Cancer Care Workbook Flashcards
- from the haem workbook, tutorials and teaching by block lead
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?
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)
DDx for unilateral enlarged lymph node?
Lymphoma
Infection
Rheumatology conditions e.g. SLE
What features of an enlarged lymph node would you look for on examination?
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
How could you explain to a patient why chemotherapy causes neutropenia?
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
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?
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
Hodgkin’s lymphoma should be suspected in younger people with mediastinal masses.
How can it be further classified?
B type:
split into low grade (follicular) and high grade (diffuse large B cell and Burkitt’s lymphoma)
T type
Is follicular lymphoma (low grade B cell) a common subtype of Non Hodgkin’s lymphoma?
Yes
Approx how many subtypes of NHL are there in the WHO classification?
approx 30
How can you manage a very slow growing, low-grade NHL?
refer to Macmillan nurse specialist team
watch and wait
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?
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
DDx for a patient with lymphoma presenting with a raised creatinine?
consider tumour lysis
consider obstruction of kidneys/ bowel by retroperitoneal mass
What should the advice be regarding need for haematological support in a cancer patient with a Hb of 92 and platelets of 96?
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
What biochemistry results would cause concern in a patient started on Rituximab in the last 48 hours?
signs of tumour lysis - calcium low, everything else high
Outline common sxs of hypercalcaemia in cancer patients ?
Acute confusion
Abdominal pain
N+V, constipation
Why is hypercalcemia an oncological emergency?
risk of seizures and death
Give some causes of massive, moderate and mild splenomegaly
Massive = myelofibrosis, CML, NPNs, EBV
Moderate = lymphomas
Mild = portal htn, infection, haemolytic anaemia
What lab tests would you request for a patient with splenomegaly?
FBC, CRP, LFTs (portal htn), Bone Profile
Blood film (malaria)
Viral screen (EBV)
splenomegaly, high WCC and precursor cells on blood film =
likely CLL
What complication should you be concerned about in a patient with a very high WCC?
hyperviscocity syndrome
What should be considered before starting a young patient on hydroxycarbamide?
do platelet count and Hb
Consider fertility preservation
What is Imantinib and how does it work?
tyrosine kinase inhibitor - acts on the Philadelphia chromosome
What are the potential side effects of IV bisphosphonate infusions?
flu like symptoms e.g. malaise and aching
jaw necrosis - with repeated exposure
How long do you need to carry on IV bisphosphonates to treat hypercalcemia in cancer patients?
4-6 weeks
How can disease progression for CLL be monitored?
Monitor FBC
Check morphological remission - on blood film and bone marrow
Check cytological remission for BCR/ABL returning to normal
DDx for a young person with left mediastinal opacification on CXR?
THINK HODGKINS LYMPHOMA
Other differentials:
Sarcoidosis
Infections e.g. TB
What questions would you ask a young person with left mediastinal mass on CXR?
B sxs - WL, hight sweats, fever
Skin changes? (for sarcoidosis)
New cough, chest pain, SOB?
How can you stage Hodgkin’s lymphoma?
PET CT
What may be useful when thinking about prognosis of Hodgkin’s lymphoma?
Richter Scoring System - RSS
What are the challenges to future health for young patients with Hodgkin’s lymphoma?
secondary malignancy
infertility
osteoporosis due to high steroid usage
thyroid problems
DDx for a young woman presenting with a one week hx of bruising, recurrent epistaxis and pancytopenia on blood film?
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
Other than FBC, what would you request for patients with new pancytopenia?
U&Es and LFTs for baseline renal and liver function
Coagulation screen and fibrinogen
TFTs
LDH for cell turnover
Blood film
What test can you do on a bone marrow aspirate sample?
flow cytometry - liquid sample for morphology
What are CD13, CD33, CD15 and CD117?
monocyte markers
What is CD19?
B cell marker
What are CD3 and CD7?
T cell markers
How might you manage a young female patient with AML?
Blood transfusion
Platelets
Consider fertility preservation
Baseline virology
Treat any infections
Can give norethisterone to stop periods
Chemotherapy
Who can access the teenage and young adult cancer services?
25 and younger can access TYA services
Makes stay in hospital more bearable
What can determine AML prognosis?
depends on cytogenetics
What will you look for on examination of a newly confused patient with suspected pathological fracture on Xray?
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
how would you investigate a patient with suspected pathological fracture and new confusion?
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
Radiological investigations for a patient with new confusion and suspected pathological fracture?
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
What caused raised plasma viscosity in multiple myeloma?
due to presence of paraproteins, therefore cannot cytoreduce with hydroxycarbamide
Signs of myeloma on investigation?
normocytic anaemia
raised calcium
renal impairment - raised eGFR
bony lesions on X-ray
more than 10% plasma cells on bone marrow =
think myeloma!!!
How can you establish clonality of cells on BMA?
flow cytometry or immunophenotyping
What type of lesions on the bone do you see in bone mets?
generally osteolytic apart from prostate which usually looks osteosclerotic
If tazocin doesn’t clear neutropenic sepsis, what should you suspect?
fungal infection e.g. Aspergillus - consider CXR
Causes of hypercalcaemia in cancer patients?
bone mets
myeloma
paraneoplastic syndrome e.g. PTH-rp
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?
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)
What Hb do you aim for before surgery?
135 in men, 120 in women
can give iron tablets / infusions and EPO injections before blood transfusions
What chemotherapy drug specifically requires pre-hydration with IV fluids?
Cisplatin as it can cause renal damage
What are the potential side effects of radiation to the neck?
mucositis
parotitis and increased viscosity of the saliva (may cause secondary dental issues)
skin changes
Which cancers are most commonly linked with hrHPV?
cervical
anal
squamous cell oropharyngeal cancer
What questions do you need to make sure you ask about in a patient with suspected head and neck cancer?
hearing loss
changes to voice esp. sounding more nasal
sore throat / difficulty swallowing
cough
epistaxis
Which subatomic particles are used in radiotherapy?
photons
Other than tumours, which areas light up on PET scans?
brain and heart due to high metabolic activity
kidneys and bladder due to excretion of radioisotope
What is the safest way to increase someones opioid dose?
by looking at their PRNs rather than doing an arbitrary 30-50% increase in dose
What can you try if multiple opioids are not controlling pain despite dose escalation?
consider pregabalin
consider nerve block (e.g. coealic plexus block)
refer to SPCT
What should you look for on examination of a septic oncology patient?
visible mucositis e.g. in oral cavity
any breaks in skin e.g. pressure sores
indwelling lines / catheters
Chemo in last 2 weeks + unwell =
NEUTROPENIC SEPSIS UNTIL PROVEN OTHERWISE
Which abx should be stopped in renal impairment?
aminoglycosides e.g. gentamicin and neomycin
reduce dose of meropenem
How do biochemical causes of N+V typically present? How should you manage these?
constant nausea + small vol vomiting
haloperidol
How can you manage a patient with hydronephrosis due to peritoneal disease?
USS KUB to confirm, insert nephrostomy
What can be used instead of tazocin for penicillin allergic patients with neutropenic sepsis?
meropenem
What can you give someone with sxs of raised ICP due to brain mets?
16 mg dexamethasone PO urgently
Then step down to 8mg BD
What can you give someone who is fitting on an onc ward?
SC midazolam
can give levetiracetam for seizure prophylaxis - can titrate quickly and can give in a SCSD
What do you need to remember to inform someone of with newly diagnosed brain mets?
they can’t drive
How can brain mets be managed?
very generalised rule of thumb:
< 2 may qualify for surgery
>2 = radiotherapy
What dose of metoclopramide would you give a cancer patient with N+V?
30 mg before meals
Dexamethasone is the first line steroid for most acute onc presentations e.g. MSCC and brain mets.
In what situation might you use another?
prednisolone is first line for pneumonitis / colitis due to immunotherapy
Give some causes of RUQ pain in cancer patients
Hepatic mets
Reactive hepatitis
Bone mets (ribs)
Gallstones
Constipation
Pneumonia
MSK pain
