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phase 4 > oncology emergencies > Flashcards

oncology emergencies Flashcards

1
Q

cause of febrile neutropenia

A

chemotherapy in past 1-3 weeks as chemo kills WBC
bone marrow involvement
blood cancers

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2
Q

definition of febrile neutropenia

A

fever >38
neutrophils <1x10^9
(or other signs of sepsis)

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3
Q

signs of sepsis

A 
wcc <1
temp >37.5
hypotension
confusion
reduced urine output
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4
Q

investigations in febrile neutropenia

A

identify source of pathogen
FBC + culture
CXR
MC+S

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5
Q

treatment of febrile neutropenia

A 
ABCDE
isolation and barrier nurse 
sepsis 6
abx IV within 1 hr - tazocin + gentamycin 
reduce chemo dose with subsequent cycles
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6
Q

prophylaxis of fertile neutropenia

A

GCSF (granulocytic colony stimulating factor) or co-trimoxazole or fluroquinolone

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7
Q

causes of spinal cord compression

A

extradural metastases
crush fracture
haematagenous spread of malignancies
trauma

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8
Q

symptoms of spinal cord compression

A

back pain (worse lying down, at night and coughing)
radicular pain
motor, reflex and sensory level
bladder and bowel dysfunction

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9
Q

investigations in spinal cord compression

A

urgent MRI spine

peripheral nerve exam

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10
Q

treatment of spinal cord compression

A 
dexamethasone (with PPI cover)
discuss with neuro and oncology
consider radiotherapy or surgery 
analgesia 
bisphosphonates 
anticoagulation/VTE prevention 
hormone deprivation if prostate
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11
Q

causes of SVCO

A

lung cancer
thymus malignancy
SVC thrombosis (from central lines, nephrotic syndrome)
fibrotic bands (lung fibrosis after chemo)
thoracic lymph node mets

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12
Q

symptoms of SVCO

A 
headache
dyspnoea 
orthopnoea 
plethora 
thread viens in SVC distribution 
swollen face and arms
engorged neck veins 
purple/blue face congestion
raised fixed non pulsatile JVP
blurred vision
hoarse voice 
worse lying down
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13
Q

what is pemberton’s sign

A

lifting arms above head for >1 min leads to facial plethora, increased JVP and inspiratory stridor due to narrowing of the thoracic inlet - seen in SVCO

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14
Q

investigations in SVCO

A 
sputum cytology
CXR - widespread mediastinum or mass in lung 
CT chest with contrast 
venography
biopsies (US or bronchoscopy)
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15
Q

treatment of SVCO

A 
dexamethasone 
balloon venoplasty 
SVC stenting
radical or palliative chemo/radio
anticoagulation 
keep head up
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16
Q

how would treatment of SVCO differ in SCLC and NSCLC

A 
SC = chemo and radio
NSC = radio
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17
Q

causes of hypercalcaemia in cancer

A

myeloma - increase osteoclast activity
lymphoma - production of calcitrol leads to increase calcium absorption
ectopic PTH in squamous lung cancer
bony mets - causing osteoclast activity and bone desturction

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18
Q

which cancers often cause bone mets

A

breast, lung, prostate, thyroid, myeloma

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19
Q

symptoms of hypercalcaemia

A

BONES - bone pain
STONES - renal stones
MOANS - depression, lethargy, confusion
GROANS - abdo pain, constipation, anorexia, N+V
THRONES - polyuria, polydipsia, dehydration, CKD

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20
Q

investigations in hypercalcemia

A 
increase Ca
decreased PTH (need this to exclude primary HPT)
CXR
isotope bone scan 
ECG - short QT, arrhythmias, j wave?
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21
Q

treatment of hypercalcaemia

A

1) aggressive hydration - NaCl to reduce serum calcium
2) IV furosemide - makes room for more fluid
3) if HPT excluded, give maintenance bisphosphonates to reduce osteoclast activity
4) monitor electrolytes
5) calcitonin? denosumab? steroids?

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22
Q

what would primary HPT show?

A

increase PTH and calcium but normal urinary calcium

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23
Q

action of PTH

A

increases bone, kidney and small intestine reabsorption of calcium
increase phosphate excretion from kidney

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24
Q

complications of increased calcium

A

renal stones and CKD
arrhythmias
weakness
confusion, coma

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25
Q

symptoms of cauda equina syndrome

A

bladder and bowel dysfunction
back pain
lower limb weakness and reduced sensation
loss of anal tone

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26
Q

symptoms of raised ICP

A

headache - worse in morning and bending over
N+V
focal neurological symptoms and fits
papilloedema

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27
Q

management of raised ICP

A

CT/MRI
dexamethasone
radio/chemo

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28
Q

what is tumour lysis syndrome

A

a rapid breakdown of many tumour cells usually in chemo leading to metabolic and electrolyte abnormalities

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29
Q

metabolic/electrolyte abnormalities in tumour lysis syndrome

A

increase in potassium (due to cell degradation)
increase in urate
increase in phosphate (due to nephrocalcinosis and urinary obstruction)
decrease in calcium (due to increased phosphate)

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30
Q

risk factors of tumour lysis syndrome

A

chemotherapy, worse if poor renal function as cannot clear toxins

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31
Q

symptoms of tumour lysis syndrome

A

MURDER
muscle cramps/weakness (as increased K)
urine abnormalities/AKI/reduced urine output (as uric acid and calcium phosphate crystals in renal tubules)
respiratory distress
decreased cardiac contractions (palpitations and chest pain)
ECG change (tall t waves, short QT, ST seg depression)
reflexes

fluid overload
pulmonary oedema
paralytic ileus (abdo pain and constipation)

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32
Q

prevent of tumour lysis syndrome

A 
IV allopurinol (xanthine oxidase inhibitor, therefore decreases conversion of xanthine to uric acid)
IV fluids 
IV rasburicase (recombinant urate oxidase so metabolises uric acid into allantoin which is more soluble and easily secreted by kidneys

give 24hrs before chemo

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33
Q

treatment of tumour lysis syndrome

A 
IV allopurinol
IV fluids
IV rasburicase
acetazolamide
phosphate binders 
dialyse
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34
Q

management of chemo anaphylaxis

A 
discontinue drug
ABCDE
fluid resus, O2, IV access
0.5mg 1:1000 IM adrenaline (repeat if no improvement)
IV hydrocortisone 100mg
IV chlorophenamine 10mg
salbutamol
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35
Q

symptoms of chemo anaphylaxis

A

oedema, N+V, shock
serum tryptase will be high for 12hrs after if true anaphylaxis
biphasic reaction
cardiac arrhythmia

36
Q

why does cancer cause DVT/PE

A

surgery and chemo cause vessel wall damage to increase clots
immobile
change in platelets and clotting factors

37
Q

what is carcinoid syndrome

A

when neuroendocrine tumours secrete serotonin and kinins e.g. MEN1, gastric carcinomas and bronchial adenoma

38
Q

symptoms of carcinoid syndrome

A

flushing, diarrhoea, wheeze and palpitations

39
Q

investigations of carcinoid syndrome

A

increase in 24hr urinary 5 hydroxyindoleatic acid

serum chromogramin A/B

40
Q

treatment of carcinoid syndrome

A

ocreotide (a somatostatin analogue) pre op

surgical resection

41
Q

what is extravasation

A

when in chemotherapy the cannula dislodges and the drug causes erosion of the soft tissue, presenting with blistering, pain, redness and inflammation

42
Q

treatment of extravasation

A

stop drug, steroids, apply cold pack, surgical debridement and plastics

43
Q

how does cancer cause DIC

A

leads to microvascular thrombosis and consumption of haemostatic factors

44
Q

what are the clotting results in DIC

A 
increased PT, APTT and TT
reduced fibrinogen
thrombocytopenia 
increased fibrin degradation products
fragments RBC
45
Q

treatment of DIC in cancer

A

transfusion of platelets or FFP or recombinant FVIIa or cryoprecipitate

46
Q

AFP tumour marker

A

HCC, teratoma

hepatitis, cirrhosis, pregnancy

47
Q

CA 125 tumour marker

A

ovary, uterus, breast

cirrhosis, pregnancy

48
Q

CA 15-3 tumour marker

A

breast

benign breast disease

49
Q

CA 19-9 tumour marker

A

pancreas, cholangiocarcinoma, colorectal

cholestasis, pancreatitis

50
Q

CA 27-29 tumour marker

A

breast

51
Q

neuron specific enolase tumour marker

A

SCLC

52
Q

CEA tumour marker

A

colorectal cancer

pancreatitis, cirrhosis

53
Q

BhCG tumour marker

A

germ cell tumour

pregnancy

54
Q

PSA tumour marker

A

prostate

BPH

55
Q

mono Ig tumour marker

A

multiple myeloma

56
Q

S-100 tumour marker

A

melanoma, schwanomma

sarcoma

57
Q

PLAP tumour marker

A

seminoma

58
Q

acid phosphatases tumour marker

A

prostate

59
Q

thyroglobulin tumour marker

A

thyroid

60
Q

calcitonin tumour marker

A

medullary thyroid

61
Q

what is neoadjuvant chemo used for

A

to shrink tumour

control early micro mets

62
Q

what is adjuvant chemo used for

A

to decrease chance of relapse

63
Q

what is palliative chemo used for

A

provide relief of symptoms and prolong survival

64
Q

examples of monoclonal antibodies

A

trastuzumab (anti-Her2) for breast
cetuximab (anti-EGFR) for colorectal
rituximab (anti-CD20) for NHL

65
Q

examples of tyrosine kinase inhibitors

A

erlotinib for lung

imatinib for CML

66
Q

examples of endocrine modulators

A

tamoxifen

anastrazole

67
Q

common chemo side effect

A

acute = tumour lysis syndrome, neutropenic sepsis, extravasation, anaphylaxis
chronic = secondary malignancies, infertility, pulmonary fibrosis, cardiotoxicity, renal impairment
MANNA - myleosuppression, alopecia, N+V, neuropathy, anaphylaxis

68
Q

treatment of chemo N+V

A

prophylactic granisetron/ondansetron (a 5HT3 antagonist) and dexamethasone

69
Q

how does radiotherapy work

A

ionising radiation forms free radicals which damage DNA, give in daily fractions and use india ink tattoo for reproducible targeting

70
Q

radical vs palliative radio

A

radical for curative intent

palliative for symptom relief e.g. bone pain, haemoptysis, cough, dyspnoea, bleeding

71
Q

acute side effects of radiotherapy

A

tired, erythema, ulceration, mucositis, n+v, diarrhoea, cystitis, BM suppression

72
Q

late reactions of radiotherapy

A

brachial plexopathy, lymphedema, pneumonitis, xerostomia, benign strictures, fistulae, decreased fertility, panhypopituitarism

73
Q

types of surgery used in cancer treatment

A

diagnostic e.g. tissue biopsy/removal
excision
palliation e.g. bypass, stenting

74
Q

when should you 2ww

A

PR bleed >50, PMB, breast changes, frank haematuria

75
Q

what is the assessment called to assess performance status in oncology treatment

A

ECOG/WHO

1 = fully active 5 = dead

76
Q

what cytotoxic agent causes pulmonary fibrosis

A

bleomycin - as it degrades preformed DNA

77
Q

BRCA 2 gene is a RF for what cancers

A

breast and prostate

78
Q

BRCA 1 gene is a RF for what cancers

A

breast and colorectal

79
Q

what increases chances of chemo side effects

A

anxiety, <50 years, opioid use, type of chemo

80
Q

what cytotoxic agent causes haemorrhage cystitis

A

cyclophosphamide

81
Q

what cytotoxic agent causes peripheral neuropathy

A

vincristine

82
Q

what cytotoxic agent causes cardiomyopathy

A

doxorubicin

83
Q

how does a PET scan work

A

uses flurodeoxyglucose as a radio tracer to see glucose uptake

84
Q

most common cancers to metastasise

A

prostate
breast
lung

85
Q

what is the p53 gene

A

a tumour suppressor gene, cause Li Fraumeni syndrome if it is a germline mutation

86
Q

virus linked to cancer

A 
HHV-8 = kaposis
HPV = cervical 
EBV = Hodgkins, nasopharyngeal, Burkitt's
H.pylori = MALT
Hep B = HCC
87
Q

internal vs external beam radiotherapy

A 
internal = brachytherapy - radiation source placed near
external = high energy X-ray - causes DNA damage and used CT/MRI to target

phase 4 (19 decks)

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