Corrections Flashcards
Inheritance of neurofibromatosis?
Autosomal dominant
What condition can cafe au lait spots be seen in?
Neurofibromatosis type 1
What types of cancer can the following chemicals cause:
1) benzene
2) aromatic amines
3) vinyl chloride
4) wood dust
1) leukaemia
2) angiosarcoma
3) bladder cancer (TCC)
4) nadal adenocarcinoma
Which HPV strains are most commonly associated with cervical & anal cancer?
HPV 16 & 18
What cancer is strongly linked to H. pylori infection?
Gastric MALT lymphoma
Describe the TNM staging for cancer
T (size):
TX - can’t be assessed
T0 - no evidence of tumour
Tis - in situ
T1-T4 - increasing in size and/or local extent
N (nodal involvement):
NX - can’t be assessed
N0 - no nodal involvement
N1-N3 - increasing involvement in lymph nodes
M (distant mets):
MX - can’t be assessed
M0 - no mets
M1 - distant mets
What 2 key conditions can cause a raised hCG in women?
1) Pregnancy
2) Germ cell tumour (think choriocarcinoma)
What type of pregnancy is a choriocarcinoma more common following?
Molar pregnancy
What is the most common medical emergency amongst oncology and haematology patients?
Neutropenic sepsis
What are some possible sources of infection in neutropenic sepsis?
1) Chest
2) Urinary
3) Skin
4) GI
5) Indwelling devices e.g. cannula/central line
When taking blood cultures in neutropenic sepsis, how many samples are required? Where must they be taken from?
At least 2 sets from a peripheral vein
What microbiological cultures are indicated in neutropenic sepsis (if unsure of source)?
1) Wounds
2) Urine
3) Stools
4) Sputum
5) Line tip
What investigation should be done if an atypical chest source is suspected, such as Pneumocystis jirovecii?
Bronchoalveolar lavage
Typical 1st line abx in neutropenic sepsis?
IV tazocin (piperacillin + tazobactam)
What can be used for prophylaxis in reducing risk of neutropenic sepsis?
Recombinant granulocyte-colony stimulating factor (G-CSF) e.g. Filgrastim
Works by stimulating the bone marrow to produce neutrophils and may form part of specific chemotherapy regimens.
Risk of mortality in neutropenic sepsis?
10%
What is the most common presenting symptom in MSCC?
Back pain
MSCC vs cauda equina?
Both usually presents with pain and weakness and should be treated the same way.
MSCC:
- Compression of spinal cord by cancer/metastasis
- UMN pattern of weakness
Cauda equina:
- Compression occurring at or below level of cauda equina (typically L1)
- LMN pattern of weakness
Describe weakness pattern seen in MSCC vs cauda equina
MSCC causes a pyramidal pattern of weakness:
- increased tone in both legs
- bilateral weakness in flexors
- brisk reflexes
- upgoing plantars
Cauda equina typically causes LMN weakness:
- flaccid tone in both legs
- bilateral weakness
- reduced or absent reflexes
- absent plantars
Describe sacral senstation in MSCC vs cauda equina
Sacral sensation is lost in cauda equina syndrome, but may be preserved MSCC
What is a key bedside investigation in MSCC?
Bladder scan to look for urinary retention
Top 5 cancers that cause MSCC?
1) Prostate
2) Lung
3) Breast
4) Renal
5) Myeloma
Initial mx of suspected MSCC?
16mg dexamethasone + PPI cover
What is most common definitive mx option in MSCC?
Radiotherapy
What type of cancer most commonly causes SVCO?
Small cell lung cancer
What sign is examined for in suspected SVCO?
Pemberton’s sign –> pt lifts arms above head, worsening of symptoms
What may a CXR show in SVCO?
1) Widening of superior mediastinum
2) Right hilar prominance to indicate a mediastinal mass
Where is mediastinal mass seen on CXR in SVCO?
Right hilar prominance (compressing SVC)
What is the imaging of choice in SVCO?
CT chest w/ contrast
How many samples must be taken before diagnosing hypercalcaemia?
2 separate samples on 2 separate occasions
What are the 3 main mechanisms that result in hypercalcaemia of malignancy?
1) PTHrP secretion
2) Bony lesions (osteolytic)
3) Calcitriol secretion
What is the most common mechanism causing hypercalcaemia in malignancy?
PTHrP secretion
Via what 2 mechanisms does PTHrP secretion result in hypercalcaemia?
1) Stimulates osteoclastic resorption of bone and inhibits osteoblastic formation of bone
2) Reduces calcium clearance in kidney
what vitamin is needed for calcium absorption?
vitamin D (calcitriol is the active form)
What type of cancers does calcitriol-mediated hypercalcaemia usually occur in?
Lymphoma
Via what mechanism does multiple myeloma typically cause hypercalcaemia?
Osteolytic bone mets
Via what mechanism does squamous cell lung cancer typically cause hypercalcaemia?
PTHrP secretion
What are 2 key medications that can worsen hypercalcaemia?
1) Thiazide diuretics
2) Lithium
How does hypercalcaemia affect the kidneys?
Can lead to AKI due to:
a) reduced GFR
b) increased sodium excretion
c) depletion of total body water
PTH levels in malignancies producing PTHrP?
Often suppressed
2 key medical mx options in hypercalcaemia?
1) IV fluids
2) Bisphosphonates
Role of bisphosphonates in hypercalcaemia?
Inhibit osteoCLAST activity (hence why used in osteoporosis too)
What is the first-line bisphosphonate used in hypercalcaemia of malignancy?
IV zolendronic acid
What are some key complications of hypercalcaemia of malignancy?
1) AKI
2) Seizures
3) Arrhythmias
4) Acute pancreatitis
5) Coma
What is the most common cause of SVCO?
Small cell lung cancer
bronchoscopy results in lung adenocarcinoma?
Often normal due to peripheral location of lung adenocarcinoma
What are the 2 most useful markers in detecting recurrence of testicular teratoma?
AFP & beta HCG
These are often elevated in germ cell tumours, including teratomas.
What class of medication is domperidone?
Dopamine receptor antagonist
How do PET scans work?
Inject a small amount of radioactive glucose into body.
Cancer cells are more metabolically active –> consume more glucose than normal cells.
What is the only thyroid cancer that will cause a risk in calcitonin?
Medullary thyroid cancer
What 2 types of chemo drugs can cause cardiomyopathy?
1) Anthracyclines e.g. doxorubicin
2) HER2 monoclonal antibodies e.g. Herceptin
What type of chemotherapy agents can cause peripheral neuropathy and sensorineural hearing loss?
Platinum agents (cisplatin, carboplatin)
What type of chemo agents can lead to haemorrhagic cystitis and transitional cell carcinoma of the bladder?
Cyclophosphamides
Key risk factor of cisplatin?
1) ototoxicity
2) nephrotoxicity
Mx of pneumonitis?
Oral steroids
1st line imaging in prostate cancer?
Multiparametric MRI
In the UK, at what age can men request a PSA?
≥50 y/o
How are the results of an MRI in prostate cancer reported?
On a Likert scale:
1 – very low suspicion
2 – low suspicion
3 – equivocal
4 – probable cancer
5 – definite cancer
Stepwise investigation of prostate cancer?
1) PR exam
2) PSA
3) Multiparametric MRI
4) Biopsy (TRUS)
What Likert score would indicate the need for a prostate biopsy?
3 or above
What scan is used to look for bony mets in prostate cancer?
Isotope bone scan
The Gleason Grading System is used to grade prostate cancer.
What is this based on?
Histology of biopsy
What Gleason score is considered high risk for prostate cancer?
≥8
What are the 2 classes of drugs used in hormone therapy in prostate cancer?
1) GnRH agonists e.g. goserelin
2) Androgen receptor blockers eg. bicalutamide
What class of drug is goserelin?
GnRH agonists
What class of drug is bicalutamide?
Androgen-receptor blockers
What are 2 key complications of a radical prostatectomy?
1) ED
2) Urinary incontinence
What genes are involved in FAP?
Mutation of tumour suppressor gene APC (adenomatous polyposis coli)
What 2 inherited conditions can increase risk of colorectal cancer?
1) FAP
2) HNPCC (Lynch)
What genes are involved in HNPCC?
MMR (mismatch repair genes)
Which IBD is more associated with bowel cancer?
UC
NICE two week wait referral guidelines for colorectal cancer?
≥40 y/o with abdo pain & weight loss
≥50 y/o with unexplained rectal bleeding
≥60 y/o with change in bowel habit or iron def anaemia
N.B. Iron deficiency anaemia on its own without any other explanation (i.e. heavy menstruation) is an indication for a “two week wait” cancer referral for colonoscopy and gastroscopy (“top and tail”) for GI malignancy.
What is the bowel cancer screening programme in the UK?
People aged 60-74 are sent a home FIT test to do every 2 years.
If home FIT test results come back positive, what is the next investigation?
Colonoscopy
When may a sigmoidoscopy be used instead of a colonoscopy?
This may be used in cases where the only feature is rectal bleeding.
(obvious risk of missing cancers in other parts of the colon).
What investigation may be considered in patients less fit for a colonoscopy?
CT colonography - this is a CT scan with bowel prep and contrast to visualise the colon in more detail
What is removed in the following colorectal surgeries:
a) right hemicolectomy
b) left hemicolectomy
c) high anterior resection
d) low anterior resection
e) abdomino-perineal resection (APR)
a) caecum, ascending colon & proximal transverse colon
b) distal transverse colon & descending colon
c) sigmoid colon
d) sigmoid colon and upper rectum (but sparing rectum and anus)
e) rectum and anus (plus or minus sigmoid colon) and suturing over the anus.
What is Hartmann’s procedure?
What is removed?
Is usually an emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy.
The rectal stump is sutured closed.
The colostomy may be permanent or reversed at a later date.
What is the most common type of colorectal cancer?
Adenocarcinoma
Describe Duke’s staging system for colorectal cancer
Duke’s A –> cancer is in inner lining of bowel, or slightly growing into muscle layer
Duke’s B –> cancer has grown through muscle layer of bowel
Duke’s C –> cancer has spread to at least 1 lymph node close to the bowel
Duke’s D –> cancer has spread to another part of the body, such as the liver, lungs or bones
Can prostate cancer be seen with a normal PSA?
Yes
What is the second most common association of HNPCC after colorectal cancer?
Endometrial cancer
Which chemotherapy agent cause hypomagnesaemia?
Cisplatin
Mechanism of methotrexate?
Inhibits dihydrofolate reductase
Give some paraneoplastic syndromes associated with lung cancer?
1) Cushing’s syndrome (ectopic ACTH secretion)
2) Phrenic nerve palsy
3) Recurrent laryngeal nerve palsy
4) Lambert-Eaton syndrome
5) SIADH
6) Limbic encephalitis
7) SVCO
8) Hypercalcaemia (ectopic PTH)
Presenting feature of recurrent laryngeal nerve palsy?
Hoarse voice
Presenting feature of phrenic nerve palsy?
SOB
Presenting feature of SIADH?
Hyponatraemia
What antibodies is limbic encephalitis associated with?
Anti-Hu antibodies
Which type of lung cancer is most commonly related to hypercalcaemia?
Squamous cell carcinoma
What cells do small cell lung cancers arise from?
From endocrine cells (Kulchitsky cells) – these are APUD cells
Which 2 hormones with SCLCs most typically secrete? Why?
1) ACTH
2) ADH
What is Lambert-Eaton syndrome caused by?
The result of antibodies produced by the immune system against small cell lung cancer cells
Why are SCLCs responsible for multiple paraneoplastic syndromes?
SCLCs contain neurosecretory granules that can release neuroendocrine hormones
What type of lung cancer is gynaecomastia associated with?
Adenocarcinoma
A patient is found to have a suspicious lung mass on CXR.
What investigation should be done next?
CT w/ contrast of chest, liver and adrenals
Give some contraindications to surgery in NSCLC
- poor general health
- malignant pleural effusion
- FEV1 < 1.5 litres
- tumour near hilum
- vocal cord paralysis
- SVC obstruction
What are 2 key complications of a radial prostetectomy?
1) ED
2) Urinary incontinence
What is retrograde ejaculation a common complication of? (2)
1) alpha blocker therapy
2) TURP
During the first stages of treatment, goserelin may cause a transient increase in symptoms of prostatic cancer (‘flare effect’).
What can be given to help avoid this?
Flutamide (a synthetic antiandrogen) can be given PRIOR to goserelin therapy –> antagonistic effects at androgen receptors.
What is the most appropriate 1st line treatment for classical Hodgkin’s lymphoma?
Chemotherapy
What is the most important initial step in mx of neutropenic sepsis?
Start broad spectrum abx (prior to any other action)
