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Finals > Cancer care > Flashcards

Cancer care Flashcards

1
Q

What is the assessment for breast cancer

A

Triple assessment: clinical exam, USS/mammo, histology/cytology - FNA/core biopsy

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2
Q

USS or mammo for breast cancer

A

USS if <35, both if >35

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3
Q

What is sentinel node biopsy

A

Blue dye or radiocolloid into tumour area, probe/see sentinel node, biopsy and send for histology/immunohistochemistry

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4
Q

Predicting prognosis for breast cancer

A

Nottingham prognostic index = size + histological grade + nodal status
Also ER/PR status and vascular invasion

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5
Q

What is pre menstrual breast change

A

Nodularity and pain in upper outer quadrant with fibrosis, adenosis, cysts, epitheliosis, papillomatosis = benign mammary dysplasia

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6
Q

When are breast cysts common

A

Perimenopause

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7
Q

Common benign breast lumps

A

Fibroadenoma - collagenous mesenchyme, firm, smooth, mobile, multiple. Regress, stay same or get bigger (1/3 each)
Fibroadenosis - focal or diffuse nodularity

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8
Q

Infective mastitis?

A

Usually staph a, coamox/Flucloxacillin /incise, drain

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9
Q

Physiological nipple discharge/?

A

Duct ectasia - dilatation with age = green, brown, bloody discharge

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10
Q

Fat necrosis in breast?

A

Fibrosis and calcification after trauma = mass

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11
Q

Nodal status for breast cancer

A

1 = ipsilateral and mobile, 2 = fixed

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12
Q

Premalignant breast diseases?

A

Non invasive dcis = microcalcification on mammo, unifocal or widespread, 30-50% progress
Non invasive lcis = multifocal, rarer, higher risk of progression

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13
Q

Most common breast cancers

A

Invasive ductal carcinoma (70%)
Invasive lobular carcinoma
Medullary - younger patients

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14
Q

RF for breast cancer

A 
FHx, age, uninterrupted oestrogen exposure - nulliparity, first pregnancy >30y/o, early menarche and late meno
Not breast feeding
HRT
Obesity
BRCA
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15
Q

Stages of breast cancer

A 
1 = confined to breast and mobile
2 = + node in ipsilateralaxilla
3 = fixed to muscle but not chest wall, ipsilateral axilla node matted and may be fixed, skin involvement
4 = fixed to chest wall, distant mets
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16
Q

TNM for breast

A

T: 1 = <2, 2 = 3-5, 3= >5, 4 = fixed to chest wall or peau d’orange
N: 1 = mobile ipsilateral, 2 = fixed

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17
Q

Treat stage 1-2 breast cancer

A

Surgery - wide local excision or mastectomy axillary node sample/clearance
Radiotherapy - prevent local recurrence after surgery, and nodes if positive and not completely cleared
Chemo - improve survival esp if young and node pos, or neoadjuvant
Endocrine therapy

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18
Q

Types of hormone therapy for breast cancer

A

Tamoxifen oestrogen blocker
Aromatase inhibitor targets oestrogen synthesis, better tolerated, for post-meno
GnRH analogues or ovarian ablation if pre-meno and ER pos

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19
Q

ADRs of radiotherapy for breast

A

Pneumonitis, pericarditis
Rib fractures
Lymphoedema
Brachial plexopathy

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20
Q

Treat stage 3-4 breast cancer

A

Bisphosphonates for painful bony lesions to decrease pain and fracture risk
Tamoxifen, chemo

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21
Q

Investigations for stage 3-4 breast cancer

A

LFT, calcium, cxr, skeletal survey, bone scan, CT/MRI or PET/CT, liver us

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22
Q

Causes of nipple discharge

A

Intraductal papilloma - bloody or clear

Duct ectasia - yellow/green

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23
Q

RF for colorectal cancer

A 
Neoplastic polyps
UC, Crohn’s
FAP
HNPCC
Low fibre diet 
Previous cancer
Smoking
Genetics
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24
Q

Sx of colorectal cancer

A 
Left = bleeding/mucus, altered bowel habit, tenesmus, mass
Right = weigh loss, Hb low, abdo pain
Both = abdo mass, perforation, haemorrhage, fistula
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25
Q

Use of CEA in colorectal cancer

A

Monitor disease and effectiveness of treatment

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26
Q

Tests for colorectal cancer

A 
FBC - microcytic anaemia
Faecal occult blood
Sigmoidoscopy
Barium enema or colonoscopy / CT
DNA if familial polyposis once >15y
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27
Q

What is anterior resection for

A

Low sigmoid or high rectum tumour - anastamosis

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28
Q

What is APR and what is it for

A

Low rectal tumour (=<8cm from anus), permanent colostomy and remove anus and rectum

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29
Q

What is hartmann’’s procedure

A

Emergency obstruction or palliation

Proctosigmoidectomy and close rectal stump

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30
Q

Colorectal Surgery if not fit?

A

Transanal endoscopic microsurgery for local excision through wide proctoscope
endoscopic stenting

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31
Q

Chemo in colorectal cancer?

A

Reduce mortality for Duke C

Palliation for mets

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32
Q

Sx of anastomotic leak after colectomy

A

Raised temperature
Abdo pain
Peritonism

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33
Q

What are polyps and what 3 types are in GIT?

A

Lumps above the mucosa
Inflammatory - IBD, lymphoid hyperplasia
Hamartomatous - juvenile, Peutz-Jeghers syndrome
Neoplastic - adenomas with malignant potential

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34
Q

Sx of polyps in GIT

A

Blood/mucus

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35
Q

Most common site of colorectal carcinomas

A

Rectum = 45%, sigmoid = 25%

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36
Q

Duke’’s classification

A

Stage A - beneath muscularis mucosa
B - through muscularis mucosa
C - regional lymph nodes
D - distant mets

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37
Q

Potential screening programs for colorectal cancer and flaws

A

Now = FOB home test every 2y from 60-69y, but high false pos
Sigmoidoscopy for left sided, high sens and spec but expensive and not accepted
Colonoscopy - perforation rate higher than sigmoidoscopy, cost, sedation, not accepted

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38
Q

Chemo for colorectal cancer?

A

Adjuvant, including biologics for VEGF/EGFR

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39
Q

Who gets regular colonoscopy?

A

HNPCC, FAP

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40
Q

Stomach cancer pathology

A 
Mostly adenocarcinoma - diffuse (more common, worseprognosis) or intestinal (better prognosis)
Borrmann classification:
1) polypoid/fungating
2) excavating
3) ulceration and raised
4) linitis plastica
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41
Q

Symptoms of stomach cancer

A 
Non-specific
Dyspepsia (inv if >1m and >50y)
Weight loss, anorexia, early satiety, vomiting
Dysphagia and odynophagia if junctional
Anaemia
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42
Q

bad signs on exam for stomach cancer

A 
Epigastric mass
Hepatomegaly, jaundice, ascites
Virchow node = Troisier’s sign
Acanthosis nigricans
Succussion splash (outlet obstruction)
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43
Q

What is Krukenberg tumour

A

Stomach tumour spread to ovary

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44
Q

Imaging gastric cancer

A

Gastroscopy and multiple ulcer edge biopsy
Endoscopic US
CT/MRI for staging
Staging laparoscopy if locally advanced and no mets

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45
Q

Treat gastric cancer

A

Curative laparotomy
Subtotal gastrectomy
Lymphadenectomy
Neoadjuvant CRT
Endoscopic laser to decrease bleeding
Combination chemo if advanced - for QoL and survival
Endoscopic mucosal resection for early tumours confined to mucosa

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46
Q

5y survival for gastric cancer

A

<10%

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47
Q

Risk factors for oesophageal cancer

A 
Obesity
Smoking
Alcohol, radiotherapy, caustic = SCC
Achalasia
Reflux oesophagitis +- Barrett’s oesophagus, hiatus hernia, antacids = adeno
Man (5x woman)
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48
Q

Where and type of oesophageal cancer

A

50% middle, 30% bottom, 20% upper

2/3 Squamous 1/3 adeno

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49
Q

Sx of oesophageal cancer

A

Dysphagia, weight loss, retrosternal chest pain, lymphadenopathy
Hoarse, cough (paroxysmal if aspiration pneumonia) if upper

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50
Q

Tests for oesophageal cancer

A 
Barium swallow
CXR
Oesophagoscopy with biopsy/EUS
CT/MRI
Staing laparoscopy if infra-diaphragmatic
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51
Q

staging for oesophageal cancer

A 
TNM
T1 = lamina propria/submucosa
T2 = muscularis propria
T3 = adventitia
T4 = adjacent structures 
N1 = regional node mets
M1 = distant mets
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52
Q

Treatment for oesophageal cancer

A

Radical oesophagectomy if localised T1/2 = transhiatal or transthoracic
Neoadjuvant chemo
CRT if no surgery
Palliative = CRT, stent, laser

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53
Q

Causes of oesophageal rupture

A 
Iatrogenic
Trauma
Carcinoma
Boerhaave syndrome
corrosive ingestion
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54
Q

Sx of oesophageal rupture

A 
Odynophagia
Tachypnoea, dyspnoea
Fever
Shock
Surgical emphysema
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55
Q

Manage oesophageal rupture

A

NGT, Abx, PPI

Antifungals, surgery, oesogo-cutanesous fistula

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56
Q

When to order urgent endoscopy for stomach cancer

A

> 55 with dyspepsia

<55 with dyspepsia and one of: weight loss, anorexia, vomit, dysphagia, sx of bleeding

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57
Q

Causes of lung nodules on cxr

A 
Malignancy
Abscess
Granuloma
Carcinoid tumour
Pulmonary hamartoma
AV malformation
Encysted effusion
Cyst
Foreign body
Skin tumour
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58
Q

Common types of lung tumour

A

Squamous 35%
Adenocarcinoma 25%
Small cell 20%
Large cell 10%

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59
Q

Signs and symptoms of lung cancer

A

Cough, haemoptysis, dyspnoea, chest pain, slow resolving pneumonia
Cachexia, anaemia, clubbing (nsclc), hypertrophic pulmonary osteoarthropathy = wrist pain, supraclavicular or axillary nodes
Chest - consolidation, collapse, pleural effusion

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60
Q

Signs of mets from lung cancer

A

Bone tenderness
Hepatometaly
Confusion, fits, focal CNS signs, cerebellar syndrome
Proximal myopathy, peripheral neuropathy, Lambert Eaton myasthenic syndrome

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61
Q

Local complications of lung cancer

A

Local - recurrent laryngeal nerve palsy, phrenic nerve palsy, SVC obstruction, Horner’s syndrome (pancoast), rib erosion, pericarditis, AF

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62
Q

Metastatic complicatiotns fo lung cancer

A

Brain
Bone - pain, anaemia, raised calcium by squamous tumours
Liver
Adrenals - Addison’s

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63
Q

Endocrine complicatiotns fo lunc cancer

A

Small cell. = SIADH (low sodium high ADH), ACTH (cushings’)

Squamous = PTH (high calcium)

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64
Q

Tests for lung cancer

A

Sputum and pleural fluid cytology
CXR - nodule, hilar enlargement, consolidatoin, collapse, effusion, bony secondaries
Percutaneous FNA or biopsy if peripheral/superficial
Bronchoscopy for histology and operability
CT for staging

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65
Q

Treatment for lung cancer

A

Non small cell - excision if peripheral and no spread (stage 1-2)
- Curative RT if resp reserve poor
- CRT if advanced
Small cell nearly always disseminated but may respond to chemo +-RT

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66
Q

Palliation for lung cancer

A

RT for obstruction, SVC, haemoptysis, bone pain, cerebral mets
SVC obstruction - stent, RT, dexamethasone
Tracheal stent
Pleural drainage for effusions

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67
Q

Prognosis of lung cancer

A

Non small cell = 50% 2y

Small cell - 3m median survival if untreated

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68
Q

Staging for lung cancer

A

T1 <3cm in lobar or distal
T2 >3cm and >2cm distal to carina or any size + pleural involvement or obstructive pneumonitis
T3 involves chest wall, diaphragm, mediastinal pleura, pericardium
T4 involves mediastinum, heart, great vessels, trachea, oesophagus, vertebral body or malignant effusion
N1 - peribronchial or ipsilateral hilum
N2 - ipsilateral mediastinum or subcarinal
N3 - contralateral mediastinum or hilum or supraclavicular

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69
Q

Features of different lung cancers

A

Scc - bronchiobstruction causes infection - cavitation on cxr, slow grow, local spread
Adenocarcinoma - peripheral, scar tissue, bronchial mucous glands, effusion from mets to mediastinal node and pleura
Large cell - neurosecretory, poorly differentiated, grown and met early
Small cell - central, present with systemic disease, neurosecretory granules

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70
Q

Complications of surgery and CRT for oesophageal cancer

A 
Surgery = anatamotic leak, stricture, reflux, motility problems
CRT = perforation, stricture, pneumonitis, pulmonary fibrosis
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71
Q

Most common renal cancer

A

Renal cell carcinoma= 90% - proximal renal tubular epithelium

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72
Q

Sx of renal cell carcinoma

A

50% incidental finding
Haematuria, loin pain, abdo mass, anorexia, malaise, weight loss, PUO
Varicocoele from invasion of left renal vein obstruction

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73
Q

Initial test findings for renal cell carcinoma

A

BP high from renin secretion
FBC - polycythaemia from epo
ALP - high if bony mets
Urine for RBC and cytology

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74
Q

Imaging for renal cell carcinoma

A 
US
CT/MRI
IV urogram
Renal angiography 
CXR - cannonball mets
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75
Q

Treatment for renal cell carcinoma

A

Radical nephrectomy

Angiogenesis inhibitors

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76
Q

Staging for renal cell carcinoma

A 
Robson:
1 - in kidney
2 - perinephric fat
3 - renal vein
4 - adjacent/distant organs
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77
Q

Where is transitional cell carcinoma

A

Bladder, ureter, renal pelvis

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78
Q

Sx of transitional cell carcinoma

A

Painless haematuria, frequency, urgency, dysuria, urinary tract obstruction

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79
Q

Investigate transitional cell carcinoma

A

Urine cytology
IV urogram
Cystoscopy and biopsy
CT/MRI

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80
Q

Main abdominal malignancy in children and sx

A

Nephroblastoma - Wilm’s tumour

Abdo mass and haematuria

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81
Q

Where and histology of prostate cancer

A

Adenocarcinoma in peripheral prostate

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82
Q

Where does prostate cancer spread

A

Seminal vesicles, bladder, rectum

Haematoenous to bone

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83
Q

Sx of prostate cancer

A

Nocturia, hesitancy, poor stream, terminal dribble, obstruction
Weight loss and bone pain = mets

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84
Q

Inv for prostate cancer

A 
DRE
PSA
Transrectal USS and biopsy
Bone X-ray, bone scan
CT/MRI for staging
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85
Q

Treat prostate cancer

A

Local - radical prostatectomy or radiotherapy and hormonal therapy
Mets - hormonal drugs, GnRH analogues - stimulate then inhibit pituitary gonadotropin
Adjuncts - analgesia, treat hypercalcaemia, radiotherapy for bone mets/spinal cord compression

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86
Q

Prognostic factors in prostate cancer

A

Age
Pre treatment PSA level
Tumour stage
Tumour Gleason grade

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87
Q

How is Gleason grade calculated and what does it mean for treatment

A

Histology from 2 areas and add them, 2-10. High score = aggressive treatment

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88
Q

Pros and cons of PSA for asymptomatic. Men

A

May not die from it
False positive leads to invasive investigation
1/3 with high psa actually have cancer
Unnecessary treatment with ADRs

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89
Q

Risk factors for prostate cancer

A

Age - 80% of >80s
High testosterone
Family history

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90
Q

Risk and preventative factors for penile cancer

A

Very rare if circumcised

Chronic irritation, viruses, smema

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91
Q

Presentation of penile cancer

A

Fungating ulcer, bloody/purulent discharge

50% spread to lymph at presentation

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92
Q

What is balanitis

A

Balanitis - staph and strep in foreskin and glans
Common in diabetes, children with tight foreskin
Treat with abx, circumcision and hygiene advice

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93
Q

What is phimosis

A

Foreskin occludes meatus causing recurrent balanitis and ballooning
Cause painful sex, infection, ulceration and balanitis xerotica obliterans in adults

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94
Q

What is paraphimosis

A

Tight foreskin retracted and irreplaceable, including after catheterisation, preventing venous return so oedema and ischaemia of glans
Treat by squeezing glans, may need dextrose swab, aspiration, circumcision

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95
Q

What is prostatitis

A

Acute or chronic, >35y
S faecalis and E. coli
UTI, retention, pain, haematospermia, swollen/boggy prostate
Treat with analgesia and levofloxacin for 28d

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96
Q

Grading bladder tumours

A

Grade 1 = differentiated
2 = intermediate
3 = poorly differentiated

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97
Q

Common bladder cancers

A

Transitional cell

Rare = adenocarcinoma and scc

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98
Q

Risk factor for bladder cancer

A 
Male (x4)
Schistosomiasis = scc
Smoking
Aromatic amines - rubber industry
Chronic cystitis
Pelvic irradiation
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99
Q

Presentation of bladder cancer

A

Painless haematuria, recurrent UTI, voiding irritability

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100
Q

Tests for bladder cancer

A

Urine - microscopy and cytology - sterile pyuria
IVU - filling defect, ureteric involvement
Cystoscopy and biopsy = diagnostic
Bimanual EUA for spread
CT/MRI or lymphangiography for pelvic nodes

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101
Q

Staging bladder cancer

A 
Tis = in situ
Ta = epithelium
T1 = lamina propria
T2 = superficial muscle = rubbery thickening on EUA
T3 = deep muscle = mobile mass on EUA
T4 = beyond bladder = fixed mass on EUA
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102
Q

Treat bladder tcc

A

Tis, Ta, T1 = watch and wait, or TURBT - diathermy via transurethral cystoscopy. + intravesicular chemo or BCG (non specific inflammatory response) if high grade or many small
T2-3 = radical cystectomy +- adjuvant chemo
T4 = palliative CRT + catheterisation and diversions for pain

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103
Q

Follow up for bladder tcc

A

Regular cystoscopy - every 3m for 2y then every 6m if high risk
After 9m then yearly if low risk

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104
Q

Spread of bladder tcc

A

Local - pelvic
Lymphatic - iliac and paraaortic nodes
Haematogenous - liver and lung

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105
Q

Prognosis if node involvement of bladder tcc

A

6% if unilateral at 5y

0% if bilateral or para aortic

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106
Q

Complications of bladder tcc treatment

A

Sexual and urinary malfunction if cystectomy
Massive bladder haemorrhage
Ileal conduit - urine toxic to skin, ureters may stenose

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107
Q

Cause of raised PSA

A 
Big prostate
Infection  uti
Inflammation - catheter
BPH
cancer prostate
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108
Q

Bone scan findings with CaP

A

Sclerotic lesions, other cancers normally lytic

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109
Q

ADR of radical prostatetomy

A

Erectile dysfunction, retrograde ejactulation, urinary damage - incontinence

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110
Q

ADR of radiotherapy and different types of RT for prostate cancer

A

External beam or low does brachytherapy

Causes bowel symptoms ie diarrhoea

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111
Q

Hormonal treatment for CaP

A

Castration - surgical orchidectomy or medical LHRH agonist - neg feedback so suppresses T production from leydig cells. Cover with antiandrogen for first month to prevent LH surge causing growth of spinal mets

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112
Q

Screening issues with PSA

A

Lead time bias and length time bias

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113
Q

Origin of most bladder cancers

A

Papillomata, 80% confined to mucosa

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114
Q

Causes of pancytopoenia

A

Increaed peripheral destruction - hypersplenism

Decreased marrow production - aplastic anaemia, megaloblastic anaemia, myelofibrosis, marrow infiltration

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115
Q

Types of marrow infiltration causing pancytopoenia

A

Neoplasm - myeloma, lymphoma, acute leukaemia, solid tumours

TB, myelodysplasia

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116
Q

Causes of aplastic anaemia

A

AI - drugs, viruses (hepatitis, parvo), irradiation

Inherited - Fanconi anaemia

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117
Q

Treat aplastic anaemia

A

Asymptomatic - supportive
Immunosuppression
Curative - allogenic marrow transplant from HLA matched sibling
Support blood count with RBC, platelets and WBC

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118
Q

What is agranulocytosis

A

No production of wBC with granules: BEN (Basophils, Eosinophils, Neuttrophils)

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119
Q

What to safety net for agranulocytosis

A

Sore throat or fever

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120
Q

Treat agraanulocytosis

A

G-CSF
Neutropoenia regimen
Abx and cotrimoxaxole for PCP

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121
Q

ADR cotrimoxazole

A

Rash

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122
Q

What is neutropoenia regimen

A 
If neutrophils <0.5x10^9/l
Barrier nursing
No IM injections or DRE
Chlorhexidine on moist skin
Oral hygiene
Swab infection sites - mouth, axilla, perineum, IVI
Culture blood x3, sputum, urine, stool if diarrhoea
FBC, Plt, inr, U&amp;E, ,LFT
CXR
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123
Q

When to irradiate platelets

A

Immunosuppression or marrow transplant to prevent graft vs host

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124
Q

When to give platelets

A

If <10x10^9/l
Haemorrhage
Before procedure if <50x10^9/l

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125
Q

Survival of different blood products

A

RBC 120d
Platelets 7d
WBC 1-2c

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126
Q

How to do bone marrow biopspy

A 
Posterior iliac crest
Aspirate to film for microscopy
Trephine bone core for cellularity, architecture and infiltration (neoplasm)
Cytogenetics
Flow cytometry
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127
Q

What is amyloidosis

A

Extracellular deposits of protein with abnormal fibrilar form, resistant to degradation

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128
Q

3 causes of amyloidosis

A

Plasma cell clonal proliferation - myeloma, lymphoma, MGUS, Waldenstrom’s
Serum amyloid A (acute phase protein) in chronic inflammation - RA, IBD, chronic infection (TB, bronchiectasis)
Familial amyloidosis - autosomal dominant

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129
Q

Sx of plasma cell proliferation causing amyloidosis

A

Kidneys - proteinuria, nephrotic syndrome
Heart - restrictive cardiomyopathy, angina, arrhythmia
GI - macroglossia, malabsorption, obstruction, hepatomegaly
Neuro - peripheral and autonomic neuropathy, carpal tunnel
Vascular - periorbital purpura

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130
Q

Sx of serum amyloid A from chronic inflammation

A

Kidneys. - nephrotic syndrome

Hepatomegaly

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131
Q

Sx of familial amyloidosis

A

Sensory/autonomic neuropathy

Renal/cardiac involvement

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132
Q

Treat familial amyloidosis

A

Liver transplant

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133
Q

Diagnosis of amyloidosis

A

Biopsy of rectum or sc fat as non invasive

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134
Q

What affects plasma viscosity

A

Concentration of large plasma proteins, chronic inflammation >24h - not acute:
RBC raised in polycythaemia rubra vera
WBC raised in leukaemia
Plasma components raised in myeloma and Waldenstrom’ss Macroglobulinaemia (IgM)

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135
Q

Treat raised plasma components

A

Plasmapheresis - remove plasma and discard, return RBC in more suitable medium

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136
Q

Sx of increased plasma viscosity

A

Decreased vision
Amaurosis fugax
Retinopathy - haemorrhage, exudates, blurred disc

CNS - disturbance, reduced cognition, falls
Chest and abdo pain
Spontaneous GI/Gu bleeding

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137
Q

What is ESR

A

How far RBC fall through anticoagulated blood column in 1h

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138
Q

What changes ESR

A

Proteins as make RBC stick together

- inflammation from infection, malignancy, rheumatoid arthritis, MI; anaemia; macrocytosis

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139
Q

Investigate raised ESR

A 
History and exam
FBC, U&amp;E
PSA
Plasma electrophoresis 
CXR, AXR (AAA)
Marrow or temporal artery biopsy
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140
Q

Calculate ESR

A 
Male = age/2
Female = age+10 /2
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141
Q

Associations with ALL

A

Genetic susceptibility
Environmental ie radiation in pregnancy
Down’s syndrome

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142
Q

Ways of classifying ALL

A

Morphological - FAB
Cytogenetic - chromosomal abnormalities
Immunological - precursor B, B or T

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143
Q

Sx of ALL

A

Marrow failure - anaemia, infection, bleeding
Organ infiltration - hepatosplenomegaly, lymphadenopathy including parotid and mediastinal, orchidomegaly, CNS - cranial nerve palsy, meningism

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144
Q

Common infections in ALL

A 
Chest, mouth, perianal, skin
Bacterial septicaemia
cmv, zoster, measles
pneumocystis pneumoniae
candidiasis
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145
Q

Investigations for ALL

A

Blast cells characteristic on film
CXR for mediastinal and abdominal lymphadenopathy
LP for CNS involvement

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146
Q

Treatment for ALL

A

Educate and motivate
Support - blood/platelet transfusion, IV fluids, allopurinol for tumour lysis prophylaxis, Hickman line
Chemotherapy - trials of remission/consolidation/CNS prophylaxis/maintenance ie monoclonal antibodies, cytokines, T cell infusions
Neutropoenia - abx, antifungals, antivirals
Matched related allogenic marrow transplant

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147
Q

Prognosis of ALL and bad prognostic signs

A 
70-90% in children, 40% in adults
Bad factors:
Adult, male
Philadelphia chromosome
CNS signs on presentation
Low haemoglobin
WCC >100
B cell ALL
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148
Q

What gene is related to ALL

A

Philadelphia chromosome - BCR-ABL gene fusion from translocation of chromosomes 9 and 22

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149
Q

How common is AML, what’s the prognosis and what is it associated with

A

Most common leukaemia of adults, 2m prognosis if untreated

RF: Chemo for lymphoma, myelodysplasia, radiation, syndromes ie downs

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150
Q

Classification of AML

A

WHO classification

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151
Q

Sx of AML

A

Marrow failure - anaemia, infection, bleeding
DIC in some
Hepatosplenomegaly, gum hypertrophy, skin involvement

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152
Q

Inv AML

A 
WCC may be high, normal or low
Marrow biopsy
Microscopy = Auer rods
Immunophenotyping
Cytogenetic analysis guides treatment
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153
Q

Complications of AML

A

Infection
Fever without infection
Tumour lysis causing plasma urate levels to rise
Leukostasis

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154
Q

Treatment of AML

A

Supportive
Chemo causing marrow suppression
Bone marrow transplant - pluripotent haematopoetic stem cells, using ciclosporin and methotrexate to prevent graft vs host

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155
Q

Complication of AML treatment

A 
Graft vs host disease
Leukaemia
Opportunistic infections
Infertility 
Relapse
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156
Q

What are myelodysplastic syndromes

A

MDS, myelodysplasia
Marrow failure
Most Primary, or secondary to CRT. 30% become acute leukaemia

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157
Q

Tests for myelodysplastic syndromes

A

Pancytopoenia, reduced reticulocytes
Marrow cellularity increased due to ineffective haematopoeisis
Ring sideroblasts in marrow

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158
Q

Treatment for myelodysplastic syndromes

A

Multiple RBC and platelet transfusions
Epo and G-CSF lowers transfusion requiremen
Immunosuppressants ie cyclosporin
Curative allogenic stem cell transplant - only if younger
Thalidomide analogues

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159
Q

When is CML mostly found

A

40-60y, slight male predominance

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160
Q

Chromosome associated with CML and what does it mean

A

Philadelphia chromosome in 80%, has tyrosine kinase activity

Without ph have worse prognosis

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161
Q

Sx of CML

A

Insidious - weight loss, tired, fever, sweats
Gout from purine breakdown
Bleeding
Abdo discomfort - splenic enlargment
Massive splenomegaly, hepatomegaly, anaemia, bruising

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162
Q

Inv CML

A 
WBC >100 with whole spectrum of myeloid cells - myelocytes, neutrophils, basophils, eosinophils
Hb low or normal
urate and b12 high
Marrow - hypercellular
Ph on blood or marrow cytogenetics
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163
Q

Stages of CML

A

Chronic - months/years with few sx
Accelerated - Increasing symptoms, spleen size and counts
Blast transformation - features of acute leukaemia and death

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164
Q

Treatment for CML and side effects

A

Imatinib - BCL/ABL tyrosine kinase inhibitor
SE = nausea, cramps, oedema, rash, headache, arthralgia, myelosuppressiosn
+- a interferon
Stem cell transplant but high mortality and morbidity

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165
Q

What is CLL

A

Accumulation of mature B cells that have undergone cell cycle arrest in G0/1 phase

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166
Q

Commonest leukaemia?

A

CLL

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167
Q

What can trigger CLL

A

Pneumonia

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168
Q

Sx of CLL

A 
Often incidentally found on FBC
Anaemia/infections
Weight loss, sweats, anorexia
Enlarged rubbery non tender nodes
Hepatosplenomegaly
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169
Q

Inv CLL

A

High lymphocytes

Then AI haemolysis, marrow infiltration - low Hb, neutrophils and platelets

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170
Q

Complicatiosn of CLL

A

AI haemolysis
Infection from hypogammaglobulinaemia (reduced IgG) - esp herpes zoster
Marrow failure

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171
Q

Progression of CLL

A

Nodes slowly enlarge and can cause lymphatic compression
Infections cause death
Transform to aggressive lymphoma - Richter’s transformation
1/3 don’t progress, 1/3 will progress, 1/3 actively progressing

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172
Q

Infections found in CLL that can cause death

A 
Haemophilus
Pneumococcus
Aspergillosis
Meningococcus
Candida
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173
Q

Treat CLL

A

Chemo if symptomatic, or depending on genes
Steroids for AI haemolysis
RT for lymphadenopathy and splenomegaly
Supportive - transfusions, IV human Ig if recurrent infection, prophylactic azithromycin acyclovir (+cotrimoxazole nebs for PCP)
Stem cell transplant

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174
Q

Staging CLL

A 
Rai stages:
1 - lymphocytosis
2 - with lymphadenopathy
3 - with spleno/hepatomegaly
4 - with anaemia
5 - with platelets <100
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175
Q

Differentiate between AML and ALL

A

More hepatosplenomegaly, testicular infiltration and CNS involvement in ALL. Mediastinal/thymic mass in ALL
Bone and skin involvement in AML
Gum hypertrophy in AML

176
Q

Prophylaxis for PCP

A

Cotrimoxazole neb

177
Q

CNS prophylaxis for ALL

A

Intrathecal or high dose IV methotrexate +- CNS irradiation

178
Q

What is ALL remission defined as?

A

No evidence of leukaemia in blood or normal/recovering FBC
And <5% blasts in normal regenerating marrow
Can detect minimal residual disease with PCR

179
Q

FAB stages of ALL

A 
L1 = children, good prognosis 
L2 = adults, intermediate prognosis
L3 = Burkitt’s lymphoma, adults, poor prognosis
180
Q

Infection difficulties with leukaemia

A

Rare organisms
Common organisms present differently
Fever from AML
Fewer antibodies

181
Q

Basis of definitive treatment in AML

A

Destroy marrow with cyclophosphamide and total body irradiation then repopulate with IVIg

182
Q

Advantage of autologous instead of allogenic bone marrow transplant

A

Faster haematopoetic recovery and lower morbidity

183
Q

Signs of Richter’s transformation for CLL

A

Systemic - night sweats and fever
Increased spleen and nodes (tonsils = breathing problems, sore throat)
Cytopoenias
WCC >200

184
Q

Causes of lymphadenopathy

A

Infection - bacteria (TB = matted), viral (EBC, HIV), Protozoa (toxoplamosis)
Malignancy - primary (leukaemia, lymphoma), secondary (mets, neuroblastoma, virchow’s node)
AI - RA, SLE
Drugs

185
Q

Classify lymphadenopathy

A

Size - >10mm, long and short axes

Extent - localised to infection, localisation not region ie mediastinum, generalised

186
Q

Investigate lymphadenopathy

A 
CXR if supraclavicular or cervical
Infection swabs for culture and sensitivity 
FBC, blood film, ESR/plasma viscosity
LFTs, LDH (released by cell turnover)
Urate, calcium
Lymph node excision biopsy
Body CT/MRI
Marrow biopsy - aspirate, trephine, cytogenetic, flow cytometry
LP for cytology if CNS signs
Effusion cytology
187
Q

Findings on flow cytometry of bone marrow in lymphoma

A 
Non-hodgkin’s = B cellswith abnormal kappa:lambda ratio
Hodgkin’s = Reed-Sternberg cells
188
Q

Causes of massive splenomegaly

A

3Ms:
Myelofibrosis
cMl
Malaria

189
Q

Cause of splenomegaly

A

Increased function
Abnormal flow - organ, vascular or infection
Infiltration - metabolic or benign/malignant

190
Q

Cause of increased spleen function

A

Immune hyperplasia - infection or AI
Extramedullary haematopoesis - marrow infiltration or destruction (toxins, radiation)
Defective RBCs - sickle cell, thalassaemia

191
Q

Cause of abnormal flow through spleen

A

Organ - liver cirrhosis (portal hypertension - caput medusae?)
Vascular - hepatic/portal/splenic vein obstruction, Budd-Chiari
Infection - hepatic schistosomiasis

192
Q

Types of spleen infiltration

A 
Metabolic - amyloidosis
Benign/malignant: leukaemia, lymphoma, myeloproliferative disorder
- Eosinophilic granulomas
- Metastatic tumour ie melanoma
- Hamartoma
193
Q

When is splenectomy indicated

A

Trauma
Hypersplenism
AI haemolysis (ITP, congenital haemolytic anaemia, warm AI haemolytic anaemia)

194
Q

Risk in splenectomy or hyposplenism and why

A

Infection as spleen contains macrophages which phagocytise bacteria
Encapsulated organisms - strep pn, H influenza, neisseria meningitidis

195
Q

2 causes of hyposplenism

A

Sickle cell

Coeliac

196
Q

Management of hyposplenism or splenectomy

A

Advice:
Mobilise asap as transient increase in platelets can cause thrombi
Medical alert bracelet
Safety net for infection

Mediation:
Malaria prophylaxis if abroad
Immunisations - pneumococcal, meningococcal C, H influenzae B, annual influenzae
Prophylactic abx lifelong - phenoxymethylpenicillin or erythromycin

197
Q

When to have/not have pneumococcal vaccine if splenectomy/hyposplenism

A

Every 5-10y
2w pre-op
Not if pregnant

198
Q

What is lymphoma

A

Malignant proliferation of lymphocytes in lymphadenopathy, blood and organ infiltration

199
Q

Sx for lymphoma

A

Anaemia, thrombocytopoenia x
B sx - fever, night sweats
Hyperviscosity - headache, blurred vision
Infections

200
Q

PMH relevant to lymphoma

A

Diabetes, hypertension, kidney disease as most treatment includes steroids which can affect these

201
Q

Drug history relevant tolymphoma

A

Azathioprine or methotrexate can cause macrocytosis

Previous chemo can. Cause myelodysplasia

202
Q

Who gets Hodgkin’s lymphoma?

A

Young people and elderly - 2 peaks

203
Q

Risk factors for hodgkin’s lymphoma

A 
Sibling
Westernisation
Obese
EBV
SLE
Post-transplant
204
Q

Causes of non-hodgkin’s lymphoma

A 
Congenital immunodeficiency
Acquired immunodeficiency
AIDS - high grade lymphoma
Infection - HTLV1, EBV, h. Pylori
Environmental toxins
205
Q

Histology for Hodgkin’s and non-hodgkin’s lymphoma

A 
Hodgkin’s = Reed-Sternberg cells - mirror image nuclei
Non-hodgkin’s = no reed-sternberg, mostly B cell lines, extranodal sites ie MALT
206
Q

Association of H pylori and lymphoma

A

Causes MALT - extranodal Non-hodgkin’s

Regresses if treated

207
Q

Classification of Hodgkin’s (4)

A
  1. Nodular sclerosing - indolent B cell lymphoma
  2. Mixed cellularity - higher incidence and worse prognosis if HIV
  3. Lymphocyte rich
  4. Lymphocyte depleted - poor prognosis
208
Q

Classification of Non-Hodgkin’s (grades) and implication and 2-3 examples of each

A

WHO classification -
Low grade = indolent,incurable, widely disseminated at presentation - follicular and marginal zone (MALT) and lymphocytic lymphoma
High grade = more aggressive ,more curable long term, short hx of rapid node enlargement and systemic sx - Burkitt’s, lymphoblastic lymphoma

209
Q

Burkitt’s lymphoma associations

A

Kids
Jaw lymphadenopathy
High grade non-hodggkin’s lymphoma

210
Q

Staging of lymphoma

A

Ann Arbor - uses CXR, CTCAP, marrow biopsy if b sx or stage 3-4
1 - one node
2 - 2+ nodal areas on 1 side of diaphragm
3 - nodes on both sides of diaphragm
4 - spread beyond nodes ie liver or marrow
+ a = no systemic sx except pruritis
+ b = B sx ie weight loss unexplained fever, night sweats
+ E = localised extranodal extension

211
Q

Sx of lymphoma

A

Nodes - enlarged, painless, rubbery, superficial, mostly cervical (some axillary or inguinal), alcohol-induced node pain, may change size +- matting
Systemic - fever >38, weight loss >10% in m, pruritis, lethargy
Mass effect (mediastinal) - SVC/bronchial obstruction, pleural effusion
Signs - anaemia, cachexia, hepatosplenomegaly

212
Q

Treatment of Hodgkin’s lymphoma

A

Chemo, radio or both

+- stem cells - autologous or allogenic

213
Q

ADR of chemo and radiotherapy for Hodgkin’s lymphoma

A

Chemo - nausea, allopecia, myelosuppression, infection
Radiotherapy - solid tumour, IHD, hypothyroid, lung fibrosis
AML, non-hodgkin’s lymphoma, infertility

214
Q

Prognosis of Hodgkin’s lymphoma

A

40-95%

215
Q

Sx of SVC obstruction - 5

A 
Raised JVP
Sensation of fullness in head
Black outs
Dyspnoea
Facial oedema
216
Q

Treatment of non-hodgkin’s lymphoma

A

Low grade and asymptomatic - none, localised = radiotherapy 9curative))
High grade - chemotherapy (CHOP)
Neutropoenia - G-CSF

217
Q

Prognostic factors of non-hodgkin’s lymphoma and prognosis

A

> 60y, systemic, disseminated, bulky mass, raised LDH
Low grade = 50% 5y survival,
High grade = 30%

218
Q

Causes of spinal cord compression

A

Extradural metastases
Extension of tumour from vertebral body
Crush fracture

219
Q

Sx of spinal cord compression

A

Backpain, disturbing sleep , worse lying down or coughing
Weakness
Sensory loss with root distribution or sensory level
Bowel and bladder dysfunction

220
Q

Determination of reflexes and neuro signs depending on level of spinal cord compression?

A

Above L1 = umn signs in legs
Below L1 = lmn signs in legs
Sensation reduced at level of lesion

221
Q

Investigate spinal cord compression

A

Urgent MRI of whole spine

222
Q

Manage cord compression

A

Dexamethasone IV then PO
Urgent RT
Vertebral body reinforcement for pain,or spinal reconstruction
Laminectomy if isolated tumour

223
Q

Cause of SVCO

A

Normally lung cancer, also mediastinal enlargement from germ cell tumour or lymphadenopathy from lymphoma

224
Q

Test for SVCO

A

Pemberton’s test - lift arms above head for 1m, makes facial plethora/cyanosis, raised jvp, inspiratory stridor

225
Q

Inv svco

A

CXR, CT, venography, sputum cytology

226
Q

Manage svco

A

Dexamethasone PO
Balloon venoplasty and SVC stenting
Radical or palliative C/RT

227
Q

Causes of hypercalcaemia in cancer

A

10-20% in cancer patients
40% in myeloma
Lytic bone mets
Osteoclast activating factor or PTH like hormones from tumour

228
Q

Sx of hypercalcaemia in cancer

A 
Lethargy, anorexia, nausea
Confusion
Polydipsia, polyuria
Constipation 
Dehydration
229
Q

Treat hypercalcaemia in cancer

A

Manage underlying malignancy
Bisphosphonates IV or PO
Calcitonin if resistant

230
Q

Manage RICP in cancer

A

Dexamethasone, RT, surgery

Mannitol for cerebral oedema

231
Q

What is tumour lysis syndrome and complication?

A

Rapid cell death from starting chemo for rapidly proliferating leukaemia, lymphoma,, myeloma, some germ cell tumours
Rise in serum urate, K and phosphate, can cause renal failure

232
Q

Prevent tumour lysis syndrome

A

Hydrate and allopurinol 24h before chemo

233
Q

Treat tumour lysis syndrome

A

Dialysis

Rasburicase IVI - recombinant urate oxidase

234
Q

ADR rasburicase

A

Fever, D&V, headache
Bronchospasm
Haemolysis
Rash

235
Q

Medication for neutropoenia

A

Abx - aminoglycoside (gentamicin) and ceftazidime
G-CSF
Cotrimoxazole for pneumocystis

236
Q

Risk factors for tumour lysis synddrome

A

High LDH
High creatinine or urate
WCC >25x10^9

237
Q

Dangers of leukaemia

A

Tumour lysis
Neutropoenia
Hyperviscosity - WBC thrombi if WCC >100, in brain/lung/heart = leukostasis
DIC

238
Q

Test findings for DIC

A 
Plt low
APTT and PT high
Fibrinogen low
Fibrin degradation products D dimers very high
Schistocytes on film
239
Q

Treat DIC

A 
Treat cause
Platelets if <50
Cryoprecipitate to replace fibrinogen
FFP to replace coag factors
Activated protein c reduces mortality
240
Q

Types of chemo drugs

A

Alkylating agents - cyclophosphamide
Antimetabolites - methotrexate, 5-fluorouracil
Vinca alkaloids - vincristine
Antitumour antibiotics - actinomycin D, doxorubicin
Monoclonal antibodies ie against EGFR receptors

241
Q

When does neutropoenia normally happen after chemo

A

10-14d

242
Q

Manage extravasation of chemo agent

A

Stop infusion, attempt to aspirate blood from cannula then remove
Steroids and antidotes
Elevate arm
Steroid cream

243
Q

How does radiotherapy work?

A

Ionising radiation makes free radicals which damage DNA

Normal cells repair better than cancer cells so recover before the next dose

244
Q

When can radiotherapy be used for palliation?

A

Haemoptysis, cough, SOB
Bone pain
Bleeding

245
Q

Early reactions to RT

A 
Tired
Skin - erythema, desqamation, ulceration
Mucositis - avoid spicy food, smoking and alcohol if head and neck RT,  oral thrush
Nausea and vomiting if stomach, liver or brain
Diarrhoea if abdo/pelvis
Dysphagia if thoracic
Cystitis if pelvic
Bone marrow suppression if large areas
246
Q

Manage oral thrush, diarrhoea, n&v, pelvic cystitis, from RT

A

Thrush - oral solution nystatin +- fluconazole
Diarrhoea - loperamide, not high fibre bulking agents
N&V - metaclopramide (dopamine antagonist) or domperidone (blocks chemoreceptor trigger zone), then ondansetron (serotonin antagonist)
Cystitis - fluids, NSAIDs (diclofenac)

247
Q

Late CNS reactions to RT and management

A

CNS - somnolence, spinal cord myelopathy (progressive weakness), brachial plexopathy (numb, weak, painful arm), reduced IQ if <6yo
MRI to exclude cord compression
Steroids for somnolence

248
Q

Late lung effects of RT

A

Pneumonitis - dry cough, SOB

Give prednisolone and reduce over 6w

249
Q

Late GI effects of RT

A

Xerostomia - give pilocarpine or artificial saliva with meals
Reduced healing - care with dental care
Benign strictures of oesophagus or bowel - dilatation
Fistulae - surgery
Radiation proctitis from prostate irradiation

250
Q

Late GU effects of RT

A

Urinary frequency from small fibrosis bladder
Fertility - ova/sperm storage
Premature menopause or reduced testosterone - hormones
Vaginal stenosis and dyspareunia
Erectile dysfunction - can happen after several years

251
Q

Late complications of RT

A 
CNS
Lung
GI - mouth and intestines
GU - urinary and repro
Panhypopituitarism - consider growth hormones in children 
Hypothyroid
Secondary cancers - sarcomas - often 10+y after
Cataracts
252
Q

Considerations of fertility in CRT

A

Damage germ cell spermatogonia
- impaired spermatogenesis or male sterility
- hastened oocyte depletion - premature menopause
GnRH agonists for women during chemo can help
Semen or embryo cryopreservation or ovarian tissue banking before treatment, the outcome depends on uterus integrity after treatment

253
Q

Causes of n&v in palliative care

A 
Chemo
Constipation
GI obstruction
Drugs
Pain
Cough
Squashed stomach
Oral thrush
Infection
Uraemia
254
Q

Basis for n&v treatment

A

Cause - analgesia, antibiotics, laxatives, fluconazole, drug management including route
Base drug on mechanism and site of action
Give regularly, not prn

255
Q

Action of cyclizine

A

Antihistamine, central action, most causes

256
Q

Action of domperidone

A

Blocks central chemoreceptor trigger zone - for younger patients who won’t have acute dystonic SE

257
Q

Action of metaclopramide

A

Central antidopaminergic and peripheral proketic - good for gut stasis

258
Q

Action of haloperidol

A

Dopamine antagonist, for drug or metabolic induced nausea

259
Q

Action of Ondansetron

A

Serotonin antagonist, second line

260
Q

Action of Levomepromazine

A

Morphine induced nausea, broad spectrum, can cause sedation

261
Q

Prevent and treatment constipation in cancer treatment

A

From opiates, give bisacodyl or stimulant with softener
Movicol useful if resistant
Glycerol suppositories or arachis oil enema if oral therapy fails

262
Q

Manage breathlessness in palliative care

A

Morphine - reduces respiratory drive and sensation of breathlessness
Relaxation techniques and bzds
Check for pleural or pericardial effusion
Thoracocentesis +- pleurodesis for significant pleural effusion
Pericardiocentesis or external beam radiotherapy for malignant pericardial effusion

263
Q

Manage coated/dry mouth

A

Treat candida - fluconazole
Ice chips, pineapple chunks, gum
Chlorhexidine, saliva substitutes

264
Q

Problems with venepuncture in palliative care

A

Extravasation, phlebitis

Infection, blockage - give saline or heparin, thrombosis/obstruction

265
Q

Manage agitation, nightmares, hallucinations, vomiting in palliation

A

Haloperidol

266
Q

What’s hyoscine for in palliative care

A

Vomiting from upper GI obstruction or noisy bronchial rattles

267
Q

Manage ascites in palliative care

A

Spironolactone and bumetanide

268
Q

What are syringe drivers and what drugs are they for in palliative care?

A

Sc continuous infusion of fluids and drugs to avoid cannulation repeatedly

1) Glycopyrronium or hyoscine hydrobromide for terminal secretions
2) Diamorphine for pain - better than morphine due to greater solubility reducing risk of precipitation at high doses
3) Midazolam for agitation and seizure control
4) Cyclizine or haloperidol for nausea
5) Hyoscine butylbromide for bowel colic

269
Q

Work out dose for morphine

A

Start at 5-10mg/4h orally

Then add total over 24h and divide by 2 for 12h release, with 1/6 daily dose for breakthrough

270
Q

ADR of morphine

A

Drowsy, n&v, constipation, dry mouth

271
Q

Signs of morphine toxicity

A

Hallucinations and myoclonic jerks

272
Q

What if morphine oral isn’t working

A

Diamorphine IV/SC
Oxycodone PO/IV/SC/syringe driver/PR has fewer side effects and more potent
Fentanyl transdermal patch

273
Q

Morphine resistant pain?

A

Methadone or ketamine
Adjuvants - NSAIDs, steroids, muscle relaxants, anxiolytics
Neuropathic - amitriptylline or gabapentin
SSRI if depression

274
Q

WHO analgesia ladder

A

1 - non opioid - aspirin, paracetamol, NSAID
2 - weak opioid - codeine, dihydrocodeine, tramadol
3 - strong opioid - morphine, diamorphine, hydromorphine, oxycodone, fentanyl

275
Q

Tumour markers

A

Alpha-fetoprotein - germ cell tumour, hepatocellular carcinoma
CA125 - ovary, uterus, breast, hepatocellular carcinoma
CA19-9 - pancreas or colorectal carcinoma or cholestasis
Carcino-embryonic antigen - GI carcinoma especially colorectal cancer
Human epidermal growth factor receptor 2 - Overexpression of HER2 in breast cancer carries a worse prognosis - target with herceptin/trastuzumab, also ovarian, stomach, uterine
B-HCG - pregnancy and germ cell tumours

276
Q

Causes of polycythaemia

A

Relative - reduced plasma volume - acute from dehydration or chronic from obesity, hypertension, alcohol, tobacco
Absolute - increased RBC mass - primary from rubra vera or secondary from hypoxia (chronic lung disease, cyanotic CHD, high altitude) or increased epo (renal carcinoma, hepatocellular carcinoma)

277
Q

Polycythaemia rubra vera?

A

Malignant proliferation of a clone from one pluripotent marrow stem cell
JAK2 mutation
Excessive RBC, WBC and platelets - can cause hyperviscosity and thrombosis

278
Q

Sx of polycythaemia rubra vera

A

Symptoms of hyperviscosity - headache, dizzy, tinnitus, visua disturbance
Itch after hot bath
Erythromelalgia - burnings in fingers and toes
Facial plethora
Splenomegaly
Gout from increased urate in increased RBC turnover
Arterial or venous thrombosis

279
Q

Signs of arterial and venous thrombosis in polycythaemia rubra vera

A

Arterial - cardiac, cerebral, peripheral

Venous - DVT, cerebral, hepatic

280
Q

Inv for polycythaemia rubra vera and findings

A

FBC - raised RBC, Hb, HCT, PCV, often raised WBC and platelets
B12 high
Marrow - hypercellular with erythroid hyperplasia
Neutrophil alkaline phosphatase high
Serum epo low

281
Q

Treat polycythaemia rubra vera

A

Monitor HCT to decrease thrombosis risk
Venesection in young and low risk
If old and high risk (previous thrombosis), give hydroxycarbamide or a-interferon if pregnant
Low dose aspirin

282
Q

Complications of polycythaemia rubra vera

A

thrombosis and haemorrhage (defectives platelets)

Transition to myelofibrosis or acute leukaemia

283
Q

What is increased platelets and sx?

A

Essential thrombocytopoenia from clonal proliferation of megakaryocytes
Abnormal function - bleeding, or arterial/venous thrombosis, or microvascular occlusion = headache, chest pain, light headed, erythromelalgia

284
Q

Treat essential thrombocythaemia

A

Exclude other causes of thrombocytosis
Aspirin low dose daily
Hydroxycarbamide to lower platelets if >60 or previous thrombosis

285
Q

Result of myeloproliferative disorders

A

Myelofibrosis - hyperplasia of megakaryocytes produces platelet derived growth factor, leads to

  • intense marrow fibrosis and
  • myeloid metaplasia (haemopoesis in spleen and liver) causing massive hepatosplenomegaly
286
Q

Presentation of myelofibrosis

A

Hypermetabolic syndrome - night sweats, fever, weight loss, abdo discomfort from splenomegaly
Bone marrow failure

287
Q

Inv findings for myelofibrosis

A

Blood film - leukoerythroblastic cells (nucleated RBC)
Characteristic teardrop RBC
Hb low
Trephine for diagnosis

288
Q

Manage myelofibrosis

A

Marrow support

Allogenic stem cell transplant - curative in young , but mortality high

289
Q

Causes of thrombocytosis

A 
Reactive = 
Bleeding
Infection
Chronic inflammation 
Malignancy
Trauma
Post-surgery
Iron deficiency 
Essential thrombocythaemia
290
Q

Causes of marrow fibrosis

A 
Myelofibrosis
Myeloproliferative disorder
Lymphoma, leukaemia 
Secondary carcinoma
TB
Irradiation
291
Q

What is myeloma?

A

Malignant clonal proliferation of B-lymphocyte derived plasma cells
Normally different plasma cells produce different Ig = polyclonal, but here get single clone of plasma cells = monoclonal band or paraprotein on serum or urine electrophoresis

292
Q

Classify myeloma

A

On Ig product - 2/3 = IgG, 1/3 = IgA

293
Q

Findings of myeloma investigations

A

Monoclonal band in serum or urine electrophoresis
Other Ig low - infection risk
Urine has Bence-Jones protein (free Ig light chains of kappa or lambda) filtered by kidney

294
Q

Peak age of myeloma

A

70yo

295
Q

Sx of myeloma

A

Osteolytic bone lesions due to increased osteoclast activation from myeloma cell signalling = back ache, pathological fracture in long bones/ribs, vertebral collapse
Hypercalcaemia sx
Anaemia, neutropoenia, thrombocytopoenia
recurrent bacterial infections - immunoparesis and neutropoenia
Renal impairment from light chain deposition - distal loop of henle and changes in glomeruli, can be deposited in form of AL-amyloid which causes nephrosis

296
Q

Test findings for myeloma

A 
FBC - normocytic normochromic anaemia
- raised ESR
- raised urea and creatinine
- raised calcium 
- ALP normally normal
Film = rouleaux formation
Serum and urine electrophoresis for bence-jones and monoclonal bands
X-ray = lytic lesions ie pepper pot skull and vertebral collapse, or osteoporosis
297
Q

Treat myeloma

A

Supportive
- analgesia but avoid nsaid as renal impairment
- Bisphosphonates to reduce fracture rate and bone pain
- Local rt for focal disease
- Vertebroplasty if vertebral collapse
- Correct anaemia with transfusion or epo
- Renal failure - hydrate, dialysis if acute
- Infection - abx, regular IVIg if recurrent
Chemo - including prednisolone, reduces paraprotein levels and bone lesions
Stem cell transplant

298
Q

Prognosis for myeloma

A

3-4y, worse if raised B2 microglobulin

Death from infection or renal failure

299
Q

3 myeloma diagnostic criteria

A

Monoclonal protein band in serum or urine electrophoresis
Increaed plasma cells on BM biopsy
Evidence of end organ damage from myeloma - hypercalcaemia, renal failure, anaemia, or bone lesions (skeletal survey)

300
Q

Causes of bone pain

A

V - osteonecrosis from microemboli
I - osteomyelitis, osteosclerosis from hep c
T - trauma/fractures
A - renal osteodystrophy, CREST
M - paget’s, sickle cell anaemia, hyperparathyroid
N - myeloma or primary malignancies, secondaries (breast, lung, prostate), hydatid cyst

301
Q

Complications of myeloma and treatment

A

Hypercalcaemia - at presentation or relapse, rehydrate with saline, IV Bisphosphonates (zolendronate or pamidronate)
Spinal cord compression - urgent mri and dexamethasone 8-16mg OD PO, local radiotherapy
Hyperviscosity - reduced cognition, disturbed vision, bleeding - plasmapheresis
Acute renal failure - rehydration, dialysis

302
Q

What is paraproteinaemia

A

Immunoglobulins from single clone of plasma cells - monoclonal band on serum electrophoresis

303
Q

Categories of paraproteinaemia

A

Multiple myeloma
Waldenstrom’s macrolobulinaemia
Primary amyloidosis
MGUS - low concentration of paraprotein but no myeloma, amyloid, macroclobulinaemia orlymphoma, no bone lesions or bence-jones
Paraproteinaemia in lymphoma or leukaemia
Heavy chain disease - neoplastic cells produce free Ig heavy chains

304
Q

What is Waldenstrom’s macroglobulinaemia, sx and treatment

A

Lymphoplasmacytoid lymphoma producing monoclonal IgM paraprotein
Causes hyperviscosity with CNS and ocular symptoms, lymphadenopathy, splenomegaly, increased ESR
Only treat if symptomatic - with chemo or plasmaphoresis for hyperviscosity

305
Q

Inherited causes of thrombophilia - 4

A

Factor V Leiden = activated protein C (apc) resistance
Prothrombin gene mutation - downregulation of fibrinolysis
Protein c and s deficiency
Antithrombin deficiency

306
Q

What is antiphosopholipid sydrome

A

Lupus anticoagulant and anticardiolipin antibodies = antiphospholipid antibodies
Risk of venous and arterial thrombosis, thrombocytopoenia and recurrent foetal loss in pregnancy
Normally primary disease but can be in SLE

307
Q

Tests for thrombophilia

A

FBC, film, clotting, INR, PT
APC resistance test
Fibrinogen concentration
Lupus anticoagulant and anticardiolipin antibodies
Assays for antithrombin and protein c and s
PCR for factor V Leiden mutation and prothrombin gene mutation

308
Q

Treat thrombophilia

A

Acute - heparin then warfarin to target INR 2-3
Lifelong warfarin in recurrence - target INR 3-4
High dose heparin if antithrombin deficiency

309
Q

Danger in protein c and s deficient treatment

A

Warfarin can cause skin necrosis

310
Q

Prophylaxis for thrombophilia in pregnancy

A

Aspirin and heparin

311
Q

Risk factors for arterial thrombosis

A

Smoking
Hypertension
Hyperlipidaemia
Diabetes

312
Q

Risk factors for venous thrombosis

A 
Surgery
Trauma
Immobility
Pregnancy, OCP, HRT
Age
Obesity
Varicose veins
Conditions - heart failure, malignancy, IBD, nephrotic syndrome
313
Q

What conditions can be made worse by steroids

A

TB, chicken pox
Hypertension, diabetes
Osteoporosis

314
Q

Main drug interactions with prednisolone

A

Antiepileptics and rifampicin lower concentration

315
Q

Guidance when starting steroids

A

Carry steroid card with dose and reason
Don’t stop suddenly - takes time for endogenous production to start again, can cause collapse, if >3w or >7.5mg/d
Warn about side effects if long term
Go to doctor if ill - may need to increase dose if ill or stressed
OTC drugs - no NSAIDs as increase DU risk
Prevent osteoporosis if long term - exercise, bisphosphonates, calcium and vit d supplements, smoking cessation

316
Q

When should steroid withdrawal be gradual

A 
Repeated courses
>3w
Hx of adrenal suppression
>40mg/d
Doses at night
317
Q

Organs with SEs of steroids

A 
GI
MSK
Endocrine
CNS
Eyes
Immune
318
Q

GI SEs of steroids

A

Candidiasis
Oesophageal ulceration
Peptic ulceration
Pancreatitis

319
Q

Msk SEs of steroids

A

Osteoporosis
Fractures
Growth suppression
Myopathy

320
Q

Endocrine SEs of steroids

A

Adrenal suppression

Cushing’s

321
Q

CNS SEs of steroids

A

Depression
Psychosis
Aggravation of epilepsy

322
Q

Eye SEs of steroids

A

Cataracts
Glaucoma
Papilloedema

323
Q

immune SEs of steroids

A

Increased susceptibility and severity of infections

Fever and raised WCC

324
Q

DDI of azathioprine and mercaptopurine

A

Allopurinol, a xantine oxidase inhibitor. Azathioprine and mercaptopurine are metabolised by XO so can reach toxic levels if with allopurinol

325
Q

What does ciclosporin do, and main SEs

A

Calcineurin inhibior, with tacrolimus
For reducing rejection in organ and marrow transplant
SE - dose related nephrotoxicity - monitor UEs and creatinine every 2w for 3m, reduce dose if creatinine rises by >30%
Also = gum hyperplasia, hypertension, paraesthesia, confusion, seizures
Lymphoma and skin cancer

326
Q

How does methotrexate work

A

Antimetabolite, inhibits dihydrofolate reductive which is needed for synthesis of purines and pyrimidines

327
Q

How does cyclophosphamide work and SEs

A

Alkylating agent
Marrow suppression, nausea, infertility, teratogenic
Haemorrhagic cystitis as irritative urinary metabolite, slight increased risk of bladder cancer or leukaemia

328
Q

2ww criteria lung

A

> 40yo
Haemoptysis
Smoker

329
Q

2ww bowel criteria

A

Abdo pain and unexplained weight loss >40y
Unexplained rectal bleeding >50yo
Iron deficiency anaemia or change in bowel habit >60yo

330
Q

WHO performance status

A 
0 - asymptomatic
1 - symptoms, fully ambulatory
2 - symptomatic, in bed <50%
3 - symptomatic, in bed >50% but not bedridden
4 - bedridden
331
Q

Staging and grading in general how

A

Imaging - staging CT

Biopsy - grading

332
Q

Lung cancer rf

A

Smoking x10

Asbestos x5

333
Q

Where are NSCLC and which is worst

A

Squamous - central, airways
Adeno - peripheral
Large cell - worst

334
Q

Lung cancer inv

A

CXR
Staging CT NTAP
PET CT
Biopsy - percutaneous or bronchoscopy (+endobronchial US and alveolar lavage)

335
Q

curative lung cancer treatment

A

Surgery

Radical RT or chemo if unfit for surg

336
Q

PAlliative lung cancer treatment

A

Stents
Brachytherapy
Palliative chemo

337
Q

Curative lung cancer treatment

A

Surgery

Radical RT or chemo if unfit for surg

338
Q

Palliative lung cancer treatment

A

Stents
Brachytherapy
Palliative chemo

339
Q

RF for colorectal cancer - 4

A

FAP - APC gene
Lynch syndrome
Smoking
UC (pancolitis for 15y+ = 15-20%)

340
Q

Inv colorectal cancer

A

CEA
Staging CT TAP for liver mets
Colonoscopy and biopsy

341
Q

Curative treatment colorectal cancer

A

Surgical, neoadjuvant RT, adjuvant chemo

342
Q

Palliative management colorectal cancer

A

Stent/bypass

Chemo

343
Q

Screening for colorectal

A

FOB every 2y 60-74yo

5/10 will have normal colonoscopyl, 4/10 will have polyps on colonoscopy, 1/10 will have cancer

344
Q

Duke staging and 5y survival

A 
A - confined to mucosa 90%
B1 - muscularis propria
B2 - through muscularis propria and serosa - 60%
C1 - 1-4 nodes - 30%
C2 - 4+ regional nodes
D - distant mets
345
Q

Upper GI 2ww criteria

A

> 55
Dysphagia - progressive
Weight loss
Mass

346
Q

Upper GI RF

A

Smoking, alcohol
Barret’s
H pylori - ask about ulcers

347
Q

Inv upper GI cancer

A

OGD and biopsy
Staging CT TAP, PET CT/staging laparoscopy
Barium swallow = apple core sign

348
Q

Pallliative upper GI cancer management

A 
[LASER]
Laser
Analgesia
Stent
EtOH injection - for pain 
Radiotherapy
349
Q

Complications of upper GI cancer

A

Upper GI bleed
Obstruction - succussion splash, projectile vomiting
Perforation

350
Q

What is acute leukaemia

A

Defective maturation of myeloid/lymphoid cells in bone marrow which spill out as immature blast cells that infiltrate
- liver, spleen, node, BM

351
Q

What is chronic leukaemia

A

Proliferation of mature myeloid/lymphoid cells in BM which spill out and cause proliferative effects and infiltrate into all lymphatic systtems

352
Q

What is Lymphoma

A

Proliferation of lymphoid cells from within lymphoid tissues that infiltrate into lymphatic tissues and bone marrow (sx)

353
Q

What are lymphoid proliferation/infiltration symptoms

A

Invasion into HSM, bone, skin, gums, testes, thymus

354
Q

Lymph nodes to check

A

Cervical
Inguinal
Axillary

355
Q

Myeloid proliferation signs

A

HSM
Hyperviscosity - headache,visual, vte
Hyperuricaemia - gout

356
Q

Features of blood cancers

A 
B symptoms - BM infiltration 
FBC symptoms - BM infiltration 
Lymph nodes
Lymphoid proliferation/infiltration 
Myeloid proliferation
357
Q

Bloods for blood cancer

A 
Fbc
Blood film
Flow cytometry
LDH, urate, folate = markers of excess cell turnover
Clotting - DIC in APML
358
Q

Biopsy for blood cancer

A

Cytology - blast/plasma cells, hypercellular, Reed-sternberg
Morphology - M3 = APML
Immunophenotyping - B/T cells
Cytogenetics - Philadelphia t(9:22), APML t(15:17)

359
Q

imaging for blood cancers

A

Lymphoma - Ann Arbor - CT TAP, PET CT

Myeloma - skeletal survey, PET CT

360
Q

CLL features

A

Elderly, indolent
Lymphocytosis - symmetrical LN
Smudge cells

361
Q

Features of CML

A

Adults
Philadelphia
Myeloproliferative

362
Q

Non-Hodgkin’s lymphoma features

A

Asymmetrical non-continuous node enlargement

Low (follicular) or high (diffuse) grades

363
Q

AML features

A

Auer rods, blasts
BM and tissue infiltration
Less chemoreponsive

364
Q

ALL

A

Children
Blasts
BM and Tissue infiltration including CNS
chemo responsive

365
Q

Myeloma and MGUS differentiate

A

CRAB in myeloma
IgG high and rest low in myeloma
Rest normal in MGUS

366
Q

Diagnose Al-amyloid

A

Rectal biopsy

367
Q

Types of myeloma/myeloid prolif

A

Myeloma
MGUS
Al-amyloid

368
Q

DIC treatmetn

A

FFP and cryoprecipitate (has fibrinogen)

+- platelets

369
Q

DIC

A

Low Hb, Plt, fibrinogen
High INR, APTT, FDP
Schistocytes

370
Q

2ww skin cancer

A

ABCDEF

371
Q

Types of skin cancer histoloy

A

Superficial - flat
Nodular - worst as can infiltrate
Acral - on hands
Lentigo maligna

372
Q

Inv skin cancer

A

Excision biopsy for breslow thickness for planning margin needed

373
Q

Manage skin cancer

A

Widen excision margin

+- adjuvant chemo

374
Q

BCC features

A

Rodent ulcer
Pearly colour
Rolled edge

375
Q

SCC features

A

Ulcerated nodule

Hard everted edge

376
Q

Diagnostic inv for myeloma

A

Serum protein electrophoresis

377
Q

Bad prognostic signs in myeloma

A

Hb low

Clonal plasma cells high

378
Q

Inv for sepsis after oesophagectomy

A

Contrast swallow - likely anastamotic leak

= mediastinitis

379
Q

Inv when slow growing lymphadenopathy has had a sudden drop in Hb and increase in reticulocytes with splenomegaly

A

Direct antiglobulin test - warm AI haemolytic anaemia in CLL

380
Q

Most common type of inherited bowel cancer

A

Lynch syndrome

381
Q

What is lynch syndrome and inheritance signs

A

HNPCC
Extensive GI polyps
Endometrial, renal, CNS cancers
2 generations, 3+ first degree relatives to each other, 1 tumour <50yo

382
Q

Lung cancer - when is hypercalceamie more likely?

A

SCC = PTHrP

383
Q

Immediate management for abdo pain, constipation and high calcium in lung cancer

A

IV fluids

384
Q

What is FAP

A

APC TSG gene
>100 adenomatous polyps in colon and rectum
Can have duodenal and fundic glandula
100% cancer

385
Q

biggest RF for melanoma

A

Intense UV radiation

386
Q

What skin cancer does immunosuppression make more likely

A

BCC

SCC

387
Q

types of prostate cancer

A

Adenocarcioma peripheral zone:

Localised (inside capsule), local advanced (leaves capsule but not in organs) or mets

388
Q

Prostate 2ww

A

Craggy or nodular DRE
PSA increased without other cause (increased with age - different cut offs)
Red flags eg bone pain

389
Q

Inv prostate cancer

A

DRE and PSA
TRUS biopsy and Gleason grade
Isotope bone scan for sclerotic lesions

390
Q

Manage CaP

A

Localised - active surveillance (curative intent - TRUS, rectal exams until found to be progressive then treat) vs watchful waiting (minimally invasive, palliative intent)
Local advanced - radical prostatectomy or RT, hormonal - LHRH agonist
Mets - hormonal, steroids/radio for bone mets

391
Q

Features of non-seminoma

A

young, fast growing, tumour markers

392
Q

Testicular cancer 2ww

A

Unexplained testicular lump,, usually painless

393
Q

Inv testicular cancer

A 
Tumour markers - bHCG, AFP, LDH, oestradiol = teratoma 
US testes, CT TAP
Excision biopsy  (core = tracking)
394
Q

types of testicular cancer

A

Seminoma
Non-seminoma
Teratoma

395
Q

Manage testicular cancer

A

Sperm bank
Inguinal orchidectomy
Adjuvant RT for seminoma
Chemo for relapses in non-seminoma

396
Q

Rf for bladder/renal cancer

A

Substances - smoking, cyclophosphamide, dye

SCC. - schistosomiasis

397
Q

2ww for bladder/renal cancer

A

Visible haematuria >45, unexplained (eg no UTI)

Non visible haemoaturia >60yo, no exercise etc

398
Q

Inv bladder/renal cancer

A

Urine microscopy (?sterile pyuria?)
Flexible cystoscopy
Staging CT TAP

399
Q

manage bladder/renal cancer

A

Invasive -
- renal = radical nephrectomy and RT
- bladder = cystectomy and ideal conduit and RT
Superficial bladder - TURBT via rigid cystoscopy and intravesicular chemo (BCG = higher risk)

400
Q

Testicular lump with raised tumour markers

A

Teratoma

401
Q

Complication of testicular lump

A

Torsion - surgery

402
Q

When can you do PSA after DRE

A

2w later

403
Q

Mood problems and flushes with hormonal therapy for prostate cancer

A 
= testosterone flare a couple of weeks after starting hormonal therapy 
Cyproterone acetate (anti androgen)
404
Q

PUO and left varicoele?

A

Renal cell carcinoma - compresses left renal vein (drains into left testicular vein)

405
Q

Prognostic factors in breast cancer

A 
ER+ = better prognosis
HER2+ = worse prognosis
406
Q

2ww for breast cancer

A

> 30 with unexplained breast lump
50 with unilateral nipple discharge/retraction
? Family history

407
Q

Most common breast cancer

A

DCIS/invasive

408
Q

Histology inv for breast cancer

A

Cystic - FNAC

Solid, or blood/abn on FNA - core biopsy

409
Q

MAnage breast cancer

A

Surgery - wide loop excision and RT, or mastectomy, and axillary clearance if sentinel node biopsy
Hormonal treatment - tamoxifen (ER+) or trastuzumab (HER+)

410
Q

Screening for breast cancer

A

47-73yo

Microcalcificatiotn on mammogram = DCIS

411
Q

What is anastrazole for

A

Peripheral aromatisation after menopause makes most of oestrogen, it inhibits this

412
Q

Ovarian cancer RF

A

BRCA1
Lynch
Ovulation
Reduced by COCP

413
Q

Histology of ovarian cancer

A

Epitheilal - serous (most common)/mucinous cystadenoma

Germ cell/stromal

414
Q

2ww for ovarian cancer

A

Vague bloating
Then CA125 high
Then TVUS
Then refer

415
Q

inv ovarian cancer

A

Ca125, CEA, CA19-9
If young, do atypicals (for germ cell) - HCG, LDH, AFP, oestradiol
TV US - CT TAP for staging - MRI pelvis
Ascetic tap for malignant cells on cytology

416
Q

Manage ovarian caner

A

Staging laparotomy - TAHBSO, omentectomy, peritoneal washings, LN
Adjuvant chemo
Tumour marker survaillance

417
Q

Complication of surgery for heterogenous ovarian cyst removal

A

Chemical peritonitis

418
Q

Small RUQ breast lump manage

A

Adjuvant RT

Wide local excision

419
Q

Nipple eczema involving nipple and spreading out - what to do and what suspecting?

A

2ww for punch biopsy

Suspect Paget’s disease

420
Q

Risks of tamoxifen - 4

A

DVT
Post meno bleeding - endometrial cancer
Teratogenic
Hot flushes

421
Q

Recognising death - 3

A

Progressive physical decline
Reduced oral intake/medication response
Rising EWS

422
Q

End of life care points

A 
Discuss with family 
Palliative care referral
Anticipatory meds
Comfort obs
Stop non essential meds
Fast tracking
Opate prescribing - background (BD)/breakthrough (24h dose/6), syringe driver, patch
423
Q

Pain medication in end of lfile

A

Pain - Morphine 2.5-5mg SC PRN max 60mg
Agitation - midazolam 2.5-5mg SC PRN max 60
NV/confusion - Haloperidol, levopromazine
Secretions - Hyoscine, glycopyrronium

424
Q

Morphine conversion - SC and patch

A

SC = PO divided by 2

Patch lasts 3d, 30mg PO morphine = 12mcg/h fentanyl patch

425
Q

Post-death process - 4

A

Verifying death
Death certificate - immediate cause, plus what led to it and contributing factors
Cremation form
Coroners referral

426
Q

Post-death process - 4

A

Verifying death
Death certificate
Cremation form
Coroners referral

427
Q

When to refer to coroner

A

<24h admission
Unnatural cause eg substance, accident
Linked to occupational

428
Q

When to refer to coroner

A

<24h admission
Unnatural cause eg substance, accident, violence
Linked to occupational

429
Q

What is on death certificate

A
  • 1a (immediate cause eg pneumonia), plus 1b (what led to it eg COPD) and 2 (contributing factors eg HF)
430
Q

Causes of hypercalcaemia in oncology - 2

A

Lytic bone mets
Myeloma
Osteoclasts activating factor or PTH like hormones from tumour

431
Q

Red flags for GI

A 
ALARM >55yo:
Anorexia
Loss of weight
Anaemia
Recent onset
Melaena/haematemesis
Swallowing difficulty
432
Q

Red flag sx for back pain

A 
TUNAFISH
Trauma
Unexplained weight loss
Neuro sx
Age >50yo
Fever
Ivdu
Steroids
Hx of cancer - prostate, renal, breast, lung, thyroid
433
Q

Assess melanoma

A 
Asymmetry
Border - irregular
Colour - non uniform
Diameter >6mm
Elevation
434
Q

What is BPH and sx

A

Benign nodular or diffuse proliferation of musculofibrous and glandular layers of tissue in inner transitional zone of prostate, so early sx:
Nocturnal, frequency, terminal dribble, hesitancy, uti, stones, retention

435
Q

Manage BPH

A

DRE, MSU, UE, USS for residual volume and hydronephrosis
Rule out cancer - PSA, TRUS USS +- biopsy
Conservative - alcohol, caffeine, bladder training
Medical
- a-blocker tamsulosin reduces smooth muscle tone. ADR hypotension, drowsy, ejaculatory failure
- 5a reductase inhibitor finasteride (reduces conversion of testosterone to dihydrotestosterone). ADR impotence, reduced libido, excreted in semen (use condom), takes a while to work

Surgery - TURP. ADR:
- clot, bleeding, haematospermia, infection
- TUR syndrome (absorption of wash out fluid = hyponatraemia and fits), cross match 2u first
- erectile dysfunction, incontinence, retrograde ejactulation
No driving or sex for 2w, haematuria for 2w, initial increase in frequency for 6w

Finals (13 decks)

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