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Long case clinical skills > Haem/onc for long case > Flashcards

Haem/onc for long case Flashcards

1
Q

Palliative care related social needs

A
  • Finances not working and access – not being able to drive to chemist, unable to afford medications
  • Social isolation – impact on pain and mood overall adherence to therapy, increased risk of readmission
  • Drug addicted son – Risk of opioid misuse, disruption of family dynamic, stress on patient and attending son’s care needs, risk of palliate care service seeing patient
  • Lack of GP notice – out of loop, may be reluctant to prescribe opioid at doses without proper correspondence
  • Driving – a stable dose of opioids given alertness and retained cognition is not a contraindication to drive, but at the discretion of state and territory jurisdiction and GP concerns
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2
Q

Management of Chronic Myelogenous Leukaemia

A

1) WCCs, bone marrow biopsy (bone marrow hyperplasia), cytogenetic karyotype testing (BCR-ABL t(9:22) philedelphia chromosome)
2) stabilise cell counts with hydroxyurea, prevent secondary gout with hydroxyurea
3) Imatinib - tyrosine kinase inhibitor - monitor with FBE, bone marrow 3 monthly, BCR-ABL PCR
- dasatinib/nilotinib second line if not responsive to imatinib
4) Allograft bone marrow transplant in blast phase not responsive to imatinib

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3
Q

Management of Acute myeloid leukaemia

A

1) Stratify risk - FBE, coag profile
- Bone marrow biopsy >20% blast cells
- Immunophenotyping - PML-RARA transcript, CBF leukaemia,
- Karyotyping -t(15:17), t(8:12), inv 6 (good prognosis), del 7 or complex karyotypes Poor prognosis) - APML - evidence of DIC
2) Chemotherapy for pt <70 and good performance state
- ICE (idarubicin, cytarabine, etoposide) or fludarabine, cytatabine combinations
3) Allograft stem cell transplant - poor risk and/or good performance status
- Poor prognosis factors (secondary leukaemia, poor performance status, Age > 60, Adverse cytogenetics)
4) acute promyelocytic leukaemia treatment
- All-trans-rentinoic acid and idarubicin
- ATRA, methotrexate and 6-mercaptopurse

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4
Q

Management of Acute lymphoblastic leukaemia

A

1) chemotherapy - prednisolone, combination chemotherapy, CNS prophylaxis with methotrexate and cranial irradiation
2) Allogenic stem cell transplant
3) poor cytogenetic markers include t(9:22) and t(4:11)

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5
Q

Chronic lymphocytic leukaemia management

A

1) Stage and prognosticate
- Lymph node count - Stage A <2, stage B>2, stage C - anaemia or thrombocytopaenia
- Indications for therapy: B symptoms, bulky disease/advanced stage, autoimmune phenomena (autoimmune haemolytic anaemia), rapid doubling time <6 months, young age < 40, bone marrow failure
- Cytogenetic and immunophenotyping - CD38, trisomy 12, 11q, del 17p unmutated IgH, ZAP70 (all poor prognosis)
2) Chemotherapy < 70 with good prognosis
- fludarabine/cyclophosphamide and rituximab
- Relapse: alemtuzumab
3) Chemo >70 years and/or poor prognosis
- fludarabine or chlorambucil and rituximab
4) < 50yrs old - allogenic stem cell transplant

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6
Q

Management of Hodgkin’s lymphoma

A

1) Early stage disease (AA stage - I, IB, IIA, non-bulky disease)
- Good prognostic markers - doxorubicin, bleomycin, vinblastine dacarbazine (ABVD) for 4 months, (> 6 months for poor prognosis)
- Consider omitting bleomycin if DLCO is reduced or consider Mechlorethamine, vincristine, prednisolone, procarbazine (MOPP)
2) Advanced disease (AA stage bulky disease, IIB, III, IV)
- Good prognosis (IPS <4) - 6 months of ABVD followed by radiotherapy to bulky sites
- Poor prognosis (IPS >4) - BEACOP for < 60yrs - bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, prednisolone, procarbazine), ABVD for age> 60yrs
3) Monitor for risk of AML and NHL after 10yrs and solid tumours after 15yrs

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7
Q

Prognostication of Hodgkin’s lymphoma

A

Serum alb <40

Hb <10.5

Male

Age >45yrs

Stage IV

WCC >15

Lymphocytes <0.6

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8
Q

Prognosis of non-Hodgkin’s lymphoma

A

Age >60 years

Stage III or IV

LDH >10

Extranodal spread

Poor performace status 2-4

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9
Q

NHLs and treatment

A

1) Diffuse B cell lymphoma - RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone); intrathecal methotrexate if CNS involvement
- Relapse - fludarabine followed by allogenic stem cell transplant, hypomethylating agents, monoclonal antibodies
2) Mantle cell lymphoma - low grade but poor prognosis - R-hyper CVAD (MDACC), R- CHOP, FCR - followed by allogenic stem cell transplant
3) Burkitt’s and lymphoblastic lymphoma - managed as ALL
4) T cell lymphoma - hyperCVAD, allogenic stem cell transplant
5) Follicular lymphoma (indolent) - treat as per CLL

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10
Q

Secondary causes of NHLs

A

Hepatitis C

HIV and immunosuppression

Sjogrens

Radiation exposure

Coeliac’s disease - gastrointestinal lymphoma

Helicobacter pylori - MALT lymphoma

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11
Q

Examination for haematological malignancy

A

Plethoric facies, hypertension,

Conjunctival pallor, mucosal bleeding

gum hypertrophy (AML)

Bony tenderness (MM, ALL)

Lymphadenopathy (epitrochlear, axillary, cervical, inguinal)

Hepatosplenomegaly (CML, AML, polycythemia vera)

Arthritis (gout), digital infarcts (erythromelalgia)

Fundus for retinal venous engorgement (PV), retinal ischaemia (hyperleukocytosis syndrome in AML)

Retinal ischaemia, neurological deficit, respiratory distress (hyperleucocytosis syndrome)

Cirrhosis (Budd-Chiari in PV)

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12
Q

Investigation of polycythemia

A

History of - headache, vertigo, tinnitus, blurred vision, pruritis, tingling in extremities in heat, previous stroke (hyperviscosity syndrome)

Investigation - FBE, red cell mass to exclude erythocytosis in setting of low plasma volume

EPO >4 secondary polycythemia, <4 primary

oxygen sats overnight - exclude sleep apnoea

High uric acid, low iron and raised B12 supports polycythemia vera

Abdo uss - exclude erythropoietin secreting mass lesions

Bone marrow - myeloid cell hyperplasia

JAK2 2 gene mutation 95% sensitivity for PCV

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13
Q

Management of PCV

A

Raised haematocrit controlled by venesection

Low dose aspirin for thrombosis

Chemotherapy busulfan or P32 for resistant cases

Erythromelalgia successfully managed with salicylate therapy

Hyperuricaemia is managed with allopurinol

Massive splenomegaly with splenectomy

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14
Q

Ann Arbor staging for Hodgkin’s lymphoma

A

Stage 1 - Single lymph node region

Stage 2 - 2 or more lymph node regions located on same side of diaphragm

Stage 3 - 2 or more lymph node regions on both sides of diaphragm

Stage 4 disseminated disease

B symptoms - night sweats, fevers, weight loss >10% of body in 6 months

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15
Q

History for cancer patient

A

Initial presenting symptoms

Diagnostic tests carried out

Treatment received so far

Exposure to carcinogens

Past medical history (UC w/ colonic carcinoma, H pylori w/ MALT, HL for AML, CML patients, cirrhosis for hepatic carcinoma, HPV infection for cervical and head and neck Ca)

Exposure to immunosuppressive therapies, chemotherapy, radiation exposure, hormonal treatment

Family history

Social - smoking, alcohol, sexual activity, sun exposure, asbestos

Type and regime of chemotherapy an radiotherapy

Side effects such as nausea, vomiting and oral mucositis, hair loss, sepsis, organ specific - cardiac toxicity, pulmonary toxicity, peripheral neuropathy, bladder toxicity)

Sperm and ova harvesting

Depression

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16
Q

Examination for cancer patients

A

General - cachexia, alopecia, cushingoid body habitus, vascular access devices, flat affect

Skin - radiation dermatitis, radiation burns, surgical scars, radiotherapy tattoos

Buccal mucosa for pigmented lesions - Peutz-Jegher’s syndrome - colorectal Ca

Organomegaly, hepatomegaly, splenomegaly, bony tenderness

Lymphadenopathy

Define mass lesions by quoting measurements, consistency, fixation/mobility, shape and temp

Evidence of pulmonary toxicity (cyclophosphamide, bisulphan, bleomycin, radiotherapy)

Neurological examination (exclude cord compression, cerebral mets, paraneoplastic phenomenan neurotoxic phenomena)

Evidence of heart failure (treatment with anthracyclines)

17
Q

Management of Breast Cancer

A

1) screening - ages 50 to 70 mammogram 2 years
2) mass discovery - FNA or core biopsy; need to check for axillary lymphadenopathy and hepatomegaly; LFTs (raised ALP) and X ray, uss or CT CAP +/- bone scan
3) Early stage disease
- Resection and breast conserving surgery and radiotherapy or modified radical mastectomy
- Adjuvant chemotherapy (hormonal and/or monoclonal antibody depending on hormone receptor positivity, HER2 receptor positivity, menopausal state)
4) Advanced stage disease
- Induction chemotherapy
- Regional therapy with surgery and/or radiotherapy
- oophorectomy or chemical castration with LH in younger hormone receptor positive patients
- Older patient hormone receptor positive - tamoxifen, aromatase inhibitor or single agent chemotherapy

18
Q

Adjuvant chemotherapy early stage in breast cancer

A

1) Hormone receptor positive
- Premenopausal - Chemotherapy with taxanes and anthracyclines - Ovarian ablation and tamoxifen for 5 years
- Post menopausal - Aromatase inhibitors and chemotherapy; regular follow up with yearly mammogram
2) Hormone receptor negative
- Chemotherapy +/- radiotherapy
- HER2 receptor positive patients can undergo treatment with trastuzumab

19
Q

Identifying cancers of unknown primary

A

1) immunoperoxidase tumour markers
- Mesenchymal cancer - vimentin
- rhabdomyosarcoma - desmin
- breast ca - oestrogen or progesterone
- prostate ca - PSA
- Malignant melanoma - S-100, HMB45
- Squamous cell carcinoma - cytokeratin
2) serum tumour markers
- Testicular - AFP, bHCG
- cholangiocarcinoma - CA19-9
- Ovarian CA125

20
Q

Management of prostate cancer

A

1) Early disease
- Radical prostatectomy - complications - impotence (90% patients), urinary incontinence, rectovesical fistula formation
- Radiotherapy - external beam or brachytherapy - bladder irradiation, proctitis, impotence, diarrhoea, dysuria, severe perineal cutaneous reaction
- Surveillence
2) Advanced disease
- Hormonal caustration - for those not suitable for surgery and those with metastatic disease - total androgen blockage wtih goserelin/luprelide with anti-androgen flutamide to prevent paradoxical worsening of bony pain; 3 year expectancy
- Hormonal therapy refractory - antiandrogen withdrawal, antifungal agent ketoconazole, corticosteroids, docetaxel
- Radiotherapy for acute bony pain

21
Q

Management of non-small cell carcinoma of the lung

A

1) Non-small-cell lung cancer
- Stages I and II (ipsilateral peribronchial or hilar lymph nodes) - lobectomy; 3 monthly follow up for 2 years, 6 monthly for 5 years
- Stage IIIA (mediastinal or subcarinal lymph node involvement or spread to pleura, pericardium or chest wall) - surgery, radiotherapy and chemotherapy
- Stage IIIB - locally advanced disease - radiotherapy and chemotherapy
- Stage IV - palliation, double or single agent cisplatin or another agent

Chemotherapy includes - cisplatin, taxanes, gemcitabine, vinorelbine, camphothecin

22
Q

Management of small cell lung cancer

A

1) Limited disease (limited to single radiation field)
- platinum based etoposide - life expectancy 18months
- mediastinal radiotherapy and prophylactic cranial irradiation
2) Extensive disease
- gentle chemotherapy
- palliation

Paraneoplastic syndrome, LAMS, SIADH, cushing’s syndrome

23
Q

Management of colorectal Ca

A

Investigations - ALP, CTCAP colonoscopy/sigmoidoscopy, transrectal ultrasound, MRI and PET

Follow up colonoscopy 1 month following stenosed carcinoma to look for synchronous tumours; 1 yearly colonoscopies following

Dukes A and B - mucosa/submucosa or muscularis- surgery

Dukes C - lymph node involvement - adjuvant chemotherapy with 5-fluorouracil and leucovorin and oxaliplatin

Dukes D - palliative surgery and/or chemotherapy

Rectal carcinoma may benefit from neo-adjuvant chemotherapy (prior to surgery)

24
Q

Cancer of head and neck

A

Investigations include CT CAP, endoscopy, PET/MRI for TNM staging

Stage 1 and 2 - Radiotherapy and surgery depending on site and organ function

Stage 3 and 4 - chemo-radiotherapy with cisplatin and 5-FU

25
Q

1) Cancers that metastasise to brain
2) Cancers that metastasise to bone
3) Cancers that cause DVT

A

1) Lung breast, kidney, melanoma, colon
2) Breast, lung, thyroid, kidney, prostate
3) Breast, lung, colon, pancreas

26
Q

Presentations of Multiple Myeloma

A

Bony pain, pathological fractures

Symptomatic anaemia

Pancytopaenia

Sepsis

Renal failure

Acute symptomatic hypercalcaemia

Hyperviscosity (IgM)

27
Q

Criteria for Multiple Myeloma

1) Major
2) Minor

A

1) >30% plasma cells in bone marrow, M band in SPEP (>3.5g/L IgG or >2g/L IgA), 1g/24hr of Bence Jones protein in urine, Plasmacytoma confirmed on Bx
2) 10-30% plasma cells in BM, M band and Bence-Jones at lower levels, Lytic lesions on skeletal survey, low immunoglobulins

1 major and 3 minor criteria present for Dx

28
Q

Management of Multiple Myeloma

A

Treat acute complications - Hypercalcaemia (hydration, bisphosphonates), spinal cord compression (radioTx), renal failure (IV fluids, dialysis)

For patients < 70yrs and good prognosis - cytoreductive chemotherapy w/ VAD (vincristine, doxorubicin, dexamethasone)/stem cell collection/ and melphalan followed by stem cell rescue

Second ASCT if good partial response

Maintenance thalidomide +/- steroids if in remission

Thalidomide based therapy +/- Dexamethasone if not suitable

Second line therapy

  • Thalidomide based therapy, Bortezomib, Lenalidomide
  • Allograft Tx for suitable patients

Supportive therapy

  • Bisphosphonates for pathological #
  • transfusion
  • IV immunoglobulin
  • RadioTx for osteolytic lesions
29
Q

Differential diagnosis for Multiple Myeloma

A

MGUS

Smouldering Myeloma

Solitary Plasmacytoma

Waldenstrom’s macroglobulinaemia

Primary or light chain amyloidosis

Lymphoma

CLL

30
Q

Poor prognostic signs in Multiple Myeloma

A

Cytogenetic abnormalities del 13q, t(4:14), del 17p

Hb <8.5

Hypercalcaemia

High M protein

CRF

Low Alb

Elevated beta 2 microglobulin >5.5

High LDH

Age > 70

Poor performance status

31
Q

Moderate increase in breast cancer 4%

A

Family history of breast cancer in 2 family members on same side AND/OR at least one age <50yrs

One family member with breast cancer age < 50yrs

Requires

Biennial referral to family cancer clinic

Annual mammograms, from 40 years if one family member with breast ca <50yrs.

32
Q

High risk breast cancer

Need annual breast mammogram, MRI and/or USS, family cancer genetic clinic, consideration of chemo-preventative measures

A

Family member with known high risk gene mutation BRCA

Two first or second degree family members on the same side with breast or ovarian cancer and one or more of:

  • additional relatives with breast or ovarian Ca
  • breast cancer diagnosed before age 40 years
  • bilateral breast cancer
  • breast and ovarian cancer in the same woman
  • Ashkenazi Jewish ancestry
  • breast cancer in male relative

One relative (first or second degree) with breast Ca <45 and another with a sarcoma diagnosis

Long case clinical skills (12 decks)

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