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what is the leading cause of cancer death in men and women?
lung cancer
what are the two main groups of lung/bronchogenic cancer?
non small cell lung cancer (NSCLC) and small cell lung cancer (SCLC)
what are examples of NSCLC?
adenocarcinoma (most common), SCC, large cell cancer
which major group is associated w/ more rapid growth and increased metastases?
SCLC
what is the major risk factor in 80% of cases of lung cancer?
cigarette smoking- risk correlates w/ pack years
What is a pack year?
number of packs smoked per day for number of years
how much does COPD increase your risk of lung cancer?
4x
which types of smoking have less risk factors?
pipe and cigar smoking - tend to be inhaled less deeply
what are sx of lung cancer?
frequently asx
cough, hemoptysis
dyspnea, pleural or chest wall pain
LAD
anorexia, wt loss
fatigue
anemia
which tumor marker is associated w/ lung cancer?
CEA
How is NSCLC staged?
TNM (tumor size, regional lymph nodes, metastasis)
How is SCLC staged?
limited stage vs extensive stage
cannot use TNM due to assumption of micro-metastases present on dx
what would be seen on a CT scan in a lung cancer pt?
hilar/mediastinal nodes
In a PET scan in a lung cancer pt, what are you looking for?
distant metastases - bone, liver, adrenal
Why are PET scans more sensitive than CTs for staging?
identifies areas of inc glucose metabolism
what is tx for limited stage SCLC (1/3 pts)?
disease is limited to ipsilateral hemithorax and regional lymph nodes- tx w/ combo chemo and radiation
what is tx for extensive stage SCLC (2/3 pts)?
chemo used as initial therapy + immunotherapy;
RT, prophylactic cranial irradiation and thoracic may also be options
what is neoadjuvant?
administration of therapeutic agents before a main tx
what is adjuvant?
regimens given after primary tx
Why is most lung cancer incurable?
it is not found until it’s advanced; screening SXRs have been unsuccessful in improving outcome
what is recommended for people aged 50-80 with a >20 pack year history?
yearly CT to screen for lung cancer
what is mesothelioma?
tumor of the lungs from asbestos exposure
How do tumors usually spread in mesothelioma?
locally (metastasis is rare)
what are the sx of mesothelioma?
SOB, chest wall discomfort, unintentional weight loss, fluid buildup
sx occur 10-50 years after asbestos exposure
what would you see on a CXR in a mesothelioma pt?
nodular, irregular unilateral pleural thickening; unilateral pleural effusion
What scan is better to distinguish the extent o pleural involvement when dx mesothelioma?
CT scans
In analysis of fluid after thoracentesis in mesothelioma, how would the pleural fluid appear?
exudative and often hemorrhagic
What is VATS and how is it used to dx mesothelioma?
video assisted thorascopic surgery- bx pleural tissue
what are the tx options for mesothelioma?
surgery, chemotherapy, and radiotherapy (questionable benefit)
How is the prognosis for mesothelioma?
poor- median survival is 12 mos from dx and 5 year survival is < 5%
What is the 3rd leading cause of cancer related deaths?
colorectal cancer
What are the most common types of colorectal cancer?
adenomas (benign polyp w/ malignant potential), adenocarcinomas, anal carcinoma
What do majority of colorectal cancers arise from?
malignant transformations of:
adenomatous polyp (80-90%) or
serrated polyp (10-20%)
what are the 3 types of adenomatous polyps?
tubular, tubulovillous, villous
What are high risk advanced polyps?
>1 cm in size, villous features, and high grade dysplasia
What does sporadic CRC demonstrate?
loss of 1 or more tumor suppressor genes: P53, APC, DCC
or activation of oncogenes: KRAS, BRAF
what are risk factors for CRC?
inc age (90% cases >50 y/o)
inflammatory bowel disease: ulcerative colitis and Crohn’s disease
FHx, esp if dx <45 y/o
diets high in fats and red meats
inc risk in African Americans and ashkenazi jews
what is the clinical presentation of CRC?
usually asx
rectal bleeding- w/o presence of hemorrhoids
change in stool size/shape or bowel pattern, positive stool Guaiac
obstruction w/ left sided lesions (rare)
iron def anemia
tenesmus, urgency, recurrent hematochezia
what is the gold standard for dx in CRC?
colonoscopy- allows for visualization AND bx
besides colonoscopy, what are other methods to dx CRC?
fecal occult blood test (FOBT), flexible sigmoidoscopy, DRE, barium radiography, CT enterography
How is CRC staged?
TNM system
what are tx options for CRC?
surgical resection, radiation, chemo (FOLFOX for stage III, FOLFIRI for stage IV), biotherapy (bevacizumab- anti-EGFR ab)
What is the prognosis for CRC?
long term survival
when should screening for CRC be started?
age 45- continue until age 75
What are the methods of screening for CRC and how often should they be performed?
flex sigmoidoscopy x 5 yrs
colonoscopy x 10 yrs
double contrast barium enema x 5 yrs
What do you do if mass if found in CRC screening?
immediate surgical referral
What is familial adenomatous polyposis (FAP)?
autosomal dominant (APC or MYH) inherited syndrome that develops into CRC by 40 if untx
hallmark: development of hundred-thousands of adenomatous polyps in colon at young age (15-25yrs)
what is a desmoid tumor?
abnormal growth that arises from connective tissue
what is the tx for FAP?
proctocolectomy w/ ileostomy or ileoanal pouch - before age 20
flex proctosigmoidoscopy annually from age 12 (even if negative for APC)
frequent endoscopic surveillance
NSAIDs- decreases number and size of polyps
What are examples of extra-intestinal manifestations that FAP has an increased tendency for?
osteomas of skull, mandible, long bones
skin- epidermoid cysts, mesenteric fibromas, lipomas, demoed tumors
congenital hypertrophy of retina (most common)
what is hereditary nonpolyposis colorectal cancer (HNPCC)?
autosomal dominant inherited disorder w/ multiple polyps in proximal colon that undergo a rapid transformation due to high grade dysplasia
usually in 45-50 y/o and has inc assoc. w/ other cancers
what is another name for HNPCC?
Lynch syndrome (4% of all CR cancers)
what are other cancers that HNPCC is associated w/?
ovary, endometrium, renal, hepatobiliary, gastric, small intestine
when should you start screening colonoscopies for HNPCC?
10 years prior to earliest onset of CRC in a family member
repeat every 1-2 yrs
what is tx for HNPCC?
colonoscopy w/ frequent surveillance
What does every patient who presents w/ rectal bleeding need?
imminent GI referral for colonoscopy
What are 95% of esophageal cancers?
SCC or adenocarcinomas (out of Barrett’s esophagus)
Where are the majority of esophageal SCC’s located?
mid portion of esophagus
Where are the majority of esophageal adenocarcinomas located?
near the gastroesophageal junction, assoc. w/ endoscopic evidence of Barrett’s esophagus
what are sx of esophageal cancer?
progressive solid food dysphagia, wt loss, retrosternal discomfort/burning
regurgitation of saliva and food w/ no gastric secretions- advanced dz
aspiration PNA- infrequent
hoarsenesss w/ recurrent laryngeal nerve involvement
chronic GI blood loos → iron def anemia
tracheobronchial fistula - late complication
How do you dx esophageal cancer?
endoscopic bx, barium studies, integrated PET/CT
what is the standard tx for early stage esophageal cancer?
surgery
what are 90-95% of stomach cancers?
adenocarcinomas
what are risk factors for stomach cancer?
atrophic gastritis
salt / salt - preserved foods
nitroso compounds (processed meats)
obesity
blood group A / familial predisposition
smoking, occupation exposures, h. pylori, abdominal irradiation
What are protective factors against stomach cancer?
fruits, vegetables, fiber, and possibly NSAIDS
What are sx of stomach cancer?
no sx in early stages
too many sx to type in late stages :)
what kind of chemotherapy is used in stomach cancer tx?
platinum-based combo chemotherapy
What are gastrointestinal stromal tumors (GIST)?
uncommon tumors of GI tract that start in interstitial cells of Cajal or cells of ANS (more than half start in stomach)
behavior is driven by mutations in KIT, PDGFRA, or BRAF kinase
what are sx of GIST?
vague abdominal pain or discomfort, dysphagia, GI hemorrhage , or metastases mainly in the liver
Dx for GIST
biopsy (endoscopic, percutaneous CT, u/s, or during surgery)
what is the tx for GIST?
targeted therapy: imatinib (Gleevec)- inhibits c-kit TKI and PDGFRA mutations
what is the clinical presentation of pancreatic cancer?
painless jaundice- pathognomonic
vague dull epigastric/LUG discomfort that may radiate to back
wt loss, anorexia, weakness, diarrhea
courvoiser’s sign- palpable distended gallbladder due to obstruction of distal gallbladder by tumor
what is the tumor marker for pancreatic cancer?
Ca19-9
what labs would you see in pancreatic cancer?
elevated Ca19-9, anemia, glycosuria, hyperglycemia,
elevated: ESR, alkaline phosphatase, bilirubin, LFTs
what occurs w/ lesions in the head of the pancreas?
CBD obstruction
what is the gold standard for dx in pancreatic cancer?
endoscopic retrograde cholangiopancreatography (ERCP)- to visualize pancreatic duct and biliary system
How is pancreatic cancer staged?
TNM
Why do most pancreatic cancer pt’s present w/ advanced disease?
lack of sx and lack of appropriate screening mechanism
what surgical procedure is used to tx pancreatic cancer if the lesion is in the head of the pancreas?
whipple
Where are neuroendocrine cells found?
lung and GI tract - stomach, pancreas, appendix, intestines, colon, rectum
(can also appear in thymus, thyroid, adrenal gland, pituitary gland)
what are neuroendocrine tumors sometimes referred to as?
carcinoids
What do neuroendocrine tumors cause?
release of excess hormones
What are common symptoms seen w/ carcinoid syndrome / neuroendocrine tumors?
flushing in face or neck w/o sweating, diarrhea, SOB, tachycardia/palpitations, feeling of fullness, nausea, weight gain or loss
what is carcinoid syndrome often misdiagnosed as?
IBS
What percentage of neuroendocrine tumors have already metastasized at dx?
50% (liver, peritoneal cavity, bone)
what are risk factors for hepatocellular carcinoma?
HBV, HCV, hereditary hemochromatosis, cirrhosis (alcohol use, nonalcoholic fatty liver dz)
why is hepatocellular carcinoma often diagnosed late?
lack of pathognomonic sx
what are PE findings for hepatocellular carcinoma?
splenomegaly, ascites, jaundice, hepatomegaly, bruit heard over liver
What devleops in setting of chronic liver disease (chronic hep B and C)?
hepatocellular carcinoma
what are signs/sx of hepatocellular carcinoma?
upper abdominal pain or palpable mass, weight loss, early satiety, obstructive jaundice, etc
What should raise concern for developed HCC?
rising alpha-fetoprotein (AFP) levels in a pt w/ cirrhosis or hep B
What AFP level is diagnostic for hepatocellular carcinoma in a high risk pt?
>500 mcg/L
When dx hepatocellular carcinoma, why is it not typically biopsied?
risk pf spreading tumor along needle track (germ cell tumor)
what is the mainstay of tx for hepatocellular carcinoma?
surgical resection- but depends on tumor extent or underlying liver dysfunction
What is cholangiocarcinoma?
bile duct cancer- can be any part of bile duct system; intrahepatic, or distal bile duct
what are most cholangiocarcinomas?
adenocarcinomas (start in glandular cells)
when do sx for cholangiocarcinoma present?
when tumor obstructs biliary drainage system:
jaundice, pruritus, clay-colored stools, dark urine
what are PE findings for cholagniocarcinoma?
jaundice, hepatomegaly, RUQ mass, fever, palpable gallbladder is rare
what labs do you look at to determine if cholestasis is present/
serum aminotransferases, alkaline phosphatase, and bilirubin
what are most gallbladder cancers (GBC)?
adenocarcinomas (90%)