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DPD 2019 > Could it be cancer > Flashcards

Could it be cancer Flashcards

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1
Q

What are the oncological emergencies

A 
Neutropenic sepsis 
Tumour lysis syndrome
Hypercalcaemia 
SVCO
Cord compression
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2
Q

Which cancers often present as emergencies

A

CNS, lung, HPB, upper GI

Rarely melanoma or breast

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3
Q

Outline the investigations for cancer

A

Radiological
Endoscopic
Biochemical
Surgical

Specialist clinics (e.g. breast)

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4
Q

Give example of radiological cancer investigations

A 
CT chest/abdo/pelvis 
CT or MRI brain 
MRI Whole Spine 
USS
PET-CT (if MDT recommends) 
Ba swallow
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5
Q

Bichemical investigations

A

CEA, Ca199, Ca153, PSA, aFP, betaHcG, Ca125

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6
Q

What is CEA associated with

A

Carcinoembryonic antigen

  • associated with lower GI tumours
  • normally <2.5 in non smokers or <5 in smokers
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7
Q

Other causes of CEA increasing

A

Not just lower GI tumours.

Also:

  1. Stomach/breast/lung/pancreas cancer
  2. Infections, pancreatitis, IBD

Can all increase CEA (but lower GI cancer can increase it into the hundreds or thousands)

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8
Q

What is Ca199 associted with

A

Almost always elevated in pancreatic cancer

Also can be elevated in other GI tumours

Poor specificity and sensitivity

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9
Q

How is Ca199 used clinically

A

Elevated levels typically associated with METASTATIC pancreatic disease

Also used to track response to treatment (e.g. chemo)

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10
Q

What is Ca 15-3 linked to

A

Breast cancer….

Also not diagnostic and used to assess treatment efficacy

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11
Q

What is PSA

List in 3 situtations where PSA may be elevated without there being cancer

A

Prostate specific antigen

If it is raised into the hundreds it usually indicated cancers

It says specific because it is the only one that is exclusive to the prostate, but it is not only raised in prostate cancer.

It can also be increased in BPH, Prostatitis, Catheterisation

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12
Q

What is Ca 125

A

Associated with ovarian cancer

Can be elevated in benign reasons (e.g. peritonitis) but also malignancy

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13
Q

Give examples of endoscopic investigations

A 
OGD
Colonoscopy
ERCP 
Bronchoscopy 
Nasendoscopy
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14
Q

What is the advantage of endoscopic investigations

A

Ability to obtain tissue
Therapeutic intervention – e.g. stents
Detect small lesions not visible radiologically

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15
Q

Give 3 exampes of surgical interventions

A

Examination under anaesthetic
Laparoscopy
Laparotomy

(not always needed, sometimes for pelvic tumours, can give you an idea of clearance)

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16
Q

What is crucial before treating cancer

A

Tissue diagnosis

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17
Q

Why is getting a tissue diagnosis important

A

Anticancer therapy varies depending on histopathological subtype.

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18
Q

Which condition can look like cancer

A

TB

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19
Q

T/F lymphoma can be diagnosed with FNA

A

Often it is very difficult to, really the lymph node needs to be taken out

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20
Q

How long does IHC and profiling take

A

IHC- up to 5 days

Profiling- up to a month

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21
Q

What is the role of the MDT for cancer

A

Facilitate rapid diagnosis and treatment
Carefully assess cancer stage
Set treatment goals
Implement best-practise treatment plan

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22
Q

Limitations of MDT

A

Only once a week

Only as good as the history it is given

Mainly designed to facilitate OP investigation and treatment

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23
Q

What information does an MDT need

A

Presenting complaint
Co-morbidities
Overall fitness – Performance status
Relevant investigations performed already

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24
Q

If you think it might be cancer, should you wait to talk to the MDT?

A

If you are worried it might be cancer don’t wait for MDT, talk to relevant team to get investigations under way.

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25
What is the role of acute oncology
Advise on investigations in unknown cancer. Advise on management of side-effects of chemotherapy/radiotherapy. Advise on treatment of effects of known cancer Advise on prognosis of cancer to facilitate planning of care. Assist in discussions with patients/relatives.
26
Which tumours need a fast diagnosis
- Small cell cancer - Lymphoma - Germ cell tumours - Cord compression of any cause
27
List the common acute presentations of cancer
``` Confusion/fitting SoB Obstruction Pain Liver/renal failure Off legs ```
28
What are your differentials for confusion/fitting
``` Infection Biochemical abnormality Drugs Cerebrovascular event Brain mets/primary Pseudo-seizure ```
29
What investigations would you do for seizure
Bloods (FBC, U&E, LFTs, Mg, Ca, CRP) | CT Brain
30
Management of brain metastases
Steroids- dexamethasone (16mg), for the oedema Surgery or radiotherapy (whole brain, cyber knife, stereotactic) Antiepileptics if seizure Identify primary site/biopsy brain if not able to Advise not to drive and inform DVLA Physio and OT assessment
31
Differential diagnosis for SoB
``` HF Pneumonia COPD Lung cancer PE Pulmonary HTN Wet disease ```
32
What is wet disease
Pleural effusion, ascites and pericardial effusion Often it is cancer related
33
Investigations for a breathless patient
``` CXR Bloods ABGs CTPA CT CAP ECG ```
34
Why might you do an ECG in a patient with SoB?
Ischaemic changes AND Pericardial effusion
35
What might an ECG with a massive pericardial effusion show?
Tachycardia Low Voltage Electrical alternans
36
What might you be looking for as a cause of PE if there is no obvious risk factor
Malignancy markedly increase risk of PE 4x higher risk Go looking for the cause if there is no obvious one already e.g. recent surgery
37
What is the first treatment for PE
Treat with low molecular weight heparin
38
What do you need to be careful about with pneumonia on chest xray
Consolidation may hide underlying malignancy
39
How do you ensure a consolidation is not hiding an underlying malignancy
Repeat chest imaging 6 weeks post to ensure changes have resolved
40
What cancer is associated with wet disease
Ovarian
41
How do you manage wet disease
Drain the fluid - image guided and send for cytology If malignancy is the cause- effective treatment is chemotherapy ONCE the patient is haemodynamically stable this can be delivered as an outpatient
42
What would you do with fluid from a tap
Biochemistry (exudate or transudate) and cytology and microbiology
43
What is the problem with giving chemotherapy when someone has wet disease
Chemotherapy can accumulte in collections of fluid 'third space' This can affect the pharmacodynamics of the drugs
44
Differentials for bowel obstruction
Severe constipation Malignant obstruction (single site or multifocal) Adhesion from previous surgery IBD
45
Investigations for bowel obstruction
AXR CT CAP Barium/gastrograffin (if at risk of aspiration) swallow Surgical review if lower GI
46
If there is multifocal obstruction (i.e. the bowel is obstructed at multiple points) in the bowel, it's more likely to be what
More likely to have come from outside the bowel (i.e. be peritoneal metastases)
47
Most common tumour types causing obstruction
Colon Ovary Gastro-oesophageal (dysphagia)
48
How are the following managed: 1. Single transition point 2. Multifocal bowel obstruction
If single transition point surgery or stenting possible. Multifocal subacute bowel obstruction often seen with ovarian cancer may be managed conservatively
49
Outline the conservative management sometimes used for multifocal subacute bowel obstruction
Drip & Suck NBM Iv fluids Normalise electrolytes Chemo once resolved if possible. If not palliation may be only option
50
Learn about maintenance fluid vs insensible losses
.........
51
Differentiate the likely tumour given the site of disease in the liver
Parenchymal disease – metastases - Colon cancer - Breast Cancer - Upper GI cancers Obstructive - Pancreas cancer - Cholangiocarcinoma - Portal Metastases from other cancers
52
What is liver failure
Abnormal liver function- AST, ALT, Alk Phos, Bili, Albumin, clotting, platelets
53
How do you investigate abnormal liver function
USS, CT CAP, MRI liver (best)
54
Which enzymes would increase proportionately in biliary obstructive picture
Alk phos and bili
55
How do you treat an obstructed liver
Make the diagnosis – tissue is needed ERCP and stent PTC drainage If someone has obstructed duct they need to be on prophylactic Abx
56
T/f if the malignancy causing obstruction is in an early stage it could be resectable
T
57
When can chemo be given in obstructed liver
Chemo usually not possible until LFTs have normalised Which is why you need to get a stent in asap
58
Explain the cause of renal impairment in cancer
Hydronephrosis = swelling of a kidney due to a build-up of urine. It happens when urine cannot drain out from the kidney to the bladder from a blockage or obstruction. Common in cervix and bladder cancers
59
How do you treat renal impairment in cancer
Treat Antegrade nephrostomy and stent Retrograde stent insertion
60
T/F stents are usually uncomfortable for patients
T- Stents are uncomfortable for patients. If a patient is frail and may not be fit for treatment sometimes kinder not to insert stent
61
What can cause renal impairment without hydronephrosis and how to treat
May be due to sepsis Fluid depletion Cancer burden Treat with iv fluids and ABXs May be end stage disease and mode of death
62
Outline how you can treat pain
WHO ladder Opioids Neuropathic agents Identify cause of pain and address
63
When can nerve block be useful in cancer
Pancreatic
64
Other methods of pain management other than pharmacology in cancer
Radiotherapy (bone mets) Chemotherapy Pathological fractures – surgery Pain from masses may be helped with surgery Psychological support Hypnotherapy Bisphosphonates/RANKL
65
Why can cord compression be missed
Patients admitted unwell, no clear history Drs rounds with patient in bed – no-one notices Too willing to accept incontinence and poor mobility as “normal”
66
Which cancers can cause cord compression
Prostate, Breast, Lung, Kidney, Thyroid, Lymphoma, Multiple Myeloma
67
What are the features of cord compression
Weakness, numbness, urological dysfunction, faecal dysfunction, sexual dysfunction
68
What is key to not miss cord compression
``` What were they like at home? Any back pain? Any known malignancy? Duration of symptoms and speed of decline Current bladder/bowel function ```
69
What must you do if you expect cord compression
Do full neurological examination, including PR | Document bladder and bowel function
70
Management for cord compression
``` 16mg Dexamethasone Urgent MRI whole spine CT with spinal reconstruction Nurse supine Liase with Neurosurgery (Will they operate? Is the spine stable for PT/OT?) Liase with Oncology ```
71
How long does it take for nerves to die following compression
Nerves start to die within 24hrs of compression.
72
T/F if a patient is bedbound we don't need to worry about preserving contientnce with spinal cord compression
Even if bedbound, if we can preserve continence there is possibility of being cared for at home.
73
What can off legs mean
Many patients will be decompensating because they are weak | Cancer burden increasing
74
Which tumour needs a fast diagnosis A Breast cancer B colon cancer C small cell lung cancer
C....because if you can get chemo in early enough it is often very responsive and you can really change the diagnosis ("exquisitely chemo and radio sensitive")
75
What percentage of lung cancers are small cell? T/f all small cell cancers are in the lung
10-15% F
76
How do you stage small cell lung cancer
Limited disease – confined to one hemithorax | Extensive disease – any disease beyond limited
77
What are the prognostic factors for small cell lung cancer
Manchester score ``` Extensive disease WHO PS ≥ 2 Serum Na ≤ 132 mM/l Bicarbonate ≤ 24 mM/l Alk Phos > 165 IU/l LDH > 450 iu/l ```
78
Treatnebt for Small Cell Lung Cancer
Carboplatin/Etoposide chemotherapy Consolidation radiotherapy to lung Prophylactic cranial irradiation
79
T/F lymphomas are usually not aggressive
Diverse group of haematological malignancies that range from very indolent to highly aggressive.
80
Presentation of lymphoma
``` Lymphadenopathy B symptoms: -Fevers >38C -Night sweats -Weight loss >10% body weight ```
81
In which case would you not give high dose steroids in
Lymphoma

DPD 2019 (30 decks)

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