Could it be cancer Flashcards
What are the oncological emergencies
Neutropenic sepsis Tumour lysis syndrome Hypercalcaemia SVCO Cord compression
Which cancers often present as emergencies
CNS, lung, HPB, upper GI
Rarely melanoma or breast
Outline the investigations for cancer
Radiological
Endoscopic
Biochemical
Surgical
Specialist clinics (e.g. breast)
Give example of radiological cancer investigations
CT chest/abdo/pelvis CT or MRI brain MRI Whole Spine USS PET-CT (if MDT recommends) Ba swallow
Bichemical investigations
CEA, Ca199, Ca153, PSA, aFP, betaHcG, Ca125
What is CEA associated with
Carcinoembryonic antigen
- associated with lower GI tumours
- normally <2.5 in non smokers or <5 in smokers
Other causes of CEA increasing
Not just lower GI tumours.
Also:
- Stomach/breast/lung/pancreas cancer
- Infections, pancreatitis, IBD
Can all increase CEA (but lower GI cancer can increase it into the hundreds or thousands)
What is Ca199 associted with
Almost always elevated in pancreatic cancer
Also can be elevated in other GI tumours
Poor specificity and sensitivity
How is Ca199 used clinically
Elevated levels typically associated with METASTATIC pancreatic disease
Also used to track response to treatment (e.g. chemo)
What is Ca 15-3 linked to
Breast cancer….
Also not diagnostic and used to assess treatment efficacy
What is PSA
List in 3 situtations where PSA may be elevated without there being cancer
Prostate specific antigen
If it is raised into the hundreds it usually indicated cancers
It says specific because it is the only one that is exclusive to the prostate, but it is not only raised in prostate cancer.
It can also be increased in BPH, Prostatitis, Catheterisation
What is Ca 125
Associated with ovarian cancer
Can be elevated in benign reasons (e.g. peritonitis) but also malignancy
Give examples of endoscopic investigations
OGD Colonoscopy ERCP Bronchoscopy Nasendoscopy
What is the advantage of endoscopic investigations
Ability to obtain tissue
Therapeutic intervention – e.g. stents
Detect small lesions not visible radiologically
Give 3 exampes of surgical interventions
Examination under anaesthetic
Laparoscopy
Laparotomy
(not always needed, sometimes for pelvic tumours, can give you an idea of clearance)
What is crucial before treating cancer
Tissue diagnosis
Why is getting a tissue diagnosis important
Anticancer therapy varies depending on histopathological subtype.
Which condition can look like cancer
TB
T/F lymphoma can be diagnosed with FNA
Often it is very difficult to, really the lymph node needs to be taken out
How long does IHC and profiling take
IHC- up to 5 days
Profiling- up to a month
What is the role of the MDT for cancer
Facilitate rapid diagnosis and treatment
Carefully assess cancer stage
Set treatment goals
Implement best-practise treatment plan
Limitations of MDT
Only once a week
Only as good as the history it is given
Mainly designed to facilitate OP investigation and treatment
What information does an MDT need
Presenting complaint
Co-morbidities
Overall fitness – Performance status
Relevant investigations performed already
If you think it might be cancer, should you wait to talk to the MDT?
If you are worried it might be cancer don’t wait for MDT, talk to relevant team to get investigations under way.
What is the role of acute oncology
Advise on investigations in unknown cancer.
Advise on management of side-effects of chemotherapy/radiotherapy.
Advise on treatment of effects of known cancer
Advise on prognosis of cancer to facilitate planning of care.
Assist in discussions with patients/relatives.
Which tumours need a fast diagnosis
- Small cell cancer
- Lymphoma
- Germ cell tumours
- Cord compression of any cause
List the common acute presentations of cancer
Confusion/fitting SoB Obstruction Pain Liver/renal failure Off legs
What are your differentials for confusion/fitting
Infection Biochemical abnormality Drugs Cerebrovascular event Brain mets/primary Pseudo-seizure
What investigations would you do for seizure
Bloods (FBC, U&E, LFTs, Mg, Ca, CRP)
CT Brain
Management of brain metastases
Steroids- dexamethasone (16mg), for the oedema
Surgery or radiotherapy (whole brain, cyber knife, stereotactic)
Antiepileptics if seizure
Identify primary site/biopsy brain if not able to
Advise not to drive and inform DVLA
Physio and OT assessment
Differential diagnosis for SoB
HF Pneumonia COPD Lung cancer PE Pulmonary HTN Wet disease
What is wet disease
Pleural effusion, ascites and pericardial effusion
Often it is cancer related
Investigations for a breathless patient
CXR Bloods ABGs CTPA CT CAP ECG
Why might you do an ECG in a patient with SoB?
Ischaemic changes
AND
Pericardial effusion
What might an ECG with a massive pericardial effusion show?
Tachycardia
Low Voltage
Electrical alternans
What might you be looking for as a cause of PE if there is no obvious risk factor
Malignancy markedly increase risk of PE 4x higher risk
Go looking for the cause if there is no obvious one already e.g. recent surgery
What is the first treatment for PE
Treat with low molecular weight heparin
What do you need to be careful about with pneumonia on chest xray
Consolidation may hide underlying malignancy
How do you ensure a consolidation is not hiding an underlying malignancy
Repeat chest imaging 6 weeks post to ensure changes have resolved
What cancer is associated with wet disease
Ovarian
How do you manage wet disease
Drain the fluid - image guided and send for cytology
If malignancy is the cause- effective treatment is chemotherapy
ONCE the patient is haemodynamically stable this can be delivered as an outpatient
What would you do with fluid from a tap
Biochemistry (exudate or transudate) and cytology and microbiology
What is the problem with giving chemotherapy when someone has wet disease
Chemotherapy can accumulte in collections of fluid ‘third space’
This can affect the pharmacodynamics of the drugs
Differentials for bowel obstruction
Severe constipation
Malignant obstruction (single site or multifocal)
Adhesion from previous surgery
IBD
Investigations for bowel obstruction
AXR
CT CAP
Barium/gastrograffin (if at risk of aspiration) swallow
Surgical review if lower GI
If there is multifocal obstruction (i.e. the bowel is obstructed at multiple points) in the bowel, it’s more likely to be what
More likely to have come from outside the bowel (i.e. be peritoneal metastases)
Most common tumour types causing obstruction
Colon
Ovary
Gastro-oesophageal (dysphagia)
How are the following managed:
- Single transition point
- Multifocal bowel obstruction
If single transition point surgery or stenting possible.
Multifocal subacute bowel obstruction often seen with ovarian cancer may be managed conservatively
Outline the conservative management sometimes used for multifocal subacute bowel obstruction
Drip & Suck
NBM
Iv fluids
Normalise electrolytes
Chemo once resolved if possible. If not palliation may be only option
Learn about maintenance fluid vs insensible losses
………
Differentiate the likely tumour given the site of disease in the liver
Parenchymal disease – metastases
- Colon cancer
- Breast Cancer
- Upper GI cancers
Obstructive
- Pancreas cancer
- Cholangiocarcinoma
- Portal Metastases from other cancers
What is liver failure
Abnormal liver function- AST, ALT, Alk Phos, Bili, Albumin, clotting, platelets
How do you investigate abnormal liver function
USS, CT CAP, MRI liver (best)
Which enzymes would increase proportionately in biliary obstructive picture
Alk phos and bili
How do you treat an obstructed liver
Make the diagnosis – tissue is needed
ERCP and stent
PTC drainage
If someone has obstructed duct they need to be on prophylactic Abx
T/f if the malignancy causing obstruction is in an early stage it could be resectable
T
When can chemo be given in obstructed liver
Chemo usually not possible until LFTs have normalised
Which is why you need to get a stent in asap
Explain the cause of renal impairment in cancer
Hydronephrosis
= swelling of a kidney due to a build-up of urine. It happens when urine cannot drain out from the kidney to the bladder from a blockage or obstruction.
Common in cervix and bladder cancers
How do you treat renal impairment in cancer
Treat
Antegrade nephrostomy and stent
Retrograde stent insertion
T/F stents are usually uncomfortable for patients
T- Stents are uncomfortable for patients. If a patient is frail and may not be fit for treatment sometimes kinder not to insert stent
What can cause renal impairment without hydronephrosis and how to treat
May be due to sepsis
Fluid depletion
Cancer burden
Treat with iv fluids and ABXs
May be end stage disease and mode of death
Outline how you can treat pain
WHO ladder
Opioids
Neuropathic agents
Identify cause of pain and address
When can nerve block be useful in cancer
Pancreatic
Other methods of pain management other than pharmacology in cancer
Radiotherapy (bone mets)
Chemotherapy
Pathological fractures – surgery
Pain from masses may be helped with surgery
Psychological support
Hypnotherapy
Bisphosphonates/RANKL
Why can cord compression be missed
Patients admitted unwell, no clear history
Drs rounds with patient in bed – no-one notices
Too willing to accept incontinence and poor mobility as “normal”
Which cancers can cause cord compression
Prostate, Breast, Lung, Kidney, Thyroid, Lymphoma, Multiple Myeloma
What are the features of cord compression
Weakness, numbness, urological dysfunction, faecal dysfunction, sexual dysfunction
What is key to not miss cord compression
What were they like at home? Any back pain? Any known malignancy? Duration of symptoms and speed of decline Current bladder/bowel function
What must you do if you expect cord compression
Do full neurological examination, including PR
Document bladder and bowel function
Management for cord compression
16mg Dexamethasone Urgent MRI whole spine CT with spinal reconstruction Nurse supine Liase with Neurosurgery (Will they operate? Is the spine stable for PT/OT?) Liase with Oncology
How long does it take for nerves to die following compression
Nerves start to die within 24hrs of compression.
T/F if a patient is bedbound we don’t need to worry about preserving contientnce with spinal cord compression
Even if bedbound, if we can preserve continence there is possibility of being cared for at home.
What can off legs mean
Many patients will be decompensating because they are weak
Cancer burden increasing
Which tumour needs a fast diagnosis
A Breast cancer
B colon cancer
C small cell lung cancer
C….because if you can get chemo in early enough it is often very responsive and you can really change the diagnosis
(“exquisitely chemo and radio sensitive”)
What percentage of lung cancers are small cell?
T/f all small cell cancers are in the lung
10-15%
F
How do you stage small cell lung cancer
Limited disease – confined to one hemithorax
Extensive disease – any disease beyond limited
What are the prognostic factors for small cell lung cancer
Manchester score
Extensive disease WHO PS ≥ 2 Serum Na ≤ 132 mM/l Bicarbonate ≤ 24 mM/l Alk Phos > 165 IU/l LDH > 450 iu/l
Treatnebt for Small Cell Lung Cancer
Carboplatin/Etoposide chemotherapy
Consolidation radiotherapy to lung
Prophylactic cranial irradiation
T/F lymphomas are usually not aggressive
Diverse group of haematological malignancies that range from very indolent to highly aggressive.
Presentation of lymphoma
Lymphadenopathy B symptoms: -Fevers >38C -Night sweats -Weight loss >10% body weight
In which case would you not give high dose steroids in
Lymphoma
