Other Cancers

Cervical Cancer

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

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

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

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

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

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

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

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