Corrections - Oncology pt2 Flashcards
What is the drug of choice in palliative care for reducing the discomfort of a painful mouth?
Benzydamine hydrochloride mouthwash or spray
Are prostatic bony mets sclerotic or lytic?
Sclerotic
What are the carcinogenic types of HPV (assocaiated with an increased risk of cervical cancer)?
16, 18 and 33
What is Ca15-3 a tumour marker for?
Breast cancer
Which lung cancer has the strongest association with smoking?
Squamous cell lung cancer
What is calcitonin a tumour marker in?
Medullary thyroid cancer
What breast condition is blood stained discharge most likely to be associated with?
Intraductal papilloma.
Which chemotherapy agent is most commonly associated with hypomagnesaemia?
Cisplatin
What does a PET scan demonstrate?
Glucose uptake
Where is the most common site of bony mets?
Spine
Which chemotherapy agent is most associated with haemorrhage cystitis?
Cyclophosphamide
Which 2 chemo agents can cause peripheral neuropathy??
1) vincristine
2) cisplatin
What cancer does a raised beta-HCG and raised AFP indicate?
Non-semiomatous testicular cancer (a raised AFP excludes a seminoma)
What investigation must be done on a daily basis in patients with post-op ileus?
Electrolyte panel
What is calcitonin a tumour marker for?
Medullary thyroid cancer
What are the 3 key side effects of cisplatin?
Nephrotoxicity, ototoxicity & peripheral neuropathy
Screening for patients at high risk of HCC (e.g. alcoholic liver disease, hep B, hep C, haemochromatosis and A1AT deficiency)?
6-12 monthly US + AFP
How can squamous cell lung cancer cause brachial neuropathy?
Pancoast tumour
Symptoms of brachial neuropathy?
- Severe pain in the upper arm or shoulder.
- Pain usually affecting just one side of the body.
- After a few hours or days, the pain transitions to weakness, limpness, or paralysis in the muscles of the affected arm or shoulder.
Which type of testicular cancer does a raised AFP indicate?
Non-seminoma testicular tumour
WHO classification 0?
able to carry out all normal activity without restriction
WHO classification 1?
restricted in strenuous activity but ambulatory and able to carry out light work
WHO classification 2?
ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours
WHO classification 3?
symptomatic and in a chair or in bed for greater than 50% of the day but not bedridden
WHO classification 4?
completely disabled; cannot carry out any self-care; totally confined to bed or chair.
In what 2 cancers if transcoelomic spread seen?
ovarian carcinoma and mesothelioma
What is transcoelomic spread?
Refers to spread of a primary tumour through the peritoneal cavity and onto the surface of organs covered by the peritoneum.
What is the 1st line pharmacological treatment for nausea and vomiting in the last days of life for patients with obstructive bowel disorders?
Cyclizine
What cancer are Orphan-Annie cells on histology pathognomonic of?
Papillary thyroid cancers
What medication can be considered in metastatic bone pain?
Zolendronic acid (bisphosphonate)
What are the 3 most likely cancers to metastasise to the liver?
1) Colorectal (via the portal circulation which drains the gut)
2) Breast
3) Lung
What is the Hb threshold for blood transfusion in patients without features of ACS?
<70
What is the Hb threshold for blood transfusion in patients with features of ACS?
<80
What dose of morphine sulphate is typically given for opioid naive patients in end of life care?
1-2.5mg
What is the dose equivalent of 10mg oral morphine for oral oxycodone?
5mg
What is the dose equivalent of 10mg oral morphine for SC oxycodone?
1.5mg
What is the dose equivalent of 10mg oral morphine for diamorphine?
3mg
What are the 2 types of pain?
1) Nociceptive –> directs damage to body tissue (somatic e.g. muscle/skin/bones or visceral i.e. internal organs).
2) Neuropathic –> direct damage to nerve tissue (CNS or PNS)
What are the adjuvant analgesics? (4)
1) Neuropathic agents e.g. amitriptyline, pregabalin, gabapentin
2) NSAIDs
3) Corticosteroids
4) Non-pharmalogical –> TENS, radiotherapy, acupuncture, heat
What is usual starting dose of a strong opioid?
5-10mg modified release morphine
5mg (or 2mg if patient is frail) immediate release opioid
In patients with mild renal or hepatic impairment, how should an opioid dose be changed?
Doses should be reduced by 50%
Specialist advice should be sought before prescribing strong opioids for patients with moderate to severe renal or hepatic impairment.
Contraindications of opioids?
- Severe renal & hepatic impairment (specialist advice needed)
- Pregnancy
- Breastfeeding (presence in breast milk)
Other notes:
- Reduced doses in elderly
- Cessation of treatment should be tapered slowly
NSAIDs contraindications
1) IHD
2) Active bleeding or history of active bleeding
3) Uncontrolled HTN
4) Peptic ulcer disease
5) Asthma (caution, contraindication in asthma with nasal polyps)
What 3 classes of drugs can interact with NSAIDs and increase risk of bleeding?
1) SSRIs
2) Anticoagulants e.g. warfarin
3) Antiplatelets e.g. aspirin
What 2 classes of drugs can interact with NSAIDs and increase risk of electrolyte imbalances?
1) ACEi e.g. ramipril (increased risk of hyperkalaemia)
2) Diuretics e.g. spironolactone (increased risk of hyponatraemia or hyperkalaemia)
How do NSAIDs affect seizure activity?
Can worsen seizure activity
What class of drugs can interact with NSAIDs and increase risk of seizures?
Fluoroquinolone antibiotics (e.g. ciprofloxacin)
Before prescribing any strong opiate, consider ABC.
What is this?
A - prescribe Antiemetic
B - consider Breakthrough pain
C - prescribe laxative for Constipation
What can be considered for people with localised neuropathic pain who wish to avoid oral treatments?
Capsaicin cream
What is the role of capsaicin cream?
Relieve neuralgia
What class of drug is cyclizine?
Antihistamine with some anticholinergic activity
Major contraindication of metoclopramide?
Parkinson’s (use domperidone instead as doesn’t cross BBB)
What medication should be considered 1st line for N&V in people in the last days of life with obstructive bowel disorders?
hyoscine butylbromide
Contraindications of haloperidol and levomepromazine?
Parkinson’s
Most common side effect of ondansetron?
Constipation
What is a common cause of N&V in advanced intra-abdominal malignancy ie. ovarian, bowel, peritoneal?
Malignant bowel obstruction
what type of laxative is docusate?
Stool softener
Typical management of SVCO?
SVC stent
What can be used in reducing the discomfort associated with a painful mouth that may occur at the end of life?
Benzydamine hydrochloride mouthwash or spray
1st line anti-emetic for intracranial causes of nausea and vomiting?
Cyclizine
3 options for metastatic bone pain?
1) analgesia
2) bisphosphonates
3) radiotherapy
What is analgesic of choice in patients with:
a) mild-moderate renal impairment
b) severe renal impairment (eGFR <10)
a) oxycodone
b) buprenorphine or fentanyl
Pharmacological management of hiccups in palliative care?
Chlorpromazine or haloperidol
Why is diazepam not given as an end of life drug?
It is an irritant when given SC
What is 1st line in cancer related breathlessness when no reversible element?
Low dose immediate release PO morphine (i.e. oramorph)
Describe WHO performance status levels
0 = normal
1 = symptomatic and ambulatory
2 = ambulatory >50% of time
3 = ambulatory <50% of time
4 = bed ridden
5 = dead
What drug is indicated for agitation and confusion in patients who are NOT in the terminal phase?
Haloperidol
What drug is indicated for agitation and confusion in patients who are in the terminal phase?
SC midazolam
What tends to be the presenting feature of MEN II?
medullary carcinoma of the thyroid
1st line management of suspected spinal cord compression in the acute setting?
Oral dexamethasone
Which chemotherapy agent used in the management of lymphoma can cause peripheral neuropathy?
Vincristine
What 2 medications is it important to prescribe alongside strong opioids?
Regular laxative (senna)
As required antiemetic
Which chemo agent can cause haemorrhagic cystitis?
Cyclophosphamide
What side effect of radiation therapy can cause difficulty swallowing, hoarseness and coughing?
Radiation-induced laryngeal oedema.
Patients with unexplained ulceration in the oral cavity lasting for how long should be referred under the suspected oral cancer pathway?
3 weeks
What is 1st line for breathlessness in end of life?
Morphine –> relieves the sensation of dyspnoea, and so relieves distress.
Is papillaty thyroid cancer ‘hot’ or ‘cold’?
‘Cold’ i.e. does not take up the iodine
What is the initial management of MSCC?
Dexamethasone + radiation therapy
What are some early side effects of radiotherapy?
- Tiredness
- Fatigue
- Skin erythema
- Alopecia
- Mucositis (diarrhoea, dysuria)
What are some late side effects of radiotherapy?
- Skin pigmentation changes
- Pulmonary fibrosis
- Infertility
- 2ary cancers
- Constrictive pericarditis
- Dysphagia, sore throat (note - coughing is a sign of the larynx being affected, less likely affected in oesophagitis)
MST dose in opioid naive patients?
5mg immediate release to be given 4 hourly
What chemical can cause angiosarcomas?
Vinyl chloride
What cancer can long-term exposure to high levels of benzene in the air lead to?
Leukaemia
What are aromatic amines?
Aromatic amines are chemicals found in industrial and manufacturing plants, tobacco smoke, commercial hair dyes, and diesel exhaust
What type of cancer can exposure to aromatic amines lead to?
Bladder cancer
What is the most common site of bone mets?
Spine
Which chemo drug can cause hypomagnesaemia?
Cisplatin
What is Gardners syndrome?
A variant of familial adenomatous polyposis coli (FAP) that is characterised by the development of numerous adenomatous polyps in the colon and rectum.
Although these polyps start out as benign, if left untreated they have a nearly 100% chance of becoming malignant, leading to colorectal cancer
what are 3 sites of extra colonic disease in Gardners syndrome?
1) skull osteoma
2) thyroid cancer
3) epidermoid cysts
What gene is implicated in Gardners syndrome?
APC gene located on chromosome 5
What surgery will most patients with Gardners syndrome undergo?
Colectomy
What appearance do prostate cancer mets typically have on an XR?
Sclerotic appearance
What are the 2 main types of syringe driver?
1) Graseby MS16A (blue): the delivery rate is given in mm per hour
2) Graseby MS26 (green): the delivery rate is given in mm per 24 hours
Conversion of morphine to diamorphine?
/3
