Dan's Oncology Questions Flashcards
(187 cards)
1
Q
What sort of radiation do radiotherapy machines produce? Is it radioactive?
A
X-rays by targeting electromagnetic beams towards tungsten. RT is not radioactive.
2
Q
What are the types of brachytherapy?
A
Intracavitary – the source is placed within a body cavity (used to treat oesophageal, cervical or lung cancers. Also intrauterine tubes and vaginal sources are used in the treatment of gynaecological Ca)
Interstitial – placed within tissues (rx of prostate, breast cancer, tongue and floor of mouth Ca.)
Surface mould – superficial skin lesions
3
Q
What are the 3 components to biological radiation dose?
A
Total dose
Number of treatments (fractions) of a given dose
Overall time of treatment
4
Q
What is the understanding behind planning fractions?
A
The same total dose given in fewer fractions has a greater effect than the same dose given over a longer time in many fractions.
However, smaller fraction sizes minimise negative effects on normal tissues.
If the fractions are too small, the overall treatment time will take too long.
5
Q
What is consideration given to the overall treatment time?
A
Treatments over 6 to 7 weeks should be avoided to avoid repopulation of tumour cells.
6
Q
What are the acute effects of radiotherapy?
A
These can be split into -
Non-specific effects: such as fatigue and lack of energy
Specific local effects: (self-limiting and restore after the treatment is stopped)
Skin – erythema (desquamation if severe)
Bowel – diarrhoea/colic
Bladder – frequency and dysuria
Scalp – hair loss
Mouth/pharynx – mucositis
7
Q
Is lymphoedema an acute or long-term effect of radiotherapy?
A
Lymphoedema is a longer term effect of radiotherapy
8
Q
What is desquamation and how is it treated?
A
The shedding of the outermost membrane (in this case skin).
Wet desquamation is when the skin starts to weep.
Desquamation is managed by the application of dressings.
9
Q
What are the late effects after radical radiotherapy?
A
Loss of stem cell recovery potential and damage to small blood vessels causes changes that are irreversible.
Fibrosis!
• Bowel (stricture, perforation, fistula)
• Bladder (fibrosis causing frequency, haematuria, fistula)
• CNS (myelitis > paraplegia, cerebral necrosis)
• Lung (fibrosis)
10
Q
What is the treatment for poor urinary flow and constipation?
A
Tamsulosin (alpha blocker) – improves urinary flow
Fybogel – bulk stool
11
Q
How long after RT treatment does pneumonitis set in?
A
Pneumonitis – occurs 6-8 weeks after RT. Progressive SOB and cough. Treated with high dose steroids and oxygen
12
Q
What is radical and neo-adjuvant chemo?
A
Radical chemo is for curative intent.
Neo-adjuvant means before surgery.
13
Q
What is hand-foot syndrome?
A
Reddening, swelling, erythema and desquamation of the skin on the hands and the feet.
14
Q
How is hand-foot syndrome managed?
A
Firstly, lifestyle changes (avoiding harsh chemicals, heat)
Topical analgesic emollients (lidocaine)
15
Q
Which drugs are implicated in hand-foot syndrome?
A
Capecitabine, 5-FU, erlotinib, Sunitinib
16
Q
Which chemo drugs are excreted by the Liver, and which by the kidneys?
A
Liver - Taxanes
Renal - Cisplatin
17
Q
Which immune modifying drug is used in Gastrointestinal stromal tumours (GIST)?
A
Imatinib! It proved to be very successful and causes drastic remissions of PET FDG scans
(Inhibit BCR-Abl protein, cross-reacts with c-KIT product)
18
Q
What are the first steps taken to control N+V of chemo?
A
Odansetron OR dexamethasone 8mg IV
Post –dose at home with:
Metoclopramide 10mg tds PO 14days
Dexamethasone 6mg PO
19
Q
Which drug can be used for anticipatory nausea?
A
Lorazepam to cool nerves
20
Q
How is mucositis managed?
A
- Good oral hygiene and painkillers (can be difficult to speak) to avoid infection.
- Laser therapy and palifermin (growth factor- stimulates growth of the mouth mucosal cells)
21
Q
What are the two mechanisms of action for chemotherapy drugs?
A
DNA STRUCTURE - (antimetabolites, alkylating, intercalating agents),
MITOSIS - (signal transduction inhibitors, drugs inducing apoptosis)
22
Q
How are methotrexate and 5-fluorouracil similar, but also how are they different?
A
They are both anti-metabolites.
Methotrexate inhibits folate production
5-FU incorporates itself into the DNA structure and prevents accurate replication.
23
Q
How do the vinca alkaloids cause their effect?
A
The vinca alkyloids are spindle poisons that inhibit mitosis (vincristine, vinblastine, vindesine)
24
Q
What are paclitaxel and docetaxel?(
A
Taxanes. These drugs also affects spindle formation.
25
What are the platinum based chemo drugs?
Oxaliplatin, Cisplatin, Carboplatin. They are intercalating agents and form abnormal bonds within DNA and prevent accurate replication.
(intercalating makes you richer!) –platinum is expensive
26
What is the purpose of separating cancers in terms of chemotherapy sensitivity?
High sensitivity cancers are given chemo as the treatment of choice.
Moderately sensitive are given chemo but as adjuvant therapy or for recurrent disease
Low sensitivity cancer will only really be given chemo in the palliation of advanced disease
27
Which cancers are high sensitivity and moderate sensitivity?
HIGH SENSITIVITY – Blood cancers (leukaemia, lymphoma), germ cell tumours, small cell lung cancer, myeloma, neuroblastoma, Wilms tumour
MODERATE SENSITIVITY – Breast, colorectal, bladder, ovary and cervix
LOW SENSITIVITY – Prostate, kidney, primary brain tumours, adult sarcomas, melanoma
28
What is the common mode of delivery of chemotherapeutic agents?
Through an indwelling central venous catheter (PICC/Hickman's line) - cancer patients require the administration of venotoxic drugs for long periods of time.
29
What is a PICC line?
Peripherally inserted central catheter (enters in the antecubital fossa)
30
Into which veins are central lines inserted?
Large veins – Internal Jugular vein, subclavian or femoral
Hickmann lines and portacaths are inserted into the internal jugular as it is close to the surface and easy to find
(note! the only difference between a portacath and the Hickmann is the catheter externally. They are inserted the same)
31
Where do PICC lines lie?
They are inserted through a peripheral vein, through the subclavian and lie in the Superior vena cava
32
What is a portacath?
Indwelling central catheter which is tunnelled under the skin and over the collar bone and into the internal jugular vein. Blood can be taken from the portal and drugs can be administered.
It is more discrete than other CCs and does not interfere with tasks such as washing.
33
What are the four oncological emergencies?
Neutropenic sepsis, Hypercalcaemia, Spinal Cord Compression, SVC compression
34
Which cell types do chemotherapy drugs target and how does this lead to neutropenic sepsis?
Chemotherapy targets high turnover rate (dividing cells) - mucosal layers and bone marrow.
Thereby, the damage done to the mucosa by chemotherapy allows translocation of bacteria into the bloodstream > sepsis.
The damaged bone marrow leads to a reduction in neutrophil count. The neutropenia and the translocation of bacteria into the blood stream result in neutropenic sepsis.
35
Flora found in the gut are gram positive or negative?
Gram negative
36
What are the most common organisms involved in neutropenic sepsis?
Gram negative organisms! – E Coli, Klebsiella, and pseudomonas
BUT staph aureus and Strep epidermidis are also involved
37
What investigations and results are required for a neutropenic sepsis diagnosis?
Full blood count. A neutrophil count of <0.5x109/L with either
-temperature higher than 38oC for 1 hour / single temperature higher than 38.5oC
OR
-other signs or symptoms consistent with clinically significant sepsis
38
What is the management of neutropenic sepsis?
BUFALO. Antibiotic of choice TAZOCIN (pipercillin/tazobactam) should be given on suspicion of NS.
39
How do cancers cause hypercalcaemia?
Some cancers release parathyroid related protein (PTrP) and increase serum calcium
40
Which organs does PTH work on?
It targets three organs: the kidneys, the bone and the gut. It results in increase reuptake of Ca2+ by the kidneys, increased release of osteoclasts and the subsequent breakdown of bone, and the increase absorption of dietary Ca2+ from the gut.
41
Which cancers are most likely to cause hypercalcaemia?
1. Breast cancer
2. Non-small cell Lung cancer (squamous cell)
3. Multiple myeloma
4. Prostate cancer
42
What are some symptoms of hypercalcaemia?
Painful BONES, kidney STONES, psychiatric MOANS, and abdominal GROANS
Polydipsia and polyuria. Weight loss and fatigue are two non-descript symptoms that are present in hypercalcaemia.
43
What are the first line treatments for hypercalcaemia?
FLUIDS AND BISPHOSPHONATES
0.9% Saline 4-6L over 24hours (Patient must be monitored closely for risk of fluid overload)
Bisphosphonates (Panidronate IV)
44
What are some symptoms of spinal cord compression?
Back pain and neurological symptoms below the level of the compression - lower limb weakness, saddle anaesthesia, sensory loss.
This will be accompanied by constipation and urinary retention
45
Which cancers are most commonly associated with spinal cord compression?
Breast cancer, multiple myeloma, prostate cancer (commonly spreads to bone), lymphoma
46
What investigations are done for SCC?
```
Blood tests (check for bone marrow involvement, ALP and increased Ca2+)
MRI whole spine is gold standard
```
47
What is the spinal cord compression pathway for a patient with suspected SCC?
```
If a patient is suspected of SCC:
Lie flat
Administer 16mg dexamethasone (with PPI!)
Consider LMWH is reduced mobility
THEN
Order an urgent MRI spine
THEN
If MRI spine is positive for SCC:
THEN
Consider neurosurgical intervention
THEN
Radiotherapy
```
48
What are some symptoms of Superior Vena Cava Obstruction?
Fluid retention in the face, neck and arms and also a raised JVP.
Breathlessness - worse on lying supine. Pain may occur and is worse on cough.
49
What is the most common cause of SVCO?
Lung cancer. Any cancers in the mediastinum and chest can cause compression of the SVC
50
What is the management for SVCO?
16mg dexamethasone
Treat the underlying cause (obstructing malignancy/non-malignancy)
There may also be a role for SVC stents
51
What is tumour lysis syndrome?
A syndrome arising from the rapid breakdown of a large number of cells – usually in response to instigation of chemotherapy with a highly sensitive tumour like lymphoma or leukaemia.
52
What are the symptoms of tumour lysis syndrome?
It presents with extensive metabolic disturbances. Can present as AKI or cardiac arrhythmias and can be life-threatening.
Hyperphosphataemia, hyperuricaemia, hyper-something? Everything goes up apart from calcium
53
What are some possible causes of vomiting in cancer?
Gastric stasis, gastric outflow obstruction, oesophageal blockage, bowel obstruction, raised intracranial pressure, anxiety related
54
How does a patient present with gastric stasis?
Large volume of vomitus with infrequent vomiting and relief after vomiting episode. It also presents with epigastric fullness and early satiation.
55
If a patient presents with symptoms similar to gastric stasis but with low-volume vomiting what is a likely diagnosis?
‘Squashed stomach syndrome’ – space occupying lesion that results in the reduction in the gastric cavity
56
A patient presents with effortless vomiting, often in the morning, which is associated with headache. What is the most likely cause of the patients vomiting?
Raised intracranial pressure
57
What anti-emetic would you use to manage raised ICP vomiting?
Cyclizine
58
What is the mechanism of action of Haloperidol and which types of vomiting is it used to manage?
Haloperidol is a first generation anti-psychotic that can be used to control nausea and vomiting. It is a dopamine antagonist. It is mainly used to treat drug-induced and metabolic causes of nausea.
59
What are the three types of laxatives?
Stimulant, osmotic and bulk-forming
60
Name an osmotic laxative.
Lactulose, Phosphate enema. These hold water in the stool and maintain its volume and stimulating peristalsis.
61
What are the adverse effects of osmotic laxatives?
Flatulence, abdo cramps and nausea. Diarrhoea is of course an adverse effect.
62
What type of laxative is Senna?
Senna is a Stimulant
63
How do bulk-forming and stimulant laxatives work differently?
Bulk forming laxatives draw water into the stool and increase its volume which in turn stimulates peristalsis.
Stimulant laxatives act on the nerve plexus and promote peristalsis (they also alter water and electrolyte secretion!)
64
When are laxatives contraindicated?
Whenever obstruction is expected!
65
Which is the most common gynaecological cancer?
Endometrial
66
What is the typical demographic for endometrial cancer?
Obese nulliparous women (with a tendency of CVD or DM), with a family history of endometrial cancer.
67
What are the risk factors of endometrial cancer?
Obesity
Diabetes
Early menarche, late menopause
Unopposed oestrogen HRT
Tamoxifen – partial agonist affect on endometrium which can cause proliferation
FHX of endometrial, breast cancer, colorectal
68
What is the most common type of uterine cancer?
Adenocarcinoma is around 90%
69
Where are common sites of spread of endometrial cancer?
Lungs and bone
70
What is the classic presentation of endometrial cancer?
Pre-Menstrual Bleeding is endometrial cancer until proven otherwise.
On examination, uterus may feel bulky and vaginal discharge or bleeding may be apparent
Irregular, heavy or inter-menstrual bleeding, is <40
71
What percentage of women presenting with PMB have malignancy?
Only 10%
72
What is stage 2 endometrial cancer (FIGO)?
Spread to the cervix. Spread to other pelvic structures is stage 3.
73
What are the investigations for endometrial cancer?
Transvaginal ultrasound and pipelle
| Hysteroscopy and biopsy if endometrial thickening
74
What is the treatment of stage 1 endometrial cancer?
Total abdominal hysterectomy with salpingo-oopherectomy is the treatment of choice for localised disease.
75
What is Wertheim’s hysterectomy?
A radical type of hysterectomy which involves the removal of the uterus, pelvic lymph nodes, ovaries, fallopian tubes and the upper part of the vagina.
76
When is palliative treatment indicated in endometrial cancer?
Palliative radiotherapy is indicated in advanced local tumours and painful bone metastases.
77
What is the prognosis of endometrial cancer?
Most are identified early (70-80%) so prognosis is good – cure rates of around 85%.
78
What is the 5 year survival percentage for stage 2 and stage 3?
Stage 2 – 65%
| Stage 3 – 35%
79
Which ages does cervical cancer affect?
Most common cancer in women under 35
80
How frequently is the cervical screening programme offered?
Every 3 years from 25 until 49
| then every 5 years until 64
81
What is thought to be a feature of all cervical cancers?
HPV infection. HPV 16 and 18 are most implicated.
82
What are other risk factors for cervical cancer?
HPV infection!!! Sexual activity (exposure to HPV) - early age of first intercourse, multiple sexual partners, smoking, miscarriage, oral contraceptives,
83
Which HPVs are most high risk in cervical cancer?
16 and 18
| Most people are exposed to HPV in their lives but 90% of women clear the infection by 2 years
84
What solution is used in colposcopy?
Acetic acid
85
At which stage in the screening process is Cervical Intra-epithelial Neoplasia diagnosed and what does it mean?
At colposcopy – punch biopsy. CIN 1 is 1/3 dyskaryosis, CIN 2 2/3 and so on
86
What imagining investigations can be used in cervical cancer?
MRI pelvis
| CT abdo, X-ray chest for mets
87
How does cervical cancer usually present?
Post Coital Bleeding (requires referral to gynae), IMB, PMB – RED FLAGS
Persistent offensive vaginal discharge – which has been treated
Haematuria or rectal bleeding (with local spread),
Lumbar back and sacral pain (pelvic/para-aortic lymphadenopathy)
Swollen leg – thrombosis in pelvic
88
How do you examine for cervical cancer?
Speculum, bimanual and PR
| Colposcopy and cervical biopsy for diagnosis
89
Microscopically what are the majority of cervical cancers?
90% are squamous cell carcinomas. The other 10% are adenocarcinoma.
90
According to FIGO, what stage is a cervical cancer that has extended to the lower third of the vagina?
Stage 3A.
91
What is the treatment for stage 1 cervical cancer?
Radical treatment is considered for all CC apart from those with metastatic spread. However, for those who may be medically unfit for surgery then chemo-radiation may be considered.
92
What is the treatment of choice for stage 2 or 3 cervical cancer?
Radiotherapy is now the treatment of choice, as the cancer is no longer localised.
Any stage 2 or above surgery is no longer viable
93
Is cervical cancer hormone dependent?
No. Hormone manipulation is not useful in treatment. However, HRT should be considered in women (especially young women), following radical treatment i.e. oophorectomy.
94
How common is ovarian cancer?
2nd most common gynae cancer
95
What is the prognosis?
43% 5 year survival.
| Bad because it presents late
96
At what stage do women usually present?
75% present at stage 3 or 4
97
What are the risk factors of ovarian cancer?
```
Nulliparity
HRT
Endometriosis
Difficulties conceiving
5-10% have BRCA1/2 gene mutations
```
98
How would ovarian cancer present?
Abdo pain and swelling
Pressure effects on rectum and bladder
Dyspnoea
GI upset and anorexia
99
What is found on examination in ovarian cancer?
```
Adnexal or pelvic mass
Shifting dullness (ascites)
Irregular abdo mass – omental cake (an omentum completely replaced by solid tumour)
```
100
What imaging is used to investigate ovarian cancer?
Pelvic ultrasound
101
What are the two common macroscopic appearances of ovarian cysts?
Mucinous – multi-loculated tumour containing mucinous material
Serous cysts – containing clear fluid
102
What are the common types of OC?
Epithelial adenocarcinoma is the most common – includes clear cell carcinomas and endometrioid carcinomas
103
What is Meig’s syndrome?
It is a triad of ascites, pleural effusion and a benign ovarian tumour
104
What are the symptoms of ovarian cancer?
Can be asymptomatic. Vague symptoms of abdominal and pelvic discomfort, haematuria, abdo swelling (tumour or ascites?), urinary or bowel disturbances due to local pressure
105
What are the investigations for ovarian cancer?
Serum CA125.
If +/= to 35 do USS.
If USS is + then urgent referral is needed.
106
What two blood tests should be used as secondary investigations when suspecting ovarian cancer in women under 40. What do they show?
AFP and bHCG are useful indicators for germ cell tumours
107
What is stage 1a and 1b ovarian cancer? (FIGO)
Stage 1a is when one ovary is affected, stage 1b is when both are affected
108
How do you treat stage 1a and 1b ovarian cancer?
Stage 1 OC (A or B) are treated with surgery to remove the tumour bulk (hysterectomy, salping-oopherectomy and omenectomy)
Chemotherapy with platinum based compounds (cisplatin) has been shown to benefit women with no residual disease following surgery (adjuvant)
109
What is a Brenner tumour?
Fibroma of the ovaries and are usually benign.
110
What is RMI and how is it calculated?
Risk of malignancy index. It is calculated with CA125 (iU/ml) x USS factors x Menopausal score
111
What percentage of gynae cancers are cancer of the vagina?
1%. It is a rare cancer.
112
What are the risk factors for vaginal cancer?
Closely related to HPV infection (genital warts HPV 6&11 is closely related). Also there is an association with CIN or invasive cervical cancer.
113
What are the symptoms of vaginal cancer?
Itch! Vaginal discharge and bleeding; pain is rare unless extensive pelvic infiltration
114
What are the differentials for vaginal cancer?
Atrophic vaginitis
Mets from cervical cancer or endometrial cancer
Bartholin’s cyst (4 and 8 o’clock)
115
How is vaginal cancer diagnosed?
Punch biopsy
116
What is the treatment for early vaginal cancer?
Radical hysterectomy and total vaginectomy with pelvic lymphadenectomy
117
What are the symptoms of choriocarcinoma?
PV bleeding within a year of pregnancy; abdo or pelvic discomfort
118
What are the two main types of breast carcinoma?
Ductal carcinoma in situ (DCIS) and Invasive ductal carcinomas. Carcinomas in situ are a Stage 0. There are other rarer types of breast cancer: inflammatory breast cancer, phyllodes tumour, invasive lobular carcinoma.
119
1 in ? women in the UK will be diagnosed with breast cancer in their lifetime?
1 in 8 women in the UK will be diagnosed with breast cancer in their lifetime according to Cancer Research UK.
120
At which age do women in the UK get free breast screening from the NHS?
50-70 years
121
How common is breast cancer in the UK?
Breast cancer is the most common cancer in the UK. It accounts for 15% of all new cases in the UK. It is more common in Caucasian women
122
How do DCIS and LCIS present differently, clinically?
1. DCIS is associated with calcification on mammography. LCIS is almost always an incidental finding; you can’t see it on mammography.
2. LCIS is often bilateral; DCIS is usually unilateral.
123
What symptoms does DCIS present with?
It is rare for DCIS to produce symptoms or a breast lump that one can feel (the carcinoma is limited to the lining of the breast ducts- Stage 0). DCIS is therefore often diagnosed by mammography which identifies the microcalcifications in the malignancy. The diagnosis would need to be confirmed with mammography.
In the small number of cases where DCIS presents with symptoms it has typical breast symptoms such as discharge, lump/thickening in the breast, change of shape in the breast.
124
What does an invasive ductal carcinoma look like on a mammogram?
An invasive ductal carcinoma appears as a mass with fine spikes radiating from it.
125
What symptoms can an invasive ductal carcinoma present with?
Painless, enlarging mass in the breast that does not fluctuate with the menstrual cycle. If the IDC presents as inflammatory breast disease then this could result is swelling, erythema, pain and a peau d’orange appearance of the breast.
126
A patient presents with a breast lump around 1.5cm in diameter but fluctuates in size with her menstrual cycle. What are your differentials?
The change in size with the menstrual cycle suggests that this is likely to be fibrocystic change or simple cysts.
Fibrocystic disease is the formation of small cysts in the breast as a response to normal changes in hormones during normal, monthly menstrual cycles.
127
Where are common sites of breast cancer metastasis?
Breast cancer commonly metastasises to the brain, lung, liver and bone.
128
How is early breast cancer managed, surgically?
Patients can undergo different types of surgery such as:
- breast conserving surgery plus radiation
- mastectomy and reconstruction (which can be done in the same operation)
- and mastectomy alone
129
What is the sentinel node?
The SLN is the first draining node from the breast, located in the axilla.
If SLN biopsy is negative, no further surgery is required, however, if positive, possible treatment options include complete axillary node dissection or adjuvant axillary radiation.
130
When is chemotherapy used in breast cancer?
Both pre- and post-menopausal women benefit from adjuvant chemotherapy. It is routinely offered to women with a tumour 1cm or larger.
131
What types of hormonal treatment is there for breast cancer and why is it used?
Breast cancers can receive oestrogen stimulation (ER- or PR- positive). Hormonal treatments like oestrogen receptor antagonists (Tamoxifen) and aromatase antagonists (Anastrozole –Arimidex).
In premenopausal women the main source of oestrogen is from the ovaries but in postmenopausal women it is from conversion or adrenal androgens to oestrogen using aromatase.
Hence;
Pre MP > tamoxifen
Post MP > aromatase inhibitors
132
What are the biological therapies for breast cancer?
If a breast cancer is HER2 positive then transtuzumab (Herceptin) should be used
133
What is HER2 and how does transtuzumab (herceptin) work?
HER2 is found in all human cells. It controls cell growth and repair.
But high levels of HER2 are found in some types of breast, oesophageal and stomach cancer, which helps the cancer cells grow and survive.
Herceptin works by blocking the effects of HER2 and encouraging the immune system (the body's natural defences) to attack and kill the cancer cells.
134
Prostate cancer mainly affects men aged over 50 years. But what is the average age for men to be diagnosed with prostate cancer in the UK?
65-69 years
135
How common is prostate cancer in men in the UK?
Prostate cancer is the most common cancer in men in the UK. 40,000 new cases are diagnosed each year.
136
Which harmless hyperplasia can cause similar symptoms to those in symptomatic prostate cancer?
Benign Prostatic Hypertrophy. In men, the prostate naturally grows with age. In some men this can lead to obstruction of the urethra in which case it would become symptomatic.
137
Name some other differentials for urinary retention symptoms?
BPH
Acute and Chronic prostatitis
Urethritis
138
How can prostate cancer cause problems with sexual dysfunction and painful ejaculation?
The vas deferens deposits seminal fluid in the prostatic urethra. Here, the prostatic secretions are also added. The prostate also contains smooth muscles that aid with ejaculation.
139
What is the treatment for symptoms of prostate cancer? How does it work and give some examples.
The symptoms would preferably be controlled with exercise and altering voiding positions.
However, if these are unsuccessful then alpha blockers or 5alpha reductase inhibitors could be used- for example, doxazosin/tamsulosin or finasteride.
Surgical intervention is available in the form of transurethral resection of the prostate (TURP).
140
How is prostate cancer diagnosed? Why is there no screening programme in the UK for prostate cancer?
Prostate cancer is diagnosed mainly with a digital rectal examination and PSA levels. To confirm diagnosis a biopsy is needed. However, because the PSA blood test is not specific there has been no national screening programme because it would cause more harm than good. Most men with a raised PSA would not have prostate cancer and screening would lead to interventional procedures that could be dangerous.
141
Where are some common sites of prostate cancer metastasis?
Initially, hyperplasia will begin as prostatic intraepithelial neoplasia (PIN). Gradually, if untreated it will invade into surrounding structures like the seminal vesicles, bladder and rectum. Common sites of metastases in the body are the bone and lymph nodes.
142
What is acute myeloid leukaemia?
Acute Myeloid Leukaemia is a blood cancer of the blood in which there is neoplastic proliferation of myeloblastic cells in the bone marrow. This over production of poorly differentiated cells leads to a deficiency in other types of blood cells also produced in the marrow- such as neutrophils, thrombocytes and erythrocytes.
143
What are the symptoms of acute myeloid leukaemia?
The symptoms arise from the blood cells deficiencies. Hence, patients will present with bleeding and bruising, high fevers and general malaise, and fatigue and pallor. There are also symptoms of infiltration such as gum hypertrophy and splenomegaly.
144
AML can present with disseminated intravascular coagulopathy which is a medical emergency. What is DIC and how is it caused by AML?
DIC is the widespread activation of the clotting cascade which results in the formation of blood clots in small vessels around the body- this can then lead to multiple organ failure. Furthermore, when clotting factors are consumed this leads to the loss of the ability to clot and leads to widespread bleeding.
AML causes this due to the improper formation of thrombocytes leading to the release of thromboplastin.
145
How is AML distinguished from Acute Lymphoblastic Leukaemia?
Histologically, a way to distinguish AML from ALL is by noticing granular crystallised lines called Auer Rods present in myeloid leukaemia blasts.
146
Which treatments are commonly used for AML?
Pluripotent haematopoietic stem cells are transplanted into patients who have previously had the leukaemic cells and their immune system destroyed by cyclophosphamide and total body irradiation, this destroys the patients bone marrow.
If patients are ineligible from stem cell transplants then NICE recommends that Azacitidine is used as the chemotherapy drug.
147
Which chromosomes are translocated in the formation of the Philadelphia chromosome and which cancer is it associated with?
Both the long (q) arms of chromosomes 9 and 22 are translocated to form the Philadelphia chromosome. This is associated with CML.
148
Is prognosis better in patients with or without the Philadelphia chromosome?
The prognosis happens to be better in patients with the Philadelphia chromosome compared to those without the abnormal chromosome.
149
What are the three stages of CML?
As the name suggest chronic myeloid leukaemia has a more gradual onset of symptoms. These can be split into three stages – the chronic stage, the accelerated stage and blast transformation.
Chronic stage:
90% asymptomatic/ fever WBC^^^
Accelerated stage:
There is massive splenomegaly and petechiae
Final stage (blast phase):
Patients presents like AML (bone pain, fever)
150
How does CML present?
Hepatomegaly (higher basal turnover) and Splenomegaly
Fever – WBC high!
Petechiae/ecchymoses
151
What do the investigations show in CML?
FBC - Increased WBC (50-200x10^9) – massively increased!
Peripheral blood smear – leucocytosis
FISH shows Philadelphia chromosome
Bone marrow aspiration – myeloblasts
152
What is the median survival for a diagnosis of CML and what drug has aided this?
5-6 years thanks to imatinib!
153
What is ALL and who does it commonly affect?
Acute lymphoblastic leukaemia is the abnormal proliferation of lymphoblasts in the bone marrow. It is the most common cancer in children and affects mainly children aged 2-5 years.
154
What is multiple myeloma?
Over-proliferation of plasma cells in the bone marrow that leads to the overproduction of abnormal Ig (immunoglobulin) and the underproduction of normal Ig (which predisposes to infection)
155
What are the symptoms of multiple myeloma?
Remember! Babs the CRAB!
HyperCalcaemia – constipation, nausea, vomiting, abdo cramps
Renal impairment (high Creatinine!) – due to accumulation of abnormal IG- leads to polydipsia
Anaemia – Pallor and fatigue
Back pain – Low back pain due to increased bone turnover
156
What is the age of onset of multiple myeloma?
Affects the elderly. 70+ usually
157
What investigations can be done for multiple myeloma?
Monoclonal proteins (usually IgG or IgA) in the serum and the urine (Bence-Jones Proteins!)
Increased plasma cells (obvious!)
Bone lesions on a skeletal survey
158
What kind of Lung Cancers are non-small cell and small cell lung cancer?
NSCLC and SCLC are types of bronchial carcinoma
159
What pathological types of non-small cell cancer are there?
Adenocarcinomas (40% of all LC), squamous cell (25-30%), large cell and mixed (10-15%)
160
What percentage of all cancers is non-small cell cancer?
80-90%
161
What type of aspiration method could be used to histologically examine thoracic lesions?
Percutaneous transthoracic needle biopsy can be used to assess most thoracic lesions (pleura, lung parenchyma, mediastinum.)
The needle is inserted through the rib cage.
162
What is the five year survival for patients with NSCLC?
<10%
163
What is the management for patients with stage 1 or 2 NSCLC?
Usually surgical resection of the tumour. The aim is to remove the cancer with clear margins. The options include: wedge resection, lobectomy, pneumonectomy, sleeve resection(Surgery to remove a lung tumor in a lobe of the lung and a part of the main bronchus ).
164
What sort of stage three lung cancer patients are more likely to be referred for surgery?
Those without large nodal involvement and without larger tumour margins. N2, T4 tumours are usually contraindicated for surgery.
165
What is indicated for management of stage 3 lung cancers when surgical resection is not appropriate?
Chemoradiation
166
What is CHART?
Continuous hyperfractionated accelerated radiotherapy. This is an accelerated course of radiotherapy where a similar dose is given over a shorter period of time (such as 12 days instead of around 6 weeks).
167
What does MST stand for?
Morphine sulphate
168
How long should MST modified preparation be effective for?
It should be effective for around 12 hours. Oramorph and non-modified releases should take effect in around 30 mins and cause effect up to 4 hours.
169
By what increments should you titrate up daily MST dose?
Increase by 30%-50% of the daily dose if MST is not effectively controlling pain (PRN being used too frequently). Alternatively, the amount of breakthrough pain required can just be added on.
170
How much stronger is parenteral morphine than oral?
2-3 times. IV diamorphine can be given every 4 hours.
| Divide daily oral dose of morphine by 3 to get diamorphine dose or by 2 to get the IV MST dose.
171
If a patient is taking 120mg of MST orally per day, what is a suitable subcutaneous dose?
40mg. Divide by three to calculate the SC dose.
172
What are the four drug groups that are essential for end of life care?
```
Four As:
Analgesic
Antiemetic
Anxiolytic
Antisecretory
```
173
What is the anxiolytic of choice in palliative care? What is the dose?
Midazolam can ease the anxiety produced from tachypnoea.
| It is given 5mg SC PRN or 10mg-60mg/24hours.
174
Which groups of drugs should you consider stopping in palliation based on the patient?
Corticosteroids
Hypoglycaemics
Anticonvulsants
175
What are the two types of mucolytics given?
Hyoscine butylbromide (Buscopan) and hyoscine hydrobromide are used to prevent the accumulation of secretions that lead to ‘death rattle’.
176
What is the dose for hyoscine hydrobromide?
400mcg stat OR 1.2-2.4mg/24 hours
177
Which drug is hyoscine butylbromide incompatible with?
Cyclizine
178
Which anti-emetic is used if delirium co-exists with the nausea?
Haloperidol
179
What is the dose for Haloperidol?
1.5 – 3mg stat OR 3-10mg/24 hours
180
What is the dose for levopromazine?
6.25 stat OR 6.25mg – 12.5 mg/24hours
181
What does AMBER stand for in the Leeds amber care bundle?
```
Assessment
Management
Best practice
Engagement
Recovery uncertain
```
182
What criteria must be met to move a patient on to the amber care bundle?
The patient must be deteriorating with an unstable condition and death could be expected within the next 1-2 months.
183
What are the possible outcomes of the amber care bundle?
Recovery, patient dies in hospital, patient is sent home to die
184
How long must a person be observed to diagnose death?
5 minutes.
185
What two things must be assessed to confirm cardio arrest?
Auscultate for heart sounds. Feel for central pulse.
186
After 5 minutes of cardiopulmonary arrest how is death confirmed?
Absence:
- of pupillary light reflex
- of corneal reflex,
- motor response to supraorbital pressure
187
How is death registered?
Within 5 days of death must be registered at the registry in the area where the person died.
