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Other Cancers

Cervical Cancer

Reference: Lec Not Onc 130, OHCSp 34
Epidemiology
10% ♀ cancer. Age 35-44
Pathology

HPV→CIN 1-3 (histological equivalent is Squamous IN low-high grade)→Ca

66% Squamous, 15% adenocarcinomas.

Risk Factors
HPV 16/18, Smoking, promiscuity, ↓socioecomonic, OCP, genital warts, HSV-2
Clinical

Inter-menstrual/post-coital bleeding, dysparaunia, vaginal discharge (bloody, offensive), frequency, ↓weight

Mets: back pain (↑abdo LNs), referred pain to legs.

Investigations

  1. Diagnosis: VE→Smear (CIN)→Colposcopy (visualisation and biopsies)→cone biopsy
  2. Staging: FBC, CXR, CT/MRI abdo + pelvis ( CT to look at LNs, lung, liver, and MRI to image Cervix).
Stage/Management

0 (in-situ) IntraEpidemiologythelial carcinoma 1-3 Cone biopsy
1 A: Microscopic confined to Cervix Cone biopsy/local excision, but usually hyster
B: Confined to Cervix, greater than A Radical Hyster./lymphadenect or radiother + chem
2 A: Beyond Cervix without parametrial Radical Hyster./lymphadenect or radiother + chem
B: Parametrial Radiotherapy
3 A: Pelvic side wall Radiotherapy
B: Pelvic side wall w hydronephrosis Radiotherapy
4 A: Beyond true pelvis Chemotherapy
B: Distant organs Chemotherapy

Grade
G1, G2, G3 on differentiation. In-situ graded I, II, III and abbreviated to CIN or CGIN (squamous, adeno)
Management

Radical
Radiotherapy+Chemo (these have synergy). Cisplatin. SEs : premature menopause, small bowel stenosis, fistula, lymphoedema, rectal bleed.
Progressive/mets
Cisplatin, Methotrexate, Bleomycin
In-Situ
Cone biopsy 100% success rate
Palliative
Bladder-vagina fistula, rectum-vagina/bladder fistula . Blocked ureters : stent, colostomy/ileostomy relieves bowel or bladder obstruction.
Prognosis
Good generally. 5% w 1A progress to advanced. 25%-45% 3B have 5YS. 4 v poor.

Ca CNS

Reference: OHCM 386, Lec Not Onc 81
Clinical

Focal Neuro deficit (mass effect)

Depends on site eg. frontal (Δpersonality, apathy, ↓IQ, dysphasia, motor cortex). Note that dominant hemisphere is L in majority of R and L handed people.

Papilloedema : pink disc, haemorrhages (forced out of vessels), blurred sides disc

False localising signs : CN6 (LR 6 ) = cannot abduct beyond midline, inward strabismus. CN3 (AO 3 ) = unilateral ptosis, fInvestigationsed to light, dilated eye, faces down and out.

Good list in OHCM.

↑ICP
Headache (worse in morning cos have been lying down, better on standing, may be induced by straining), vomiting, papilloedema (only 50% tumours), Δconsciousness
Seizures
Blackouts, tongue biting, incontinence, 3rd parties
Differential
Stroke, head injury, vaculitis (eg SLE, syphilis, giant cell arteritis, MS, encephalitis, post-ictal, metabolic), benign intracranial hypertension
Pathology

Tumour, aneurysm, abscess, chronic subdural haematoma, granuloma, cyst

Adults mostly supratentorial, children usually subtentorial. About 50:50 1 o and 2 o (breast, lung, melanoma). 1 o classification (any struct in brain): astrocytoma, glioblastoma multiforme, oligodendroglioma, ependydoma, cerebellar haemangioblastoma (40% 20YS), meningioma (♀:♂ = 2:1)

Investigations
CT w gadolinium/MRI. Consider biopsy. Avoid LP (coning, i.e. cerebellar tonsils herniate through foramen magnum)
Management

Admit as emergency

Benign
Remove them
Glioma
Surgery/radiotherapy/chemotherapy.
Oedema
Dexamethasone
Epidemiologylepsy
Prophylaxis
↑ICP
Shunt
Headache
Eg. codeine
Prognosis
Complete removal may cure. Most <50% 5YS.

Ca Pancreas

Reference: OHCM 248, Lec Not Onc 96
Epidemiology
5th most common cause of Ca death
Risk Factor
Smoking, alcohol, DM, chronic pancreatitis, ♂
Pathology
Most are ductal adenoca (mets early, present late). 60% arise in head , 15% tail , 25% body . Minority in Ampulla of Vater , or islet cells (insulinoma, gastrinoma, gucagonoma, aomatostatinoma): better prognosis.
Symptoms

Head : painless obstructive jaundice. Body and tail : Epidemiologygastric pain which may radiate to back, and may be relieved by sitting forward.

General : Anorexia, weight loss, DM, acute pancreatitis. Rarer : throbophlebitis migrans, ↑Ca, Cushings, ascites (peritoneal mets), portal ↑BP (splenic V thrombosis), nephrotic syndrome (renal V mets)

Si
Jaundice + palpable gall bladder (Courvoisier's), Epidemiologygastric mass, hepatomegaly, splenomagaly, ↑LNs, ascites, thrombophlebitis migrans
Spread

Direct invasion
Cbd (jaundice), duodenum (bleeding, obstruction), portal vein (p. hypertension), IVC (leg oedema)
Lymp
Adjacent, & porta hepatis
Blood
Liver, then lungs
Trans-coeloemic
Peritoneal seeding & ascites
Differential
Other causes of obstructive jaundice
Investigations

  1. Bloods: FBC, Risk FactorT, LFT (↑ALP), Ca199, bilirubin
  2. Imaging: CXR, CT abdo, endoscopy (peri-ampullary growth), EUS (look at head inside duodenum)
  3. Diagnostic: ERCP+cytology (obstrution in bile duct), (FNA if unsuccesful)
Management

  1. Radical Surgery + Chemo (just 10% suitable): Whipples Pancreatoduodenectomy if fit and <3cm w no mets. Chemo delays disease progression.
  2. Palliative: Chemotherapy , ERCP/percutaneous stent to relieve jaundice, coeliac axis block/radiotherapy to reduce pain
Prognosis
Dismal. Mean survival <6m. 5YS 5-14% w surgery and 2% w/o.

Ca Ovary

Reference: OHCSp 42, Lec Not Onc 138
Epidemiology
Rare but causes many deaths cos presents late
Pathology
Benign (94%), malignant (6%) [?]
Risk Factor
BRCA1/BRCA2 (so also FH of breast ca), ↑ovulations. (OCP protects), dietary fat.
Clinical
Often vague: abdo pain, discomfort, distension. Ascites (blocked lymph in omentum). Rupture : causing peritonitis and shock. Hirsuitism.
Spread
Can be transcoelemic (via omentum)
Investigations

  1. General: bloods (FBC, biochemistry, CA125 - not specific and can even rise in hrt failure ), CXR
  2. Diagnostic: Transvaginal USSStaging: CT
Management

Inoperability : ↓peRisk Factorormance status, Ca attached to bowel.

  1. Radical Surgery + chemotherapy: cisplatin/carboplatin (can cure this Ca even if peritoneal spread)
  2. Palliative Chemotherapy

Ca Endometrial

Reference: OHCSp 40
Risk Factor

Post-menopausal, FH of br/ov/colon, DM, pelvic irradiation

E 2 : unopposed HRT, nulliparity/early menarche/late menopause, tamoxifen, PCOS, obesity

Pathology
Most adenocarcinomas, most start in fundus.
Spread
Myometrium→Cervix→vagina, ovary, LNs
Clinical

Postmenopausal bleeding (10-20% risk of ca). Early may be scant, over time becomes heavier + more frequent. Premenopausal have intermenstrual bleeding (rare in this group).

Examination may be normal.

Investigations
Diagnostic: USS→(sample if wall>5mm) Hysteroscopy+uterine sampling/curettage
Stage
I: confined to body. II: cervical involvement. III: beyond uterus. IV: beyond pelvis
Management

  1. I/II: total hysterectomy w bilateral salpingo-oopherectomy. If extends beyond inner half of myometrium w LN involvement then radiotherapy.
  2. Palliative: Radiotherapy + progestogens

Renal Cell Carcinoma

Reference: Reference: OHCM 498, Lec Not Onc 108
Epidemiology
90% renal cancers, mean age 55, ♂>♀. Other tumours: TCC (Proximal renal tubular Epidemiologythelium), Wilms, lymphomas
Pathology
Adenocarcinomas (“clear cell carcinomas”)
Clinical
Haematuria, loin pain, abdo mass , anorexia, malaise, ↓weight, L varicocele (due to compression of L testicular V. Note not R because R testicular V drains straight in to IVC ). Paraneoplastic: hypertension (renin), polycythaemia (erythropoetin), hyperCa (ectopic parathormone production)
Spread
Direct (Renal V), LNs (para-aortic), blood (bone, liver, lung, brain)
Investigations

  1. Bedside: RBCs, haematuria, urine cytology
  2. Bloods: FBC (polycythaemia from ↑epo secretion), ESR, U&E, ALP
  3. Diagnostic: USS (cystic from solid)
  4. Staging: CT/MRI, renal angiography, IVU (filling defect + calcification), CXR (Cannon ball mets), bone scan
Management

  1. Radical nephrectomy. Partal if small. No advantage to radiotherapy/chemo (IL-2).
  2. Metastatic: immunotherapy w inteRisk Factoreron-α or IL-2
  3. Tumours of renal pelvis: nephro-ureterectomy, or if feasible local wide excision & plsstic reconstruction
Prognosis
Variable

Ca Liver

Reference: Reference: OHCM 242, Lec Not Onc 93
Pathology

Commonest are 2 o : ♂ stomach, lung, colon. ♀ br, colon, stomach, uterus.

1 o (just 2% of liver ca): hepatocellular carcinoma (90% of 1 o s), cholangiocarcinoma, angiosarcoma

Risk Factor
Hep B or C (HCC), UC/primary sclerosing cholangitis (cholangioca), cirrhosis (alcohol, haemochromatosis, drugs), haemochromatosis
Symptoms
Jaundice, RUQ pain (due to liver capsule stretch), ↓weight, fever, malaise, anorexia. Rupture→intraperitoneal haemmorhage
Si
Hepatomegaly (smooth, or hard and irregular), chronic liver disease, decompensation (jaundice, ascites), arterial bruit (HCC)
Cx
Portal vein obstruction (varices, ascites), IVC obstruction (leg oedema)
Investigations

  1. Blood: FBC, clotting, LFT, hepatitis serology, ↑↑αFP (HCC. Also in ovarian, testicular, hepatoma, pregnancy choriocarcinoma ), CEA/CA199 (for monitoring)
  2. Diagnostic: USS/CT + biopsy
  3. Other if its a 2 o : eg CXR, mammogram
Management

  1. Surgery (solitary HCCs): lobectomy/transplantation. Only 10% operable.
  2. Surgery not possible: embolization, sclerotherapy, chemotherapy
Prognosis
Operable 33% 5YS, transplant 80% 5YS, non-curative median <1y

Malignant Melanoma

Reference: Reference: OHCSp 584, Lec Not Onc 189
Risk Factor
FH, excessive UV (burning in past, esp as child), low skin type/caucasian, moles, dysplastic naevi, age
Si

Sun exposed areas, irregular edges, non-uniform pigmentation, may be brown/black/R/B

Major : Δ size, shape, colour. Minor : diameter > 7mm, inflammation, oozing/bleeding, itch/odd sensation

Categories

  1. SupeRisk Factoricial spreading (50%)Nodular (30%)
  2. Lentigo maligna (15%)Acral lentiginous (5%)
Stage
Breslow's thickness : < 0.75mm, 0.76-1.5mm, 1.51-3.99mm, > 4mm
Investigations
Excision biopsy w wide excision (excise 1cm for every mm of depth)
Management

  1. (Excised during biopsy)
  2. Local skin mets and nodal disease: excision of local, and radical LN dissection. Radiotherapy if inoperable
  3. Metastatic Melanoma: Chemo (↓response rate)
Prognosis
< 1mm thick have 90% 5YS. > 1mm have 50% 5YS. V poor if mets.

Testicular Tumours

Claim to Fame
Commonest solid tumours in young men
Epidemiology
But less than 2% ♂ malignancies.
Types

GCT

20-40y, 2% bilateral, ↑ in undescended testicles

  1. Seminoma: grow slowly, met to regional & para-aortic LNs. Middle aged
  2. Teratoma: more aggressive, well differentiated/poorly. Blood & lymph spreads. Young
NGCT
Can release E 2 causing virilisation or feminisation
Clinical
Painless, testicular mass. Hydrocele, painful lump. Look for lymph spread. Hard mass which can not get above & does not transilluminate
Investigations

  1. USS: cystic or solid
  2. ALP, αFP, βHCG
  3. Stage: CT chest, abdo, pelvis
Management
Orchidectomy via groin incision (clamp cord, prevemt seeding into scrotal skin, keep incision in radiotherapy field). Seminoma: radiosensitive. Teratoma: chemosensitive
Prognosis
Good
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