases of colorectal carcinoma.
>Tumours should be verified by pathologic examination.
154
Alternative to Amsterdam criteria for HNPCC.
Bethesda guidelines.
155
What gene is mutated in Peutz-Jeghers syndrome (PJS)?
STK11 (tumour suppressor gene).
The function of STK11 is to regulate cell growth and division.
156
Signs/symptoms of Peutz-Jeghers syndrome (PJS).
>Mucocutaneous pigmentation: dark blue or brown spots, often appearing in childhood, typically around the lips, mouth, eyes, nostrils, and fingers. These spots may fade with age.
>GI polyps: hamartomatous polyps primarily in the small intestine, but also in the stomach, colon, and other parts of the GI tract. These polyps can cause abdominal pain, bleeding, and intussusception.
>Cancer risk: individuals with PJS have an increased risk of developing various cancers, including GI (small intestine, stomach, colon), pancreatic, breast, ovarian, and testicular cancers.
157
Diagnosis of PJS.
>Clinical evaluation: diagnosis is often based on the presence of characteristic pigmented spots and polyps.
>Genetic testing: confirmatory testing for mutations in the STK11 gene.
>Imaging and endoscopy: used to detect and monitor polyps in the GI tract.
158
What is the first-line investigative procedure for suspected bladder cancer?
Cystoscopy (usually flexible cystoscopy).
159
If muscle-invasive bladder cancer is suspected at cystoscopy, what should you consider doing before TURBT?
You should consider CT or MRI staging.
160
According to NICE, what should be offered to patients with suspected bladder cancer at the same time as their first TURBT?
A single dose of intravesical mitomycin C.
161
Mitomycin C
An antineoplastic agent used in the treatment of various cancers. In bladder cancer, it is administered intravesically as a single dose during the TURBT procedure in an attempt to prevent recurrence.
The drug functions as an alkylating agent, causing cross-linking of DNA.
162
What is the most common type of TCC?
Papillary TCC. Exophytic, frond-like growths that project into the bladder lumen.
They have a relatively better prognosis than flat TCCs, which are usually non-muscle-invasive.
163
What is Trousseau's sign of malignancy?
Trousseau's sign of malignancy, also known as Trousseau's syndrome, is characterised by recurrent, migratory thrombophlebitis (inflammation of veins due to blood clots) that appears in different locations over time. It is often associated with underlying malignancies, particularly adenocarcinomas such as pancreatic, gastric, and lung cancers.
164
What is the pathophysiology behind Trousseau's sign of malignancy?
The exact mechanism is not fully understood, but it is believed to involve a hypercoagulable state induced by the cancer. Tumours may secrete substances that increase blood clotting.
165
How does Trousseau's sign of malignancy typically present clinically?
Patients may present with tender nodules under the skin where the clots form. These clots can migrate to different parts of the body.
166
Which types of cancer are most commonly associated with Trousseau's sign of malignancy?
It is particularly associated with pancreatic, gastric, and lung cancers.
167
What is the primary treatment approach for managing Trousseau's sign of malignancy?
The primary treatment approach includes anticoagulation therapy, often with heparin, to prevent future clots, and addressing the underlying malignancy.
168
Why is it important to manage the underlying malignancy in patients with Trousseau's sign of malignancy?
Managing the underlying malignancy is crucial because the hypercoagulable state and recurrent thrombophlebitis are driven by the cancer. Effective cancer treatment can help reduce the risk of further clot formation.
