Solid tumours Flashcards
(196 cards)
1
Q
What is the most common cancer?
A
Lung cancer
2
Q
Where do lung cancers arise from?
A
Malignant epithelial cells
3
Q
What is the prognosis of lung cancer?
A
Poor (5 year survival rate of 17%)
4
Q
What are the two categories of lung cancer?
A
Non-small cell carcinoma (adenocarcinoma, squamous cell carcinoma, large cell carcinoma)
Small cell carcinoma
5
Q
Where are adenocarcinomas found and what are their clinical features?
A
Peripherally (smaller airways)
More common in non-smokers and asian females
Metastasise early
Respond well to immunotherapy
6
Q
What are the features of squamous cell carcinoma and where are they found?
A
Cenrally (in the bronchi)
More common in smokers
Secrete PTHrP = hypercalcaemia
Metastasise late (via lymph nodes)
7
Q
What are the features of large cell carcinoma and where are they found?
A
Located peripherally and centrally
More common in smokers, metastasise early
8
Q
What are the features of small cell carcinoma and where is it found?
A
Located centrally (poorly-differentiated)
More common in older smokers
Metastasise early
Secrete ACTH (cushing’s syndrome) and ADH (SIADH)
Associated with Lambert-Eaton syndrome
9
Q
What are the risk factors for lung cancer?
A
Tobacco smoking
Air pollution (indoor and outdoor)
FH of cancer, especially lung cancer
Male sex
Radon gas (miners)
10
Q
Which symptoms indicate lung cancer?
A
Unexplained cough 3 weeks (with / without haemoptysis)
Weight loss (>5% in last 6 months)
New onset dyspnoea
Pleuritic chest pain (tumour invade pleura)
Bone pain (mets - spine, pelvis, long bones)
Fatigue (anaemia of chronic disease)
11
Q
What else to cover in history of lung cancer?
A
Family history (lung cancer in 1st degree relative - doubles risk of LC)
Smoking history (quantify in pack-years)
Occupation
12
Q
What examination to perform for suspected lung cancer? Name some suggestive findings?
A
Full respiratory examination
Cachexia (increased resting energy expenditure and lipolysis)
Finger clubbing (unknown mechanism - may be due to increase in GH causing extracellular matric in nails to grow)
Dullness to percussion
Cervical lymphadenopathy (mets to lymphatic system)
Wheeze on auscultation (tumour blocks airway0
13
Q
When to refer on 2WW for suspected lung cancer?
A
“Red flag symptoms”
X-ray findings suggestive of lung cancer
Over 40 and unexplained haemoptysis
14
Q
What is a 2WW referral?
A
Hospital must see pt within 2 weeks of receiving the referral form
15
Q
Which patients must recieve an urgent chest x-ray (within 2 weeks)?
A
Over 40 + 2 x (weight loss, appetite loss, cough, dyspnoea, chest pain, fatigue)
1 additional symptom if ever smoked
16
Q
What are the differential diagnoses for lung cancer?
A
Tuberculosis
Mets to lungs from other sites
Sarcoidosis
Granulomatosis with polyangiitis (Wegener’s disease)
Non-Hodgkin’s lymphoma
17
Q
What features are unique to TB?
A
Drenching night sweats
Positive sputum culture and microscopy
CXR: cavitating lesion / hilar lymphadenopathy
18
Q
Which features are unique to mets to the lungs from other sites?
A
Symptoms of primary tumour (haematuria due to RCC)
CT head-abdo pelvis (shows primary tumour)
FDG-PET: increased uptake at primary tumour site
19
Q
Which features are unique to sarcoidosis?
A
Enlarged parotids
Skin signs e.g. erythema nodosum and lupus pernio
Tissue biopsy: non-caseating granulomas
20
Q
Which features are unique to granulomatosis with polyangiitis (Wegener’s disease)?
A
Saddle nose deformity
Positive cANCA
Urinalysis: haematuria, proteinuria, red cell casts
21
Q
Which features are unique to Non-Hodgkin’s lymphoma?
A
Drenching night sweats
Hepatosplenomegaly
Positive lymph node biopsy (anti-CD20 strain)
22
Q
What are some bedside investigations for lung cancer?
A
Pulse oximetry: aim for 94-98% ot 88-92% if patient has COPD
ECG: always pre-operatively
23
Q
What are the lab investigations for lung cancer?
A
FBC (anaemia)
LFTs (raised ALP and GGT = hepatic mets raised ALP alone = bone mets)
U&E: for baseline before treatment (hyponatraemia = SIADH - small cell carcinoma)
Serum calcium: elevated with secretion of PTH-related protein (PTHrP) more common in squamous cell carcinoma
24
Q
What imaging is required in lung cancer?
A
CXR - first line (opacities, pleural effusion, lung collapse)
CT chest-abdo-pelvis - confirm findings / look for mets
Bronchoscopy and biopsy - directly visualise tumour, biopsy taken (lung cancer subtype, and presence of targetable mutations e.g. EGFR) - essential for diagnosis
PET-CT (positron emission tomography CT) for staging
25
Which **staging classification** is first used for **lung cancer**?
**TNM staging**
26
What is **stage 1-IV** for **lung cancer**?
Stage I = One **small tumour** (\<4cm) in one lung
Stage II = **Larger tumour** (\>4cm) in nearby lymph nodes
Stage III = Spread to **contralateral lymph nodes** or grown into structures e.g. trachea
Stage IV = Spread to **lymph nodes outside of chest** or **other organs** (e.g. liver)
27
What is the **treatment** of **non-small cell lung cancer**?
**_Stage I-III_**
**Sugery**: lobectomy/pneumonectomy for intact lung function or wedge resection in patients with reduced function e.g. elderly, underlying respiratory conditions
**Pre-op chemo**
**Post-op chemo and radiotherapy**
**_Stage IV_**
Targeted therapies: **target mutations** which **drive the pathogenesis** of **lung cancer**
**Immunotherapy:** target immune checkpoints which prevent immune system from killing tumour cells
**Chemotherapy**: important for patients without mutations that can be targeted
**Paliative care**: including palliative radiotherapy for mets and symptom control
28
What **targatable mutations** exist in **lung cancer**?
EGFR
ALK
ROS1
29
What is the **treatment** of **small cell lung cancer**?
**Chemotherapy** and **radiotherapy**
**Surgery**: rare in small cell lung cancer (usually present with advanced disease)
**Prophylactic cranial irradiation** (as its associated with brain mets, radiotherapy is directed at brain)
30
What are some **disease related complications** of **lung cancer**?
**Horners syndrome** (due to **pancoast tumour**) in the lung apex infiltrating the brachial plexus - ptosis, miosis, anhidrosis, enophthalmos
**SVC obstruction** - tumour compresses SVC causing **facial swelling** and **distended neck / chest veins**
**Paraneoplastic syndromes**: e.g. SIADH and Lambert-Eaton syndrome
31
What are some **treatment related complications** for lung cancer?
Due to **chemotherapy**: alopecia, neutropaenia, bone marrow toxicity
Due to **radiotherapy**: mucositis, pneumonitis, oesophagitis
32
What is the most common malignancy affecting women in the UK?
**Breast cancer**
33
What are the **risk factors** for **breast cancer**?
**Female gender**
Age
**FH** (or personal history)
**Genetic predispositions** (e.g. BRCA1, BRCA 2)
**Early menarche** and **late menopause**
**Nulliparity**
**Increased age** of **first pregnancy**
**Multiparity** (risk increased in period after birth, then protective later in life)
**COCP** (still debated, effect likely minimal)
**HRT**
**White** ethnicity
Exposure to **radiation**
34
Where are BRCA1 and BRCA2 genes found respectively? What do they cause?
**BRCA1** - mutation on chromosome 17
**BRCA2** - mutation on chromosome 13
Increase risk of **breast** and **ovarian cancer**
35
Label the following:
36
What are the **categories** of **breast cancer**?
**Carcinomas = Ductal** or **lobular** (in situ or invasive - if penetrating **basement membrane**)
37
What is the **most common invasive breast cancer**?
Invasive **ductal carcinoma**
38
What are the **molecular subtypes** of **breast cancer** based on **gene expression**?
**Luminal A**
**Luminal B**
**Basal**
**HER2**
39
What age is **breast cancer screening offered**?
**50 - 71** for women and transmen
40
Which imaging is used for **breast cancer screening**? What are the possible results?
Mammogram
**Satisfactory**: no evidence of breast cancer
**Abnormal**: abnormality detected and further investigations needed (25% with abnormal result with subsequently have breast cancer
**Unclear:** imaging is unclear / inadequate
41
How to deal with breast implants on **mammography**?
**Eklund technique** - way of obtaining images to optimise breast cancer detection
42
What are the **clinical features of breast cancer**?
**Breast** and/or **axillary lump**
- Irregular
- Hard / firm
- Fixed to skin / muscle
**Breast pain**
**Breast skin changes** (change to normal appearance, skin tethering, oedema, peau d'orange)
**Nipples**: inversion, discharge (bloody), dilated veins
43
What are the potential **features of mets**?
**Bone** (bone pain)
**Liver** (malaise, jaundice)
**Lung** (SoB, cough)
**Brain** (confusion, seizures)
44
Who should be referred on **2WW** for **breast cancer**?
**30 and over** with unexplained **breast lump** with/without pain
**50 and over**, with any of:
* Dischage
* Retraction
* Other changes of concern
45
When else do **NICE** recommend a **2WW** referral?
**Skin changes** suggestive of breast cancer
Aged **30 or over** with unexplained lump in axilla
46
When to **consider non-urgent referral** in people aged under 30 for breast cancer?
**Unexlained breast lump** with / without pain
47
Where are suspected breast cancers reffered to?
'**One stop breast clinic**' for triple assessment
48
What are the **three elements** of the **triple assessment**?
**History and exam** (including FH)
**Imaging**
Over 40 = mammogram (soft tissue masses / microcalcifications)
Under 40 = Breast USS
**Histopathology** (depending on first 2 steps) - tissue / cellular sample may be taken
Fine needle aspiration (provisional same-day results)
Core biopsy (sometimes have to wait a few days)
49
Why are **further investigations** required for breast cancer?
Help stage disease and plan management
50
Which **bloods** are requested in suspected **breast cancer**?
RBC
Renal function
LFT
Bone profile
51
Which **imaging** is required in **suspected breast cancer**?
**CXR**
**Breast tomosynthesis** (uses mammography to produce 3-D representation of breast)
**MRI breast** (under guidance of MDT, used in pts with high risk FH / genetics / occult primary tumours / invasive cancers to guide treatment / assess tumour size for breast conserving surgery)
**CT chest / abdo / pelvis**: suspected advanced disease for visceral metastasis
**CT brain**: in symptomatic patients with neurological spread
**Contrast enhanced liver USS**: for suspected liver metastasis
**Bone scan:** spread to bones
**PET/CT**: not routine, use guided by breast MDT
52
Which **receptor testing** is done in **breast cancer**?
**Oestrogen receptor** (ER) status
**Progesterone receptor** (PR) status
**Human epidermal growth receptor** (HER2)
53
What **assessment** of **axilla** is done in **breast cancer**?
USS to assess axillary **lymph nodes** - can be sampled with **ultrasound-guided needle sampling** (for early invasive breast cancer)
54
What **genetic testing** should be performed for **breast cancer**?
Consideration for age / medical history / FH as to **indication**
If **under 50** with **triple-negative breast cancer** testing for **BRCA1** and **BRCA2** should be offered
55
Who is involved in the **management** of **breast cancer**?
**_MDT_**
- Breast surgeons
- Plastic surgeons
- Oncologists
- Radiologists
- Histopathologies
- Specialist nurses
- Palliative care
56
When can **surgery** be used for **breast cancer** and what is **involved**?
In **early and locally** advanced breast cancer
* **Breast conservation** - wide local excision (whole breast radiotherapy after)
* **Mastectomy** - for unfavourable tumour to breast ratio, where radiotherapy is contraindicated, multifocal tumours and recurrent
Along with **sentineal lymph node biopsy** (SLNB)
57
When is **breast reconstruction performed**?
At **time of mastectomy** or **delayed as separate procedure**
58
When is **radiotherapy** usually performed?
**Key adjunct**, reducing recurrence following **breast conserving surgery**
59
What are the local complications of radiotherapy?
**Soreness**
**Fibrosis of breast tissue**
Change in skin tone
60
What is the treatment **after breast conservation surgery**?
**Radiotherapy**
Partial breast radiotherapy / omitting radiotherapy (with very low risk of recurrence taking adjuvant endocrine theraoy)
61
What is the **treatment** after **mastectomy**?
Radiotherapy for:
* **node positive** (macrometastases) invasive breast cancer or involved resection margins
* node negative **T3/T4 disease**
62
When may **chemotherapy** be used for **breast cancer**?
To **reduce risk of recurrence** and **improve survival**
**Neoadjuvant therapy** (guided by MDT - reduce tumour size pre-operatively or with inflammatory breast cancer)
**Adjuvant chemotherapy** (usually contain a taxane and anthracycline)
63
Which **biologic** may be offered to **HER2 positive** breast cancers?
What are the **side effects**?
**Trastuzumab** (herceptin)
Also used for T1c / greater invasive disease
**Monoclonal antibody** which **targets HER2 receptors**
Significant **cardiac** based adverse effects, harmful in **pregnancy** and must be avoided for **7 months after treatment**
64
Which patients are offered **adjuvant endocrine therapy**? What does treatment choice depend on?
Patients with **ER / PR positive** disease
65
What are the **options** for **adjuvant endocrine therapies**?
**Tamoxifen** (selective oestrogen receptor modulator) first line in **men and pre-menopausal women** (also for post-menopausal at low risk of disease reccurence / if aromatase inhibitors contra-indicated)
**Aromatase inhibitors** first line in post-menopausal women at high risk of disease recurrence (prevents peripgeral conversion of androgens to oestrogens - not effective in premenopausal women where oestrogens are primarily synthesised by ovaries)
66
What are the **risks** of **tamoxifen**?
**Blood clots**
**Endometrial cancer**
**Osteoporosis**
NOT TO BECOME PREGNANT WHILST ON TAMOXIFEN OR FOR 2 MONTHS AFTER
67
What is a side effect of **aromatase inhibitor**? e.g. anastrozole
Menopausal symptoms
Osteoporosis
MSK pain
68
When is **endocrine therapy commenced**?
**After any adjuvant chemo** (standard course is 5 years)
(neo-adjuvant endocrine therapy may be used - in the context of a clinical trial)
69
What may be considered for **pre-menopausal women** with **ER +ve disease**?
**Ovarian function suppression** (use guided by MDT)
GnRH analogue (e.g. goserelin)
Laparoscopic oophorectomy
70
What is the **treatment aim** in **advanced metastatic cancer**?
**Prolong survival** and **improve quality of life**
71
What is **key** in guiding treatment for **advanced metastatic disease**?
**Receptor status** (ER, PR, HER2)
Endocrine treatment with **tamoxifen** or **anastrozole** or targeted therapy with **Herceptin**
72
Is **chemo** advisable for metastatic breast cancer?
73
Which **medications** can be used to **prevent lytic bone lesions** and **reduce bone pain / fracture**?
**Denosumab**
**Bisphosphonates**
74
Where do **colorectal cancers** affect?
**Beginning** of **colon**
**Caecum**
**End of rectum**
75
How may **colorectal cancer** present?
Screening
Incidentally on imaging
Endoscopy
Change in bowel habit
Iron deficiency anaemia
Bowel obstruction
76
What are the **risk factors** of **colorectal cancer**?
**Family history**
**Hereditary syndromes**
**Inflammatory bowel disease**
**Ethnicity**
**Radiotherapy**
**Obesity**
**Diabetes mellitus**
**Smoking**
Dietary factors (data conflicting - red meates and processed foods increase risk, fibre is protective)
77
Which **hereditary syndromes** increase risk of CRC?
**Lynch syndrome** (HNPCC) = autosomal dominant, mutation to DNA mismatch repair gene, most common inherited cause
**FAP** = autosomal dominant, mutation to APC, a tumour suppressor
78
What is the pattern of **CRC**?
**Sporadic** (no FH / genetics) or inherited
79
What type of cancer are most CRC?
**Adenocarcinomas**
80
What is the **adenoma-carcinoma sequence**?
**Mutations** = normal epithelium becomes **adenomas** progressively dysplastic and develop into **carcinoma**
81
Where does **CRC** most commonly occur?
**Rectum** and **sigmoid colon**
82
Why is there a **screening programme** for **CRC**?
Asymptomatic for much of it's course
83
Where does **CRC metastasise** to?
**Liver** (symptoms may lead to diagnosis)
**Rectal cancers** cause lung metastasis (due to **direct haematogenous spread** via the **inferior rectal vein** and **IVC**)
84
What type of cancers are **appendiceal cancers** (often considered separately)? Where do they typically spread?
**Carcinoids** (1 in 3 are adenocarcinomas)
Spread into **peritoneum**
Presence of **pseudomyxoma peritonei** (if mucus producing) may be seen
85
What are the **clinical features** of **colorectal cancer**?
**Change in bowel habit**
**Anaemia** (key indication for endoscopy)
**Weight loss**
86
What are the **symptoms of CRC**?
**Change** in **bowel habit**
## Footnote
**Weight loss**
**Malaise**
**Tenesmus**
**PR bleeding**
**Abdo pain**
87
What are the **signs** of **CRC**?
**Pallor**
**Abnormal PR exam**
**Abdo mass**
88
What may suggest **metastatic disease** in **CRC**?
**Hepatomegaly**
**Jaundice**
**Abdo pain**
**Lymphadenopathy**
89
Why may **liver / lung mets** occur in **CRC**?
**Portal** system = liver mets
**Inferior rectal vein** - IVC = lung mets
90
How to **right vs left sided CRC** present differently?
**Right** = develops mass from **dysplastic polyp** (classically presents as iron-deficient anaemia)
**Left** = grow circumferentially causing 'apple core' appearance causing **narrowing of lumen** and **symptoms of change in bowel habit** / obstruction
91
What are the aspects of the NHS screening programme?
(NOT OFFERED ANYMORE) **Flexible sigmoidoscopy**: Aged 55 invited for one-off screening with flexible sigmoidoscopy - if polyps found then **completion colonoscopy** will be organised (1% will be found with cancer)
**Faecal immunochemical test** (FIT) for those aged 60-74. After age of 75 people can request further test every two years (if abnormal then colonoscopy)
92
If patient is **indicated** for **coloscopy** from referral - what may suggest review in **colorectal clinic first**?
**Dementia**
**Learning difficulties**
**Physical impairments**
On **anticoagulation**
**Anal pathology**
93
When should patients be **referred** on 2WW for **CRC?**
**Aged 40** and over with **unexplained weight loss** / **abdo pain**
**Aged 50** or over with **rectal bleeding**
**Aged 60** or over with:
**Iron deficiency anaemia** / **changes in bowel habit**
Tests show **occult blood in faeces**
**Rectal / abdo mass**
94
When may a referral for a patient **under 50** be considered for **CRC**?
**_Rectal bleeding_** and any of the following:
## Footnote
**Abdo pain**
**Change in bowel habit**
**Weight loss**
**Iron-deficiency anaemia**
95
What is the **gold standard** for those with suspected **CRC**?
**Colonoscopy**
96
What is a **completion colonoscopy**?
Reaching and visualising the **terminal ileum** (typically done with conscious sedation - or GA or CT pneumocolon)
97
What are some **potential complications** of **colonoscopy**?
**Perforation** of the colon (increased risk in diverticular disease)
98
What **preparation** is there for **colonoscopy**?
Bowel prep - **specific diet** and **Moviprep**
99
Where does **flexible sigmoidoscopy** allow visualisation up to?
**Splenic flexure**
100
How is a **CT pneumocolon** performed? What can be used if not tolerated?
**Air insufflation** via the **rectum** is needed (bowel prep also needed through less intensive preparation)
Plain **CT abdo/pelvis**
101
What is the **disadvantage** of **CT pneumocolon** vs endoscopy?
No **removal of polyps** / **biopsy** of lesions
102
Why may **further investigations** be required in **CRC**?
Assessment of **distant spread** and key-organ function to **guide management**
103
Which **bloods** may be taken in **CRC**?
**FBC**
**Serum iron, transferrin saturation, TIBC**
**Renal function**
**LFT**
**Clotting screen**
104
What **tumour marker** is there for **CRC** when is it used?
**CEA** (carcinoembryonic antigen) - monitor as a marker of recurrence
105
Which **imaging** is used for **CRC**?
**CT chest abdo pelvis** (characterise disease burden / sites of metastatic spread)
**MRI liver** for liver mets
**MRI rectum** for better staging of rectal tumours
**Endoanal USS** for better stage rectal tumours
**PET / CT** not routine but may help with staging, prior to pelvic exenteration
106
How is **colorectal cancer** staged?
**TNM classification**
107
What are the **management options** for **CRC**?
**Surgery**
**Endoscopic techniques**
**Radiotherapy**
**Systemic anti-cancer therapy**
**Palliative care**
108
Why is a **stoma** typically needed after surgery for **CRC**?
To **protect the anastomosis** (temporary with plan to reverse during second procedure)
Typically used in **low anterior resection** when anastomotic leak is more common
Typically **reversed** several months after primary operation
109
What **surgical options** are there for **rectal cancer**?
**Transanal excision**
**Endoscopic submucosal dissection**
**Total mesorectal excision**
110
What **surgical options** are there for **colonic cancer**?
**Sigmoid colectomy**
**Right hemicolectomy**
**Left hemicolectomy**
**Subtotal colectomy**
**Total abdominal colectomy**
111
What are the **complications** from **CRC surgery**?
**Infection** (intra-abdominal, wound, urinary, chest)
**Bleeding / haematomas**
**Blood clots** (DVT/PE)
Damage to ureters during surgery
**Anastomotic leak** (commonly in operations with low rectal anastomosis - as such these are protected with look ileostomy)
112
What are some **risk factors** for **prostate cancer**?
**Age**
**Black ethnicity**
**Family history**
**Obesity**
113
What type of cancer is **prostate cancer**?
Where do the **majority of prostate cancers arise**?
**Adenocarcinomas**
**Peripheral zone**
114
Label the following
115
What are the **clinical features** of **prostate cancer**?
**LUTS** = nocturia, frequency, hesitancy, urgency, dribbling, overactive bladder, retention
**Visible haematuria**
**Abnoral DRE** (hard, nodular, enlarged, asymmetrical)
**Symptoms of advanced disease**(e.g. lower back pain, bone pain, weight loss, anorexia)
116
When should **DRE** be considered in men?
**LUTS** (e.g. nocturia, frequency, hesitancy, urgency or retention)
**Haematuria**
**Unexplained symptoms**
**Erectile dysfunction**
**Other reasons to be concerned of prostate cancer** (e.g. elevated PSA)
117
What is **prostate specific antigen**?
Protein produced by **prostate epithelial cells**
118
What is the **purpose** of **PSA** in normal physiology?
Helps **liquefy sperm**
119
What should men avoid before PSA?
**UTI** in last 6 weeks
**Urological intervention** in last 6 weeks
**Ejaculation** in previous 48 hours
**Vigorous exercise** in previous 48 hours
120
When should **PSA testing** be performed?
**Men over 50** who request it
121
When should a **2WW referral** be made for **prostate cancer**?
**Abnormal prostate** (feels malignant) on DRE
**PSA level elevated** above age-specific range
122
What is the **first line investigation** in the **diagnosis** of **prostate cancer**?
**Multiparametric MRI** (with Likert score - 5-point score based on radiologists impression of scan)
123
What **further imaging** may be used for **prostate cancer**?
**Bone isotope scan**
**CT**
**Further MRI**
For distant spread
124
How is **prostate cancer** staged and graded?
**TNM classification** for staging
**Gleason score** for histological grade
125
What are the **management options** for **localised prostate cancer**?
Active **surveillance** (not for high risk)
Radical **prostatectomy**
Radical **radiotherapy**
126
What are the **management options** for **locally advanced prostate cancer**?
**Radical prostatectomy**
**Radical chemotherapy** (docetaxel chemo may be used)
127
How may **metastatic** disease in **prostate cancer** be managed?
**Docetaxel chemotherapy**
**Androgen depravation** therapy (bilateral orchidectomy used as alternative)
128
What are **head and neck cancers**?
**Malignancies** of **oral cavity, pharynx, larynx, paranasal sinuses, nasal cavity or salivary glands**
129
What is the common **cell type** involved in **H&N cancers**?
**Squamous cell epithelium** (often called head and neck squamous cell carcinomas)
130
What are the **risk factors** for HNSCCs?
Alcohol and tobacco use
**HPV 16** (oropharyngeal cancer)
**betel quid** (oral cancer)
**Occupational** wood dust exposure (sinonasal cancer)
**EBV infection** (linked to nasopharyngeal cancer)
131
What are the **premalignant conditions** of HNSCC?
**Leukoplakia** (white patches)
**Erythroplakia** (red patches)
**Erythroleukoplakia** (mixed red and white patches)
**Oral lichen planus**
**Actinic cheilitis**
132
How do **oral cavity cancers present**?
**A mass** (typically painless) felt on the **inner lip**, **tongue**, **floor of mouth** or **hard palate**
Less commonly present with **oral cavity bleeding**, localised pain in oral cavity or **jaw swelling**
133
How do **pharyngeal cancers** present?
**Odynophagia**
**Dysphagia**
**Stertor**
**Referred otalgia**
Nasopharngeal carcinoma can present initally with neck lump
134
What is **trotters syndrome**?
Trial of **clinical features** suggestive of **nasopharyngeal malignancy**:
* **Unilateral conductive deafness** (secondary to middle ear effusion)
* **Trigeminal neuralgia** (secondary to perineural invasion)
* **Defective mobility** of the **soft palate**
135
How does **laryngeal cancer present?**
**Hoarse voice**
**Stridor**
**Dysphagia**
**Persistent cough**
**Referred otalgia**
136
How are **laryngeal cancers divided**?
**Glottis** (present earlier and no lymphatic spread as no lymphatic drainage)
## Footnote
**Supraglottis**
**Subglottis**
137
What are the **investigations** for **HNSCC**?
Investigations for those **solely with lymphadenopathy**?
**Biopsy of lesion**
**Flexible nasal endoscopy** (FNE) - if lesion seen then **examination under anaesthesia and biopsy**
Solely lymphadenopathy = **ultrasound-guided fine needle aspiration** (FNA)
138
How are **HNSCC staged**?
**CT scan of neck and chest** (lung mets) for tumour extension, local invasion and **cervical lymphadenopathy**
**PET-CT** for tumours of unknown origin
**MRI** as it's better in assessing oral cavity and oropharyngeal lesions
139
When to refer for specialist centre for suspected HNSCC?
Patient **presents with**:
* **Laryngeal cancer** (persistent unexplained hoarse voice, unexplained lump in neck)
* **Oral cancer** (lump on lip or in oral cavity, erythroplakia / erythroleukoplakia, unceration in oral cavity \> 3 weeks, unexplained lump in neck)
140
What is the **mainstay of treatment** for **HNSCCs**?
**Surgical resection** +/- adjuvant radiotherapy or chemo or **primary radiotherapy** + / - adjuvant chemotherapy
141
What is the **management** of small and large tumours of the **oral cavity**?
**Small** = wide local excision + / - neck dissection
**Larger** = surgical resection (flap reconstruction) / neck dissecrion / post op radio / chemotherapy
142
What is the **management** of **small tumours of the tonsil**?
**Surgical resection** using laser or transoral robotic surgery +/- neck dissection or primary radiotherapy or both
143
What is the management of **small tumours** of the tongue base?
**Surgical ressection** usuin **transoral robotic surgery** with neck dissection or primary radiotherapy or both
144
What is the management of **smaller tumours** of the **supraglottis**?
**Surgical resection** using **transoral laser** microsurgery with bilateral neck dissecrion or primary radiotherapy
145
What is the **management** of **larger tumours** of the **supraglottis**?
**Laryngectomy** with **post-operative radiotherapy**
146
What are the **complications** following treatment for **head and neck cancers**?
**Dysphagia** (secondary to pharyngeal / oesophageal stricture)
**Pharyngocutaneous fistula** (following laryngectomy)
Injury to the **accessory, vagus, hypoglossal** or **marginal mandibular nerves** (following neck dissection) or **chyle leak** (following neck dissection)
**Mucositis** (early complication of radiotherapy) or **xerostomia** (complication of radiotherapy)
Chronic pain, persistent hoarse voice, hearing loss (following chemoradiotherapy)
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What is **melanoma**?
**Cancerous growth** of **melanocytes**
148
What are the **features** suspicious of a melanoma?
**ABCDE**
**A**symmetry
**B**order (irregular)
**C**olour alterations
**Diamter** \> 6mm
**E**volving lesion
149
What are the **risk factors** for **melanoma**?
**Exposure to UV ligh****t**
**Severe sun burn in childhood** (e.g. blistering)
**Immunosuppression**
**Multiple** (\>100) or **giant** (\>20cm) naevi
**Skin type** (Fitzpatrick skin types I&II)
**FH**
**Genetic mutations** (e.g. CDK4, xeroderma pigmentosum)
150
Who does **melanoma** typically affect?
**Light-skinned populations**
151
What are **melanocytes**?
**Specialised melanin-producing cells** found in the **basal epidermis** (deepest layer of skin)
152
What is the **typical tumour progression** in **melanomas**?
**Benign naevus** (typical mole) = controlled proliferation of melanocytes
**Dysplastic naevus** (atypical mole) = abnormal proliferation of melanocytes resulting in pre-malignant condition (atypical cellular structure
**Radical growth phase** = extend superficially and outwards initially
**Vertical growth phase** = malignant cells invade basement membrane and proliferate into dermis
**Metastasis** = spread to other areas of body (typically to regional lymph nodes first) may spread to other areas
153
What are the **clinical features** of **melanomas**?
**Pigmented lesion with irregular border** and tendency to **grow / change**
154
What is a **dermascope**?
**Examination** of a suspicious skin lesion with a **dermascope** (small, hand-held microscope)
155
What is the first step **after identifying a suspicious lesion**?
Refer for **e****xcisional biopsy**
156
What is an **excisional biopsy**?
Suspicious lesion is **excised** with a **margin of 1-2mm of healthy surrounding skin** including a **portion of subcut fat** (ensuring full thickness of dermis sampled) - under **local anaesthetic** as a day case (care taken to not cause trauma as this can **alter** the **histological grading**)
157
When is a **punch** or incisional biopsy (small sample of lesion taken) ?
**Large lesions**
**Close proximity to vital structures** (ears, eyes, nose)
158
What are the **five major histological subtypes** of melanomas?
- Sperficial spreading
- Nodular
- Lentigo maligna
- Acral lentiginous
- Desmoplastic melanoma
159
What is **amelanotic melanoma**?
Malignant cells = **little or no pigment** (classically skin coloured) - **any subtype** can be amelanotic
160
What is a **superficial spreading melanoma**?
Most common
Initial **radial** growth later changing to **vertical growth** (deep into the dermis)
161
What is a **nodular melanoma**?
Seen at more advanced stage
Dark coloured
Grow **rapidly**
162
What is **lentigo maligna melanoma**?
Occurs on **elderly** on **chronically sun-exposed sites**
**Slow growing** (good prognosis)
163
What are **acral lentiginous melanomas**?
Melanomas occuring **under nails** or on **palmar / plantar surfaces** of hand and feet
**Subungal** lesions often **mistaken for traumatic haematomas**
164
What are **desmoplastic melanomas**?
**Rare form** of **melanomas** characterised by **abnormal deposits of collagen**
165
What can be used to **classify** the **depth of melanoma invasion** and / or give an indication of prognosis?
**Clark level** (use prognostic significance of depth of invasion, system is up for debate, not particularly used)
## Footnote
**Breslow thickness**
**Ulceration**
**Mitotic index**
166
What is the **breslow thickness**?
Based on **vertical thickness** of the **tumour in millimeters**
Measured from the **stratum granulosum** of epidermis (if ulcerated then from the bottom of the ulceration)
Correlates strongly with mortality
167
What is the **mitotic index**?
Indication of cell turnover (number of mitoses per mm2)
168
What is the **initial i****nvestigations**for**melanomas**?
**Skin** and **lymph node examination**
169
How should a clinically suspicious lymph node be investigated in suspected melanomas?
**Fine needle aspiration** (FNA) and **cytology**
170
When should a **total body CT** or **PET-CT** be used in melanomas?
**Aggressive lesions** (pT4, ulcerated, highmitotic index etc) or presence of **known lymph node spread**
171
What **marker** can be used to **risk stratify** in **melanomas**?
**LDH** (lactate dehydrogenase - maker of cell turnover)
172
What **staging system** is used for **melanomas**?
**Americal joint committee on cacner** (AJCC) system
173
What are the **management options** for **melanomas**?
**Surgical**: wide local excision (down to muscular fascia), SLNB (under GA), lymph-adenectomy, electro-chemotherapy
**Exision is the only treatment**
174
How is a **sentinel lymph node biopsy** performed?
Radio-labelled tracer **injected at old biopsy scar** - **CT to locate 'hot spots'**
**Blue dye** injected into **biopsy scar** during operation - gamma probe locates 'hot spots' and correlates these
If **positive** then **lymphadenectomy** is performed - removal of **all regional lymphatics**
175
What **adjuvant** therapy is given after **surgical excision** of a **melanoma**?
**Chemotherapy**
**Radiotherapy**
**Immunotherapy**
176
Which skin cancer has the highest mortality?
**Melanoma**
177
What is the **commonest form of skin cancer**?
**Basal cell carcinoma**
178
What are the **risk factors** for **BCC**?
**Exposure to UV light**
Fitzpatrick **skin types I&II** (light skin, tans poorly)
**Male**
**Genetics** (mutations in PTCH, p53 or albinism, Gorlin's syndrome, xeroderma pigmentosum)
**Increasing age**
**Previous skin cancers**
**Immunosuppression** (AIDS / transplantation)
179
What is **Gorlin-Golz syndrome**?
**Genetic condition** inceraseing risk of developing BCCs
**Autosomal dominant** (mutation in PTCH1 gene)
Develop BCC in **adolescence** ot **early adulthood**
180
What are the **features** of **Gorlin-Golz syndrome?**
Hyper-telorism
Palmar and plantar pits
Bifid ribs
Calcification of falx cerebri
181
What are the **clinical features** of a typical **nodular BCC**?
**TURP**
T - **Telangiectasia**
U - **Ulceration**
R - **Rolled edges**
P - **Pearly edge**
182
What is the **treatment** of **BCC**?
**Surgical excision** (3mm margin)
Topical **imiquimod** (immunotherapy - NOT if on head and neck)
**Cyrotherapy** for smaller, superficial, well defined lesions
183
What are the **risk factors** for **squamous cell carcinoma**?
Smoking
Sun exposure
Premalignant lesions (actinic kertosis)
Age
Skin trauma
184
How does **SCC** present?
**Papule** eroded at centre
**Fleshy lesion**
May be **painful**
Usually in **sun-exposed area**
185
What are the **treatment** options of **SCC**?
**Surgical excision** with minimum 2mm margin
**Topical cream** (5-fluorouracil recommended treatment)
186
What are the **problems** with topical **immunotherapy cream**?
Can cause scarring
No histological diagnosis
Never sure if its fully treated
187
What are the **features** of **seborrhoeic keratoses**?
**Crusty**
Look '**stuck on**' - like barnacles
**Benign** (if patient doesn't like appearance / catch / itchy = reasonalble indication for removal)
**Shave off** or use **curettage** (burn off)
Mistaken for melanoma as often **pigmented**
188
What are **campbell de morgan spots**?
red spots ocur over body with **age**
**benign**
raised / flat
189
What is **solar keratoses** (aka actinic keratosis)?
Sun damaged skin
Pre cancerous - can turn into **SCC**
Red and scaly
Treated with **cryotherapy / effufix** (5-fluorouracil)
190
What is a **dermatofibroma**?
Central scar like area with **peripheral light brown network**
**Benign**
Pinch and pulls inwards as its **attached to underlying subcut tissue** (moles push outwards)
191
What is a **congenital naevus**?
"**Cobblestone**" pattern - develops early in life
192
What is the term for **mole**?
**Reticular naevi**
193
What are the side effects of **surgery** for **lung cancer**?
**Shortness of breath**
**Pneumonia**
Pain due to **nerve damage**
Problems with swimming (**buoyancy**) after pneumonectomy
194
Why is staging in cancer important?
Guides treatment (trial eligibility)
Guides prognosis
195
What are the **pros and cons** of **PSA** testing?
**_Pros_**
Picks up prostate cancer before symptoms
Can help pick up a fast-growing cancer at an early stage
**_Cons_**
Might have raised PSA and no cancer
1 in 7 men with normal PSA may have PSA
You might be diagnosed with a slow growing cancer, take treatment and suffer side effects
196
# Define the following terms:
**Macule**
**Patch**
**Plaque**
**Papule**
**Nodule**
**Vesicle**
**Pustule**
**Bulla**
**Macule** - **flat lesion less than 1 cm**, without elevation or depression
**Patch** - **flat lesion greater than 1 cm**, without elevation or depression
**Plaque** - **flat, elevated lesion, usually greater than 1 cm**
**Papule** - **elevated**, solid lesion less than **1 cm**
**Nodule** - **elevated**, solid lesion greater than **1 cm**
**Vesicle** - **elevated**, **fluid-filled lesion**, usually **less than 1 cm**
**Pustule** - elevated, pus-filled lesion, usually less than 1 cm
**Bulla** - elevated, fluid-filled lesion, usually greater than 1 cm
