Oncology Flashcards
1
Q
Define oncological emergency
A
Acute medical problem related to cancer (or its treatment), which may result in serious morbidity/mortality if not treated quickly
2
Q
3 main categories of oncological emergency?
A
Metabolic
Structural/obstructive
Treatment-related
3
Q
Main oncological emergencies?
A
Hypercalcaemia SIADH Spinal cord compression SVC obstruction Neutropenic sepsis Tumour lysis syndrome Raised ICP Airway obstruction Anaphylaxis Extravasation Tamponade
4
Q
Definition of hypercalcaemia?
A
Serum corrected calcium > 2.6 mmol/L
5
Q
What is meant by corrected calcium?
A
4% circulating Ca is bound to albumin
Unbound, ionised Ca is physiologically important
To correct Ca levels, add 0.1mmol/L to Ca level for every 4g/L that albumin levels are <40g/L
6
Q
What are the corrected calcium levels (mmol/L) for hypercalcaemia that is:
a) Mild
b) Moderate
c) Severe
A
a) Mild: 2.6-3.0
b) Moderate: 3-3.4
c) Severe: >3.4
7
Q
Causes of hypercalcaemia?
A
Bone destruction (e.g. bony mets) PTH-related protein (released by some tumours) Primary hyperparathyroidism Sarcoidosis Vit D intoxication Thyrotoxicosis Lithium Tertiary hyperparathyroidism Dehydration
8
Q
What is the cause of hypercalcaemia if PTH is high-normal/raised?
A
Hyperparathyroidism
9
Q
What are the possible causes of hypercalcaemia if PTH is low/low-normal?
A
Malignancy Drugs (thiazides, high dose vit D, Li) Thyrotoxicosis Adrenal insufficiency Sarcoidosis or TB
10
Q
How does hypercalcaemia present?
A
Painful bones Urinary stones Abdominal groans (abdo pain, constipation, N+V, etc) Psychic moans Fatigue HTN Ectopic calcification Cardiac arrest
11
Q
What investigations should be done for hypercalcaemia?
A
Corrected calcium levels (Ca and albumin) ECG (shortened QT interval) Chloride ABG K+ Phosphate Alkaline phosphatase PTH Protein electrophoresis CXR - sarcoidosis Isotope bone scan (?bony mets) 24hr urinary Ca2+ excretion (for familial hypocalciuric hypercalcaemia)
12
Q
What are some pointers on investigation towards malignancy as the cause of hypercalcaemia?
A
Low albumin, Cl-, K+
Alkalosis
Raised phosphate, alk phos
PTH normal
13
Q
Pointers on investigation towards hyperparathyroidism as cause of hypercalcaemia?
A
Raised PTH
14
Q
How is hypercalcaemia treated?
A
1) Diagnose and Rx underlying cause
2) Correct dehydration (IV 0/9% saline, 3L over 24h)
3) Bisphosphonates (pamidronate, zolendronic acid)
15
Q
How do bisphosphonates work to treat hypercalcaemia?
A
Inhibit osteoclasts - reduces bone turnover
Reduces Ca2+ levels over several days
16
Q
Side effects of bisphosphonates?
A
Flu-like Sx Oesophagitis Osteonecrosis of the jaw Bone pain, myalgia Reduced phosphate levels Nausea and vomiting
17
Q
Other than treating the underlying cause, correcting dehydration, and giving bisphosphates, what else can be done to manage hypercalcaemia associated with malignancy?
A
1) Denosumab (inhibits RANK ligand to inhibit osteoclast maturation)
2) Chemotherapy may help
3) Furosemide (promotes renal excretion of Ca2+)
Steroids may be used in sarcoidosis
18
Q
What is Denosumab, and what is it used for?
A
Human monoclonal antibody
Inhibits RANK ligand (inhibits osteoclast maturation)
Used to treat hypercalcaemia of malignancy
19
Q
What is SIADH?
A
Syndrome of inappropriate ADH secretion Excess ADH Failure to excrete dilute urine - water retention Low serum sodium and plasma osmolarity High urine osmolarity
20
Q
How is the osmolarity affected in SIADH:
a) plasma
b) urine
A
a) plasma osmolarity low
b) urine osmolarity high
21
Q
What are the causes of SIADH?
A
Cancer: Small cell lung cancer Pancreatic Lymphoma (NHL and Hodgkin's) Prostate
Non-cancer:
Neuro (stroke, SAH, SDH, meningitis, etc)
Infections (TB, pneumonia)
Drugs (sulfonylureas, SSRIs, TCAs, carbamazepine, vincristine, cyclophosphamide)
Other causes: PEEP, porphyrias
22
Q
How does SIADH present?
A
Fatigue
N+V
Confusion
Coma
23
Q
What investigations should be done for SIADH?
A
Serum Na (low, dilutional) Plasma osmolarity (low)
Urine Na (high, concentrated) Urine osmolarity (high)
CT scan - look for underlying cause
24
Q
How is SIADH managed?
A
1) Fluid restriction
2) Demeclocycline
3) ADH receptor antagonists
4) Treat underlying cause where possible
25
What is demeclocycline? How does it work to treat SIADH?
Tetracycline antibiotic
Causes reversible nephrogenic diabetes insipidus
Kidneys excrete too much water - compensates for excess ADH secretion
26
How is SIADH managed in an emergency?
Slow IV infusion NaCl 1.8%
27
Why is it important to correct SIADH slowly?
To avoid precipitating central pontine myelinolysis
Neurological disorder caused by severe damage of the myelin sheath of nerve cells in the pons
28
What is spinal cord compression?
1) Pressure from tumour between vertebral bodies
| 2) Collapsed vertebral bodies (ie due to bone cancer) on the spinal cord of caudal equina
29
Briefly describe the anatomy of the spinal cord
Extends from base of skull
Terminates at L1
Cauda equina extends below L1 and contains lumbar, sacral and coccygeal spinal nerves
30
Which spinal nerves are responsible for the knee and ankle jerk reflexes?
Knee: L3-4
Ankle: S1
31
What are the causes of spinal cord compression?
```
Malignancy (primary or secondary)
Trauma
Disc prolapse
Inflammatory disease, esp in RA
Spinal infection
Epidural or subdural haematoma
```
32
Which types of cancer most commonly cause spinal cord compression?
```
Breast
Lung
Thyroid
Kidney
Prostate
Bowel
Melanoma
Myeloma
Lymphoma
```
33
In women with bony mets, where is the cancer most likely to have originated?
Breast
34
How does spinal cord compression present?
Back pain
Radicular pain (radiates to lower extremity via nerve route)
Weakness + sensory loss below level of compression
Difficulty walking
Bladder/bowel dysfunction
Erectile dysfunction
Abnormal neuro exam (LMN signs at level of compression, UMN signs below)
35
How are the following affected in UMN vs LMN lesions?
1) tone
2) power
3) reflexes
4) wasting
5) fasciculations
1) inc vs dec
2) dec and dec
3) brisk vs absent
4) absent vs present
5) absent vs present
36
How is spinal cord compression investigated?
MRI whole spine
| Bloods - FBC, U&Es, LFTs (could indicate liver mets)
37
How is spinal cord compression managed?
High-dose corticosteroids - PO DEXAMETHASONE 8mg BD (one at 8am, one at 12pm - do not give after noon as will keep them up all night)
PPI cover whilst on steroids
Bed rest if spinal instability
Neurology assessment
Definitive treatment depends on: site and extent of lesion, overall prognosis, fitness for GA, neurological ability, functional status
38
When would surgery be indicated for spinal cord compression?
Single area of compression - decompress then radiotherapy
39
What is the role of radiotherapy in the management of spinal cord compression?
Needed ASAP to prevent deterioration of neurology
Aims to shrink tumour that causes the symptoms
For patients that require definitive therapy but aren't suitable for surgery
Can be used for pain control
40
What are some other methods of treatment for spinal cord compression?
```
Chemotherapy (if tumour chemo-sensitive)
Hormone deprivation (in prostate ca patients)
```
Other measures: bisphosphonates, VTE prophylaxis, pressure sore prevention, manage bladder and bowel dysfunction, plan for rehab
41
What is the prognosis of spinal cord compression?
Related to severity of the neurological deficit at the time of presentation
If paraplegia and sphincter involvement has occurred, recovery is uncommon
42
What is superior vena cava obstruction (SVCO)?
Compression, invasion or occasionally intra-luminal obstruction of the SVC
43
Describe the anatomy of the SVC.
| Is it in the R or L side of the mediastinum?
Provides venous drainage for head, neck, upper limbs, upper thorax
Extends from the junction of the R and L innominate veins into the right atrium
Surrounded by sternum, trachea, R bronchus, aorta, pulmonary artery, and perihilar and peritracheal nodes
The SVC runs along the R side of the mediastinum
In SVCO, collateral pathways form to provide alternative route for blood to return to RA
44
What are the main causes of SVCO?
90% due to:
Small cell lung cancer
Non-SCLC
Lymphoma
45
What are the other causes of SVCO?
Thymoma
Germ-cell tumours
Others, e.g. thrombus, direct tumour invasion, etc.
46
What are the symptoms of SVCO?
Can have sudden or insidious onset
```
DYSPNOEA = most common symptom
Chest pain (often at rest)
Cough
Oedema (neck, face, arm)
Dizziness, headache (worse in AM), visual disturbance, nasal stuffiness, syncope
```
47
What are the signs of SVCO?
Dilated veins over arms, neck and anterior chest wall
Oedema of upper torso, arms, neck and face
Severe respiratory distress
Cyanosis
Engorged conjunctiva
Convulsions and coma
48
Pemberton's sign is positive in SVCO. What does this mean?
You ask the patient to raise their arms up to the side of their face until they touch.
If they develop cyanosis, worsening SoB or facial congestion, it is said to be positive
49
What investigations are done for SVCO?
```
Clinical diagnosis
CXR - widened mediastinum or mass on R side of heart
CT scan
Biopsy of any mass for histopathology
Doppler studies
Invasive contrast-venography
```
50
How is SVCO managed?
Symptomatic relief (elevation of bed head + O2)
Steroids - Dexamethasone 8mg BD PO
Endovascular stenting
Anticoagulation
Ultimate Rx depends on cause (radio vs chemo) - radio indicated in some lung cancers. Chemo useful in chemo-sensitive tumours, e.g. SCLC
51
Normal value for intracranial pressure in adults?
<15 mmHg
Vol inside cranium is fixed, so any increase in the contents can lead to raised ICP
This can be mass effect, oedema, or obstruction to fluid outflow
52
What are the causes for raised ICP?
```
Brain tumours/mets
Cerebral oedema
Haemorrhage (SD, ED, SAH, IC, IV)
Infection (meningitis, encephalitis, brain abscess)
Status epilepticus
Idiopathic intracranial hypertension
Head injury
Hydrocephalus
```
53
How does raised ICP present?
```
Headache (worse on bending forwards)
Vomiting
Visual disturbance (reduced acuity and peripheral field loss)
Hx trauma
Reduced GCS
Falling pulse and rising BP (Cushing's response)
Cheyne-stokes respiration
Pupil changes
Papilloedema
```
54
What pupil changes can be seen with raised ICP?
Constriction at first
Later filatation
Important to not mask these signs by using agents which dilate the pupil to aid fundoscopy (e.g. tropicamide)
55
What investigations need doing for raised ICP?
CT/MRI to determine underlying lesion
Fundoscopy
U+E, FBC, LFT, glucose, serum osmolality, clotting, blood cultures
Consider toxicology screen
CXR - any source of infection that may indicate abscess
Consider LP if safe, measuring opening pressure
56
What is the immediate management for raised ICP?
```
ABCDE
Avoid pyrexia and maintain normoglycemia
Manage seizures and keep MAP >90
CSF drainage
Elevate head of bed 30-40 degrees
Analgesia and sedation (IV propofol etc)
Neuromuscular blockade
Mannitol
Hyperventilation (if intubated)
```
Diagnose and Rx underlying cause and exacerbating factors
57
What is the role of mannitol in raised ICP?
Osmotic agent - used to 'suck' water out of the brain
Can be used initially but may lead to rebound raised ICP after prolonged use (12-24 hrs)
58
What is the role of corticosteroids in raised ICP?
ONLY useful if the cause of raised ICP is cancer
Not effective in reducing ICP except for oedema surrounding tumours
Dexamethasone 10mg IV
59
What are the 3 main herniation syndromes associated with raised ICP?
1) Uncal herniation
2) Cerebellar tonsil herniation
3) Subfalcian (cingulate) herniation
60
What is uncal herniation? Symptoms?
Caused by a lateral supratentorial mass (pushes uncus against midbrain)
3rd nerve compressed - causes dilated ipsilateral pupil, ophthalmoplegia
Followed by contralateral hemiparesis due to pressure on the cerebral peduncle
Coma from pressure on the ascending reticular activation system (ARAS) in the midbrain
61
What is cerebellar tonsil herniation? Symptoms?
INCREASED PRESSURE IN THE POSTERIOR FOSSA (ie posterior mass), forcing the cerebellar tonsils through the foramen magnum
Symptoms: ataxia, 6th nerve palsies, upgoing plantars, loss of consciousness, irregular breathing, apnoea
Syndrome may proceed v rapidly given the small size and poor compliance of posterior fossa
62
What is subfalcian (cingulate) herniation?
FRONTAL MASS
May be silent unless ACA is compressed and causes a stroke
Symptoms: contralateral leg weakness, abulia (inability to make decisions)
63
What may cause airway obstruction in cancer?
Pressure from a tumour, e.g. bronchial carcinoma compressing trachea
Rx: ABCDE, intubate/cricothyroid
64
What is neutropenic sepsis?
Emergency caused by chemotherapy
Neut <1 + Fever >37.5
OR
Unwell in absence of fever
65
What can cause neutropenic sepsis?
Current/recent chemotherapy regime - particularly for blood cancers (also lung, breast, ovarian, colorectal)
66
What is the definition for sepsis?
Life-threatening organ dysfunction due to dysregulated host response to infection
67
What is septic shock?
Hypotension despite adequate fluid resus along with perfusion abnormalities leading to end-organ dysfunction (lactic acidosis, oliguria, altered mental state)
68
What investigations need to be done for neutropenic sepsis?
FBC!!
```
Identify source (CXR, Urine MC+S, Blood cultures)
May also want to rule out DIC
```
69
How is neutropenic sepsis managed?
```
ABCDE and Sepsis 6 (?HDU)
IV access - 500ml NaCl fluid challenge
O2 if hypoxic
15 min obs
Consider GCSF
IV ABx (Tazocin, +/- gentamicin)
Review regularly
```
70
What is GCSF, and why would you consider it in the management of neutropenic sepsis?
Granulocyte macrophage colony stimulating factor
| Stimulates bone marrow to produce granulocytes and stem cells and release them into bloodstream
71
How is neutropenic sepsis prevented in patients undergoing chemotherapy with a high risk of developing it?
Fluoroquinolone
72
What is anaphylaxis?
| What type of hypersensitivity reaction is it?
Acute, life-threatening, multi-system severe reaction of the body's immune system
Type 1 hypersensitivity
73
What causes anaphylaxis?
Exposure to trigger (allergen) to which they have already been sensitised
Can occur in response to chemotherapy
74
Give 4 differentials for anaphylaxis
Carcinoid
Phaeochromocytoma
Systemic mastocytosis
Hereditary angioedema
75
How is anaphylaxis managed?
```
STOP OFFENDING AGENT and call for help
ABCDE
Resus - O2, IV saline
0.5mg 1 in 1000 adrenaline IM
IV hydrocortisone
IV piriton
Fluid resus
```
76
What is tumour lysis syndrome?
Sudden tumour necrosis due to cancer treatment
Leading to metabolic abnormalities
Caused by abrupt release of large quantities of cellular components into blood following rapid lysis of malignant cell
77
What metabolic disturbances are seen in tumour lysis syndrome?
Hyperkalaemia/phosphataemia/uricaemia
Hypocalcaemia
Raised lactate, LDH
AKI (raised urea and Creat, reduced UO)
78
What causes tumour lysis syndrome?
Usually treatment-mediated (may be spontaneous)
79
Which type of malignancies is tumour lysis most commonly seen in?
Haematological (Burkitt's lymphoma, ALL)
Other bulky chemo-sensitive tumours (leukaemia, germ cell tumours)
80
What are the RFs for tumour lysis syndrome?
Volume depletion (dehydration, bleeding)
Renal impairment
Treatment-sensitive tumours
High pre-treatment rate, lactate and LDH levels
Elevated LDH levels on blood tests predicts increased risk (LDH is a product of cell breakdown, so increased levels can indicate tumour breakdown)
81
How does tumour lysis syndrome present?
```
Weakness
Constipation, vomiting, nausea
Abdominal pain (paralytic ileus)
Palpitations, chest pain, collapse (cardiac arrhythmias due to metabolic abnormalities)
Seizures
Reduced urine output, lethargy
AKI
```
82
Why can tumour lysis syndrome lead to AKI?
Deposition of uric acid and calcium phosphate crystals in the renal tubules can cause acute renal failure
This can be exacerbated by concomitant intravascular depletion
83
What investigations need to be done for tumour lysis syndrome?
FBC
U+E
Serum LDH, phosphate, urate
Calcium profile
84
How can tumour lysis syndrome be prevented?
IV fluids
Rasburicase (recombinant urate oxidase) - catalyses uric acid conversion to allantoin
Allopurinol (xanthine oxidase inhibitor) - prevents uric acid production from xanthines
85
How does rasburicase work to prevent tumour lysis syndrome?
Catalyses the oxidation of uric acid into allantoin (more soluble)
86
How is acute tumour lysis syndrome treated?
```
Vigorous hydration - IV fluids
Correct hyperkalaemia
Rasburicase (stop allopurinol)
Acetazolamide (alkalinise urine - makes uric acid more soluble)
Phosphate binders
Dialysis
```
87
How does acetazolamide help in the treatment of tumour lysis syndrome?
Alkalinises urine (makes uric acid more soluble)
88
What type of shock is caused by cardiac tamponade?
Obstructive shock
89
What are the signs of tamponade?
Becks triad:
1) Falling BP
2) Rising JVP
3) Muffled heart sounds
```
Kussmaul's sign (increased JVP on inspiration)
Pulsus paradoxus (pulse fades on inspiration)
```
90
What investigations should be done in cardiac tamponade?
Echo
CXR (globular heart, L heart border convex/straight, R cardiophrenic angle <90)
ECG (electrical alternans)
91
How is cardiac tamponade treated?
```
Early senior involvement
Give O2, monitor ECG, set up IVI
Group and save
Pericardiocentesis
Cardiothoracic surgery (CABG, ventricular repair, etc)
```
92
Give some examples of complementary therapies that may be used alongside traditional cancer treatment?
```
Acupuncture
Aromatherapy/massage
Clinical hypnosis
Reflexology
Shiatsu
Healing/Reiki
Western herbal medicine
Manipulative therapies (osteopathy, chiropractic)
Homeopathy
```
93
What is the conversion factor between codeine and morphine?
Codeine to morphine - divide by 10
94
Which chemotherapy is commonly associated with peripheral neuropathy?
Vincristine
Urinary hesitancy may also develop secondary to bladder atony
95
What treatments are there for a patient who is experiencing bony mets?
NSAIDs (diclofenac)
Bisphosphonates
Radiotherapy
96
What are the 5 most common sites for bony mets?
Desc. order:
1) spine
2) pelvis
3) ribs
4) skull
5) long bones
97
Which is the most common cancer causing bony mets?
Prostate
98
What are the side effects associated with cyclophosphamide?
Haemorrhagic cystitis
Myelosuppression
Transitional cell carcinoma
99
What are the side effects associated with:
1) Bleomycin?
2) Doxorubicin
1) Lung fibrosis
| 2) Cardiomyopathy
100
What are the side effects associated with methotrexate?
Myelosuppression
Mucositis
Liver fibrosis
Lung fibrosis (methotrexate cough!)
101
What are the side effects associated with 5-fluorouracil?
Myelosuppression
Mucositis
Dermatitis
102
Which tumour marker is raised in pancreatic cancer?
CA19-9
| remember - 9 looks a bit like a pancreas?
103
Which tumour marker is raised in breast cancer?
CA15-3
| 3 looks like boobs?
104
What should the breakthrough morphine dose be for breakthrough pain compared to the normal daily dose?
1/6th
ie if someone is taking 30mg BD (60mg total), breakthrough dose is 10mg
105
Which opioids are safest to use in patients with CKD?
Alfentanil
Buprenorphine
Fentanyl
106
Define neoplasm
A new and abnormal growth of tissue in the body
107
What are the 6 hallmarks of cancer?
1) Evading growth suppressors
2) Activating invasion and metastasis
3) Enabling replicative immortality
4) Inducing angiogenesis
5) Resisting cell death
6) Sustained proliferative signalling
108
# Define:
1) pharmacodynamics
| 2) pharmacokinetics
1) what the drug does to the body
| 2) what the body does to the drug
109
What are the 3 features of chemotherapy that must be present for a treatment to be effective?
1) the drug must reach cancer cells
2) the cell must be sensitive to the cytotoxicity of the drug
3) the toxic effect must be minimal to the benefit of the drug
110
Define screening
A process of identifying apparently healthy people who may be at increased risk of a disease or condition
111
Who does the MDT comprise of in cancer care?
```
Oncologist
Surgeon specific to the body system affected by the cancer
Clinical nurse specialist
Macmillan team
Patient and their family
```
112
What is the purpose of neoadjuvant chemotherapy?
Given before surgery/radical Rx to shrink the tumour - makes it easier to operate on
Can eradicate micro-metastatic disease and can allow some tumours to be downstages before the definitive/curative treatment
113
Give 3 possible downsides to neo-adjuvant chemotherapy
1) delays the definitive treatment
2) adds the risk of potentially fatal chemotherapy related complications (eg neutropenic sepsis)
3) may cause a decrease in patient performance status which may mean they are no longer fit for surgery
114
What is the purpose of adjuvant chemotherapy?
Given after surgery
To ensure any margins or micrometastatic sites are free from disease
In some cancers (breast, colorectal), it can improve survival
115
Possible limitation with adjuvant chemo?
Morbidity from surgery may mean patients are not fit for chemo within an appropriate timeframe
116
What are the side effects of radiotherapy?
```
Nausea, vomiting or anorexia
Mucositis (esp with ENT tumours - PEG may be advised)
Oesophagitis
Diarrhoea
Skin rashes
```
Early SE involve local inflammation
Late SE involve local fibrosis
117
What are the 3 different groups of systemic anti-cancer treatment?
1) Cytotoxic chemotherapy
2) Hormone therapy
3) Molecularly-targeted therapy
118
What are the 3 main groups of cytotoxic chemotherapy agents?
1) Alkylating agents (not cell-cycle phase specific), e.g. Cyclophosphamide
2) Antimetabolites (target S phase of cell cycle), e.f. Fluorouracil, methotrexate, hydroxycarbamide
3) Natural products, e.g. Bleomycin, Doxorubicin
119
What are some general side effects of chemotherapy?
```
Nausea
Taste changes
Hepatic/renal impairment
Immune suppression
Peripheral neuropathy
Constipation
Hair loss
Skin rashes
Infertility
Heart failure
```
120
Lung cancer. What are the 3 main subtypes of NSCLC?
Squamous cell cancer
Adenocarcinoma
Large cell lung carcinoma
121
Lung cancer. Which type of NSCLC is most seen in non-smokers?
Adenocarcinoma
122
Which tumour marker is raised in ovarian cancer?
CA 125
123
Which tumour marker is raised in prostatic carcinoma?
PSA
124
Which tumour marker is raised in hepatocellular carcinoma and teratomas?
Alpha-feto protein (AFP)
125
Which tumour marker is raised in colorectal cancer?
Carcinoembryonic antigen (CEA)
126
Lung cancer. Which type of lung cancer is most associated with smoking?
Squamous cell
127
Other than bone pain, what signs/symptoms may a patient with bony mets suffer?
Pathological fractures
Hypercalcaemia
Raised ALP
128
Common side effects of chemotherapy are nausea and vomiting. How could these be managed?
Metoclopramide (if low risk of symptoms)
Ondansetron (if high risk of symptoms)
129
How does ondansetron work?
5HT3 antagonist
130
What are the 5 most common causes of cancer in the UK?
```
Desc order:
Breast
Lung
Colorectal
Prostate
Bladder
```
