Cancer care Flashcards
(435 cards)
1
Q
What is the assessment for breast cancer
A
Triple assessment: clinical exam, USS/mammo, histology/cytology - FNA/core biopsy
2
Q
USS or mammo for breast cancer
A
USS if <35, both if >35
3
Q
What is sentinel node biopsy
A
Blue dye or radiocolloid into tumour area, probe/see sentinel node, biopsy and send for histology/immunohistochemistry
4
Q
Predicting prognosis for breast cancer
A
Nottingham prognostic index = size + histological grade + nodal status
Also ER/PR status and vascular invasion
5
Q
What is pre menstrual breast change
A
Nodularity and pain in upper outer quadrant with fibrosis, adenosis, cysts, epitheliosis, papillomatosis = benign mammary dysplasia
6
Q
When are breast cysts common
A
Perimenopause
7
Q
Common benign breast lumps
A
Fibroadenoma - collagenous mesenchyme, firm, smooth, mobile, multiple. Regress, stay same or get bigger (1/3 each)
Fibroadenosis - focal or diffuse nodularity
8
Q
Infective mastitis?
A
Usually staph a, coamox/Flucloxacillin /incise, drain
9
Q
Physiological nipple discharge/?
A
Duct ectasia - dilatation with age = green, brown, bloody discharge
10
Q
Fat necrosis in breast?
A
Fibrosis and calcification after trauma = mass
11
Q
Nodal status for breast cancer
A
1 = ipsilateral and mobile, 2 = fixed
12
Q
Premalignant breast diseases?
A
Non invasive dcis = microcalcification on mammo, unifocal or widespread, 30-50% progress
Non invasive lcis = multifocal, rarer, higher risk of progression
13
Q
Most common breast cancers
A
Invasive ductal carcinoma (70%)
Invasive lobular carcinoma
Medullary - younger patients
14
Q
RF for breast cancer
A
FHx, age, uninterrupted oestrogen exposure - nulliparity, first pregnancy >30y/o, early menarche and late meno Not breast feeding HRT Obesity BRCA
15
Q
Stages of breast cancer
A
1 = confined to breast and mobile 2 = + node in ipsilateralaxilla 3 = fixed to muscle but not chest wall, ipsilateral axilla node matted and may be fixed, skin involvement 4 = fixed to chest wall, distant mets
16
Q
TNM for breast
A
T: 1 = <2, 2 = 3-5, 3= >5, 4 = fixed to chest wall or peau d’orange
N: 1 = mobile ipsilateral, 2 = fixed
17
Q
Treat stage 1-2 breast cancer
A
Surgery - wide local excision or mastectomy axillary node sample/clearance
Radiotherapy - prevent local recurrence after surgery, and nodes if positive and not completely cleared
Chemo - improve survival esp if young and node pos, or neoadjuvant
Endocrine therapy
18
Q
Types of hormone therapy for breast cancer
A
Tamoxifen oestrogen blocker
Aromatase inhibitor targets oestrogen synthesis, better tolerated, for post-meno
GnRH analogues or ovarian ablation if pre-meno and ER pos
19
Q
ADRs of radiotherapy for breast
A
Pneumonitis, pericarditis
Rib fractures
Lymphoedema
Brachial plexopathy
20
Q
Treat stage 3-4 breast cancer
A
Bisphosphonates for painful bony lesions to decrease pain and fracture risk
Tamoxifen, chemo
21
Q
Investigations for stage 3-4 breast cancer
A
LFT, calcium, cxr, skeletal survey, bone scan, CT/MRI or PET/CT, liver us
22
Q
Causes of nipple discharge
A
Intraductal papilloma - bloody or clear
Duct ectasia - yellow/green
23
Q
RF for colorectal cancer
A
Neoplastic polyps UC, Crohn’s FAP HNPCC Low fibre diet Previous cancer Smoking Genetics
24
Q
Sx of colorectal cancer
A
Left = bleeding/mucus, altered bowel habit, tenesmus, mass Right = weigh loss, Hb low, abdo pain Both = abdo mass, perforation, haemorrhage, fistula
25
Use of CEA in colorectal cancer
Monitor disease and effectiveness of treatment
26
Tests for colorectal cancer
```
FBC - microcytic anaemia
Faecal occult blood
Sigmoidoscopy
Barium enema or colonoscopy / CT
DNA if familial polyposis once >15y
```
27
What is anterior resection for
Low sigmoid or high rectum tumour - anastamosis
28
What is APR and what is it for
Low rectal tumour (=<8cm from anus), permanent colostomy and remove anus and rectum
29
What is hartmann’’s procedure
Emergency obstruction or palliation
| Proctosigmoidectomy and close rectal stump
30
Colorectal Surgery if not fit?
Transanal endoscopic microsurgery for local excision through wide proctoscope
endoscopic stenting
31
Chemo in colorectal cancer?
Reduce mortality for Duke C
| Palliation for mets
32
Sx of anastomotic leak after colectomy
Raised temperature
Abdo pain
Peritonism
33
What are polyps and what 3 types are in GIT?
Lumps above the mucosa
Inflammatory - IBD, lymphoid hyperplasia
Hamartomatous - juvenile, Peutz-Jeghers syndrome
Neoplastic - adenomas with malignant potential
34
Sx of polyps in GIT
Blood/mucus
35
Most common site of colorectal carcinomas
Rectum = 45%, sigmoid = 25%
36
Duke’’s classification
Stage A - beneath muscularis mucosa
B - through muscularis mucosa
C - regional lymph nodes
D - distant mets
37
Potential screening programs for colorectal cancer and flaws
Now = FOB home test every 2y from 60-69y, but high false pos
Sigmoidoscopy for left sided, high sens and spec but expensive and not accepted
Colonoscopy - perforation rate higher than sigmoidoscopy, cost, sedation, not accepted
38
Chemo for colorectal cancer?
Adjuvant, including biologics for VEGF/EGFR
39
Who gets regular colonoscopy?
HNPCC, FAP
40
Stomach cancer pathology
```
Mostly adenocarcinoma - diffuse (more common, worseprognosis) or intestinal (better prognosis)
Borrmann classification:
1) polypoid/fungating
2) excavating
3) ulceration and raised
4) linitis plastica
```
41
Symptoms of stomach cancer
```
Non-specific
Dyspepsia (inv if >1m and >50y)
Weight loss, anorexia, early satiety, vomiting
Dysphagia and odynophagia if junctional
Anaemia
```
42
bad signs on exam for stomach cancer
```
Epigastric mass
Hepatomegaly, jaundice, ascites
Virchow node = Troisier’s sign
Acanthosis nigricans
Succussion splash (outlet obstruction)
```
43
What is Krukenberg tumour
Stomach tumour spread to ovary
44
Imaging gastric cancer
Gastroscopy and multiple ulcer edge biopsy
Endoscopic US
CT/MRI for staging
Staging laparoscopy if locally advanced and no mets
45
Treat gastric cancer
Curative laparotomy
Subtotal gastrectomy
Lymphadenectomy
Neoadjuvant CRT
Endoscopic laser to decrease bleeding
Combination chemo if advanced - for QoL and survival
Endoscopic mucosal resection for early tumours confined to mucosa
46
5y survival for gastric cancer
<10%
47
Risk factors for oesophageal cancer
```
Obesity
Smoking
Alcohol, radiotherapy, caustic = SCC
Achalasia
Reflux oesophagitis +- Barrett’s oesophagus, hiatus hernia, antacids = adeno
Man (5x woman)
```
48
Where and type of oesophageal cancer
50% middle, 30% bottom, 20% upper
| 2/3 Squamous 1/3 adeno
49
Sx of oesophageal cancer
Dysphagia, weight loss, retrosternal chest pain, lymphadenopathy
Hoarse, cough (paroxysmal if aspiration pneumonia) if upper
50
Tests for oesophageal cancer
```
Barium swallow
CXR
Oesophagoscopy with biopsy/EUS
CT/MRI
Staing laparoscopy if infra-diaphragmatic
```
51
staging for oesophageal cancer
```
TNM
T1 = lamina propria/submucosa
T2 = muscularis propria
T3 = adventitia
T4 = adjacent structures
N1 = regional node mets
M1 = distant mets
```
52
Treatment for oesophageal cancer
Radical oesophagectomy if localised T1/2 = transhiatal or transthoracic
Neoadjuvant chemo
CRT if no surgery
Palliative = CRT, stent, laser
53
Causes of oesophageal rupture
```
Iatrogenic
Trauma
Carcinoma
Boerhaave syndrome
corrosive ingestion
```
54
Sx of oesophageal rupture
```
Odynophagia
Tachypnoea, dyspnoea
Fever
Shock
Surgical emphysema
```
55
Manage oesophageal rupture
NGT, Abx, PPI
| Antifungals, surgery, oesogo-cutanesous fistula
56
When to order urgent endoscopy for stomach cancer
>55 with dyspepsia
| <55 with dyspepsia and one of: weight loss, anorexia, vomit, dysphagia, sx of bleeding
57
Causes of lung nodules on cxr
```
Malignancy
Abscess
Granuloma
Carcinoid tumour
Pulmonary hamartoma
AV malformation
Encysted effusion
Cyst
Foreign body
Skin tumour
```
58
Common types of lung tumour
Squamous 35%
Adenocarcinoma 25%
Small cell 20%
Large cell 10%
59
Signs and symptoms of lung cancer
Cough, haemoptysis, dyspnoea, chest pain, slow resolving pneumonia
Cachexia, anaemia, clubbing (nsclc), hypertrophic pulmonary osteoarthropathy = wrist pain, supraclavicular or axillary nodes
Chest - consolidation, collapse, pleural effusion
60
Signs of mets from lung cancer
Bone tenderness
Hepatometaly
Confusion, fits, focal CNS signs, cerebellar syndrome
Proximal myopathy, peripheral neuropathy, Lambert Eaton myasthenic syndrome
61
Local complications of lung cancer
Local - recurrent laryngeal nerve palsy, phrenic nerve palsy, SVC obstruction, Horner’s syndrome (pancoast), rib erosion, pericarditis, AF
62
Metastatic complicatiotns fo lung cancer
Brain
Bone - pain, anaemia, raised calcium by squamous tumours
Liver
Adrenals - Addison’s
63
Endocrine complicatiotns fo lunc cancer
Small cell. = SIADH (low sodium high ADH), ACTH (cushings’)
| Squamous = PTH (high calcium)
64
Tests for lung cancer
Sputum and pleural fluid cytology
CXR - nodule, hilar enlargement, consolidatoin, collapse, effusion, bony secondaries
Percutaneous FNA or biopsy if peripheral/superficial
Bronchoscopy for histology and operability
CT for staging
65
Treatment for lung cancer
Non small cell - excision if peripheral and no spread (stage 1-2)
- Curative RT if resp reserve poor
- CRT if advanced
Small cell nearly always disseminated but may respond to chemo +-RT
66
Palliation for lung cancer
RT for obstruction, SVC, haemoptysis, bone pain, cerebral mets
SVC obstruction - stent, RT, dexamethasone
Tracheal stent
Pleural drainage for effusions
67
Prognosis of lung cancer
Non small cell = 50% 2y
| Small cell - 3m median survival if untreated
68
Staging for lung cancer
T1 <3cm in lobar or distal
T2 >3cm and >2cm distal to carina or any size + pleural involvement or obstructive pneumonitis
T3 involves chest wall, diaphragm, mediastinal pleura, pericardium
T4 involves mediastinum, heart, great vessels, trachea, oesophagus, vertebral body or malignant effusion
N1 - peribronchial or ipsilateral hilum
N2 - ipsilateral mediastinum or subcarinal
N3 - contralateral mediastinum or hilum or supraclavicular
69
Features of different lung cancers
Scc - bronchiobstruction causes infection - cavitation on cxr, slow grow, local spread
Adenocarcinoma - peripheral, scar tissue, bronchial mucous glands, effusion from mets to mediastinal node and pleura
Large cell - neurosecretory, poorly differentiated, grown and met early
Small cell - central, present with systemic disease, neurosecretory granules
70
Complications of surgery and CRT for oesophageal cancer
```
Surgery = anatamotic leak, stricture, reflux, motility problems
CRT = perforation, stricture, pneumonitis, pulmonary fibrosis
```
71
Most common renal cancer
Renal cell carcinoma= 90% - proximal renal tubular epithelium
72
Sx of renal cell carcinoma
50% incidental finding
Haematuria, loin pain, abdo mass, anorexia, malaise, weight loss, PUO
Varicocoele from invasion of left renal vein obstruction
73
Initial test findings for renal cell carcinoma
BP high from renin secretion
FBC - polycythaemia from epo
ALP - high if bony mets
Urine for RBC and cytology
74
Imaging for renal cell carcinoma
```
US
CT/MRI
IV urogram
Renal angiography
CXR - cannonball mets
```
75
Treatment for renal cell carcinoma
Radical nephrectomy
| Angiogenesis inhibitors
76
Staging for renal cell carcinoma
```
Robson:
1 - in kidney
2 - perinephric fat
3 - renal vein
4 - adjacent/distant organs
```
77
Where is transitional cell carcinoma
Bladder, ureter, renal pelvis
78
Sx of transitional cell carcinoma
Painless haematuria, frequency, urgency, dysuria, urinary tract obstruction
79
Investigate transitional cell carcinoma
Urine cytology
IV urogram
Cystoscopy and biopsy
CT/MRI
80
Main abdominal malignancy in children and sx
Nephroblastoma - Wilm’s tumour
| Abdo mass and haematuria
81
Where and histology of prostate cancer
Adenocarcinoma in peripheral prostate
82
Where does prostate cancer spread
Seminal vesicles, bladder, rectum
| Haematoenous to bone
83
Sx of prostate cancer
Nocturia, hesitancy, poor stream, terminal dribble, obstruction
Weight loss and bone pain = mets
84
Inv for prostate cancer
```
DRE
PSA
Transrectal USS and biopsy
Bone X-ray, bone scan
CT/MRI for staging
```
85
Treat prostate cancer
Local - radical prostatectomy or radiotherapy and hormonal therapy
Mets - hormonal drugs, GnRH analogues - stimulate then inhibit pituitary gonadotropin
Adjuncts - analgesia, treat hypercalcaemia, radiotherapy for bone mets/spinal cord compression
86
Prognostic factors in prostate cancer
Age
Pre treatment PSA level
Tumour stage
Tumour Gleason grade
87
How is Gleason grade calculated and what does it mean for treatment
Histology from 2 areas and add them, 2-10. High score = aggressive treatment
88
Pros and cons of PSA for asymptomatic. Men
May not die from it
False positive leads to invasive investigation
1/3 with high psa actually have cancer
Unnecessary treatment with ADRs
89
Risk factors for prostate cancer
Age - 80% of >80s
High testosterone
Family history
90
Risk and preventative factors for penile cancer
Very rare if circumcised
| Chronic irritation, viruses, smema
91
Presentation of penile cancer
Fungating ulcer, bloody/purulent discharge
| 50% spread to lymph at presentation
92
What is balanitis
Balanitis - staph and strep in foreskin and glans
Common in diabetes, children with tight foreskin
Treat with abx, circumcision and hygiene advice
93
What is phimosis
Foreskin occludes meatus causing recurrent balanitis and ballooning
Cause painful sex, infection, ulceration and balanitis xerotica obliterans in adults
94
What is paraphimosis
Tight foreskin retracted and irreplaceable, including after catheterisation, preventing venous return so oedema and ischaemia of glans
Treat by squeezing glans, may need dextrose swab, aspiration, circumcision
95
What is prostatitis
Acute or chronic, >35y
S faecalis and E. coli
UTI, retention, pain, haematospermia, swollen/boggy prostate
Treat with analgesia and levofloxacin for 28d
96
Grading bladder tumours
Grade 1 = differentiated
2 = intermediate
3 = poorly differentiated
97
Common bladder cancers
Transitional cell
| Rare = adenocarcinoma and scc
98
Risk factor for bladder cancer
```
Male (x4)
Schistosomiasis = scc
Smoking
Aromatic amines - rubber industry
Chronic cystitis
Pelvic irradiation
```
99
Presentation of bladder cancer
Painless haematuria, recurrent UTI, voiding irritability
100
Tests for bladder cancer
Urine - microscopy and cytology - sterile pyuria
IVU - filling defect, ureteric involvement
Cystoscopy and biopsy = diagnostic
Bimanual EUA for spread
CT/MRI or lymphangiography for pelvic nodes
101
Staging bladder cancer
```
Tis = in situ
Ta = epithelium
T1 = lamina propria
T2 = superficial muscle = rubbery thickening on EUA
T3 = deep muscle = mobile mass on EUA
T4 = beyond bladder = fixed mass on EUA
```
102
Treat bladder tcc
Tis, Ta, T1 = watch and wait, or TURBT - diathermy via transurethral cystoscopy. + intravesicular chemo or BCG (non specific inflammatory response) if high grade or many small
T2-3 = radical cystectomy +- adjuvant chemo
T4 = palliative CRT + catheterisation and diversions for pain
103
Follow up for bladder tcc
Regular cystoscopy - every 3m for 2y then every 6m if high risk
After 9m then yearly if low risk
104
Spread of bladder tcc
Local - pelvic
Lymphatic - iliac and paraaortic nodes
Haematogenous - liver and lung
105
Prognosis if node involvement of bladder tcc
6% if unilateral at 5y
| 0% if bilateral or para aortic
106
Complications of bladder tcc treatment
Sexual and urinary malfunction if cystectomy
Massive bladder haemorrhage
Ileal conduit - urine toxic to skin, ureters may stenose
107
Cause of raised PSA
```
Big prostate
Infection uti
Inflammation - catheter
BPH
cancer prostate
```
108
Bone scan findings with CaP
Sclerotic lesions, other cancers normally lytic
109
ADR of radical prostatetomy
Erectile dysfunction, retrograde ejactulation, urinary damage - incontinence
110
ADR of radiotherapy and different types of RT for prostate cancer
External beam or low does brachytherapy
| Causes bowel symptoms ie diarrhoea
111
Hormonal treatment for CaP
Castration - surgical orchidectomy or medical LHRH agonist - neg feedback so suppresses T production from leydig cells. Cover with antiandrogen for first month to prevent LH surge causing growth of spinal mets
112
Screening issues with PSA
Lead time bias and length time bias
113
Origin of most bladder cancers
Papillomata, 80% confined to mucosa
114
Causes of pancytopoenia
Increaed peripheral destruction - hypersplenism
| Decreased marrow production - aplastic anaemia, megaloblastic anaemia, myelofibrosis, marrow infiltration
115
Types of marrow infiltration causing pancytopoenia
Neoplasm - myeloma, lymphoma, acute leukaemia, solid tumours
| TB, myelodysplasia
116
Causes of aplastic anaemia
AI - drugs, viruses (hepatitis, parvo), irradiation
| Inherited - Fanconi anaemia
117
Treat aplastic anaemia
Asymptomatic - supportive
Immunosuppression
Curative - allogenic marrow transplant from HLA matched sibling
Support blood count with RBC, platelets and WBC
118
What is agranulocytosis
No production of wBC with granules: BEN (Basophils, Eosinophils, Neuttrophils)
119
What to safety net for agranulocytosis
Sore throat or fever
120
Treat agraanulocytosis
G-CSF
Neutropoenia regimen
Abx and cotrimoxaxole for PCP
121
ADR cotrimoxazole
Rash
122
What is neutropoenia regimen
```
If neutrophils <0.5x10^9/l
Barrier nursing
No IM injections or DRE
Chlorhexidine on moist skin
Oral hygiene
Swab infection sites - mouth, axilla, perineum, IVI
Culture blood x3, sputum, urine, stool if diarrhoea
FBC, Plt, inr, U&E, ,LFT
CXR
```
123
When to irradiate platelets
Immunosuppression or marrow transplant to prevent graft vs host
124
When to give platelets
If <10x10^9/l
Haemorrhage
Before procedure if <50x10^9/l
125
Survival of different blood products
RBC 120d
Platelets 7d
WBC 1-2c
126
How to do bone marrow biopspy
```
Posterior iliac crest
Aspirate to film for microscopy
Trephine bone core for cellularity, architecture and infiltration (neoplasm)
Cytogenetics
Flow cytometry
```
127
What is amyloidosis
Extracellular deposits of protein with abnormal fibrilar form, resistant to degradation
128
3 causes of amyloidosis
Plasma cell clonal proliferation - myeloma, lymphoma, MGUS, Waldenstrom’s
Serum amyloid A (acute phase protein) in chronic inflammation - RA, IBD, chronic infection (TB, bronchiectasis)
Familial amyloidosis - autosomal dominant
129
Sx of plasma cell proliferation causing amyloidosis
Kidneys - proteinuria, nephrotic syndrome
Heart - restrictive cardiomyopathy, angina, arrhythmia
GI - macroglossia, malabsorption, obstruction, hepatomegaly
Neuro - peripheral and autonomic neuropathy, carpal tunnel
Vascular - periorbital purpura
130
Sx of serum amyloid A from chronic inflammation
Kidneys. - nephrotic syndrome
| Hepatomegaly
131
Sx of familial amyloidosis
Sensory/autonomic neuropathy
| Renal/cardiac involvement
132
Treat familial amyloidosis
Liver transplant
133
Diagnosis of amyloidosis
Biopsy of rectum or sc fat as non invasive
134
What affects plasma viscosity
Concentration of large plasma proteins, chronic inflammation >24h - not acute:
RBC raised in polycythaemia rubra vera
WBC raised in leukaemia
Plasma components raised in myeloma and Waldenstrom’ss Macroglobulinaemia (IgM)
135
Treat raised plasma components
Plasmapheresis - remove plasma and discard, return RBC in more suitable medium
136
Sx of increased plasma viscosity
Decreased vision
Amaurosis fugax
Retinopathy - haemorrhage, exudates, blurred disc
CNS - disturbance, reduced cognition, falls
Chest and abdo pain
Spontaneous GI/Gu bleeding
137
What is ESR
How far RBC fall through anticoagulated blood column in 1h
138
What changes ESR
Proteins as make RBC stick together
| - inflammation from infection, malignancy, rheumatoid arthritis, MI; anaemia; macrocytosis
139
Investigate raised ESR
```
History and exam
FBC, U&E
PSA
Plasma electrophoresis
CXR, AXR (AAA)
Marrow or temporal artery biopsy
```
140
Calculate ESR
```
Male = age/2
Female = age+10 /2
```
141
Associations with ALL
Genetic susceptibility
Environmental ie radiation in pregnancy
Down’s syndrome
142
Ways of classifying ALL
Morphological - FAB
Cytogenetic - chromosomal abnormalities
Immunological - precursor B, B or T
143
Sx of ALL
Marrow failure - anaemia, infection, bleeding
Organ infiltration - hepatosplenomegaly, lymphadenopathy including parotid and mediastinal, orchidomegaly, CNS - cranial nerve palsy, meningism
144
Common infections in ALL
```
Chest, mouth, perianal, skin
Bacterial septicaemia
cmv, zoster, measles
pneumocystis pneumoniae
candidiasis
```
145
Investigations for ALL
Blast cells characteristic on film
CXR for mediastinal and abdominal lymphadenopathy
LP for CNS involvement
146
Treatment for ALL
Educate and motivate
Support - blood/platelet transfusion, IV fluids, allopurinol for tumour lysis prophylaxis, Hickman line
Chemotherapy - trials of remission/consolidation/CNS prophylaxis/maintenance ie monoclonal antibodies, cytokines, T cell infusions
Neutropoenia - abx, antifungals, antivirals
Matched related allogenic marrow transplant
147
Prognosis of ALL and bad prognostic signs
```
70-90% in children, 40% in adults
Bad factors:
Adult, male
Philadelphia chromosome
CNS signs on presentation
Low haemoglobin
WCC >100
B cell ALL
```
148
What gene is related to ALL
Philadelphia chromosome - BCR-ABL gene fusion from translocation of chromosomes 9 and 22
149
How common is AML, what’s the prognosis and what is it associated with
Most common leukaemia of adults, 2m prognosis if untreated
| RF: Chemo for lymphoma, myelodysplasia, radiation, syndromes ie downs
150
Classification of AML
WHO classification
151
Sx of AML
Marrow failure - anaemia, infection, bleeding
DIC in some
Hepatosplenomegaly, gum hypertrophy, skin involvement
152
Inv AML
```
WCC may be high, normal or low
Marrow biopsy
Microscopy = Auer rods
Immunophenotyping
Cytogenetic analysis guides treatment
```
153
Complications of AML
Infection
Fever without infection
Tumour lysis causing plasma urate levels to rise
Leukostasis
154
Treatment of AML
Supportive
Chemo causing marrow suppression
Bone marrow transplant - pluripotent haematopoetic stem cells, using ciclosporin and methotrexate to prevent graft vs host
155
Complication of AML treatment
```
Graft vs host disease
Leukaemia
Opportunistic infections
Infertility
Relapse
```
156
What are myelodysplastic syndromes
MDS, myelodysplasia
Marrow failure
Most Primary, or secondary to CRT. 30% become acute leukaemia
157
Tests for myelodysplastic syndromes
Pancytopoenia, reduced reticulocytes
Marrow cellularity increased due to ineffective haematopoeisis
Ring sideroblasts in marrow
158
Treatment for myelodysplastic syndromes
Multiple RBC and platelet transfusions
Epo and G-CSF lowers transfusion requiremen
Immunosuppressants ie cyclosporin
Curative allogenic stem cell transplant - only if younger
Thalidomide analogues
159
When is CML mostly found
40-60y, slight male predominance
160
Chromosome associated with CML and what does it mean
Philadelphia chromosome in 80%, has tyrosine kinase activity
| Without ph have worse prognosis
161
Sx of CML
Insidious - weight loss, tired, fever, sweats
Gout from purine breakdown
Bleeding
Abdo discomfort - splenic enlargment
Massive splenomegaly, hepatomegaly, anaemia, bruising
162
Inv CML
```
WBC >100 with whole spectrum of myeloid cells - myelocytes, neutrophils, basophils, eosinophils
Hb low or normal
urate and b12 high
Marrow - hypercellular
Ph on blood or marrow cytogenetics
```
163
Stages of CML
Chronic - months/years with few sx
Accelerated - Increasing symptoms, spleen size and counts
Blast transformation - features of acute leukaemia and death
164
Treatment for CML and side effects
Imatinib - BCL/ABL tyrosine kinase inhibitor
SE = nausea, cramps, oedema, rash, headache, arthralgia, myelosuppressiosn
+- a interferon
Stem cell transplant but high mortality and morbidity
165
What is CLL
Accumulation of mature B cells that have undergone cell cycle arrest in G0/1 phase
166
Commonest leukaemia?
CLL
167
What can trigger CLL
Pneumonia
168
Sx of CLL
```
Often incidentally found on FBC
Anaemia/infections
Weight loss, sweats, anorexia
Enlarged rubbery non tender nodes
Hepatosplenomegaly
```
169
Inv CLL
High lymphocytes
| Then AI haemolysis, marrow infiltration - low Hb, neutrophils and platelets
170
Complicatiosn of CLL
AI haemolysis
Infection from hypogammaglobulinaemia (reduced IgG) - esp herpes zoster
Marrow failure
171
Progression of CLL
Nodes slowly enlarge and can cause lymphatic compression
Infections cause death
Transform to aggressive lymphoma - Richter’s transformation
1/3 don’t progress, 1/3 will progress, 1/3 actively progressing
172
Infections found in CLL that can cause death
```
Haemophilus
Pneumococcus
Aspergillosis
Meningococcus
Candida
```
173
Treat CLL
Chemo if symptomatic, or depending on genes
Steroids for AI haemolysis
RT for lymphadenopathy and splenomegaly
Supportive - transfusions, IV human Ig if recurrent infection, prophylactic azithromycin acyclovir (+cotrimoxazole nebs for PCP)
Stem cell transplant
174
Staging CLL
```
Rai stages:
1 - lymphocytosis
2 - with lymphadenopathy
3 - with spleno/hepatomegaly
4 - with anaemia
5 - with platelets <100
```
175
Differentiate between AML and ALL
More hepatosplenomegaly, testicular infiltration and CNS involvement in ALL. Mediastinal/thymic mass in ALL
Bone and skin involvement in AML
Gum hypertrophy in AML
176
Prophylaxis for PCP
Cotrimoxazole neb
177
CNS prophylaxis for ALL
Intrathecal or high dose IV methotrexate +- CNS irradiation
178
What is ALL remission defined as?
No evidence of leukaemia in blood or normal/recovering FBC
And <5% blasts in normal regenerating marrow
Can detect minimal residual disease with PCR
179
FAB stages of ALL
```
L1 = children, good prognosis
L2 = adults, intermediate prognosis
L3 = Burkitt’s lymphoma, adults, poor prognosis
```
180
Infection difficulties with leukaemia
Rare organisms
Common organisms present differently
Fever from AML
Fewer antibodies
181
Basis of definitive treatment in AML
Destroy marrow with cyclophosphamide and total body irradiation then repopulate with IVIg
182
Advantage of autologous instead of allogenic bone marrow transplant
Faster haematopoetic recovery and lower morbidity
183
Signs of Richter’s transformation for CLL
Systemic - night sweats and fever
Increased spleen and nodes (tonsils = breathing problems, sore throat)
Cytopoenias
WCC >200
184
Causes of lymphadenopathy
Infection - bacteria (TB = matted), viral (EBC, HIV), Protozoa (toxoplamosis)
Malignancy - primary (leukaemia, lymphoma), secondary (mets, neuroblastoma, virchow’s node)
AI - RA, SLE
Drugs
185
Classify lymphadenopathy
Size - >10mm, long and short axes
| Extent - localised to infection, localisation not region ie mediastinum, generalised
186
Investigate lymphadenopathy
```
CXR if supraclavicular or cervical
Infection swabs for culture and sensitivity
FBC, blood film, ESR/plasma viscosity
LFTs, LDH (released by cell turnover)
Urate, calcium
Lymph node excision biopsy
Body CT/MRI
Marrow biopsy - aspirate, trephine, cytogenetic, flow cytometry
LP for cytology if CNS signs
Effusion cytology
```
187
Findings on flow cytometry of bone marrow in lymphoma
```
Non-hodgkin’s = B cellswith abnormal kappa:lambda ratio
Hodgkin’s = Reed-Sternberg cells
```
188
Causes of massive splenomegaly
3Ms:
Myelofibrosis
cMl
Malaria
189
Cause of splenomegaly
Increased function
Abnormal flow - organ, vascular or infection
Infiltration - metabolic or benign/malignant
190
Cause of increased spleen function
Immune hyperplasia - infection or AI
Extramedullary haematopoesis - marrow infiltration or destruction (toxins, radiation)
Defective RBCs - sickle cell, thalassaemia
191
Cause of abnormal flow through spleen
Organ - liver cirrhosis (portal hypertension - caput medusae?)
Vascular - hepatic/portal/splenic vein obstruction, Budd-Chiari
Infection - hepatic schistosomiasis
192
Types of spleen infiltration
```
Metabolic - amyloidosis
Benign/malignant: leukaemia, lymphoma, myeloproliferative disorder
- Eosinophilic granulomas
- Metastatic tumour ie melanoma
- Hamartoma
```
193
When is splenectomy indicated
Trauma
Hypersplenism
AI haemolysis (ITP, congenital haemolytic anaemia, warm AI haemolytic anaemia)
194
Risk in splenectomy or hyposplenism and why
Infection as spleen contains macrophages which phagocytise bacteria
Encapsulated organisms - strep pn, H influenza, neisseria meningitidis
195
2 causes of hyposplenism
Sickle cell
| Coeliac
196
Management of hyposplenism or splenectomy
Advice:
Mobilise asap as transient increase in platelets can cause thrombi
Medical alert bracelet
Safety net for infection
Mediation:
Malaria prophylaxis if abroad
Immunisations - pneumococcal, meningococcal C, H influenzae B, annual influenzae
Prophylactic abx lifelong - phenoxymethylpenicillin or erythromycin
197
When to have/not have pneumococcal vaccine if splenectomy/hyposplenism
Every 5-10y
2w pre-op
Not if pregnant
198
What is lymphoma
Malignant proliferation of lymphocytes in lymphadenopathy, blood and organ infiltration
199
Sx for lymphoma
Anaemia, thrombocytopoenia x
B sx - fever, night sweats
Hyperviscosity - headache, blurred vision
Infections
200
PMH relevant to lymphoma
Diabetes, hypertension, kidney disease as most treatment includes steroids which can affect these
201
Drug history relevant tolymphoma
Azathioprine or methotrexate can cause macrocytosis
| Previous chemo can. Cause myelodysplasia
202
Who gets Hodgkin’s lymphoma?
Young people and elderly - 2 peaks
203
Risk factors for hodgkin’s lymphoma
```
Sibling
Westernisation
Obese
EBV
SLE
Post-transplant
```
204
Causes of non-hodgkin’s lymphoma
```
Congenital immunodeficiency
Acquired immunodeficiency
AIDS - high grade lymphoma
Infection - HTLV1, EBV, h. Pylori
Environmental toxins
```
205
Histology for Hodgkin’s and non-hodgkin’s lymphoma
```
Hodgkin’s = Reed-Sternberg cells - mirror image nuclei
Non-hodgkin’s = no reed-sternberg, mostly B cell lines, extranodal sites ie MALT
```
206
Association of H pylori and lymphoma
Causes MALT - extranodal Non-hodgkin’s
| Regresses if treated
207
Classification of Hodgkin’s (4)
1. Nodular sclerosing - indolent B cell lymphoma
2. Mixed cellularity - higher incidence and worse prognosis if HIV
3. Lymphocyte rich
4. Lymphocyte depleted - poor prognosis
208
Classification of Non-Hodgkin’s (grades) and implication and 2-3 examples of each
WHO classification -
Low grade = indolent,incurable, widely disseminated at presentation - follicular and marginal zone (MALT) and lymphocytic lymphoma
High grade = more aggressive ,more curable long term, short hx of rapid node enlargement and systemic sx - Burkitt’s, lymphoblastic lymphoma
209
Burkitt’s lymphoma associations
Kids
Jaw lymphadenopathy
High grade non-hodggkin’s lymphoma
210
Staging of lymphoma
Ann Arbor - uses CXR, CTCAP, marrow biopsy if b sx or stage 3-4
1 - one node
2 - 2+ nodal areas on 1 side of diaphragm
3 - nodes on both sides of diaphragm
4 - spread beyond nodes ie liver or marrow
+ a = no systemic sx except pruritis
+ b = B sx ie weight loss unexplained fever, night sweats
+ E = localised extranodal extension
211
Sx of lymphoma
Nodes - enlarged, painless, rubbery, superficial, mostly cervical (some axillary or inguinal), alcohol-induced node pain, may change size +- matting
Systemic - fever >38, weight loss >10% in m, pruritis, lethargy
Mass effect (mediastinal) - SVC/bronchial obstruction, pleural effusion
Signs - anaemia, cachexia, hepatosplenomegaly
212
Treatment of Hodgkin’s lymphoma
Chemo, radio or both
| +- stem cells - autologous or allogenic
213
ADR of chemo and radiotherapy for Hodgkin’s lymphoma
Chemo - nausea, allopecia, myelosuppression, infection
Radiotherapy - solid tumour, IHD, hypothyroid, lung fibrosis
AML, non-hodgkin’s lymphoma, infertility
214
Prognosis of Hodgkin’s lymphoma
40-95%
215
Sx of SVC obstruction - 5
```
Raised JVP
Sensation of fullness in head
Black outs
Dyspnoea
Facial oedema
```
216
Treatment of non-hodgkin’s lymphoma
Low grade and asymptomatic - none, localised = radiotherapy 9curative))
High grade - chemotherapy (CHOP)
Neutropoenia - G-CSF
217
Prognostic factors of non-hodgkin’s lymphoma and prognosis
>60y, systemic, disseminated, bulky mass, raised LDH
Low grade = 50% 5y survival,
High grade = 30%
218
Causes of spinal cord compression
Extradural metastases
Extension of tumour from vertebral body
Crush fracture
219
Sx of spinal cord compression
Backpain, disturbing sleep , worse lying down or coughing
Weakness
Sensory loss with root distribution or sensory level
Bowel and bladder dysfunction
220
Determination of reflexes and neuro signs depending on level of spinal cord compression?
Above L1 = umn signs in legs
Below L1 = lmn signs in legs
Sensation reduced at level of lesion
221
Investigate spinal cord compression
Urgent MRI of whole spine
222
Manage cord compression
Dexamethasone IV then PO
Urgent RT
Vertebral body reinforcement for pain,or spinal reconstruction
Laminectomy if isolated tumour
223
Cause of SVCO
Normally lung cancer, also mediastinal enlargement from germ cell tumour or lymphadenopathy from lymphoma
224
Test for SVCO
Pemberton’s test - lift arms above head for 1m, makes facial plethora/cyanosis, raised jvp, inspiratory stridor
225
Inv svco
CXR, CT, venography, sputum cytology
226
Manage svco
Dexamethasone PO
Balloon venoplasty and SVC stenting
Radical or palliative C/RT
227
Causes of hypercalcaemia in cancer
10-20% in cancer patients
40% in myeloma
Lytic bone mets
Osteoclast activating factor or PTH like hormones from tumour
228
Sx of hypercalcaemia in cancer
```
Lethargy, anorexia, nausea
Confusion
Polydipsia, polyuria
Constipation
Dehydration
```
229
Treat hypercalcaemia in cancer
Manage underlying malignancy
Bisphosphonates IV or PO
Calcitonin if resistant
230
Manage RICP in cancer
Dexamethasone, RT, surgery
| Mannitol for cerebral oedema
231
What is tumour lysis syndrome and complication?
Rapid cell death from starting chemo for rapidly proliferating leukaemia, lymphoma,, myeloma, some germ cell tumours
Rise in serum urate, K and phosphate, can cause renal failure
232
Prevent tumour lysis syndrome
Hydrate and allopurinol 24h before chemo
233
Treat tumour lysis syndrome
Dialysis
| Rasburicase IVI - recombinant urate oxidase
234
ADR rasburicase
Fever, D&V, headache
Bronchospasm
Haemolysis
Rash
235
Medication for neutropoenia
Abx - aminoglycoside (gentamicin) and ceftazidime
G-CSF
Cotrimoxazole for pneumocystis
236
Risk factors for tumour lysis synddrome
High LDH
High creatinine or urate
WCC >25x10^9
237
Dangers of leukaemia
Tumour lysis
Neutropoenia
Hyperviscosity - WBC thrombi if WCC >100, in brain/lung/heart = leukostasis
DIC
238
Test findings for DIC
```
Plt low
APTT and PT high
Fibrinogen low
Fibrin degradation products D dimers very high
Schistocytes on film
```
239
Treat DIC
```
Treat cause
Platelets if <50
Cryoprecipitate to replace fibrinogen
FFP to replace coag factors
Activated protein c reduces mortality
```
240
Types of chemo drugs
Alkylating agents - cyclophosphamide
Antimetabolites - methotrexate, 5-fluorouracil
Vinca alkaloids - vincristine
Antitumour antibiotics - actinomycin D, doxorubicin
Monoclonal antibodies ie against EGFR receptors
241
When does neutropoenia normally happen after chemo
10-14d
242
Manage extravasation of chemo agent
Stop infusion, attempt to aspirate blood from cannula then remove
Steroids and antidotes
Elevate arm
Steroid cream
243
How does radiotherapy work?
Ionising radiation makes free radicals which damage DNA
| Normal cells repair better than cancer cells so recover before the next dose
244
When can radiotherapy be used for palliation?
Haemoptysis, cough, SOB
Bone pain
Bleeding
245
Early reactions to RT
```
Tired
Skin - erythema, desqamation, ulceration
Mucositis - avoid spicy food, smoking and alcohol if head and neck RT, oral thrush
Nausea and vomiting if stomach, liver or brain
Diarrhoea if abdo/pelvis
Dysphagia if thoracic
Cystitis if pelvic
Bone marrow suppression if large areas
```
246
Manage oral thrush, diarrhoea, n&v, pelvic cystitis, from RT
Thrush - oral solution nystatin +- fluconazole
Diarrhoea - loperamide, not high fibre bulking agents
N&V - metaclopramide (dopamine antagonist) or domperidone (blocks chemoreceptor trigger zone), then ondansetron (serotonin antagonist)
Cystitis - fluids, NSAIDs (diclofenac)
247
Late CNS reactions to RT and management
CNS - somnolence, spinal cord myelopathy (progressive weakness), brachial plexopathy (numb, weak, painful arm), reduced IQ if <6yo
MRI to exclude cord compression
Steroids for somnolence
248
Late lung effects of RT
Pneumonitis - dry cough, SOB
| Give prednisolone and reduce over 6w
249
Late GI effects of RT
Xerostomia - give pilocarpine or artificial saliva with meals
Reduced healing - care with dental care
Benign strictures of oesophagus or bowel - dilatation
Fistulae - surgery
Radiation proctitis from prostate irradiation
250
Late GU effects of RT
Urinary frequency from small fibrosis bladder
Fertility - ova/sperm storage
Premature menopause or reduced testosterone - hormones
Vaginal stenosis and dyspareunia
Erectile dysfunction - can happen after several years
251
Late complications of RT
```
CNS
Lung
GI - mouth and intestines
GU - urinary and repro
Panhypopituitarism - consider growth hormones in children
Hypothyroid
Secondary cancers - sarcomas - often 10+y after
Cataracts
```
252
Considerations of fertility in CRT
Damage germ cell spermatogonia
- impaired spermatogenesis or male sterility
- hastened oocyte depletion - premature menopause
GnRH agonists for women during chemo can help
Semen or embryo cryopreservation or ovarian tissue banking before treatment, the outcome depends on uterus integrity after treatment
253
Causes of n&v in palliative care
```
Chemo
Constipation
GI obstruction
Drugs
Pain
Cough
Squashed stomach
Oral thrush
Infection
Uraemia
```
254
Basis for n&v treatment
Cause - analgesia, antibiotics, laxatives, fluconazole, drug management including route
Base drug on mechanism and site of action
Give regularly, not prn
255
Action of cyclizine
Antihistamine, central action, most causes
256
Action of domperidone
Blocks central chemoreceptor trigger zone - for younger patients who won’t have acute dystonic SE
257
Action of metaclopramide
Central antidopaminergic and peripheral proketic - good for gut stasis
258
Action of haloperidol
Dopamine antagonist, for drug or metabolic induced nausea
259
Action of Ondansetron
Serotonin antagonist, second line
260
Action of Levomepromazine
Morphine induced nausea, broad spectrum, can cause sedation
261
Prevent and treatment constipation in cancer treatment
From opiates, give bisacodyl or stimulant with softener
Movicol useful if resistant
Glycerol suppositories or arachis oil enema if oral therapy fails
262
Manage breathlessness in palliative care
Morphine - reduces respiratory drive and sensation of breathlessness
Relaxation techniques and bzds
Check for pleural or pericardial effusion
Thoracocentesis +- pleurodesis for significant pleural effusion
Pericardiocentesis or external beam radiotherapy for malignant pericardial effusion
263
Manage coated/dry mouth
Treat candida - fluconazole
Ice chips, pineapple chunks, gum
Chlorhexidine, saliva substitutes
264
Problems with venepuncture in palliative care
Extravasation, phlebitis
| Infection, blockage - give saline or heparin, thrombosis/obstruction
265
Manage agitation, nightmares, hallucinations, vomiting in palliation
Haloperidol
266
What’s hyoscine for in palliative care
Vomiting from upper GI obstruction or noisy bronchial rattles
267
Manage ascites in palliative care
Spironolactone and bumetanide
268
What are syringe drivers and what drugs are they for in palliative care?
Sc continuous infusion of fluids and drugs to avoid cannulation repeatedly
1) Glycopyrronium or hyoscine hydrobromide for terminal secretions
2) Diamorphine for pain - better than morphine due to greater solubility reducing risk of precipitation at high doses
3) Midazolam for agitation and seizure control
4) Cyclizine or haloperidol for nausea
5) Hyoscine butylbromide for bowel colic
269
Work out dose for morphine
Start at 5-10mg/4h orally
| Then add total over 24h and divide by 2 for 12h release, with 1/6 daily dose for breakthrough
270
ADR of morphine
Drowsy, n&v, constipation, dry mouth
271
Signs of morphine toxicity
Hallucinations and myoclonic jerks
272
What if morphine oral isn’t working
Diamorphine IV/SC
Oxycodone PO/IV/SC/syringe driver/PR has fewer side effects and more potent
Fentanyl transdermal patch
273
Morphine resistant pain?
Methadone or ketamine
Adjuvants - NSAIDs, steroids, muscle relaxants, anxiolytics
Neuropathic - amitriptylline or gabapentin
SSRI if depression
274
WHO analgesia ladder
1 - non opioid - aspirin, paracetamol, NSAID
2 - weak opioid - codeine, dihydrocodeine, tramadol
3 - strong opioid - morphine, diamorphine, hydromorphine, oxycodone, fentanyl
275
Tumour markers
Alpha-fetoprotein - germ cell tumour, hepatocellular carcinoma
CA125 - ovary, uterus, breast, hepatocellular carcinoma
CA19-9 - pancreas or colorectal carcinoma or cholestasis
Carcino-embryonic antigen - GI carcinoma especially colorectal cancer
Human epidermal growth factor receptor 2 - Overexpression of HER2 in breast cancer carries a worse prognosis - target with herceptin/trastuzumab, also ovarian, stomach, uterine
B-HCG - pregnancy and germ cell tumours
276
Causes of polycythaemia
Relative - reduced plasma volume - acute from dehydration or chronic from obesity, hypertension, alcohol, tobacco
Absolute - increased RBC mass - primary from rubra vera or secondary from hypoxia (chronic lung disease, cyanotic CHD, high altitude) or increased epo (renal carcinoma, hepatocellular carcinoma)
277
Polycythaemia rubra vera?
Malignant proliferation of a clone from one pluripotent marrow stem cell
JAK2 mutation
Excessive RBC, WBC and platelets - can cause hyperviscosity and thrombosis
278
Sx of polycythaemia rubra vera
Symptoms of hyperviscosity - headache, dizzy, tinnitus, visua disturbance
Itch after hot bath
Erythromelalgia - burnings in fingers and toes
Facial plethora
Splenomegaly
Gout from increased urate in increased RBC turnover
Arterial or venous thrombosis
279
Signs of arterial and venous thrombosis in polycythaemia rubra vera
Arterial - cardiac, cerebral, peripheral
| Venous - DVT, cerebral, hepatic
280
Inv for polycythaemia rubra vera and findings
FBC - raised RBC, Hb, HCT, PCV, often raised WBC and platelets
B12 high
Marrow - hypercellular with erythroid hyperplasia
Neutrophil alkaline phosphatase high
Serum epo low
281
Treat polycythaemia rubra vera
Monitor HCT to decrease thrombosis risk
Venesection in young and low risk
If old and high risk (previous thrombosis), give hydroxycarbamide or a-interferon if pregnant
Low dose aspirin
282
Complications of polycythaemia rubra vera
thrombosis and haemorrhage (defectives platelets)
| Transition to myelofibrosis or acute leukaemia
283
What is increased platelets and sx?
Essential thrombocytopoenia from clonal proliferation of megakaryocytes
Abnormal function - bleeding, or arterial/venous thrombosis, or microvascular occlusion = headache, chest pain, light headed, erythromelalgia
284
Treat essential thrombocythaemia
Exclude other causes of thrombocytosis
Aspirin low dose daily
Hydroxycarbamide to lower platelets if >60 or previous thrombosis
285
Result of myeloproliferative disorders
Myelofibrosis - hyperplasia of megakaryocytes produces platelet derived growth factor, leads to
- intense marrow fibrosis and
- myeloid metaplasia (haemopoesis in spleen and liver) causing massive hepatosplenomegaly
286
Presentation of myelofibrosis
Hypermetabolic syndrome - night sweats, fever, weight loss, abdo discomfort from splenomegaly
Bone marrow failure
287
Inv findings for myelofibrosis
Blood film - leukoerythroblastic cells (nucleated RBC)
Characteristic teardrop RBC
Hb low
Trephine for diagnosis
288
Manage myelofibrosis
Marrow support
| Allogenic stem cell transplant - curative in young , but mortality high
289
Causes of thrombocytosis
```
Reactive =
Bleeding
Infection
Chronic inflammation
Malignancy
Trauma
Post-surgery
Iron deficiency
Essential thrombocythaemia
```
290
Causes of marrow fibrosis
```
Myelofibrosis
Myeloproliferative disorder
Lymphoma, leukaemia
Secondary carcinoma
TB
Irradiation
```
291
What is myeloma?
Malignant clonal proliferation of B-lymphocyte derived plasma cells
Normally different plasma cells produce different Ig = polyclonal, but here get single clone of plasma cells = monoclonal band or paraprotein on serum or urine electrophoresis
292
Classify myeloma
On Ig product - 2/3 = IgG, 1/3 = IgA
293
Findings of myeloma investigations
Monoclonal band in serum or urine electrophoresis
Other Ig low - infection risk
Urine has Bence-Jones protein (free Ig light chains of kappa or lambda) filtered by kidney
294
Peak age of myeloma
70yo
295
Sx of myeloma
Osteolytic bone lesions due to increased osteoclast activation from myeloma cell signalling = back ache, pathological fracture in long bones/ribs, vertebral collapse
Hypercalcaemia sx
Anaemia, neutropoenia, thrombocytopoenia
recurrent bacterial infections - immunoparesis and neutropoenia
Renal impairment from light chain deposition - distal loop of henle and changes in glomeruli, can be deposited in form of AL-amyloid which causes nephrosis
296
Test findings for myeloma
```
FBC - normocytic normochromic anaemia
- raised ESR
- raised urea and creatinine
- raised calcium
- ALP normally normal
Film = rouleaux formation
Serum and urine electrophoresis for bence-jones and monoclonal bands
X-ray = lytic lesions ie pepper pot skull and vertebral collapse, or osteoporosis
```
297
Treat myeloma
Supportive
- analgesia but avoid nsaid as renal impairment
- Bisphosphonates to reduce fracture rate and bone pain
- Local rt for focal disease
- Vertebroplasty if vertebral collapse
- Correct anaemia with transfusion or epo
- Renal failure - hydrate, dialysis if acute
- Infection - abx, regular IVIg if recurrent
Chemo - including prednisolone, reduces paraprotein levels and bone lesions
Stem cell transplant
298
Prognosis for myeloma
3-4y, worse if raised B2 microglobulin
| Death from infection or renal failure
299
3 myeloma diagnostic criteria
Monoclonal protein band in serum or urine electrophoresis
Increaed plasma cells on BM biopsy
Evidence of end organ damage from myeloma - hypercalcaemia, renal failure, anaemia, or bone lesions (skeletal survey)
300
Causes of bone pain
V - osteonecrosis from microemboli
I - osteomyelitis, osteosclerosis from hep c
T - trauma/fractures
A - renal osteodystrophy, CREST
M - paget’s, sickle cell anaemia, hyperparathyroid
N - myeloma or primary malignancies, secondaries (breast, lung, prostate), hydatid cyst
301
Complications of myeloma and treatment
Hypercalcaemia - at presentation or relapse, rehydrate with saline, IV Bisphosphonates (zolendronate or pamidronate)
Spinal cord compression - urgent mri and dexamethasone 8-16mg OD PO, local radiotherapy
Hyperviscosity - reduced cognition, disturbed vision, bleeding - plasmapheresis
Acute renal failure - rehydration, dialysis
302
What is paraproteinaemia
Immunoglobulins from single clone of plasma cells - monoclonal band on serum electrophoresis
303
Categories of paraproteinaemia
Multiple myeloma
Waldenstrom’s macrolobulinaemia
Primary amyloidosis
MGUS - low concentration of paraprotein but no myeloma, amyloid, macroclobulinaemia orlymphoma, no bone lesions or bence-jones
Paraproteinaemia in lymphoma or leukaemia
Heavy chain disease - neoplastic cells produce free Ig heavy chains
304
What is Waldenstrom’s macroglobulinaemia, sx and treatment
Lymphoplasmacytoid lymphoma producing monoclonal IgM paraprotein
Causes hyperviscosity with CNS and ocular symptoms, lymphadenopathy, splenomegaly, increased ESR
Only treat if symptomatic - with chemo or plasmaphoresis for hyperviscosity
305
Inherited causes of thrombophilia - 4
Factor V Leiden = activated protein C (apc) resistance
Prothrombin gene mutation - downregulation of fibrinolysis
Protein c and s deficiency
Antithrombin deficiency
306
What is antiphosopholipid sydrome
Lupus anticoagulant and anticardiolipin antibodies = antiphospholipid antibodies
Risk of venous and arterial thrombosis, thrombocytopoenia and recurrent foetal loss in pregnancy
Normally primary disease but can be in SLE
307
Tests for thrombophilia
FBC, film, clotting, INR, PT
APC resistance test
Fibrinogen concentration
Lupus anticoagulant and anticardiolipin antibodies
Assays for antithrombin and protein c and s
PCR for factor V Leiden mutation and prothrombin gene mutation
308
Treat thrombophilia
Acute - heparin then warfarin to target INR 2-3
Lifelong warfarin in recurrence - target INR 3-4
High dose heparin if antithrombin deficiency
309
Danger in protein c and s deficient treatment
Warfarin can cause skin necrosis
310
Prophylaxis for thrombophilia in pregnancy
Aspirin and heparin
311
Risk factors for arterial thrombosis
Smoking
Hypertension
Hyperlipidaemia
Diabetes
312
Risk factors for venous thrombosis
```
Surgery
Trauma
Immobility
Pregnancy, OCP, HRT
Age
Obesity
Varicose veins
Conditions - heart failure, malignancy, IBD, nephrotic syndrome
```
313
What conditions can be made worse by steroids
TB, chicken pox
Hypertension, diabetes
Osteoporosis
314
Main drug interactions with prednisolone
Antiepileptics and rifampicin lower concentration
315
Guidance when starting steroids
Carry steroid card with dose and reason
Don’t stop suddenly - takes time for endogenous production to start again, can cause collapse, if >3w or >7.5mg/d
Warn about side effects if long term
Go to doctor if ill - may need to increase dose if ill or stressed
OTC drugs - no NSAIDs as increase DU risk
Prevent osteoporosis if long term - exercise, bisphosphonates, calcium and vit d supplements, smoking cessation
316
When should steroid withdrawal be gradual
```
Repeated courses
>3w
Hx of adrenal suppression
>40mg/d
Doses at night
```
317
Organs with SEs of steroids
```
GI
MSK
Endocrine
CNS
Eyes
Immune
```
318
GI SEs of steroids
Candidiasis
Oesophageal ulceration
Peptic ulceration
Pancreatitis
319
Msk SEs of steroids
Osteoporosis
Fractures
Growth suppression
Myopathy
320
Endocrine SEs of steroids
Adrenal suppression
| Cushing’s
321
CNS SEs of steroids
Depression
Psychosis
Aggravation of epilepsy
322
Eye SEs of steroids
Cataracts
Glaucoma
Papilloedema
323
immune SEs of steroids
Increased susceptibility and severity of infections
| Fever and raised WCC
324
DDI of azathioprine and mercaptopurine
Allopurinol, a xantine oxidase inhibitor. Azathioprine and mercaptopurine are metabolised by XO so can reach toxic levels if with allopurinol
325
What does ciclosporin do, and main SEs
Calcineurin inhibior, with tacrolimus
For reducing rejection in organ and marrow transplant
SE - dose related nephrotoxicity - monitor UEs and creatinine every 2w for 3m, reduce dose if creatinine rises by >30%
Also = gum hyperplasia, hypertension, paraesthesia, confusion, seizures
Lymphoma and skin cancer
326
How does methotrexate work
Antimetabolite, inhibits dihydrofolate reductive which is needed for synthesis of purines and pyrimidines
327
How does cyclophosphamide work and SEs
Alkylating agent
Marrow suppression, nausea, infertility, teratogenic
Haemorrhagic cystitis as irritative urinary metabolite, slight increased risk of bladder cancer or leukaemia
328
2ww criteria lung
>40yo
Haemoptysis
Smoker
329
2ww bowel criteria
Abdo pain and unexplained weight loss >40y
Unexplained rectal bleeding >50yo
Iron deficiency anaemia or change in bowel habit >60yo
330
WHO performance status
```
0 - asymptomatic
1 - symptoms, fully ambulatory
2 - symptomatic, in bed <50%
3 - symptomatic, in bed >50% but not bedridden
4 - bedridden
```
331
Staging and grading in general how
Imaging - staging CT
| Biopsy - grading
332
Lung cancer rf
Smoking x10
| Asbestos x5
333
Where are NSCLC and which is worst
Squamous - central, airways
Adeno - peripheral
Large cell - worst
334
Lung cancer inv
CXR
Staging CT NTAP
PET CT
Biopsy - percutaneous or bronchoscopy (+endobronchial US and alveolar lavage)
335
curative lung cancer treatment
Surgery
| Radical RT or chemo if unfit for surg
336
PAlliative lung cancer treatment
Stents
Brachytherapy
Palliative chemo
337
Curative lung cancer treatment
Surgery
| Radical RT or chemo if unfit for surg
338
Palliative lung cancer treatment
Stents
Brachytherapy
Palliative chemo
339
RF for colorectal cancer - 4
FAP - APC gene
Lynch syndrome
Smoking
UC (pancolitis for 15y+ = 15-20%)
340
Inv colorectal cancer
CEA
Staging CT TAP for liver mets
Colonoscopy and biopsy
341
Curative treatment colorectal cancer
Surgical, neoadjuvant RT, adjuvant chemo
342
Palliative management colorectal cancer
Stent/bypass
| Chemo
343
Screening for colorectal
FOB every 2y 60-74yo
| 5/10 will have normal colonoscopyl, 4/10 will have polyps on colonoscopy, 1/10 will have cancer
344
Duke staging and 5y survival
```
A - confined to mucosa 90%
B1 - muscularis propria
B2 - through muscularis propria and serosa - 60%
C1 - 1-4 nodes - 30%
C2 - 4+ regional nodes
D - distant mets
```
345
Upper GI 2ww criteria
>55
Dysphagia - progressive
Weight loss
Mass
346
Upper GI RF
Smoking, alcohol
Barret’s
H pylori - ask about ulcers
347
Inv upper GI cancer
OGD and biopsy
Staging CT TAP, PET CT/staging laparoscopy
Barium swallow = apple core sign
348
Pallliative upper GI cancer management
```
[LASER]
Laser
Analgesia
Stent
EtOH injection - for pain
Radiotherapy
```
349
Complications of upper GI cancer
Upper GI bleed
Obstruction - succussion splash, projectile vomiting
Perforation
350
What is acute leukaemia
Defective maturation of myeloid/lymphoid cells in bone marrow which spill out as immature blast cells that infiltrate
- liver, spleen, node, BM
351
What is chronic leukaemia
Proliferation of mature myeloid/lymphoid cells in BM which spill out and cause proliferative effects and infiltrate into all lymphatic systtems
352
What is Lymphoma
Proliferation of lymphoid cells from within lymphoid tissues that infiltrate into lymphatic tissues and bone marrow (sx)
353
What are lymphoid proliferation/infiltration symptoms
Invasion into HSM, bone, skin, gums, testes, thymus
354
Lymph nodes to check
Cervical
Inguinal
Axillary
355
Myeloid proliferation signs
HSM
Hyperviscosity - headache,visual, vte
Hyperuricaemia - gout
356
Features of blood cancers
```
B symptoms - BM infiltration
FBC symptoms - BM infiltration
Lymph nodes
Lymphoid proliferation/infiltration
Myeloid proliferation
```
357
Bloods for blood cancer
```
Fbc
Blood film
Flow cytometry
LDH, urate, folate = markers of excess cell turnover
Clotting - DIC in APML
```
358
Biopsy for blood cancer
Cytology - blast/plasma cells, hypercellular, Reed-sternberg
Morphology - M3 = APML
Immunophenotyping - B/T cells
Cytogenetics - Philadelphia t(9:22), APML t(15:17)
359
imaging for blood cancers
Lymphoma - Ann Arbor - CT TAP, PET CT
| Myeloma - skeletal survey, PET CT
360
CLL features
Elderly, indolent
Lymphocytosis - symmetrical LN
Smudge cells
361
Features of CML
Adults
Philadelphia
Myeloproliferative
362
Non-Hodgkin’s lymphoma features
Asymmetrical non-continuous node enlargement
| Low (follicular) or high (diffuse) grades
363
AML features
Auer rods, blasts
BM and tissue infiltration
Less chemoreponsive
364
ALL
Children
Blasts
BM and Tissue infiltration including CNS
chemo responsive
365
Myeloma and MGUS differentiate
CRAB in myeloma
IgG high and rest low in myeloma
Rest normal in MGUS
366
Diagnose Al-amyloid
Rectal biopsy
367
Types of myeloma/myeloid prolif
Myeloma
MGUS
Al-amyloid
368
DIC treatmetn
FFP and cryoprecipitate (has fibrinogen)
| +- platelets
369
DIC
Low Hb, Plt, fibrinogen
High INR, APTT, FDP
Schistocytes
370
2ww skin cancer
ABCDEF
371
Types of skin cancer histoloy
Superficial - flat
Nodular - worst as can infiltrate
Acral - on hands
Lentigo maligna
372
Inv skin cancer
Excision biopsy for breslow thickness for planning margin needed
373
Manage skin cancer
Widen excision margin
| +- adjuvant chemo
374
BCC features
Rodent ulcer
Pearly colour
Rolled edge
375
SCC features
Ulcerated nodule
| Hard everted edge
376
Diagnostic inv for myeloma
Serum protein electrophoresis
377
Bad prognostic signs in myeloma
Hb low
| Clonal plasma cells high
378
Inv for sepsis after oesophagectomy
Contrast swallow - likely anastamotic leak
| = mediastinitis
379
Inv when slow growing lymphadenopathy has had a sudden drop in Hb and increase in reticulocytes with splenomegaly
Direct antiglobulin test - warm AI haemolytic anaemia in CLL
380
Most common type of inherited bowel cancer
Lynch syndrome
381
What is lynch syndrome and inheritance signs
HNPCC
Extensive GI polyps
Endometrial, renal, CNS cancers
2 generations, 3+ first degree relatives to each other, 1 tumour <50yo
382
Lung cancer - when is hypercalceamie more likely?
SCC = PTHrP
383
Immediate management for abdo pain, constipation and high calcium in lung cancer
IV fluids
384
What is FAP
APC TSG gene
>100 adenomatous polyps in colon and rectum
Can have duodenal and fundic glandula
100% cancer
385
biggest RF for melanoma
Intense UV radiation
386
What skin cancer does immunosuppression make more likely
BCC
| SCC
387
types of prostate cancer
Adenocarcioma peripheral zone:
| Localised (inside capsule), local advanced (leaves capsule but not in organs) or mets
388
Prostate 2ww
Craggy or nodular DRE
PSA increased without other cause (increased with age - different cut offs)
Red flags eg bone pain
389
Inv prostate cancer
DRE and PSA
TRUS biopsy and Gleason grade
Isotope bone scan for sclerotic lesions
390
Manage CaP
Localised - active surveillance (curative intent - TRUS, rectal exams until found to be progressive then treat) vs watchful waiting (minimally invasive, palliative intent)
Local advanced - radical prostatectomy or RT, hormonal - LHRH agonist
Mets - hormonal, steroids/radio for bone mets
391
Features of non-seminoma
young, fast growing, tumour markers
392
Testicular cancer 2ww
Unexplained testicular lump,, usually painless
393
Inv testicular cancer
```
Tumour markers - bHCG, AFP, LDH, oestradiol = teratoma
US testes, CT TAP
Excision biopsy (core = tracking)
```
394
types of testicular cancer
Seminoma
Non-seminoma
Teratoma
395
Manage testicular cancer
Sperm bank
Inguinal orchidectomy
Adjuvant RT for seminoma
Chemo for relapses in non-seminoma
396
Rf for bladder/renal cancer
Substances - smoking, cyclophosphamide, dye
| SCC. - schistosomiasis
397
2ww for bladder/renal cancer
Visible haematuria >45, unexplained (eg no UTI)
| Non visible haemoaturia >60yo, no exercise etc
398
Inv bladder/renal cancer
Urine microscopy (?sterile pyuria?)
Flexible cystoscopy
Staging CT TAP
399
manage bladder/renal cancer
Invasive -
- renal = radical nephrectomy and RT
- bladder = cystectomy and ideal conduit and RT
Superficial bladder - TURBT via rigid cystoscopy and intravesicular chemo (BCG = higher risk)
400
Testicular lump with raised tumour markers
Teratoma
401
Complication of testicular lump
Torsion - surgery
402
When can you do PSA after DRE
2w later
403
Mood problems and flushes with hormonal therapy for prostate cancer
```
= testosterone flare a couple of weeks after starting hormonal therapy
Cyproterone acetate (anti androgen)
```
404
PUO and left varicoele?
Renal cell carcinoma - compresses left renal vein (drains into left testicular vein)
405
Prognostic factors in breast cancer
```
ER+ = better prognosis
HER2+ = worse prognosis
```
406
2ww for breast cancer
>30 with unexplained breast lump
>50 with unilateral nipple discharge/retraction
? Family history
407
Most common breast cancer
DCIS/invasive
408
Histology inv for breast cancer
Cystic - FNAC
| Solid, or blood/abn on FNA - core biopsy
409
MAnage breast cancer
Surgery - wide loop excision and RT, or mastectomy, and axillary clearance if sentinel node biopsy
Hormonal treatment - tamoxifen (ER+) or trastuzumab (HER+)
410
Screening for breast cancer
47-73yo
| Microcalcificatiotn on mammogram = DCIS
411
What is anastrazole for
Peripheral aromatisation after menopause makes most of oestrogen, it inhibits this
412
Ovarian cancer RF
BRCA1
Lynch
Ovulation
Reduced by COCP
413
Histology of ovarian cancer
Epitheilal - serous (most common)/mucinous cystadenoma
| Germ cell/stromal
414
2ww for ovarian cancer
Vague bloating
Then CA125 high
Then TVUS
Then refer
415
inv ovarian cancer
Ca125, CEA, CA19-9
If young, do atypicals (for germ cell) - HCG, LDH, AFP, oestradiol
TV US - CT TAP for staging - MRI pelvis
Ascetic tap for malignant cells on cytology
416
Manage ovarian caner
Staging laparotomy - TAHBSO, omentectomy, peritoneal washings, LN
Adjuvant chemo
Tumour marker survaillance
417
Complication of surgery for heterogenous ovarian cyst removal
Chemical peritonitis
418
Small RUQ breast lump manage
Adjuvant RT
| Wide local excision
419
Nipple eczema involving nipple and spreading out - what to do and what suspecting?
2ww for punch biopsy
| Suspect Paget’s disease
420
Risks of tamoxifen - 4
DVT
Post meno bleeding - endometrial cancer
Teratogenic
Hot flushes
421
Recognising death - 3
Progressive physical decline
Reduced oral intake/medication response
Rising EWS
422
End of life care points
```
Discuss with family
Palliative care referral
Anticipatory meds
Comfort obs
Stop non essential meds
Fast tracking
Opate prescribing - background (BD)/breakthrough (24h dose/6), syringe driver, patch
```
423
Pain medication in end of lfile
Pain - Morphine 2.5-5mg SC PRN max 60mg
Agitation - midazolam 2.5-5mg SC PRN max 60
NV/confusion - Haloperidol, levopromazine
Secretions - Hyoscine, glycopyrronium
424
Morphine conversion - SC and patch
SC = PO divided by 2
| Patch lasts 3d, 30mg PO morphine = 12mcg/h fentanyl patch
425
Post-death process - 4
Verifying death
Death certificate - immediate cause, plus what led to it and contributing factors
Cremation form
Coroners referral
426
Post-death process - 4
Verifying death
Death certificate
Cremation form
Coroners referral
427
When to refer to coroner
<24h admission
Unnatural cause eg substance, accident
Linked to occupational
428
When to refer to coroner
<24h admission
Unnatural cause eg substance, accident, violence
Linked to occupational
429
What is on death certificate
- 1a (immediate cause eg pneumonia), plus 1b (what led to it eg COPD) and 2 (contributing factors eg HF)
430
Causes of hypercalcaemia in oncology - 2
Lytic bone mets
Myeloma
Osteoclasts activating factor or PTH like hormones from tumour
431
Red flags for GI
```
ALARM >55yo:
Anorexia
Loss of weight
Anaemia
Recent onset
Melaena/haematemesis
Swallowing difficulty
```
432
Red flag sx for back pain
```
TUNAFISH
Trauma
Unexplained weight loss
Neuro sx
Age >50yo
Fever
Ivdu
Steroids
Hx of cancer - prostate, renal, breast, lung, thyroid
```
433
Assess melanoma
```
Asymmetry
Border - irregular
Colour - non uniform
Diameter >6mm
Elevation
```
434
What is BPH and sx
Benign nodular or diffuse proliferation of musculofibrous and glandular layers of tissue in inner transitional zone of prostate, so early sx:
Nocturnal, frequency, terminal dribble, hesitancy, uti, stones, retention
435
Manage BPH
DRE, MSU, UE, USS for residual volume and hydronephrosis
Rule out cancer - PSA, TRUS USS +- biopsy
Conservative - alcohol, caffeine, bladder training
Medical
- a-blocker tamsulosin reduces smooth muscle tone. ADR hypotension, drowsy, ejaculatory failure
- 5a reductase inhibitor finasteride (reduces conversion of testosterone to dihydrotestosterone). ADR impotence, reduced libido, excreted in semen (use condom), takes a while to work
Surgery - TURP. ADR:
- clot, bleeding, haematospermia, infection
- TUR syndrome (absorption of wash out fluid = hyponatraemia and fits), cross match 2u first
- erectile dysfunction, incontinence, retrograde ejactulation
No driving or sex for 2w, haematuria for 2w, initial increase in frequency for 6w
