Misc + Emergencies Flashcards
Most common cancers in the UK?
- Breast
- Lung
- Colorectal
- Prostate
- Bladder
- Non-Hodgkin’s lymphoma
- Melanoma
- Stomach
- Oesophagus
- Pancreas
(EXCLUDES NON-MELENOMA SKIN CANCERS)
Most common deaths caused by cancer in the UK?
- Lung
- Colorectal
- Breast
- Prostate
- Pancreas
- Oesophagus
- Stomach
- Bladder
- Non-Hodgkin’s lymphoma
- Ovarian
What type of cancer does the carcinogen Aflatoxin (produced by Aspergillus) cause?
Liver - (hepatocellular carcinoma)
What type of cancers does the carcinogen Aniline dyes cause?
Bladder - (transitional cell carcinoma)
What type of cancers does the carcinogen Asbestos cause?
Mesothelioma and bronchial carcinoma
What type of cancer do the carcinogens Nitrosamines cause?
Oesophageal and gastric cancer
What type of cancer does the carcinogen Vinyl chloride cause?
Hepatic angiosarcoma
What is Li-Fraumeni syndrome?
Autosomal dominant genetic condition,
Consists of germline mutations to p53 tumour suppressor gene,
High incidence of malignancies particularly sarcomas and leukaemias
What malignancies are there a particularly high incidence of in Li-Fraumeni Syndrome?
*Individual develops sarcoma under 45 years
*First degree relative diagnosed with any cancer below age 45 years and another family member develops malignancy under 45 years or sarcoma at any age
On which chromosome is BRCA 1 carried on?
Chromosome 17 - BRCA 1
Chromosome 13 - BRCA 2
What cancers are the BRCA mutations associated with?
Carried on chromosome 17 (BRCA 1) and Chromosome 13 (BRCA 2)
Linked to developing breast cancer (60%) risk.
Associated risk of developing ovarian cancer (55% with BRCA 1 and 25% with BRCA 2).
BRCA2 mutation is associated with prostate cancer in men
What is lynch syndrome?
Autosomal dominant genetic condition
Develop colonic cancer and endometrial cancer at young age
80% of affected individuals will get colonic and/ or endometrial cancer
High risk individuals may be identified using the Amsterdam criteria
What Amsterdam criteria
Identifies individuals at his risk of Lynch Syndrome:
- Three or more family members with a confirmed diagnosis of colorectal cancer, one of whom is a first degree (parent, child, sibling) relative of the other two.
- Two successive affected generations.
- One or more colon cancers diagnosed under age 50 years.
- Familial adenomatous polyposis (FAP) has been excluded.
What is Gardners syndrome?
Autosomal dominant familial colorectal polyposis
Multiple colonic polyps
Extra colonic diseases include: skull osteoma, thyroid cancer and epidermoid cysts
Desmoid tumours are seen in 15%
Mutation of APC gene located on chromosome 5
Due to colonic polyps most patients will undergo colectomy to reduce risk of colorectal cancer
Now considered a variant of familial adenomatous polyposis coli
What investigations does NICE recommend for all patients with metastases of an unknown origin?
FBC
U&E
LFT
Calcium
Urinalysis
LDH
Chest X-ray
CT of chest, abdomen and pelvis
AFP and hCG
What additional investigations does NICE recommend for patients with metastases of an unknown origin where there are lytic bone lesions?
Myeloma screen
What additional investigations does NICE recommend for male patients with metastases of an unknown origin?
PSA
What additional investigations does NICE recommend for female patients with metastases of an unknown origin with peritoneal malignancy or ascities?
CA 125
What additional investigations does NICE recommend for male patients with metastases of an unknown origin with germ cell tumours?
Testicular US
What additional investigations does NICE recommend for female patients with metastases of an unknown origin with clinical or pathological features compatible with breast cancer?
Mammography
Do NICE recommend endoscopy when investigating metastases of unknown origin?
In some specific patients, directed towards symptoms
What is positron emission tomography and how does it work?
Positron Emission Tomography (PET) is a form of nuclear imaging which uses fluorodeoxyglucose (FDG) as the radiotracer.
This allows a 3D image of metabolic activity to be generated using glucose uptake as a proxy marker.
The images obtained are then combined with a conventional imaging technique such as CT to decide whether lesions are metabolically active.
What can PET scanning show in regards to a lesion?
Whether lesions are metabolically active
Uses of positron emission tomography?
evaluating primary and possible metastatic disease
cardiac PET: not used mainstream currently
Examples of oncological emergencies?
Neoplastic spinal cord compression
Superior vena cava compression
Malignant hypercalcemia
Neutropenic sepsis
Tumour lysis syndrome
What is the MOST COMMON symptom of SVC obstruction?
dyspnoea
What are the features of superior vena cava obstruction?
dyspnoea (most common)
swelling of the face, neck and arms - conjunctival and periorbital oedema may be seen
headache: often worse in the mornings
visual disturbance
pulseless jugular venous distension
Why might you be concerned about swelling (ie. face, neck, arms, conjunctival + periorbital oedema) in an oncology patient?
Sign of superior vena cava obstruction - oncological emergency
Why might you be concerned about dysponea in an oncology patient?
Sign of superior vena cava obstruction - oncological emergency
Why might you be concerned about headache/visual disturbance in an oncology patient?
Sign of superior vena cava obstruction - oncological emergency
Why might you be concerned about pulseless jugular venous distension in an oncology patient?
Sign of superior vena cava obstruction - oncological emergency
Causes of SVC obstruction?
common malignancies: small cell lung cancer, lymphoma
other malignancies: metastatic seminoma, Kaposi’s
sarcoma, breast cancer
aortic aneurysm
mediastinal fibrosis
goitre
SVC thrombosis
Management options for SVC obstruction?
- endovascular stenting is often the treatment of choice to provide symptom relief
- certain malignancies such as lymphoma, small cell lung cancer may benefit from radical chemotherapy or chemo-radiotherapy rather than stenting
- the evidence base supporting the use of glucocorticoids is weak but they are often given
What are the two most common malignancies associated with SVC obstruction?
Small cell lung cancer
Lymphoma
Into what groups can the various tumour markers be divided into?
monoclonal antibodies against carbohydrate or glycoprotein tumour antigens
tumour antigens
enzymes (alkaline phosphatase, neurone specific enolase)
hormones (e.g. calcitonin, ADH)
What are the monoclonal antibody tumour markers and what are their associations?
CA 125 - Ovarian cancer
CA 19-9 - Pancreatic cancer
CA 15-3 - Breast cancer
What are the tumour antigen tumour markers and what are their associations?
Prostate specific antigen (PSA) - Prostatic carcinoma
Alpha-feto protein (AFP) - Hepatocellular carcinoma, teratoma
Carcinoembryonic antigen (CEA) - Colorectal cancer
S-100 - Melanoma, schwannomas
Bombesin - Small cell lung carcinoma, gastric cancer, neuroblastoma
What is AFP?
Alpha fetoprotein (AFP) is a protein of fetal serum that is usually undetectable after birth.
Causes of raised AFP?
Hepatocellular carcinoma
Gastro-intestinal cancers
Metastatic Lung Cancer
Pregnant patients (particularly elevated if there are fetal neural tube defects)
Germ cell tumours
What are the potential causes of confusion in oncology patients?
Metabolic disturbance (hypoglycaemia, hypercalcaemia)
Infection (pneumonia, UTI)
Metastatic spread to the brain
Anaemia
Intense pain
Side effects of pain medication
Differentials of dyspnoea in oncology?
Pneumonia
Anxiety
Lung collapse due to tumour or narrowing of airway
Pleural effusions
Radiation pneumonitis
Anaemia
Oncological emergencies (superior vena cava obstruction)
What is Li Fraumeni syndrome, what does it occur due to and what cancers it is linked with?
A rare autosomal dominant disorder.
It is the result of germ line mutation of the p53 tumour suppressor gene.
It leads to an increased risk of sarcoma and cancer of the breast, brain and adrenal glands.
What is MEN 1 syndrome and what does it cause?
Causes neoplastic mutations of the pituitary, parathyroid and the pancreas. It is caused by mutations in the MEN1 gene.
What causes MEN 2A syndrome and what does it cause?
Caused by mutations within the RET oncogene
Results in medullary thyroid cancer, phaechromocytoma and parathyroid adenoma.
What causes MEN 2B syndrome and what does it cause?
Caused by mutations within the RET oncogene.
Results in medullary thyroid cancer, phaechromocytoma, mucosal neuroma, gastro-intestinal complaints, craniosynostosis
What is SVC obstruction?
Vena caval obstruction is narrowing or occlusion of the caval veins (the inferior vena cava or the superior vena cava), which return blood from the body to the heart.
Superior vena cava obstruction (SVCO) is a common oncological emergency. It is considered an emergency if there is difficulty in breathing. If this is absent then planning treatment in advanced is preferred.
Common symptoms and signs of SVC obstruction?
Dyspnoea
Orthopnoea
Facial plethora
Dilated/engorged veins
Pemberton’s test- where lifting the arms over the head for more than 1 minute will precipitate facial plethora and cyanosis.
How is diagnosis of SVC obstruction
Diagnosis is confirmed with CT scan of the Thorax.
What id the definition of neutropenic sepsis?
- Temp >38.5 degrees or two consec. reading over 38 degrees
- IN a patient with a neutrophil count of less than 0.5x10^9 (or expected to fall below this level in the next 48 hrs)
In what patients does neutropenic sepsis most commonly arise?
Most commonly arises in patients receiving cytotoxic chemotherapy, and is often the only indication of a severe infection.
Below what level of neutrophils meets the criteria of neutropenic sepsis?
a neutrophil count of less than 0.5x10^9 (or expected to fall below this level in the next 48 hours)
Which patients are at high risk of neutropenic sepsis?
Have sustained, significant neutropenia that is expected to last more than 7 days.
Are clinically unstable
Have an underlying malignancy and are being treated with high-intensity chemo
Have significant co-morbidities
What gram-negative pathogens might be involved in neutropenic sepsis?
E.coli
Klebsiella
Enterobacter spp. - can get carbapenem-resistant strains (CRE)
Pseudomonas aeruginosa
Acinetobacter
Can all produce extended-spectrum beta-lactams
What gram positive organisms might be involved in neutropenic sepsis?
Coagulase-negative staphylococci (e.g. staph epidermidis)
Staphylococcus aureus (including MRSA)
Enterococcus (including VRE)
Viridans group strep
Strep pneumoniae
Group A streptococci
What fungal pathogens may be involved in neutropenic spesis?
Candida
Aspergillus
Investigating neutropenic sepsis?
2 sets of blood cultures
Swabs from any indwelling lines
Blood tests from complete blood cell count, WCC, inflammatory markers, renal and liver function.
CXR
Serology and PCR for viruses e.g. CMV
Sputum, urine, stool samples, CT scans etc. where clinically indicated.
?Neutropenic sepsis - examination
DRABCDE
Systems-based examinations
ENT
Fundoscopy
DO NOT perform DRE until antibiotics given)
History - ?neutropenic sepsis?
Type and timing of chemo regimen and any other immunosuppressive medication being taken.
Localizing symptoms e.g right lower-quadrant pain associated with neutropenic enterocolitis
Recent infections and antibiotics used
Latent infections are known to reactivate (e.g.
TB), sick contacts, blood transfusions
Co-morbidities
Any intravascular devices
Management of neutropenic sepsis?
DRABCDE approach
If low risk can give oral antibiotics (quinolone + co-amoxiclav)
Features suggesting low risk:
Hemodynamically stable
Doesn’t have acute leukaemia
No organ failure
No soft tissue infection
No indwelling lines
For most patients, they need empirical IV treatment with piperacillin and tazobactam (tazocin), with added coverage for MRSA or gram-negatives if thought at risk.
A macrolide should also be added if diagnosed with pneumonia (to cover atypical organisms)
Daily measures of fever and baseline bloods until the patient is apyrexial and neutrophil count above 0.5x10^9^
When the neutrophil count is normal, has been afebrile for 48 hours and blood tests have normalized, antibiotics can be stopped.
Prophylaxis with a fluoroquinolone can be offered
When can antibiotics be stopped in neutropenic sepsis?
When the neutrophil count is normal, has been afebrile for 48 hours and blood tests have normalized, antibiotics can be stopped.
When can you give oral antibiotics (quinolone + co-amoxiclav) in neutropenic sespsis?
If low risk
Features suggesting low risk:
Hemodynamically stable
Doesn’t have acute leukaemia
No organ failure
No soft tissue infection
No indwelling lines
What antibiotic treatment if given to most (non-low risk) patients with neutropenic sepsis?
Empirical IV treatment with piperacillin and tazobactam (tazocin)
+ added coverage for MRSA or gram-negatives if thought at risk
A macrolide should also be added if diagnosed with pneumonia (to cover atypical organisms)
What prophylaxis against neutropenic sepsis may be offered?
Prophylaxis with a fluoroquinolone can be offered
?Neutropenic sepsis - history
Type and timing of chemo regimen and any other immunosuppressive medication being taken.
Localizing symptoms e.g right lower-quadrant pain associated with neutropenic enterocolitis
Recent infections and antibiotics used
Latent infections are known to reactivate (e.g. TB), sick contacts, blood transfusions
Co-morbidities
Any intravascular devices
What is metastasis and what routes might it take?
Cancer cells can spread by moving into nearby tissue (local invasion) and can then spread to more distant locations within the body through invasion of the body’s transport systems; including the blood stream (haematogeneous) or lymphatic system.
The process by which cancer cells spread from their primary tumour site to other regions in the body is known as metastasis.
What is Pemberton’s sign?
A positive Pemberton’s sign is indicative of superior vena cava syndrome (SVC), commonly the result of a mass in the mediastinum.
The sign is positive when bilateral arm elevation causes facial plethora.
