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Y4 Cancer Care > Cancer Care Workbook > Flashcards

Cancer Care Workbook Flashcards

- from the haem workbook, tutorials and teaching by block lead

1
Q

A 48 year old man is presents to the GP with an enlarged lymph node on one side of his neck. What would you ask?

A

When he first noticed it and progression over time

Size, shape, consistency, mobility, tenderness

Pain in the node and anything that makes it worse e.g. alcohol in Hodgkins

Recent hx of infection - less likely with unilateral nodes but consider dental issues

Any other enlarged lymph nodes anywhere else?

B sxs- e.g WL, night sweats, fever

Itching - common in haem maligancy due to cytokine release

PMH - transplant (post transplant lymphoproliferative disorders - PTLD)

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2
Q

DDx for unilateral enlarged lymph node?

A

Lymphoma
Infection
Rheumatology conditions e.g. SLE

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3
Q

What features of an enlarged lymph node would you look for on examination?

A

Hard / soft consistency
fixed / mobile
regular / irregular
tender / non tender

Hard, irregular, fixed and non tender is concerning

Rule of 2s - > 2cm for > 2 weeks is a red flag

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4
Q

How could you explain to a patient why chemotherapy causes neutropenia?

A

chemotherapy destroys rapidly dividing cells like cancer cells

can therefore destroy other cells that divide very quickly like the lining of your mouth (mucositis) and also you cells that fight infection

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5
Q

What diagnostic test would you do for a patient with a suspicious enlarged lymph node but no systemic sxs?

What other tests may be useful at this stage?

A

excisional lymph node biopsy

FBC for bone marrow involvement + infection
ESR, CRP
LDH - for disease burden and cell turnover

Screen for EBV, Hepatitis (surface antigen and core antibody), HIV - for other causes of lymph node enlargement and also because hepatitis can react to monoclonal antibody treatments

USS of the lymph node if low suspicion of lymphoma

CT neck, chest, abdo, pelvis for staging / spread if higher suspicion of lymphoma

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6
Q

Hodgkin’s lymphoma should be suspected in younger people with mediastinal masses.

How can it be further classified?

A

B type:
split into low grade (follicular) and high grade (diffuse large B cell and Burkitt’s lymphoma)

T type

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7
Q

Is follicular lymphoma (low grade B cell) a common subtype of Non Hodgkin’s lymphoma?

A

Yes

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8
Q

Approx how many subtypes of NHL are there in the WHO classification?

A

approx 30

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9
Q

How can you manage a very slow growing, low-grade NHL?

A

refer to Macmillan nurse specialist team
watch and wait

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10
Q

A patient with low grade NHL presents with abdo pain, tiredness, WL and SOB - what is the most likely cause?

How could you investigate this?

A

transformation of a low grade to a high grade lymphoma

Repeat bloods - FBC, LDH, creatinine, blood film
PET CT scan - normal CT is structural, PET CT can measure metabolic activity

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11
Q

DDx for a patient with lymphoma presenting with a raised creatinine?

A

consider tumour lysis
consider obstruction of kidneys/ bowel by retroperitoneal mass

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12
Q

What should the advice be regarding need for haematological support in a cancer patient with a Hb of 92 and platelets of 96?

A

no real need - Hb is 92 (concern when under 70), platelets need to be above 50 for surgery and 10 in general which they are

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13
Q

What biochemistry results would cause concern in a patient started on Rituximab in the last 48 hours?

A

signs of tumour lysis - calcium low, everything else high

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14
Q

Outline common sxs of hypercalcaemia in cancer patients ?

A

Acute confusion
Abdominal pain
N+V, constipation

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15
Q

Why is hypercalcemia an oncological emergency?

A

risk of seizures and death

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16
Q

Give some causes of massive, moderate and mild splenomegaly

A

Massive = myelofibrosis, CML, NPNs, EBV
Moderate = lymphomas
Mild = portal htn, infection, haemolytic anaemia

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17
Q

What lab tests would you request for a patient with splenomegaly?

A

FBC, CRP, LFTs (portal htn), Bone Profile
Blood film (malaria)
Viral screen (EBV)

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18
Q

splenomegaly, high WCC and precursor cells on blood film =

A

likely CLL

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19
Q

What complication should you be concerned about in a patient with a very high WCC?

A

hyperviscocity syndrome

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20
Q

What should be considered before starting a young patient on hydroxycarbamide?

A

do platelet count and Hb
Consider fertility preservation

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21
Q

What is Imantinib and how does it work?

A

tyrosine kinase inhibitor - acts on the Philadelphia chromosome

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22
Q

What are the potential side effects of IV bisphosphonate infusions?

A

flu like symptoms e.g. malaise and aching
jaw necrosis - with repeated exposure

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23
Q

How long do you need to carry on IV bisphosphonates to treat hypercalcemia in cancer patients?

A

4-6 weeks

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24
Q

How can disease progression for CLL be monitored?

A

Monitor FBC
Check morphological remission - on blood film and bone marrow
Check cytological remission for BCR/ABL returning to normal

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25
Q

DDx for a young person with left mediastinal opacification on CXR?

A

THINK HODGKINS LYMPHOMA

Other differentials:
Sarcoidosis
Infections e.g. TB

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26
Q

What questions would you ask a young person with left mediastinal mass on CXR?

A

B sxs - WL, hight sweats, fever
Skin changes? (for sarcoidosis)
New cough, chest pain, SOB?

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27
Q

How can you stage Hodgkin’s lymphoma?

A

PET CT

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28
Q

What may be useful when thinking about prognosis of Hodgkin’s lymphoma?

A

Richter Scoring System - RSS

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29
Q

What are the challenges to future health for young patients with Hodgkin’s lymphoma?

A

secondary malignancy
infertility
osteoporosis due to high steroid usage
thyroid problems

30
Q

DDx for a young woman presenting with a one week hx of bruising, recurrent epistaxis and pancytopenia on blood film?

A

ALL / AML due to sudden history

Myelodysplastic syndrome, Myelofibrosis although uncommon in young people

Nutritional deficiencies e.g. B12 deficiency can cause pancytopenia - monitor reticulocyte counts as you give B12 injections/ folate

Drugs

31
Q

Other than FBC, what would you request for patients with new pancytopenia?

A

U&Es and LFTs for baseline renal and liver function
Coagulation screen and fibrinogen
TFTs
LDH for cell turnover
Blood film

32
Q

What test can you do on a bone marrow aspirate sample?

A

flow cytometry - liquid sample for morphology

32
Q

What are CD13, CD33, CD15 and CD117?

A

monocyte markers

33
Q

What is CD19?

A

B cell marker

34
Q

What are CD3 and CD7?

A

T cell markers

35
Q

How might you manage a young female patient with AML?

A

Blood transfusion
Platelets
Consider fertility preservation
Baseline virology
Treat any infections
Can give norethisterone to stop periods
Chemotherapy

36
Q

Who can access the teenage and young adult cancer services?

A

25 and younger can access TYA services
Makes stay in hospital more bearable

37
Q

What can determine AML prognosis?

A

depends on cytogenetics

38
Q

What will you look for on examination of a newly confused patient with suspected pathological fracture on Xray?

A

Consider hypercalcaemia but keep ddx broad!

Neurological examination for conscious level, reflexes, pupillary responses

Signs of opioid toxicity e.g. pinpoint pupils and resp depression

Abdo exam for constipation and enlarged bladder for retention

Auscultation of chest for signs of infection

Check for any visible bleeding

39
Q

how would you investigate a patient with suspected pathological fracture and new confusion?

A

investigate for other causes of confusion!

Urine dip and culture
Sputum culture
FBC, U&Es, LFTs, CRP
Blood culture
Bone profile
Serum electrophoresis

MYELOMA SCREEN:
serum immunoglobulins
serum light chains

40
Q

Radiological investigations for a patient with new confusion and suspected pathological fracture?

A

CXR - quick test for potential focus of infection

CT CAP to look for primary cancer that has caused bone mets

PET CT/ whole body MRI for myeloma

41
Q

What caused raised plasma viscosity in multiple myeloma?

A

due to presence of paraproteins, therefore cannot cytoreduce with hydroxycarbamide

42
Q

Signs of myeloma on investigation?

A

normocytic anaemia
raised calcium
renal impairment - raised eGFR
bony lesions on X-ray

43
Q

more than 10% plasma cells on bone marrow =

A

think myeloma!!!

44
Q

How can you establish clonality of cells on BMA?

A

flow cytometry or immunophenotyping

45
Q

What type of lesions on the bone do you see in bone mets?

A

generally osteolytic apart from prostate which usually looks osteosclerotic

46
Q

If tazocin doesn’t clear neutropenic sepsis, what should you suspect?

A

fungal infection e.g. Aspergillus - consider CXR

47
Q

Causes of hypercalcaemia in cancer patients?

A

bone mets
myeloma
paraneoplastic syndrome e.g. PTH-rp

48
Q

When patients are actively dying, many of the long term medications they are on (for example statins) become superfluous and are stopped.

What medications are essential to continue?

A

long term steroids

insulin

heparin SC if they have had a massive PE (generally most other prophylactic anticoagulants can be stopped)

anti-epileptics (can put Keppra / midazolam in a SCSD)

49
Q

What Hb do you aim for before surgery?

A

135 in men, 120 in women

can give iron tablets / infusions and EPO injections before blood transfusions

50
Q

What chemotherapy drug specifically requires pre-hydration with IV fluids?

A

Cisplatin as it can cause renal damage

51
Q

What are the potential side effects of radiation to the neck?

A

mucositis
parotitis and increased viscosity of the saliva (may cause secondary dental issues)
skin changes

52
Q

Which cancers are most commonly linked with hrHPV?

A

cervical
anal
squamous cell oropharyngeal cancer

53
Q

What questions do you need to make sure you ask about in a patient with suspected head and neck cancer?

A

hearing loss
changes to voice esp. sounding more nasal
sore throat / difficulty swallowing
cough
epistaxis

54
Q

Which subatomic particles are used in radiotherapy?

A

photons

55
Q

Other than tumours, which areas light up on PET scans?

A

brain and heart due to high metabolic activity
kidneys and bladder due to excretion of radioisotope

56
Q

What is the safest way to increase someones opioid dose?

A

by looking at their PRNs rather than doing an arbitrary 30-50% increase in dose

57
Q

What can you try if multiple opioids are not controlling pain despite dose escalation?

A

consider pregabalin
consider nerve block (e.g. coealic plexus block)
refer to SPCT

58
Q

What should you look for on examination of a septic oncology patient?

A

visible mucositis e.g. in oral cavity
any breaks in skin e.g. pressure sores
indwelling lines / catheters

59
Q

Chemo in last 2 weeks + unwell =

A

NEUTROPENIC SEPSIS UNTIL PROVEN OTHERWISE

60
Q

Which abx should be stopped in renal impairment?

A

aminoglycosides e.g. gentamicin and neomycin

reduce dose of meropenem

61
Q

How do biochemical causes of N+V typically present? How should you manage these?

A

constant nausea + small vol vomiting

haloperidol

62
Q

How can you manage a patient with hydronephrosis due to peritoneal disease?

A

USS KUB to confirm, insert nephrostomy

63
Q

What can be used instead of tazocin for penicillin allergic patients with neutropenic sepsis?

A

meropenem

64
Q

What can you give someone with sxs of raised ICP due to brain mets?

A

16 mg dexamethasone PO urgently
Then step down to 8mg BD

65
Q

What can you give someone who is fitting on an onc ward?

A

SC midazolam

can give levetiracetam for seizure prophylaxis - can titrate quickly and can give in a SCSD

66
Q

What do you need to remember to inform someone of with newly diagnosed brain mets?

A

they can’t drive

67
Q

How can brain mets be managed?

A

very generalised rule of thumb:
< 2 may qualify for surgery
>2 = radiotherapy

68
Q

What dose of metoclopramide would you give a cancer patient with N+V?

A

30 mg before meals

69
Q

Dexamethasone is the first line steroid for most acute onc presentations e.g. MSCC and brain mets.

In what situation might you use another?

A

prednisolone is first line for pneumonitis / colitis due to immunotherapy

70
Q

Give some causes of RUQ pain in cancer patients

A

Hepatic mets
Reactive hepatitis
Bone mets (ribs)
Gallstones
Constipation
Pneumonia
MSK pain

Y4 Cancer Care (13 decks)

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