Ways to detect a tumor based on sensation
Breast Cancer: annual physical exam, monthly breast exam
Soft tissue sarcomas: may present with mass
Does a mass alone tell you something is cancer?
Skin invasion overlying a mass is far more concerning for malignancy, though
What are some clues that a mass could be causing obstruction?
Lung Carcinoma: endobronchial growth, causes stridor, collapsed lung, and SVCS (below)
Superior Vena Cava Syndrome: venous distension of neck, chest wall, facial edema and plethora, upper arm edema (Pemberton's sign)
Abdominal and pelvic tumors: can compress GI, bladder, biliary system, vessels
A tumor around the spinal cord can cause what sort of sudden emergency?
Spinal cord compression
may cause permanent paralysis or worse
What are some examples of hemorrhage in tumors?
Hemorrhage can be a presenting sign in teh following
post-menopausal bleeding (always concerning for uterine cancer, do biopsy)
Less specific concerns: hematuria, hematochezia, hematemesis, hemoptysis
What are some ways that hemorrhaging tumors can manifest (besides seeing it)
rapid enlargement of a tumor or compartment from the blood with significant associated pain
chronic bleeding leading to iron-deficient anemia
What are some reasons that tumors cause irritation?
peritoneum and pleural spaces are easily irritated by tumor cells
can cause ascites (ovarian carcinoma)
can cause malignant pleural effusions (tumor irritating pleura)
What are some approaches we can take as physicians to detect tumors?
palpable/visible mass (pt will tell you about)
hemorrhage (pt will tell you)
indications of invasion
all of the above
62 y/o f pt with increasing fatigue, abdominal weight gain, increased gas/constipation
Exam: ascites, adnexal mass
Orders: Ca125 elevated, full body imaging, biopsy with surgery and removal of tumor
Dx: Ovarian Cancer
How to stage cancer
T: Tumor size/invasion
N: lymph Node metastasis
M: other Metastasis/other considerations
Different types of metastatic spread:
travels through lymph (typical of carcinomas)
travels through blood (typical of sarcomas, advanced carcinomas)
punches through serosa
travels through duct/lumen
How does understanding the spread of cancers impact clinical care?
helps us know where to look for metastasis (check LN palpably or with rad.)
what types of sx of metastasis to look for
if a previous cancer diagnosis, how to order radiology in anticipation for metastasis
Sentinel biopsies and LN dissections are done in which cancers?
Endometrial carcinoma spreads via lymph, where do you check for metastasis?'
Myometrial sarcoma would metastasize where?
Breast carcinoma and melanoma
Blood and can go to lungs and liver (common for sarcomas)
Carcinomas need to be staged by looking at what?
What is the one exception?
Renal cell carcinoma (spreads hematogenously, even though it's a carcinoma)
What are some general metastatic cancer symptoms we should beware of?
fatigue, weight loss
bone pain/back pain
What is the Sister Mary Joseph nodule?
What is the Virchow node?
umbilical metastasis, typically from ovarian cancer
Supraclavicular LAD, typically left sided, associated with thoracic/abdominal carcinoma due to drainage of thoracic duct into subclavian vein in the supraclavicular region
What is the difference between a primary and metastatic tumor?
solitary, no other cancer dx, unusual met location, typical demographic
multiple, history of other cancer, location typical for mets, unusual demographic
What kind of surveillance should be done in a pt with a prior diagnosis of cancer or in anticipation of metastasis?
depends on the cancer!
checking regional LN is most important, using radiology as appropriate
can use serum cancer markers as well
Myeloma: B2 microglobulin
Medullary thyroid: Calcitonin
What does a late metastasis from a sarcoma present like?
lung metastasis from sarcoma can arise a decade later and pt's may not even remember that they had a primary sarcoma (like a uterine leiomyosarcoma)
(it actually happens a lot that people forget diagnoses, esp if they were relatively easy, minor to treat)
What does late metastasis from breast cancer present like?
metastasis from breast carcinomas can arise decades later
back pain decades after definitive breast cancer can indicate osseous metastsis to the spine
What is the definition of paraneoplastic syndrome?
tumor secretes a substance (PTH-rP, ACTH)
tumor evokes eleboration of other factors (autoantibodies, cytokines)
68 yo m, smoker with acute AMS
exam: drowsy, confused, Ca elevated, Phos low, PTH low, PTH-rP is elevated
Dx: Humoral Hypercalcemia of Malignancy from squamous carcinomas of any site, likely lung in this case due to hx of smoking
Sx mediated by PTH-rP secretion from tumor
CT shows right hilar lung mass
52 yo f, smoker, c/o lethargy and weakness
Exam: drowsy, irritable, normal BP, euvolemic, Na low, Osm low, urine Osm elevated
secretion of ADH signals renal receptors to retain free water, diluting serum osm and causing AMS
Dx: SIADH most often from small neuroendocrine carcinoma but can be from lung, GI and GU/ovarian carcinomas
Hers is from lung due to smoking history
48 yo m, new onset HTN
Exam: low K, weight loss, muscle weakness
morning serum cortisol elevated
Dx: Cushing syndrome due to small cell carcinoma and ectopic ACTH
often neuroendocrine tumors, but can be lung, bronchial, pancreatic islet, medullary thyroid, or pheochromocytoma
What is Eaton-Lambert Myasthenic syndrome?
often associated with small cell malignancy
assx with muscle weakness and dry mouth
dz is mediated by antibodies to voltage gated Ca channels
Dx via antibody and nerve stimulation testing
When is surgery for malignancy not indicated
metastatic disease removes the advantage of surgery
leukemia/lymphoma can't really be surgical excised
systemic therapy can be so effective that surgery isn't needed
Types of radiation therapy
external beam radiation
How does external beam radiation work?
How does brachytherapy work?
linear accelerator delivers direct radiation beams to affected site
very localized high-dose therapy delivered continuously for a prolonged time through implanted devices
What is an example of systemic radionucleotides?
I131 is used for thyroid cancer and noncancerous thyroid diseases
the metabolism of iodine by neoplastic thyroid cells results in cellular ingestion of the killing radionucleotide
When do you use radiation therapy?
it is part of adjuvant and neoadjuvant therapy
Use when surgery is contraindicated
Use for palliative care (prevent spinal cord compression, ENT carcinoma to prevent suffocation, pelvic side wall to prevent pain)