oncology and palliative medicine notes detailing all common oncological pathologies and conditions across all bodily systems for medical school exams, including palliative care medicine. Notes made from multiple resources such as oxford handbook, question banks, university lectures and UK guideline...
Hallmarks of Cancer
Self-Sufficiency in Growth Signals Tissue Invasion and Metastasis
- Path: Do not require external signals to replicate - Path: Spreads from origin sites to elsewhere
Insensitivity to Anti-Growth Signals Evasion of Immune System
- Path: Resistant to growth-restricting signals - Path: Avoids detection by host immune system
Evading Apoptosis Tumour-Promoting Inflammation
- Path: Resistant to programmed cell-death - Path: BM degradation leads to Metastasis
Replicative Immortality Genomic Instability
- Path: No limit to number of cell divisions - Path: Mutations and chromosomal polyploidy
Sustained Angiogenesis Dysregulated Metabolism
- Path: Formation of new vasculature - Path: Alternative metabolism pathways
Lung Cancer in General
Classifications Investigations
- Small Cell Lung Cancer (SCLC) (15 %) - CXR: First line; 10 % of cases will have normal CXR
o Small cell carcinoma: Also called oat cell cancer - Contrast-Enhanced CT: Ix of choice for lung cancer
o Combined small cell carcinoma: Mix of SC + NSCLC - NB: HRCT involves slices so can miss cancer
- Non-Small Cell Lung Cancer (NSCLC) (85 %) - Bronchoscopy: Biopsy aided by endobronchial US
o Adenocarcinoma: 40 %; Occurs in non-smokers - PET: 18-FDG is preferentially used by NSCLC
o Squamous: 30 %; Occurs typically in smokers - Bloods: ↑ Platelet count (PTC)
o Large cell: 15 %; Occurs typically in smokers Referral Guidelines
o Alveolar cell: Rare; Unrelated to smoking - Referral for suspected cancer pathway (2 wk)
o Bronchial adenoma: Rare; 90 % are carcinoid o CXR: Suggestive of lung cancer
o NB: Carcinoid tumours can lead to carcinoid syn. o Features: ≥ 40 YO + unexplained haemoptysis
Presentation - Refer for urgent CXR (2 wk) if ≥40 YO plus one sx
- Key: Persistent cough; Haemoptysis; Dyspnoea o Sx: Cough; Fatigue; SOB; Pleurisy; ↓ Weight
- Other: Chest pain; ↓ Weight; SVC syndrome - Consider urgent CXR (2 wk) if ≥40 YO plus one sx
- Hoarseness: Pancoast tumour on Rec. Laryngeal n. o Sx: Multi-chest infx; Clubbing; ↑ SCL; ↑ PTC
- Examination: Supraclavicular lymphadenopathy (SCL) Risk Factors
- Auscultation: Monophonic rhonchi - Risks: Smoking; Radon gas; FHx; Asbestos; RT
Small Cell Lung Cancer Management
Features - Surgery: Very early disease (T1-2a, N0, M0)
- Location: Usually central - Chemo-Radiotherapy: Offered in limited disease
- Pathology: Typically arise from APUD cells - Palliative: Chemotherapy for extensive disease
- Histology: Kulchitsky cells (Enterochromaffin cells) Prognosis
Paraneoplastic Syndromes - Poor: 70 % diagnosed when metastasised
- ADH: Dilutional Hyponatraemia - 5-Year Survival: 6 % late; 27 % earlier
- ACTH: Cushing’s; Bilateral adrenal hyperplasia
- Lambert Eaton Syndrome: AID to calcium channels
Non-Small Cell Lung Cancer
Squamous Cell Cancer Management
- Sx: Grade IV Finger clubbing; HPOA (see below) - Surgery: Only 20 % suitable
- Location: Typically central - Mediastinoscopy: Sees lymph node involvement
- NB: Associated with ↑ PTHrp secretion causing ↑Ca2+ - Radiotherapy: Used curatively or palliatively
Adenocarcinoma - Chemotherapy: Tumours poorly respond
- Sx: Gynaecomastia; HPOA; New persistent cough Surgical Contraindications
- location: Typically peripheral - Location: Tumour near hilum
- NB: Commonest non-smoking LC - FEV1: <1.5 lobectomy; <2.0 pneumonectomy
Large Cell Lung Carcinoma - Metastases: Stages IIIb or IV; Malignant effusion
- Sx: May secrete β-hCG - Other: Vocal cord paralysis; SVC syndrome
- Location: Typically peripheral Prognosis
- NB: Anaplastic Ca; Minority neuroendocrine - Px: Large cell has worst prognosis
Mesothelioma
Description Investigations
- Location: Common – Pleura; Rare – Peritoneum - CXR: Effusions; Plaques (benign – Pre-malignant)
- Exposure: 90 % asbestos exposure; 20 % asbestosis - Pleural CT: Confirms diagnosis of tumour in pleura
- Latency: Period of up to 45 years post-exposure - Aspirate: Send effusion for MC&S and cytology
Presentation - Thoracoscopy: Biopsy diagnostic yield 95 %
- Key: Pleurisy; Dyspnoea; Recurrent pleural effusions - Biopsy: CT-guided pleural biopsy
- Other: ↓ Weight; Finger clubbing Management
Causes - Intervention: Chemotherapy ± Surgery if possible
- Asbestos: Crocidolite (blue asbestos) has highest risk - Compensation: Industrial injuries act
Prognosis Complications
- Poor: Median survival 12 months - Metastases: Highly metastatic (liver and bone)
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