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DPD 2020 > Could it be cancer? The cancer patient in hospital > Flashcards

Could it be cancer? The cancer patient in hospital Flashcards

1
Q

Is most cancer managed as an inpatient or outpatient?

A

Outpatient. Asymptomatic lesions could be investigated as an outpatient. Refer to relevant MDT- include details of PMH and overall fitness.

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2
Q

What proportion of cancers present as an emergency?

A

25%- they are the sickest. Especially CNS, lung, HPB and upper GI. Rarely melanoma or breast.

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3
Q

Which cancers commonly present as an emergency?

A

Especially CNS, lung, HPB and upper GI.

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4
Q

Which cancers are less likely to present as an emergency?

A

Melanoma

Breast

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5
Q

What are the reasons for emergency cancer admission to hospital/ common acute presentations of cancer?

A

Confused

Weakness

Fits

Breathless

Off legs- can’t walk

Pain

Bleeding

Obstruction

Liver/renal dysfunction

Incidental

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6
Q

What investigations are required for emergency cancer admissions?

A

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.

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7
Q

List radiological investigations for emergency cancer admissions.

A

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

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8
Q

What is carcinoembryonic antigen CEA?

A

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.

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9
Q

What is Ca 19-9?

A

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

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10
Q

What is PSA?

A

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.

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11
Q

What is Ca 125?

A

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.

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12
Q

List endoscopic investigations.

A

OGD.

Colonosocopy.

ERCP.

Bronchoscopy.

Nasendoscopy.

Can take a biopsy with any of these procedures

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13
Q

What are the advantages of endoscopic investigations?

A

Ability to obtain tissue- biopsy

Therapeutic intervention, e.g. stents.

Detect small lesions not visible radiologically.

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14
Q

Give examples of surgical investigations for cancer.

A

Laparoscopy

Laparotomy.

Allows for biopsy, Examination under anaesthetic

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15
Q

What is the importance of tissue diagnosis in cancer?

A

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.

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16
Q

In which cancer is PSA raised? a) breast b) lymphoma c) prostate

A

Prostate cancer

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17
Q

In which cancer is Ca 19-9 a tumour marker? a) colon b) pancreatic c) breast

A

Pancreatic cancer. Can also be raised in colon cancer.

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18
Q

What proportion of patients develop MSCC (metastatic spinal cord compression)? a) 5% b) 20% c) 50%

A

5%

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19
Q

What is the increased risk of pulmonary embolus in cancer patients? a) 4-fold b) 10-fold c) 40-fold

A

4-fold

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20
Q

What is the management plan for patients with brain metastases?

A
  • 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
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21
Q

What are the oncological emergencies?

A

Neutropenic Sepsis

Tumour Lysis syndrome

Superior Vena Cava Obstruction

Spinal Cord compression

Hypercalcaemia

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22
Q

Which cancers are screened for in the UK?

A

Breast.

Cervical.

Colon- FIT- faecal immunochemical testing

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23
Q

What is Ca 15-3?

A

Tumour marker- breast cancer

Elevated especially if mets elevated in GI cancer too

Used to track progesss of cancer/response to chemo- not diagnostic

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24
Q

Are any tumour markers diagnostic?

A

No.

Only PSA can be- only linked to prostate pathology, poor specificity

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25
Q

How should lymphoma be diagnosed?

A

Core biopsy of lymph node/lymph node sampling

FNA NOT enough

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26
Q

What is IHC and how long does it take?

A

Immunohistochemistry

Takes time

Profiling can take even longer- up to a month

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27
Q

What is the role of an acute oncology team? Not sure we need this tbh

A

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

28
Q

What are the differential diagnoses for a patient in hospital that is:

Confused/having a fit

What investigations do you do?

A

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

29
Q

What do these images show?

A

Top left: multiple brain mets

Top right: one brain met- black around it is swelling

Bottom middle: Abscess

Bottom right: Thrombus

Bottom left: Mets

30
Q

What is wet disease? How do you manage this?

A

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

31
Q

What are the main differential diagnoses for [chronic] shortness of breath?

A
  • COPD
  • Asthma
  • Pneumonia
  • PE
  • Heart failure/cardiac
  • Pulmonary hypertension

Cancer related?

  • Wet disease
  • pleural effusion
  • Thoracic malignancy [heart, lung]
32
Q

What investigations would you do for a breathless patient? Non cancer and cancer related causes

A
  • 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
33
Q

What are the ECG signs of pericardial effusion?

A

Tachycardia

Short QRS complexes= low voltage

Electrical alternans- pulsus alternans- one short, then one long complex

34
Q

What are the examination signs of pericardial effusion?

A

Beck’s triad

Hypotension

Muffled heart sounds

Raised JVP

35
Q

How are PEs related to cancer? How do you treat a PE? How is this affected in cancer?

A

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

36
Q

Relationship with pneumonia and cancer

A

Consolidation may hide underlying malignancy

Repeat chest X ray after 6 weeks once consolidation cleared

37
Q

What are the differentials for bowel obstruction? What are the investigations you can do?

A
  • 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
38
Q

What are the common tumour types that cause bowel obstruction

A
  • Colon- lower GI
  • Gastro oesophageal- upper GI/dysphagia too
  • Ovarian
39
Q

How do you manage bowel obstruction due to cancer?

A

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

40
Q

How do you investigate liver failure? How do you manage this when due to obstructive bile duct malignancy?

A

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

41
Q

What does this show?

A

Biliary duct dilatation in the liver

42
Q

What does this image show? How is this treated?

A

Liver metastases

Systemic treatment- chemo

ASAP

43
Q

Which cancers most commonly metastasise to the liver?

A

Breast

Upper GI

Colon

44
Q

Which cancers cause obstruction of the biliary duct?

A

Pancreatic head cancer

Cholangiocarcinoma

Portal metastases from other organs

45
Q

What are the two main types of cancer causing liver disease?

A

Obstructive- biliary picture

Parenchymal liver mets

46
Q

Where can ovarian cancer often metastasise to?

A

SURFACE OF THE LIVER

47
Q

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?

A

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
48
Q

How do you treat pain in cancer?

A

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

49
Q

What is the main concern if someone can’t walk who has cancer and why?

A

Cord compression

Easy to miss- esp if patients in bed

Causes permanent disability

50
Q

What are the main cancers that cause cord compression

A

Prostate

Breast

Lung

Kidney

Thyroid

Lymphoma

Multiple myeloma

51
Q

How many people with cancer get cord compression in their last two years of life?

A

One in twenty cancer patients

52
Q

What are the symptoms of cord compression?

A

Weakness Numbness [LMN signs] Back pain Urological dysfunction/incontinence Faecal dysfunction Sexual dysfunction Sudden changes

53
Q

What investigations and management should you do for cord compression?

A

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

54
Q

What does this show? What type of imaging is it?

A

Bony metastasis causing cord compression

MRI spine

55
Q

Features of lymphoma

Epidemiology

Symptoms and signs

Prognosis

Investigations

Treatment

A

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

56
Q

What are germ cell tumour? What is the prognosis? What is the treatment?

A

Tumours affecting cells producing sperm and eggs

Usually testicular or ovarian germ cell tumour

Prognosis

Curative- even at advanced stage

Treatment

Surgery and chemotherapy

57
Q

Which cancer should be quickly diagnosed because they are very sensitive to chemotherapy and easily curable in early stages?

A

Lymphoma

Germ cell tumours

Small cell lung carcinoma

58
Q

What are the types of treatment intent?

A

Radical Adjuvant Neoadjuvant Palliative

59
Q

What is radical treatment?

A

Curative intent

60
Q

What is palliative treatment

A

Non curative intent

61
Q

What is adjuvant therapy?

A

Given to reduce risk of recurrence

62
Q

What is neo adjuvant therapy?

A

Given to improve chances of curative/ extensive surgery?ef

63
Q

What are three cancers that can be cured by chemotherapy alone?

A

Germ cell Leukaemia Lymphomas

64
Q

What are cancers that can be cured by radiotherapy alone?

A

Head and neck

Cervical Bladder Skin- non melanoma Oesophageal - Squamous cell carcinomas

65
Q

What are the side effects of chemotherapy?

A

Early:

  • Hair loss
  • Neutropenia
  • Nausea

Late:

Increased risk of secondary cancer

DPD 2020 (48 decks)

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