Oncology + palliative care Flashcards

Question

Calcium physiology: where is calcium stored in the body?

Answer 1

* 99% in bone * 1% intracellular * 0.1% extracellular * 50% ionised- metabolically active, free pool of calcium * 41% bound- to albumin (90%) and globulin (10%) * 9% complexed- complexes w/ phosphate & citrate

Answer 2

1. Primary hyperparathyroidism 2. Malignant hypercalcaemia 1. Breast 2. Myeloma 3. Lymphoma 4. Lung cancer

Answer 3

* PTHrP secretion - "humoral hypercalcaemia of malignancy" (HHM) ~80% * Osteolytic metastasis, commonly w/ breast cancer, deposition of tumour cells within bone leads to local production of inflammatory cytokines & other mediators stimulating osteoclasts leading to bone resorption ~20% * Production of caltriol (vit D)- Hodgkin's lymphoma

Answer 4

* Stones- kidney stones, polyuria, DI * Moans- constipation * Groans- abdominal pain, N&V, peptic ulcers, pancreatitis * Bones- bone pain, muscular weakness * Psychiatric overtones- depression, anxiety, impaired cognition, confusion, coma * Fatigue, weakness * Often non-specific

Answer 5

* Aggressive rehydration- IV fluids * Bisphosphonates- inhibit osteoclastic bone resorption * IV pamidronate or zolendronic acid * Can cause renal failure- properly hydrate first * Seek advice in renal impairment * Take up to 4 days to work, effects last up to 4wks * Systemic treatment of malignancy

Answer 6

* Previous episode of hypercalcaemia? * Most patients who develop hypercalcaemia have disseminated disease * Many die in \< 3/12 * Px= 52 days for solid organ malignancy * Px= 362 days for haematological malignancy

Answer 7

Malignant superior vena cava obstruction (SVCO) refers to an obstruction to the flow of blood through the superior vena cava (SVC) secondary to a cancer 90% cases are extrinsic compression- intrathoracic primary, lung cancer (80% all cases), mesothelioma others = mediastinal LN, metastatic or lymphoma (10%)

Answer 8

3-8% all pts with cancer

Answer 9

The left & right brachiocephalic veins unite to form the superior vena cava The SVC travels through the mediastinum and terminates by emptying into the superior aspect of the right atrium

Answer 10

* **Lung carcinoma- non small cell more common (although small cell lung carcinoma is less common overall but has a central location & rapid growth so more likely to cause SVCO)** * **Non-Hodgkin's lymphoma** * Thymus tumour * Breast cancer * Mediastinal germ cell tumours

Answer 11

Signs: * Facial swelling * Distended neck & chest wall veins * Upper limb oedema * Facial plethora * Cyanosis * Cognitive dysfunction * Can lead to laryngeal oedema, airway obstruction, cerebral oedema Symptoms: * Dyspnoea * Facial swelling * Head 'fullness'/ headache * Conjunctival swelling & blurred vision * Symptoms exacerbated by bending forward/ lying down * Cough * Dysphagia * Lethargy * Stridor * Hoarse voice

Answer 12

* Lifting arms above head for 1-2 * Watch for signs of congestion, facial plethora, cyanosis * Resp. distress, inspiratory stridor may occur * Venous congestion may be apparent as distension of the neck veins * Narrowing of the thoracic inlet against the thyroid

Answer 13

Imaging is key to diagnosis: * CXR- helps exclude other causes of breathlessness * Mediastinal widening * Malignant pleural effusion * URGENT CT- diagnostic * Reveals the extent & level of obstruction * Presence of collateral vessel formation (is this a chronic obstruction?) * Reveals the likely underlying cause * Staging for lung cancers * Duplex ultrasound * To identify SVCO in pts with indwelling catheter

Answer 14

* Sit upright, elevate head * Asses need for O2 * Dexamethasone 16mg + PPI * Opioids * Benzodiazepines * Stent: if not radio or chemo sensitive- rapid relief of symptoms; doesn't treat cause * Radiotherapy for other malignant causes, response rate 60% * Chemotherapy for SCLC, lymphoma, teratoma, response rate \>70%

Answer 15

Patients presenting with malignant SVCO have an average life expectancy of six months.

Answer 16

Tumour lysis syndrome (TLS) results from metabolic disturbances arising from the breakdown of malignant cells following the initiation of treatment for malignancy. Massive tumour cell lysis → release of large amounts of **potassium, phosphate and uric acid** into the systemic circulation * **Hyperuricaemia** * **Hyperkalaemia** * **Hyperphosphataemia** * AKI from uric acid or calcium phosphate crystals in renal tubules * **Hypocalcaemia** Sudden death can occur

Answer 17

* Greatest risk with haematological malignancy * Also seen in other lymhphomas, CLL, myeloma * Much less common in solid tumours- germ cell, small cell lung, breast

Answer 18

* Pre-existing hyperuricaemia, hyperphosphataemia * Renal impairment * High volume/ bulky disease * Pre-treatment LDH high * High circulating WCC * Hypovolaemia * Pre-treatment diuretic use * Urinary tract obstruction from tumour

Answer 19

* Normally day 3-7 post chemotherapy * N&V * Diarrhoea * Anorexia * Lethargy * Haematuria → oliguria → anuric * Fluid overload * Cardiac arrhythmia/ arrest- peaked T waves, QTc deranged * Muscle cramps, tetany, seizures

Answer 20

Prevention: * Hydrate, maintain UO, lower uric acid levels * Pre-hydration & vigorous hydration throughout treatment * Keep monitoring electrolytes * Allopurinol * Xanthine oxidase inhibitor- less hyperuricaemia * Doesn't act on pre-existing uric acid so is used for prophylaxis Treatment/ prophylaxis: * Rasburicase * Synthetic uricase- degrades uric acid to allantoin (water soluble) * Actively lowers uric acid levels & works on renal deposits, hence can be used prophylactically & for treatment * Dialysis * Phosphate binders for severe hyperphosphataemia * Manage hyperkalaemia- IV calcium gluconate, insulin/ dextrose infusion, nebulised salbutamol & cardiac monitoring for K\>6 or 25% increase above baseline * Cardiac monitoring for hypocalcaemia; otherwise don't treat * IV replacement if arrhythmias or symptomatic

Answer 21

* Renal function * Electrolytes * Serum urate * Urine dip * Urine microscopy * Serum lactate * LDH * ECG * Cardiac monitor

Answer 22

The diagnosis of Tumour Lysis Syndrome is based on the Cairo-Bishop definition Divides TLS into both a labaroty and clinical definition at presention & within 7 days of treatment **_Labaratory diagnosis: 2 or more of_** * Hyperuricaemia * Hyperkalaemia- \>6 or 25% increase * Hyperphosphataemia * Low calcium **_Clinical diagnosis: 1 or more of_** * Serum creatinine \>1.5 x normal * Cardiac arrhythmia/ sudden death * Seizure The definition is also used to help stage the TLS

Answer 23

* CXR findings suggesting lung cancer * Unexplained haemoptysis + age \>40

Answer 24

Age \> 40 + 2+ of the following OR if they've smoked and have 1 of the following: * Cough * Fatigue * SoB * Chest pain * Weight loss * Appetite loss Age \>40 with ANY of the following: * Clubbing * Persistent/ recurrent chest infection * Supraclavicular lymphadenopathy, or persistent cervixal lymphadenopathy * Chest signs consistent with lung cancer * Thrombocytosis

Answer 25

Direct + urgent access to upper GI endoscopy for the following: * dysphagia * age \>55 + weight loss + any of the following: * upper abdo pain * reflux * dyspepsia Non-urgent referral for: * Haematemesis * Age \> 55 + treatment resistant dyspepsia * Age \> 55 + upper abdo pain w/ one of the following: * Low Hb * Raised platelet + nausea/ vomiting, wt loss/ reflux/ dyspepsia/ upper abdo pain * N&V + wt loss/ reflux/ dyspepsia/ upper abdo pain

Answer 26

Age\>40 + jaundice for urgent appointment For an urgent direct access CT scan: age \>60 + weight loss + any of the following: * diarrhoea * back pain * abdo pain * nausea * vomiting * constipation * new-onset diabetes

Answer 27

* age \> 40 + unexplained weight loss + abdo pain * age \> 50 + unexplained rectal bleeding * age \> 60 with IDA or changes in bowel habit * Tests showing occult blood in faeces * Rectal or abdominal mass * age \< 50 + unexplained rectal bleeding + unexplained abdo pain/ change in bowel habit/ weight loss/ IDA

Answer 28

* age \> 30 + unexplained breast lump +/- pain * age \> 50 with discharge/ retraction/ any other concerning symptom in ONE nippple only * skin changes suggestive of cancer * age \> 30 w/ unexplained axillary lump

Answer 29

* Prostate feels malignant on examination * PSA levels above the normal for their age Consider PSA and DRE in: * Any LUTs- nocturia, frequency, hesitancy, urgency, retention * Erectile dysfunction * Visible haematuria

Answer 30

age \> 45 + * unexplained visible haematuria w/o UTI * visible haematuria that persists/ recurs after UTI treatment age \> 60 + unexplained non-visible haematuria + dysuria/ raised WCC Consider non-urgent referral for recurrent UTIs

Answer 31

Using the weighted 7 point checklist, scoring 3 or more

Answer 32

Typical features of basal cell carcinoma include: an ulcer with a raised rolled edge; prominent fine blood vessels around a lesion; or a nodule on the skin (particularly pearly or waxy nodules) Urgent referral only if a delay will worsen prognosis eg lesion site or size Otherwise, BCC is a routine referral

Answer 33

0: able to carry out all normal activity without restriction 1: restricted in strenuous activity but ambulatory and able to carry out light work 2: ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours 3: symptomatic and in a chair or in bed for greater than 50% of the day but not bedridden 4: completely disabled; cannot carry out any self-care; totally confined to bed or chair.

Answer 34

Colorectal cancer

Answer 35

* Family history * Hereditary syndromes (25%) * Lynch syndrome is the most common inherited cause (HNPCC) * FAP- familiar adenomatous polyposis * Autosomal dominant disorder, mutation in APC gene * If untreated, almost all develop cancer by age 40 * Inflammatory bowel disease * Ethnicity- more common in white people * Radiotherapy * Obesity/ diet * Low fibre, high fat * Red processed meat * Garlic, milk, calcium may be protective * Diabetes mellitus * Smoking * Alcohol

Answer 36

Lynch syndrome * Can also cause endometrial cancer * Also, less commonly, ovarian, gastric, small bowel, hpb, brain malignancies * Autosomal dominant * One of the mismatch repair genes (MMR)

Answer 37

Adenocarcinoma One of the earliest mutations is to the tumour suppressor adenomatous polyposis coli (APC) which leads to the hyperproliferative epithelium. One of the key mutations that follows is KRAS, a proto-oncogene, that becomes an oncogene following mutation. Further mutations to p53 (tumour suppressor and ‘guardian of the genome’) as well as SMAD4 and others leads to the development of a carcinoma from an adenoma. *This is of course a simplification of a much more complex process, but gives an idea of how multiple mutations are required to develop CRC. In inherited conditions, there are often existing mutations along this pathway (e.g. APC in FAP) that predispose individuals to CRC.*

Answer 38

CRC most commonly occurs in the rectum and sigmoid colon (left side of the colon)

Answer 39

Approximately 23-26% of CRC have metastatic spread at diagnosis The **liver** is the organ most commonly affected Rectal cancers are more commonly associated with **lung** metastasis (prior to liver metastasis) due to direct haematogenous spread via the inferior rectal vein and IVC. Other locations of metastatic spread includes the **peritoneum brain and bone.**

Answer 40

Signs 1. Pallor 2. Abnormal PR exam 3. Abdominal mass Symptoms 1. Change in bowel habit 2. Malaise 3. Weight loss 4. Tenesmus 5. Abdo pain 6. Bleeding Right colon cancer: * Weight loss * Weakness * Rarely obstruction * Iron deficiency anaemia Left colon cancer: * Constipation * Abdo pain * Decreased stool calibre * Alternating bowel habit * Rectal bleeding * Bright red PR bleeding * LBO Rectal cancer: * Obstruction * Tenesmus * Bleeding * Bright red PR bleed * Palpable mass on rectal exam

Answer 41

The NHS uses the Faecal Immunochemical Test (FIT) to screen for colorectal cancer. This tests for the presence of blood in the stool. People aged 60-74 (and expanding to 56 years-old from 2021) will be sent a home test kit consisting of a FIT every two years. After the age of 75, people can request further tests every two years. Approximately 98% have a normal result. Those with abnormal results will be invited for colonoscopy.

Answer 42

Colonoscopy = gold standard diagnosis * allows visualisation of the colon, identification of malignant lesions and pre-malignant or suspicious polyps * risks- perforation- esp. those with diverticular disease * bowel prep required- specific diet is followed and agents like Moviprep are given (may have to do this inpatient for some elderly pts) * alternatives- CT pneumocolon * disadv- can't visualise polyps or take biopsy, may miss some lesions

Answer 43

Modified Dukes * A: Not into the muscularis propria * B: tumour spread beyond muscularis propria * C1: LN +ve (apical node spared) * C2: LN +ve (apical node involved) * D: distant mets TNM staging- Tumour * TX: Primary tumour cannot be assessed. * T0: No evidence of primary tumor * Tis: Carcinoma in situ, intramucosal carcinoma (involvement of lamina propria with no extension through muscularis mucosae) * T1: Tumor invades submucosa (through the muscularis mucosa but not into the muscularis propria) * T2: Tumor invades muscularis propria * T3: Tumor invades through the muscularis propria into the pericolorectal tissues * T4: * T4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum) * T4b: Tumor directly invades or adheres to other adjacent organs or structures Node * NX: Regional lymph nodes cannot be assessed * N0: No regional lymph node metastasis * N1: Metastasis in 1 - 3 regional lymph nodes * N1a: Metastasis in 1 regional lymph node * N1b: Metastasis in 2 - 3 regional lymph nodes * N1c: No regional lymph nodes are positive but there are tumor deposits in the subserosa, mesentery or nonperitonealized pericolic or perirectal / mesorectal tissues * N2: Metastasis in 4 or more regional lymph nodes * N2a: Metastasis in 4 - 6 regional lymph nodes * N2b: Metastasis in 7 or more regional lymph nodes Metastasis M0: No distant metastasis by imaging; no evidence of tumor in other sites or organs (this category is NOT assigned by pathologists) * M1: Nistant metastasis * M1a: Metastasis confined to 1 organ or site without peritoneal metastasis * M1b: Metastasis to 2 or more sites or organs is identified without peritoneal metastasis * M1c: Metastasis to the peritoneal surface is identified alone or with other site or organ metastases NOTE: Non-regional lymph node spread is considered M1a disease.

Answer 44

Surgery is the mainstay of treatment * Laparoscopic \> open * Stoma- can be temporary * Early rectal cancer: * Transanal excision * Endoscopic submucosal dissection * Total mesorectal excision * Colonic cancer: offer neo-adjuvant chemotherapy * Sigmoid colectomy * Right hemicolectomy * Left hemicolectomy * Subtotal colectomy * Total abdominal colectomy * Complications of surgery * Infection * Bleeding * Clots * ureteric damage * Anastomotic leak- commoner in low rectal anastomosis - as such these are often protected with a loop ileostomy * Sexual dysfunction * Change in bowel habit * Neoadjuvant therapy (before surgery) * Rectal cancer cT1-T2, cN1-N2, M0, or cT3-T4, any cN, M0 should be offered neoadjuvant radiotherapy or chemoradiotherapy. * Colonic cancer with cT4 disease. Consider the use of chemotherapy. There is evidence this improves rate of clear surgical margins and survival. * Adjuvant therapy * FOLFOX (FOLinic acid, Fluorouracil and OXaliplatin) * CAPOX (CAPecitabine and OXaliplatin)

Answer 45

Neoadjuvant chemotherapy is delivered before surgery with the goal of shrinking a tumor or stopping the spread of cancer to make surgery less invasive and more effective. Adjuvant chemotherapy is administered after surgery to kill any remaining cancer cells with the goal of reducing the chances of recurrence.

Answer 46

Modifiable risk factors * Healthy balanced diet, 5 fruits/ veg a day * Reduce red meats * Stop smoking * Maintain healthy weight Specifically- in people with Lynch syndrome, taking aspirin for \>2years has a protective effect

Answer 47

Following diagnosis with CRC: * 78% survive one year * 58% survive five years or more Prognosis is related to both stage and age at diagnosis. Around 70% of those 15-39 survive 5 years compared to around 40% of those aged over 80. Interestingly survival is also higher in those aged 60-69 - this may be related to the screening programme. One year survival is around 98% if diagnosed at stage 1, compared to 44% in those with stage 4 disease.

Answer 48

* Fibroadenoma- mobile, firm breast lumps * Breast cyst- smooth discrete lump (may be fluctuant) * Epithelial hyperplasia- generalised lumpiness or discrete lumps * Fat necrosis- hx of trauma * Mammary duct ectasia- may present with a tender lump around the areola +/- a green nipple discharge * Duct papilloma- usually present with nipple discharge, if large may be a mass * Breast cancer- hard, irregular lump * Breast abscess- more common in lactating woman- red, hot tender swelling

Answer 49

Breast and/or axillary lump: * Often irregular * Typically hard/firm * May be fixed to skin or muscle * Breast pain Breast skin: change to normal appearance * Skin tethering * Oedema * Peau d’orange Nipples: * Inversion * Discharge, especially if bloody * Dilated veins Features may also reflect metastatic spread. The bone (bone pain), liver (malaise, jaundice), lungs (shortness of breath, cough) and brain (confusion, seizures) are most commonly affected

Answer 50

* Female gender * Age * Family history * Personal history of breast cancer * Genetic predispositions (e.g. BRCA 1, BRCA 2) * Early menarche and late menopause * Nulliparity * Increased age of first pregnancy * Multiparity (risk increased in period after birth, then protective later in life) * Combined oral contraceptive (still debated, effect likely minimal if present) * Hormone replacement therapy * White ethnicity * Exposure to radiation * BRCA

Answer 51

BRCA 1: * Chromosome 17 mutation * 65-80% lifetime risk of breast cancer (normal baseline 12%) * Ovarian cancer lifetime risk 40-45% (normal baseline 1.3%) * 1% men breast cancer BRCA 2: * Chromosome 13 mutation * Lifetime breast cancer risk 45-70% * Ovarian cancer risk 11-25% * 8% men breast cancer * Other malignancies * includes peritoneal, endometrial, fallopian, pancreatic and prostate cancer

Answer 52

Majority are carcinomas * Ductal * Ductal carcinoma in situ (DCIS) * Invasive ductal carcinoma (IDC) *(most common invasive breast cancer)* * Lobular * Lobular carcinoma in situ (LCIS) *(uncommon)* * Invasive lobular carcinoma (ILC) Does it invade the basement membrane? * Yes - 'invasive' * No - 'in situ'

Answer 53

* Ages 50-71 * Every 3 years * Mammogram of each breast * Radiologist reviews & says whether it's satisfactory (96%) or abnormal/ unclear

Answer 54

One-stop breast clinic: triple assessment 1. Clinical history & examination 2. Imaging 1. Mammogram- soft tissue masses and microcalcifications. 2. USS- used for pts \<40 3. Histopathology 1. FNA 2. Core biopsy

Answer 55

* Paget's disease of the nipple is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer. * In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. * 30% of patients without a mass lesion will still be found to have an underlying carcinoma. * The remainder will have carcinoma in situ.

Answer 56

* Inflammatory breast cancer where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast. * This accounts for around 1 in 10,000 cases of breast cancer.

Answer 57

Resection of the primary tumour: * Mastectomy * Multi-focal tumour * Central tumour * Large lesion in small breast * DCIS \> 4cm * Patient choice * Wide local excision (breast conservation) * Solitary lesion * Peripheral tumour * Small lesion in large breast * DCIS \< 4cm * Patient choice * Whole breast radiotherapy to reduce the risk of recurrence

Answer 58

Radiotherapy * After wide local excision: whole breast radiotherapy- reduces recurrence by 66% * After mastectomy: in T3, T4 tumours or if 4+ positive axillary nodes offer RT Chemotherapy * Neoadjuvant: prior to surgery to reduce tumour size, or for pts w/ inflammatory breast cancer * Adjuvant: eg FEC (fluorouracil, epirubicin, cylophosphamide) for axillary node disease Hormone therapy: treatments are for ~ 5 years * Pre/peri-menopausal women/ men: tamoxifen (SERM) * Side effects of tamoxifen: endometrial cancer risk, VTE, menopausal symptoms, osteoporosis * Post-menopausal women: aromatase inhibitors (inhibits peripheral conversion of androgens to oestrogens- not effective in premenopausal women where oestrogens are synthesised primarily by the ovaries) eg anastrozole Biologics * Trastuzumab (Herceptin): HER2 + cancers * Contraindicated in heart disease

Answer 59

Distribution * Extensor * Flexural * Follicular * Acral (distal areas of hands and feet) * Dermatomal * Seborrhoeic Configuration- shape and outline * Discrete * Confluent * Linear * Discoid * Target * Annular Colour * Erythematous * Purpuric * Hyperpigmented lesions * Hypopigmented lesions * Depigmentation Morphology * Macule- flat, \<0.5cm * Patch- flat, \> 0.5cm * Papule- solid raised palpable \<0.5cm * Nodule- \> 0.5cn * Plaque * Vesicle * Bulla * Pustule * Abscess * Boil/ furuncle * Carbuncle

Answer 60

* Exposure to UV light * Severe sun burn in childhood (e.g. blistering) * Immunosuppression * Multiple (\>100) or giant (\>20 cm) naevi * Skin type (Fitzpatrick Skin types I & II) * Family history (cyclin-dependent kinase mutations are linked to 20-40% of familial melanoma) * Genetic mutations (CDK4, xeroderma pigmentosum, melanocortin 1 receptor)

Answer 61

5th most common cancer in the UK

Answer 62

* Benign naevus (typical mole) - controlled proliferation of melanocytes * Dysplastic naevus (atypical mole) - abnormal proliferation of melanocytes resulting in a pre-malignant lesion with atypical cellular structure. * Radial growth phase - melanomas tend to extend superficially and outwards initially. Melanocytes acquire the ability to proliferate horizontally in the epidermis, but few cells invade the papillary dermis. * Vertical growth phase - malignant cells invade the basement membrane and proliferate vertically downwards into the dermis. * Metastasis - malignant cells may spread to other areas of body. Typically they travel to regional lymph nodes first; but they may spead to other areas of the skin / soft tissue, or to solid organs (such as the lungs, liver, bone or brain).

Answer 63

* Melanoma originates from uncontrolled proliferation of melanocytes in the basal epidermis. * Melanocytes are specialised melanin-producing cells that are found within the basal epidermis (the deepest layer of the epidermis). The melanin produced is transferred to the mitotically-active keratinocytes above. Here, it protects the nucleus of keratinocytes from UV damage.

Answer 64

A - Asymmetry B - Border irregularity C - Colour alterations D - Diameter \> 6 mm E - Evolution

Answer 65

* Complete excision with a margin of 1-2mm of healthy surrounding skin * Portion of subcut fat- ensuring the full thickness of the dermis has been samples * Local anaesthetic; day case procedure

Answer 66

1. Superficial spreading (70%) 1. Any location- arms, back, legs, chest 2. Young pts 3. Growing moles 4. Initial radial growth pattern- progresses to invade deep into dermis 2. Nodular (15%) 1. Seen at a more advanced stage 2. Immediately vertical growth 3. Red or black lump or lump which bleeds or oozes 4. Sun exposed skin, middle-aged pts 3. Lentigo maligna (10%) 1. Elderly pts 2. Chronically sun-exposed sites 3. A growing mole 4. Long period of intraepithelial growth (slow)- better prognosis 4. Acral lentiginous (\<5%) rare 1. Under nails, palmar/ plantar surfaces of hands/ feet 2. Subungual pigmentation - Hutchinson's sign 5. Desmoplastic melanoma (\<1%) 1. 50% amelanotic

Answer 67

Major criteria * Change in size * Change in shape * Change in colour Minor criteria * Diameter \>=7mm * Inflammation * Oozing or bleeding * Altered sensation

Answer 68

BT is based on the vertical thickness of malignant melanoma in mm Measured from stratum granulosum of the epidermis or if the lesion is ulcerated, from the bottom of the ulceration upwards to the point of maximum ulceration Correlates strongly w/ mortality

Answer 69

Surgical * Wide local excision * Involves removal of the biopsy scar with a surrounding margin of ‘healthy’ skin, with fat, down to muscular fascia. * Determined by Breslow thickness (see attached image) * Sentinel lymph node biopsy (SLNB) * The sentinel node = the 1st lymph node that receives drainage from an affected area * Performed under GA * Lymphadenectomy * Positive SLNB (deposits found within sentinel lymph nodes): usally results in referral for a subsequent lymphadenectomy * A lymphadenectomy is performed in an attempt to gain regional control of disease * Electro-chemotherapy * Locally advanced melanoma * Pulses of electricity + chemotherapy- given IV or injected directly into tumour * The electricity allows the chemotherapy drug to pass through more effectively Medical * Adjuvant therapy eg interferon alpha * Chemotherapy not very good for melanoma * Radiotherapy * Immunotherapy

Answer 70

Spread occurs via lymphatic system/ blood vessels Can spread to subcut tissue under the skin, lymph nodes, or other organs eg lungs, liver, bone, brain

Answer 71

Basal cell carcinoma * Slow growing * Locally invasive * Malignant epidermal (basal layer) skin tumour * Months- years * Sun-exposed areas of the body- 80% head and neck

Answer 72

* Skin type * Male sex * Increasing age * Genetics- albinism, Gorlin's syndrome, zeroderma pigmentosum * Previous skin cancers * Immunosuppression * Carcinogens- ionising radiation

Answer 73

* Majority adenocarcinomas (95%) * Rarer forms- transitional cell, squamous cell, neuroendocrine cancers * Majority arise in peripheral zone (70%) * 10-20% central zone * 10-20% transitional zone

Answer 74

* ↑ Age * Black African \> White \> Asian * Family history * Prostate cancer in 1st/2nd degree relative * Breast cancer in mother * 4x increased risk if one 1st degree relative diagnosed with CaP before age 60 * Obesity * Genetics * BRCA2 mutation * Lynch syndrome * Diet * Red meat, fat, dairy, calcium * Chemicals * High pesticide exposure * Hormones * High levels of IGF-1

Answer 75

* Frequently asymptomatic * LUTS: * Nocturia * Frequency * Hesitancy * Urgency * Dribbling * Overactive bladder * Retention * Visible haematuria * Abnormal DRE (hard, nodular, enlarged, asymmetrical) * Symptoms of advanced disease (e.g lower back pain, bone pain, weight loss, anorexia) * Ejaculatory symptoms (rare)

Answer 76

DRE should be considered in men with: * Lower urinary tract symptoms (e.g. nocturia, frequency, hesitancy, urgency or retention) * Haematuria * Unexplained symptoms that may be explained by advanced prostate cancer (e.g lower back pain, bone pain, weight loss) * Erectile dysfunction * Other reasons to be concerned of prostate cancer (e.g. elevated PSA)

Answer 77

PSA is produced by normal prostate tissue but levels increase in malignancy, can be used to air diagnosis and surveillance of prostate cancer Issues- * Normal PSA: * 1 in 7 (15%) men with normal PSA will have prostate cancer * 1 in 50 (2%) will have a higher risk prostate cancer * ↑ PSA * Age 50-70 10% will have raised PSA * PSA 4-10 ng/ml: 25% chance of having CaP * PSA\>10 ng/ml: 50% chance of having CaP * Most, where cancer of the prostate is not detected, will continue to have PSA checked * Consider anxiety and uncertainty fears in pts- psychosocial factors Issues for PSA screening * Overdiagnosis * Over-treatment * QoL- co-morbidities of estabilished treatments * Cost-effectiveness Before testing men should not have: * Active or recent UTI (last 6 weeks) * Ejaculated for 48 hours * Engaged vigorous exercise for 48 hours * Had a urological intervention in the past 6 weeks

Answer 78

* benign prostatic hyperplasia (BPH) * prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment) * ejaculation (ideally not in the previous 48 hours) * vigorous exercise (ideally not in the previous 48 hours) * acute urinary retention * instrumentation of the urinary tract * prostate cancer

Answer 79

Multiparametric MRI Radiologist reviews & gives it a Likert score 1. Clinically significant cancer highly unlikely to be present 2. Clinically significant cancer is unlikely to be present 3. Chance of clinically significant cancer is equivocal 4. Clinically significant cancer is likely to be present 5. Clinically significant cancer is highly likely to be present Score of 3+ - offer biopsy (guided by the MRI)

Answer 80

1. Active surveillance- for low risk disease or for those who decline 2 and 3 in intermediate risk, not recommended for high risk disease 1. 3 monthly PSA 2. 6 month to yearly DRE 3. Re-biopsy every 1-3 years 4. Mp-MRI too 2. Radical prostatectomy 1. Removal of prostate gland, resection of the seminal vesicles, along with surrounding tissues +/- dissection of the pelvic lymph nodes 2. SE- Erectile dysfunction, stress incontinence, bladder neck stenosis 3. Radical radiotherapy 1. Offer people with intermediate- and high-risk localised prostate cancer a combination of radical radiotherapy and androgen deprivation therapy 2. Consider brachytherapy in combination with external beam radiotherapy for people with intermediate- and high-risk localised prostate cancer 3. Pelvic radiotherapy may be considered in patients who are to have neoadjuvant hormonal therapy and radical radiotherapy and have risk of pelvic wall involvement (\>15% risk) 4. Chemotherapy 1. Docetaxel 1. For those who have newly diagnosed non-metastatic prostate cancer + no significant co-morbidities + high risk disease + starting long-term androgen deprivation therapy 2. Start treatment within 12wks of androgen deprivation therapy 5. Androgen-deprivation therapies 1. Prostate cancer is stimulated by circulating androgens (testosterone) 2. LNrH agonists eg goserelin 3. GnRH receptor antagonists (LHRH agonists)

Answer 81

Gleason score is used * Gleason grade * The sum of the most common growth pattern + the second most common growth pattern seen * Lowest score an individual with prostate cancer can have is 3+3 * Sum is inversely proportional to prognosis * Gleason X: The Gleason score cannot be determined. * Gleason 6 or lower: The cells look similar to healthy cells, which is called well differentiated. * Gleason 7: The cells look somewhat similar to healthy cells, which is called moderately differentiated. * Gleason 8, 9, or 10: The cells look very different from healthy cells, which is called poorly differentiated or undifferentiated.

Answer 82

* Active surveillance: part of a curative strategy aimed at people with localized prostate cancer for whom radical treatments are suitable, keeping them within a window of curability, only those with signs of tumour progression or those with a preference for intervention are considered for radical treatment, active surveillance may avoid or delay the need for RT or surgery * Watchful waiting: controlling rather than curing the prostate cancer, for those with localized prostate cancer who don’t want curative treatment/ are unsuitable for it, avoids the use of surgery or radiation but implies that curative treatment will not be attempted

Answer 83

LARYNGEAL CANCER- refer 2WW for pts \>45 and: * Persistent unexplained hoarseness, or * An unexplained lump in the neck ORAL CANCER- refer 2WW for pts with either: * Unexplained ulceration in the oral cavity lasting for more than 3 weeks, or * A persistent and unexplained lump in the neck Refer 2WW for assessment by dentist for pts who have either: * A lump on the lip or in the oral cavity, or * A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia THYROID CANCER- refer 2WW for people with an unexplained thyroid lump.

Answer 84

Mostly SCC- hence often collectively referred to as HNSCCs: Head and Neck Squamous Cell Carcinomas Common sites- * Oral cavity * Larynx * Nasal cavity * Pharynx * Middle ear * Salivary gland * Thyroid glands Most H&N cancers are of the upper aerodigestive tract- oral cavity, pharynx & larynx

Answer 85

* Smoking (laryngeal cancer) * Alcohol excess (pharynx/oral cavity) * HPV 16 * Associated with oropharyngeal cancer * Almost always cleared with no adverse affects * Presents in younger patients * More aggressive, increasing incidence, more amendable to treatment * Vaccine available * Betel quid (oral cancer) * Occupational wood dust exposure (sinonasal cancer) * EBV infection (nasopharyngeal cancer)

Answer 86

* Different to other cancers * Metastasises to cervical LNs first * Hard, fixed neck lump * Still curable – neck radiotherapy or surgical lymph node clearance (neck dissection) * Distant mets usually to lung

Answer 87

* leukoplakia (white patches) * erythroplakia (red patches) * erythroleukoplakia (mixed red and white patches) * oral lichen planus * actinic cheilitis

Answer 88

–US and FNA –FNE –CT/MRI scan –Panendoscopy and biopsy EUA –PET scan –P16 staining

Answer 89

Surgical resection +/- adjuvant radiotherapy or chemotherapy or primary radiotherapy +/- adjuvant chemotherapy are the mainstays of treatment for most HNSCCs. _The details:_ * Oral cavity * Small tumours - wide local excision +/- neck dissection * Large tumours- surgical resection +/- flap reconstruction + neck dissection +/- post operative radiotherapy +/- chemotherapy * Oropharynx * Small tumours of the tonsil can undergo surgical resection using Laser or Transoral Robotic Surgery +/- neck dissection or primary radiotherapy or both (if margin involved). Larger tumours of the tonsil will undergo solely primary radiotherapy +/- adjuvant chemotherapy * Small tumours at the tongue base will undergo surgical resection using Transoral Robotic Surgery with neck dissection or primary radiotherapy or both (if margin involved). Larger tumours at the tongue base will undergo primary radiotherapy +/- adjuvant chemotherapy * Larynx * Supraglottis- * Small tumours will undergo surgical resection using **transoral** **laser microsurgery** with bilateral neck dissection or primary radiotherapy +/- adjuvant chemotherapy * Larger tumours will undergo laryngectomy with post-operative radiotherapy +/- adjuvant chemotherapy or primary radiotherapy +/- adjuvant chemotherapy * Glottis * Small tumours will have surgical resection using transoral laser microsurgery with bilateral neck dissection or primary radiotherapy * Larger tumours undergo laryngectomy with neck dissection and post-operative radiotherapy +/- adjuvant chemotherapy or primary radiotherapy +/- adjuvant chemotherapy * Subglottis- rare. similar principles as glottis * Salivary glands * Excision

Answer 90

* Disease recurrence * Secondary primary malignancies * Dysphagia (secondary to pharyngeal/oesophageal stricture) * Pharyngocutaneous fistula (following laryngectomy) * Injury to the accessory, vagus, hypoglossal, or marginal mandibular nerves (following neck dissection), or chyle leak (following neck dissection) * Mucositis (early complication of radiotherapy) or xerostomia (complication of radiotherapy) * Chronic pain, persistent hoarse voice, or hearing loss (following chemoradiotherapy)

Answer 91

Thyroid follicular epithelial derived cancer: * Papillary- most common, local spread, younger peak incidence compared to follicular, overall good prognosis * Follicular- pulmonary & skeletal spread, more common in women * Anaplastic- local, skin + brain spread, mean age onset 5, highly aggressive Medullary thyroid cancer- 25% familial associated with MEN type 2 Primary thyroid lymphoma- treatment normally with chemo/ radiotherapy

Answer 92

The major risk factors are: * Radiation exposure (particularly in childhood) * Family history / familial thyroid cancer * Female sex * Other risk factors include obesity, endemic goitre, FAP and Cowden’s syndrome The most common presentation of differentiated thyroid cancer is a thyroid nodule/mass. Majority thyroid lumps (95%) are benign * Thyroid nodule / mass * Hoarseness / change in voice * Cervical lymphadenopathy * Stridor Investigations- triple assessment * Thyroid function tests * Ultrasound of thyroid lumps * Fine needle aspiration cytology Then, may need diagnostic hemithyroidectomy

Answer 93

Surgical resection forms the mainstay of management Post-op: monitor calcium and PTH Complications of surgery * RLN injury * Haematoma * Hypoparathyroidism Adjuvant therapy * Radioiodine remnant ablation- Iodine mediated destruction of remnant thyroid tissue * External beam radiotherapy-may be considered in certain patients with high risk features (high risk of recurrence, local spread, residual/recurrent tumour). * Also used in the palliative setting, particularly in cases of bone/spinal and brain metastasis

Answer 94

1. Oral cavity cancer 1. Painless mess, felt on inner lip, tongue, floor of mouth or hard palate 2. Non-specific- oral cavity bleeding, localised pain in oral cavity, jaw swelling 2. Pharyngeal cancer 1. Odynophagia 2. Dysphgia 3. Stertor 4. Referred otalgia 5. Nasopharyngeal carcinoma- neck lump 3. Laryngeal cancer 1. Hoarse voice 2. Stridor if advanced 3. Dysphagia 4. Persistent cough 5. Referred otalgia * \*Trotters Syndrome is a triad =* **nasopharyngeal malignancy** * (1) unilateral conductive deafness (secondary to middle ear effusion)* * (2) trigeminal neuralgia (secondary to perineural invasion)* * (3) defective mobility of the soft palate*

Answer 95

Anatomically, the internal cavity of the larynx can be divided into three sections: * Supraglottis – From the inferior surface of the epiglottis to the vestibular folds (false vocal cords) * Glottis – Contains vocal cords and 1cm below them. The opening between the vocal cords is known as rima glottidis, the size of which is altered by the muscles of phonation * Subglottis – From inferior border of the glottis to the inferior border of the cricoid cartilage Most malignancies originate in the glottis region

Answer 96

* Physician * Surgeon * Radiologist * Pathologist * Oncologist * AHPs (allied health professionals)

Answer 97

* Skin reaction * Mucositis * Dry mouth * Difficulty swallowing * Osteonecrosis * Secondary cancers Smoking causes hypoxia & reduces the effectiveness of radiotherapy

Answer 98

* Palliative care is the active, total care of the patients whose disease is not responsive to curative treatment * Control of pain, of other symptoms, and of social, psychological and spiritual problems * Patients are ‘approaching the end of life’ when they are likely to die within the next 12 months * Palliative care encompasses end of life care and enhanced supportive care

Answer 99

* Unclear diagnosis/ prognosis * Lack of confidence, knowledge, skill * Disease focused vs pt focused * Focus on specific results less on overal picture * Unrealistic expectations * Fear, destroying hope * Culture, religious reasons * Death anxiety not acknowledged * Considered "giving up" on pt?

Answer 100

SPICT: Supportive and Palliative Care Indicators Tool * Used to identify people with deteriorating health due to advanced conditions or serious illness * Prompts holistic assessment and future care planning * Planning ahead is important for people: * whose health is deteriorating gradually * who are at risk of an acute illness due to underlying frailty or ill health * who are at risk of developing a complication of a LTC

Answer 101

* Unplanned hospital admissions * Performance status poor/ deteriorating * Dependent on others for care * Carer needs more help + support * Significant weight loss * Persistent symptoms despite optimal treatment * A decision to reduce, stop, or not have treatment

Answer 102

* a judgement-based frailty tool that evaluates specific domains including comorbidity, function, and cognition to generate a frailty score ranging from 1 (very fit) to 9 (terminally ill) * Based on 5 indicators * weakness, slowness, weight loss, exhaustion and low physical activity

Answer 103

* Bedbound * Drowsiness, impaired cognition, leading to coma * Difficulty taking oral medications * Reduced food and fluid intake, difficulty swallowing * Agitation or restlessness * Descreased urine output/ incontinence * Increasing symptom burden * Respiratory secretions * Skin colour changes * Temperature changes at extremeties * Breathing changes: * Shallow breathing * Use of accessory muscles * Cheyne-stokes resp. pattern

Answer 104

1. The **_possibility of death is recognised and communicated clearly_**; decisions are made and actions taken in accordance with the person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly 2. **_Sensitive communication takes place_** between staff and the dying person, and those identified as important to them 3. The dying person, and those identified as important to them, are **_involved in decisions about treatment and care_** to the extent that the dying person wants 4. The **_needs of families and others_** identified as important to the dying person are actively explored, respected and met as far as possible 5. An **_individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support_**, is agreed, coordinated and delivered with compassion

Answer 105

1. Pain 1. Morphine 2.5-5 mg SC PRN 2. Nausea & vomiting 1. Levomepromazine 2.5-5mg SC PRN 3. Breathlessness 1. Morphine 2.5-5mg 4. Restlessness & agitation 1. Midazolam 2.5-5mg SC PRN 2. Levomepromazine 6.25-12.5mg SC PRN (where delirium and psychosis) 5. Respiratory tract secretions 1. Glycopyronium 200-400 mcg SC PRN

Answer 106

* Offer frequent sips if able- use beaker or oral syringe * Moisten mouth regularly w/ foam sticks * Artificial saliva eg biotene gel * Vaseline to lips- KY jelly is using O2

Answer 107

* _CANCER related_: chest wall invasion, bone metastases, MSCC * _TREATMENT related_: oesophagitis, local reaction to RT * _OTHER:_ CAP, PE pneumothorax, MI, anxiety, musculoskeletal

Answer 108

* NOCICEPTIVE: normal nervous system, identigiable lesion causing tissue damage * Somatic: originates from skin/ muscles/ bone * *sharp, throbbing, well localised* * Visceral: originates from hollow viscus or solid organ * *diffuse ache, difficult to localise* * NEUROPATHIC: malfunctioning nervous system, nerve structure is damaged * *stabbing, shooting, burning, stinging, allodynia, numbness, hypersensitivity* * MIXED: nociceptive and neuropathic

Answer 109

Background pain * Persistent baseline pain * Regular analgesia Breakthrough pain * Pain breaks through regular pain medicine schedule * Quality of pain like background pain but more severe * It is managed by as required short acting medications * Approx 1/6 of total daily dose

Answer 110

* No CV or GI risk→ ibuprofen, diclofenac, naproxen * GI risk but no CV risk→ cox2; celecoxib * CV risk but less GI risk; naproxen or ibuprofen

Answer 111

* Diet controlled or metformin treated: stop metformin, glucose monitoring required * On other tablets or insulin or GLP1 agonist- stop tablets and GLP1 injections, consider stopping insulin if pt only requires small dose * If insulin is stopped, check urine for glucose daily, if over 2+ check blood glucose, give rapid acting insulin if blood glucose \>20 * If insulin is continued, prescribe once daily morning dose long acting

Answer 112

* Do not stop insulin * Continue once daily morning dose of insulin, reduce dose * Check blood glucose once a day at teatime- if \<8, reduce insulin, if \>20, increase insulin (to avoid ketosis)

Answer 113

* Amitriptyline start 10-25mg * Gabapentin 300mg TDS over 3/7 * Pregabalin 75mg BD * Full benefit often takes at least 5/7 and may need further titration

Answer 114

* By the mouth * By the clock * By the ladder * Individual dose titration * Use adjuvants at any steps * Attention to detail

Answer 115

* Drugs whose primary indications is not for pain * Consider for pain that is only partially responsive to opioid analgesia * Can have a significant opioid sparing effect Examples * Antidepressants; amitriptyline, duloxetine * Anti-convulsants; gabapentin, pregabalin * Benzodiazepines; diazepam, clonazepam * Steroids; dexamethasone * Bisphosphonates for bony pain

Answer 116

1. Paracetamol, NSAIDs 2. Dihydrocodeine, codeine phosphate, tramadol, co-codamol 3. Oxycodone, morphine, fentanyl, diamorphine

Answer 117

* Soft tissue pain * Good response to opioid * Visceral pain * Good/ partial response to opioid * Bone pain * NSAIDs, RT * Bisphosphonate * Neuropathic pain * Poor response to opioids * Adjuvants- amitryptyline, gabapentin, pregabalin * Full benefit often takes at least 5 days & may require further titration * Early specialist referral required * Incident pain * IR analgesia * Physio/ OT * Spinal analgesia * Orthopaedic intervention

Answer 118

* Constipation * Dry mouth * N&V * Drowsiness/ sedation

Answer 119

Laxative Anti-emetic

Answer 120

IR: Oramorph liquid 10mg/ 5ml SR: Zomorph capsules BD (10,30,60,100,200mg)

Answer 121

Add up 24 hours worth of morphine = TOTAL DAILY DOSE (TDD) TDD/2 = New Morphine SR dose TDD/6 = New Morphine IR ‘breakthrough’ (PRN) dose

Answer 122

Fentanyl- non-renal excretion

Answer 123

codeine to morphine is 10:1

Answer 124

* Transdermal opioid * Non-renal excretion * 12-24hr to achieve steady state * Smallest patch is 12mcg/hr which equates to about 45mg morphine in 24 hours * Generally use oramorph as PRN (1/6th of 24 hour morphine equivalent)

Answer 125

Prescribe syringe driver- via SCSD

Answer 126

Signs- * Pinpoint pupils * Hallucinations * Drowsiness * Vomiting * Confusion * Myoclonic jerks * Resp. depression Causes- * Dose escalated too quickly * Renal impairment * Poorly opioid responsive pain but escalated * Has had intervention to reduce pain eg nerve block Emergency management- * IV or IM naloxone: has a rapid onset and relatively short duration of action

Answer 127

1. Drug name 2. Drug form 3. Drug strength Eg * Morphine SR (Zomorph) capsules 10mg (Prescribing MR products by brand reduces risk of error) * Morphine IR (Oramorph) oral solution 10mg/5ml (Prescribing liquid dose in mg reduces risk of error)

Answer 128

* Infection- UTI, pneumonia, gastro-enteritis, thrush * Metabolic- renal impairment, hepatic impairment, low Na, high Ca, tumour toxins, sepsis * Drug related- opioids, iron, abx, nsaids, diuretics, digoxin, ssri's, chemo * Gastric stasis- pyloric tumour or nodes, ascites, hepatomegaly, opioids, anticholinergics, autonomic neuropathy, gastrostomy * GI disturbance- constipation, gastritis, ulceration, obstruction * Organ damage- distension, obstruction, RT * Neurological- raised ICP, motion sickness, meningeal disease * Psychological- anxiety, fear

Answer 129

* Haloperidol- * D2 antag in CTZ * Metoclapramide- * D2 receptor antagonist * Acts on gut * Increases ACh at muscarinic receptors in gut * Promotes gastric emptying * Increases peristalsis * Cyclizine- * H1 receptor antagonist * Acts on vestibular nuclei * Levomepromazine- * D2 receptor antag * Acts on CTZ * Ondansetron- * 5HT3 receptor antagonist * Reduces GI motility & secretions * Inhibits CTZ centrally * Domperidone- * Similar to metoclopramide * SE: sudden cardiac death, long QT

Answer 130

1. Reduced gastric motility- may relate to opioid use 1. **Metoclopramide**, domperidone (not in BO) 2. Chemically mediated- high Ca, opioids, chemo 1. Ondansetron, **haloperidol** 3. Visceral/ serosal- constipation, oral candidiasis 1. Cyclizine, levomepromazine 4. Raised ICP- cerebral mets 1. **Cyclizine** 2. Dexamethasone 3. RT 5. Vestibular- ACh and H1 receptors activation, opioid related, can relate to motion too 1. Cyclizine 2. Metoclopramide, prochlorperazine 6. Cortical- anxiety, pain, fear 1. **Benzo** eg lorazepam or cyclizine Other- bowel obstruction: functional- cyclizine

Answer 131

* Female gender * Specific chemo agents * Age \<50 * past hx of N&V eg pregnancy, prior chemo, motion sickness

Answer 132

* NK1 antagonist; acts mainly centrally * Used for more emetogenic chemo * Augments 5HT3 and dex * SE: constipation, headache

Answer 133

Hyoscine hydrobromide Controlling respiratory secretions Also relieving bowel obstruction

Answer 134

* Anaemia- transfusion * PE- LMWH, DOAC * CCF - diuretics, ACEi * COPD- bronchodilators * Resp tract infection- abx * Pleural effusion- aspirate * SVCO- stent, RT, steroids * Anxiety- CBT, relaxation, benzodiazepines, SSRIs

Answer 135

Dyspnoea can result from impaired ventilation or increased ventilatory demand, or both factors. There are multiple possible causes of dyspnoea in people with cancer, including: * Direct causes — such as primary lung cancer or lung metastases * Indirect effects of cancer — such as pleural effusion, superior vena cava syndrome, anaemia, pulmonary embolism, and surgery * Non-malignant causes — such as pneumonia, chronic obstructive pulmonary disease, heart failure, and anxiety

Answer 136

* Features of the dyspnoea (for example severity, timing, onset, and precipitating and exacerbating factors) * Associated physical symptoms (for example cough, sputum, haemoptysis, wheeze, stridor, pleuritic pain, fatigue, and panic) * Effect on the person’s quality of life

Answer 137

Stepwise approach depending on underlying cause + illness * Simple measures, such as keeping the room cool, the use of a fan, opening a window, relaxation and breathing techniques * Encouraging exercise within the person's capabilities * Adaptations in activities of daily living and lifestyle expectations * Strategies to manage other physical symptoms, and the psychological, social, and spiritual needs of the person and their family * A strong opioid, such as an immediate-release oral morphine * A benzodiazepine short term, especially if dyspnoea is associated with acute anxiety or the person is nearing the end of life * Diazepam * Lorazepam * A bronchodilator if wheeze is thought to be caused by partial airway obstruction from a tumour * Oxygen therapy ideally following specialist assessment, especially if the person is at risk of symptomatic hypoxia

Answer 138

Offers people the opportunity to plan their future care & support, including medical treatment while they have the capacity to do so * People at risk of losing mental capacity - for example, through progressive illness. * People whose mental capacity varies at different times - for example, through mental illness.

Answer 139

* Mental Capacity Act * designed to protect and empower people who may lack the mental capacity to make their own decisions about their care and treatment. It applies to people aged 16 and over * Advanced Decisions to Refuse Treatment * These are for decisions to refuse specific medical treatments and are legally binding * Lasting power of Attorney * This involves giving one or more people legal authority to make decisions about health and welfare, and property and finances

Answer 140

* Small-cell lung cancer (SCLC)- neuroendocrine cells, produce neuroendocrine hormones- paraneoplastic syndromes- eg ACTH: cushings, siADH,. Grow very fast, poor prognosis, multiple sites, central location near bronchus * Non-small cell lung cancer (NSCLC): * Adenocarcinoma- most common (38%), more in non-smokers, perioheral, form glands & produce mucin * Squamous cell carcinoma- 20%, produce keratin (keratin pearls), central, 98% smokers * Large cell- 5%, poorly differentiated, big cells, peripheral, may secrete B-hCG, early mets * Mesothelioma * Neuroendocrine tumour

Answer 141

* Smoking * Lung disease eg TB, COPD * Radiotherapy * Toxins eg asbestos, radon gas, arsenic * Pulmonary fibrosis * HIV * Family history

Answer 142

Lung cancer is frequently asymptomatic. When symptomatic, **cough, malaise and weight loss** predominate. **_Symptoms_** * Fever * Malaise * Nausea * Cough * Haemoptysis * Hoarseness * Weight loss * Anorexia * Fatigue * Recurrent chest infections * Chest pain **_Signs_** * Cachexia * Anaemia * Supraclavicular/ cervical/ axillary lymphadenopathy * Stridor * Wheeze * Clubbing * Hypertrophic pulmonary osteoarthropathy (HPOA) * Signs of pleural effusion (exudative): * Dull (‘stony dull') percussion * Reduced vocal fremitus * Reduced breath sounds * SVCO * Horner's syndrome NSCLC * Pancoast tumour * RLN palsy- hoarse voice * Hypercalcaemia (give fluids & zolendronic acid) Small cell * Rapidly progressing symptoms: ~6wks * SVCO- headaches, facial swelling, plethora, collaterals over chest walls * SiADH- hyponatraemia symptoms * Paraneoplastic syndromes * Bulky mediastinal disease- dyspnoea, dysphagia due to oeseophageal compression * Bone mets- pathological fracture, pain * Brain mets- seizure, visual changes, headaches

Answer 143

This is a tumour of the pulmonary apex. Their location means local spread may affect: * Brachial plexus * Cervical sympathetic trunk and the stellate ganglion * Subclavian vein, brachiocephalic vein * Subclavian artery * RLN * Vagus nere Pancoast tumours are associated with NSCLC Pancoast tumours are known to cause: * Horner’s syndrome * Pain in the shoulder that radiates into the arm and hand * Atrophy of muscles of the upper limb * Oedema of the upper limb * Recurrent laryngeal nerve palsy presenting as a hoarse voice Symptoms * Symptoms of lung cancer * Pain/ weakness in muscles of arm & hand * Hoarse voice * Bovine cough * SVCO

Answer 144

Paraneoplastic syndromes refer to remote effects of tumours unrelated to mass effect, invasion or metastasis. 1. ***_Hypercalcaemia_*** 1. May occur due to bony mets or tumour secretion of PTHrP and calcitriol 2. Stones, bones, groans, thrones, psychiatric moans = renal calculi, bone pain, abdominal pain, polyuria and signs of altered mental status 3. High calcium seen in 50% of patients with **squamous cell carcinoma**, 20% of adenocarcinoma and 15% of small cell carcinoma 2. ***_SiADH_*** 1. Hyponatraemia 2. Cerebral oedema if severe 3. Caused by **small cell lung carcinoma** 3. ***_Cushing's syndrome_*** 1. Ectopic ACTH released increasing glucocorticoid release 2. Caused by **small cell lung carcinoma** 4. ***_Lambert-Eaton syndrome_*** 1. Antibodies to voltage-gated calcium channels 2. 1-3% SClC 3. Proximal & ocular muscle weakness 4. Caused by **small cell lung carcinoma** 5. ***_Hypertrophic osteoarthropathy_*** 1. Clubbing & periostitis 2. Symmetrical, painful arthropathy affecting distal joints

Answer 145

Bedside * Observations * Blood pressure * Lung function tests- spirometry Bloods * FBC * U&Es * LFTs * Bone profile * CRP Imaging * CXR * CT CAP scan * Staging- spread outside chest? * PET-CT * To see if there's any hidden disease elsewhere that lights up * Bronchoscopy * Brain imaging * CT head- not good for looking at every single met, so follow up with MRI head * MRI head if looking for surgical/ RT curative treatment Special tests * Tissue biopsy * Obtained via bronchoscopy, image-guided biopsy, video-assisted thoracoscopic surgery (VATS) or mediastinoscopy * Obtained from the tumour, lymph node or metastasis * Sometimes pleural fluid is taken * Cytology * From aspirates, washings, pleural fluids * Obtained from the tumour, lymph node or metastasis

Answer 146

TNM staging for NSCLC Tumour * TX: Primary tumour cannot be assessed or tumour proven by presence of malignant cells in sputum or bronchial washings but not visualised by imaging or bronchoscopy * T0: No evidence of a primary tumour * Tis: Carcinoma in situ * T1: Tumour measuring 3 cm or less in greatest dimension surrounded by lung or visceral pleura without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e. not in the main bronchus) * T2: Tumour \> 3 cm but ≤ 5 cm or tumour with any of the following features: * Involves the main bronchus regardless of distance from the carina but without the involvement of the carina * Invades visceral pleura * Associated with atelectasis or obstructive pneumonitis that extends to the hilar region involving part or all of the lung * T3: Tumour \> 5 cm but ≤ 7 cm in greatest dimension or associated with separate tumour nodule(s) in the same lobe as the primary tumour or directly invades any of the following structure: * Chest wall (including the parietal pleura and superior sulcus) * Phrenic nerve * Parietal pericardium * T4: Tumour \> 7 cm in greatest dimension or associated with separate tumour nodule(s) in a different ipsilateral lobe than that of the primary tumour or invades any of the following structures: diaphragm, mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, oesophagus, vertebral body or carina) Node * Nx: Regional lymph nodes cannot be assessed * N0: No regional lymph node metastasis * N1: Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension * N2: Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s) * N3: Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s) Metastasis * M0: no distant metastasis * M1: distant metastasis present Small cell lung carcinoma can be staged in the above TNM staging system too, however the VALSG staging system may be used instead/ in conjunction with it- it better reflects the limited opportunities for treatment with curative intent * Limited disease: tumour not spread beyond hemithorax, regional nodes that may be treated with single radiotherapy field. * Extensive disease: tumour spread beyond hemithorax or extensively through the hemithorax, distant metastasis, malignant effusions or contralateral hilar/supraclavicular involvement.

Answer 147

NSCLC * Surgery * Stage I and II disease- lobectomy most often, wedge resection * Lymph node sampling to offer prognostic info * Chemotherapy * Neo-adjuvant (before surgery) * Adjuvant (after surgery) * Platinum-based regiments * MAbs targeting EGFR (e.g. cetuximab) or TKI (e.g. erlotinib) * Radiotherapy * Often palliative * Radical (curative) in early disease SCLC * Surgery * Only early disease, small tumour- \<5% cases * Chemo-radiotherapy * Can be given if limited stage- give chemo and radiotherapy * Palliative * Prophylactic cranial irradiation (PCI) given because those with SCLC are at high risk of brain metastases * Immunotherapy Supportive care * Breathlessness * Bronchial stent / RT * Home O2 * LOROS breathlessness service * Drugs- oramorph, steroids * Pain * Analgesia * Nerve blocks * RT * Social * OT/ PT/ Dietician * Psychological support- Macmillan, Support groups, PsychOnc * Smoking cessation * Financial Support services

Answer 148

Most diagnosed are \>65 years old One-year survival: 40.6% Five-year survival: 16.2% Lung cancer makes up 25% of all cancer deaths

Answer 149

* Primary bronchial carcinoma * Infection- TB, fungal * Non infectious granuloma- granulomatosis with polyangiitis (Wegener's) * Rheumatoid nodule * Bronchial carcinoid * Haemartoma * Metastasis Management options * Sequential CT surveillance over 24 months * If patient fit, they may wish to have nodule removed – lobectomy

Answer 150

* This lady has presented with – Cord Compression * **_Urgent MRI spine_** & discussion with neurosurgeon & oncologist * High dose steroids IV or PO dexamethasone * RT +/- surgical decompression * Urinary catheterisation * Delay = paraplegia, loss of bowel & urinary function

Answer 151

1. HYPERCALCAEMIA \>3mmol/l usually symptomatic – confusion, weakness, nausea, constipation, reduced fluid intake * IV normal saline * Bisphosphonates- IV pamidronate * Other Causes – Lung Cancer, often squamous cell or bony metastases, raised PTH, sarcoid, vitamin D excess* 2. SYNDROME OF INAPPROPRIATE ADH RELEASE Low Sodium & urine osmolality \>100 mosmol/kg Symptoms – Headache, lethargy, confusion, seizures * Fluid restrict * Consider Demeclocycline (causes diabetes insipidus) * Other Causes – Lung cancer (mainly SCLC), pneumonia, drugs (carbamazapine, fluoxetine), stroke* 3. BRAIN METS * Dexamethasone IV or PO 8-12mg/day in morning/early afternoon – avoid in evenings (side effect of insomnia, agitation) * Urgent Radiotherapy

Answer 152

* The condition should be an important health problem * There should be a treatment for the condition * Facilities for diagnosis and treatment should be available * There should be a latent stage of the disease * There should be a test or examination for the condition * The test should be acceptable to the population * The natural history of the disease should be understood * There should be an agreed policy on who to treat * The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole * Case-finding should be a continuous process, not just a "once and for all" project

Answer 153

* Assessment of local disease * Assessment of distant disease Determines operability & choices of treatment

Answer 154

Urological * Cancer * Renal cell carcinoma * Upper tract TCC * Bladder carcinoma * Advanced prostate carcinoma * Other * Stones * Infection * Inflammation * BPH (large) Nephrological (glomerular) causes * Persistent asymptomatic non visible haematuria, age \<40 with associated proteinuria, ↑BP & ↓eGFR is most likely to be nephrological in origin

Answer 155

* Radiology * Ultrasound * Endoscopy * Flexible cystoscopy * Urine * Cytology Primary care will usually have checked eGFR, albumin/creatinine ratio, MSU (if appropriate) before referring to Urology

Answer 156

* Urgent ultrasound of scrotum to confirm diagnosis * Check testis tumour markers if testicular mass on ultrasound * aFP, hCG, LDH

Answer 157

* Smoking * Occupational exposure (20yr latent period) * Rubber or plastics manufacture (Arylamines) * Handling of carbon, crude oil, combustion, smelting (Polyaromatic hydrocarbons) * Painters, mechanics, printers, hairdressers

Answer 158

* Cryptorchidism * Hypospadias * Infertility * Klinefelter’s syndrome * Tall men

Answer 159

* The majority of testicular tumours are germ cell in origin (95%) * 2 major types- * Seminoma * Non-seminoma * 5% are sex cord/ gonadal stromal tumours eg Leydig cell tumour, Sertoli cell tumour, granulosa cell tumour

Answer 160

* Commonly as a unilateral scrotal mass * Testicular lump, pain, discomfort * Back or flank pain (mets) * Lymphadenopathy * Gynaecomastia (NSGCT)

Answer 161

* Testicular USS is the diagnostic modality of choice

Answer 162

* Alpha-fetoprotein (AFP)- NSGCT, particularly yolk sac subtype * Beta-HCG- NSGCT, particularly choriocarcinoma subtype, can be seen in seminoma * Lactate dehydrogenase- general marker of increased cell turnover, may be raised in seminomas or NSGCTs

Answer 163

* Orchidectomy via inguinal approach (to avoid crossing lymph networks) * Surveillance, radiotherapy, chemotherapy

Answer 164

* Lung * Lymph nodes- pulmonary, pelvic, base of neck

Answer 165

* Classical presentation: macroscopic (visible) haematuria * Dysuria, urgency, urinary frequency * Advanced disease- pelvic pain, flank pain, bone pain, peripheral oedema, anorexia, weight loss

Answer 166

* Cystoscopy * Allows visualisation of the bladder and for biopsies to be taken * Can be therapeutic- allows TURBT to be completed

Answer 167

* Trans-urethral resection of bladder tumour * Intra-vesical BCG (TB live attenuated vaccine) used as immunotherapy * Intravesical mitomycin C- antibiotic with anti-neoplastic effects, given following TURBT to reduce recurrence * Radical cystectomy * Radical radiotherapy * Chemotherapy

Oncology + palliative care Flashcards

(195 cards)