Oncology Flashcards
(150 cards)
1
Q
What are the properties of cancer?
A
- Self sufficiency in growth signals
- Evading growth suppressors
- Avoiding immune destruction
- Enabling replicative immortality
- Tissue invasion and metastasis
- Inducing angiogenesis
- Resisting apoptosis
2
Q
What are some mechanisms of cancer cell resistance?
A
Increased efflux Decreased uptake Increased drug metabolism Alter drug targets Inhibition of apoptosis Alter cell cycle checkpoints
3
Q
What cancers are AFP associated with?
A
Hepatocellular and testicular
4
Q
What else can raise AFP apart from cancer?
A
Pregnancy and cirrhosis
5
Q
What is the tumour marker for ovarian cancer?
A
CA125
6
Q
What else can raise CA125 apart from cancer?
A
Liver disease, pancreatitis, pregnancy, heart failure, cystic fibrosis
7
Q
What is CA19-9 associated with?
A
Pancreatic cancer, acute cholangitis, cholestasis, jaundice
8
Q
What is the tumour marker for breast?
A
CA15-3
9
Q
What else apart from prostate cancer can raise PSA?
A
BPH, DRE, recent ejaculation, UTI, BMI <25
10
Q
What is the tumour marker for colorectal cancer?
A
CEA
11
Q
What else can increase CEA levels?
A
Smoking, liver disease, CKD, diverticulitis, jaundice
12
Q
Give 5 principles of screening
A
- Important health problem
- Recognisable latent or early symptomatic stage
- Accepted treatment available
- Cost effective
- Acceptable to population
13
Q
What is lead time bias?
A
Screening leads to earlier identification so there’s a longer perceived survival
14
Q
What is length time bias?
A
Screening picks up less severe disease so there’s an improved perceived prognosis
15
Q
What is a female’s risk of breast cancer?
A
1 in 8
16
Q
What is the second most common cause of death from cancer?
A
Colorectal
17
Q
Which is the most common invasive breast cancer?
A
Ductal carcinoma (around 70%)
18
Q
What percentage of breast cancers are oestrogen receptor positive?
A
60-70% (better prognosis)
19
Q
What percentage of breast cancers express HER2?
A
Around 30% (worse prognosis)
20
Q
What are the risk factors for breast cancer?
A
Female Family history - BRCA1/BRCA2 mutations Obesity Nulliparity Early menarche/late menopause COCP/HRT use Previous benign breast disease
21
Q
What are the clinical features of breast cancer?
A
Lump - painless, non mobile, hard, irregular Nipple retraction Nipple discharge Skin tethering or dimpling Axillary lump
22
Q
What are some differentials for breast lumps other than cancer?
A
Fibroadenoma, lipoma, cyst
23
Q
What is the triple assessment?
A
1) Clinical examination
2) Radiology - USS/mammography
3) Histology from US guided core biopsy or cytology from aspirate
24
Q
Describe the TNM staging for breast cancer
A
T1 = <2cm T2 = 2-5cm T3 = >5cm T4 = skin/chest wall involved
N1 = 1-3 LNs N2 = 4-9 LNs N3 = >9 LNs
M0 =.no mets, M1 = mets
25
What is the surgical management of breast cancer?
Wide local excision (1cm margin) or mastectomy with reconstruction
Axillary node sampling or clearance or sentinel node biopsy
26
When is mastectomy preferred over WLE?
- Multifocal disease
- High tumour:breast tissue ratio
- Disease recurrence
- Patient choice
27
What are some chemotherapy agents used in breast cancer?
CMF - cyclophosphamide, methotrexate, 5FU
28
What hormone treatment can be used in breast cancer?
Tamoxifen in ER+ in premenopausal
| Aromatase inhibitors eg anastrazole in postmenopausal
29
What immunotherapy can be used in certain breast cancers?
Herceptin (Trastuzumab) in HER2 positive (can cause cardio toxicity)
30
What is the Nottingham prognostic index?
NPI = (size*0.2) + nodal status + histological grade
31
Where can breast cancers metastasise?
Axillary nodes, bone, lung, liver, brain, adrenals, ovaries
32
What are some risk factors for prostate cancer?
Increasing age, afro-caribbean ethnicity, family history, BRCA2/BRCA1 gene, obesity, smoking, diabetes
33
What are the clinical features of prostate cancer?
```
Hesistancy
Frequency
Urgency
Nocturia
Poor urinary stream
Terminal dribbling
```
34
What is the normal upper limit of PSA in people >70 years?
6.5ng/ml
35
What other investigations apart from bloods are required in prostate cancer diagnosis?
TRUS biopsy, MRI prostate
36
What is active surveillance in prostate cancer management?
3 monthly PSA, 6m-1 yearly DRE and rebiopsy at 1-3 yearly intervals
37
What is a radical prostatectomy?
Removal of the prostate gland, resection of the seminal vesicles and pelvic lymph node dissection
38
What are some side effects of radical prostatectomy?
Erectile dysfunction (60-90%)
Stress incontinence
Bladder neck stenosis
39
What radiotherapy options are available for prostate cancer?
External beam radiotherapy or brachytherapy
40
What are some side effects of radiotherapy to the prostate?
Urinary frequency, fatigue, cystitis, proctitis, problems with ejaculation, erectile dysfunction, skin irritation
41
What hormone therapies can be used in the treatment of prostate cancer?
Anti-androgens - GnRH antagonists eg goserelin
| Enzalutamide and abiraterone
42
What is the most common cause of cancer deaths?
Lung cancer
43
What is the 5 year survival for lung cancer?
13%
44
What percentage of lung cancers are small cell?
20%
45
What is Lambert-Eaton syndrome?
Proximal arm and leg weakness due to autoimmune destruction of voltage gated calcium channels at the neuromuscular junction
Associated with small cell lung cancer
46
What paraneoplastic syndromes are associated with small cell lung cancer?
Cushings, SIADH, Lambert eaton
47
Which lung cancer cavities?
Squamous cell
48
What is squamous cell lung cancer associated with?
Hypercalcaemia due to secretion of PTHrp
49
Which lung cancer is more common in non smokers and asian females?
Adenocarcinomas
50
What is hypertrophic pulmonary osteoarthropathy and which cancer is it associated with?
Clubbing + arthritis + symmetrical periosteal formation
In 1% of those with adenocarcinoma of lung
51
What paraneoplastic syndrome is large call lung cancer associated with?
GnRH secretion - gynaecomastia
52
What do you see on CXR of mesothelioma?
Pleural thickening/plaques
53
What are the main risk factors for developing lung cancer?
```
Smoking
Asbestos exposure
Increasing age
Male
Radon exposure
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54
How does lung cancer present?
```
Cough
Haemoptysis
Dyspnoea
Chest pain
Weight loss
Anaemia
Hoarse voice
Finger clubbing
Lymphadenopathy
Slow resolving pneumonia
```
55
What are some complications of lung cancer?
```
Horners syndrome
Recurrent laryngeal nerve palsy
SVC obstruction
Pericarditis
Paraneoplastic syndromes
VTE
```
56
What is Horners syndrome?
Miosis, ptosis and anhydrosis
57
What would trigger the 2 week wait pathway for lung cancer?
If >40 with unexplained haemoptysis or findings on CXR
| Urgent CXR if >40 with 2 red flags or one for smokers
58
What might you see on CXR with lung cancer?
Nodules, masses, pleural effusions, lung collapse, hilar enlargement
59
Outline the TNM staging for lung cancer
I - one small tumour (<4cm) localised to 1 lung
II - tumour >4cm - may have spread to local LNs
III - spread to contralateral LNs or nearby structures
IV - LNs outside chest or other organs
N1 - ipsilateral hilar
N2 - ipsilateral mediastinal
N3 - contralateral mediastinal
N4 - other side of the diaphragm
60
What chemotherapy is given in lung cancer?
Usually 4 cycles of cisplatin, gemcitabine
61
What immunotherapy can be given in lung cancer?
Pembrolizumab - targets immune checkpoint
62
What is the 5 year survival for NSCLC?
10-13%
63
What is the prognosis of small cell lung cancer
3 months if untreated, 1.5 years if treated
64
Where does lung cancer often spread?
Liver, bone, pleura, brain, adrenals
65
What percentage of people with colorectal cancer have a family history?
Around 25% (5% have identified mutations)
66
What is familial adenomatous polyposis?
Autosomal dominant mutations in the APC tumour suppressor gene
67
What cancers are implicated in Lynch syndrome?
Colorectal, endometrial, ovarian, urinary tract, stomach, small bowel, HPB
68
What are some inherited causes of colorectal cancer?
FAP, Lynch syndrome, Peutz-Jeghers syndrome
69
What are some risk factors for colorectal cancer?
```
Inherited mutations
Low fibre, high fat diet
Red processed meat consumption
IBD
Smoking
Alcohol
```
70
How does a left colon cancer present?
PR bleeding+mucous, altered bowel habit, tenesmus, constipation, obstruction
71
How does a right colon cancer present?
Weight loss, Fe deficiency anaemia, abdominal pain, less likely obstruction
72
How does a rectal cancer present?
PR bleeding, tenesmus, PR mass, obstruction
73
When would a 2 week referral be appropriate in colorectal cancer?
>40 and unexplained weight loss/adbominal pain
>50 and PR bleeding
>60 and anaemia or change in bowel habit
74
When would you refer within 2 weeks in breast cancer?
30yo and unexplained breast lump
>50yo with one nipple discharge/retraction/other concerning changes
Consider if >30yo with unexplained lump in axilla
75
What investigations could you use in colorectal cancer?
```
FBC, LFTs, U+Es, CEA, FOB
Sigmoidoscopy or colonoscopy + biopsy
CT colon
CT C/A/P
Barium enema - apple core
```
76
Outline the TNM staging for colorectal cancer
```
T1 = invading submucosa
T2 = invading muscular propria
T3 = invading subserosa and beyond (not other organs)
T4 = Invasion of adjacent structures
```
N1 = 1-3 nodes, N2 = >3 nodes
77
When would you do a right hemicolectomy?
Caecal tumours or ascending colon tumours
78
Screening for colorectal?
In England and Wales, screening is offered every 2 years to men and women aged 60-75 years. For most of the UK, a faecal immunochemistry test (FIT) is used, superseding the previous faecal occult test, which utilises antibodies against human haemoglobin to detect blood in faeces
79
When would you do a left hemicolectomy?
Descending colon tumours
80
When would you do a sigmoidectomy
Sigmoid tumours
81
When would you do an anterior resection?
Rectal (high) tumours
82
When would you do an AP resection?
Low rectal tumour within 5cm of anus
83
What chemotherapy regime is used in colorectal cancer?
FOLFOX
Folinic acid, Fluorouracil (5-FU), and Oxaliplatin
84
What biological agents can be used in colorectal cancer?
Cetuximab, bevacizumab (anti VEGF), panitumumab (EGFR antagonist)
85
What are some side effects of cetuximab?
Acneform rash, skin toxicity, pruritus, hair growth disorders, fatigue
86
Which tumours are highly sensitive to chemotherapy?
Lymphomas, germ cell tumours, small cell lung, neuroblastoma, Wilm's tumour
87
Which tumours show modest sensitivity to chemotherapy?
Breast, colorectal, bladder, ovary, cervix
88
Which tumours show low sensitivity to chemotherapy?
Prostate, renal cell, brain tumours, endometrial
89
Give 2 examples of antimetabolites
Methotrexate and 5-FU
90
How do antimetabolites work?
Interfere with DNA synthesis
91
How does 5-FU work?
Inhibits thymidylate synthase so interrupts pyrimidine synthesis
92
How does methotrexate work?
Inhibits dihydrofolate reductase so interferes with the folate cycle that forms purine
93
Give 3 examples of alkylating agents
Carmustine, cyclophosphamide, chlorambucil
94
How do alkylating agents work?
Interfere with DNA replication
95
Give 3 examples of platinum compounds
Cisplatin, oxaliplatin, carboplatin
96
How do platinum compounds work?
Alkylating-like -- Interfere with DNA replication
97
Why has oxaliplatin been more effective than cisplatin in some tumours?
Has a bulky DACH side group which forms covalent bonds with the cell constituents to prevent DNA replication - harder for repair processes to ligate out
98
Give 2 examples of intercalating agents
Doxorubicin, daunorubicin - inhibit DNA replication
99
Give 2 examples of spindle poisons
Vincristine and vibnlastine
100
How do vinca alkaloids work?
Prevent spindle formation
101
Explain some mechanisms of resistance in alkylating agents
Decreased entry and increased exit of drug
Inactivation of drug in the cell
Enhanced DNA repair
102
List some side effects of chemotherapy
```
Alopecia
Mucositis
Pulmonary fibrosis
Cardiotoxicity
Nausea and vomiting
Diarrhoea
Cystitis
Inferitility
Renal failure
Myalgia
Myelosuppression
Peripheral neuropathy
Fatigue
Phlebitis
```
103
In what chemo drugs is alopecia a big side effect?
Doxorubicin, vincristine, cyclophosphamide
104
What are the lines called on nails that are a side effect of chemo?
Beau's lines
105
Which chemo drugs can cause cardiomyopathy?
Doxorubicin, high dose cyclophosphamide
106
Which chemo drugs can cause arrhythmias?
Cyclophosphamide, etoposide
107
Which chemo drugs can cause pulmonary fibrosis?
Bleomycin, mitomycin c, cyclophosphamide, chlorambucil
108
Certain chemotoxicity:
Cisplatin + carboplatin?
Ototoxicity, nephrotoxicity
109
Certain chemotoxicity:
Vincristine?
Peripheral neuropathy
110
Certain chemotoxicity:
Doxorubine and transtuzumab (Herceptin)?
Cardiotoxicity
111
Certain chemotoxicity:
Cyclophosphamide?
Haemorrhage cystitis
112
Certain chemotoxicity:
Methotrexate + 5FU?
Myelosuppression
113
What can cause variability in pharmacokinetics of chemo?
ABNORMALITIES IN ABSORPTION
- nausea and vominting, gut problems
ABNORMALITIES IN DISTRIBUTION
- weight loss, reduced body fat, ascites
ABNORMALITIES IN ELIMINATION
- liver and renal dysfunction eg mets
ABNORMALITIES IN PROTEIN BINDING
- low albumin, other drugs
114
What can vincristine and itraconazole cause?
More neuropathy
115
What is an important drug interaction of capecitabine (oral 5FU)?
Warfarin, St John's wart and grapefruit juice
116
What are important drug interactions of methotrexate?
Penicillin and NSAIDs
117
Over how long is a course of radical radiotherapy?
4-7 weeks
Low daily dose, high total dose
2Gy/day for 37d = 74Gy
118
Over how long is a course of palliative radiotherapy?
1-10 daily treatments
Higher daily dose
4Gy day for 5d = 20Gy
119
What are some early side effects of radiotherapy?
```
Tiredness
Skin - erythema, desquamation, ulceration
Mucositis
N+V
Diarrhoea
Cystitis
Proctitis
Haematuria
Erectile dysfunction
:ymphoedema
```
120
What are some late side effects of radiotherapy?
Skin - pigmentation, necrosis, ulceration, telangiectasia
CNS/PNS - tsomnolence, spinal cord myelopathy, brachial plexopathy
Lung - pneumonitis, fibrosis
GI - strictures, adhesions, fistulae, mouth ulcers, dry mouth
Eyes - cataracts, sight loss
GU - frequency, dyspareunia, erectile dysfunction, infertility
SECONDARY CANCERS!
121
What cancer is Ipilimumab used in?
Melanoma - targets CTLA-4
122
Which cancer is rituxumab used in?
Non Hodgkins as part of RCHOP
123
When is pembrolizumab used?
GU cancer, H+N cancer, lung?
124
What does pembrolizumab block?
PD-1/PD-L1 checkpoint inhibitor
Restores anti tumour immunity
125
What are PD-1 and PD-L1 checkpoint inhibitors?
Pembrolizumab, nivolumab
126
What is Ipilimumab?
Fully human anti-CTLA-4 monoclonal antibody
* Negative regulator of T-cell activation.
* T-cell potentiator- blocks the inhibitory signal of CTLA-4
* T-cell activation, proliferation, & inflammation
* Tumour cell death
127
What are side effects of immunotherapy?
All the itis'
Hepatitis, dermatitis, diarrhoea, abdominal pain, pruritus, Stevens Johnson syndrome, paraesthesias, conjunctivitis, episcleritis, nephritis, pneumonitis
128
What are some side effects of pembrolizumab?
```
Fatigue
• Pruritus
• Nausea
• Decreased appetite
• Peripheral oedema
• Oral mucositis
```
```
Immune-related effects:
• Pneumonitis (2.9%)
• Colitis (1%)
• Hepatitis (0.5%)
• Nephritis (0.7%) • Hypothyroidism
```
129
How can you manage liver mets?
Surgical resection
Microwave ablation
Radiofrequency ablation
Radiofrequency-assisted liver resection
Selective internal radiation therapy (SIRT)
130
What is the prognosis of colorectal cancer?
Stage I – 85-95%
Stage II – 60-80%
Stage III – 30-60%
Stage IV – 7%
131
How does neutropenic sepsis present?
Fever >38 or >37.5 for >1 hour
Neutrophils < 0.5
Cough, SOB, GU Sx, confusion
132
In the majority of culture positive cases of neutropenic sepsis, which type of organism are responsible?
Gram positive cocci - staph aureus, staph epidermis, strep pneumoniae
133
How do you treat neutropenic sepsis?
Tazocin 4.5mg TDS or meropenem 1g TDS IV stat
134
What percentage of patients with cancer will present with Hypercalcaemia?
10-20% (40% in myeloma)
135
What are the mechanisms of Hypercalcaemia in malignancy?
- Tumours release humeral factors eg release of PTHrp or calcitriol
- Tumours release cytokines which promote local osteolysis
136
How does Hypercalcaemia present?
Polydipsia, polyuria, anorexia, N+V, costipation, abdominal pain, confusion, fatigue, bone pain
Weight loss, dehydration, bradycardia, osteopenia
137
How do you investigate Hypercalcaemia?
Bone profile - serum calcium (adjusted >2.6), serum phosphate, ALP, albumin, total protein
U+Es
PTH/rp
Myeloma screen
ECG
138
How do you manage Hypercalcaemia?
Rehydration with IV fluids
IV bisphosphonates eg zolendronic acid (inhibits osteoclasts)
Could also use calcitonin, octreotide, denosumab
139
What percentage of cancer patients experience MSCC?
5%
140
How does MSCC present?
Back pain - doesn't relieve with rest even at night, exacerbated by exertion, thoracic or cervical spine location
Neurological deficit - muscle weakness, altered sensation, bladder/bowel dysfunction
141
Which is the most common location for MSCC?
Thoracic (70%)
142
How do you investigate MSCC?
Whole spine MRI
143
How do you manage MSCC?
Lie patient flat with neutral spine
Dexamethasone 16mg stat (then 8mg BD+PPI)
Analgesia, VTE prophylaxis, surgery, radiotherapy
144
What electrolyte abnormalities are seen in tumour lysis syndrome?
Hyperuriciaemia
Hyperkalaemia
Hyperphosphataemia
Hypocalcaemia
145
How does tumour lysis present?
Low urine output, confusion, lethargy, muscle weakness, reduced GCS, seizures, palpitations, cardiac arrest
146
What are some risk factors for tumour lysis
Haematological cancers, high pretreatment LDH and rate, renal impairment
147
How do you investigate tumour lysis?
Urine dip + MSU
U+Es
LDH, urate and lactate
ECG
148
How do you manage tumour lysis?
A-E - IV Fluids
Calcium glutinate, insulin/dextrose for high K+
Phosphate binders
Rasburicase and allopurinol for high urate
149
How can SVCO present?
```
Facial swelling, neck and arm swelling
SOB/orthopnoea/stridor/cyanosis
Distended neck and chest wall veins
Non pulsatile raised JVP
Lethargy
Headache
```
150
How do you manage SVCO?
```
Sit patient upright
O2 if needed
Dexamethasone 16mg/24h
Radiotherapy in some lung cancer cases
Chemotherapy in chemosensitive
Stenting
Anticoagulation
```
