CCC Extras Flashcards
What is stepwise mx of cancer related bone pain?
1) NSAIDs
2) Bisphosphonates
3) Radiotherapy
Mx of haemoptysis in lung cancer?
Palliative radiotherapy
Mx of Duke’s C adenocarcinoma?
Surger + adjuvant chemotherapy
Note - adjuvant chemotherapy increases long term survival from 40% to 60%.
Initial investigation in painless haematuria?
Urine dip - rule out infection.
If normal - refer on 2ww.
1st line investigation in possible pancreatic cancer?
Urgent CT scan abdomen
THEN 2ww if this scan shows evidence of pancreatic cancer.
When should the dose of nitrofurantoin be reduced?
eGFR <45
Mx of subclinical hypothyroidism?
Re-test TSH and thyroid autoantibodies in 3 months.
Then consider adding levothyroxine if TSH is raised ≥10 on 2 separate occasions AND they have symptoms of hypothyroidism.
1st line for nausea due to hypercalcaemia?
Haloperidol
1st line laxative for stool that is hard to pass, but no change to bowel frequency?
Docusate (stool softener)
Are brain mets common in prostate cancer?
NO
1st line investigation in suspected HF?
Bloods for BNP (this is 1st line BEFORE an echo)
Why is hypercalcaemia in prostate cancer rare?
As mets are sclerotic and not lytic
Next line investigation in dysphagia at any age?
Urgent upper GI endoscopy –> red flag
Give some situations where a death would have to be referred to the Coroner
1) Occurred at work or due to occupational disease e.g. asbestosis causing mesothelioma
2) Sudden or unexpected
3) Died within 24h of admission
4) Cause of death unknown
5) Occurred in prison, custody or other state detention
6) Unnatural e.g. medical mistake
7) Violence or negligence e.g. accident or suicide
8) Occurred during operation or before recovery from GA
9) No doctor attended deceased during their last illness
10) Dr saw pt in last illness but not within 14 days
11) Suspicious circumstances
Give a key contraindication for pregabalin
Previous history of substance misuse.
Addition of what medications should be considered in a patient with CKD and HTN?
ACR >22.6 –> add SGLT-2 inhibitor
ACR >30 –> add ACEi/ARB
Normal spirometry results?
FEV1 and FVC are >80% predicted
FEV1/FVC >70%
Stepwise investigations in prostate cancer?
1) Patient presents to GP with symptoms of prostate cancer e.g. LUTS, or e.g. weight loss (advanced)
2) GP performs history, DRE & PSA test (if indicated)
3) If PSA raised, 2ww referral to urology
4) Multiparametric MRI
5) Biopsy (in light of MRI results)
6) PSA + MRI + biopsy results used to decide if prostate cancer or not
How long should men avoid vigorous activity and sexual activity before a PSA?
48h
Overview of Gleason grading risk classification
Low risk: Gleason score ≤6
Intermediate risk: Gleason score 7 (3+4 or 4+3)
High risk: 8
Very high: 9-10
Role of a bone scan?
Inject radioactive tracer into the bloodstream which attaches to ‘hot spots’.
There you can see high uptake in the metastatic areas.
A mutation in which tumour supressor gene can predispose to breast cancer?
p53
What syndrome is affected by a change in p53?
Li-Fraumeni syndrome
This is a rare hereditary or genetic disorder that increases the risk you and your family members will develop cancer.
What % chance do women who have Li-Fraumeni syndrome have of developing breast cancer?
nearly 100%
UK breast cancer screening programme?
50-71 y/o every 3 years.
What imaging is often done in lobular breast cancer (cancer that starts in the milk glands)?
MRI - as difficult to appreciate on mammogram
Aim of radiotherapy vs chemotherapy in breast cancer?
Radiotherapy - reduce risk of LOCAL recurrence
Chemotherapy - reduce risk of DISTANT recurrence
2ww referral for breast cancer?
≥30y/o with unexplained breast lump
or
≥50y/o with unilateral nipple changes e.g. discharge, retraction
What is mainstay of mx of SCLC?
Chemotherapy
2ww referral for lung cancer?
≥40y/o with unexplained haemoptysis
or
CXR findings suggesting lung cancer or mesothelioma
What is the initial investigation in 2ww referral for lung cancer?
CXR
2ww referral for colorectal cancer?
≥40y/o with unexplained weight loss & abdo pain
≥50y/o with unexplained rectal bleeding
≥60y/o with unexplained iron deficiency anaemia OR alteration in bowel habot
Positive FIT test (i.e. occult blood found in faeces)
3 most common cancers that spread to bone?
Breast
Lung
Prostate
Also renal & thyroid
Stepwise mx of suspected MSCC?
1) 16mg dexamethasone (with PPI cover)
2) Urgent MRI spine (within 24h)
3) If MRI +ve for MSCC –> consider neurosurgical intervention or radiotherapy
3 most common cancers causing hypercalcaemia?
1) Renal
2) SCLC
3) Breast
Hypercalcaemia as a prognostic indicator in cancer?
Usually a poor prognostic sign - median survival in patients presenting with hypercalcaemia is 3-4 months.
Give 2 ways that malignancy can cause hypercalcaemia
1) Tumours release PTHrP (most common) –> measure PTH to exclude hyperparathyroidism (as can have both)
2) Osteolytic effects on bones
PTH levels in cancer releasing PTHrP?
Typically low due to negative feedback from hypercalcaemia
Stepwise mx of hypercalcaemia?
1) Rehydration with IV fluids
2) Stop thiazide diuretics, consider furosemide
3) Bisphosphonates
4) Consider calcitonin (if very high calcium and in refractory cases)
1st line bisphosphonate for hypercalcaemia of malignancy?
1) Pamidronate (Aredia)
or
2)Coledronic acid (Zometa)
What can be considered in very high/refractory cases of hypercalcaemia?
Calcitonin
Role of calcitonin?
Calcitonin opposes action of PTH –> acts to reduce calcium levels in blood.
Calcitonin is released by thyroid gland.
Define tachyphylaxis
Decreasing responsiveness to a drug when used repetitively.
Stepwise mx of SVCO?
1) 16mg dexamethsone (with PPI cover)
2) Depending on cause:
- vascular stent (generally 1st option)
- radiotherapy
- chemotherapy
- LMWH (if thrombus confirmed)
What investigation is needed to confirm and understand cause of SVCO?
CT thorax
Pathway for suspected ovarian cancer?
If presenting to GP with symptoms but NORMAL exam:
1) Ca125
2) If raised –> refer for urgent US of abdomen and pelvis
3) If abnormal US –> 2ww referral
Immediate 2ww referral if physical exam at GP reveals either:
1) Ascites
2) Pelvic or abdominal mass (which is not obviously uterine fibroids)
What are some symptoms that would indicate the need for Ca125 test?
- persistent abdominal distension (bloating)
- early satiety and/or loss of appetite
- pelvic or abdominal pain
- increased urinary urgency and/or frequency
- new onset symptoms suggestive of IBS i.e. bowel changes (as IBS rarely presents for the first time in women of this age)
What investigation is next if Ca125 is found to be raised?
Arrange urgent US of abdomen and pelvis
2ww referral for suspected vaginal cancer?
2ww referral in a woman presenting with an unexplained palpable mass in or at the entrance to the vagina.
2ww referral for suspected vulval cancer?
2ww referral for women presenting with any of the following:
- vulval lump
- ulceration
- bleeding
2ww referral for suspected cervical cancer?
2ww referral if appearance of cervix is consistent with cervical cancer.
Note - a smear test is NOT required before referral, and a previous negative result should NOT delay referral.
2ww referral for suspected endometrial cancer?
Urgent 2ww referral for any woman ≥55 y/o with PMB (>12 months after last period).
Consider 2ww referral if <55 y/o with PMB
What investigations are involved in 2ww referral for endometrial cancer?
1) TV US + endometrial thickness (if >4mm)
2) Hysteroscopy & biopsy
What investigation can be perfromed for for histological confirmation of endometrial cancer if endometrial biopsy cannot be performed/will not be tolerated by the patient?
Hysteroscopy, dilatation and curettage (performed under GA)
An endometrial thickness of >5mm is associated with what % probability of endometrial cancer?
96%
Bladder cancer referral guidelines?
Urgent referral (2ww) for:
1) ≥45y/o with:
- unexplained visible haematuria (WITHOUT UTI - get urine dipstick first), or
- visible haematuria that persists or recurs after successful treatment of UTI
2) ≥60y/o with unexplained NON-visible haematuria and either:
- dysuria, or
- raised WCC on blood test
Prostate cancer referral guidelines?
Urgent referral (2ww) for either:
- prostate feels malignant on DRE, or
- raised PSA
Renal cancer referral guidelines?
Urgent referral (2ww) if:
≥45 y/o with either:
- unexplained visible haematuria without UTI, or
- visible haematuria that persists or recurs after successful treatment of UTI
Liver cancer referral guidelines?
Urgent direct access US (within 2 weeks) to assess in people with an upper abdominal mass consistent with an enlarged liver.
Liver cancer referral guidelines?
Urgent direct access CT scan (or an urgent US if CT not available) in the following:
≥60y/o with weight loss and any of the following:
- diarrhoea
- back pain
- abdominal pain
- nausea/vomiting
- constipation
- new-onset diabetes
Oesophageal & gastric cancer referral guidelines?
Urgent referral for endoscopy (within 2 weeks) for:
- ANY age with dysphagia
- ≥55y/o with weight loss AND upper abdo pain, reflux or dyspepsia
Should Oramorph be prescribed in mg or ml?
mg (even though it is a liquid)
Opiods can lead to drowsiness.
How long does this typically last?
Usually subsides after 24-48h
Give some signs of opioid toxicity
- confusion, hallucinations
- myoclonus
- pupillary constriction
- respiratory depression in OD
Mechanism of haloperidol?
D2 antagonist
Mechanism of ondansetron?
D2 antagonist
1st line antiemetic for vestibular causes of N&V (e.g. inner ear pathology, motion sickness, vertigo)?
Cyclizine
Is nausea or vomiting worse in cerebral causes?
Nausea
Is nausea or vomiting worse in gastric causes?
Vomiting
What are the 4 anticipatories given in end of life?
1) Analgesic - morphine sulphate
2) Anxiolytic - midazolam
3) Anti-emetic - levomepromazine or haloperidol
4) Anti-secretory - hyoscine butylbromide
Dose for morphine sulphate as an anticipatory?
2-5mg SC PRN/hourly
Max 6 doses in 24h (i.e. every 4 hours)
Dose for midazolam as an anticipatory?
2-5mg SC PRN/hourly
Max 6 doses in 24h (i.e. every 4 hours)
Dose for haloperidol as an anticipatory?
0.5-1.5mg PRN/hourly
Max 6 doses in 24h (i.e. every 4 hours)
Dose for levomepromazine as an anticipatory?
2.5-6.25mg SC PRN/hourly
Max 25mg in 24h
Dose for hyoscine butylbromide as an anticipatory?
20mg SC PRN/hourly
Max 120mg in 24h
