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Management of Disorders > Neuro-psycho-oncology > Flashcards

Neuro-psycho-oncology Flashcards

1
Q

How do rates of mental disorders in cancer patients compare to the general population?

A

They are much higher, especially as first recurrence

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2
Q

What mental health problems are most common in cancer patients?

A

▪️Mood problems
▪️Anxiety
▪️Insomnia and sleep disturbance
▪️Cognitive difficulties
▪️Body image and self-esteem

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3
Q

What mental health problems are common during treatment?

A

▪️Insomnia
▪️Cognitive difficulties

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4
Q

Which types of cancer are associated with worse mental health?

A

▪️Head and neck
▪️Lung
▪️Pancreas
▪️Haemotological

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5
Q

What factors predict worse mental health outcomes in cancer patients?

A

▪️Young age
▪️Lower SES
▪️Poor functioning
▪️Pain
▪️Comorbidities
▪️Severity of illness
▪️Prognosis

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6
Q

What did the 2017 KCH audit find about the key concerns of haemotology patients?

A

▪️30% of concerns were emotional
▪️Half of the top 10 concerns were psychological (e.g. anxiety, fatigue, intimacy, sadness)

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7
Q

How might cancer cause psychiatric effects?

A

▪️Mass effect or destruction of tissue
▪️Systemic depletion of substance
▪️Hormone secretion by tumour
▪️Paraneoplastic hormone secretion
▪️Onconeuronal antibodies
▪️Pro-inflammatory action

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8
Q

What cancer treatment might psychiatric effects?

A

All of them!

Both directly to the CNS and indirectly via distant sites

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9
Q

What is Cushings Syndrome?

A

A syndrome of chronic, low level, hypercortisolaemia caused by too much cortisol

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10
Q

How is corticol produced?

A

▪️Corticotrophin releasing factor (CRF) is produced in the hypothalamus
▪️CRF stimulates the pituitary gland to produce ACTH
▪️ACTH stimulates the adrenal gland to produce cortisol

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11
Q

Which types of tumours actively secrete ACTH?

A

▪️Active pituitary tumours
▪️Thyroid medullary tumours

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12
Q

Which tumours secrete glucocorticoids (e.g. cortisol) ?

A

Adrenocortical tumours

BUT rare

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13
Q

How might tumours cause Cushing Syndrome (too much cortisol)?

A

▪️Active secretion of ACTH or cortisol
▪️Paraneoplastic secretion (ACTH provokes adrenal glands to produce cortisol)

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14
Q

What cancer is associated with paraneoplastic ACTH secretion?

A

Small cell lung cancer

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15
Q

How do you treat Cushings Syndrome?

A

Corticosteroids

(Most commonly for GBM and Haemotological cancers)

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16
Q

What are the neuropsychiatric symptoms of Cushing Syndrome?

A

▪️Severe depression
▪️Cognitive difficulties
▪️Emotional instability
▪️Sleep disorders
▪️Fatigue

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17
Q

What neuropsychiatric sequelae might be seen with high doses of steroids?

A

Severe psychosis or mania

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18
Q

What neuropsychiatric sequelae might be seen with low doses of steroids?

A

▪️Depressed mood
▪️Anxiety
▪️Insomnia
▪️Agitation
▪️Euphoria

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19
Q

How might hypothyroidism occur as a consequence of cancer?

A

▪️Destruction of the hypothalamus or pituitary gland by tumour
▪️Thyroid damage from surgery or radiation
▪️Molecular treatments and monoclonal antibodies

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20
Q

How might hyperthyroidism occur as a consequence of cancer?

A

bHCG secreted by some testicular cancers can mimic TSH, stimulating the thyroid

(Much more rare!)

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21
Q

What are the neuropsychiatric symptoms of hypothyroidism?

A

▪️Fatigue
▪️Mood change
▪️Memory change

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22
Q

What are the neuropsychiatric symptoms of hyperthyroidism?

A

▪️Agitation
▪️Anxiety
▪️Mania
▪️Psychosis

23
Q

How might cancer cause oestrogen deficiency?

A

▪️Pelvic irradiation
▪️Oestrogen-receptor blockers
▪️Hypothalamus or pituitary surgery or irradiation

24
Q

What is the main role of oestrogen in the brain?

A

▪️Neuroprotection
▪️Increases serotonin synthesis
▪️Promotes neuroplasticity

25
Q

What neuropsychiatric sequelae may be seen with oestrogen deficiency?

A

▪️Depression
▪️Increased later dementia risk

26
Q

What hormone deficiencies might occur after pituitary or hypothalamus surgery or irradiation?

A

▪️Oestrogen
▪️Growth hormone

27
Q

What are the neuropsychiatric symptoms of growth hormone deficiency?

A

▪️Depression
▪️Anxiety
▪️Subtle cognitive deficits in attention and memory

28
Q

What are onconeuronal antibodies?

A

Antibodies produced by tumour cells that bind to targets in the CNS

29
Q

What type of cancer is associated with anti-Hu antibodies and what neurological consequences might they cause?

A

▪️Small lung cell carcinomas
▪️Encephalitis

30
Q

What type of cancer is associated with anti-Yo antibodies and what neurological consequences might they cause?

A

▪️Aggressive breast cancer
▪️Paraneoplastic cerebellar degeneration
▪️Cerebellar symptoms, cognitive deficits, disinhibition, visuospatial problems

31
Q

What type of cancer is associated with NMDAr antibodies and what are the symptoms?

A

▪️Teratomas (particularly ovarian)
▪️Acute schizophrenia-like psychosis

32
Q

What are the two main routes to deficiency and how do they relate to cancer and cancer treatment?

A

▪️Poor absorption (from surgery or radiotherapy)
▪️Poor appetite (chemo sickness, cytokine production, precursor to cancer)

33
Q

What is methotrexate and how does it work?

A

A form of chemotherapy that deprives the body of folate, preventing cells from replicating thus stopping cancerous growth

34
Q

What might cause folate (B12) deficiency in cancer?

A

▪️Impaired absorption from stomach/upper bowel surgery or radiation
▪️Methotrexate

35
Q

What is folate/B12 needed for?

A

▪️DNA replication and cell growth
▪️Myelin synthesis
▪️Red cell production

36
Q

How might cancer cause anaemia?

A

Bone marrow suppression either by invasion (blood cancer) or treatment (chemotherapy)

37
Q

How might anaemia present neuropsychiatrically?

A

Depression symptoms

38
Q

How do carcinoid tumours lead to serotonin deficiency?

A

–> Produce too much peripheral serotonin
–> Depletion of tryptophan (negative feedback loop)
–> Reduces the amount of serotonin that reaches the brain

39
Q

How do pancreatic adenocarcinoma lead to serotonin deficiency?

A

Produce an inflammatory reaction which depletes tryptophan

40
Q

What percentage of people experience cognitive deficits after brain irradiation?

A

50-90% (dose dependent)

(Particularly memory, attention, and IQ)

41
Q

How is radiation thought to impact cognition?

A

Likely through its neuroinflammatory effect (microglia activation and decreased neurogenesis)

42
Q

What are risk factors for worse cognitive reactions to radiotherapy?

A

▪️Young age (brain still developing)
▪️Intrathecal chemo (methotrexate)
▪️Pituitary radiation (hormone effects)

43
Q

What is chemo brain?

A

‘Brain fog’ and subjective cognitive difficulties commonly reported after or alongside chemotherapy.

44
Q

What factors may underlie chemo brain?

A

▪️Effect of cancer
▪️Radiation and other treatments
▪️Psychological stress
▪️Insomnia
▪️Some evidence for APOE e4 gene

45
Q

What parts of the brain appear to be affected by chemo brain?

A

Everywhere except the occipital lobe

46
Q

How might chemotherapy directly induce cognitive impairment?

A

▪️BBB penetration leading to neurotoxocity, axonal damage, demyelination etc
▪️Oxidative stress response
▪️Hormone changes
▪️Immune dysregulation and inflammation
▪️Altered LTP
▪️Cerebral vascular alteration

(Or all of the above?)

47
Q

What is CICI?

A

Chemotherapy-Induced Cognitive Impairment

(contraversial!)

48
Q

What is PML?

A

Progressive Multifocal Leukoencephalopathy (PML)

A disease caused by the JC virus, which targets myelin producing cells, leading to demyelination and white matter abnormalities

49
Q

What are the symptoms of PML?

A

▪️Progressive weakness
▪️Speech problems
▪️Loss of coordination
▪️Cognitive deficits
▪️Seizures
▪️Death

50
Q

How might cancer treatments cause PML?

A

Immunosuppression can reactivate the JC virus which is usually harmless. The virus then invades oligodendrocytes causing irreversible demyelination.

(Usually monoclonal antibodies or chemotherapy)

51
Q

How does CAR T-cell therapy work?

A

▪️CAR T-cell are made in lab from patients T-cells
▪️Infused back into patients
▪️CAR T-cells bind to cancer cells and prompts massive inflammatory response

52
Q

What symptoms do you get with CAR T-cell therapy and why?

A

Massive inflammatory response and release of cytokines causes a severe influx of symptoms including:

▪️CAR-related encephalopathy syndrome (CRES) (headaches, confusion, weakness, seizures, hallucinations, aphasia etc)
▪️Sepsis-like symptoms

53
Q

When are CAR T-cell therapy patients most at risk?

A

During the first few days.

Severe symptoms are usually temporary and reversible but have ICU bed ready just in case

Management of Disorders (28 decks)

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