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Finals > Oncology & Palliative Care > Flashcards

Oncology & Palliative Care Flashcards

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

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2
Q

How would you treat neutropenic sepsis?

A

Emipircal treatment with Tazocin (Piperacillin/Tazobactam)

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3
Q

Which cancers are most associated with spinal cord compression?

A 
Lung
Prostate
Breast
Myeloma
Melanoma
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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)

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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
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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

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7
Q

Causes of SVC obstruction

A

> 90% are due to malignancies, most commonly lung (75%), lymphoma, metastatic (e.g. breast), thymoma, germ cell

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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

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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
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10
Q

What is the most common metabolic abnormality in cancer patients?

A

Malignancy-associated hypercalcaemia

Poor prognostic sign

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11
Q

Causes of malignancy-associated hypercalcaemia

A

PTH-related protein produced by the tumour
Local osteolysis
Tumour production of calcitriol

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12
Q

Signs and symptoms of malignancy-associated hypercalcaemia

A 
Weight loss
Anorexia
Nausea
Polydipsia
Polyuria
Constipation
Abdo pain
Dehydration
Weakness
Confusion
Seizure
Coma
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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

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14
Q

How common are brain mets?

A

Affect up to 40% of pts with cancer

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15
Q

Most common cancers that met to brain

A

Lung
Breast
Colorectal
Melanoma

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16
Q

Signs and symptoms of brain mets

A 
Headache - often worse in morning, on coughing
Focal neuro signs
Ataxia
Fits
N+V
Papilloedema
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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

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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

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19
Q

What are the risks of tumour lysis syndrome

A

Arrhythmia

Renal failure

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20
Q

Management of tumour lysis syndrome

A

Prevent with hydration and uricolytics

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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
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22
Q

Which malignancies most commonly cause hypercalcaemia?

A 
Lung
Oesophagus
Skin
Cervix
Breast
Kidney
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23
Q

What metabolic abnormality is seen in SIADH?

A

Hyponatraemia

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24
Q

Which malignancies most commonly cause SIADH?

A

Lung
Pancreas
Lymphoma
Prostate

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25
Q

How do malignancies cause Cushing’s syndrome?

A

Tumour secretes ACTH or CRF causing the adrenals to produce inc corticosteroids

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26
Q

Which malignancies most commonly cause Cushing’s syndrome?

A

Lung
Pancreas
Thymus
Carcinoid

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27
Q

How does cancer cause neuropathy?

A

Antibody-mediated neuronal degeneration: peripheral, autonomic, cerebellar

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28
Q

Which malignancies most commonly cause neuropathy?

A 
Lung
Breast
Myeloma
Hodkin's
GI
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29
Q

What is Lambert-Eaton myasthenic syndrome?

A

Antibody to voltage-gated ion channel on pre-synaptic membrane causing weakness

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30
Q

Which malignancies most commonly cause Lambert-Eaton myasthenic syndrome?

A

Mostly lung

Also GI, breast, thymus

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31
Q

Which malignancies most commonly cause dermatomyositis and polymyositis?

A

Lung
Breast
Ovary
GI

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32
Q

What is Acanthosis nigricans?

A

Velvety, hyperpigmented skin

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33
Q

Which malignancies most commonly cause Acanthosis nigricans?

A

GI

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34
Q

What is pemphigus?

A

Blisters to skin/mucous membranes

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35
Q

Which malignancies most commonly cause pemphigus?

A

Lymphoma
Thymus
Kaposi’s sarcoma

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36
Q

What is hypertrophic osteoarthropathy?

A

Periosteal bone formation, arthritis, and finger clubbing

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37
Q

Which malignancies most commonly cause hypertrophic osteoarthropathy?

A

Lung

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38
Q

What are the risk factors for breast cancer?

A 
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
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39
Q

Describe the pathology of breast carcinoma

A

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

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40
Q

Describe the oestrogen receptor in breast cancer

A

60-70% of breast cancers are oestrogen receptor +ve, conveying better prognosis
30% over-express HER2, conveying aggressive disease and poorer prognosis

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41
Q

What investigations would you do for breast carcinoma?

A

Triple assessment -> clinical exam + mammography/US + histology/cytology

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42
Q

Cancer seen in Barrett’s

A

Adenocarcinoma of oesophagus

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43
Q

Most common (non-Barrett’s) oesophageal cancer

A

Squamous cell carcinoma

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44
Q

Best tumour marker in hepatocellular carcinoma

A

Serum AFP

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45
Q

Classic triad of a renal cell carcinoma

A

haematuria, loin pain, abdo mass

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46
Q

Other symptoms of a renal cell carcinoma

A 
Pyrexia of an unknown origin
Left varicocoele (due to occlusion of L testicular vein)
Endocrine effects - may secrete erythropoietin, PTH, renin, ACTH
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47
Q

Describe mesothelioma

A

Malignant disease of the pleura

Features incl SOB, chest pain and pleural effusion

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48
Q

Malignancy associated with tamoxifen use

A

Endometrial

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49
Q

Best marker to use to monitor the progression of bowel cancer, and its response to treatment

A

CEA

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50
Q

Treatment of SCLC

A

Chemo and radio

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51
Q

Painless jaundice

A

Pancreatic cancer

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52
Q

Bilateral inguinal lymphadenopathy in Coeliac

A

Enteropathy-associated T cell lymphoma

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53
Q

Contraindications for lung cancer surgery

A

SVC obstruction
FEV <1.5
Malignant pleural effusion
Vocal cord paralysis

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54
Q

Biopsy finding in gastric adenocarcinoma

A

Signet ring cells

55
Q

Describe the appearance of giant cell rumours on XR

A

Soap bubble appearance

56
Q

Presentation of multiple myeloma

A

Osteolytic bone lesions - backache, path fracture, vertebral collapse
Hypercalcaemia
Anaemia, neutropenia or thrombocytopenia
Recurrent bacterial infections - immunoparesis, neutropenia
Renal impairment

57
Q

Who gets osteosarcomas, and how do they present?

A 
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
Q

What is Ewing’s sarcoma?

A

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
Q

What are chondrosarcomas?

A

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
Q

What is osteochondroma?

A

Commonest benign bone tumour
Usually around the knee, prox femur or prox humerus
Presents as painful mass associated with trauma

61
Q

What is osteoid osteoma

A

Painful benign bone lesion that occurs in the long bones of young males
Local cortical sclerosis on XR
Relieved by simple analgesics

62
Q

Painless jaundice?

A

Pancreatic cancer

63
Q

Raised CA 19-9

A

Pancreatic cancer

64
Q

Fluctuating bowel habit with mucus

A

Colorectal Cancer

65
Q

Outline the role of oncogenes in the development of cancers

A

‘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
Q

Outline the role of tumour suppressor genes in the development of cancers

A

‘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
Q

What features would suggest a hereditary cancer?

A 
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
Q

Outline the risk of cancer with a BRCA1 mutation

A

55-65% lifetime risk of breast cancer

39% for ovarian

69
Q

Outline the risk of cancer with a BRCA 2 mutation

A

45% breast cancer

11% ovarian

70
Q

Woman without cancer but known BRCA mutation. What follow up is required?

A 
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
Q

What is Lynch syndrome?

A

HNPCC: 1-3% of colorectal Ca
AD due to mutations in mismatch repair genes
Lifetime risk of colorectal Ca is up to 80%

72
Q

What features would suggest Lynch syndrome?

A

If >= 3 affected relatives (one 1st-degree), from 2 successive generations, of whom one was affected <50yo

73
Q

Which cancers are people with Lynch syndrome at an inc risk of?

A 
Colorectal
Endometrium 
Ovary
Urinary tract
Stomach
Small bowel
HB tract
74
Q

Mutation seen in FAP

A

Mutations in the APC tumour suppressor gene

75
Q

What is Peutz-Jeghers syndrome? What genetic mutation is responsible for the development of cancers?

A

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
Q

Which cancers are people with Peutz-Jeghers syndrome at an inc risk of?

A

10-2% risk of colorectal Ca
50-60% risk of GI
60% risk of breast

77
Q

Outline the aetiology of prostate cancer

A

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
Q

Which cancer is most associated with a raised CEA?

A

Colorectal Ca

79
Q

Which cancer is most associated with a raised CA125?

A

Ovarian

80
Q

Which cancer is most associated with a raised CA19-9?

A

Pancreatic

81
Q

Which cancer is most associated with a raised CA15-3?

A

Breast

82
Q

Which cancer is most associated with a raised AFP?

A

Hepatocellular carcinoma

Teratoma

83
Q

Which cancer is most associated with a raised bHCG and raised AFP?

A

Non-seminomatous testicular cancer

84
Q

How do you convert oral codeine doses to oral morphine?

A

Divide by 10

85
Q

How do you convert transdermal fentanyl to oral morphine?

A

12mcg fentanyl patch = 30mg oral morphine daily

86
Q

How do you convert oral morphine to SC morphine?

A

Divide by 2

87
Q

What does a PET scan demonstrate?

A

Glucose uptake

88
Q

Cytotoxic agent most likely to cause cardiomyopathy

A

Doxorubicin

89
Q

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?

A

1/6 of the total

E.g. 30mg x2 = 60mg, 60mg /6 = 10mg for breakthrough

90
Q

When would consider a syringe driver in the palliative care setting?

A

When a pt is unable to take oral meds due t abuses, dysphagia, intestinal obstruction, weakness, or coma

91
Q

Pt with syringe driver is suffering from excessive resp secretions. What would you prescribe?

A

Hyoscine hydrobromide

92
Q

Pt with syringe driver is suffering from N+V. What would you prescribe?

A

Cyclizine, levomepromazine, haloperidol, or metoclopramide

93
Q

Pt with syringe driver is suffering from bowel colic. What would you prescribe?

A

Hyoscine butylbromide

94
Q

Pt with syringe driver is suffering from agitation/restlessness. What would you prescribe?

A

Midazolam
Haloperidol
Levomepromazine

95
Q

Pt with syringe driver is suffering from pain. What would you prescribe?

A

Diamorphine is the preferred opioid

96
Q

Lung cancer most strongly associated with smoking

A

Squamous cell

97
Q

Outline the pathology of squamous cell lung cancer

A 
Strongly associated with smoking
Typically central
Associated with PTHrP secretion -> hypercalcaemia
Finger clubbing
Hypertrophic pulmonary osteroarthropathy
98
Q

Outline the pathology of lung adenocarcinoma

A

Typically peripheral

Most common lung Ca in non-smokers, although majority of pts with adenocarcinoma are smokers

99
Q

Outline the pathology of large cell lung carcinoma

A

Typically peripheral
Anaplastic, poorly differentiated tumours
Poor prognosis
May secrete b-HCG

100
Q

Management of intractable hiccups in palliative care

A

Chlorpromazine or haloperidol

101
Q

Cytotoxic agents causing pulmonary fibrosis

A

Bleomycin

Methotrexate

102
Q

Cytotoxic drugs causing myelosuppression

A 
Cyclophosphamide
Methotrexate
6-mercaptopurine
Cytarabine
5-FU
103
Q

Management of metastatic bone pain

A

Analgesia
Bisphosphonates
Radiotherapy

104
Q

Preferred opioids in pts with CKD?

A

Alfetanil
Buprenorphine
Fentanyl

105
Q

How do you convert oral morphine to diamorphine via syringe driver?

A

Total daily oral morphine /3 = diamorphine dose ore 24hrs via syringe driver

106
Q

Cytotoxic agent causing peripheral neuropathy

A

Vincristine

107
Q

What cancer is calcitonin a marker of?

A

Medullary thyroid cancer

108
Q

As a GP, when would you refer a pt urgently under the 2WW for suspected lung Ca?

A

> 40yo with unexplained haemoptysis, or a CXR suggestive of Ca

109
Q

As a GP, when would you request an urgent CXR for suspected lung Ca?

A

> 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
Q

As a GP, when would you refer a pt for an urgent endoscopy for suspected upper GI cancer?

A

Dysphagia, or >55yo with w/l and upper abdo pain/reflux/dyspepsia

111
Q

As a GP, when would you refer a pt for suspected upper GI cancer?

A

> 40yo plus jaundice, or upper abdo mass

112
Q

As a GP, when would you refer a pt for an urgent CT of the pancreas?

A

> 60yo + w/l + any of:

  • diarrhoea
  • back pain
  • abdo pain
  • nausea
  • constipation
  • new-onset DM
113
Q

As a GP, when would you refer a pt for a non-urgent endoscopy?

A

> 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
Q

As a GP, when would you refer a pt urgently for suspected lower GI Ca?

A

+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
Q

As a GP, when would you order a faecal occult blood testing?

A

> 50yo + abdo pain or w/l
<60yo with change in bowel habit or iron-deficiency anaemia
60yo and anaemia

116
Q

As a GP, when would you refer under the 2WW for gynae?

A

Ascites
Pelvic mass (fibroid excl)
>55yo with post-menopausal bleeding

117
Q

As a GP, when would you refer under the 2WW for breast?

A

> 30yo with unexplained breast lump
50yo with symptoms or change to one nipple
Consider if skin changes or >30yo with axillary lump

118
Q

As a GP, when would you urgently refer under the 2WW for urology?

A

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
Q

Define adjuvant chemotherapy

A

After other initial treatment to reduce the risk of relapse, eg following surgical removal of cancer

120
Q

Define neoadjuvant chemotherapy

A

Used to shrink tumours prior to surgical or radiological treatment.
May allow later treatment to be more conservative

121
Q

Define palliative chemotherapy

A

No curative aim, offers symptomatic relief

May prolong survival

122
Q

Causes of chemotherapy side effects. Outline the most common SEs

A

Due to cytotoxic effects on non-cancer cells (greatest effect seen on dividing cells)

  • vomiting
  • alopecia
  • neutropenia
123
Q

List some indications for surgery in cancer care

A 
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
Q

Define radical radiotherapy

A

Given with curative intent

125
Q

Define palliative radiotherapy

A

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
Q

What are the early radiotherapy reactions? When would expect to see them?

A

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
Q

What are the late radiotherapy reactions? When would expect to see them?

A

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
Q

Briefly outline the pathology of acute leukaemias

A

Defective maturation of myeloid/lymphoid cells in bone marrow which spill out as immature blast cells that infiltrate

129
Q

Briefly outline the pathology of chronic leukaemias

A

Proliferation of mature myeloid/lymphoid cells in bone marrow which spill out and cause proliferative effects and infiltrate

130
Q

Briefly outline the pathology of lymphomas

A

Proliferation of lymphoid cells from within lymphoid tissue that infiltrate out

131
Q

General symptoms of haem malignancies

A

B symptoms (fever, night sweats, w/l)
FBC symptoms - anaemia, leucopenia, thrombocytopenia
Lymph nodes - cervical, inguinal, axillary

132
Q

Specific symptoms of lymphoid proliferation/infiltration

A 
Hepatosplenomegaly
Bone
Skin
Gums
Testes 
Thymus
133
Q

Specific symptoms of myeloid proliferation

A

Hepatosplenomegaly
Hyperviscosity
Hyperuricaemia

134
Q

Most common paed haem malignancy

A

ALL

Finals (25 decks)

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