Lectures: Med D Flashcards
1
Q
Define sensitivity
A
positivity in the presence of disease
2
Q
Define specificity
A
negativity in the absence of disease
3
Q
Give two prognostic indicators of testicular teratomas?
A
- HCG
- AFP
4
Q
If a patient has HER2 positive breast cancer what can they be treated with?
A
Herceptin
- works to block receptors and stop signal responsible for cancer cell growth and division
5
Q
What is Tumour Lysis Syndrome, and what are the biochemical features?
A
- massive necrosis of tumour cells
- during treatment with cytotoxic drugs
Features
1. Hyperkalaemia –> arrhythmias
2. Lactate
3. Hyperphosphatasaemia –> calcium, phosphate imbalance
6
Q
What can be done to prevent tumour lysis syndrome?
A
- Maintain adequate hydration
-
Allopurinol
- (xanthine oxidase inhibitor) inhibits uric acid synthesis
- Monitor fluids and electrolytes
- Urinary alkalisation
- Renal dialysis
7
Q
This is an immunological phenomenon:
- effectiveness of antibodies to form immune complexes can be impaired with concentrations of an antibody or antigen are too high
A
HOOK EFFECT
8
Q
Key biochemical marker in ovarian cancer:
A
CA125
9
Q
Key signs and symptoms of ovarian cancer
A
- abdominal distention
- early satiety
- pelvic / abdominal pain
- urinary urgency / frequency
10
Q
What findings on examination would lead you to urgently refer a patient with suspected ovarian cancer
A
ascites or pelvic abdominal mass
11
Q
A risk malignancy index of greater than what will lead to a patient being referred:
A
RMI = malignant features on US x menopausal status x Ca125 level
> 200 = high risk, staging ST and referral
12
Q
What tumour marker is seen to be increased in patients with breast cancer with distant metastases?
A
CA15-3
13
Q
Gene variations associated with increase risk of developing breast cancer:
A
- BRCA1
- BRCA2
14
Q
Biochemical marker in pancreatic cancer
A
CA19-9
- low sensitivity
- main use is monitoring treatment
- may also be raised in gall bladder, bile duct and gastric cancers
15
Q
Patients with what particular antigen will not produce the antigen for CA19-9 :
A
Patients who lack the LEWIS antigen will not express CA19.9
16
Q
Marker for prostate cancer:
A
PSA
TOTAL VS FREE
- malignant prostate cells produce more bound PSA
- low level of free in relation to total PSA might indicate cancer
- high level of free indicate normal prostate, BPH or other conditions
17
Q
Prolactinoma: symptoms
A
- Female: amenorrhoea, infertility, lactation, loss of libido
- Males: erectile dysfunction, libido, infertility
Pressure of prolactinoma on surrounding tissues:
- headaches
- vision loss
18
Q
Treatment of prolactinoma
A
- Cabergoline (dopamine agonist, to shrink tumour)
- Bromocriptine
19
Q
If suspecting growth hormone excess, what important test should be done:
A
Glucose tolerance test.
Notes
- glucose should suppress growth hormone levels.
- will help decide if there is excess GH production
- ACROMEGALY
20
Q
Symptoms of primary aldosteronism:
A
- HTN resistance to medication
- Hypokalaemia
21
Q
What test will be done to see where the excess aldosterone hormone is coming from:
A
- adrenal vein sampling to lateralise
- in unilateral disease
22
Q
Pheochromocytoma
A
rare tumour, that forms in adrenal medulla
23
Q
Paragangliomas
A
form outside the adrenal gland
24
Q
Investigations for pheochromocytoma and paraganglioma
A
- plasma free metadrenalines
- total fractionated urine metadrenalines
25
PTHrP: What is this and where is it found?
1. Found in pancreatic islet and ductal cells.
2. PTHrP acts on PTH1P receptor
- regulate cell proliferation
- apoptosis
- differentiation
26
Role of PTHrP
- can stimulate calcium resorption from bone
- and reabsorption in the kidneys
- causing hypercalcaemia!
27
Tumours of pancreas summarised:
**1. Insulinoma: Whipple's triad**
**2. Glucagonoma --> 5Ds**
- depression
- dermatitis
- diarrhoea
- diabetes
- deep vein thrombosis
**3. Gastronioma --> Zollinger-Edison syndrome**
**4. VIPoma --> relaxes muscles in stomach and bowel**
28
Zollinger-Ellison syndrome
multiple severe, recurrent peptic ulcers in part of small intestine
29
what occurs in carcinoid syndrome?
- tumour produces excessive amounts of serotonin that the liver can't break down
30
What gene is implicated in MEN 1 and what possible biochemical tests would you want to do?
MEN 1 tumour suppressor gene
Pituitary adenoma
Parathyroid hyperplasia
Pancreatic tumours
31
Men 2A
RET PROTONCOGENE
Parathyroid hyperplasia
Medullary thyroid carcinoma
Pheochromocytoma
32
Men 2B
RET PROTONCOGENE
- mucosal neuroma
- marfanoid body habitus
- medullary thyroid carcinoma
- pheochromocytoma
33
What might be seen on blood film in acute myeloid leukaemia?
AUER ROD
34
Commonest childhood cancer:
acute lymphoblastic leukaemia
35
What additional test would you do in a patient with suspected chronic myeloid leukaemia?
FISH to look for Philadelphia chromosome
- translocation between chromosome 9 and chromosome 22.
- present in 95% of CML patients.
36
Treatment of chronic lymphocytic leukaemia:
IMATINIB (tyrosine kinase inhibitors)
37
What is a blast crisis:
progression of CML to acute blast phase —> acute leukaemia
38
Myelodysplastic syndromes
- group of cancers
- immature blood cells in bone marrow do not mature or become healthy blood cells
- bone marrow doesn’t make normal blood cells
39
Myeloma is associated with what abnormal proteins produced by the immune system:
Paraproteins
- IgG
- IgA
- free light chain
Paraproteins in blood may lead to abnormal blood flow
- hyper viscosity
40
Vertebral collapse in myeloma may lead to what condition:
Spinal cord compression
41
What type of cell is classically seen in Hodgkin Lymphoma
- **REED STERNBERG CELL**
- abnormal lymphocytes containing more than one nucleus
42
Name the most rapidly growing type of non-Hodgkin lymphoma:
BURKITT lymphoma
43
Staging for lymphoma
**Ann Arbor staging - done with CT**
1. Localised
2. Two or more on same side of diaphragm
3. two or more above and below diaphragm
4. widespread disease, multiple organs and nodal involvement
44
Microcytic anaemia causes:
TAILS
T- thalassemia
A- anaemia of chronic disease
I- iron deficiency
L- lead poisoning
S- sideroblastic anaemia
45
Macrocytic anaemia causes:
Megaloblast
- b12 deficiency (e.g. pernicious anaemia)
- folate deficiency
Non-megaloblast
- alcohol
- reticulocytosis
- liver disease
- hypothyroid
46
LDH is a marker of:
cell turnover so can show cell and tissue damage in the body
47
What test might you do to help determine the potential cause of haemolysis
DAT (direct antiglobulin test)
Direct coombs test
48
What genetic mutation has been shown to be associated with myeloproliferative neoplasm in a patient?
JAK 2 mutation
49
When would a patient with thrombocythemia be referred to haematology?
1. Platelet count > 1000 (unexplained)
2. Platelets 600-1000 in association with thrombotic event
50
What intervention may be used to help control the blood cell count without allowing blood cell count to do down:
cytoreductive therapy: hydroxycarbamide
51
Important side effect of bisphosphonate use:
jaw necrosis
52
DRAW OUT THE CHEMOTHERAPY TOXICITY BEAR
D- doxorubicin (cardiomyopathy)
A- asparagine (alopecia)
C- cisplatin (nephrotoxic)
53
What is the ALARA principle:
- avoiding exposure to radiation that does not have direct benefit to you
- keep dose as low as reasonably possible
54
What method may be used to help define quality of life:
EQD5 questionnaire
Looks at:
- mobility
- self-care
- usual activities
- pain / discomfort
- anxiety/ depression
55
What sign is seen in superior vena cava obstruction:
Pemberton sign
56
Management of superior vena cava obstruction:
*EMERGENCY*
1. ABCDE
a. nurse upright
b. oxygen
c. **dexamethasone 8-16mg daily with PPI**
d. if thrombus then LMWH
57
Definitive treatment of superior vena cava obstruction:
vascular stenting
58
**Case 1:** 65 yo male, 4/52 hx of dyspnoea
- Cough productive of thick yellow sputum with streaks of blood
- Weight Loss ~ 1 stone
- Noticed his face is puffy at the end of the day last 2/52
- PMHx:
- T2DM
- SHx
- Smoker, 30 pack year hx. Retired factory supervisor.
Indicative of:
Superior vena cava obstruction
59
Case 2: 58 Female, generally unwell
- known breast cancer
- received her second cycle of adjuvant chemotherapy 10 days ago
- 2/7 hx of dysuria and frequency of micturition
- feeling hot and cold
- uncontrollable shaking this afternoon
**Observations:**
- **HR 110bpm , BP 92/60mmHg**
- **RR 18, oxygen sats 99% on RA**
- **Temp 38.8**
Indicative of:
Neutropenic sepsis
60
Definition of febrile neutropenia
- temperature > 38 degrees
- neutrophils < 0.5
61
What scoring system is used to identify low risk febrile neutropenic patients:
MASCC score - > 21 considered low risk
62
Antibiotic protocol for low vs high risk patients of neutropenic sepsis
**Low risk**
No allergies: PO co-amoxiclav & Ciprofloxacin
Pen allergic: PO doxy & Cipro
**High risk**
No allergies: IV TAZ & IV Gent
Pen allergic: IV meropenem & IV gentamicin
Severe allergic: IV Teicoplanin & IV cipro & IV gent
63
**Case 3: 70 Male not his usual self**
PC: attended for radical radiotherapy for known Lung Ca.
Complaining of feeling muddled over last 24 hours, disorientation. Tiredness, nauseated, increasingly thirsty, vague abdominal pain and constipation.
PMH: HTN and IHD
High creatinine, high calcium
Differential diagnosis
HYPERCALCAEMIA
- Painful bones
- renal stones
- abdominal groans
- psychiatric moans
64
Management of hypercalcaemia
1. **Vigorous rehydration**
- 4L of IV fluid in 24 hours
2. **Monitor for fluid overload**
- repeat serum Ca before giving bisphosphonate
- commence bisphosphonates 24hrs post rehydration
3. **RANK-ligand inhibitors such as denosumab**
65
Case 4:
PC: progressive lower thoracic back pain, radiates bilaterally around umbilicus, worse on coughing
PMH: metastatic prostate cancer
DH: 3 monthly zoladex (goserelin)
OE:
- normal tone, power, reflexes
- sensation normal
- spinal bony tenderness palpable at T10
Differential diagnoses:
metastatic spinal cord compression
66
Management of MSCC
**URGENT MRI WHOLE SPINE (within 24hrs)**
- lie flat (log roll)
**STEROIDS —> dexamethasone 8mg BD PO with PPI**
- WHO analgesia ladder
- Consider: catheterisation, laxatives
**Definitive treatment - surgery vs radiotherapy**
- MSCC pathway
67
Case 6: 49 Male, diarrhoea and dizziness
PC: diarrhoea watery, non bloody, no vomiting and patient is afebrile.
Obs: T36.7, 114bpm, BP 98/56
PMH: advanced kidney Ca.
DH: new cancer drug about 7 weeks ago
OE: abdomen SNT, no masses
Likely diagnosis:
Immunotherapy mediated colitis
68
Management of immunotherapy induced colitis
**GRADE 1**
---> fluids, loperamide
--> up to 3 extra stools, no blood or pain
**Grade 2**
--> admit under gastro
--> oral pred w/ PPI cover
--> omit next dose immunotherapy
--> regular obs/ NEWS/ Stool
**Grade 3-4**
--> more than 7 stools than baseline
--> severe abdo pain
--> methyl pred
--> stop immunotherapy
69
What is brachytherapy?
- Radioactive sources implanted into tumour or surrounding tissue
- Like 125 I, 103Pd, 192Ir, 137Cs
- Delivers high dose of radiation to desired target while minimizing the dose to surrounding normal tissues
70
Chemotherapy: How to antimetabolites work ?
prevent DNA synthesis
Cell cycle specific (S-phase)
- folate antagonist (methotrexate)
71
Chemotherapy: How do alkylating agents work?
prevent uncoiling of DNA for replication
1. Topoisomerase inhibitors --> prevent uncoiling of DNA but breaking down enzymes used for uncoiling
2. Non-classical alkylating agents --> lock cross links preventing them from uncoiling
72
How do Vinca alkaloids work?
cell cycle arrest
by preventing microtubule formation
73
How do antimitotic antibiotics work?
e.g. BLEOMYCIN
prevent mitosis from occuring
74
How do Taxanes work?
spindle cell inhibition
examples: paclitaxel, docetaxel
75
Give some examples of anti-metabolite drugs?
- methotrexate
- 5-FU
- Capecitabine
76
Give some examples of alkylating drugs (classical)?
- etoposide
- ifosphamide
77
Give examples of alkylating drugs (non-classical)
- cisplatin
- carboplatin
- oxaliplatin
78
Give examples of Vinca Alkaloids:
- Vincristine
- Vinblastine
79
Give examples of antimitotic antibodies
Anthracycline
- doxorubicin
- Epirubicin
Non-anthracycline
- bleomycin
80
Terminology used to determine response to chemotherapy
**Complete response** --> disappearance of all measurable disease
**Partial response** --> 30% decrease from baseline
**Minimal response** --> decrease in measurable lesions, no new lesions observed
**Stable response** --> neither partial response or progressive disease criteria have been met
**Progressive disease** --> 20% increase in one or more lesions
81
One dose of an oncology therapy is known as:
cycle
Course = number of cycles given in one block
82
What criteria may be used to determine response to treatment?
RECIST criteria
83
Grading system used to determine severity of chemotherapy:
CTCAE - common terminology criteria for adverse events
84
Intrathecal method of administration is:
given into CSF
85
What is given alongside treatments which suppress bone growth?
growth factor
86
What does it mean by maximum cumulative doses?
- the max dose of drug a patient can be given in their lifetime
- e.g. bleomycin can cause significant pneumonitis and interstitial lung disease! used in patients with testicular cancer
87
Majority of chemotherapy is dosed based on what calculation
** body surface area (Duboi and Dubois) **
Obesity may affect the way drugs are handled / metabolised
- increase blood volume (decreased steady state concentration)
- increase in lean body mass
- increase in organ size
- increase phase 2 metabolism in liver
- increase GFR
88
Specific side effects of bleomycin
pulmonary fibrosis
89
Specific side effects of gemcitabine
pneumonitis
90
Specific side effects of anthracyclines
cardiac toxicity
91
Specific side effects of cisplatin:
hearing loss
92
Peripheral neuropathy quite common with what class of chemotherapy :
Taxanes
93
What genetic deficiency in 5-FU toxicity can lead to significant mucositis, diarrhoea, extreme fatigue and dehydration
DPD deficiency
94
What mutation results in loss of drug function of cetuximab in the treatment of colorectal cancer:
KRAS mutation
- people with colorectal cancer with a RAS mutation will not respond to treatment even if treated with it
- cetuximab cannot bind !
95
Patients with BRCA mutation tend to respond well to what drug?
carboplatin
96
How do PARP inhibitors work?
- prevent cell DNA from repairing itself
- e.g. Olaraparib
97
What kind of receptors are quite active in melanoma and can be targeted with immunotherapy:
BRAF
98
Name the type of cancer which develops in the glands that line your organs:
adenocarcinoma
- produce mucin
- mucin is a protein produced by epithelial cells
99
Molecular tests in routine use for breast cancer
- ER
- PR
- HER-2
100
101
102
103
