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DPD 2019 > Could it be cancer > Flashcards

Could it be cancer Flashcards

1
Q

What are the oncological emergencies

A 
Neutropenic sepsis 
Tumour lysis syndrome
Hypercalcaemia 
SVCO
Cord compression
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2
Q

Which cancers often present as emergencies

A

CNS, lung, HPB, upper GI

Rarely melanoma or breast

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3
Q

Outline the investigations for cancer

A

Radiological
Endoscopic
Biochemical
Surgical

Specialist clinics (e.g. breast)

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4
Q

Give example of radiological cancer investigations

A 
CT chest/abdo/pelvis 
CT or MRI brain 
MRI Whole Spine 
USS
PET-CT (if MDT recommends) 
Ba swallow
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5
Q

Bichemical investigations

A

CEA, Ca199, Ca153, PSA, aFP, betaHcG, Ca125

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6
Q

What is CEA associated with

A

Carcinoembryonic antigen

  • associated with lower GI tumours
  • normally <2.5 in non smokers or <5 in smokers
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7
Q

Other causes of CEA increasing

A

Not just lower GI tumours.

Also:

  1. Stomach/breast/lung/pancreas cancer
  2. Infections, pancreatitis, IBD

Can all increase CEA (but lower GI cancer can increase it into the hundreds or thousands)

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8
Q

What is Ca199 associted with

A

Almost always elevated in pancreatic cancer

Also can be elevated in other GI tumours

Poor specificity and sensitivity

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9
Q

How is Ca199 used clinically

A

Elevated levels typically associated with METASTATIC pancreatic disease

Also used to track response to treatment (e.g. chemo)

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10
Q

What is Ca 15-3 linked to

A

Breast cancer….

Also not diagnostic and used to assess treatment efficacy

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11
Q

What is PSA

List in 3 situtations where PSA may be elevated without there being cancer

A

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

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12
Q

What is Ca 125

A

Associated with ovarian cancer

Can be elevated in benign reasons (e.g. peritonitis) but also malignancy

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13
Q

Give examples of endoscopic investigations

A 
OGD
Colonoscopy
ERCP 
Bronchoscopy 
Nasendoscopy
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14
Q

What is the advantage of endoscopic investigations

A

Ability to obtain tissue
Therapeutic intervention – e.g. stents
Detect small lesions not visible radiologically

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15
Q

Give 3 exampes of surgical interventions

A

Examination under anaesthetic
Laparoscopy
Laparotomy

(not always needed, sometimes for pelvic tumours, can give you an idea of clearance)

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16
Q

What is crucial before treating cancer

A

Tissue diagnosis

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17
Q

Why is getting a tissue diagnosis important

A

Anticancer therapy varies depending on histopathological subtype.

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18
Q

Which condition can look like cancer

A

TB

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19
Q

T/F lymphoma can be diagnosed with FNA

A

Often it is very difficult to, really the lymph node needs to be taken out

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20
Q

How long does IHC and profiling take

A

IHC- up to 5 days

Profiling- up to a month

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21
Q

What is the role of the MDT for cancer

A

Facilitate rapid diagnosis and treatment
Carefully assess cancer stage
Set treatment goals
Implement best-practise treatment plan

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22
Q

Limitations of MDT

A

Only once a week

Only as good as the history it is given

Mainly designed to facilitate OP investigation and treatment

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23
Q

What information does an MDT need

A

Presenting complaint
Co-morbidities
Overall fitness – Performance status
Relevant investigations performed already

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24
Q

If you think it might be cancer, should you wait to talk to the MDT?

A

If you are worried it might be cancer don’t wait for MDT, talk to relevant team to get investigations under way.

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25
Q

What is the role of acute oncology

A

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.

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26
Q

Which tumours need a fast diagnosis

A
  • Small cell cancer
  • Lymphoma
  • Germ cell tumours
  • Cord compression of any cause
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27
Q

List the common acute presentations of cancer

A 
Confusion/fitting 
SoB 
Obstruction 
Pain 
Liver/renal failure 
Off legs
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28
Q

What are your differentials for confusion/fitting

A 
Infection 
Biochemical abnormality 
Drugs 
Cerebrovascular event 
Brain mets/primary 
Pseudo-seizure
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29
Q

What investigations would you do for seizure

A

Bloods (FBC, U&E, LFTs, Mg, Ca, CRP)

CT Brain

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30
Q

Management of brain metastases

A

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

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31
Q

Differential diagnosis for SoB

A 
HF
Pneumonia 
COPD
Lung cancer 
PE
Pulmonary HTN
Wet disease
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32
Q

What is wet disease

A

Pleural effusion, ascites and pericardial effusion

Often it is cancer related

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33
Q

Investigations for a breathless patient

A 
CXR 
Bloods
ABGs
CTPA
CT CAP 
ECG
34
Q

Why might you do an ECG in a patient with SoB?

A

Ischaemic changes

AND

Pericardial effusion

35
Q

What might an ECG with a massive pericardial effusion show?

A

Tachycardia
Low Voltage
Electrical alternans

36
Q

What might you be looking for as a cause of PE if there is no obvious risk factor

A

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

37
Q

What is the first treatment for PE

A

Treat with low molecular weight heparin

38
Q

What do you need to be careful about with pneumonia on chest xray

A

Consolidation may hide underlying malignancy

39
Q

How do you ensure a consolidation is not hiding an underlying malignancy

A

Repeat chest imaging 6 weeks post to ensure changes have resolved

40
Q

What cancer is associated with wet disease

A

Ovarian

41
Q

How do you manage wet disease

A

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

42
Q

What would you do with fluid from a tap

A

Biochemistry (exudate or transudate) and cytology and microbiology

43
Q

What is the problem with giving chemotherapy when someone has wet disease

A

Chemotherapy can accumulte in collections of fluid ‘third space’

This can affect the pharmacodynamics of the drugs

44
Q

Differentials for bowel obstruction

A

Severe constipation

Malignant obstruction (single site or multifocal)

Adhesion from previous surgery

IBD

45
Q

Investigations for bowel obstruction

A

AXR
CT CAP
Barium/gastrograffin (if at risk of aspiration) swallow
Surgical review if lower GI

46
Q

If there is multifocal obstruction (i.e. the bowel is obstructed at multiple points) in the bowel, it’s more likely to be what

A

More likely to have come from outside the bowel (i.e. be peritoneal metastases)

47
Q

Most common tumour types causing obstruction

A

Colon
Ovary
Gastro-oesophageal (dysphagia)

48
Q

How are the following managed:

  1. Single transition point
  2. Multifocal bowel obstruction
A

If single transition point surgery or stenting possible.

Multifocal subacute bowel obstruction often seen with ovarian cancer may be managed conservatively

49
Q

Outline the conservative management sometimes used for multifocal subacute bowel obstruction

A

Drip & Suck

NBM

Iv fluids

Normalise electrolytes

Chemo once resolved if possible. If not palliation may be only option

50
Q

Learn about maintenance fluid vs insensible losses

A

………

51
Q

Differentiate the likely tumour given the site of disease in the liver

A

Parenchymal disease – metastases

  • Colon cancer
  • Breast Cancer
  • Upper GI cancers

Obstructive

  • Pancreas cancer
  • Cholangiocarcinoma
  • Portal Metastases from other cancers
52
Q

What is liver failure

A

Abnormal liver function- AST, ALT, Alk Phos, Bili, Albumin, clotting, platelets

53
Q

How do you investigate abnormal liver function

A

USS, CT CAP, MRI liver (best)

54
Q

Which enzymes would increase proportionately in biliary obstructive picture

A

Alk phos and bili

55
Q

How do you treat an obstructed liver

A

Make the diagnosis – tissue is needed
ERCP and stent
PTC drainage

If someone has obstructed duct they need to be on prophylactic Abx

56
Q

T/f if the malignancy causing obstruction is in an early stage it could be resectable

A

T

57
Q

When can chemo be given in obstructed liver

A

Chemo usually not possible until LFTs have normalised

Which is why you need to get a stent in asap

58
Q

Explain the cause of renal impairment in cancer

A

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

59
Q

How do you treat renal impairment in cancer

A

Treat
Antegrade nephrostomy and stent
Retrograde stent insertion

60
Q

T/F stents are usually uncomfortable for patients

A

T- Stents are uncomfortable for patients. If a patient is frail and may not be fit for treatment sometimes kinder not to insert stent

61
Q

What can cause renal impairment without hydronephrosis and how to treat

A

May be due to sepsis
Fluid depletion
Cancer burden

Treat with iv fluids and ABXs
May be end stage disease and mode of death

62
Q

Outline how you can treat pain

A

WHO ladder
Opioids
Neuropathic agents
Identify cause of pain and address

63
Q

When can nerve block be useful in cancer

A

Pancreatic

64
Q

Other methods of pain management other than pharmacology in cancer

A

Radiotherapy (bone mets)

Chemotherapy

Pathological fractures – surgery

Pain from masses may be helped with surgery

Psychological support

Hypnotherapy

Bisphosphonates/RANKL

65
Q

Why can cord compression be missed

A

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”

66
Q

Which cancers can cause cord compression

A

Prostate, Breast, Lung, Kidney, Thyroid, Lymphoma, Multiple Myeloma

67
Q

What are the features of cord compression

A

Weakness, numbness, urological dysfunction, faecal dysfunction, sexual dysfunction

68
Q

What is key to not miss cord compression

A 
What were they like at home?
Any back pain?
Any known malignancy?
Duration of symptoms and speed of decline
Current bladder/bowel function
69
Q

What must you do if you expect cord compression

A

Do full neurological examination, including PR

Document bladder and bowel function

70
Q

Management for cord compression

A 
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
71
Q

How long does it take for nerves to die following compression

A

Nerves start to die within 24hrs of compression.

72
Q

T/F if a patient is bedbound we don’t need to worry about preserving contientnce with spinal cord compression

A

Even if bedbound, if we can preserve continence there is possibility of being cared for at home.

73
Q

What can off legs mean

A

Many patients will be decompensating because they are weak

Cancer burden increasing

74
Q

Which tumour needs a fast diagnosis

A Breast cancer
B colon cancer
C small cell lung cancer

A

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”)

75
Q

What percentage of lung cancers are small cell?

T/f all small cell cancers are in the lung

A

10-15%

F

76
Q

How do you stage small cell lung cancer

A

Limited disease – confined to one hemithorax

Extensive disease – any disease beyond limited

77
Q

What are the prognostic factors for small cell lung cancer

A

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
78
Q

Treatnebt for Small Cell Lung Cancer

A

Carboplatin/Etoposide chemotherapy
Consolidation radiotherapy to lung
Prophylactic cranial irradiation

79
Q

T/F lymphomas are usually not aggressive

A

Diverse group of haematological malignancies that range from very indolent to highly aggressive.

80
Q

Presentation of lymphoma

A 
Lymphadenopathy 
B symptoms: 
-Fevers >38C
-Night sweats 
-Weight loss >10% body weight
81
Q

In which case would you not give high dose steroids in

A

Lymphoma

DPD 2019 (30 decks)

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