Intro To Clinical Oncology Flashcards
How should you approach communication about cancer?
Positive yet realistic approach
Compassionate
Well-informed advice to aid decision making
SEEK HELP if out of your depth
How does quality of life for cancer patients compare to that of those animals with other chronic illnesses?
Can sometimes be better
How might pets provide a good model for human disease in oncology?
—Outbred population with spontaneous cancers
—Genetically similar
—Shared environment with owners (therefore risks)
—Faster disease progression and time to reach end points therefore quicker progression with clinical studies
— Similar patient size/metabolism
What are the key DDx for patients with a mass lesion?
Inflammatory lesion e.g. abscess, granuloma
Haematoma
Seroma (pocket of clear serous fluid, usually post surgical)
Cyst
Neoplasia
What clinical signs might indicate that a lump is an abscess over something neoplastic?
Fever (although also seen with some neoplasms)
Sudden onset
Feels fluid filled
Painful to touch
History of trauma
Why should you not wait to see if a lump grows?
Because if it is cancerous then you have allowed time for metastasis
What is the first step diagnostically when investigating a lump?
Fine needle aspiration
What are the benefits of fine needle aspiration?
Quick, cheap, easy to perform, non-invasive
What can you determine from FNA?
Cell types
— inflammation vs neoplasia
Cell morphology
— benign vs malignant
How could the appearance of a cellular population indicate whether a lesion is neoplastic?
Monomorphic cells more likely to be neoplasia
heterogeneous population of cells more likely to be inflammatory
Outline how you might perform a fine needle aspirate
Place 23/25 gauge needle in lesion,
Redirect several times WITHOUT coming out of the skin
Prepare smear
If cytology indicates neoplasm, what about the cells is important to determine?
The cell type (therefore tumour type)
E.g. round cells, mesenchymal cells, epithelial cells
What do mesenchymal cells look like cytologically?
Spindle shaped,
Usually in connective tissue
What do epithelial cells look like cytologically?
Sheets of cells
When can benign masses still cause clinical problems?
When they press on delicate structures e.g. meningioma
What cytologically features indicate a malignant mass?
Cellular pleomorphism, anisocytosis Nuclear pleomorphism (anisokaryosis) Multinucleation Prominent/multiple/aberrantly shaped nucleoli High N:C ratio High No. mitotic figures Increased cytoplasmic basophilia
What is meant by the term: cellular pleomorphism?
What does it indicate
Variability in the size, shape and staining of cells and/or their nuclei
characteristic of malignant neoplasms
What is meant by the term anisocytosis?
Red blood cells of unequal size
What is meant by the term anisokaryosis?
Larger than normal variation in the size of the nuclei of cells
What special techniques may be required for a definitive diagnosis?
Cytochemical stains
ICC, IHC, flow cytometry
Tests for clonality e.g. PARR
How do you find out a tumour grade in practice?
HISTOPATHOLOGIST decides
What does the grade of a tumour depend on?
Mitotic index Degree of cellular differentiation Amount of necrosis Invasion of surrounding tissues Invasion of vasculature/lymphatics
Why is tumour grading important?
Important for treatment planning, prognosis, communication
How can Mast Cell Tumours be graded?
Patnaik system (low, intermediate, high (I,II,III))
Kiupel system (2-tier, low and high)
What are the margins?
The border of the tumour excised. Can be assessed by pathologist.
Clean if no cancer cells found at edge of tissue
Dirty if cancer cells at edge of tissue - suggests not all has been removed
Who performs the staging of a cancer patient?
CLINICIAN
What is meant by the term staging?
How is it performed?
Assesses the extent of disease
Assess: primary tumour, drainage lymph node, and distant metastasis
Outline the TNM system of tumour staging
T= primary tumour, size indicated by subscript number
N= evidence of metastasis to regional nodes (subscript 0 = no, 1=yes)
M= evidence of distant metastasis (0=no, 1=yes)
How could you determine whether regional metastasis has occurred?
Assess regional nodes for size, mobility, relationship to surrounding tissues, texture and consistency
IMAGING required for internal nodes
FNA to decide if metastasis present
How could you determine whether distant metastasis has occurred?
History and PE
Imaging e.g. thoracic radiograph
Sampling
Name a system of staging other than TNM. What is it for?
WHO system for lymphoma
** echo
What should you check in the patient other than the obvious lump?
Presence of concurrent illness and/or evidence of paraneoplastic effects (e.g. the secretion of hormones, cytokines or enzymes)
Why are concurrent illness important to consider?
What patients are they more likely to be found in?
Can affect prognosis and treatment
Geriatrics
What baseline tests should be used to assess a cancer patient?
Haematology /CBC
Biochemistry profile
Urinalysis
Potentially coagulation profile
Why would you perform haematology/CBC to assess a cancer patient?
General health screen Baseline prior to chemo Cell numbers and morphology - check for: — anaemia — cytopenias e.g. neutropenia, thrombocytopenia — abnormal circulating cells
What could cytopenias on haematology indicate about a cancer patient?
Concurrent immune-mediated disease
Why would you perform biochemistry to assess a cancer patient?
General health screen Assess organ damage/function: — prior to GA — for drug metabolism (liver/kidneys) — Choice and dose of drugs
Look for paraneoplastic effects
E.g. hypercalcaemia due to PTH-rp secretion
Why would you perform urinalysis to assess a cancer patient?
General health status
Assess renal function (SG)
Why would you perform coagulation profile to assess a cancer patient?
Tumours can cause abnormalities in coagulation
Can result in a patient being hyper- or hypo- coagulable
Potential thrombocytopenia
What paraneoplastic effects could be presented in the clinic instead of a mass?
Hypercalcaemia
Hypoglycaemia
Hyperviscosity with hyperglobulinaemia, polycythaemia
Define the term: polycythaemia
Abnormally increased concentration of Hb in the blood
Due to:
- reduction in plasma volume
- increase in red cell numbers
Define the term: hyperviscosity
Increased viscosity of the blood.
Causes several clinical signs including:
- spontaneous bleeding from mucous membranes
- visual disturbances due to retinopathy (/retinal detachment) neurologic symptoms (seizures, coma etc)
How would you expect a hypocalcaemic patient to present?
PD/PU Lethargy Anorexia Depression Vomiting Weakness Bradycardia
How would you expect a hypoglycaemic patient to present?
Weakness
Collapse
Seizures
What are the potential goals of cancer treatment?
Cure
Remission for a period of time
Reduction in burden for control
Palliative
MAINTAIN GOOD QOL
How do treatment schedules for cancer in veterinary species vary compared to those seen in humans?
Less intensive due to adverse effects - pet doesn’t understand why
What factors should be considered when trying to pick a treatment plan?
Patient temperament Patient general health status Potential adverse - how will this affect patient and client Cost Time commitment Prognosis
When would surgery be considered as a treatment option?
Treatment for primary carcinomas and sarcomas as well as MCTs (‘hard’ tumours)
Often used in combination with radiation or chemo
When is radiation treatment used?
What is a potential negative?
Primary treatment modality especially if surgical resection difficult due to site e.g. nasal tumours
Adjunctive treatment - used when incomplete resection or with neoadjuvant therapy
Need GA so patient stays still
When is chemotherapy/drug treatment indicated?
Disseminated disease
Tumours with high metastatic potential
Situations where surgery/radiation not possible
What tumours would require chemotherapy?
Hematopoeitic tumours e.g. lymphoma, leukaemias
Systemic/high grade/ high risk MCTs
Adjunctive treatment for highly metastatic tumours e.g. osteosarcoma, hemangiosarcoma, Soft Tissue Sarcoma
What supportive care is required for the cancer patient?
Nutrition - ensure adequate caloric intake and monitor BCS, feeding tube may be required but not ideal long term
Hydration - IV fluid therapy
GIT problems may require anti-emetics etc
Antibiotics
Analgesics
Physio therapy
What drugs may be required to aid with the gastrointestinal problems associated with cancer treatment?
Gastric protectants: e.g. Omeprazole
Anti-emetics: Maropitant, odansetron
Appetite stimulants e.gg mirtazepine
Why might antibiotics be required with chemotherapy?
If chemo causes neutropenia
What analgesics may be indicated?
NSAIDs
Paracetamol
Opioids e.g. tramadol, buprenorphine
Gabapentin
Why should you be careful around cytotoxic drugs?
They interfere with cell growth and division
Can be carcinogenic, mutagenic and teratogenic
What group of people need to be particularly careful around cytotoxic drugs?
Pregnant women (especially 1st trimester)
Shouldn’t handle drugs or body fluids from patients receiving these drugs
What health and safety procedures are necessary for tablets/capsules containing cytotoxic drugs ?
Don’t crush/break
If need to be reformulated, should be done by a specialist pharmacy
Wear gloves to administer
Dispense in labelled, childproof container
What protective clothing may be required for administering injectable agents?
WEAR GLOVES - chemo safe or double glove
Long sleeved water resistant gown
(Face mask and goggles)
How should you handle the body waste of a patient receiving chemo?
Wear gloves
Double bag waste
Designate toileting area if possible
