Block 34 Week 7 Flashcards
1
Q
Neutropenic sepis?
A
- occurs 7-14 days after chemotherapy
- antibiotics must be started immediately, do not wait for the WBC
- start piperacillin with tazobactam (Tazocin)immediately
2
Q
Ix for NS?
A
Bedside
- blood sugar
- pregnancy test
Bloods
- VBG / ABG
- FBC
- CRP
- U&Es
- LFTs
- Bone profile
- Clotting
- Fungal assays(e.g. beta-d-glucan galactomannan)
- Blood borne virus screen
3
Q
Cultures for NS?
A
- blood cultures
- sputum
- urine
- C diff toxin
4
Q
imaging for nS?
A
- Chest X-ray
- Lumbar puncture(meningitis, encephalitis)
- ECHO(infective endocarditis)
5
Q
What is purpura?
A
- describes bleeding into the skin from small blood vessels that produces a non-blanching rash
- caused by bone marrow failure, certain drugs like antiepileptics, antithrombins, nutritional def like B12, C and folate
6
Q
Ix for purpura?
A
- FBC - platelet count and evaluate for thrombocytopenia
- peripheral blood smear
- PT, aPTT, fibrinogen levels
- platelet function assays
- urinalaysis - haematuria, proteinuria
7
Q
Myelosuppresion Ix?
A
- FBC
- peripheral blood smear
- bone marrow biopsy/ aspiration
- iron studies
8
Q
Outline the long-term effects of cytotoxic chemotherapy?
A
- cardiotoxicity (leading to heart failure or arrhythmias),
- pulmonary toxicity (resulting in lung fibrosis or pneumonitis),
- nephrotoxicity
- hepatotoxicity
- peripheral neuropathy.
9
Q
secondary ? can occur after chemo
A
- Secondary malignancies - leukemia, solid tumouts
- can occur years after completion of chemo treatment
10
Q
infertility & chemo?
A
Long-term effects may include infertility, premature ovarian failure (menopause), and decreased sperm count or quality.
11
Q
bone side effects of chemo?
A
- osteopenia/ osteoporosis
12
Q
hormonal side effects of chemo?
A
- hypothyroidism
- adrenal insufficnecy
13
Q
CV side effects of chemo?
A
- Certain chemotherapy drugs, particularly anthracyclines and targeted therapies, can increase the risk of cardiovascular complications such as cardiomyopathy, heart failure, and myocardial infarction
14
Q
acute myeloblastic leukemia is a ?
A
- 80% adult leukemias
- incidence increases w age
15
Q
predisposing factors for AML?
A
- radiation
- benzene
- previous chemo
- inherited bone marrow failure conditions
- downs
16
Q
CF of AML?
A
- bone marrow failure
- extramedullary - e.g. gingivitis
- hyperleukostasis
17
Q
Peripheral blood film in AML?
A
- myeloblasts - malignant myeloid cells
- large nucleus
- granules in the cytoplasm - can be in rods
- fibrinogenolysis in acute promyelotic leukemia
18
Q
Prognosis of AML?
A
- cytogenetics
- worse when:
- complex karyotypes
- abn chromsome 3, 5, 7
19
Q
Acute promyelocytic leukemia?
A
- associated w 15:17 PML: RAR
- good prognosis - 70% 5 yr survival
- coagulopathy can be fatal
20
Q
what is acute promyelocytic leukemia sensitive to?
A
- sensitive to ATRA and arsenic trioxide
- doesn’t need chemo
21
Q
Tx of non-APL AML
A
- remission induction using anthracycline
- allogenic stem cell transplant for high risk patients - adverse cytogenetics, relapsed patients
22
Q
prognosis for AML?
A
- good risk genetics 65-70% 5 yr survival
- poor risk genetics 20-30% survival
- elderly >65 yrs 10%
- best survival under 40
23
Q
Acute LL age group?
A
- 12% of all adult leukemias
- 60% under 20
- peaks in the 2-5 yr age group and >50 yrs
24
Q
ALL can be associated w?
A
Downs
25
majority of childhood leukemias are?
ALL
26
clinical features of ALL?
* organomegaly
* lymphadenopathy
* CNS involvement
* mediastinal mass -> obstruction of SVC
* hyperleukostasis
* hyperuricaemia + tumour lysis syndrome
27
results for ALL?
* pancytopenia
* circ lymphoblasts
* bone marrow - hypercellular largely replaced w immunoblasts
* lumbar puncture - lymphoblasts if CNS involvement
28
ALL - good prognosis when?
* hyperdiploidy >50
* B cell 8:14 translocation
* 9:12 translocation
29
Poor cytogenetics in ALL?
* hypodiploidy
* 9:22 BCR: ABL philadelphia chromosome - very poor in adults
* t 4:11 MLL rearrangement
30
Tx of ALL?
* comb chemotherapy w intrathecal methotrexate as induction
* high dose metho as CNS prophylaxis
* allogeneic stem cell transplant for high risk
* maintenance chemo required for up to 2 yrs - not required for B cell ALL
31
prognosis of ALL?
* V good survival in children
* poor survival > 40 yrs olds
32
Most common adult leukemia?
CLL
33
who does CLL affect?
* males> females
* inc w age - median age 65
34
features of CLL?
* lymphocytosis, clonal mature B cells
* lymphadenopathy
* hepatosplenomegaly
35
Blood film of CLL?
* peripheral blood B cell lymphocytosis
* bone marrow infiltration
* smear cells - smudged and smashed cells
36
Tx of CLL?
no benefit to treating if no symptoms
image
37
CML?
* rare
* diagnosed incidentally or following development of systemic symptoms, splenomegaly or gout
38
CML is characterised by?
* charac by philadelphia chromosome producing constitutive activation of abl kinase
* risk of transformation to acute leukemia
39
features of CML?
* basophilia
* eosinophilia
* occasional blast
40
Tx of CML?
* TK inhibitors - e.g. imatinib, nilotinib, bosutinib
* allogeneic transplantation for resistant or transformed cases
41
Prognostic index for lymphomas?
* diffuse large B cell lymphoma is the most common type
* RIPI is the prognostic index
42
outcome in DLBCL ?
* low risk disease have high chanc of cure
* germinal centre type has a better prognosis than activated B cell type
43
Tx of DLBCL?
* localised disease - 3 cycles of chemo
* followed by radiotherapy to involved sites
* stage 3/4 disease x6 cycles of chemo
44
Follicular lymphoma?
* incurable
* ppl present w lympadenopathy or w constitutional symptoms
* can occur in the peripheral blood
45
Tx of follicular lymphoma?
* asymptomatic in many
* treatment only for symptomatic disease
* risk of high grade transformation
46
assessing prognosis of follicular lymphoma?
* FLIPI to assess prognosis
47
outcome for follicular lymphoma?
* low risk: 5 year survival around 90%
48
hodgkin lymphoma shows presence of?
* reed-sternberg cells
* presence of binucleate cells in LNs/ affected cells
49
staging of HL?
* Ann Arbor staging
* Hassebclever index for stage 3/4 hodgkin lymphoma
50
prognosis of HL?
* >90% cure rate in over 50
* diff to treat in elderly
51
Basic principles of radiotherapy?
* uses ionising radiation to target and destroy cancer cells
* tumour is localised using CT, MRI, PET
* target delination to accurately define tumor volume and surrounding organs at risk to spare healthy tissue
52
EBRT =
External radiation beams are delivered from a linear accelerator (LINAC) or other external radiation source directed at the tumor from outside the body.
53
Bracytherapy =
Radioactive sources are placed directly into or near the tumor, delivering a high dose of radiation to the target while sparing surrounding tissues.
54
Stereotactic radiosurgery
* Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT): Highly precise, high-dose radiation is delivered to small targets in the body, typically in one to five treatment sessions.
55
Fractination =
* fractination: allows for delivery of an effective dose of radiation to the tumor whilst minimising toxicity to surrounding normal tissues by taking advantage of differences in repair capacity between tumor cells and normal tissues.
56
Immediate radiotherapy side effects?
* skin reactions - erythema, itching and skin dryness within the radiation field
* fatigue
* mucositis - pain, dysphagia, oral mucositis
* nausea and vomiting
* alopecia in the radiation field
* if radiation is to the pelvis or bladder they may experience acute urinary symptoms like freq, urgency, dysuria, haematuria
57
Long term radiotherapy side effects - fibrosis?
* radiation fiborosis -> scarring -> tissue stiffness
* e.g. skin, subcutaneous tissue, muscles, internal organs
58
LT side effect of radiotherapy - dermatitos?
* radiation dermatitis e.g. telangiectasia (dilated blood vessels), hyperpigmentation, or hypopigmentation.
59
radiation enteritis?
* radiation enteritis -> intestinal strictures, bowel obstruction
60
radiation cystitis?
* radiation cystitis which can lead to incontience
61
other LT side effects of radiotherapy?
* lymphdema -> inc infection risk
* pulmonary fibrosis or chronic resp insufficiency
* secondary malignancies e.g. sarcomas, leukemias, solid tumours
* CV comps - inc CAD, MI, pericardial disease
62
what can cause bone pain and abn gait?
* mets bone disease
* primary bone cancer
* pathological fractures from cancer related bone weakening
* SCC
63
Ix of bone pain and abn gait?
* X rays to identify fractures
* MRI or CT
* FBC, ALP, tumour markers
* bone scans
* biopsy
64
benefits of radiotherapy?
* highly effective for local tumour control
* palliation of symptoms such as pain
* organ preservation and avoid need for radical surgery by shrinking tumours
* improved survival
* curative intent
65
common types of bracytherapy?
* Common types of brachytherapy include intracavitary (within body cavities such as the uterus or vagina), interstitial (directly into tissues), and surface (applicators placed on the skin) brachytherapy.
* Brachytherapy may be used alone or in combination with EBRT
66
proton therapy?
* Proton therapy uses protons instead of photons (X-rays) to deliver radiation to the tumor.
* Proton therapy can deliver highly conformal radiation to the tumor while minimizing dose to surrounding healthy tissues, potentially reducing side effects.
67
when is proton therapy useful?
* Proton therapy is particularly useful for treating tumors located near critical structures or in pediatric patients, where minimizing radiation exposure to healthy tissues is crucial.
68
radioisotope therapy?
* Radioisotope therapy involves administering radioactive substances, either orally or intravenously, that selectively accumulate in tumor cells, delivering radiation directly to the tumor.
69
when is radioisotope therapy used?
* Examples include radioactive iodine therapy for thyroid cancer and radiopharmaceuticals for treating bone metastases or neuroendocrine tumors.
70
causes of hypercalcaemia?
* most common causes are malignant hypercalcaemia and primary hyperparathyroidism
71
malignant hypercalcaemia?
* associated w poor prognosis
* Hypercalcaemia commonly occurs due to release of parathyroid related peptide (PTHrP), which mimics the action of PTH.
* Other mechanisms include osteolytic damage to bone or activation of vitamin D.
72
primary hyperparathyroidism?
* Primary hyperparathyroidism is the most common cause of hypercalcaemia in the general population.
- It occurs due to excess release of PTH, which leads to bone resorption and excess calcium release.
73
what is a common cause of primary hyperparathyriodism?
parathyroid adenoma
74
secondary hyperparathyroidism?
* Secondary hyperparathyroidism is characterised by excess PTH production secondary to low serum calcium, typically due to chronic kidney disease or vitamin D deficiency.
75
tertiary hyperparathyroidism?
* Tertiary hyperparathyroidism is characterised by autonomous PTH excess due to parathyroid hyperplasia in response to longstanding secondary hyperparathyroidism - seen in patients with chronic kidney disease.
76
how are primary and tertiary hyperparathyroidism similar?
both cause hypercalcaemia
77
which type of hyperparathyroidism causes HYPOcalcaemia?
secondary
78
thyroyoxicosis and hypercalcaemia?
Elevated thyroid hormones can lead to thyroid hormone-mediated bone resorption.
79
hypercalcaemia - Some conditions lead to excess endogenous production of activated vitamin D, which include:
* Granulomatous disorders (e.g. sarcoidosis)
* Cancers (e.g. lymphoma)
80
other causes of hypercalcaemia?
* Chronic lithium use: enhances PTH release
* Thiazide diuretics: lowers urinary calcium excretion
* Adrenal insufficiency
81
Hypercalcaemia - features?
* Bones - fragility fractures, bone pain
* Stones - renal calculi
* Thrones - polyuria, constipation
* Abdominal groans - abdominal pain, N&V, pancreatitis
* Psychic moans - mood disturbance, depression, fatigue, psychosis
82
signs of hypercalc?
* Dehydration (skin turgor, dry mucous membranes)
* Hypertension
* Cardiac arrhythmia (severe disease)
* Confusion (severe disease)
83
diagnosis of hypercalcaemia is based on?
serum corrected calcium > 2.6 mmol/L.
84
hypercal + elevated PTH?
* Elevated PTH (i.e. PTH-mediated): suggestive of primary hyperparathyroidism or tertiary hyperparathyroidism
85
Hypercal and mid to upper normal PTH?
* Mid-to-upper normal PTH (suspected PTH-mediated): in the context of hypercalcaemia this is considered ‘inappropriately high’ and suggestive of hyperparathyroidism
86
Hyper cal + low to low normal PTH?
* Low or low-normal PTH (i.e. non-PTH mediated): suggestive of malignancy, which needs to be excluded. Hypervitaminosis D also possible.
87
Mx of hypercal?
* management of symptomatic hypercalcaemia is primarily fluid resus
* Severe hypercalcaemia requiring inpatient management is typically indicative of a malignant cause.
88
Mild hypercal Mx?
* Mild (< 3 mmol/L) and asymptomatic/mild symptoms: increase oral fluids and avoid precipitants (e.g. thiazide diuretics, lithium, dehydration).
89
moderate hypercal Mx?
* Moderate (3-3.5 mmol/L): acute rise requires inpatient admission for intravenous fluids.
- Chronically raised elevations may not require acute management
90
Severe hypercal Mx?
* Severe (>3.5 mmol/L): all patients require urgent admission to hospital and treatment.
* Treatment involves aggressive intravenous fluids and consideration of bisphosphonates, particularly if malignancy is suspected.
91
when are bisphosphonates used in hypercal
* considered in severe hypercalcaemia particularly if malignancy is suspected
* Pamidronate or zoledronic acid are typically used.
92
Alt to bisphosphonates in hypercal?
* An alternative to bisphosphonates is denosumab, which is a monoclonal antibody that binds to RANK ligand and inhibits the action of osteoclasts.
93
Mx of hypercal - steroids?
* Corticosteroids: may be used in hypervitaminosis D.
94
Mx of hypercal - surgery?
* Surgery: able to provide a cure in primary hyperparathyroidism. Potential option in tertiary hyperparathyroidism
95
Mx of hypercal - cinacalcet?
* Cinacalcet: calcimimetic that mimics the action of calcium on calcium-sensing receptors. May be utilised in primary hyperparathyroidism if surgery has failed or not an option. Also used in secondary/tertiary hyperparathyroidism.
96
Dialysis in Mx of hypercal?
* Dialysis: may be reserved for severe, refractory hypercalcaemia.
97
Indications for primary radiotherapy?
* Indications for primary radiotherapy include early-stage cancers, inoperable tumors, or cases where surgery is not feasible due to tumor location or patient factors.
98
Adjuvant radiotherapy?
* adjuvant - after surgery to reduce risk of reccurence
* indications: high risk features such as positive surgical margins, lymph/ vascular invasion
99
Neoadjuvant radiotherapy?
* neoadjuvant therapy - before surgery to downstage the tumor, improve resectability and facilitate surgical resection
* indications: locally advanced tumors, large tumours requiring downsizing for organ preservation
100
Palliative radiotherapy?
* palliative therapy - relief of symptoms, pain alleviation, improved QOL
* Indications for palliative radiotherapy include symptomatic relief of pain, bleeding, obstruction, neurological symptoms, or other cancer-related symptoms.
101
curative intent radiotherapy?
* curative intent therapy - comb w other treatments such as surgery, chemo, or targeted therapies
* indications: localized cancers w potential for cure such as early stage non small cell lung cancer, CC, prostate cancer
102
indications of radiotherapy other than cancer?
* non cancerous conditions - e.g. benign tumours, vascular malformations, autoimmune
* aim to control symptoms, improve functional outcomes, or prevent disease progression.
103
bone mets are most commonly from?
- breast
- bronchus
- thyroid
- prostate
- kidney
104
Osteoblastic bone mets?
consequence of prostate cancer, Hodgkin's lymphoma and small cell lung cancer
105
Osteolytic bone mets?
renal cell cancer, thyroid cancer, melanoma, non-small cell lung cancer and non-Hodgkin's lymphoma
106
mixed osteoblastic and osteolytic bone mets?
GI and breast cancers
107
CFs of bone mets?
* pain - severe, often wakes them from sleep
* classicaly described as gnawing
* weight loss
* reduced motility
* pathological fracture
* paralysis and weakness rarely if SCC
108
Bone mets can lead to symptoms of ?
- hypercalcaemia
- Bone pain, muscle weakness, thirst, excessive urination, confusion, malaise.
109
Ix of bone mets?
* bone scintigraphy scan - inc uptake or assymetical
110
Bone mets - imaging modality used if the ppt presents with pain and features of nerve involvement?
* If the patient presents with pain and features of nerve involvement such as weakness or paralysis, it would be more appropriate to consider a CT or MRI scan as it is easier to visualise soft tissues and if there is any nerve compression.
* If bone metastases are found in one area, the whole body should be scanned using bone scintigraphy to find any other areas affected.
111
Bloods for bone mets?
* FBC - can show anemia
* U&Es
* LFTs - inc ALP
* CRP
* hypercalcamia
* MM screen
* tumour markers screen
112
Mx of bone mets?
* Treatment may include surgery to stabilise affected bones, radiotherapy, chemotherapy, or hormone therapy
* denosumab - osteoclast inhibition, monoclonal ab that slows progression of bone mets
* analgesia
* bisphosphonates
113
What are the symptoms of SCC?
- Weakness/ numbness of limbs
- bladder/ bowel dysfunction
- sensory loss
- noctural spinal pain
114
Patients with signs of spinal cord compression should be treated as a
medical emergency and require an urgent MRI.
115
Cancers inc risk of malignant spinal cord comp?
* Prostate
* lung
* breast
* renal
* MM
116
Red flag features of back pain that may suggest MSCC (particularly in patients with a known cancer diagnosis) include:
* Thoracic or cervical pain
* Progressive lumbar pain
* Spinal pain aggravated by straining
* Localised spinal tenderness
* Nocturnal pain preventing sleep
117
symptoms of SC compression
* Limb weakness (e.g. the limb feeling “heavy” or “stiff”, difficulty climbing stairs)
* Loss of coordination
* Sensory disturbance
* Autonomic dysfunction (e.g. urinary retention, faecal incontinence due to loss of anal tone, constipation)
- cauda equina syndrome
118
Symptoms of cauda equina syndrome?
- bladder/bowel dysfunction
- saddle anaesthesia
- leg weakness
- gait disturbance
- back pain
119
Ix of malignant SCC?
* any patients w malignant SCC should be referred for urgent MRI of the spine within 24 hrs
* If an MRI is contraindicated (e.g.pacemakers and metallic foreign bodies), the next best imaging modality is CT.
120
Other Ix of SCC?
* bladder scan to assess for urinary retention
* baseline bloods
* bone profile - hypercalcamia
* LDH
* myeloma screen if the ppt doesn't have a known cancer diagnosis
* Tumour markers
121
Mx of SCC - reducing inflammation?
* Dexamethasone to reduce inflammation and oedema
122
other Mx techniques in SCC?
* Omeprazole (or alternative PPI) for stomach protection
* Low molecular weight heparin (or alternative) for thromboprophylaxis
* Immobilise the spine if instability is suspected
* Analgesia
123
Definitive Mx of SCC?
* surgical decompression followed by radio
* radiotherapy - particularly those with multiple medical comorbidities, rapidly progressive neurological deficits and radiosensitive tumours (e.g. myeloma)
124
acute radiotherapy side effects
125
Late radiotherapy side effects
126
Pain characteristics suggesting spinal metastases:
* severe unremitting back pain
* progressive back pain
* mechanical pain (aggravated by standing, sitting or moving
* back pain aggravated by straining (for example, coughing, sneezing or bowel movements)
* night-time back pain disturbing sleep
* localised tenderness
* claudication (muscle pain or cramping in the legs when walking or exercising).
127
What should be done if there are signs of compression?
* immediately contact the MSCC co-ordinator if signs of compression
128
Causes of hypoglycaemia can be remembered by the mnemonic EXPLAIN
* Exogenous drugs (typically sulfonylureas or insulin)
* Pituitary insufficiency
* Liver failure
* Addison's disease
* Islet cell tumours (insulinomas)
* Non-pancreatic neoplasms
129
Where is folate abs?
Folate is predominantly absorbed in the duodenum and proximal jejunum and so absorption would not be affected by ileocaecal resection - ileocaecal resection causes B12 def
130
Tumour marker in medullary thyroid cancer?
Calcitonin is a tumour marker in medullary thyroid cancer
131
Follicular/Papillary thyroid cancer tumour marker?
thyroglobulin
132
ovarian cancer marker?
CA 125
133
hypercal Sx
134
when to act - hypercal
135
pancreatic cancer TM?
ca19-9
136
breast cancer marker?
CA 15-3
137
prostate cancer marker?
PSA
138
Alpha-feto protein (AFP)?
Hepatocellular carcinoma, teratoma
139
CEA tumour marker?
Carcinoembryonic antigen (CEA) Colorectal cancer
140
S-100 tumour marker?
melanoma
141
Bombesin tumour marker?
* Small cell lung carcinoma
* gastric cancer,
* neuroblastoma
142
what type of electrolyte abn is seen in cushings syndrome?
hypokalaemic metabolic alkalosis
143
Subclinical hyperthyroidism is associated with ?
atrial fibrillation, osteoporosis and possibly dementia
144
causes of CES?
* lumbar disc herniation - most common ause
* degenerative lumbar canal stenosis
* neoplastic space occupying lesion
* spinal trauma
145
CFs of cauda equina syndrome?
* bladder dysfunction - urinary retention at first which progresses to overflow incontenence which is a late sign
* bowel - constipation or faecal incontienence
* sexual
* peri-anal sensory loss - saddle anaesthesia
146
# reflexes
neuro symptoms of CES?
* unilateral or bilateral
* Lower back pain with or without sciatica
* Lower limb sensory loss
* Lower limb lower motor neurone signs: most notably weakness, hypotonia and hyporeflexia
147
Acute vs chronic CES presentation?
* Acute: Sudden onset, rapidly progressing symptoms which worsen over several hours or days
* Chronic: insidious onset with slow progression of symptoms
148
how do CES symptoms start in most patients?
* most patients start with lower back pain, may be present with or without sciatica
149
Ix for CES?
* urgent MRI scan
* if unavailable, CT is the next best method
150
Mx of CES?
* spinal decompression
* dexamethasone
* emergency surgery - espec if evidence of bladder dysfunction
151
SCC Mx?
* immobilisation
* pain management
* physical therapy
* corticosteroids - dexamethasone
* bisphosphonates
* radiotherapy
152
diagnostic vs therapeutic X rays?
* kilovoltage - diagnostic X rays
* megavoltage - therapeutic X rays
153
Mechanism of XR production?
* Breaking radiation - electron enters the atom and passes through the nucleus due to opposite charge, bends the electron and loses energy
* most common form
* characteristic X ray -e- strikes an electron orbiting an atom
154
indications for curative radio?
* curative = early stage, prostate, cervic, VC, skin e.g. non melanoma
* curative before or after surgery
155
indications for curative w chemo radiotherapy?
* curative w chemo - advance H&N cancer, lymphoma
156
indications for palliative radio?
* palliative - pain control, control bleeding, SC compression - cauda equina, reduce tumour mass so relieving the mass effects
157
dose of curative radiotherapy?
* curative: 60-70 Gy
* palliative: 8 Gy in one fraction/ 20 over a week
158
when is secondary cancer most common after radio?
* secondary cancer is more common in children and growing adolescents
159
late side effects of radiotherapy in children and growing adolescents?
* growth retardation
* hypoplasia of organ irradiated
* secondary cancer
160
mechanism of action of radiation
* OH- radical production
* reacts w DNA -> cell death
161
Tumour induced hypercalcaemia - serum calcium is bound to albumin so?
measurements should be adjusted for serum albumin
162
mechanisms of tumour induced hypercalcaemia - 3?
* paraneoplastic syndrome
* sectretion of PTHr protein: enhances osteoclast activation and bone resoprtion
* inc renal tubular calcium reabs
* sign bone lysis directly by the tumour - e.g. multiple myeloma
163
examination and Ix for TIHC?
* gen + abdo
* urine output
* other cancer related signs and symptoms
* other electromytes: albumin, ALP
* T3 and T4
* ECG
164
Causes of hypercal - lung?
squamous and small cell
165
cancers that cause hypercal?
* any advanced sq cell cancer - head and neck, bladder, anal canal, vulva
* MM
* renal cell cancer - release of PTHr
* advance breast cancer
166
Mx of tumour induced hypercalcaemia?
* rehydrate 2-4 litres of 0.9% saline IV over 24 hrs
* mobilize
* IV bisphosphonate
167
caution of fluid resus in hypercalcaemia?
* caution: elderly, cardiac history, obst uropathy, renal failure
168
Glucocorticoids in the Mx of hypercal?
* glucocorticoids: inhibit 1,25-hydroxyvit D production
169
resistant tumour induced hypercal?
* in resistant cases, consider calcitonin
170
other causes of hypercal?
* primary hyperparathyroidism
* sarcoidosis
* vit d intox
* thyrotoxicosis
* meds
171
side effects of bisphosphonates?
* can cause kidney damage
* flu like symptoms
* hypocalcemia
* jaw necrosis w long term use
172
monitoring after tumour induced hypercalcaemia?
* repeat bloods
* check other electrolytes and renal function
* pain control
* if not for anti-cancer treatment, involve palliative care
173
blood results in malignant hypercalcaemia?
* parathyroid hormone (PTH) levels are typically low or suppressed.
* This is because malignant hypercalcemia is usually caused by cancer-induced overproduction of parathyroid hormone-related protein (PTHrP) or by direct bone destruction from metastatic cancer
174
prostate cancer is the?
* most common cancer in males in the UK
* most diagnosed at 65+
* age standardised incidence rate: 173 per 100000 in 2016
175
RF for prostate cancer?
* age
* highest in african americans > white americans> asians
* red meat diet
* FHx
* genetic mutation: BRCA-2: 5x higher risk
176
what can transiently elevate PSA?
* prostatitis
* ejaculation
* urinary retention
* after endoscopic urethral manipulation
* prostatic biopsy
177
PC arises in which zone of the prostate?
* PC commonly arises in the peripheral zone
* 5-10% in the transitional zone
* 5% central
178
Sx of prostate cancer - obstruction?
* urinary hesitancy
* decreased force of urine stream
* intermittency
179
Sx of PC - irritation?
* urinary freq
* nocturia
* urgency
* urge incontinence
180
Sx of PC - obstruction of ejaculatory duct?
* haematospermia
* dec in ejaculate volume
181
Sx of PC - extension to NV bundle?
ED
182
features of metastatic PC?
* bone pain
* anaemia
* leg oedema
* leg weakness
* fracture
* weight loss
* asymptomatic
183
Ix of PC?
* DRE
* PSA - repeat
* transrectal US guided biopsy - to confirm cancer
184
How is pC staged?
* MRI/ CT - staging
* MRI preferred but CT used if suspected spread to lymph nodes or other organs
185
when should a bone scan for PC be done?
* bone scan if PSA>10 or Gleason score > 7
* routine bloods - ALP etc
186
T staging of PC?
* T1-T2c: cancer remains within prostate capsule
* T3-T4: cancer has infiltrated
187
Gleason scoring?
gleason score - higher gleason the more poorly differeniated the cancer. The more diff it looks to normal, the higher the score.
188
Low risk prostate cancer?
PSA<10, gleason 6, T2a
189
intermediate risk PC?
Gleason 7, PSA 10-20, T2b
190
high risk PC?
T3a+, gleason =>8, PSA>20
191
Localised PC Mx?
surgery + radiotherapy
192
locally advanced PC Mx?
radiotherapy, ADT
193
mX of metastatic PC?
Chemo
194
acute side effects of radiotherapy to the prostate?
* diarrhoea
* dysuria/ freq
* rectal soreness/ bleeding
* fatigue
* anal fissure: GTN cream
* exacerbation of haemorrhoids
195
LT side effects of radiotherapy to the prostate?
* 6-12 months after radiotherapy
* bleeding
* urethra/ bladder neck stenosis
* rectal ulcer/ weak sphincter
* haematuria
196
most common LT side effect following radiotherapy to the prostate?
ED
197
comps of prostatectomy?
* ED - most common
* urinary incontience
* loss of ejaculation - permanent
* shrinkage of penis
198
Prognosis of PC?
* low risk: 80-90%
* high risk: 30-50% 10 yr control
* metastatic - median 5 yrs or 3 yrs if ADT/ castrate resistant
199
PC - androgen dependent therapy?
* means of testosterone deprivation:
* removal of source/ decrease section of testosterone/ block test receptors
200
PC - ADT side effects
201
PC - if the cancer progresses despite following all available Tx
* progressive weight loss
* anaemia and thrombocytopenia
* skeletal related events
* dec mobility/ independence
* pain
202
Bony metastases usually present as pain but may also present as:
* pathological fracture
* spinal cord compression
* hypercalcaemia
* symptoms of nerve root compression
* swelling / deformity / loss of mobility
203
What to ask abt for bony mets?
- the nature of the pain
* exacerbating factors
* radiation to other areas
* loss of function
- timescale
* relief with simple analgesia
* disturbance of sleep
* a history of trauma
* existing metastatic disease
- loss of weight
204
concerning features in a pain history?
* progresses over time
* does not respond to simple analgesia
* disturbs sleep
* is associated with bony tenderness +/or weight loss
205
summary of Mx of bone mets?
- bisphosphonates or denosumab
- sugical fixation if instability
- chemo
- vertebroplasty
- radioactive isotopes
206
BM - Vertebroplasty?
percutaneous technique for spinal metastases
207
Radioactive isotopes seek out the bone mets and irradiate them selectively – work best for?
PC
208
Alpha-1 antitrypsin deficiency is a risk factor for
HCC
209
kidney cancer prev?
* comprises 3% of all cancers in men, 2% in women
* 8th most common cancer in men
* overall mortality 40%
210
Types of kidney cancer?
* 85% occur in renal parenchyma (renal cell carcinoma (RCC))
* 6% occur in renal pelvis (transitional cell carcinoma (TCC))
* 6% occur in ureter (transitional cell carcinoma)
211
RF for kidney cancer?
* age
* sex - male > female
* obesity
* smoking
* HTN
* diet - poor intake of fruit and veg
* radiotherapy for prev testicular/ gynae cancer
212
what inc risk of KC by 3-4x?
adult polycystic kidney disease
213
what inc risk of kidney cancer by 7x?
* renal dialysis - inc risk 7x after 10 yrs dialysis
214
FHx of ? inc risk of kidney cancer?
bon Hippel Lindau disease
215
# and which renal cancer?
drugs inc risk of KC?
phenacetin - inc risk of TCC of renal pelvis
216
Most common histological subtype of kidney cancer?
* conventional (aka clear cell) RCC 75-80%
217
How is clear cell RCC graded?
* graded histologically according to Fuhrman classification
* Fuhrman 1 (well differentiated) -> Fuhrman 4 (poorly differentiated)
218
other histological types of RCC?
* papillary (aka chromophilic) RCC 10-15%
* chromophobic RCC 5%
* collecting duct RCC 1%
- unclassified
219
Most common way renal cancer presents?
*asymptomatic – incidental discovery on imaging done for other reasons (commonest)
220
Symptoms of RC?
* haematuria (blood in urine) – visible and non-visible (dipstick, microscopic)
* palpable mass
* weight loss/ night sweats
* anaemia
* bone pain/ fracture from mets
221
Paraneoplastic syndromes from renal cell cancers?
renal cell cancers can inappropriately secrete ectopic peptide hormones e.g. EPO, PTH
222
staging of renal cancer?
* US and CT for formal staging
223
RC - observation for?
small tumours in elderly or those w sig medical co-morbidity
224
Tx of localised kidney disease?
* surgery (nephrectomy)
* radiofreq ablation or cryotherapy
225
Tx of metastatic kidney disease?
* cytoreductive nephrectomy
* can inc resp to subsequent biological therapy
* biological therapy
* interferon-alpha
* TKI
226
survival from kidney cancer?
* 10th highest cause of cancer deaths in men in the UK, 12th in women
* 10 yr survival = 43%
227
prev of bladder cancer?
* 4th commonest cancer in men, 11th in women
* overall mortality approx 50%
228
gender affected more by bladder cancer?
* M:F = 5:2
229
RF for bladder cancer?
* SMOKING
* occupation - analine dyes - paint, hair dye, textile and pesticide industries
* hair dyes
* pelvic irradiation
* caucasian males
* dietary factors
230
drugs inc rate of bladder cancer?
phenacetin, cyclophosphamide
231
chronic UTI predisposes to which type of bladder cancer?
squamous cell carcinoma
232
Schistosomiasis predisposes to?
sq cell carcinoma espec in the Middle East
233
histology of bladder cancer?
* 90-95% are transitional cell carcinomas (TCC)
* 3-4% are squamous cell carcinomas
* 1-2% are adenocarcinomas
234
Most common type of bladder cancer?
TCC
235
grading and staging of bladder cancer?
* graded according to degree of cytological atypia
- 1 (well differentiated, low grade) to 3 (poorly differentiated, high grade)
- staging based on TNM
236
# Three features
presentation of BC?
* haematuria
* irritative lower urinary tract symptoms (frequency, urgency)
* recurrent UTI (SCC)
237
symptoms of advanced/ metastatic bladder cancer?
* general – weight loss, lethargy
* bone pain/fracture
* pelvic pain
* lower limb/genital oedema from pelvic lymphadenopathy
238
Ix of bladder cancer?
* cytoscopy
* CT/ MRI for staging
239
initial treatment of bladder cancer?
* initial: TURBT - transurethral resection of bladder tumour
* removes primary tumour and allows formal histological grading and staging
240
?% of bladder cancers are muscle invasive
* 75% of tumours are non muscle invasive, 25% are muscle invasive from the outset
241
Low grade non-muscle invasive bladder cancer ->
Cystoscopic surveillance x5-10 years
242
Moderate/high grade non-muscle invasive BC(including carcinoma-in-situ) ->
Intravesical chemotherapy (Mitomycin C) or intravesical immunotherapy (BCG) + Cystoscopic surveillance
243
muscle invasive bladder cancer ->
Radical cystectomy or radiotherapy ± neoadjuvant Cisplatin-based systemic chemotherapy
244
metastatic bladder cancer ->
Palliative chemotherapy ± palliative radiotherapy for local symptom control
245
what is the most common cancer in men?
PC, * accounts for nearly 25% of all newly diagnosed cancers in men
246
2nd most common cause of cancer death in men?
- PC, 1st is lung
* overall mortality approx 25-30%
247
Why is PC being diagnosed more?
* increasing use of serum PSA (prostate specific antigen) test has led to increase in diagnosis of prostate cancer and detection of prostate cancers at earlier stage
248
RF for PC?
* age - 80% OF OVER 80
* Fhx
* ethnic origin -2-3x inc risk in black Africans/ Caribbean
* dietary - lycopenes and selenium protective
249
PC - 98% are ?
adenocarcinomas
250
Ix of PC
* histological material obtained via prostate biopsy or from TURP shaings
* transrectal prostate biopsy performed if clinical suspicion of prostate cancer (↑ PSA or abnormal-feeling prostate on rectal examination)
251
CP of PC?
* asymptomatic (through PSA testing)
* local disease
* haematuria
* lower urinary tract symptoms (identical to those cause by BPH)
252
Advanced prostate cancer symptoms?
* general – weight loss, lethargy
* bone pain/fracture - mets
* pelvic pain
* lower limb/genital oedema from pelvic lymphadenopathy
253
other tests for PC?
* PSA level
* pelvic MRI
* isotope bone scan
254
Tx of low risk PC
* active surveillence
* bracyhtheapy, prostatectomy, radio, waiting
255
Tx of medium risk PC
* radical prostatectomy
* radical radiotherapy
256
Tx of high risk PC?
* radical prostatectomy
* radical radiotherapy w neoadjuvant hormone therapy
257
Main Tx of metastatic PC?
* hormone manipulation - PALLIATIVE
258
hormone manipulation in PC?
* prostate cancer initially dependent on testosterone
* therapy aims at blocking testosterone production or testosterone metabolism by
* prostate cancer cell (and inducing castrate status)
259
How can hormone manipulation be done?
* surgically – bilateral scrotal orchidectomy
* medically – anti-androgens, LHRH analogues, oestrogens
* average response to 1st line therapy = 2-3 years
260
side effects of hormone manipulation (PC)
hot flushes, breast enlargement/tenderness, weight gain, osteoporosis, loss of libido, impotence
261
Castration resistant PC?
* systemic chemotherapy (Taxotere)
* new agents (Abiraterone, Enzalutamide)
* median survival 18-24 months
262
