{"id":1002,"date":"2016-09-23T13:00:27","date_gmt":"2016-09-23T13:00:27","guid":{"rendered":"http:\/\/emedsa.org.au\/CoreMed\/?p=1002"},"modified":"2016-09-23T13:00:27","modified_gmt":"2016-09-23T13:00:27","slug":"neoplasia-in-a-nutshell","status":"publish","type":"post","link":"http:\/\/emedsa.org.au\/CoreMed\/2016\/09\/23\/neoplasia-in-a-nutshell\/","title":{"rendered":"Neoplasia &#8211; in a nutshell"},"content":{"rendered":"<p><a href=\"http:\/\/twitter.com\/share?url=http%3A%2F%2Femedsa.org.au%2FCoreMed%2F2016%2F09%2F23%2Fneoplasia-in-a-nutshell%2F&amp;count=none&amp;text=Neoplasia - in a nutshell - CoreMed\" class=\"twitter-share-button\">Tweet<\/a><\/p><div class=\"mts _50f8\">\n<div class=\"uiSelector inlineBlock audienceSelector timelineAudienceSelector audienceSelectorNoTruncate dynamicIconSelector uiSelectorNormal uiSelectorDynamicTooltip\"><b>Causes<\/b><\/div>\n<\/div>\n<div class=\"_5k3v _5k3w clearfix\"><b><\/b><br \/>\nUsually chronic or recurrent exposure to:<\/p>\n<ul>\n<li>Biological agent <em>e.g. HPV &#8211; cervical cancer<\/em><\/li>\n<li>Radiation <em>e.g. \u00a0UV radiation &#8211; skin cancer<\/em><\/li>\n<li>Chemical agent <em>e.g. smoking &#8211; lung cancer<\/em><\/li>\n<\/ul>\n<p>Strong genetic component. \u00a0FHx malignancy important<\/p>\n<p><b>Types<\/b><\/div>\n<div class=\"_5k3v _5k3w clearfix\">\n<ul>\n<li>Solid tumours &#8211; managed mainly by oncologists +\/- surgeons<\/li>\n<li>Haematological malignancy &#8211; managed mainly by haematologists<\/li>\n<\/ul>\n<p><b>Pathogenesis<\/b><\/p>\n<ul>\n<li>Initially asymptomatic and indolent<\/li>\n<li>Some are slow growing\/developing (e.g SCC, chronic leukaemia)<\/li>\n<li>Benign neoplasia may not need treatment unless causing symptoms<\/li>\n<li>Depending on tumour may enter a rapid growth phase or metastasise early<\/li>\n<li>Malignant tumours display locally invasive features (cancer= &#8216;crab&#8217;) i.e. margins not well demarcated and can erode surrounding vessels, capsules, lumens, imaging studies show local destruction e.g. periosteal reaction of bone cancer or ill-defined margins on imaging studies<\/li>\n<li>Effects of metastases may be the first symptom to manifest<\/li>\n<\/ul>\n<p><b>Clinical manifestations<\/b><\/div>\n<div class=\"_5k3v _5k3w clearfix\">\n<p><i>Unexplained weight loss is a red flag<\/i><\/div>\n<div class=\"_5k3v _5k3w clearfix\">\n<p>Neoplastic<\/p>\n<ul>\n<li><strong>Vascular involvement<\/strong> &#8211; ulceration and bleeding from mucosal\/serosal surfaces, bleeding from orifices<\/li>\n<li><strong>Luminal obstruction<\/strong> &#8211; e.g. bronchial collapse &gt; dyspnoea, renal tract obstruction &gt; prostatism, obstructive renal failure, bowel obstruction &gt; vomiting, distension, obstipation<\/li>\n<li><strong>Organ dysfunction<\/strong> &#8211; e.g. marrow infiltration &gt; anaemia, thrombocytopenia &gt; pallor, spontaneous bleeding<\/li>\n<\/ul>\n<p>Paraneoplastic<\/p>\n<ul>\n<li>Due to endocrine or humoral effects at a distant site e.g. ACh antibodies &gt; Lambert-Eaton syndrome, SIADH\/lung cancer<\/li>\n<\/ul>\n<p><b>Haematological malignancies<\/b><\/div>\n<div class=\"_5k3v _5k3w clearfix\">\n<ul>\n<li>Usually affects marrow components or lymph nodes<\/li>\n<li>Diagnosis from FBC, marrow biopsy or node biopsy<\/li>\n<\/ul>\n<p><b>Investigations<\/b><\/div>\n<div class=\"_5k3v _5k3w clearfix\">\n<ul>\n<li>Imaging studies e.g. XR, Ultrasound, CT<\/li>\n<li>Endoscopic e.g. bronchoscopy, gastro-dueodenal endoscopy, cystoscopy, laryngoscopy<\/li>\n<li>Biopsy<\/li>\n<li>Staging investigations are needed at some point to determine treatment<\/li>\n<\/ul>\n<p><b>Treatment<\/b><\/p>\n<p>Choice of treatment depends on histology (grading including benign\/malignant), local spread and presence of metastases and\u00a0<i>presence of symptoms<\/i><\/p>\n<p><b>Surgery<\/b><\/div>\n<div class=\"_5k3v _5k3w clearfix\">\n<ul>\n<li>Most useful if no distant metastases<\/li>\n<li>De-bulking palliative treatment for severe symptoms<\/li>\n<li>Occasionally may be possible to resect solitary mets<\/li>\n<li>Stent insertion for luminal obstruction <em>e.g. oesophageal, biliary, ureteric<\/em><\/li>\n<\/ul>\n<p><b>Chemotherapy<\/b><\/p>\n<ul>\n<li>Most commonly employed adjuvant therapy<\/li>\n<li>Works better for faster dividing tumours<\/li>\n<li>Sometimes given pre-operatively to de-bulk tumour<\/li>\n<li>Administered by treating physician or oncologist<\/li>\n<li>Can be administered systemically to direct organ or injected directly to organ<\/li>\n<li>Occasionally may need placement of long-term vascular access <em>e.g. Infusaport<\/em><\/li>\n<li>Acute complications affects rapidly dividing cells &#8211; marrow depression (immunosuppression (beware of febrile neutropenia: PMN count &lt; 0.5), anaemia, thrombocytopenia, N&amp;V&amp;D, oral-pharyngeal mucositis, also organ-specific effects by different agents<\/li>\n<li>Late complications &#8211; other neoplasia<\/li>\n<\/ul>\n<p><b>Radiotherapy<\/b><\/div>\n<div class=\"_5k3v _5k3w clearfix\">\n<ul>\n<li>Local therapy post-surgery as adjuvant therapy<\/li>\n<li>Most often used for palliation to treat symptomatic metastases e.g. bone pain<\/li>\n<li>Specifically used to primary tumour if radiosensitive e.g. ENT tumours<\/li>\n<\/ul>\n<p>Can be administered as<\/p><\/div>\n<div class=\"_5k3v _5k3w clearfix\">\n<ul>\n<li><strong>External beam (various modalities)<\/strong> &#8211; treatments divided into &#8216;fractions&#8217; to minimise normal tissue damage but maximise tumour regression<\/li>\n<li><strong>Brachytherapy<\/strong> &#8211; radioactive pellets directly implanted in tumour e.g. prostate cancer<\/li>\n<li><strong>Radio-isotopes<\/strong> &#8211; labelled isotopes ingested and taken up directly by organ e.g. radioactive iodine\/thyroid cancer<\/li>\n<\/ul>\n<ul>\n<li>Acute complications &#8211; cutaneous\/mucosal damage or irritation, acute inflammation\/bleeding, marrow depression (if large areas of body irradiated) &gt; pancytopenia<\/li>\n<li>Chronic complications &#8211; chronic inflammation\/bleeding e.g. radiation proctitis, cystitis, fibrosis\/scarring, radiation osteonecrosis, other neoplasia<\/li>\n<li>Aside: Rare non-cancer uses e.g. pterygium, Dupuytren&#8217;s contracture<\/li>\n<\/ul>\n<p><b>Other interventions<\/b><\/p>\n<p>Angioembolisation<\/p><\/div>\n<div class=\"_5k3v _5k3w clearfix\">\n<ul>\n<li>Performed by interventional radiologist<\/li>\n<li>Feeding vessels to tumour embolised to induce tumour infarction<\/li>\n<li>Maybe performed<\/li>\n<\/ul>\n<p><b>Other management issues<\/b><\/p>\n<ul>\n<li>DVT \/PE risk<\/li>\n<li>Symptom control<\/li>\n<li>Failure to respond to therapy<\/li>\n<li>Late recurrence (beware of &#8216;cancer survivors&#8217; with recurrent symptoms)<\/li>\n<li>Palliative care<\/li>\n<li>Reconstructive surgery e.g. breast surgery<\/li>\n<li>Other cosmesis e.g. wigs<\/li>\n<li>Psychosocial (see below)<\/li>\n<\/ul>\n<p><b>Psychosocial issues<\/b><\/div>\n<div class=\"_5k3v _5k3w clearfix\">\n<ul>\n<li>Side effects of treatment e.g. loss of taste, difficulty eating, hair loss<\/li>\n<li>Disfiguring surgery or treatments e.g. mastectomy, radiation skin changes<\/li>\n<li>Travelling distances for treatment<\/li>\n<li>Loss of fertility \/ Family planning<\/li>\n<li>Depression \/ Anxiety<\/li>\n<\/ul>\n<p><b>Prognosis<\/b><\/p>\n<p>Largely dictated by<\/p><\/div>\n<div class=\"_5k3v _5k3w clearfix\">\n<ul>\n<li>Staging (nodal involvement, metastases) &#8211; &#8216;TNM&#8217; system for solid tumours<\/li>\n<li>Grading (histological and biochemical characteristics)<\/li>\n<\/ul>\n<p><b>Screening<br \/>\n<\/b><br \/>\nMost effective in high risk groups<\/p>\n<ul>\n<li>Behaviour\u00a0<em>e.g. sexually active females &#8211; Pap smear<\/em><\/li>\n<li>Age <em>e.g. breast cancer &#8211; mammography<\/em><\/li>\n<li>Strong FHx <em>e.g. multiple endocrine neoplasia<\/em><\/li>\n<li>Pre-malignant conditions <em>e.g. ulcerative colitis, cervical intra-epithelial neoplasia<\/em><\/li>\n<\/ul>\n<p><b>Acute oncological emergencies<\/b><\/p>\n<ul>\n<li><strong>Fever<\/strong>: Febrile neutropenia &#8211; urgent WCC\/diff for confirmation, septic screen and rapid administration of broad spectrum antibiotics to include Pseudomonas<\/li>\n<li><strong>Altered mental state \/ Seizures<\/strong>: Hypercalcaemia &#8211; IV hydration, biphosphonate therapy, Cerebral metastases<\/li>\n<li><strong>Luminal obstruction<\/strong>: massive lung collapse, bowel obstruction, urinary obstruction\/retention<\/li>\n<li><strong>Massive bleeding from tumour erosion<\/strong>: haematemesis or malaena, haemoptysis, PR bleeding<\/li>\n<li><strong>Dyspnoea<\/strong>: pulmonary embolus<\/li>\n<li><strong>Tumour lysis syndrome<\/strong>: sever hyperkalemia\/uricaemia post chemotherapy &gt; need IVT hydration and maintain high urine output<\/li>\n<\/ul>\n<p><b>Evaluating the possible malignancy<\/b><\/div>\n<div class=\"_5k3v _5k3w clearfix\">\n<ul>\n<li>Consider the presence or severity of symptoms<\/li>\n<li>Clinically evaluate for the likely source and the likelihood of abnormality<\/li>\n<li>Monitor asymptomatic or indeterminate imaging studies regularly<\/li>\n<li>Commence more extensive investigations and refer if symptoms, signs or tests change significantly<\/li>\n<li>Biopsy unexplained, persistent or changing skin lesions or nodes<\/li>\n<li>Discuss concerns with a specialist<\/li>\n<li>Urgent referral if an acute oncological emergency<\/li>\n<\/ul>\n<p><b>The &#8216;cancer survivor&#8217;<br \/>\n<\/b><\/p>\n<ul>\n<li>Beware of recurrent symptoms even if no longer under specialist follow-up. \u00a0Consider re-instituting investigations<\/li>\n<li>Be aware of late complications of treatment<\/li>\n<\/ul>\n<p><b>Summarising\/Documenting oncological history<\/p>\n<p><\/b><\/p>\n<ul>\n<li>Duration of symptoms<\/li>\n<li><b><\/b>Date of diagnosis<\/li>\n<li>Histological diagnosis and stage (if known)<\/li>\n<li>Treatments to date and response<\/li>\n<li>Any major complications of disease or treatment<\/li>\n<li>Active disease or in remission<\/li>\n<li>Any followup ongoing<\/li>\n<li>Treating clinician(s)<\/li>\n<\/ul>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Tweet Causes Usually chronic or recurrent exposure to: Biological agent e.g. HPV &#8211; cervical cancer Radiation e.g. \u00a0UV radiation &#8211; skin cancer Chemical agent e.g. smoking &#8211; lung cancer Strong&#8230; <a href=\"http:\/\/emedsa.org.au\/CoreMed\/2016\/09\/23\/neoplasia-in-a-nutshell\/\">Read more &raquo;<\/a><\/p>\n","protected":false},"author":1,"featured_media":1003,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"episode_type":"","audio_file":"","cover_image":"","cover_image_id":"","duration":"","filesize":"","date_recorded":"","explicit":"","block":"","filesize_raw":"","footnotes":""},"categories":[1],"tags":[],"class_list":["post-1002","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized"],"_links":{"self":[{"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/posts\/1002","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/comments?post=1002"}],"version-history":[{"count":1,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/posts\/1002\/revisions"}],"predecessor-version":[{"id":1004,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/posts\/1002\/revisions\/1004"}],"wp:featuredmedia":[{"embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/media\/1003"}],"wp:attachment":[{"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/media?parent=1002"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/categories?post=1002"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/emedsa.org.au\/CoreMed\/wp-json\/wp\/v2\/tags?post=1002"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}