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Metabolic and Endocrine > Metastatic Bone Pain, Spinal Cord Compression and an Overview of Radiotherapy > Flashcards

Metastatic Bone Pain, Spinal Cord Compression and an Overview of Radiotherapy Flashcards

1
Q

what is the presentation of bone metastases?

A 
Pathological fracture
Spinal cord compression
Hypercalcaemia
Symptoms of nerve root compression
Swelling/deformity/loss of mobility
Pain; especially if…
-Progresses over time
-Does not respond to simple -analgesia
-Disturbs sleep
-Associated with bony tenderness and or weight loss
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2
Q

what imaging would be used for diagnosing metastatic bone pain?

A 
Plain film
Bone scan
MRI 
CT 
Biopsy under screening
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3
Q

what treatment is given for treating metastatic bone pain if radiotherapy doesn’t work?

A 
Bisphosphonates
Denosumab-reduce rate of progression
Surgical fixation for pain
Chemotherapy 
Vertebroplasty
Radioactive isotopes
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4
Q

what is the most common type of cancer at the oesophagogastric junction?

A

adenocarcinoma (barrets is a precursor)

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5
Q

40yr old man present with firm non tender mass in scrotum and minimally high HCG. Diagnosis?

A

epididymitis (would be tender), hydrocele (would be soft), teratoma (high HCG) so answer is seminoma

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6
Q

Young man present with testicular mass what examination should be done?

A

Inguinal area examination,, supraclavicular examination, breast examination don’t need per rectal examination

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7
Q

what are the risk factors for cancer of the urinary bladder?

A

smoking, cyclophosphamide, aromatic amines

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8
Q

what are the risk factors for liver cancer?

A

hepatitis B, hepatitis C, cirrhosis

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9
Q

what are risk factors for prostate cancer?

A

ethnicity (black American, Caucasians, Asians have low risk

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10
Q

benign enlargement of the prostate arises in what zone of prostate?

A

peripheral zone

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11
Q

what is radiation?

A

energy carried by waves (photons) or a stream of particles
One of the main modalities to treat cancer, also chemotherapy and surgery
Only x-ray and gamma rays are used in radiotherapy
X-ray machines and CT scanners are diagnostic. Linear scan used in radiotherapy

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12
Q

what are the different types of radiotherapy

A

external beam
brachytherapy
internal

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13
Q

how is external beam radiotherapy delivered?

A

linear accelerator machine

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14
Q

what is brachytherapy?

A

keep the radioactive source very close to the organ with cancer (for cervical or prostate cancer)

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15
Q

what is internal radiotherapy?

A

administered orally or IV (oral I-131 for thyroid cancer / Ra-233 for prostate cancer)

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16
Q

what is the basic mechanism of radiation?

A

Interact with water and OH radicals produce which interact with DNA molecule and calling breaks in DNA and death

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17
Q

describe the importance of radiotherapy?

A

50% of cancer patients will need radiotherapy at some point
40% of cancer patients who are cured received radiotherapy
Effective in palliating bone pain from bone metastases

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18
Q

give examples of photons?

A 
X-rays (megavoltage X-ray therapeutic, kilovoltage X-ray diagnostic)
Gamma rays (radio isotopes)
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19
Q

give examples of particles used in radiotherapy?

A

Sub atomic particles (proton etc)

atomic (carbon ion)

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20
Q

what are the acute affects of radiotherapy?

A 
during and upto 6 months after
Temporary without much sequalae and dependent on site
Fatigue
Skin redness and itching
Nausea, vomiting, diarrhoea
Cystitis, proctitis
Oesophagitis
Odynophagia/dysphagia
Cough
SOB (pneumonitis)
Hoarse voice
Dysphagia
Mucositis
Skin pigmentation
Hair loss
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21
Q

what are the late side effects of radiotherapy (after 6 months to life long)?

A

More important as tend to linger and lead to sequalae and Less common (5-10%)
Replacement of normal cells with fibrous tissue
Skin thinning and lacking elasticity
Bowel stricture, stenosis, decreased motility
Deranged organ function (depend on volume and dose)
Mucosa-dry mouth, telangiectasia- most common in pelvic radiotherapy (rectal bleeding and haematuria)
Soft tissue necrosis and mucosal ulceration
Hypopituitarism
Short term memory impairment
Secondary cancer
Children and growing adolescent: growth retardation, hypoplasia of organ irradiated, secondary cancer

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22
Q

describe the process of treatment planning for external beam radiotherapy?

A 
CT scan or X-ray 
Contouring
Computerised planning
Checks-quality assurance
Treatment delivery
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23
Q

describe curative delivery of treatment external beam radiotherapy?

A

60-70 gy in 6-7 weeks, 5 days a week. Depends on type of tumour and site, with or without surgery or chemotherapy

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24
Q

describe palliative treatment of external beam radiotherapy?

A

8 gy (unit of radiation) in one fraction (session). 20gy in 5 fraction over one week. 30 gy in 10 fractions over 2 weeks

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25
Q

what types of cancer is radiotherapy curative on its own?

A 
Early stage
Prostate
Cervix
Vocal cord
Skin (non melanoma)
26
Q

what types of cancer is radiotherapy curative when given before or after surgery?

A 
Prostate
Breast
GYN
H&N
Sarcoma
Lung
Oesophagus
Bowel 
Skin (non-melanoma)
27
Q

what types of cancer is radiotherapy curative when given with chemotherapy?

A 
Advance H&N 
lymphoma
palliative
pain control
control bleeding
spinal cord compression (cauda equina)
reduce tumour mass so relieving mass effect
28
Q

what are the aims of radiotherapy?

A 
Curative on its own
Curative before or after surgery
Curative with chemotherapy 
Palliative care (extending life)
Shrink tumour
29
Q

describe normal calcium homeostasis?

A

Maintenance of healthy blood calcium levels include the kidneys, parathyroid glands, intestines and bones
2.2-2.6mmol/L
Serum calcium is bound to albumin and measurements should be adjusted for serum albumin

30
Q

describe how cancer can lead to hypercalcaemia?

A

Significant bone lysis directly by the tumour-multiple myeloma

Paraneoplastic syndrome (most of the cancer). PTHr protein secretion

  • Enhance osteoclast activation and bone resorption
  • Increases renal tubular calcium reabsorption
31
Q

what are the symptoms for a patient with hypercalcaemia?

A 
Lethargy
Dehydration
Anorexia
Nausea 
Polydipsia
Constipation
Renal impairment 
Polyuria
Mood disturbance
Cognitive dysfunction
Confusion
Coma 
Limb weakness
Shortened QT interval
Dysrhythmias 
Chronic: pancreatitis, gastric ulcer, kidney stones
32
Q

what are the important examinations and investigations for hypercalcaemia?

A 
General and abdominal examination
Urine output
Other cancer symptoms and signs
Electrolytes, albumin, ALP
T3 and T4
Medications
ECG changes
33
Q

what are the differentials for hypercalcaemia?

A 
Infection
Deranged kidney function/renal failure 
Brain metastases
Spinal cord compression
Depression
Sub-acute or acute bowel obstruction 
Opioids related side effects
34
Q

what are the potential causes of hypercalcaemia?

A 
Lung-squamous cell and small cell
Any advance squamous cell cancer (H&N, bladder, anal, vulva)
Multiple myeloma
Renal cell cancer-release of parathyroid hormones or other growth factors
Advance breast cancer
Primary hyperparathyroidism
Sarcoidosis 
Vit D intoxication
Thyrotoxicosis 
Medications
35
Q

what is the management for hypercalcaemia?

A

Hydration – 2-4L of 0.9% saline over 24 hours (caution in elderly, cardiac history, obstructive uropathy, renal failure)
Mobilise
IV bisphosphanate
Glucocorticoid (inhibit 1,25 OH vitamin D production)
Manage malignancy
Resistant cases-consider calcitonin
Check medication lists-calcium and vitamin D supplement
Loop diuretics? -fluid overload

36
Q

when should hypercalcaemia be treated?

A

Treat patient not calcium level
Adjusted calcium <3mmol/L and rising (often asymptomatic)- give fluids and bisphosphonates if persistent or symptomatic
Adjusted calcium 3-3.5mmol/L -fluids, bisphosphonates, glucocorticoids
Adjusted calcium >3.5mmol/L – risk of dysrrhymia and coma
End of life care-discuss and evaluate

37
Q

describe the use of bisphosphonates in treating hypercalcaemia?

A

Inhibits osteoclasts
Pamidronate -30-90mg over 90 mins (starts working over 2-3 days and max effect over 1 week)
Zoledronic acid – 4mg over 15 mins, longer duration. Caution: renal function, flu like symptoms, hypocalcaemia, long use can cause bone (jaw) necrosis

38
Q

what are the ECG changes in a patient with hypercalcaemia?

A

decreased QT interval

39
Q

what are the most common secondary tumour locations?

A

Lung
Liver
BONE (3rd most common site of metastasis)

40
Q

what are the most common primary tumours that metastasise to bone?

A 
Prostate
Breast
Lung
Kidney 
Myeloma
41
Q

what are the common sites of bone metastasis?

A 
Vertebrae
Pelvis
Ribs
Femur
Humerus 
Acrometastases- distal to elbow and knee are rare and usually due to renal and lung cancer as primary tumour)
42
Q

describe the presentation of bone metastasis?

A

Asymptomatic
Pain (dependent on what structures are being affected.)
Pathologic fractures/spinal cord compression
if cortex affected increased risk of fracture.
If outside of cortex-risk of spinal cord compression
Hypercalcaemia-secretion of parathyroid hormone secreted from primary tumour or soft tissue metastasis. This is rare.

43
Q

describe the mechanism of cancer causing bone fracture etc?

A

Bone undergoes constant remodelling maintaining osteoclastic (resorptive) and osteoblastic (Bone forming) activity
Tumour cell seeding through blood-bone marrow-cortex
Disrupts the balance between osteoclast and osteoblast activity
Osteoclast predominant-lytic metastases, greater chance of fracture than osteoblast predominant
Osteoblast predominant-disorganised ossification, still fractures

44
Q

what are the radiological characteristics of bone metastasis in different cancers?

A

Mostly lytic metastasis

  • Multiple myeloma
  • Thyroid cancer
  • Renal cell cancer
  • Melanoma

Mostly sclerotic metastasis

  • Prostate
  • Breast
  • Mucinous cancer of the bowel

Mixed sclerotic and lytic

  • Lung cancer
  • Bladder cancer
45
Q

what are the important investigations for a patient with bone metastasis?

A

Bloods

  • FBC
  • Bone related ALP
  • Kidney and liver function
  • PSA
  • Paraproteins

Urine
-Proteins (bence jones-multiple myeloma)

Imaging

  • Plain x ray-more specific, less sensitive
  • Bone scan-more sensitive, less specific
  • Cross sectional imaging (CT, MRI)
46
Q

what are the differentials for bone metastasis?

A 
Primary bone tumour (benign or malignant)
bone islands
osteomyelitis 
healing fracture
pagets disease
endocrine and metabolic disease
47
Q

describe the WHO ladder of pain management?

A

Ladder 1 = paracetamol `and anti-inflammatory
Ladder 2 = weak opioids, codeine, tramadol
Ladder 3 = stronger opioids; morphine, oxycodone, fentanyl

48
Q

describe how bone pain can be managed?

A

Palliative radiotherapy
Bisphosphonates -zolidronic acid (IV every couple of weeks)
Orthopaedic intervention if fracture or at risk

49
Q

what are the side effects of different treatments used for bone pain?

A

Paracetamol-hepatotoxic
Anti-inflammatory – renal function, gastritis
Opioids (titrate dose) – short acting then replace with long acting
Constipation, nausea, drowsiness, confusion
Bisphosphonates – nephrotoxic and jaw necrosis

50
Q

define spinal cord compression/cauda equina?

A

Neurological symptoms and signs caused by mechanical pressure over the spinal cord (from epidural extension of metastasis in vertebra, from paravertebral region, from meningeal deposits).
Similar features occurring at vertebral level below L1 is cauda equina compression

51
Q

what are the signs and symptoms of cord compression?

A

Pain 90% of patient
Worse lying down
If bone collapses pain worse on movement
Increases with Valsalva maneouver
If nerve root involved radicular pain
Tenderness
Muscle weakness 75% of patients (jelly legs, give way)
Sensory deficits-50-75%
Autonomic dysfunction 50-60% of patients
Symptoms and signs depend on timing, level of compression, pain and pre-existing condition

52
Q

describe the anatomy of the spinal cord?

A

Medulla to conus medularis L1-L2
Cord projects 31 pairs of spinal nerves (8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal
Conus meddularis-tapered structure at spinal cord end. At intervertebral disc between the first and second lumbar vertebrae. Consist of sacral spinal cord segments
Cauda equina – bundle of intradural nerve roots at end of the spinal cord
Filum terminale – fibrous extension of the cord. Non neural element that extends down the coccyx

53
Q

describe the history of cauda equina?

A 
Pain
Functional status
Mobility
Difficulty in bowel and bladder
numbness
Comorbidities
medications
54
Q

what should you look for in examination in a patient with suspected cauda equina?

A 
mobility and gait
elicit tenderness
power, tone and rigidity
tendon reflexes including plantars 
light touch (sensory level)
bladder fullness (urinary catheter?)
anal tone and perianal sensation
55
Q

describe the signs and symptoms of spinal cord UMN uniform condition?

A

pain-localised or radicular
motor-low power, rigidity
bladder-urge incontinence
reflexes-hyper

56
Q

describe the signs and symptoms of cauda equina LMN assymetrical condtion?

A

localised or radicular pain
motor-flaccid paralyses
bladder-overflow incontinence
reflexes absent

57
Q

what are the primary cancer sites causing metastatic spinal cord/cauda equina compression?

A

lung, prostate, breast, multiple myeloma, kidney, lymphoma, melanoma

58
Q

what are the differentials for spinal cord compression/cauda equina?

A 
osteoporotic fracture
disc herniation
brain metastases
vascular lesion
demyelination disorder
injury
primary tumour
59
Q

what is the inital management for spinal cord compression/cauda equina?

A

immobilisation, steroids (dexamethasone 8mg BD with PPI), MRI, neurosurgery, radiotherapy, rehabilitation
if leukaemia and lymphoma-steroid and chemotherapy

60
Q

what is the subsequent management for spinal cord compression/cauda equina?

A

taper off dexamethasone (risk of hyperglycaemia and gastric ulcer)
treat primary cancer
physiotherapy with gradual mobilisation
pain control
other specialty input (macmilln nurse, palliative care team, physiotherapist, occupational therapist, GP

61
Q

what types of spinal cord compression have a good prognosis?

A

single lesion
respond to steroid
ambulatory/limited neurological deficit
radiation sensitive-multiple myeloma and small cell lung cancer
moderately sensitive-prostate and brest
early surgery and radiotherapy (within 24 hours)

62
Q

what types of spinal cord compression have a poor prognosis?

A 
multiple location
extra spinal metastases
non ambulatory/paraplegic
radioresistant tumour (renal cell cancer, melanoma)
cord compression with vertebral fracture

Metabolic and Endocrine (12 decks)

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