Onc lec 4

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%)