Could it be cancer? The cancer patient in hospital Flashcards
Is most cancer managed as an inpatient or outpatient?
Outpatient. Asymptomatic lesions could be investigated as an outpatient. Refer to relevant MDT- include details of PMH and overall fitness.
What proportion of cancers present as an emergency?
25%- they are the sickest. Especially CNS, lung, HPB and upper GI. Rarely melanoma or breast.
Which cancers commonly present as an emergency?
Especially CNS, lung, HPB and upper GI.
Which cancers are less likely to present as an emergency?
Melanoma
Breast
What are the reasons for emergency cancer admission to hospital/ common acute presentations of cancer?
Confused
Weakness
Fits
Breathless
Off legs- can’t walk
Pain
Bleeding
Obstruction
Liver/renal dysfunction
Incidental
What investigations are required for emergency cancer admissions?
Biochemical- blood tests: FBC, renal function (U+E), biochemical, calcium, ?anaemia, ?deranged clotting, ?sepsis, etc, tumour markers
Radiological: x-ray, CT, MRI.
Endoscopic, e.g. severe haematemesis. Surgical: biopsy, excision, etc. Specialist clinics- e.g. breast clinics- mammography, biopsy, etc.
List radiological investigations for emergency cancer admissions.
CT chest/abdo/pelvis- good place to start- on all patients
CT or MRI brain.
MRI whole spine [for cord compression]
USS.
Barium swallow.
PET-CT- if MDT recommends one- SUV ability- metabolic areas glow
What is carcinoembryonic antigen CEA?
Tumour marker - lower GI tumours.
Normal range <2.5ng/mL non-smokers, <5.0ng/mL smokers - if colon cancer - in hundreds/thousands
Other causes for CEA rise: cancers of stomach, pancreas; lung, breast, infections, pancreatitis, inflammatory bowel disease.
What is Ca 19-9?
Tumour marker- pancreatic cancer. Poor sensitivity and specificity.
Elevated levels typically associated with metastatic disease. May be elevated in other GI tumours. Main use is for oncologists tracking chemo response or follow up of cancer
What is PSA?
Prostate specific antigen. Tumour marker. Protein produced almost exclusively by prostate tissue. Normal range 1.0-4.0ng/mL. PSA >10.0ng/mL associated with 43-65% risk of cancer. May be elevated by BPH, prostatitis, catheterisation.
What is Ca 125?
Tumour marker. Associated with ovarian cancer. Normal range <25-35u/mL. Check for recurrence after treatment History is key, may be elevated for many reasons both benign and malignant.
List endoscopic investigations.
OGD.
Colonosocopy.
ERCP.
Bronchoscopy.
Nasendoscopy.
Can take a biopsy with any of these procedures
What are the advantages of endoscopic investigations?
Ability to obtain tissue- biopsy
Therapeutic intervention, e.g. stents.
Detect small lesions not visible radiologically.
Give examples of surgical investigations for cancer.
Laparoscopy
Laparotomy.
Allows for biopsy, Examination under anaesthetic
What is the importance of tissue diagnosis in cancer?
Crucial before starting anti-cancer therapy
> Referrals to MDT that turn out to be TB not uncommon.
> Anticancer therapy varies depending on histopathological subtype- can tell which mutation cancer has.
> Prognostic information.
In which cancer is PSA raised? a) breast b) lymphoma c) prostate
Prostate cancer
In which cancer is Ca 19-9 a tumour marker? a) colon b) pancreatic c) breast
Pancreatic cancer. Can also be raised in colon cancer.
What proportion of patients develop MSCC (metastatic spinal cord compression)? a) 5% b) 20% c) 50%
5%
What is the increased risk of pulmonary embolus in cancer patients? a) 4-fold b) 10-fold c) 40-fold
4-fold
What is the management plan for patients with brain metastases?
- Steroids- dexamethasone- 16ml-[reduces oedema]
- Surgery + then radiotherapy - if one
- If multiple: radiotherapy
[if whole brain- multiple mets-> cyberknife technique=stereotactic- specific targeted, less side effects]
[Chemo doesn’t go through blood brain barrier well]
- Anti-epileptics if had a fit
- Advise patient they must not drive and notify DVLA.
- Physio and OT assessment.
- Identify primary- either CT chest abdo pelvis or biopsy brain met if unsuccessful CT
What are the oncological emergencies?
Neutropenic Sepsis
Tumour Lysis syndrome
Superior Vena Cava Obstruction
Spinal Cord compression
Hypercalcaemia
Which cancers are screened for in the UK?
Breast.
Cervical.
Colon- FIT- faecal immunochemical testing
What is Ca 15-3?
Tumour marker- breast cancer
Elevated especially if mets elevated in GI cancer too
Used to track progesss of cancer/response to chemo- not diagnostic
Are any tumour markers diagnostic?
No.
Only PSA can be- only linked to prostate pathology, poor specificity
How should lymphoma be diagnosed?
Core biopsy of lymph node/lymph node sampling
FNA NOT enough
What is IHC and how long does it take?
Immunohistochemistry
Takes time
Profiling can take even longer- up to a month
What is the role of an acute oncology team? Not sure we need this tbh
investigations for unknown cancer
Management of side effects of chemo/radio
Treatment of effects on known cancer
Prognosis of care advice
Discussions with patients/relatives
What are the differential diagnoses for a patient in hospital that is:
Confused/having a fit
What investigations do you do?
Infection
Biochemical- hyponatremia, hypercalcaemia
Drugs- recreational, medical
Brain mets/primary tumour
Seizure
Pseudo-seizure
Bloods: FBC, U+E, LFT, Mg, Ca, CRP
CT head
MRI head,
MRV [vessels]- rare
What do these images show?
Top left: multiple brain mets
Top right: one brain met- black around it is swelling
Bottom middle: Abscess
Bottom right: Thrombus
Bottom left: Mets
What is wet disease? How do you manage this?
Fluid collections in body:
Ascites
Pleural effusion
Pericardial effusion
Often related to cancer [certain types]
Happens recurrently
Management:
Drain fluid [guidance of imaging]
Do biochemistry- transudate or exudate
Cytology- cancer cells
Chylous effusion- lymph gland leakage
Can use indwelling long term drainage tubes/hole in pericardium- if recurrent
Treat + drain before chemotherapy- otherwise chemo accumulates in these third spaces
What are the main differential diagnoses for [chronic] shortness of breath?
- COPD
- Asthma
- Pneumonia
- PE
- Heart failure/cardiac
- Pulmonary hypertension
Cancer related?
- Wet disease
- pleural effusion
- Thoracic malignancy [heart, lung]
What investigations would you do for a breathless patient? Non cancer and cancer related causes
- CXR
- Bloods- FBC, tumour markers, CRP,
- Blood culture
- ABG
- CTPA
Cancer related
- CXR
- CT CAP - mets
- ECG - cardiac OR pericardial effusion in cancer
- Blood- tumour markers
What are the ECG signs of pericardial effusion?
Tachycardia
Short QRS complexes= low voltage
Electrical alternans- pulsus alternans- one short, then one long complex
What are the examination signs of pericardial effusion?
Beck’s triad
Hypotension
Muffled heart sounds
Raised JVP
How are PEs related to cancer? How do you treat a PE? How is this affected in cancer?
Malignancy increases risk of PE- four times
One to two percent cancer deaths= PE
If unprovoked PE- look for cancer
Immediate:
- LMWH - Dalteparin, Enoxaparin
- DOACs
- Warfarin
Avoid warfarin and DOAC if patient having chemo- possible interaction
Relationship with pneumonia and cancer
Consolidation may hide underlying malignancy
Repeat chest X ray after 6 weeks once consolidation cleared
What are the differentials for bowel obstruction? What are the investigations you can do?
- Constipation
- IBD
- Adhesions
- Malignant [single- colon cancer, or multifocal- outside bowel, peritoneal mets]
Investigations
- AXR
- CT chest, abdo, pelvis
- Barium/ gastrograffin[less toxic if aspirated] swallow- upper GI
- Surgical review- endoscopy- venting tube to let air out
What are the common tumour types that cause bowel obstruction
- Colon- lower GI
- Gastro oesophageal- upper GI/dysphagia too
- Ovarian
How do you manage bowel obstruction due to cancer?
If single obstruction:
- Surgery
- Stent
If multifocal:
Non surgical
Drip and suck- NG tube- aspirate so not vomiting, IV fluids
NBM
Normalise electrolytes
Chemo once obstruction resolved if possible, or palliate
How do you investigate liver failure? How do you manage this when due to obstructive bile duct malignancy?
LFTs- higher ALP, bilirubin- if obstructive cancer
Platelets + clotting
Liver USS
CT chest abdo pelvis- mets
Liver MRI- best, but never used
Management
ERCP + insert stent
PTC- percutaneous drainage- if ERCP doesn’t work
Antibiotics- avoid sepsis from bile duct obstruction
Surgery if early stages
Chemo ONLY after LFTs back to normal
What does this show?
Biliary duct dilatation in the liver
What does this image show? How is this treated?
Liver metastases
Systemic treatment- chemo
ASAP
Which cancers most commonly metastasise to the liver?
Breast
Upper GI
Colon
Which cancers cause obstruction of the biliary duct?
Pancreatic head cancer
Cholangiocarcinoma
Portal metastases from other organs
What are the two main types of cancer causing liver disease?
Obstructive- biliary picture
Parenchymal liver mets
Where can ovarian cancer often metastasise to?
SURFACE OF THE LIVER
What is the usual cause of renal impairment in cancer?
Which cancers commonly cause this?
How do you treat it?
What are other causes of renal impairment in cancer?
How do you treat this? What is the prognosis of renal failure in cancer? What investigations are done in renal impairment?
Obstructive hydronephrosis
Cervical, ovarian, bladder
Anterograde nephrostomy and stent [through bladder]
Retrograde stent [through back straight into kidney]
Painful and uncomfortable- stents- think carefully if patient palliative
Sepsis
Fluid balance dysregulation
Cancer burden/deterioration
Bad prognosis- often end stage disease/mode of death
- Bloods- U+E, CRP
- USS renal
How do you treat pain in cancer?
WHO ladder- non opioids, weak opioids, strong opioids + adjuncts
Opioids
Neuropathic agents- gabapentine, amitryptilline etc.
Nerve blocks
Counselling/psychological support
Hypnotherapy
Treat underlying cause
Radiotherapy
Chemotherapy
Pathological fractures- Surgery, Radiotherapy, Bisophosphonates/RANK ligand inhibitor
What is the main concern if someone can’t walk who has cancer and why?
Cord compression
Easy to miss- esp if patients in bed
Causes permanent disability
What are the main cancers that cause cord compression
Prostate
Breast
Lung
Kidney
Thyroid
Lymphoma
Multiple myeloma
How many people with cancer get cord compression in their last two years of life?
One in twenty cancer patients
What are the symptoms of cord compression?
Weakness Numbness [LMN signs] Back pain Urological dysfunction/incontinence Faecal dysfunction Sexual dysfunction Sudden changes
What investigations and management should you do for cord compression?
Investigations
Full neuro exam PR- anal tone
Document bladder and bowel function
Management
Dexamethasone- IV- 16mg
Urgent MRI spine- [whole spine]
Keep supine
Liaise with neurosurgery urgently
Liaise with oncology
Nerves die within twenty four hr of compression - Try to preserve continence- big impact on dignity and care needs
What does this show? What type of imaging is it?
Bony metastasis causing cord compression
MRI spine
Features of lymphoma
Epidemiology
Symptoms and signs
Prognosis
Investigations
Treatment
Diverse haematological malignancies- mild to aggressive
Epidemiology
Any age
Symptoms and signs
Lymphadenopathy
B symptoms- fever, night sweats, low >10% body weight
Prognosis
Curative
DLBCL- 50%- 5 year survival
Mantle cell 25% 5 year survival
Hodgkins 90% 5 year survival, 50% in advanced stage
Complications
SVC Obstruction
Investigations
Biopsy of lymph node
Treatment
Don’t give steroids before biopsy- need to see which type of lymphoma to treat and steroids will get rid of lymphoma cells
What are germ cell tumour? What is the prognosis? What is the treatment?
Tumours affecting cells producing sperm and eggs
Usually testicular or ovarian germ cell tumour
Prognosis
Curative- even at advanced stage
Treatment
Surgery and chemotherapy
Which cancer should be quickly diagnosed because they are very sensitive to chemotherapy and easily curable in early stages?
Lymphoma
Germ cell tumours
Small cell lung carcinoma
What are the types of treatment intent?
Radical Adjuvant Neoadjuvant Palliative
What is radical treatment?
Curative intent
What is palliative treatment
Non curative intent
What is adjuvant therapy?
Given to reduce risk of recurrence
What is neo adjuvant therapy?
Given to improve chances of curative/ extensive surgery?ef
What are three cancers that can be cured by chemotherapy alone?
Germ cell Leukaemia Lymphomas
What are cancers that can be cured by radiotherapy alone?
Head and neck
Cervical Bladder Skin- non melanoma Oesophageal - Squamous cell carcinomas
What are the side effects of chemotherapy?
Early:
- Hair loss
- Neutropenia
- Nausea
Late:
Increased risk of secondary cancer
