Qs Flashcards
(90 cards)
Diagnosis of melanoma
Over 6mm, assymetric, uneven borders, shades of colour, enlargement, FIRM
Two major types and their Subtypes of melanoma
Rapid growth phase which inc superficial spreading which is commonest, lentigo maligna, acral lentiginous
And vertical growth phase inc nodular which has poor prognosis,
Prognostic factors in melanoma
Dermal thickness is most critical, ulceration upstages all else, LDH important in metastatic disease
Staging in melanoma
Stage 0 is in Situ, 1 is under 2mm without ulceration or under 1mm with ulceration
Stage 2 is more than 2mm without ulceration or more than 1mm with ulceration
Stage 3 is LN
Main site of met in melanoma
Lung
Management of stage 1-3 melanoma
Wide local surgical excision .
For stage 3 also do lymph node resection (TLND)
If over 1mm or if over 0.75mm but with high risk features- do sentinel node biopsy . And if this is positive only do complete LN dissection
Commonest mutation in melanoma
BRAF
Management of metastatic melanoma
Surgical resection of Mets
If BRAF mutant, do combo BRAF (dabrafenib>vemurafenib, only dabrafenib has CNS activity and inhibits all V600) with MEK (trametinib) inhibitor. Another targeted therapy is cKIT (imatinib) also can be used (this activates RAS)
Second line is immunotherapy or if wild type BRAF- nivo/ipi combo esp for CNS disease
What happens if BRAF inhibitor used in their own
Higher risk of keratoacanthoma and squamous fell cancer
Immunotherapy SEs and management
Pseudoprogression with antiCTLA4 (thus don’t scan too early), GI immunotoxicity esp with ipi, whilst nivo causes more hypothyroidism. Mx- symptom relief alone if mild, if moderate steroids . If severe may need additional mycophenolate
Grade 4 colitis May need prolonged steroid weaning and TNF blockage and bowel resection
List mutations causing breadt cancer and which has highest causative link
BRCA (esp 1), TP53 (Li Fraumeni has highest!), STKII (Peutz Jegher), MSH/MLH
Role and pathogens is of PARP inhibitor in BRCA breast cancer
Like BRCA, PARP is another DNA base excision repair - they result in higher mutations causing genomic instability - tumor selective cell death via synthetic lethality
Commonest breast cancer type
Invasive carcinoma not otherwise specified
Describe staging of breast cancer
Stage 1 is small and node negative
Stage 2 is large and/or under 4 LNs, stage III is inflammation on chest wall or more than 4 LNs.
Screening in normal risk, moderately high risk and high risk women
Normal risk mammogram every 2 from age 50-74
Moderately increased risk is if one FDR under 50 years, 2 SDR with one under 50 in same side of family, annual mammogram from age 40. If two FDR in same side both over 50, annual mammogram from 50
If high risk (2 or more FDR under 50)- MRI annually from age 30
Management of stages 1-3 breast cancer
Wide local excision with RTX (sane outcomes as mastectomy) - mastectomy preferred if multi centric tumors, high tumor to breadt ratio, risk reduction, contraindication to RTX (e.g. prev RTX to same field lymphoma)
If high risk mastectomy parients (triple neg or node pos tumor over 5cm) also do RTX
Need to do sentinel biopsy in all at axillary . If pos- LN clearance
Describe the adjuvant systemic breast cancer therapies in non metastatic disease
If ER pos and low risk- endocrine . If ER pos and high risk- endocrine AND chemo If HER2 pos , trastizumab AND chemo If triple neg- chemo Bisphosphonate increases survival!
Endocrine therapy for premenopausal is OFS (surgery or GNRH agonist with Goserelin) with AI (anastrozole) best, next is tamoxifen
Another endocrine therapy is fulvestrant (selective estrofen receptor degradation)
If postmenopaisal- AI alone, or tamoxifen
HER2 inhibitor last are trastuzumab and pertumab sometimes uses jointly
SEs of AIs, tamoxifen and HER2 blockers
AIs- hot fluishes, osteoporosis, vaginal dryness, CVD risk, higher cholesterol, AIMSS
Tamoxifen- hot flushes, VTE risk, uterine cancer (only in post menopausal- as when used in post menopause there’s low estrogen and thus tamoxifen agonist effects predominate , NAFLD
In premenopausal can increase OP risk but protects bone in post menopausal women
Trastuzumab- reversible myosin shunning , reduces LVEF by 10%- can rechallenge once EF improves
Management of metastatic breast cancer
ER pos- endocrine first WITH AI and chemo (and OFS if premenopausal- give chemo first if severely symptomatic or high volume of disease) and CDK4/6 inhibitors (prevent G1 to S progression- inc ribociclib, palbociclob)
If HER2 pos- herceptin and chemo
Chemo used is taxanes and anthracyclines inc doxorubicin
Indication for chemo in ovarian cancer and what agent is used
Carboplatin, pacitaxel used.
Adjuvant chemo used if high grade or clear cell histology , stage 2 and beyond
Indication for radiotherapy in ovarian cancer
Stage iii , palpitation
Management of low risk, intermediate risk and high risk endometrial cancers (and define risks)
Low risk is stage 1 under 50% myometrial invasion- surg alone
If intermediate LN clearance- stage 1 but over 50% myometrium, surg +/- brachytherapy
If high risk- pelvic radiotherapy, local brachytherapy, chemo and surg
Management of advanced invasive cervical cancer
Chemo radiation with cisplatin (no surg)
Management of metastatic cervical cancer
Carbo/pacitaxol +/- Bevacizumab
