Oncology and
Palliative Care
Seán Keenan
2022
,Principles of Oncology
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
Cancer in the UK
Commonest Cancers Commonest Cancer Deaths
- 1: Breast - 1: Lung
- 2: Lung - 2: Colorectal
- 3: Colorectal - 3: Breast
- 4: Prostate - 4: Prostate
- 5: Bladder - 5: Pancreas
- 6: Non-Hodgkin’s Lymphoma - 6: Oesophagus
- 7: Melanoma - 7: Stomach
- 8: Stomach - 8: Bladder
- 9: Oesophagus - 9: Non-Hodgkin’s Lymphoma
- 10: Pancreas - 10: Ovarian
,Respiratory Malignancy
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
, Adenocarcinoma
Squamous Cell Carcinoma Metastatic Squamous Cell Carcinoma
Nail Bed
Fluctuation
Nailbed
angle loss
Parrot
Beaking
.
. .
HPOA
- . - .
Hypertrophic Pulmonary Osteoarthropathy (HPOA) – Sx: Periostitis, Digital Finger Clubbing Grading
Clubbing and Painful Osteoarthropathy. Indicated Grade IV clubbing
Paraneoplsatic Syndromes
System Manifestations
Endocrine Ectopic secretion - ACTH (Cushing's); ADH (Dilutional Hyponatraemia); PTH (Hypercalcaemia); HCG (Gynaecomastia)
Neurological Cerebellar degeneration; Myopathy; Polyneuropathy; Myasthenic syndrome
Vascular Thrombophlebitis migrans; Anaemia; DIC
Cutaneous Dermatomyositis; Herpes Zoster; Acanthosis nigrificans
Skeletal Clubbing; Hypertrophic Pulmonary Osteoarthropathy (HPOA)
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)
Palliative Care
Seán Keenan
2022
,Principles of Oncology
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
Cancer in the UK
Commonest Cancers Commonest Cancer Deaths
- 1: Breast - 1: Lung
- 2: Lung - 2: Colorectal
- 3: Colorectal - 3: Breast
- 4: Prostate - 4: Prostate
- 5: Bladder - 5: Pancreas
- 6: Non-Hodgkin’s Lymphoma - 6: Oesophagus
- 7: Melanoma - 7: Stomach
- 8: Stomach - 8: Bladder
- 9: Oesophagus - 9: Non-Hodgkin’s Lymphoma
- 10: Pancreas - 10: Ovarian
,Respiratory Malignancy
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
, Adenocarcinoma
Squamous Cell Carcinoma Metastatic Squamous Cell Carcinoma
Nail Bed
Fluctuation
Nailbed
angle loss
Parrot
Beaking
.
. .
HPOA
- . - .
Hypertrophic Pulmonary Osteoarthropathy (HPOA) – Sx: Periostitis, Digital Finger Clubbing Grading
Clubbing and Painful Osteoarthropathy. Indicated Grade IV clubbing
Paraneoplsatic Syndromes
System Manifestations
Endocrine Ectopic secretion - ACTH (Cushing's); ADH (Dilutional Hyponatraemia); PTH (Hypercalcaemia); HCG (Gynaecomastia)
Neurological Cerebellar degeneration; Myopathy; Polyneuropathy; Myasthenic syndrome
Vascular Thrombophlebitis migrans; Anaemia; DIC
Cutaneous Dermatomyositis; Herpes Zoster; Acanthosis nigrificans
Skeletal Clubbing; Hypertrophic Pulmonary Osteoarthropathy (HPOA)
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)
