Oncology & Palliative Care Flashcards
(134 cards)
1
Q
What would make you suspect neutropenic sepsis in a chemotherapy patient?
A
Temp >38 and neutrophil count <0.5x10^9/L
Pt would be unwell and within 6wks of last chemo
2
Q
How would you treat neutropenic sepsis?
A
Emipircal treatment with Tazocin (Piperacillin/Tazobactam)
3
Q
Which cancers are most associated with spinal cord compression?
A
Lung Prostate Breast Myeloma Melanoma
4
Q
Causes of spinal cord compression in cancer
A
Collapse of compression of a vertebral body due to metastases (common), or direct extension of a tumour into the vertebral column (rare)
5
Q
Signs and symptoms of spinal cord compression in cancer
A
Back pain in 95% Nocturnal pain Pain on straining Cervical/thoracic pain -> inc concern Limb weakness Difficulty walking Sensory loss Bladder/bowel dysfunction
6
Q
Management of spinal cord compression in cancer
A
Admit for bed rest
Urgent (<24hr) MRI of whole spine
Dexamethasone (16mg/24h) PO with gastroprotection
Reduced mobility? - consider thromboproph
Refer urgently to oncology/cancer MDT
Radiotherapy
7
Q
Causes of SVC obstruction
A
> 90% are due to malignancies, most commonly lung (75%), lymphoma, metastatic (e.g. breast), thymoma, germ cell
8
Q
Signs and symptoms of SVC obstruction
A
Clinical diagnosis
SOB, orthopnoea, stridor, plethora/cyanosis, oedema of face and arm, cough, headache, engorged neck veins, engorged chest wall veins
9
Q
Management of SVC obstruction
A
Prop them up Assess for hypoxia + O2 if needed Dexamethasone (16mg/24h) CT to define anatomy of obstruction Balloon venoplasty and SVC stenting to relieve symptoms Radiotherapy or chemotherapy
10
Q
What is the most common metabolic abnormality in cancer patients?
A
Malignancy-associated hypercalcaemia
Poor prognostic sign
11
Q
Causes of malignancy-associated hypercalcaemia
A
PTH-related protein produced by the tumour
Local osteolysis
Tumour production of calcitriol
12
Q
Signs and symptoms of malignancy-associated hypercalcaemia
A
Weight loss Anorexia Nausea Polydipsia Polyuria Constipation Abdo pain Dehydration Weakness Confusion Seizure Coma
13
Q
Management of malignancy-associated hypercalcaemia
A
Aggressive rehydration
Bisphosphonates IV (if eGFR >30)
Calcitonin - gives more rapid but short-term effect
Long-term -> control of malignancy
14
Q
How common are brain mets?
A
Affect up to 40% of pts with cancer
15
Q
Most common cancers that met to brain
A
Lung
Breast
Colorectal
Melanoma
16
Q
Signs and symptoms of brain mets
A
Headache - often worse in morning, on coughing Focal neuro signs Ataxia Fits N+V Papilloedema
17
Q
Management of brain mets
A
Urgent CT/MRI depending on underlying diagnosis, disease stage, and performance status
Dexamethasone (16mg/24h) to dec cerebral oedema
Stereotactic radiotherapy
Discuss with neurosurgery
18
Q
What is the cause of tumour lysis syndrome
A
Chemotherapy for rapidly proliferating tumours (leuk, lymph, myeloma) leads to cell death and inc urate, inc phosphate and dec calcium
19
Q
What are the risks of tumour lysis syndrome
A
Arrhythmia
Renal failure
20
Q
Management of tumour lysis syndrome
A
Prevent with hydration and uricolytics
21
Q
List the paraneoplastic syndromes
A
Hypercalcaemia SIADH Cushing's syndrome Neuropathy Lambert-Eaton myasthenic syndrome Dermatomyositis and polymyositis Acanthosis nigricans Pemphigus Hypertrophic osteoarthropathy
22
Q
Which malignancies most commonly cause hypercalcaemia?
A
Lung Oesophagus Skin Cervix Breast Kidney
23
Q
What metabolic abnormality is seen in SIADH?
A
Hyponatraemia
24
Q
Which malignancies most commonly cause SIADH?
A
Lung
Pancreas
Lymphoma
Prostate
25
How do malignancies cause Cushing's syndrome?
Tumour secretes ACTH or CRF causing the adrenals to produce inc corticosteroids
26
Which malignancies most commonly cause Cushing's syndrome?
Lung
Pancreas
Thymus
Carcinoid
27
How does cancer cause neuropathy?
Antibody-mediated neuronal degeneration: peripheral, autonomic, cerebellar
28
Which malignancies most commonly cause neuropathy?
```
Lung
Breast
Myeloma
Hodkin's
GI
```
29
What is Lambert-Eaton myasthenic syndrome?
Antibody to voltage-gated ion channel on pre-synaptic membrane causing weakness
30
Which malignancies most commonly cause Lambert-Eaton myasthenic syndrome?
Mostly lung
| Also GI, breast, thymus
31
Which malignancies most commonly cause dermatomyositis and polymyositis?
Lung
Breast
Ovary
GI
32
What is Acanthosis nigricans?
Velvety, hyperpigmented skin
33
Which malignancies most commonly cause Acanthosis nigricans?
GI
34
What is pemphigus?
Blisters to skin/mucous membranes
35
Which malignancies most commonly cause pemphigus?
Lymphoma
Thymus
Kaposi's sarcoma
36
What is hypertrophic osteoarthropathy?
Periosteal bone formation, arthritis, and finger clubbing
37
Which malignancies most commonly cause hypertrophic osteoarthropathy?
Lung
38
What are the risk factors for breast cancer?
```
Family Hx
Age
Uninterrupted oestrogen exposure -> so nulliparity, 1st pregnancy >30y/o, early menarche, late menopause, HRT
Obesity
BRCA genes
Not breastfeeding
Past breast cancer
```
39
Describe the pathology of breast carcinoma
Non-invasive ductal carcinoma in situ (DCIS) is premalignant and seen as microcalcification on mam
Non-invasive lobular CIS is rarer
Invasive ductal carcinoma is most common (70%) whereas invasive lobular carcinoma is rarer (15%)
Medullary cancers (5%) tend to affect younger
Colloid/Mucoid (2%) tend to affect the elderly
Others incl papillary, tubular, adenoid-cystic and Paget's
40
Describe the oestrogen receptor in breast cancer
60-70% of breast cancers are oestrogen receptor +ve, conveying better prognosis
30% over-express HER2, conveying aggressive disease and poorer prognosis
41
What investigations would you do for breast carcinoma?
Triple assessment -> clinical exam + mammography/US + histology/cytology
42
Cancer seen in Barrett’s
Adenocarcinoma of oesophagus
43
Most common (non-Barrett’s) oesophageal cancer
Squamous cell carcinoma
44
Best tumour marker in hepatocellular carcinoma
Serum AFP
45
Classic triad of a renal cell carcinoma
haematuria, loin pain, abdo mass
46
Other symptoms of a renal cell carcinoma
```
Pyrexia of an unknown origin
Left varicocoele (due to occlusion of L testicular vein)
Endocrine effects - may secrete erythropoietin, PTH, renin, ACTH
```
47
Describe mesothelioma
Malignant disease of the pleura
| Features incl SOB, chest pain and pleural effusion
48
Malignancy associated with tamoxifen use
Endometrial
49
Best marker to use to monitor the progression of bowel cancer, and its response to treatment
CEA
50
Treatment of SCLC
Chemo and radio
51
Painless jaundice
Pancreatic cancer
52
Bilateral inguinal lymphadenopathy in Coeliac
Enteropathy-associated T cell lymphoma
53
Contraindications for lung cancer surgery
SVC obstruction
FEV <1.5
Malignant pleural effusion
Vocal cord paralysis
54
Biopsy finding in gastric adenocarcinoma
Signet ring cells
55
Describe the appearance of giant cell rumours on XR
Soap bubble appearance
56
Presentation of multiple myeloma
Osteolytic bone lesions - backache, path fracture, vertebral collapse
Hypercalcaemia
Anaemia, neutropenia or thrombocytopenia
Recurrent bacterial infections - immunoparesis, neutropenia
Renal impairment
57
Who gets osteosarcomas, and how do they present?
```
Primary = adolescents, arises in metaphyses of long bone (knee)
Secondary = Paget's disease or after irradiation
```
Non-mechanical bone pain or joint pain
Bone pain at night
Bone swellings
Pathological fractures
58
What is Ewing's sarcoma?
Malignant round-cell tumour of long bones and limb girdles
Usually presents in adolescents
Bone destruction
New bone formation in concentric layers (onion ring sign)
Soft tissue swelling
Periosteal elevation
59
What are chondrosarcomas?
Malignant
May arise de novo or from malignant transformation of chondromas. Usually associated with pain, or a lump
Presents in the axial skeleton of the middle-aged
60
What is osteochondroma?
Commonest benign bone tumour
Usually around the knee, prox femur or prox humerus
Presents as painful mass associated with trauma
61
What is osteoid osteoma
Painful benign bone lesion that occurs in the long bones of young males
Local cortical sclerosis on XR
Relieved by simple analgesics
62
Painless jaundice?
Pancreatic cancer
63
Raised CA 19-9
Pancreatic cancer
64
Fluctuating bowel habit with mucus
Colorectal Cancer
65
Outline the role of oncogenes in the development of cancers
‘Gain of function’
They have pathological activity in the absence of a relevant signal. E.g. RAS is a protein involved in signal transduction and is mutated in ~30% of cancers. Oncogenes behave in a dominant manner - mutation in one allele results in unchecked activation
66
Outline the role of tumour suppressor genes in the development of cancers
‘Loss of function’
No longer act as inhibitors of pro-malignant processes. In most cases, mutations to both alleles must occur for a cancer phenotype. This may occur as two separate events, or in the case of predisposition genes, the first ‘hit’ is inherited and the second occurs somatically.
67
What features would suggest a hereditary cancer?
```
Unusual early age or presentation
Multiple primary cancers or bilateral/multifocal cancers
Clustering of cancers in relatives
Cancers in multiple generations
Rare tumours or histology
Ethnicity
```
68
Outline the risk of cancer with a BRCA1 mutation
55-65% lifetime risk of breast cancer
| 39% for ovarian
69
Outline the risk of cancer with a BRCA 2 mutation
45% breast cancer
| 11% ovarian
70
Woman without cancer but known BRCA mutation. What follow up is required?
```
Annual MRI 30-49yo, and annual mammography 50-69yo
Prophylactic tamoxifen or raloxifene may be appropriate depending on tolerance and VTE/endometrial cancer risk.
Surgical management (mastectomy/oophorectomy) should only be considered via a specialist MDT
```
71
What is Lynch syndrome?
HNPCC: 1-3% of colorectal Ca
AD due to mutations in mismatch repair genes
Lifetime risk of colorectal Ca is up to 80%
72
What features would suggest Lynch syndrome?
If >= 3 affected relatives (one 1st-degree), from 2 successive generations, of whom one was affected <50yo
73
Which cancers are people with Lynch syndrome at an inc risk of?
```
Colorectal
Endometrium
Ovary
Urinary tract
Stomach
Small bowel
HB tract
```
74
Mutation seen in FAP
Mutations in the APC tumour suppressor gene
75
What is Peutz-Jeghers syndrome? What genetic mutation is responsible for the development of cancers?
AD condition causing benign hamartomatous polyps in the GI tract and hyperpigmented macules on the lips and oral muscosa
Malignancies occur due to a mutation in a tumour suppressor gene
76
Which cancers are people with Peutz-Jeghers syndrome at an inc risk of?
10-2% risk of colorectal Ca
50-60% risk of GI
60% risk of breast
77
Outline the aetiology of prostate cancer
5-10% estimated to be due to inherited factors
| Genes incl BRCA1, BRCA 2, mismatch repair, and HOXB13 which interacts with androgen receptor. Age and race contribute
78
Which cancer is most associated with a raised CEA?
Colorectal Ca
79
Which cancer is most associated with a raised CA125?
Ovarian
80
Which cancer is most associated with a raised CA19-9?
Pancreatic
81
Which cancer is most associated with a raised CA15-3?
Breast
82
Which cancer is most associated with a raised AFP?
Hepatocellular carcinoma
| Teratoma
83
Which cancer is most associated with a raised bHCG and raised AFP?
Non-seminomatous testicular cancer
84
How do you convert oral codeine doses to oral morphine?
Divide by 10
85
How do you convert transdermal fentanyl to oral morphine?
12mcg fentanyl patch = 30mg oral morphine daily
86
How do you convert oral morphine to SC morphine?
Divide by 2
87
What does a PET scan demonstrate?
Glucose uptake
88
Cytotoxic agent most likely to cause cardiomyopathy
Doxorubicin
89
For a patient already taking MR oral morphine, how would you calculate the dose for breakthrough pain?
E.g. Pt takes 30mg BD, what would you prescribe for breakthrough pain?
1/6 of the total
E.g. 30mg x2 = 60mg, 60mg /6 = 10mg for breakthrough
90
When would consider a syringe driver in the palliative care setting?
When a pt is unable to take oral meds due t abuses, dysphagia, intestinal obstruction, weakness, or coma
91
Pt with syringe driver is suffering from excessive resp secretions. What would you prescribe?
Hyoscine hydrobromide
92
Pt with syringe driver is suffering from N+V. What would you prescribe?
Cyclizine, levomepromazine, haloperidol, or metoclopramide
93
Pt with syringe driver is suffering from bowel colic. What would you prescribe?
Hyoscine butylbromide
94
Pt with syringe driver is suffering from agitation/restlessness. What would you prescribe?
Midazolam
Haloperidol
Levomepromazine
95
Pt with syringe driver is suffering from pain. What would you prescribe?
Diamorphine is the preferred opioid
96
Lung cancer most strongly associated with smoking
Squamous cell
97
Outline the pathology of squamous cell lung cancer
```
Strongly associated with smoking
Typically central
Associated with PTHrP secretion -> hypercalcaemia
Finger clubbing
Hypertrophic pulmonary osteroarthropathy
```
98
Outline the pathology of lung adenocarcinoma
Typically peripheral
| Most common lung Ca in non-smokers, although majority of pts with adenocarcinoma are smokers
99
Outline the pathology of large cell lung carcinoma
Typically peripheral
Anaplastic, poorly differentiated tumours
Poor prognosis
May secrete b-HCG
100
Management of intractable hiccups in palliative care
Chlorpromazine or haloperidol
101
Cytotoxic agents causing pulmonary fibrosis
Bleomycin
| Methotrexate
102
Cytotoxic drugs causing myelosuppression
```
Cyclophosphamide
Methotrexate
6-mercaptopurine
Cytarabine
5-FU
```
103
Management of metastatic bone pain
Analgesia
Bisphosphonates
Radiotherapy
104
Preferred opioids in pts with CKD?
Alfetanil
Buprenorphine
Fentanyl
105
How do you convert oral morphine to diamorphine via syringe driver?
Total daily oral morphine /3 = diamorphine dose ore 24hrs via syringe driver
106
Cytotoxic agent causing peripheral neuropathy
Vincristine
107
What cancer is calcitonin a marker of?
Medullary thyroid cancer
108
As a GP, when would you refer a pt urgently under the 2WW for suspected lung Ca?
>40yo with unexplained haemoptysis, or a CXR suggestive of Ca
109
As a GP, when would you request an urgent CXR for suspected lung Ca?
>40yo and:
- persistent/recurrent chest infection
- finger clubbing
- supraclavicular/cervical lymphadenopathy
- thrombocytosis
- two of: cough, fatigue, SOB, chest pain, w/l, dec appetite, smoker, asbestos
110
As a GP, when would you refer a pt for an urgent endoscopy for suspected upper GI cancer?
Dysphagia, or >55yo with w/l and upper abdo pain/reflux/dyspepsia
111
As a GP, when would you refer a pt for suspected upper GI cancer?
>40yo plus jaundice, or upper abdo mass
112
As a GP, when would you refer a pt for an urgent CT of the pancreas?
>60yo + w/l + any of:
- diarrhoea
- back pain
- abdo pain
- nausea
- constipation
- new-onset DM
113
As a GP, when would you refer a pt for a non-urgent endoscopy?
>55yo and one of: treatment-resistant dyspepsia, upper abdo pain + low HB, inc plts, or N+V, + other upper GI symptoms/ w/l
Haematemesis
114
As a GP, when would you refer a pt urgently for suspected lower GI Ca?
+ve faecal occult blood
>40yo with abdo pain + w/l
>50yo with unexplained rectal bleeding
>60yo with iron-deficient anaemia or change in bowel habit
115
As a GP, when would you order a faecal occult blood testing?
>50yo + abdo pain or w/l
<60yo with change in bowel habit or iron-deficiency anaemia
>60yo and anaemia
116
As a GP, when would you refer under the 2WW for gynae?
Ascites
Pelvic mass (fibroid excl)
>55yo with post-menopausal bleeding
117
As a GP, when would you refer under the 2WW for breast?
>30yo with unexplained breast lump
>50yo with symptoms or change to one nipple
Consider if skin changes or >30yo with axillary lump
118
As a GP, when would you urgently refer under the 2WW for urology?
1) Irregular prostate on PR, abnormal age-specific PSA
2) >40yo with unexplained visible haematuria, >60yo with unexplained non-visible haematuria plus dysuria or inc WCC
3) Non-painful enlargement or change in shape/texture of testicle
119
Define adjuvant chemotherapy
After other initial treatment to reduce the risk of relapse, eg following surgical removal of cancer
120
Define neoadjuvant chemotherapy
Used to shrink tumours prior to surgical or radiological treatment.
May allow later treatment to be more conservative
121
Define palliative chemotherapy
No curative aim, offers symptomatic relief
| May prolong survival
122
Causes of chemotherapy side effects. Outline the most common SEs
Due to cytotoxic effects on non-cancer cells (greatest effect seen on dividing cells)
- vomiting
- alopecia
- neutropenia
123
List some indications for surgery in cancer care
```
Prevention - colectomy in FAP
Screening - endoscopy, colonoscopy
Diagnosis + staging - fine needle aspiration, core needle biopsy etc
Treatment - resection of tumour
Reconstruction - following treatment
Palliative - bypass, stoma, stenting
```
124
Define radical radiotherapy
Given with curative intent
125
Define palliative radiotherapy
Aims to relieve symptoms, may not impact on survival
| Doses are smaller and given in fewer fractions to offer short-term tumour control with minimal SEs
126
What are the early radiotherapy reactions? When would expect to see them?
Occurs ~2wks into treatment
- tiredness -> 80%, improves at ~4wks, advise to stay active
- skin reactions -> erythema, dry + wet desquamation, ulceration
- mucositis -> dental checkup if head+neck treatment, avoid smoking, antiseptic mouthwashes can help
- N+V -> if stomach, liver or brain. Give metoclopramide, domperidone or ondansetron
- diarrhoea -> usually after abdo or pelvic treatments, maintain hydration
- dysphagia -> following thoracic treatments
- cystitis -> after pelvic treatments
127
What are the late radiotherapy reactions? When would expect to see them?
Occur months-years after treatment
- CNS/PNS -> somnolence, spinal cord myelopathy progressive weakness), brachial plexopathy (numb, weak, or painful arm)
- lung -> pneumonitis can. Occur 6-12wks after thoracic treatment
- GI -> xerostomia, radiation proctitis
- GU -> urinary frequency, vaginal stenosis, dyspareunia, ED, dec fertility
- endocrine -> panhypopituitarism, hypothyroidism
- secondary Ca
128
Briefly outline the pathology of acute leukaemias
Defective maturation of myeloid/lymphoid cells in bone marrow which spill out as immature blast cells that infiltrate
129
Briefly outline the pathology of chronic leukaemias
Proliferation of mature myeloid/lymphoid cells in bone marrow which spill out and cause proliferative effects and infiltrate
130
Briefly outline the pathology of lymphomas
Proliferation of lymphoid cells from within lymphoid tissue that infiltrate out
131
General symptoms of haem malignancies
B symptoms (fever, night sweats, w/l)
FBC symptoms - anaemia, leucopenia, thrombocytopenia
Lymph nodes - cervical, inguinal, axillary
132
Specific symptoms of lymphoid proliferation/infiltration
```
Hepatosplenomegaly
Bone
Skin
Gums
Testes
Thymus
```
133
Specific symptoms of myeloid proliferation
Hepatosplenomegaly
Hyperviscosity
Hyperuricaemia
134
Most common paed haem malignancy
ALL
