Onc/Pall

Question 1

SVC obstruction

• features?
• causes?

Answer 1

• dyspnoea commonest, swelling of face/arms/neck, conjunctival & periorbital oedema, headache worse in AM, visual disturbance, pulseless jugular venous distension
• commonly: NSCLC, lymphomas (LN on CXR)
• other ca: metastatic seminoma, Kapok’s sarcoma, breast ca
• aortic aneurysm (CT disease, uncontrolled HTN)
• mediastinal fibrosis
• enlarged multi nodular goitre
• SVC thrombosis (+ve d-dimer)

Question 2

Rx of SVC obstruction?

Answer 2

• > Dex + PPI, balloon venoplasty, stenting
• > (if small cell: chemo + RT
• > if NSCLC: RT)
• eg even though lymphomas are highly chemo-sensitive (and therefore chemo should be planned if poss), stenting should be done until chemo can take affect - optimise Hb, platelets, coag. If end-stage, stents can still become blocked
• RT causes increased swelling acutely, although long-term shrinkage

Question 3

1st choice in pall care to treat hiccup AND nausea?

Answer 3

METOCLOPRAMIDE

- also baclofen, nifedipine, chlorpromazine

Question 4

Rx of hiccups in palliative care?

Answer 4

CHLORPROMAZINE - for intractable hiccups

• haloperidol, gabapentin also used
• DEXAMETHASONE also used esp if HEPATIC lesions

Question 5

Concern of spinal metastases - what scan?

Answer 5

MRI WHOLE spine

• 30-50^ have multi-level involvement by the time of presentation
• within 24h if ?SCC
• of no neuro involvement, can be within 7d - but important to detect before any neuro compromise

Question 6

Sx/findings of spinal metastases?

Answer 6

• unrelenting lumbar back pain
• any thoracic/cervical back pain
• worse withs needing, coughing, straining
• nocturnal
• ass with tenderness

Question 7

Commonest chemo regime for SCLC?

Answer 7

ETOPOSIDE & CISPLATIN

Question 8

Common side effect of Cisplatin?

Answer 8

Hypomagnasaemia -> cramps, tremor, cardiac arrhythmias, confusion

Question 9

MoA of Cyclophosphamide?

Adverse effects?

Answer 9

Alkylating: causes cross-linking in DNA

• haemorrhagic cystitis
• myelosuppression
• TCC

Question 10

MoA of Bleomycin?

Adverse effect?

Answer 10

Degrades preforemd DNA (cytotoxic Abx)

- lung fibrosis

Question 11

MoA of Doxorubicin?

Adverse effect?

Answer 11

Stabilises DNA-topoisomerase II complex, inhibiting DNA & RNA synthesis (cytotoxic Abx)
- cardiomyopathy

Question 12

MoA of Methotrexate?

Adverse effects?

Answer 12

Inhibits dihydrofolate reductase & thymidylate synthesis - antimetabolite

• myelosuppression
• mucositis
• liver & lung fibrosis

Question 13

MoA of 5-Fluorouracil?

Adverse effect?

Answer 13

Primidine analogue inducing cell cycle arrest & apoptosis by blocking thymidylate synthase (works during S phase) - antimetabolite

• myelosuppression
• mucositis
• dermatitis

Question 14

MoA of 6-mercaptopurine?

Adverse effect?

Answer 14

Antimetabolite - purine analogue activated by HGPRTase, decreasing purine synthesis
- myelosuppression

Question 15

MoA of Cytarabine?

Adverse effect?

Answer 15

Antimetabolite - Pyrimidine antagonist, interfering with DNA synthesis specifically at the S phase, and inhibits DNA polymerase

• myelosuppression
• ataxia

Question 16

MoA of Vincristine/Vinblastine?

Adverse effects?

Answer 16

Inhibits formation of microtubules

• Cristine: peripheral neuropathy (reversible), paralytic ileus
• Blastine: myelosuppression

Question 17

MoA of Docetaxel?

Adverse effect?

Answer 17

Prevents microtubule depolymerisation & disassembly, decreasing free tubular
- neutropenia

Question 18

MoA of Cisplatin?

Adverse effects?

Answer 18

Causes cross-linking in DNA

• ototoxicity
• peripheral neuropathy
• low Mg

Question 19

MoA of Hydroxyurea/hydroxycarbamide?

Adverse effect?

Answer 19

Inhibits ribonucleotide reductase, decreasing DNA synthesis

- myelosuppression

Question 20

Analgesia in palliative pain relief with renal failure

- what is appropriate?

Answer 20

In CKD: Alfentanil, buprenorphine and fentanyl are preferred

• Fentanyl patch is appropriate to replace regular long-acting MST
• Oxycodone is ok in moderate renal failure, but only as breakthrough (MR should be avoided)
• Pregabalin is ok at reduced dose
• Alfentanil & methadone safe even in severe impairment (SC) - alfentanil may be appropriate if unstable pain requiring dose titration

Question 21

Starting treatment when prescribing analgesia in palliative care?

Answer 21

20-30mg MR a day with 5mg prn morhine if no comorbidities

• oral in preference to transdermal patches
• laxatives for everyone
• nausea often transient (antiemetic if it persists)
• drowsiness usually transient, adjust dose if it doesn’t settle

Question 22

Rx for metastatic bony pain?

Answer 22

• strong opioids, bisphosphonates or RT
• give opioids, refer everyone to oncologist for consideration of RT etc
• denosumab may be used too

Question 23

converting oral codeine to oral morphine?

oral tramadol to oral morphine?

Answer 23

Both divide by 10

Question 24

Difference between oxycodone & morphine?

Answer 24

Oxycodone generally causes less sedation, vomiting & pruritus than morphine, but more constipation

Question 25

converting oral morphine to oral oxycodone?

Answer 25

Divide by 1.5-2

Question 26

converting fentanyl 12 patch to oramorph?

Answer 26

= 30mg oral morphine

Question 27

converting buprenorphine 10 patchy to oral morph?

Answer 27

= 24mg oral morphine /24h

Question 28

oral morphine to SC morphine? oral morphine to SC diamorphine? oral oxycodone to SC diamorphine?

Answer 28

oramorph-> SC morphine divide by 2 oramorph -> SC diamorphine divide by 3 oral oxycodone-> SC diamorphine divide by 1.5

Question 29

3 main types of NSCLC?

Answer 29

1. SCC - central, PTHrP-> hypercalcaemia, stonrgly ass with clubbing, HPOA 2. Adenocarcinoma - peripheral, commonest type that occurs in non-smokers but majority who get it are smokers 3. Large cell ca - peripheral, anaplastic poorly differentiated tumours with poor prognosis, may secrete beta-hCG

Question 30

Features of SCC?

Answer 30

- back pain is earliest & commonest - may be worse on lying down/coughing - LL weakness - sensory changes - loss & numbness - neuro signs depending on level - above L1: UMN signs in legs with sensory level - below L1: LMN signs in legs with peri-anal numbness. tendon reflexes increased below the level, absent at the level

Question 31

Rx of SCC?

Answer 31

- high dose Dex + PPI - urgent onc assessment for RT/surgery - neurological status at time of Rx initiation is set predictor of neuro outcome - surgery superior to RT in retaining/regaining neuro function & relieving pain - eg surgery then RT if suitable is ideal in someone with a good performance status - if RT is appropriate as 1st line it would be e.g. 20Gy in 5 daily fraction for Rx, or less e.g. single dose 8Gy to help pain control - chemo can have a role in chemo-sensitive malignancies e.g. SCLC or germ cell tumours

Question 32

What Rx is effective in refractory chemo-induced vomiting?

Answer 32

Dexamethasone + Ondansetron (if low risk, metoclopramide is 1st line) - dexamethasone is the most useful agent in preventing the delayed phase of chemo-induced emesis

Question 33

SOL identified as solitary on contrast enhanced CT brain suspicious of brain metastasis - next step?

Answer 33

Start 16mg Dexamethasone Arrange urgent MRI brain - to assess extent of intracranial disease - give anticonvulsants if presenting with seizure activity

Question 34

Adverse effects of cisplatin: causes X-linking of DNA?

Answer 34

ototoxicity peripheral neuropathy low Mg

Question 35

Adverse effects of hydroxyurea/hydroxycarbamide: inhibits ribonucleotide reductase, decreasing DNA synthesis?

Answer 35

Myelosuppression

Question 36

Adverse effects of Irinotecan: inhibits topoisomerase I which prevents relaxation of supercoiled DNA?

Answer 36

Myelosuppression

Question 37

Adverse effects of Vincristine/Vinblastine that inhibits formation of microtubules?

Answer 37

Vincristine: reversible peripheral neuropathy, paralytic ileus Vinblastine: myelosuppression

Question 38

Adverse effects of Docetaxel: prevents microtubule depolymerisation & disassembly, decreasing free tubulin?

Answer 38

Neutropaenia

Question 39

Adverse effects of MTX: inhibits dihydrofolate reductase & thymidylate synthesis?

Answer 39

Myelosuppression, mucositis, liver fibrosis, lung fibrosis

Question 40

Adverse effects of 5-FU fluorouracil: pyrimidine analogue inducing cell cycle arrest & apoptosis by blocking thymidylate synthase during S phase?

Answer 40

myelosuppression, mucositis, dermatitis

Question 41

Adverse effects of 6-mercaptopurine: purine analogue activated by HGPRTase, decreasing ourine synthesis?

Answer 41

Myelosuppression

Question 42

Adverse effects of Cytarabine: pyrimidine antagonist: interferes with DNA synthesis specifically at S phase & inhibits DNA polymerase?

Answer 42

Myelosuppression | ataxia

Question 43

Adverse effects of Bleomycin: degrades preformed DNA?

Answer 43

Lung fibrosis

Question 44

Adverse effects of Doxorubicin: stabilises DNA-topoisomerase II complex, inhibits DNA & RNA synthesis?

Answer 44

Cardiomyopathy

Question 45

Adverse effects of Cyclophosphamide: alkylating agent causing cross-linking of DNA?

Answer 45

Haemorrhagic cystitis, myelosuppression, TCC

Question 46

Broad-spectrum anti-emetic which blocks lots of different receptors (e.g. ACh, DA, 5HT)?

Answer 46

Levomepromazine

Question 47

Opioid that can be used 3rd line in complex pain not responding to other analgesics, that acts as a neuropathic agent by NMDA antagonism?

Answer 47

Methadone

Question 48

What acute complication is it important to monitor for with Ketamine?

Answer 48

Raised intracranial pressure - monitor headache, vomiting, papilloedema - it can be used for neuropathic pain poorly responsive to titrated opioids & oral adjuvant analgesics esp when abnormal pain sensitivity - bladder & liver dysfunction can occur with long term use

Question 49

RT-induced mucositis - occurs esp following RT to head & neck - often they'll have a PEG inserted prior to Rx to help maintain oral intake Rx?

Answer 49

LA gels Benzydamine mouthwashes who-based analgesic ladder for liquid pain relief

Question 50

Causes of lymphoedema?

Answer 50

``` 1ry = inherited 2ry = surgery, radiation, infection classically filariasis, or injury resulting in damage to lymphatic system ```

Question 51

Capecitabine = oral analog of 5-FU which is broken down predominantly by dihydropyrimidine dehydrogenase - what happens in toxicity?

Answer 51

- eg deficiency of the enzyme | - diarrhoea, weakness, desquamation, pancytopenia, electrolyte abnormalities