HAEMATOLOGY & ONCOLOGY Flashcards
(173 cards)
1
Q
Where is Hb made? What is needed to make it?
A
Bone marrow
Iron
2
Q
Where and how is iron absorbed?
A
As Fe2+ (ferrous) in the duodenum and jejunum - if stomach acid is reduced e.g. by PPIs then absorption may be impaired.
3
Q
What is the soluble form of iron?
A
Ferrous
4
Q
What form of iron exists in the blood?
A
Ferric ions
5
Q
What is transferrin saturation?
A
Serum iron/total iron binding capacity
6
Q
When is serum iron highest?
A
Morning
After iron containing meal
7
Q
What is the total iron binding capacity?
A
Space available for iron molecules to bind to transferrin
8
Q
What is the most common cause of anaemia in children? And adults?
A
Coeliac
Iron deficiency
9
Q
Give four causes of iron deficiency.
A
Inadequate intake of iron
Inadequate absorption
Loss of iron e.g. bleeding
Increase requirements e.g. pregnancy
10
Q
What should be considered if patients present with a DVT and stroke?
A
Septal defect (ASD/VSD)
11
Q
What are the risk factors of DVT?
A
• Immobility • Recent surgery • Long haul flights • Pregnancy • Hormone therapy with oestrogen (combined oral contraceptive pill and hormone replacement therapy) • Malignancy • Polycythaemia • Systemic lupus erythematosus Thrombophilia
12
Q
Name 7 thrombophilia’s that predispose patients to developing blood clots.
A
• Antiphospholipid syndrome (this is the one to remember for your exams) • Antithrombin deficiency • Protein C or S deficiency • Factor V Leiden • Hyperhomocysteinaemia • Prothombin gene variant Activated protein C resistance
13
Q
When should patients receive VTE prophylaxis?
A
Increased risk of VTE
14
Q
Name two contraindications to VTE prophylaxis.
A
Active bleeding
Warfarin
15
Q
What is the main contraindication to compression stockings?
A
PVD
16
Q
What alternative diagnoses should be considered if symptoms are bilateral?
A
Heart failure
Chronic venous insufficiency
17
Q
How do you examine for leg swelling?
A
Measure both calves, 10cm below the tibial tuberosity.
If they are >3cm different, DVT is likely.
18
Q
What scoring system is used to determine the risk of DVT/PE?
A
Wells
19
Q
Name 5 other conditions that can cause a raised D-dimer.
A
• Pneumonia • Malignancy • Heart failure • Surgery Pregnancy
20
Q
Under what circumstances should a negative proximal leg Doppler scan be repeated? When should it be repeated?
A
If scan is negative, but D-dimer is positive, repeat the scan in 6-8 days.
21
Q
What is the initial management of a DVT?
A
Enoxaparin SC
22
Q
What is the target INR for treatment using warfarin?
A
2-3
23
Q
What is the first-line choice of prophylaxis in patients with pregnancy or cancer?
A
LMWH
24
Q
How long should anti-coagulation be continued after a DVT?
A
3 months - if reversible cause identified.
>3 months - if no identifiable cause.
6 months - cancer.
25
What is the treatment for recurrent DVTs?
IVC filter (prevents PE)
Can also be used if anti-coagulation is contraindicated.
26
How should an unprovoked DVT be investigated?
```
• History and examination
• Chest X-ray
• Bloods (FBC, calcium and LFTs)
• Urine dipstick
• CT abdomen and pelvis in patients over 40
Mammogram in women over 40
```
27
If patients have an unprovoked DVT and a family history of DVT, how do you investigate?
In patients with an unprovoked VTE with a family history of VTE they recommend testing for hereditary thrombophilia:
• Factor V Leiden (most common hereditary thrombophilia)
• Prothrombin G20210A
• Protein C
• Protein S
Antithrombin
28
What is Budd-Chiari syndrome?
Blood clot develops in the hepatic vein blocking the outflow of blood. It is associated with hypercoagulable states and causes acute hepatitis.
29
What is the triad of symptoms seen in Budd-Chiari syndrome?
Abdominal pain
Hepatomegaly
Ascites
30
Name 3 chronic myeloproliferative disorders.
* Polycythaemia vera.
* Primary myelofibrosis (also called chronic idiopathic myelofibrosis).
* Essential thrombocythemia.
31
What is the pathophysiology of myeloproliferative diseases?
Proliferation of a single type of stem cell.
| Considered to be bone marrow cancer.
32
What condition do myeloproliferative disorders transform into?
Acute myeloid leukaemia
33
What is myelofibrosis?
Proliferation of the cell line leads to fibrosis of the bone marrow.
The bone marrow is replaced by scar tissue.
Fibrosis affects the production of blood cells leading to anaemia and leukopenia.
34
What cytokine causes myelofibrosis?
Fibroblast growth factor
35
What is extramedullary haematopoiesis? What are the signs of haematopoiesis?
Blood cells are produced outside of the bone marrow.
Mostly in the liver and spleen.
Leading to hepatosplenomegaly.
Can also cause portal hypertension and spinal cord compression.
36
Which cell line proliferates to cause primary myelofibrosis?
Haematopoietic stem cells
37
Which cell line proliferates to cause PCV?
Erythroid cell line
38
Which cell line proliferates to cause essential thrombocythemia?
Megakaryocytic cell line
39
Which genes are associated with myeloproliferative disorders? Which gene can be specifically targeted by drugs?
JAK2
MPL
CALR
40
If a patient presents with back pain and a PMHx of myeloproliferative disorders, what should be suspected?
Spinal cord compression (due to extramedullary haematopoiesis)
41
How do myeloproliferative disorders generally present?
Asymptomatic
Fever
Weight loss
Malaise
Night sweats
41
How do myeloproliferative disorders generally present?
Asymptomatic
Fever
Weight loss
Malaise
Night sweats
42
What are the three key signs on examination in suspected PCV?
Ruddy complexion
Conjunctival plethora
Splenomegaly
43
What are the findings on FBC in PCV?
High Hb
44
What might be seen on an FBC in myelofibrosis?
Low Hb
Low WCC or high WCC
Low platelets or high platelets
45
What are the findings on FBC in ET?
High platelets
46
What is seen on blood film in myeloproliferative disorders?
```
Tear-shaped RBCs
Poikilocytosis (varying size RBCs)
Blast cells (immature WBCs)
```
47
What investigation is needed for a definitive diagnosis of myeloproliferative disorders?
Bone marrow biopsy
48
What is found on bone marrow aspiration in primary myleofibrosis?
Dry (due to scar tissue)
49
What is the management of primary myelofibrosis?
Mild = monitor
Allogenic stem cell transplantation
Chemotherapy
Supportive management
50
What is the management of PCV?
Venesection - first-line
Aspirin (VTE prophylaxis)
Chemotherapy
51
What is the management of essential thrombocythemia?
Hydroxyurea (hydroxycarbamide) to reduce the platelet count
Interferon-α is in younger patients
Aspirin (VTE prophylaxis)
Chemotherapy
52
How is aspirin used in the management of myeloproliferative disorders?
VTE prophylaxis
53
Which cell lines are affected in leukaemia?
Myeloid
| Lymphoid
54
What are the four types of leukaemia?
Acute lymphoblastic leukaemia
Chronic lymphocytic leukaemia
Acute myeloid leukaemia
Chronic myeloid leukaemia
55
How does leukaemia lead to pancytopenia?
The excessive production of a single type of cell can lead to suppression of the other cell lines causing underproduction of other cell types.
This results in a pancytopenia, which is a combination of low red blood cells (anaemia), white blood cells (leukopenia) and platelets (thrombocytopenia).
56
What is the mnemonic used to remember the different ages that each type of leukaemia presents?
ALL CeLLmates have CoMmon AMbitions
```
ALL = <5 years old and >45 years old
CLL = >55 years old
CML = >65 years old
AML.= >75 years old
```
57
What are the typical features that a patient with leukaemia might present with?
```
• Fatigue
• Fever
• Failure to thrive (children)
• Pallor due to anaemia
• Petechiae and abnormal bruising due to thrombocytopenia
• Abnormal bleeding
• Lymphadenopathy
Hepatosplenomegaly
```
58
What are petechiae? Why are they found in leukaemia?
Small, non-blanching spots due to bleeding under the skin.
Caused by low platelets - thrombocytopenia.
59
What investigation should be done if there is central nervous system involvement in leukaemia?
LP
60
What investigations are used for staging of leukaemia?
CT
MRI
PET
61
What might be seen on CXR of a patient with leukaemia?
Infection
| Mediastinal lymphadenopathy
62
Where are bone marrow biopsies taken from?
Iliac crest
63
What is the difference between a bone marrow aspiration and trephine?
```
Aspiration = liquid sample, can be examined straight away
Trephine = solid sample, takes a few days to be examined
```
64
Which two features should prompt immediate referral to hospital in suspected leukaemia?
Petechiae
| Hepatosplenomegaly
65
Name some complications of chemotherapy.
```
Infections
Infertility
Neurotoxicity
Cardiotoxicity
Tumour lysis syndrome
```
66
What is tumour lysis syndrome?
Release of uric acid.
| Kidneys normally excrete uric acid before levels can build up. High levels form crystals in the tubules of the kidney.
67
What drugs are used to treat tumour lysis syndrome?
Allopurinol and rasburicase.
68
What is a characteristic symptom of ET?
Burning sensation in the hands
69
What is the management of a bleeding patient who is taking warfarin and requires emergency surgery?
25-50 units/kg four-factor prothrombin complex
70
What is the normal Hb range for women? And men?
```
Women = 120-165 g/L
Men = 130-180g/L
```
71
What is the normal MCV for men and women?
80-100 femtolitres
72
What are the three types of anaemia?
Microcytic anaemia
Normocytic anaemia
Macrocytic anaemia
73
What are the causes of microcytic anaemia?
```
TAILS
Thalassaemia
Anaemia of chronic disease
Iron deficiency anaemia
Lead poisoning
Sideroblastic anaemia
```
74
What is the most common cause of microcytic anaemia?
Iron deficiency anaemia
75
What are the causes of normocytic anaemia?
2 H's
- Hypothyroidism
- Haemolytic anaemia
3 A's
- Acute blood loss
- Anaemia of chronic disease (CKD)
- Aplastic anaemia
76
What are the two groups of macrocytic anaemia?
Megaloblastic anaemia
| Normoblastic anaemia
77
What causes megaloblastic anaemia?
```
B12 deficiency (+ pernicious anaemia)
Folate deficiency
```
78
What causes normoblastic anaemia?
```
Alcohol
Reticulocytosis
Hypothyroidism
Liver disease
Drugs - azathioprine
```
79
How does anaemia present? What are the symptoms? What are the signs?
```
Symptoms:
• Tiredness
• SOB
• Headaches
• Dizziness
• Palpitations
• Worsening of other conditions such as angina, heart failure or peripheral vascular disease
```
```
Signs:
• Pallor
• Conjunctival pallor
• Tachycardia
Raised respiratory rate
```
80
Which blood tests should be ordered to check for anaemia?
FBC - Hb, MCV
Haematinics - B12, folate, iron
Ferritin
Blood film
81
Name some relative causes of polycthaemia.
dehydration
| stress: Gaisbock syndrome
82
Give a primary cause of polycythaemia
PCV
83
Give some secondary causes of polycythaemia
COPD
altitude
obstructive sleep apnoea
excessive erythropoietin: cerebellar haemangioma, hypernephroma, hepatoma, uterine fibroids*
84
How do you diagnose laboratory tumour lysis syndrome?
```
2 or more of the below within 7 days of chemotherapy or 3 days before:
uric acid > 475umol/l or 25% increase
potassium > 6 mmol/l or 25% increase
phosphate > 1.125mmol/l or 25% increase
calcium < 1.75mmol/l or 25% decrease
```
85
How do you diagnose clinical tumour lysis syndrome?
Positive clinical TLS requires any one of:
increased serum creatinine (1.5 times upper limit of normal)
cardiac arrhythmia or sudden death
seizure
86
How do you diagnose tumour lysis syndrome?
Clinical AND laboratory
87
What is the management of tumour lysis syndrome in low risk patients?
PO allopurinol
88
What is the management of tumour lysis syndrome in high risk patients?
IV allopurinol OR IV rasburicsae
Immediately prior and during chemo
89
Why should you not use allopurinol and rasburicase together in tumour lysis syndrome?
Allopurinol limits the effects of rasburicase
90
What is a characteristic feature of PCV?
Pruritis after hot shower
91
What is the pathophysiology of factor V Leiden?
Activated protein C resistance
92
What is the most common inherited thrombophillia?
Factor V leiden
93
Which NOAC is preferred in renal impairment?
Apixaban
94
How quickly should one unit of RBCs be administered in a non-urgent scenario?
90 mins
Must be within 4 hours of leaving the fridge
95
Which drugs can trigger Haemolysis in patients with G6PD deficiency?
sulph- drugs: sulphonamides, sulphasalazine and sulfonylureas
96
What are the B symptoms seen in Hodgkin's lymphoma?
weight loss > 10% in last 6 months
fever > 38ºC
night sweats
97
What indicates a poor prognosis in Hodgkins lymphoma?
B symptoms
98
How can Hodgkin's lymphoma be classified?
Histologically
Nodular sclerosing - most common (lacunar cells)
Mixed cellularity - Reed-Sternberg cells ++++
Lymphocyte predominant - best prognosis
Lymphocyte depleted - worst prognosis
99
Which types of anaemia can cause glossitis?
B12 def
| Iron def
100
What is myeloma?
Ca of plasma cells (B-lymphocytes --> Ab's)
101
What is multiple myeloma?
Myeloma affecting multiple parts of the body
102
What is MGUS?
Monoclonal gammopathy of undetermined significance - usually incidental, can progress to myeloma
103
What is smouldering myeloma?
Type of MGUS --> progressive
| More likely to lead to myeloma
104
What is Waldernstrom's macroglobinaemia?
Type of smouldering myeloma with increased levels of IgM
105
What types of Ig are there?
```
A
G
M
D
E
```
106
Which Ig is most commonly affected in myeloma?
IgG (50%)
107
What is a monoclonal paraprotein?
Single Ig's that proliferate in myeloma
108
What causes myeloma bone disease?
^osteoclast activation
| decreased osteoblast
109
Which bones are most commonly affected by myeloma bone disease?
skull
spine
long bones
ribs
110
How might a patient present with myeloma bone disease?
Osteolytic lesions --> pathological fractures
111
What is a plasmacytoma?
individual tumours made up of the cancerous plasma cells. They can occur in the bones, replacing normal bone tissue or can occur outside bones in the soft tissue of the body.
112
How does myeloma lead to renal disease?
Ig's accumulate in glomerulus/tubules
^Ca impairs renal function
113
How is the viscosity of the blood affected in myeloma?
Raised
Leads to: brushing, bleeding, blindness, purple palmar erythema, heart failure (heart has to work harder)
114
What are the symptoms of multiple myeloma?
C - hypercalcaemia
R - renal failure
A - anaemia
B - bone pain
115
Which blood tests should be done in myeloma?
FBC - ^WCC, low Hb
ESR^
Ig's^
Ca^
116
Which investigations should be done in myeloma?
BLIP
B - Bence-Jones proteins (urine electrophoresis)
L - Serum free Light chain assay
I - serum Ig's
P - serum Protein electrophoresis
117
What imaging should be done in myeloma?
1. WB MRI
2. WB CT
3. Skeletal surgery (XR)
118
What are the XR signs seen in myeloma?
Punched out lesions
Lytic lesions
Pepper-pot skull
119
What is the management of myeloma?
1. Chemo - Bortezomid, Thalidomide, Dexamethasone
2. VTE prophylaxis
3. Treat bone disease = bisphosphonates, radiotherapy, surgery
120
What are the complications of myeloma?
Infection
Renal failure
Ca^
Peripheral neuropathy
121
What is the management of suspected neoplastic spinal cord compression?
1. urgent whole spine MRI (<24 hours)
2. High-dose pral dexamethasone
3. Urgent oncological assessment
122
Which HPV subtypes are carcinogenic?
16,18, 33
123
What is the most common and early presenting feature of spinal cord compression?
Back pain
124
Name two types of tumour markers
Monoclonal antibodies
| tumour antigens
125
Which tumour marker is found in ovarian cancer?
CA125
126
Which tumour marker is found in pancreatic cancer?
CA19-9
127
Which tumour marker is found in breast cancer?
CA15-3
128
Which conditions are indicated by AFP tumour marker?
HCC
| Teratoma
129
Which conditions are indicated by S-100 tumour marker?
Melanoma
| Schwannomas
130
Which conditions are indicated by bombesin tumour marker?
Small cell lung carcinoma, gastric cancer, neuroblastoma
131
Give some examples of immune checkpoint inhibitors? What are they used for?
Treat solid tumours
Nivolumab (melanoma, lymphoma, NSCLC)
Atezolizumab (lung, breast)
132
Name some side-effects of immune checkpoint inhibitors
The over-active T-cells can produce side effects such as:
```
Dry, itchy skin and rashes (most commonly)
Nausea and vomiting
Decreased appetite
Diarrhoea
Tiredness and fatigue
Shortness of breath and a dry cough.
```
133
Which type of cytotoxic drug can cause cardiomyopathy?
Anthracyclines (e.g. doxorubicin)
134
Which types of cancer are associated with the BRCA2 mutation?
BRCA2 mutations substantially increase the risk of developing breast cancer in both men and women. It is also associated with ovarian cancer in women and prostate cancer in men.
135
Which cytotoxic agent is associated with cyclophosphamide?
Cyclophosphamide
136
How can you distinguish between iron deficiency anaemia and anaemia of chronic disease?
```
IDA = low ferritin, high transferrin & TIBC
AoCD = high ferritin, low transferrin & TIBC
```
Reason for high ferritin in AOCD is hepcidin (ARP) blocks release of ferroproteins that are needed to release Iron from ferritin.
137
What is the typical blood picture seen in DIC?
```
DIC typical blood picture:
↓ platelets
↓ fibrinogen
↑ PT & APTT
↑ fibrinogen degradation products
```
138
What is haemolytic anaemia?
Haemolytic anaemia is where there is destruction of red blood cells (haemolysis) leading to anaemia
139
Name 5 inherited haemolytic anaemias
```
Hereditary Spherocytosis
Hereditary Elliptocytosis
Thalassaemia
Sickle Cell Anaemia
G6PD Deficiency
```
140
Name 5 acquired anaemias
```
Autoimmune haemolytic anaemia
Alloimmune haemolytic anaemia (transfusions reactions and haemolytic disease of newborn)
Paroxysmal nocturnal haemoglobinuria
Microangiopathic haemolytic anaemia
Prosthetic valve related haemolysis
```
141
What are the features of haemolytic anaemia?
Anaemia due to the reduction in circulating red blood cells
Splenomegaly as the spleen becomes filled with destroyed red blood cells
Jaundice as bilirubin is released during the destruction of red blood cells
142
What is indicated by a positive Direct Coombs test?
Autoimmune haemolytic anaemia
143
What is the inheritance pattern of hereditary spherocytosis?
Autosomal dominant
144
What is the treatment of hereditary spherocytosis?
Folate supplementation
| Splenectomy
145
What is the inheritance of G6GP deficiency?
X linked recessive
146
What are the triggers for crises in G6GP deficiency?
infections, medications or fava beans (broad beans).
147
Which medications can trigger a crisis in haemolytic anaemia?
primaquine (an antimalarial), ciprofloxacin, sulfonylureas, sulfasalazine and other sulphonamide drugs.
148
What is seen on blood film in haemolytic anaemia?
Heinz Bodies
149
How is a diagnosis made in G6PD deficiency?
G6PD enzyme assay.
150
What are the two types of auto-immune haemolytic anaemia? Which is more common?
Warm - more common (idiopathic)
| Cold
151
Which conditions are associated with cold autoimmune haemolytic anaemia?
lymphoma, leukaemia, systemic lupus erythematosus and infections such as mycoplasma, EBV, CMV and HIV.
152
What is the management of autoimmune haemolytic anaemia?
Blood transfusions
Prednisolone (steroids)
Rituximab (a monoclonal antibody against B cells)
Splenectomy
153
What are the features of paroxysmal nocturnal haemolobinurea?
Anaemia
red urine in the morning (containing haemoglobin and haemosiderin)
thrombosis (e.g. DVT, PE and hepatic vein thrombosis)
smooth muscle dystonia (e.g. oesophageal spasm and erectile dysfunction)
154
What are the two types of thalassaemia?
alpha - chromosome 16
| beta - chromosome 11
155
What are the signs and symptoms of thalassaemia?
Fractures
Fatigue
Gallstones
Failure to thrive
Splenomegaly
Mallor eminences
Pallor
Jaundice
156
What investigations are done in thalassaemia?
FBC - microcytic anaemia
Hb electrophoresis
DNA testing
157
What are the three types of beta thalassaemia?
Minor - one abnormal gene
Intermedia - one defective/one deletion
Major - two deletions (most severe)
158
What are the complications of sickle-cell anaemia?
```
Anaemia
Increased risk of infection
Stroke
Avascular necrosis in large joints such as the hip
Pulmonary hypertension
Painful and persistent penile erection (priapism)
Chronic kidney disease
Sickle cell crises
Acute chest syndrome
```
159
Which blood product is used in the treatment of haemophilia A?
Cryoprecipitate
160
What are the components of cryoprecipitate?
factor VIII (8)
fibrinogen,
von Willebrand factor
factor XIII (13)
161
Name 4 types of blood products that can be transfused. What are they used for?
Packed red blood cells = Severe anaemia, haemorrhage
Platelets = Severe thrombocytopenia
Fresh frozen plasma = Massive haemorrhage, factor deficiency or DIC
Cryoprecipitate = vWD, deficiency or DIC
162
What is the single most important factor when deciding whether to transfuse cryoprecipitate?
Low fibrinogen level
163
What classifies as a massive transfusion?
>1x circulating volume in a day
| >50% circulating volume in 3 hours
164
What considerations should be made when transfusing patients who are immunosuppressed?
Does the blood need to be irradiated?
| CMV negative
165
What are the two types of transfusion reactions?
Immunological: anaphylaxis, allergy, acute haemolytic, non-haemolytic febrile, TRALI
Non-immunological: infections, TACO
166
Name 5 immunological transfusion reactions.
```
Anaphylaxis
Allergy
Acute haemolytic reaction
Non-haemolytic febrile reaction
TRALI
```
167
Which type of blood product is most likely to cause an infection?
Platelets
168
What is a non-haemolytic febrile reaction? How does it present?
Caused by antibodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage - more likely with platelet transfusions.
Fever, chills
169
What is the Hb threshold for receiving a blood transfusion?
Without ACS = 70g/L
| With ACS = 80g/L
170
When should bleeding patients be offered a platelet transfusion?
Platelet count <30 x10^9
171
Which conditions are contraindications to platelet transfusion?
Chronic bone marrow failure
Autoimmune thrombocytopenia
Heparin-induced thrombocytopenia, or
Thrombotic thrombocytopenic purpura.
172
If severe bleeding or bleeding at a critical site (e.g. CNS), what is the threshold for platelet transfusion?
Platelet count <100 x10^9
