Neoplasm Growth

When a cell undergoes programmed cell death, the process is known as: Apoptosis o Where the cell membrane is destroyed first If something comes along and destroys the cell, this process is known as: Necrosis o Where the nucleus is destroyed first When the nucleus forms blebs it is called: Pyknosis When the nucleus breaks up into chunks it is called: Karyohexis When the nucleus dissolves, it is called: Karyolysis In every cell this will happen in 6 hours EXCEPT in (1) organ which is the: Brain o Which will occur in 20 minutes Anytime you have Irreversible Cellular Damage, there are three important organelles: 1) Nucleus 2) Mitochondria B/c it provides the ATP 3) Lysosome B/c they release the acid hydrolases to destroy the nucleus When a cell is going on its merry way and a STRESSOR comes by, there are (3) ways it can deal with it: 1) Atrophy Decrease in cell size Ex. Uterus post menstruation 2) Hyperplasia Increase in cell number Ex. Skin Ex. Endometrium & Breast every month in females 3) Hypertrophy Increase in cell size Myocardium hypertrophies inward Is compensatory b/c it has more cross-bridges You will hear an S4 Ex. Skeletal muscle against resistance Ex. Endometrium & Breast every month in females

If the STRESSOR persist you can handel this in (3) ways as well: 1) Anaplasia a. Regression of cells back to their mesenchymal origin b. Cells do not mature anymore and therefore, is a fast growing cancer i. Poor prognosis & High metastasis ii. Responds well to Chemo & Radiation 1. Small Cell Lung Cancer only lung cancer to respond to chemo & radiation 2. Seminoma 2) Metaplasia a. Replacement of one adult cell type for another i. The replacing cell type must be able to handle the environment in which it is going into. 1. Ex. Squamous cells in the lower esophagus CANNOT handle the acid reflux and therefore will be replaced with columnar cells which can, therefore, columnar meteplasia. 3) Desmoplasia a. Is when the cell wraps itself around collagen i. Collagenous tissue around a tumor If the STRESSOR still continues to persist you can handel this in (1) way: 1) Dysplasia a. Which is the 1st stage of Cancer b. Loss of cell to cell inhibition c. Limited to 1st layer of cells i. Carcinoma in situ= CIN 1. CIN 1 Epithelium if found here, 90% 5yr survival rate 2. CIN2 Middle 1/3rd 3. CIN3 Penetrated through the Basement membrane d. If you detect this early, there is a 90% 5 year survival rate Note: Anytime you screen for cancer you are looking for DYSPLASIA!!! FINALLY, if the STRESSOR still continues to persist it will lead to NEOPLASIA = New Growth Benign cancer are the most common forms EXCEPT in (2) places where Malignant is more predominant b/c of the fact that we remove everything. You must assume that normally there are 10 benign before 1 malignant for any place in the body that you just take something out (example: Lump in breast = lumpectomy)BUT when you remove the entire organ, assume that it is MALIGNANT: 1) Ovary 2) Breast total mastectomy

Benign vs. Malignant Benign Well circumscribed -Which means that you can feel its borders Movable Has a capsule doesnt outgrow capsule (Well Encapsulated) Obey physiology (Ex. respond to hormones Breast CA) NO METS Hurts by compression of something else Answer relates to type of compression Ex. Compressed nerve loss of sensation Surgery is usually for cosmetic reasons, and then medically for compression Malignant Not well circumscribed (invading borders; irregular borders) Fixed ; Adherent; Infiltrating Outgrows capsule (go into neighboring areas) Does not obey physiology METS Hurt you by invasion (need to be removed before invade other tissues) Surgery is due to pain due to invasion Outgrows blood supply, therefore, needs plenty of blood- vascularization for rapid growth Angiogenin- hormone secreted by CA that causes growth of new blood vessels. Endostatin- hormone to inhibit other cancers from growing. (Ex. if remove a
dominant CA that produces most endostatin, other CA suppressed by this tumor will start regrowing.)

Breast and Ovary- think benign mass before malignant

Everything else should be considered a malignant mass

Before you can see or feel a cancer you need 1 billion cells which takes 3-5 years to form. Cancer likes Blood o Organs with most blood supply will primarily have metastases 1. Brain (gray-white junction) 2. Lung 3. Bone (bone marrow) 4. Liver (portal vein, hepatic artery) 5. Pericardium (coronaries) 6. Adrenal Gland (renal arteries) The most common CA in these areas is METS!!! DONT BE FOOLED

Name your own CA: First: o What is the most common cell type and then add oma to the end Ex. Most common fibrous tumor: Fibroadenoma Second: o If you want to know what is the MC Cancer for a tissue is by figuring out which cell is being irritated and then if it is: If it is Epithelium add carcinoma at the end If it is Connective Tissue add sarcoma at the end Ex. Blood vessels/Skeletal muscle Third: o For any gland, add ADENO- at the beginning.

Histology: o Adeno = Gland o Lipo = fat o Osteo = Bone o Hemangio = blood vessel o Rhabdo = skeletal muscle o Leio = smooth muscle

You should note: Cancers are rapidly dividing and therefore need a lot of Nucleotides. Therefore, if you need a lot of Nucleotides then you need a lot of HMP, therefore, you can say that every cancer takes a lot of energy away from you. What I am trying to get to is that all the signs and symptoms can be connected to the LOW ENERGY STATE. Cancers is more common in males UNDER the age of 30 and AFTER the age of 50. Females predominate only b/w the ages of 3050 MCCOD for every cancer is INFECTION b/c either the cancer wipes out the bone marrow or the chemo is going to wipe out the bone marrow and you have no immune system to fight it off. o EXCEPT for (2) Cancers: WILL COME BACK TO THIS Remember that Oligodendrocytes (CNS) do not divide but Schwann Cells (PNS) do divide. These Schwann cells will grow at a rate of 1mm/day. Inoperable Brain Tumor means that it is so close to your medulla that if you risk the operation you can nick the medulla and the patient will die. Therefore, what you do is cut away as much as possible and leave a thin layer above the medulla and then give the patient radiation.

To determine prognosis in malignancy: Always look for SARCOMA first they will always have the worst prognosis. Except: Cystosarcoma phyloides can have a good prognosis, just need wide resection. Organ Name Clue Menigioma (MC Intracranial Tumor) Brain Displaces brain compression/herniation Psammoma body collection MC Presenting Symptom: of calcifications. - Headache due to increase in ICP MC Presenting Sign: Tumors with Psammoma Body -Papillaedema o Papillary CA of thyroid Vomitting is due to: o Serous cystAdenocarcinoma of -Pushing down on the floor of the 4th ovary Ventricle where the CTZ is located. o Meningioma o Mesothelioma o O o M o A

- 10 Brain Tumor (Of Tissue Proper)

- 10 Brain Cancer

Astrocytoma (b/c Astrocytes are the MC cell type in the brain) Now astrocytes are called differently in certain locations: Glioma in Optic Nerve Oligodendrioma therefore, must rule out MEN III & NF. Classic Clue whoorling pattern Schwannoma Appendomoma MC loc Cauda Equina Astrocytoma Grade IV Gliobastoma multiforme Posterior Fossa Tumors: Meduloblastoma (Cerebellar Tumor) (To visualize the Posterior Fossa in Children you must perform an MRI)

Neurocutaneous Syndrome Assoc.

mass in whirly patten/fried egg appearance

GBM = High Grade Astrocytoma

Craniopharyngioma Clue: Tooth enamel or hard palate; pt is deficient in Ant. Pit. hormones;cut into it & looks like motor oil

MC in Children; actually derived from cerebellum Usually present with early morning vomiting (vomiting center right there) when gets up b/c tumor hits the 4th Vent. pseudorosettes Develops from the anterior pituitary Rathkes pouch

Lets Discuss the Neurocutaneous Syndromes: o The Neuro part is common to ALL the Neurocutaneous Syndromes which all can have: o Mental Retardation o Seizures o Cerebral Calcifications o It is the Cutaneous part that differentiates them from one another: o Neurofibromatosis: Neurofibromatosis Type I: Von Recklinghausens Disease associated with o Chromosome 17 o Peripheral neuromas (ex. optic glioma) o Lisch nodules o Scoliosis Neurofibromatosis Type II: Acoustic Neuroma associated with: o Chromosome 22 o Central neuromas o Cataracts o Bilateral deafness CN 7 & 8 are wiped out Diagnostic Feature: Caf-au-lait Spots (but the BOARDS will refer to them as Hyperpigmented Macules) o You need at least (3) of them and they have to be at least 1.5 cm in diameter o Tuberous Sclerosis: Ashen Leaf Spots (HYPOpigmented Macules) Associated with: Primary Brain Tumors Rhabdomyomas and Rhabdosarcomas o Especially of the Heart High incidence of Renal Cell Carcinoma Shagreen Spots (leathery) o Sturge-Weber: Port Wine Stain on the forehead (which is a flat blood vessel) Associated with: Other angiomas in the Retina and Brain

Organ Pineal Gland

Name Pinealoma (adenoma)

Clue Precoucious puberty

The Pineal Gland is responsible for Circadian Rhythms and uses Melatonin as its NT which is made from the amino acid Tryptophan. o When the sunlight is out Melatonin levels are LOW o When it is dark Melatonin levels are HIGH Classic Clues for Pineal Gland tumors: o Precocious Puberty is it is a young girl The 1st test you want to run is to administer GnRH or Leuprolide to see if it is really precocious puberty or not. With the administration of GnRH you should notice a drop in the patients FSH & LH, thereby signifying that this is indeed truly precocious puberty. If you cannot stop it then there must be some tumor producing her excess estrogen. o Irregular Menstrual Cycle if it is a older female Being that the Pineal Gland is lateral to the Pituitary and therefore, can knock out the Lateral Rectus and you will notice that the patients eyes will turn INWARD. o Esotropia

Organ Pituitary Tumor Non-Functinoal Pit. Tumor (95%) Functional Pit. Tumor (5%)

Name Adenoma Chromophobic Adenoma Prolactinoma (5%)

Clue If suspect tumor 1st check prolactin levels Prolactin d/t loss of inhibitory fxn of Dopamine

To remove a Pituitary Tumor you use a Transsphenoidal Approach:

Lets understand what comprises the different sections of the mediastinum:

Now lets discuss the 4Ts:

Organ ANTERIOR MEDIASTINUM The 4 Ts: T#1 Thymus Name Clue Thymoma (MC Thymus Tumor) Recap on Myasthenia Gravis: Associated with ALL Autoimmune diseases except Graves Highly assoc. with MG

Organ The 4 Ts: T#2 Thyroid MC Thyroid Mass MC Thyroid Tumor MC Thyroid Cancer

Name Thyroglossal Cyst Follicular adenoma Papillary CA of Thyroid

Clue

#1 Risk Factor Previous exposure to radiation to the neck COLD Nodule with (+) Psammoma body history of radiation: Evaluation of Tumor Perform a lobectomy Soft = cystic Sonagram and then a COLD Nodule with no FNA to collapse it. history of radiation: Firm + previous Perform a lumpectomy exposure to radiation and if it comes back Remove it malignant then perform Firm without exposure a lobectomy. Do thyroid scan (hot/cold spots)

Organ Parathyroid Gland MC Tumor

Lets just quickly talk about the Parathyroid Glands here: Name Parathyroid adenoma MCC of isolated hypercalcemia in adults (PTH; Ca2+; PO4-) Medullary CA of Thyroid

Clue

MEN I Wermers calcitonin levels Severe hypocalcemia MEN II & III

MC Cancer Parafollicular cells C-cells

Remember that: The Superior Parathyroids come from the 4th Arch and the Inferior come from the 3rd Arch. If your lab work comes back with PTH; Ca2+ and a PO4- then the next step in management if to perform a Parathyroid Scan and then take them to surgery to cut out the gland that lit up on the scan.

Continuation with the 4Ts: Organ The 4 Ts: T#3 T-cell Leukemia Name Hairy Cell (MC site of metastasis is to the mediastinum) 1. Sezary Syndrome (cutaneous T-cell) 2. Mycosis fungiodes Name Clue (+) TRAP Fried egg appearance Sunburst appearance Indented T cell Memb. Invasion of blood Rash Clue All embryo layers present Ecto (hair & teeth), Endo(Struma ovariiwhich liked to become thyroid tissue), Meso). Boards may say that it has a Tri-phasic appearance Abnormal growth of normal tissue Keloid

Lymphoma (2 types)

Organ The 4 Ts: T#4 Teratoma - 90% benign - 10% malignant (Ecto)

Hamartoma

Organ MIDDLE MEDIASTINUM Cardiac Endocardium (Inner layer)

Name

Clue

Atrial Myxoma is the MC Tumor of the Endocardium

Diasoltic/atrial plop 90% in Left Atrium Female passes out and comes right back to consciousness. This is due to the Estrogen Connection- relaxes. Most commonly associated with Tuberous Sclerosis 90% of rhabdomyosarcomas occur under the age of 3 due to rapidly dividing muscle cells.

Myocardium:

Rhabdomyoma is the MC Tumor of the Myocardium Rhabdomyosarcoma is the MC Cancer of the Myocardium

Epicardium Pericardium MC Tumor is Fibroma MC Cancer is METS

Continuation with the MIDDLE MEDIASTINUM

Organ MIDDLE MEDIASTINUM Lung MC Lung Mass (Child) MC Lung Mass (Adult)

Name Hamartoma abnormal growth of normal tissue Granuloma (T cells & Macrophage) Ex. Granuloma from Midwest: -Histopplasmosis Granuloma from East Coast -Blastomycosis Granuloma from Southwest -Coccidiomycosis Granuloma from S. America -Paracoccidiomycosis Granuloma from a mold -Aspergillous Granuloma from rosebush -Sporothrix

Clue DO surgery b/c of V/Q mismatch

MC Lung Tumor MC CA MC Intrathoracic CA

Glandular Adenoma METS dont forget Squamous cell carcinoma Involves trachea (central) 1st - Bronchogenic adenocarcinoma

Not a big problem - benign Produces PTH hypercalcemia Pink staining Peripheral location To the terminal bronchioles b/c thats where small particles settle. Alveolus involved!!! Only Lung CA not directly associated with smoking Associated with Pneumoconioses 90% producing ACTH Cushings 5% ADH SIADH 3% PTH hypercalcemia < 1% TSH rare 5-HIAA in urine due to seratonin break down Flushing, itching, diarrhea Grows out like a polypTHE ONLY ONE Its always metastasis Carcinoid Tumors are MC in the Appendix Carcinoid Syndrome: 90% pancreas 10% ileum Everything is described as Big giant cells

MC 10 Lung CA

2nd Bronchioalveolar carcinoma

At Bifurcation

Small cell carcinoma - (central at carina) - Oat cell/Anaplastic

Random Note: Risks for Lung Ca: #1 Smoking #2 Radon #3 2nd hand smoke #4 Pneumoconiosis (environment)

Carcinoid Tumor Remember FDR Flushing Diarrhea Resp. Diff.

Large cell

Management of Lung Masses: Coin Lesion: (Any lung mass < 2cm) o 1st Find and compare to previous studies (x-ray, ect) b/c you want to see if that lung mass has been there for more than 2 years and has not changed. If it has not changed then you do nothing b/c it is most likely a hamartoma or granuloma depending on the patients age. If it has CHANGED then you perform a CT scan b/c it is cancer until ruled otherwise.

Organ Pleural Cavity (Space) Risks #1 Smoking #2 Radon #3 2nd hand smoke #4 Pneumoconiosis (environment) MCC CA of Pleural cavity

Name

Clue

Mesothelioma Ferruginous bodies 70% are Malignant, therefore, it is the MC Cancer of the Pleural Cavity. 30% are Benign, therefore, it is the MC Tumor of the Pleural Cavity

Pleural calcifications Pleural thickening psamoma bodies #1 Risk factor Asbestos Shipyard workers Insulation installers Pipe fitter Brake mechanics MC Cancer associated with
Asbestos Exposure Bronchogenic Adenocarcinoma

Environmental Lung Disease

Silicosis Berylliosis Bissinosis Anthrocosis

Sandblaster, glass prod. Tv/sat. worker Cotton industry Carbon dust/black deposits No predisposition to CA

Organ POSTERIOR MEDISTINUM Being that there are only Sympatheitic Chain Ganglia in the Posterior Mediastinum, the MC Tumor would be a Neuroma. Anytime you see a neuroma you should always consider and think about MEN III & Neurofibromatosis.

Name MC Cancer = Neuroblastoma (Children)

Clue Most common cancer in this area MC abdominal mass in children (Dont get fooled b/c the MC flank mass is Wilms Tumor) Mostly found in the abdomen hypsarrhythmia dancing eyes opsoclonus dancing feet Presents like pheochromocytoma in adults Has intermittent HTN, palpitations, HA, Diaphoresis due to increased Epi & NE Phentolamin to Diagnose Phenoxybenzamine to Tx

Labs: VMA & Metanephrines in urine

Neuroblastoma has the HIGHEST spontaneous regression rate of all cancers (Usually 1-3% spontaneous regression rate) Being that Neuroblastoma in children presents like Pheochromocytoma in adults we will discuss it here but first have to understand the cells which originate from the Neural Crest:

o Pheochromocytoma: is a tumor of the adrenal gland that causes excess release of epinephrine and norepinephrine, hormones that regulate heart rate and blood pressure. may occur as a single tumor or as multiple growths. Usually develops in the medulla (center or core) of one or both adrenal glands. Sometimes this kind of tumor occurs outside the adrenal gland, usually somewhere else in the abdomen. Less than 10% of pheochromocytomas are malignant (cancerous), with the potential to spread to other parts of the body. Symptoms: Severe headache Palpitations Rapid heart rate Sweating Flushing Chest pain Abdominal pain Nervousness Irritability Increased appetite Loss of weight Tests & Labs: VMA & Metanephrines in urine An adrenal biopsy that shows pheochromocytoma A MIBG scintiscan that shows tumor o is a nuclear scan test that uses injected radioactive material (radioisotope) and a special scanner to locate or confirm the presence of pheochromocytoma and neuroblastoma, which are tumors of specific types of nervous tissue. An MRI of abdomen that shows adrenal mass An abdominal CT scan that shows mass. Elevated urine metanephrine Elevated urine catecholamines Abnormal results of a glucose test Abnormal levels of catecholamines in the blood Diagnosis: Phentolamin to Diagnose Treatment: Phenoxybenzamine to Tx Lastly, you must know the RULE OF 10s: 10% Occur in children 10% Malignant 10% Bilateral 10% Familial 10% Extra-Adrenal 10% Calcify 10% Recur

Now lets move into the GI Tract NASOPHARYNX: MC Mass is a Polyp which is a Hamartoma o Hamartoma is abnormal growth of normal tissue Remember that if a patient has Nasal Polyps in someone who has allergies, you should AVOID the use of ASPIRIN & NsAIDs in these patients. o Because if you block the cyclo-oxygenase pathway then everything is shunted to the Lipoxygenase pathway and you will have an increase in Leukotrienes. MC Tumor is a Fibroma MC Cancer is called Nasopharyngeal Carcinoma o Which is a squamous cell carcinoma o Associated with Chinese Women o Associated with EBV Remember that the only (2) cancers associated with EBV: Nasopharyngeal Carcinoma Burkitts Lymphoma OROPHARYNX: MC Tumor is a Fibroma MC Cancer is Squamous Cell Carcinoma o Classic Clue: Tends to Ulcerate o Connection: Leukoplakia (white plaque on the Buccal Mucosa) o #1 Risk Factor Smoking MC location for oral cancer: Floor of the mouth due to the angle of the cigarette. Lips Tip of Tongue o #2 Risk Factor Chewing Tobacco MC location for oral cancer: Lower lip Tongue Floor of the mouth

Organ Esophagus MC Tumor MC CA

Name Leiomyoma Squamous Cell Carcinoma

Clue Tends to Ulcerate and can produce a whole in the esophagus which will be painful when eating. Odynaphagia = painful swallowing Commonly due to Barretts Esophagus, complication of GERD Presentation: Painful swallowing

MC CA of the Lower 1/3rd

Esophageal Adenocarcinoma Risk Factors: smoking alcohol nitrites japanese

Organ Stomach MC Tumor MC CA

Name Leiomyoma Adenocarcinoma Risk Factors: smoking alcohol nitrites (smoked foods) Japanese Note: Vitamin E absorbes free radicals out of the blood and vitamin C in the GI tract.

Clue Infiltrates the stomach wall and distends it, thereby, by distention it will fire to the Satiety Center and therefore, has the most significant weight loss. (5) Classic Clues: 1. Leather water bottle Linnitis Plastica (infiltration of wall) 2. Virchows nodes mets to superclavicular area (esp. Left side) 3. Krukenberg seeding of the ovaries 4. Signet ring cells on biopsy 5. Significant Weight Loss

Organ Small intestine MC Tumor MC CA

Name Leiomyoma Adenocarcinoma

Clue Napkin-Ring appearance OR Eaten Apple Core Appearance Tends to cause an Obstruction, therefore, you will hear: - Decreased Bowel Sounds - Absent Bowel Sounds - Tinkling Bowel Sounds - Rushing Bowel Sounds

Anytime a patient comes in with abdominal pain due to obstruction what are your steps in management:

1) 2) 3) 4) 5) At the Ileum Appendix

Make the patient NPO NG Tube to decompress the belly Fluids Normal Saline Opiates for Pain Meperidine Abdominal X-ray

Lymphoma Ileum is 70% Lymphoid Tissue Carcinoid NO METS Carcinoid Syndrome pancreas/ileum

Colon MC tumor MC CA Leiomyoma Adenocarcinoma Presentation: Bleeding obstruction Fe2+ anemia Napkin ring Appearance Eaten Apple Core Appearance Risk Factors: #1 Low fiber diet #2 High fat intake promotes free radicals/mutations #3 Polyps

Being that the 3rd MC Risk Factor for Adenocarcinoma of the Colon are Polyps, Lets discuss them in further detail

POLYPS Benign Hyperplastic SEEN IN CHILDREN MCC of Bleeding in a Child Note: MCC of Bleeding in a Newborn: Swallowed Maternal Blood -therefore, you should run an APT Test to determine if there is HbF Complication : bleeding Malignant Adenomatous (Glandular) SEEN IN ADULTS

Peutz Jeghers Syndrome: polyposis hyperpigmented mucosa dark gums and vagina These genes run very close together with the oncogenes for: Breast CA Ovarian CA Lymphatic CA

Complications: bleeding Go on to CA 100% risk Secrete K+ hypokalemia (villous) Below are the (3) Types of Malignant Polyps: Tubular Tubulovillous Villous When it When it is When it is mostly flat sticks and (sessile) out Hypokalemia (U wave on EKG) Highest Risk of CA Familial Adenomatous Polyposis: - If suspected at birth with family history must perform annual colonoscopy with biopsy starting at age 5 -Autosomal Dominant form of Inheritance -100% Malignancy rate and at age 20 the risk jumps up -Wait until teenage years to take colon out Marsupialization Ileostomy and then ileo-anal pull through -If at anytime you notice DYSPLASIA, take out the entire colon, therefore, full colectomy. Subclasses of Familial Polyposis: Gardner syndrome: Familial Polyposis + Sebacceous adenomas + osteomas (benign tumor of bone) Turcots: Familial Polyposis with Brain tumors (astrocytoma)

Organ Liver MC Mass MC Tumor

Name Cyst #1 Hepatic Adenoma

Clue Associated with Estrogen -Will give you a patient on BCPs or a weightlifter that uses steroids. Notorious for rupturing if you have an increased intra-abdominal pressure.

#2 Hemangioma also referred to as an AVM -Remember that too many AVMs throughout your lungs is called Osler-Weber Rendu -Remember that AVMs in the abdomen & brain is known as Von Hippel Lindau which is associated with the short arm of chromosome 3 and have a high incidence of Renal cell carcinoma. MC CA MC 1 Liver Cancer Rare 1 Liver Cancer Metastasis Hepatocellular carcinoma Angiosarcoma of the Liver

Being that an artery is connected to a vein you will hear a continuous or machinery murmur AVO2 difference Patient can die in (3) ways: - If they burst and bleed it can cause massive hemorrhage - Sequester the platelets and cause bleeding - sequester blood and put the patient into heart failure Treatment of Hemangioma: -Embolization

Associated with CCl4

Risk Factors: HAVE BS CASH (PP clues) o Hepatitis B & C o Aflatoxin (Aspergilous) o Vinyl Chloride o Ethanol o Benzene o Smoking o CCl4 unique for giving Angiosarcoma of the liver o Analine dyes o Schistomomiasis o Hemochromatosis (HLA A3) (Smoking is #1 and then Alcohol is #2) Predisposing infections: o Hepatits B o Hepatitis C o shistocomyosis

Organ Gall Bladder MC Tumor MC CA

Name Leiomyoma Adenocarcinoma

Clue Thickened/calcified Gall Bladder seen on X-ray or Sonogram

Organ Biliary Tract MC Mass MC Tumor MC CA

Name Choledochocyst Cholangioma Cholangiocarcinoma

Clue Causes a conjugated direct hyperbilirubinemia (cholestatic jaundice) Predisposing Reason: -Scleosing-Cholangitis as seen in Ulcereative Colitis (Biopsy the sctrictures) -10 Biliary Sclerosis (anti-mitochondrial Abs)

Organ Pancreas MC Mass MC Tumor

Name Cyst Adenomas that produce hormones Glucagonoma

Clue Association with MEN I Glucagon Glucose Lipids Ketones insulin, C-peptide Watery diarrhea Constipation Flushing, Diarrhea, Respiratory P Serotonin (Made from Tryptoph) Measure 5-HIAA in urine Zollinger Ellison Syndrome: Gastrin levels b/w meals Ulcers everywhere all the way through ileum MEN I (Wermers) Painless Jaundice conjugated bilirubin d/t obstruction 90 % located in the head of the pancreas Trousseaus Syndrome (not sign) Migratory thrombophlebitis Mucin = clots

Insulinoma VIPoma Somatostatinoma Carcinoid Gastrinoma

MC CA

Adenocarcinoma

GENITOURINARY SYSTEM Organ Name KIDNEY Renal cyst MC Mass Renal adenoma MC Tumor WILMs TUMOR (Children) MC CA

Clue

MC Presentation: 1st Flank mass in abdomen 2nd Painless hematuria 90% seen in upper pole Actually a teratoma triphasic histology WAGR Wilms tumor Aniridia colorless eyes -caused when the gene responiable for eye development - the PAX6 gene - does not function correctly Genitourinary malformation Retardation Hemihypertrophy d/t cancer taking blood supply away (ex. One leg is thicker than the other; produces a lot of angiogenin) 20% recurrence in other kidney Diagnosis Sonagram Renal cell carcinoma (Adults) MC Presentation: 1st Painless hematuria 2nd Flank mass in abdomen 90% seen in upper pole Most vacular think angiogenin Likes to METS to Lung through the retroperitoneum Cannon ball mass Polycythemia Vera d/t erythropoietin Predisposition: Von Hippel Landau/Tuberous Sclerosis Connection b/w Wilms Tumor and Aniridia: o Wilms Tumor is due to an inherited WT1 mutation on human chromosome 11p13. The reason why these patients also have aniridia is because 98% of these are caused by a mutation of the PAX6 gene, which is found on band 13 on the short arm of the 11th chromosome (11p13) as well. This gene is responsible for the development of the eye, brain and nasal tissue. A mutation of this gene causes haploinsufficiency, the gene is unable to function. Management/Diagnosis Workup for Renal Cell Carcinoma: o 1. Perform a Urinalysis To detect if there is any blood in the urine o 2. Perform a Sonogram To evaluate the anatomy to see the involvement o 3. Perform an IVP To assess the function of the kidney o 4. Perform a CT scan of Abdomen & Chest To determine if there are any metastases; annual CT scans are needed o 5. Perform an Angiogram To allow the Surgeon a visual of the best approach to the cancer

Organ URETER/BLADDER MC Mass MC Tumor MC CA

Name Diverticulum (pocket) Leiomyoma Transitional Cell Carcinoma

Clue 2 complications: UTI & Stones Painless hematuria Risk Factors: Smoking - #1 Aflatoxin Benzene Schistomiasis Clue It is a Cyst b/c it is glandular Psammoma body Most mucinous cancer in women Jelly belly When the mucinous material leaks out into the belly it is called Pseudomyxoma peritoni Heavy Bleeding in older female Secretion of estrogen precocious puberty Call-Exner bodies (eosinophilic inclusion body) Is the most osmotically active ovarian tumor Can pull fluid out of the lungs or from the belly Meigs Syndrome = ascities + pleural effusion Leydig cells produce testosterone which leads to Masculization (androgen secretion) (+) -feto protein (+) HCG Ectoderm is the favorite cell line but it can become Ecto, Endo or Meso; This site has Endodermic differentiation. Hair and teeth in ovary Hyperthyroidism b/c composed of thyroid tissue

Organ OVARY MC Mass MC Tumor MC CA Misc.

Name Follicular cyst Serous cystadenoma Serous cystaadenocarcinoma Mucinous cystadenoma

Granulosa Cell Tumor Fibroma Sertoli-Leydig Cell Tumor Yolk sac Tumor Choriocarcinoma Teratoma

Struma ovarii (monodermal teratoma)

Organ UTERUS MC Mass MC Tumor Polyp

Name

Clue

MC CA

Hamartoma which is an abnormal growth of normal tissue Leiomyoma (Fibroid) 90% are Submucosal present with menorrhagia (focal thickening or the uterus) 10% are Subserosal chronic pain & pressure (pelvis) Fibroid estrogen dependent Tx: BCP >> Leuprolide (GnRH analog blocks LH/FSH) >> surgery (laser or hysterectomy) Endometrial Adenocarcinoma Present with vaginal bleeding between periods after AGE 35 In b/w periods #1 Risk = unopposed estrogen Tx: Hysterectomy Name Wart Clue HPV Condyloma accuminatum Verrucous or Mushroom shape HPV 16 & 18 CA Koilocytes, therefore, irritation and cells are on their way to metaplasia into squamous cells and then become Carcinoma Tx: Podophyline or Cryosurgery Syphillis Condyloma lata Fleshy Warts Tx: Podophyline or Cryosurgery Chronic irritation Post-coital bleeding recommend PAP Smear Chamydia Elisa Test #1 cause of infertility Tx: Hysterectomy

Organ CERVIX MC Cervical Mass

MC Cervical Tumor MC Cervical CA

Fibroma Squamous Cell Carcinoma

PAP Smear Management: First PAP smear is at the age of 16 OR within 3 years of sexual activity o This is because it takes 3-5 years before we can see any cancer o If mother and daughter like one another then the mother should be present for the 1st PAP It is normal to see the cervix bleed while performing a PAP b/c you have to have an adequate sample If you get (2) normal PAP results then you can spread them out to every 3-5 years On a PAP smear you are looking for DYSPLASIA (Remember catch it at Stage 1) Low Grade Finding o MCC = Infection (90% of times it is GC & Chlamydia, therefore, treat with Azithromycin) Then perform a Culture on the Cervical Secretions o If the dysplasia is less than CIN 2, then see them back in 6 months and repeat_ o Screen for Hepatitis B, RPR (Syphillis), HIV Anything from CIN 2 on: o Do culposcopy to rule out cancer by painting the cervix with acetic acid and watch the dysplastic area turn white and then perform either a Cone biopsy (O.R.) or a LEEP High Grade Findings: o Not caused by Infection and is cancer until proven otherwise straight to surgery

Endometrial Cancer and Cervical Cancer are the ONLY (2) cancers where the MCCOD is Renal Failure -This is b/c the Ureters run right next to them compresses both Ureters and the patient loses both kidneys at once. Organ VAGINA MC Mass #1 Polyp #2 Bartholin cyst Hamartoma abnormal growth of normal tissue Fluctuant mass behind Labia majora Complication: Infection/Abcess Tx of 1st Infection/Abcess Antibiotics Tx of 2nd Infection/Abcess Marsupialization Name Clue

MC Tumor MC CA Upper Mucosa (Cervical cancer coming downward) MC CA Lower Mucosa (Skeletal Muscle) MISC

Fibroma Squamous cell Carcinoma from cervix coming downward Rhabdomyosarcoma * If < 3 y.o. = Sarcoma botryoides Clear cell Carcinoma bunch of grapes Skeletal muscle > 90% d/t DES exposure White ridge on vaginal wall Clue Strains to urinate, weak stream, dribbling, urgency, frequency. Obstruction Management: 1st Line: 1 blocker Terazocin, Doxazocin (relax sphincter) but if you have S.E.s from these (2) you should switch to Tamsulosin. 2nd Line: Fenesteride (-) 5 reductase Surgery (TURP) if necessary MC Complication: Impotence PSA Complication 80% impotence d/t accidental severing of the pudendal nerve Hormone Treatment Flutamide blks. DHT receptors DES can cause irritability Likes to mets to spine OSTEOBLASTIC CA

Organ PROSTATE MC Tumor

Name Benign Prostatic Hypertrophy MCly occurs centrally around the middle of prostatic urethra

MC CA

Adenocarcinoma MCly occurs peripherally in the posterior lobe of the prostate Adult Screening (DRE): Age 35 Tx: Remove the prostate and testicles (remove testosterone)

Organ TESTICLE MC Mass

Name Hydrocele

Clue Patent Tunica Vaginalis Collection of H2O Transilluminates Tx: Nothing; Goes away by itself Trauma Complications: Infertility d/t impingement of spermatocord deoxygenated blood leads to decreased sperm production -feto protein MC CA in youth RARE solid testicular mass Tri-phasic almost like teratoma Tx: Orchiectomy on side of Cancer -hCG

2 MC Mass

nd

Hematoma (Child) Varicocele (Adult)

MC CA (1st Year of Life) MC CA (Teenage Years onward)

Yolk Sac (Germ Cell Tumor) Seminoma Choriocarcinoma

Remember that the RIGHT Testicular Vein drains right into the IVC so any infection on the RIGHT has a poor prognosis b/c it can become systemic Remember that the LYMPHATIC drainage of the Gonads (Ovaries & Testicles) drain to the PARA-AORTIC nodes

HYDROCELE

VARICOCELE

Organ SKIN MC Mass

Name #1 Skin Tags (acrochordon) #2 Hemangioma

Clue Tx: Tie it & shave it off Flat blood vessel 90% go away in 18 months on their own, therefore, just observe -If it is not gone you can inject it with steroids -If it is still not gone you can perform laser surgery on it If there are a lot, you should rule out Neurofibromatosis Papular with a central ulceration Associated with Sun Exposure Predominantly on head and neck No METS, therefore, good prog. Tx: Wide excision (1mm tumor free margins) Predisposing conditions: Actinic keratitis = thickened skin Skin deiseases that predispose to skin cancer: PKU Xeroderma pigmentosum Albinism Vitiligo Jobs Syndrome Porphyrin Cutaneous Tarda Wiskott Aldrich #1 Risk Factor = UV light Bowens Disease if it is on the penis or vulva Most Malignant but Rare ABCDs of Prognosis: Area Borders Color Diameter

MC Tumor MC CA

Fibromas (adult) Basal Cell Carcinoma

MC Malignancy

Squamous Cell Carcinoma

Melanoma

Note: Depth is the most important factor and it the melanoma has a depth of 1mm or greater then there is a 90% mortality associated with that.

BONE 1. Epiphysis: cartilaginous end(s) of a bone. 2. Physis: cartilaginous zone in between the epiphysis and calcified cartilage (metaphysis); also known as the epiphyseal plate or the growth plate. As it "closes", it is referred to as the epiphyseal line. 3. Metaphysis: The ossified portion of an epiphysis. 4. Diaphysis: Shaft of a tubular bone.

Organ BONE Epiphysis MC Tumor MC 10 CA

Name Chondroblastoma or Chondroma (however you want to name it) Chondrosarcoma Giant cell tumor

Clue LOCATIONS ARE KEY

Soap bubble appearance on Xray Moth eaten

Metaphysis MC Tumor MC 10 CA

Osteoblastoma or Osteoma (however you want to name it) Osteosarcoma (Adults)

Primarily after age 21 Codmans Triangle which is when it bursts (sunburst) through the cortex and you can see a triangle Pagets Disease

Diaphysis MC Tumor MC 10 CA (Children)

Osteoblastoma or Osteoma (however you want to name it) Osteosarcoma also known as Ewings Sarcoma (Children)

MC 10 CA (Adults)

Multiple Myeloma if mult lytic lesions Plasmacytoma if (1) lytic lesion

MICELLANEOUS

Osteoid Osteoma Giant Cell Tumor

(t11:22) Onion-skinning of the bone One hit; high incidence of RB Locations: Distal femur Proximal tibia Distal humerus Serum Ca2+ d/t bone destruction; Rouleau formation IgG (monoclonal) = M spike Bence Jones Protein (kappa) Punched out lesions on x-ray Benign 10 Bone Tumor with one hole in bone which hurts at night Osteoclasts eating bones- mothlike

Organ BREAST MC Mass MC Tumor < 25 y.o. MC Tumor > 25 y.o. MC CA Simple Cysts Fibroadenoma

Name

Clue If there are a lot of cysts it is called Fibrocystic Disease Due to estrogen Enlarges AFTER menses Due to progesterone Enlarges BEFORE menses MC location = upper outer quadrant of the breast b/c most of glands are in this location. 2nd location is around the nipple Dependent on Estrogen Pagets Disease: Is when you have this type of cancer and the patient forms a rash/ulcer around the nipple. Favorite site of Metastasis are to: Supraclavicular Nodes Lungs Chest Wall Axillary Nodes Bleeding from the nipple Associated with a contralateral second primary in the other breast Indian filing = clusters of cells fill intralobar ductules Multiple areas of focal areas of necrosisblack heads Grows LIKE a fungus exploding out of the breast Good prognosis Peau dorange WORST prognosis Lymphatic involvement

Fibrocystic Change Intraductal carcinoma (Infiltrating/invasive)

Benign Other Malignant tumors

Intraductal papilloma Lobular Carcinoma of the Breast

Comedocarcinoma Cystosarcoma phylloides Inflammatory Breast Carcinoma

Management of Breast Cancer Treatment Age 35 40 years Starting at 40 years of age 50-79 years of age The average life expectance for the White Female The average life expectance for the White Male The average life expectance for the Black Female The average life expectance for the Black Male

Management Baseline Breast Exam Monthly self exam by the patient Annual physician exam Annual mammograms looking for microcalcification is 80 84 is 76 80 is 66 70 is 60 64

Findings: Cyst/Soft Breast Mass: o Do H & P o Perform sonogram o fine needle aspiration Firm Breast Mass: o Do H & P o Mammogram o Surgery for lumpectomy Send to pathology If benign do nothing If malignant perform a wide resection by doing a Modified Radical Mastectomy meaning that you remove ALL breast tissue but you leave the Pectoralis Major behind so the patient can get an implant later on. o Then do a Nodal Biopsy Biopsy Supraclavicular Nodes Biopsy Axillary Nodes o Then Check for Estrogen Receptor o Anyone who is Estrogen Receptor positive place them on medications which block estrogen receptors at the pituitary and at the breast. But they are pro-estrogen at the bone and thereby protect her from osteoporosis. Recall that the liver breaks down estrogen, if there is more estrogen circulating it will stimulate the liver to work the liver produces proteins such as, Angiotensinogen BP and also makes the clotting factors clot formation and DVT/PE. Tamoxifen is proestrogen at the endometrium, thereby promotes endometrial cancer where Rolaxafen does not. Rolaxafen shows a lower incidence of DVTs, PEs and strokes than Tamoxifen o After surgery the patient must be places on: Chemotherapy if she is Pre-Menopausal Raditation if she is Post-Menopausal