Cancer Flashcards
1
Q
CUP- characteristics, common primaries, presentation
A
- Character:
- Met early –> multiple sites
- Absence of primary cancer
- Unpredictable
- Aggressive
- Common primaries
- Common primaries- liver, bone, lung, LN
- Presentation- depends on primary!
- Anaemia
- SOB
- Fatigue
- Lymphadenopathy
- Ascites
- Pain
- Skin tumours
2
Q
Approach to CUP + Ix + Tx
A
- Early referral to oncology. Search for primary.
- Rule out potentially treatable/ curable.
- Treat! ?Curative/ palliative?
- Ix:
- Bedside- urinalysis, FOB
- Bloods- FBC, U+Es, LFTs, CRP, tumour markers
- Imaging- CT thorax/abdo/pelvis, PET. ?endoscopy ?MRI
- ?Biopsy
- Tx- chemo, hormonal, radio, surgery. ?Palliation
3
Q
What are paraneoplastic syndromes and their broad categories?
A
- = Set of Sx that come as a consequence of cancer.
- Endocrine- SIADH, Cushing’s syndrome, hypercalcaemia
- Growth factor related- Acanthosis nigricans, hypertrophic pulmonary arthropathy (clubbing + peristitis)
- Immune system mediated- cerebellar syndrome, Lambert-eaton syndrome
- Vascular- Trousseau’s
4
Q
What is SIADH and what might cause it?
A
- = Syndrome of Inappropriate Anti-Diuretic Hormone
- ++ ADH –> more reabsorption of water in kidneys –> dilutional hyponatraemia. Osmosis into cells –> cerebral oedema.
- Causes:
- Cancer- SCLC, mesothelioma, GI, bladder, urethral, prostate, endometrial, lymphoma
- Drugs- carbamazepine, sodium valproate, SSRIs, TCAs, morphine
- Diseases affecting the CNS- meningitis, encephalitis, trauma, SAH, MS
5
Q
SIADH - Presentation and diagnostic criteria
A
- Presentation:
- Euvolaemic hyponatraemia
- N+V
- Cramps
- Cerebral oedema –> confusion, low GCS, seizures, coma
- Diagnostic criteria= strict!
- Urine osmolality >500mosm/kg
- No recent diuretics
- Clinical euvolaemia
- Urine Na+ >20mmol/L
- Normal adrenal and thyroid function
6
Q
Ix and Tx of SIADH
A
Ix:
- Bedside- urine osmolality + Na+
- Bloods- FBC, U+Es, LFTs, CRP, TFTs, plasma osmolality
- Imaging - ?Ca
- Special - Short synacthen test
Tx:
- Cons- remove cause, restrict fluids (1200mL/d)
- ?Hypertonic saline
- Mannitol (osmotic diuretic), demeclocycline
7
Q
How does cancer cause Cushing’s syndrome and what cancers might cause it? Ix + Tx
A
- Tumour –> ectopic release of ACTH –> raised cortisol –> Cushing’s
- Causes: SCLC, pancreatic, thoma, (cervix/prostate)
- Ix:
- High blood cortisol
- Dexamethasone suppression - dosen’t suppress at 1mg or 8mg
- Serum ACTH detectable
- Imaging - ?? where is the cancer?
- Tx: Tx underlying Ca. Reduce cortisol- ketonazole, metyrapone
8
Q
How does cancer cause hypercalcaemia and what cancers might do this?
A
- Ectopic release of PTHrP –> stimulates osteoclasts –> release calcium from bone. Also calcitriol production.
- Causes: Lung SCC, breast, renal, bladder, ovaria, myeloma (40% of those with myeloma)
9
Q
Bloods that make cancer more likely cause of hypercalcaemia
A
- Low albumin, low chloride, alkalosis, hypokalaemia, high phosphate, high alk phos
- More likely hyperparathyroidism- high PTH
10
Q
Paraneoplastic cerebellar degeneration - cause, presentation and Tx
A
- Cause: Cancer produces proteins similar to those in cerebellum –> AI attack of cancer and native proteins
- Presentation= DANISH
- Dysdiadochokinesia
- Ataxia
- Nystagmus
- Intention tremor
- Slurred/staccato speech
- Hypotonia/ Heel-shin test
- Tx- Tx cause. Immunosuppression- cyclophosphamide, methylprednisolone
11
Q
What is Lambert Eaton Syndrome? How is it caused?
A
- Antibodies bind to cancer cells –> change shape –> attack calcium channels in muscle –> reduced muscular action potentials.
- Cause= Cancer (SCLC, GI, breast, thymus) or AI
12
Q
Presentation of Lambert-Eaton Syndrome. Ix and Tx
A
- Muscle weakness legs>arms
- Hyporeflexia
- Weakness and hyporeflexia improve after exercise!
- Resp issues
- Gait
- Eye - eye muscle weakness, drooping, diplopia, reduced pupillary reflex
- ANS- dry mouth, constipation, impotence
- Ix: nerve conduction studies, anti-VGCC Abs
- Tx: Plasmapheresis, IV immunoglobulin
13
Q
What is acanthosis nigricans? Causes, presentation, Tx
A
- Insulin mediated growth factors –> AN.
- Causes: DM, malignancy (type 4) - GI adenocarcinomas, lung, endometrial, prostate, breast, ovary, lymphoma
- Presentation- velvety, hyperpigmented skin. Flexural. Armpits/ neck.
- Tx- topical fade creams
14
Q
What is Trousseau’s sign of malignancy? Causes, presentation, Tx
A
- = Thrombophlebitis migrans
- Cause= cancer. Hypercoaguable state –> more blood clots –> vessel inflammation.
- Causes- Cancer- pancreatic, gastric, lung
- Presentation- inflammation around clot. Red, painful, oedema. Recurrent in diff locations over time.
- Tx- anticoagulation, TED stockings
15
Q
What is hypertrophic pulmonary osteoartropathy? +causes, Tx
A
- Growth factor release from tumour. Lung cancer.
- Clubbing, periostitis of MCPs + DIPs
- Tx= NSAIDs
16
Q
Neutropoenic Sepsis - Presentation, Ix and Tx
A
- = Pyrexia >38C and neutrophils <0.5x109/L
- Presentation:
- Always suspect if unwell and chemo <6w
- NB examine indewelling cannulas/ catheters
- Fever + rigors
- Tachycardia
- Hypotension
- ??Localising signs
- Ix:
- INFECTION SCREEN inc swabs, catheter + lines
- Bloods inc culture
- Tx: ASAP! High dose empirical Tazocin IV
17
Q
What cancers are more likely to cause spinal cord compression?
A
- Lung
- Prostate
- Breast
- Myeloma
- Melanoma
18
Q
What is superior vena cava obstruction and what might cause it?
A
- = Extrinsic compression (most common) or venous thrombosis (current/past central venous access) –> less venous return from head, neck and upper limbs.
- Causes: >90% due to malignancy- lung, lymphoma, breast, thmoma, germ cell, mets
19
Q
Presentation of SVC obstruction
A
- SOB + orthopnoea
- Oedema - face, arm
- Cough
- Headache
- Engorged neck/ chest wall veins
- Plethora/ cyanosis
- Stridor
- Pemberton’s test- elevation of arms –> facial plethora/ cyanosis
20
Q
Ix and Tx of SVC obstruction
A
- Dx= clinical.
- Ix= CT
- Tx:
- ABCDE. Sit up.
- Medical- dexamethasone 16mg/24h
- Surgical- balloon venoplasty and SVC stenting
- Refer to oncology –> Tx underlying cause. Chemo/ radio.
21
Q
Causes and presentation of brain metastases
A
- Causes= mets from: lung, breast, colorectal, melanoma.
- Presentation:
- Raised ICP headache
- Ataxia
- N+V
- Papilloedema
- Fits
- Focal neurology
22
Q
Ix and Tx of brain mets
A
- Ix= urgent CT/MRI
- Performance status?
- Tx:
- Cons- Sx control
- Med- dexamethasone 16mg/24h, stereotactic radiotherapy
- Surg- neurosurgery
23
Q
What is tumour lysis syndrome and how might it present?
A
- High tumour burden –> death of large no. of cells over short time (eg chemo/ steroids)
- More common in rapidly proliferating tumours- leukaemia, lymphoma, myeloma.
- Presentation:
- Chest pain
- SOB
- Arrhythmias
- Diarrhoea
- Muscle weakness
- Anorexia
- N+V
- Seizures
- Syncope
- Precipitants- chemo, radio, steroids, immune modifiers, surgery, spontaneous
24
Q
Diagnosis of tumour lysis syndrome
A
- Ix- bloods, ECG, imaging for underlying Ca
- Bloods:
- Uraemia
- Hyperkalaemia
- Hyperphosphataemia
- Hypocalcaemia
- Raised LDH
- Raised serum creatinine
25
Q
Complications of tumour lysis syndrome
A
- Metabolic disturbance (K+) –> cardiac arrest, arrhythmias
- High urate –> AKI
- High LDH –> DIC
26
Q
Tx and prevention of tumour lysis syndrome
A
- Prevention- ++ hydration, allopurinol, avoid drug interactions (ACEi, spironolactone, NSAIDs)
- Twice daily bloods in those at risk!
- Correct electrolytes- calcium gluconate, insulin, hydration, IV bicarbonate?
- Haemodialysis
- Reduce urate- Allopurionol, urate oxidase inhibitor
27
Q
Causes/ RF, presentation and Tx of lymphoedema
A
- = Accumulation of interstitial fluid due to abnormal lymphatic drainage.
- Causes- congenital, surgery, radio, malig
- RF: female, obesity, FHx, obesity, breast Ca esp axillary node clearance.
- Presentation:
- Limb swelling - pitting acute, woody in chronic
- Reduced mobility
- Recurrent infection
- Tx:
- Cons- elevation, compression bandage, massage
- Med- ABx for secondary inf
- Surg- ?Excisional techniques
28
Q
Presentation and RF for testicular cancer
A
- Presentation:
- Usually young adults/ teens
- Mass/ swelling
- Hydrocoele
- Gynaecomastia
- Pain / back ache
- ?SVC obstruction
- Fatigue, weight loss
- RF: Genetics, Down’s, Maldescended testicles, Klinefelter’s, infertility
29
Q
Ix and Tx of testicular cancer
A
- Ix: TUMOUR MARKERS V USEFUL!
- AFP
- Beta-hCG
- LDH
- CXR- mediastinal lymphadenopathy. ?Canon ball mets
- CT- staging
- Tx:
- Surgery- radical orchidectomy
- Surveillance- CXR monthly 1 y –> 6 monthly 5y
- Chemo/radio
- Complications of Tx- Tumour lysis, infertility, malignancy, CVS, psychosocial
30
Q
What anticipatory meds might you prescribe in palliative care?
A
- Pain/ SOB: Morphine, eGFR <30 –> alfentanil
- Secretions: Hyoscine hydrobromide, eGFR <30 –> hyoscine butlbromide
- Nausea and vomiting: Cyclizine, eGFR <30 –> haloperidol
- Agitation: Midazolam
- Capillary bleeding - tranexamic acid
