cancer care Flashcards
1
Q
2WW appointment criteria for lung ca
A
40+ with unexplained haemoptysis
suspicious CXR findings
2
Q
criteria for which you offer urgent CXR for ?lung ca
A
40+ with 2 of following sx / 1 sx + hx smoking
- cough
- fatigue
- sob
- chest pain
- UEW
- loss of appetite
3
Q
2WW upper GI endoscopy referral criteria
A
dysphagia
55+ with UEW and upper abdo pain/reflux/dyspepsia
4
Q
2WW gynae criteria
A
PMB; ascites; pelvic mass exc fibroid
5
Q
2WW lower GI appt
A
Give PR and FBC in all Positive FOB 40+ with abdo pain + UEW 50+ with unexplained rectal bleeding 60+ with IDA or change in bowel habit
6
Q
2WW prostate
A
suspicious PR
PSA>age-adjusted normal range + abnormal PR/normal PR but excluded infection
7
Q
2WW urology (exc prostate)
A
40+ with visible haematuria
60+ non-visible haematuria and dysuria/raised WCC
non-painful enlargement/change in shape or texture of testicle
8
Q
Class, MoA and S/E of cyclophosphamide?
A
Alkylating agent, crosslinks DNA, haemorrhagic cystitis, TCC, myelosuppression
9
Q
Class, MoA and S/E of vincristine and vinblastine?
A
Vinca alkaloids - inhibits microtubule formation - VC = reversible peripheral neuropathy, paralytic ileus and myelosuppresion; VB = myelosuppression
10
Q
Class, MoA and S/E of methotrexate?
A
Antimetabolite - dihydrofolate reductase antagonist prevents folate metabolism to prevent DNA synthesis - myelosuppression, mucositis, liver and lung fibrosis
11
Q
Class and S/E of bleomycin?
A
cytotoxic antibiotic - lung fibrosis
12
Q
Class and S/E of doxorubicin?
A
cytotoxic antibiotic -cardiomyopathy
13
Q
Class, MoA and S/E of 6-mercaptopurine?
A
antimetabolite - prevents purine synthesis and thus DNA synthesis - myelosuppression
14
Q
Class, MoA and S/E of docetaxel?
A
vinca alkaloid - prevents microtubule disassembly - neutropenia
15
Q
Class, MoA and S/E of 5-fluorouracil?
A
antimetabolite - pyrimidine analogue causing cell cycle arrest in S phase and cell apoptosis - mucositis, dermatitis, myelosuppression
16
Q
Class, MoA and S/E of cisplatin?
A
alkylating agent - crosslinks DNA preventing replication - peripheral neuropathy, ototoxicity, hypomagnaesaemia
17
Q
Radiotherapy early S/E
A
occur around 2 weeks in, peak 2-4wks after rx
tiredness, N+V, diarrhoea, skin reaction (erythema, dry/moist desquamation reaction, ulceration), mucositis, dysphagia, cystitis
18
Q
Radiotherapy late s/e
A
months years after rx
secondary ca - of greatest concern in young pt
somnolence, spinal cord myelopathy, brachial plexopathy; pneumonitis; xerostomia, benign strictures of oesophagus/bowel, fistulae, radiation proctitis; urinary frequency, vaginal stenosis, dyspareunia, ED, subfertility; hypothyroidism, panhypopituitarism
19
Q
Monoclonal antibody tumour markers - list assoc ca
- CA125
- CA19-9
- CA15-3
A
ovarian ca
pancreatic ca
breast ca
20
Q
tumour antigens - list assoc ca
- PSA
- AFP
- CEA
- hCG
A
prostate ca
hepatocellular and testicular ca
colorectal ca
germ cell testicular ca and GTD
21
Q
cervical ca screening programme
A
women aged 25-49 every 3yrs, women aged 50-64 every 5 years for a cervical smear test
22
Q
breast ca screening programme
A
women aged 47-73 invited for mammogram every 3yrs
23
Q
colorectal ca screening programme
A
open to men and women
One off Flexible sigmoidoscopy at 55
faecal immunochemical test (FIT) screening - home kit every 2yrs aged 60-74
(test for human Hb in stool (prev FOB but false positive from animal Hb in diet). Can have FIT testing 75+ but it is by request.)
24
Q
Describe Dukes staging of colorectal cancer
A
Dukes A - invasion into but not through the bowel wall (muscular mucosa)
B - extends through bowel wall but does not involve LN
C - involvement of LNs
D - widespread metastases
25
Pre-op ix for patient having colorectal surgery
pregnancy test if any doubt
FBC, U+Es, clotting, glucose, LFTs (if indicated)
Group and save
ECG
26
Who should be considered for bowel prep
People having L sided operations, Klean-Prep macrogol night before. Not usually needed in right sided op.
27
Abx prophylaxis for urological/bowel surgery
IV gentamicin + metronidazole
28
Abx prophylaxis for breast/upper GI/obstetric/gynaecology surgery?
IV co-amoxiclav
29
Features of a colostomy
Typically LIF, flush to skin, thick and sludgy faeces-like output
30
Features of an ileostomy
typically RIF, spouted (small bowel contents are an irritant to skin), output is watery and often tinged with green.
31
What is a loop stoma and when is it used?
When a loop of bowel (small or large) is brought through the surgical incision in the skin and partially divided to form two adjoining stomas. This is used to definition downstream bowel by diverting faeces.
- Loop colostomy - often temporary, can be used in severe peri-anal CD, obstructive rectal ca.
- Loop ileostomy - in anterior resections to prevent anastomotic leak
32
Risk factors for malignant melanoma
Excessive UV exposure, Fitzpatrick type 1 skin, hx of multiple/atypical moles, family/personal hx melanoma
33
Features suspicious of malignant melanoma in a skin lesion?
ABCDE Symptoms
Asymmetrical
Border irregularity
Colours irregular, multiple colours within lesion
Diameter >6mm
Evolution of lesion (change in shape/size)
Symptoms - itching, oozing, bleeding
34
Types of malignant melanoma and how they present differently
Nodular - most aggressive; red/black lump which bleeds/oozes; seen mainly in middle age on sun exposed skin of trunk
Superficial spreading - most common, intermittent high intensity UV exposure, commonly lower limbs
Lentigo maligna - due to chronic UV exposure, older people face
Acral lentiginous - rare, seen in nails/palms/soles in Asian/African-Americans.
35
What is the most important prognostic factor malignant melanoma?
Breslow thickness measured from the top of the stratum granulosum of the epidermis to the deepest invasive cell
36
How is ?malignant melanoma investigated and managed?
2WW dermatology
Excision biopsy, histopathology and Breslow thickness to determine need for re-excision to clear margins .
Radiotherapy and chemotherapy may be used in metastatic
37
What is basal cell carcinoma in pathophysiological terms?
Slow growing, locally invasive malignant tumour of the epidermal keratinocytes. Rarely metastasises.
38
Types of BCC
Nodular (most common), superficial, cystic, keratotic, morphoeic
39
How does nodular BCC present?
Slow growing skin coloured papule or nodule with pearly rolled edge and surface telangiectasia, may have central ulceration or necrosis.
40
Risk factors for BCC?
UV exposure, hx freq/severe childhood sunburn, skin type I, age, male, immunosuppression, hx of skin cancer, and genetic predisposition
41
How is BCC managed?
Surgical excision with histopathology of tumour and margins; can use Mohs Micrographic if high-risk, recurrent or in a difficult spot e.g. face.
Metastatic - radiotherapy
Small low-risk lesions - topical imiquimod cream, cryotherapy, curettage and cautery
42
What is a squamous cell carcinoma?
locally invasive malignant tumour of the epidermal keratinocytes or its appendages, with potential to metastasise
43
Risk factors for SCC
UV exposure, immunosuppression, chronic inflammation or pre-malignant skin conditions (e.g. actinic keratosis), smoking
44
How is SCC managed?
2WW for surgical excision (margins 4mm if <20mm, 6mm if >20mm), Mohs micrographic surgery in high risk patients or cosmetically important sites.
Radiotherapy for large non-resectable tumour
45
How does SCC present?
keratotic ill defined nodule which may ulcerate
46
Risk factors for breast cancer
Family history (esp 1st degree relative/relatives under 40), BRCA1/2 mutation, nulliparity/late primigravida, early menarche, late menopause, combined HRT/OCP, past breast ca, not breastfeeding, ionising radiation, p53 mutations, obesity
47
Most common type of breast cancer?
Invasive ductal carcinoma (no special type)
48
What is DCIS and how does it usually present?
ductal carcinoma in-situ, where cancerous cells are contained by the basement membrane. Some will go on to become invasive malignancy. Usually picked up as incidental finding of micro calcifications on mammogram.
49
2 main classifications of breast cancer in terms of cellular origin
ductal and lobular
50
how does pagets disease of the nipple present?
eczematoid change of the nipple (spreading to areola) associated with underlying breast malignancy
51
How does breast cancer typically present?
If not on screening, if symptomatic
Breast lump - hard, fixed, irregular
asymmetry and swelling of breast, mastalgia
nipple retraction/abnormal discharge
skin changes - e.g. peau d'orange, dimpling, tethering
palpable axillary lump
52
Ddx for a breast lump
Fibroadenoma (<30, breast mouse)
fibroadenosis (middle age - lumpy ± pain)
breast cyst
fat necrosis (obese, hx trauma)
mammary duct ectasia (tender lump around areola ± green nipple discharge)
breast abscess (hot, red, tender swelling commonly in lactation)
53
How would you investigate a ?breast ca
triple assessment - clinical history and examination, imaging (ultrasound scan/mammogram), histology and cytology (core bx or FNA if cyst)
54
How is breast cancer prognosis assessed?
Nottingham Prognostic Index = ( size cm x 0.2) + nodal status + bloom-richardson grade
55
What treatment modalities are available to rx breast ca?
Surgery - mastectomy/WLE + radiotherapy
Hormonal rx - adjuvant if ER+
Immunotherapy - if HER2+
Chemotherapy - FEC-D used mainly neoadjuvant/adjuvant in axillary node disease
56
When would you advise mastectomy vs WLE and vice versa?
Mastectomy - large tumour:breast ratio, multifocal disease, central tumour, DCIS>4cm.
WLE - small tumour:breast ratio, solitary lesion, peripheral tumour, DCIS<4cm
57
How would you assess whether or not LN dissection is needed in breast ca surgery?
Palpable axillary LN at presentation - LN clearance
| No palpable axillary LN at presentation = LN USS, if positive then SLNB to assess nodal burden
58
When should you offer radiotherapy in breast ca rx?
After WLE - whole breast radiotherapy to reduce recurrence
| After mastectomy if T3/T4 tumour or extensive nodal disease
59
What hormonal treatment is available for breast cancer and duration of rx?
ER positive then can give SERM tamoxifen (if premenopausal) or aromatase inhibitor (e.g. anastrozole/letrozole if post-menopausal). 5 years.
60
S/E of tamoxifen
Hot flushes - main reason why women stop
menstrual disturbances - abnormal PV bleeding
increased risk of endometrial cancer, VTE and osteoporosis
61
S/E of aromatase inhibitors
osteoporosis (baseline DEXA scan)
hot flushes
arthralgia/myalgia
insomnia
62
What specific rx is available for a HER2 positive breast ca? What are the side effects?
Herceptin (trastuzumab) - monoclonal antibody
Flu-like symptoms e.g. fever, chills, mild pain
Nausea and diarrhoea
Cardiomyopathy, arrhythmia, heart failure - cardiotoxicity so do not offer to pt with LVEF<55%, hx poorly controlled htn, high risk uncontrolled arrhythmia, medication requiring angina, CCF. Baseline ECHO and every 3m
63
What histological class of cancer is most common in colorectal ca?
adenocarcinoma
64
Risk factors for colorectal ca
age
polyps (adenoma-carcinoma seq)
family hx and genetics - FAP (APC mutation), HNPCC
IBD
diet - low fibre, high processed meat intake
smoking and high alcohol intake
65
Clinical features of colorectal ca
R sided - IDA, weightloss, FOB, abdo pain, RIF mass, presents late
L sided - change in bowel habit, rectal bleeding, tenesmus, mass in LIF/on DRE
66
Ddx in ?colorectal ca
diverticular disease
IBD
haemorrhoids
67
Ix in ?colorectal ca
FBC, U+Es, LFTs, clotting; CEA - monitoring not diagnosis
Colonoscopy and bx
CTCAP staging
rectal ca - MRI rectum and endoanal ultrasound (T1/t2)
68
What surgery would you perform for an ascending colon ca?
Right hemicolectomy
69
What surgery would you perform for a proximal transverse colon ca?
extended right hemicolectomy
70
What surgery would you perform for descending colon ca?
left hemicolectomy
71
What surgery would you perform for a sigmoid colon ca?
sigmoid colectomy
| anterior resection takes superior rectum too
72
What surgery would you perform for a high rectal ca >5cm above the anal verge?
anterior resection with a defunctioning loop ileostomy (can be reversed)
73
What surgery would you perform for a low rectal ca <5cm above the anal verge?
abdominoperineal resection and permanent colostomy
74
What surgery would you perform for colorectal cancer that has perforated or obstructed?
Hartmanns procedure (resection of rectosigmoid colon with end colostomy and closure of the rectal stump)
75
In what type of colorectal cancer is radiotherapy used as a treatment modality?
Rectal cancer as neoadjuvant rx
76
Palliative surgery for colorectal ca?
In obstruction - Endoluminal stenting (l sided tumour), stoma formation
resection of secondaries - not commonly performed but can be done with adjuvant chemo for liver mets
77
when is chemo used to treat colorectal ca?
adjuvant in advanced disease (Dukes C) - folfox chemo
78
In what are of the prostate does prostate ca most commonly occur?
Peripheral zone
79
What histological type of cancer are most prostate ca's?
adenocarcinoma (95%) - most commonly acinar, ductal Is less common but more aggressive
80
Risk factors for prostate ca
age, ethnicity (black African/caribbean), family hx, BRCA2. Less sig modifiable - obesity, DM, smoking, lack of exercise
81
Sx of prostate ca
Local - LUTS inc weak stream, urgency, frequency
Locally advanced - haematuria, haematospermia, dysuria, incontinence, suprapubic/loin pain, tenesmus
Mets - bone pain, lethargy, anorexia, UEW
82
Ix prostate ca
DRE (irregular hard nodular asymmetrical mass)
PSA
Biopsy - transrectal ultrasound guided bx (TRUS) or Transperineal bx; may have pre/post negative bx multi parametric MRI
Staging CT abdopelvis + bone scan
83
How is prostate ca risk stratified?
Gleason score + PSA + tumour staging (from TNM)
Low risk - PSA<10, Gleason 6 or less, T1-2a
Intermediate risk - PSA10-20, Gleason 7, T2b
High risk - PSA>20, Gleason 8-10, T2c
84
How is risk used to determine management of prostate ca?
low - active surveillance, radical rx if evidence of progression
Intermediate risk - offer radical rx, may be suitable for active surveillance
high risk - offer radical therapy
Metastatic disease - chemotherapy + anti-hormonal agents
85
How is active surveillance different to watchful waiting?
Active surveillance is only offered to those with low risk disease or select patients with intermediate risk disease. Monitor with 3-monthly PSA, 6-12monthly DRE, and rebiopsy at 1-3yr interval. Assess for progression and intervene as appropriate.
Watchful waiting - older patients, limited life expectancy, at any stage of disease, symptom guided, definitive rx is delayed + hormonal rx often initiated at time of symptomatic disease.
86
Surgical management of prostate ca?
Radical prostatectomy - removal of prostate gland, seminal vesicles and surrounding tissues ± pelvic LN dissection. Can be open, laparoscopic or robot assisted. S/E - ED in 60-90%, SUI, bladder neck stenosis.
87
What radiotherapy is used for prostate ca and in whom?
External beam radiotherapy and brachytherapy can be used. Can be curative in locally advanced disease. Increased risk bladder, colon and rectal ca.
88
What hormonal rx is offered in prostate ca?
T3/4 locally advanced disease, metastatic disease
GnRH agonist goserelin + initial anti-androgen cover to prevent tumour flare with rise in testosterone; anti-androgens; orchidectomy
89
What are the main testicular ca classifications? Which is more common?
Germ cell tumours 95% - seminomas (35yo, good prognosis) or non-seminomatous e.g. teratoma (25Y/O), yolk sac, choriocarcinoma.
Non germ-cell
90
Risk factors for testicular ca?
```
Infertility (3x risk)
family hx
cryptorchidism
klinefelters syndrome
mumps orchiditis
```
91
Sx of testicular ca
Testicular lump - irregular fixed and firm with no transillumination, minority are painful
Hydrocoele
Gynaecomastia
92
Ix testicular ca
AFP (may be raised in NSGCT), b-hcg (raised - more likely NSGCT), LDH (raised in GCST) tumour markers
ultrasound scan testicle
CT CAP with contrast for staging
93
Ddx testicular lump
epididymal cyst, haematoma, epididymitis, hydrocoele
94
Mx of testicular ca
NSGCT - orchidectomy ± adjuvant chemo (may use sole rx chemo if metastatic)
seminoma - orchidectomy + surveillance, high risk relapse = + chemo. Mets = chemoradiotherapy
95
Classifications of lung cancer
Small cell
| Non-small cell lung ca inc squamous cell, adenocarcinoma, large cell
96
Most common type of lung ca
squamous cell
97
lung ca with worst prognosis
small cell
98
of non-smokers with lung ca, this subtype is most common
adenocarcinoma - most of pt with it were smokers but most common type in non-smokers
99
Describe the characteristics of small cell lung ca - how does it tend to present?
tumour of small immature neuroendocrine cells, usually seen centrally around main bronchus. grows fast and metastasises early, commonly large tumours seen in multiple sites. sx from secretion of ectopic ACTH (cushings synd), ADH (hyponatraemia), paraneoplastic syndrome LEMS
100
Signs and sx of lung ca?
dyspnoea, chest pain, haemoptysis, cough, UEW, anorexia, hoarseness (Pancoast), SVCO
O/E - fixed monophonic wheeze, supraclavicular/cervical lymphadenopathy, clubbing
101
Paraneoplastic syndromes of squamous cell lung ca
PTHrP, HPOA, hyperthyroidism
102
Paraneoplastic syndromes of adenocarcinoma?
gynaecomastia, HPOA
103
What might you see on CXR in lung ca?
Nodule, hilar enlargement, consolidation, pneumothorax, pleural effusion, bony secondaries.
104
How would you ix lung ca?
CXR
CT Chest with contrast for staging
If for curative rx ensure prior to this they have PET-CT, also endobronchial ultrasound guided trans bronchial biopsy/FNA
105
Mx of NSCLC
Curative intent = radiotherapy/resection + adjuvant cisplatin-based combination chemo. Not suitable for surgery = chemotherapy ± immunotherapy
106
management of small cell lung ca?
May consider surgery if T1/2
| Cisplatin based combination chemotherapy ± radiotherapy if early.
107
Side effects of immunotherapy
fatigue, change in mental state, headaches
GI - abdo pain, diarrhoea, ileus, perforation
skin - immune-related dermatitis, pruritis, dry skin, SJS/TEN
neuro - neuropathies, weakness, sensory changes, paraesthesia, MG, GBS
endocrine - hypophysitis, hypopituitarism, hypothyroidism, adrenal insufficiency
eye - blepharitis, conjunctivitis, uveitis, episcleritis
GCA, vasculitis, PMR, arthritis, haemolytic anaemia, hepatitis/hepatotoxicity, myocarditis
108
Who is ALL most commonly seen in? briefly describe pathophysiology
children, rare in adults. Uncontrolled and dysregulated proliferation of immature lymphocytes can affect B or T cells. Bone marrow failure and tissue infiltration.
109
Sx of ALL
BM failure - anaemia, thrombocytopenia (bleeding, bruising, petechiae), leukopenia (infections, pyrexia);
Bone pain from BM infiltration
hepatosplenomegaly ± testicular swelling.
110
Ix ALL
FBC, film, clotting; BM trephine bx to confirm, LP for CNS involvement, CXR to exclude mediastinal mass
111
What is AML and how does it present?
acute myeloid leukaemia, commonest acute leukaemia in adults. Rapidly progressive can be primary or secondary transformation of myeloproliferative disorder. Clonal proliferation of myeloid progenitor 'blast' cells.
Sx of BM failure, anaemia/neutropenia (may have raised WCC but functional deficiency), thrombocytopenia, splenomegaly, bone pain, DIC.
112
How would you ix ?AML
FBC, blood film, BM bx, immunophenotyping and molecular methods. Auer rods on biopsy are diagnostic.
113
Mx of AML
chemotherapy + hydration + allopurinol to prevent TLS
BM transplant
supportive
114
What is CML?
Uncontrolled clonal proliferation of myeloid cells - see increased number of granulocytes of various maturation ± thrombocytosis, a MPD seen in middle age
115
Sx of CML
Systemic - night sweats, fever, UEW, lethargy
MASSIVE HEPATOSPLENOMEGALY (abdo discomfort)
bleeding, bruising, gout, hyper viscosity
116
Ix CML
FBC, blood film (raised WCC - polymorphic neutrophils, basophils and myelocytes; ± anaemia and low platelets), increased urate
cytogenetics of blood/BM - Philadelphia chromosome t(9;22) which results in BCR-ABL fusion gene which causes constitutive tyrosine kinase activity - good prognostic factor, present in >80%.
117
Mx of CML
Imatinib (TK inhibitor) if Philadelphia chromosome - well tolerated, S/E nausea, cramps, headache, oedema, rash, arthralgia, myelosuppresion
hydroxyurea, interferon a
118
What is CLL
chronic lymphocytic leukaemia - very common, usually an incidental finding on FBC in elderly men. Monoclonal proliferation of well differentiated B cells. May remain stable for years.
119
Sx of CLL
```
often none!
constitutional - anorexia, UEW
more marked lymphadenopathy than CML
bleeding
infection
```
120
Complications of CLL
anaemia, hypogammaglobulinaemia, warm AIHA, richters transformation to high grade NHL
121
Ix of CLL
blood film (smudge cells), immunophenotyping (distinguish from NHL), positive DAT
122
Rx CLL
mainly if symptomatic with chemotherapy, radiotherapy for LN/HSM, supportive care/
1/3 never progress, 1/3 progress with time, 1/3 actively progressing
123
How does NHL present?
lymphadenopathy - classically painless, rubbery, at multiple sites
B sx - UEW, fever, night sweats
Splenomegaly
extranodal disease - gastric (dyspepsia, dysphagia, abdo pain), BM, CNS (nerve palsy), lung, skin
124
Ix NHL
FBC (normocytic anaemia), LDH, ESR, blood film (r/o leukaemia), HIV test (risk factor)
LN excisions bx and Ann Arbor staging
Staging CT CAP
Other ix as clinical picture suggests - LP ?CNS involvement, BM bx for ?BM infiltration
125
Mx of NHL
high grade - R-CHOP chemotherapy, flu and pneumococcal vaccines, BMT for relapse
low grade - watchful waiting
126
How does Hodgkins lymphoma present?
bimodal age distribution peak in 3rd and 7th decades
Lymphadenopathy - painless, non tender, asymmetrical w/contiguous spread, alcohol-induced pain, mediastinal LN involvement can cause SVCO/bronchial obstruction
B sx - UEW, fever, night sweats
Itch, Pel-Ebstein fever (cyclical), hepato/splenomegaly
127
Ix Hodgkins lymphoma
FBC, U+Es, LFTs, LDH, Ca, blood film
LN excision biopsy - reed Sternberg cells with owl eye nucleus
staging CT CAP
BM bx if B sx or stage 3/4
128
Mx for Hodgkins lymphoma
chemo/radio/both - ABVD chemo
| BMT for relapse
129
What is multiple myeloma?
haematological malignancy characterised by clonal proliferation of plasma cells due to genetic mutations which occur as B cells differentiate into mature plasma cells. May see raised monoclonal IgG (less commonly IgA), free light chain (deposit in renal tubules, causing renal impairment; seen in urine Bence-Jones protein), clones produce IL6 which inhibit osteoblasts and activate osteoclasts (hypercalcaemia and lytic lesions)
130
Sx of myeloma
CRABBI
hyperCalcaemia - constipation, nausea, anorexia, confusion
renal impairment - polydipsia, polyuria
anaemia - fatigue and pallor, due to BM crowding
bleeding (BM crowding -> thrombocytopenia)
bone lytic lesions (BM infiltration and IL6 mediated osteoclast activity - back pain, fragility #)
Infections - reduced normal Ig increasing susceptibility to infection
131
How would you ix myeloma?
FBC, U+Es, Ca, serum electrophoresis (raised monoclonal IgA/IgG proteins), blood film (rouleaux ± cytopenia)
urine dipstick - increased specific gravity
urine electrophoresis- bence jones protein
BM aspiration and trephine bx - plasma cells 10%+
MRI/CT skeletal survey - punched out lytic lesions, vertebral collapse, fracture
132
Mx of myeloma
relapsing and remitting malignancy not cured
induction therapy - chemotherapy + autologous bone marrow transplant if fit; 3-monthly blood tests and electrophoresis to assess for relapse. If relapse mono therapy chemo ± repeat BMT.
Sx relief - analgesia (avoid NSAIDs), anaemia (transfusions and EPO), zolendronic acid, annual flu vaccines, VTE prophylaxis
133
When would you expect neutropenic sepsis to occur in a cancer patient?
usually 7-14d after chemo, but suspect in anyone who is unwell and has had chemo in the last 6wks
134
Sx of neutropenic sepsis, and what WCC is neutropenic?
WCC<0.5*10^9
T>38, or T>37.5 taken on two occasions 30 mins apart; or less commonly T<36. Other clinically sig sepsis sx - EWS3+, tachypnoea, tachycardia, hypotension, low sats, oliguria/anuria, delirium/unresponsive.
135
prophylaxis for neutropenic sepsis?
prophylactic fluoroquinolone - levofloxacin, if neutropenic sepsis is anticipated/high risk
GCSF is not routinely given for prophylaxis, maybe in select patients
136
How would you manage neutropenic sepsis?
Low threshold - sx infection + chemo in last 6/52 = neutropenic sepsis until proven otherwise
Initiate sepsis 6 bundle (chemo red flag) - IV tazocin 4.5g QDS before blood results, ± vancomycin if ?indwelling venous catheter infection/sig mucositis. Mero if pen allergic. Still unwell and febrile after 48h ?change abx, after 4-6d ?fungal infection
Escalate to senior r/v and haem-onc r/v
May be a role for GCSF in select patients.
137
what symptom/sign differentiates spinal cord mets from spinal cord compression?
neurological compromise seen in spinal cord compression
138
Sx of spinal cord METS and how would you investigate this?
back pain - thoracic/cervical/unrelenting lumbar, may be worse on coughing, sneezing or straining, may be nocturnal, associated with tenderness on examination
Whole spine MRI within 1wk (urgent if ?compression)
139
What is the usual mechanism of malignant spinal cord compression?
extradural compression as a result of vertebral body mets (usually thoracic)- most common in myeloma, lung, breast and prostate ca.
140
clinical features of malignant spinal cord compression
Back pain - earliest and most common sx
sensory loss and numbness
motor weakness - usually in legs.
- Lesion above L1 = UMN sx in legs below level of lesion - spastic paresis, hypertonia, clonus, brisk reflexes and upgoing plantars
- Lesions below L1 = LMN sx, caudal equina sx - flaccid paraperesis and saddle anaesthesia.
bladder and anal sphincter involvement is a late sx
141
What is your immediate management of malignant spinal cord compression?
Immobilise - complete bed rest and lie flat
PO dexamethasone 16mg STAT and 24h then on, + PPI for gastroprotection, + prophylactic LMWH and TEDs
contact MSCC co-ordinator, alert senior + clinical oncology r/v
142
How would you investigate malignant spinal cord compression?
Urgent MRI whole spine - within 24h
| if for surgery - bloods - FBC, U+Es, LFTs, bone profile inc calcium, clotting and G+S
143
How is malignant spinal cord compression treated?
PO dexamethasone until surgery/radiotherapy started
Surgical decompression and stabilisation + adj radio
Radiotherapy within 24h
144
What factors in patient history and examination would make them unlikely candidates for surgical mx MSCC?
clearly not fit for surgery - PS 3 or worse
life expectancy <3months
no motor function for >24h
multiple levels compression
radiosensitive malignancy without spinal instability - lymphoma, myeloma, SCLC, seminoma
145
by what timepoint should radiotherapy be started in MSCC unless patient is for surgery?
within 24h presentation unless they have had complete paraplegia with loss of sphincter control for >48h at which point radiotherapy is for palliation of pain, and is not urgent.
146
For how long should PO high dose steroids be taken in MSCC?
Start tapering dose as soon as the radiotherapy/surgery has taken place
147
What is superior vena cava obstruction?
external pressure by tumour (most common), thrombus or direct invasion by tumour causes reduced venous return from the head, neck and upper limbs by obstructing the superior vena cava.
148
What cancers is malignant SVCO most commonly associated with?
lung cancer (both NSCLC and SCLC) and NHL thought to account for 95% SVCO. Others = thymoma, germ cell neoplasm, mesothelioma, mediastinal LN mets from solid tumour e.g. breast
149
How would SVCO typically present
Dyspnoea
swelling of face, neck and arms - Pembertons sx +
dilatation of chest wall veins + raised non-pulsatile JVP
signs of severe SVCO - headache, confusion, altered consciousness (cerebral oedema), stridor (laryngeal oedema)
150
How would you manage SVCO?
Prop up, A to E assessment to stabilise - checking for hypoxia and O2 needs, alert senior and oncology r/v to guide mx
Life threatening sx - PO dexamethasone 16mg, balloon venoplasty and stenting
Non-life threatening sx - SCLC = chemo + radio, NSCLC = radiotherapy.
151
which malignancies most commonly cause hypercalcaemia?
bony mets, myeloma, PTHrP in squamous cell lung ca
152
How does hypercalcaemia of malignancy present?
Bones, groans, thrones and stones
abdo pain, N+V, constipation; polyuria, polydipsia; renal stones; depression, confusion; fragility fracture
anorexia + UEW, weakness, severe - htn, seizures, coma, arrhythmia, cardiomyopathy
153
Ix ?hypercalcaemia of malignancy
bloods - corrected ca, U+Es, PTH, vitamin D, phosphate
| ECG - shortened QTc
154
Mx hypercalcaemia of malignancy
stop any thiazides and vit D/Ca supplements, ?stop nephrotoxins such as NSAIDs/ACEis/diuretics
aggressive rehydration with IV NaCl 0.9% 2-4L
severe/12-24h no improvement = add IV bisphosphonates (e.g. zoledronic acid)
definitive rx is rx ca
155
What is the context in which tumour lysis syndrome is usually seen?
combination chemo treatment of rapidly proliferating tumours e.g. high grade lymphoma and leukaemia
156
what electrolyte changes are associated with tumour lysis syndrome?
increased - urate, potassium, phosphate
| decreased - calcium
157
what are some of the consequences of TLS?
AKI, cardiac arrhythmia, seizure, sudden death
158
How can you prevent tumour lysis syndrome?
Hydration and prophylactic IV rasburicase before chemo (up to 7d after); lower risk may give PO allopurinol.
159
How does allopurinol prevent TLS?
xanthine oxidase inhibitor, reduces conversion of hypoxanthine to xanthine to uric acid; hypoxanthine and xanthine more water soluble so less likely to crystallise in tubules and precipitate AKI
160
How does rasburicase prevent TLS?
rasburicase is a recombinant version of urate oxidase, it converts uric acid to water-soluble allantoin. Used for acute rx of TLS because it metabolises already formed urate, rather than preventing further build up as allopurinol does.
161
In high risk patients you may give both allopurinol and rasburicase true or false?
false - allopurinol would reduce the efficacy of rasburicase
162
How would you mx TLS?
Aggressive IV fluid hydration + IV rasburicase, rx electrolyte abnormalities
(high K - insulin/dextrose infusion, calcium gluconate to stabilise cardiac membrane if ECG changes; low ca = calcium gluconate)
163
How would you start opioids in an opioid-naive patient in palliative care?
Start low and go slow, increase dose 30-50% every 24h - could start MR zomorph 15mg BD + oramorph 5mg PRN
prescribe laxative, anti-emetics if nausea persists
can use non-opioids as sparing agents
164
S/E of opioids?
drowsy, N+V (usually improve in ~5d), constipation and dry mouth
165
sx opioid toxicity?
sedation
respiratory depression
visual hallucinations and delirium
myoclonic jerks
166
what opioids should be used in impaired renal function?
mild impairment could use oxycodone
| severe impairment - fentanyl, alfentanil, buprenorphine (hepatic metabolism)
167
What fraction of daily dose do you give PRN?
1/6
168
conversion rate from oral codeine or tramadol to oral morphine?
dose/10
169
conversion rate from oral morphine to oral oxycodone?
dose/1.5
170
conversion rate from PO morphine to SC morphine?
dose/2
171
conversion rate from PO morphine to SC diamorphine?
dose/3
172
Causes of N+V in cancer patient?
```
chemo/drugs
constipation
GI obstruction
hypercalcaemia
oral candidiasis
severe pain
infection
renal failure
```
173
How would reduced gastric motility N+V present? How would you rx this?
feeling of fullness and distension, regurgitation, vomiting large volumes which relieves nausea, epigastric discomfort, reduced appetite, hiccups
Metoclopramide - blocks CTZ, peripheral pro kinetic (also domperidone)
174
How would chemical N+V present? How would you rx this?
persistent and often severe nausea unrelieved by vomiting, aggravated by sight/smell of food, drowsiness, confusion
haloperidol
175
How would you rx bowel obstruction or raised ICP related N+V?
cyclizine - centrally acting, antihistaminergic and anticholinergic
176
Rx anticipatory N+V
short-acting benzodiazepine e.g. lorazepam
177
post-op/radiotherapy related N+V
ondansetron - 5ht3 antagonist acts in CTZ
178
What laxative would you prescribe with strong opioids?
stimulant laxative - senna
179
how would you treat constipation with faecal loading
stimulant laxative (Senna) + osmotic agent (macrogol/lactulose) or stool softener docusate
180
How would you rx breathlessness in palliative care?
simple measures - improve air circulation in room, pursed lip breathing, positioning - sat up, leaning forward, relax shoulders; reassure; exercise within limits
medication - IR oramorph to reduce respirator drive
if sig anxiety component could consider lorazepam second line
181
how would you rx intractable hiccups?
1st line chlorpromazine (low potency typical antipsychotic)
| 2nd - haloperidol/gabapentin
182
rx agitation and confusion in palliative care?
correct any underlying cause e.g. hypercalcaemia, infection, urinary retention, medications
1st line - haloperidol
terminal agitation - midazolam
183
rx secretions in palliative care?
reassure loved ones it is not uncomfortable to patients, more distressing for them due to noise
avoid fluid overload
glycopyrronium bromide/ hyoscine hydrobromide
184
give examples of a typical set of anticipatory medications prescribed in palliative care
assuming none of these medications are already in place (otherwise would stick with the dose and class of drug they've found works)
SC morphine 2.5-5mg - pain
SC midazolam 2.5-5mg - agitation and confusion
SC levomepromazine 2.5-5mg - N+V
SC glycopyrronium bromide 200-400mcg - resp secretions
