Onc / palliative Flashcards
Side effect long term amiodarone
Hepato / pulm fibrosis
Hyper/Hypo thyroid
Corneal deposits
Pancreatitis
Long QT
supraclavicular fossa lymph node usually which tumour
Gastric
[Virchow’s node and
Infection assoc with 1/3 gastric tumours
H pylori
Metastatic gastic adenoma. What testing do you do? What is treatment if this is positive
HER2
[human epidermal growth factor receptor 2]
Trastuzumab
What is Zollinger-Ellison syndrome? Which syndrome are they linked to? Main symptoms ?
Gastrin secreting tumours -> gastric / duodenal ulceration
[Usually pancreatic in origin]
MEN1
Epigastric pain
Steatorrhoea (acid-related inactivation of digestive enzymes)
Diarrhoea - From acid secretion
Zollinger-Ellison syndrome - high serum gastrin levels and elevated basal gastric acid output.
Main Ix? 2 parts of medical RX?
Endoscopy + CT
High dose PPI
Surgical resection ( in most)
chemo
Somatostatin analogues - Eg Ocretide to reduce gastric secretion and diarrhoea
acrocyanosis
Blue discolouration of hands - especially when in cold
Poikilocytosis
Abnormal shape RBCs (making up >10%)
What is cryoglobulinemia? Conditions assoc? Ix?
abnormal blood proteins called cryoglobulins clump together at cold temperatures
Seen in myeloma / leukaemia / lymphoma
-Some infections too Eg HepC, HIV, toxoplasmosis, EBV, malaria
Incubate serum at 4°C
Some less common cancer markers…
Neurone specific enolase NSE
Small cell lung Ca
Neuroblastoma
Some less common cancer markers…
HCG
Testis
Some less common cancer markers…
Calcitonin
Medullary thyroid
Some less common cancer markers…
Parathormone
Parathyroid
Some less common cancer markers…
IgG, IgA, IgM, IgE
Multiple myeloma
Some less common cancer markers…
AFP - name 2
Liver
Testis
Yolk sac
Some less common cancer markers…
Ca 15-3
Breast
Bowel
Lung
how does late chemo toxicity usually present
Peripheral neuropathy
Ototoxicity
why do 5% of testis Ca have gynaecomastia
Tumour secretes HCG
Enzyme sometimes used for seminoma marker
PLAP
Placental alkaline phosphatase
2 main classes of testis Ca
-Seminoma
-Non-semonomas germ cell tumour (NSGCT)
Eg Yolk sac, teratoma, choriocarcinoma, embryonal
80% cure of testis Ca with orchidectomy.
What is offered to reduce the risk of relapse
Single dose carboplatin
Who gets resection of HCC? Transplant?
Need Childs-pugh class A for resection
[still 20% operative mortality]
Transplant
-Single tumour <5cm with no metastatic spread
-AFP <1000iu/ml
Which lung Ca usually has Mets at presentation
Small cell
Which lung Ca is usually more peripheral
Adenocarcinoma
General differentiation between lung mets and primary lung Ca on CT
Primary - soft tissue mass with irregular borders
Met - smooth and rounded
Paraneoplastic syndromes which lung Ca ?
Hypovolaemic hyponatraemia
Raised ACTH
Hyper Ca
Gynaecomastia
Hyperthyroid
Lambert-eaton
Hypertrophic pulmonary osteoarthropathy
Hypovolaemic hyponatraemia - SIADH = small cell
Raised ACTH - Small cell
Hyper Ca - Squamous - from bony mets [rarely produces PTH too)
Gynaecomastia - Large cell (large breasts) and adenocarcinoma
Hyperthyroid - Squamous (produces TSH)
Lambert-eaton - Small cell
Hypertrophic pulmonary osteoarthropathy - Adenocarcinoma
What is lambert eaton? How is it differentiated from myasthenia gravis
Paraneoplastic from small cell
-> proximal myopathy
Weakness improves with repetitive movements
What is Hypertrophic pulmonary osteoarthropathy
Paraneoplastic from lung adenocarcinoma (and rarely small cell)
Osteitis, Gross finger clubbing, and arthritis
Long bones usually affected
What is pancoast found? Where does it affect? Sx?
On CXR
Non small cell [in superior sulcus]
Affects C8 nerve root -> pain down arm
-may get hand muscle wasting
- Horners syndrome
CXR - shadow at apex + possible destruction of 1st/2nd ribs
Most common causes of fever (when neutropenic)
60% Gram positive - staph epi / strep viridans
30% gram neg - E coli, klebsiella, pseudomonas
Roll of MENSA in chemo
To prevent haemorrhagic cystis
[given with some chemo drugs (cyclophosphamide/ifosfamide) to protect bladder]
A and C fibres in pain
A - Acute
C - slower - chronic pain
Colorectal and endometrial cancer as a pair often in?
HNPCC
B symptoms hodgkins
Fevers
Night sweats
Weight loss
Main side effects of hyoscine
Anticolinergic
-> Tachycardia, dry mouth, urinary retention
When might you think colorectal ca is more likely HNPCC than sporadic
Young <45
Second cancer eg endometrial
Usually proximal colon
Strong family Hx
NHS bowel screening in who
60-74 every 2 years
Diagnosis of SIADH
Concentrated urine Na >20
HypoNatraemia <125
High osmolality
NO hypovolaemia, diuretics or oedema/ascities
What is demeclocycline used for
SIADH
->Blocks ADH and causes partial nephrogenic diabetes insipidus
Paraneoplastic cerebella degeneration is in tumours of breast, ovarian, fallopian tube… What is the antibody found
Anti-yo
Anti Hu found in
Small cell lung ca
Anti-ro
SLE
Anti-Tr
Hodgkins lymphoma
[The reed cells]
Anti zic4
small cell lung ca
Gabapentin mechanism
Blocks a2d receptor
Pt lacks capacity and has no NOK. Who is best to contact re DNACPR decision
Independent mental health advocate
Pt treated with doxorubicin (chemo) then develops cardiac failure several months later what has happened
Chemo induced cardiomyopathy
->biventricular failure
Genetic risk factor for breast Ca (not BRCA ?
Other risks
BRCA 1 and 2, TP53
COCP, HRT
Early menarche, late menopause, nulliparity
In order, what are the 2 most common met sites from breast Ca
Bones
Lungs
What should be given after resection of breast Ca
Tamoxifen
When would you get a mastectomy in breast Ca
> 4cm
multifocal
central
ER and HER2 status in Breast Ca prognosis?
ER +ve = better prognosis
HER2 = Poorer prognosis
Tachycardia, flushing, bronchoconstriction, diarrhoea, CV instability = ?
ix?
Carcinoid syndrome
5-HAI
Cancer with bone mets + anaemia. What would be seen on blood film
Leukoerythroblastic blood film
(nucleated erythrocytes and immature white cells of the neutrophilic myeloid series.)
Prostate Ca are adenocarciomas which area of prostate do they usually arise? BPH?
Peipheral zone
BPH is in transition zone
[Transition into old age]
What is the roll of LH agonists in prostate Ca ? Side effects? Eg?
Act on pit -> reduce LH secretion
-> Leydig cells in testes produce less testosterone
Loss of libido, flushing, malaise
Goserelin, buserelin, gonadorelin, leuprolide, nafarelin.
[-relin]
what is cyproterone acetate / flutamide / biclatumide
Anti androgen used in Protstate Ca
Main risks causing thyroid Ca
Radiation
MEN2
BRAF gene
What is most common type of thyroid cancer? Which gene is this linked to - not part of multi-ca syndromes?
Papilliary
BRAF
Which thyroid Ca in MEN2? produces what ? Diagnosis of MEN2 ?
Medullary
Calcitonin
RET- proto oncogene test
Rash over lots of areas, muscle weakness + something in history about Ca Eg Weight loss and bloating =
Dermatomyositis
From ovarian/pancreas/breast and lung.
Dont get thrown by rash and go for SLE …
Most common location for thyroid Ca mets to
lung
then bone
Genetic condition very closely assoc with RCCs
Von hipple lindau
How do RCCs present
Painless haematuria
May have varicocoele from obstructed veonous drainage
Why dex in tumour pain Eg liver
Reduce oedema
Bar 5HAII what is senstitive marker of carcinoid
Chromogranin A
Differentiation on exam of serotonin syndrome vs NMS
Serotonin
-Develops over 24hrs
-Clonus clonus clonus
-Agitation and sweating
NMS
-Develops over days / weeks
- Rigidity and bradyreflexia
2 main pharma options for seritonin syndrome
Cryptoheptadine
Propranolol
MAIN RX IS TO COOL THEM DOWN
Clin trials stages are for what
1
2
3
4
1 - Pharmacokinetics + toxicity
2- measure effects of drug
3- Compare to conventional therapy
4- Long term toxicity
Chemo drugs side effects TOXMAN
C (ears) - Cisplatin carboplatin -> Ototoxicity
T (eyes) - Tamoxifen
->Reduced acuity
B (lungs) - bleomycin, bulsupham
->Fibrosis
D with T (heart) - Doxorubicin
Tratasizumab
-> cardiac
M liver - methotrexate
Liver toxiticy
C - kidney. Cisplatin and carbocystine
O bladder (cycle) - cyclophosphamide - haemorrhage cystitis
V - Vincristine - peripheral neuropathy
5,6,MPH - Bone marrow suppression
5-fluorouracil
6-mercaptopurine
Methotrexate
Paclitaxel
Hydroxyurea
How does SCC skin ca get about
Lymphatics
Who can support a patient wishing to die at home? eg after big stroke
Mari curie nurses
Who are the specialist dementia nurses for home visits
Admiral nurses
Cancer nurses
Macmillan
who arranges care in community for complex patients
Community matron
Antiemetics receptors
Aprepitant
Domperidone
Metoclopramide
Ondansetron
Aprepitant - NK-1 receptor
[used for very emetogenic chemo regimes]
Domperidone/metoclopramide - Dopamine antagonist
Ondansetron - 5HT pathway
Cisplatin mechanism
Causes cross linking of DNA to form adducts
Fluorouracil mechanism
Inhibits protein synthesis
Doxorubicin mechanism
topoisomerase inhibitor
dOxO - tOpO
How long CPR if given fibrinolytic for known PE
60-90 mins
Metastatic lung ca. Now tired, hypotensive and hyperK. What has happened
Adrenal mets -> hypoadrenalism
Vomiting due to hyperCa - first line
Haloperidol
Ca ->D2 agonism
Haloperidol -> d2 antagonism
Why is metoclopramide not recommended in young people
Acute dystonic reactions
First line antiemetic for intracranial pathology
Cyclizine (+ dex if raised ICP)
First line antiemetic for vestibular (movement related)
cyclizine
First line antiemetic drug induced
haloperidol
First line antiemetic pregnant
prochlorperazine
First line antiemetic post op
droperidol and dex
or substitue ondansetron for either
First line antiemetic nausea vomiting end of life
levomepromazine 6.25mg
First line antiemetic obstructive bowel disorder end of life
hyoscine
then ocretide
Cytarabine key side effect
irreversible cerebellar dysfunction
What is given with paclitaxel ?
Dex and antihistamine as high rates of anaphylaxis
What is meptazinol, when is it useful
partial mu opioid agonist.
Has a low risk of constipation
Oral morphine to SC morphine? SC diamorphine
Half for SC
1/3 for diamorphine SC
Haematuria, loin pain, HyperCa, renal mass, night sweats, varicocele
Clear cell renal Ca
(hypernephroma or renal adenocarcinoma)
Von-hippel-lindau which tumours
Renal cell - often bilat
hemangioblastomas
Phaeos
Pancreatic neuroendocrine tumor.
Superficial Bladder <2cm ca low risk Rx?
Superficial Bladder 2-3cm ca intermediate risk Rx?
Superficial Bladder ca >3cm HIGH risk
TURBT + Intravesical mitomycin C
TURBT + Intravesical mitomycin C (6 doses)
TURBT + intravesical BCG
End of life IV hydration. Main issue? how often should they be examined
Overload
12hrly
Na level in MRCP to cause seizures
<125
Contraindication to metoclopramide
Bowel obstruction
(Congenital long QT and diagnosis of parkinsons are use with caution)
Which antiemetic contraindicated in cardiac disease
domperidone
Which antiemetics contraindicated in congenital long QT
Haloperidol and ondansetron
name an acute phase protein
Ferritn
Poor prognosis for breast Ca. High grade, positive lymph nodes. What about receptor status’ and age?
Progesterone/oestrogen negative status
HER2 positive
Age <40
All poor prognosis
Risk of breast / ovarian Ca with BRCAs
BRCA1
70% Breast
30-60% Ovarian
BRCA2
55% breast
10-30% ovarian
First line Ix for breast lump in <35
US as dense tissue
Smoker chronic cough with neutrophils of 28. Normal platelets / Hb. Dx ?
paraneoplastic neutrophilia
(from Small cell lung Ca)
Lung ca -> swelling of face, distended neck /upper arm vessels = ? Rx?
Superior vena cava syndrome
Stenting for immediate relief
Radiotherapy
opiate induced constipation first line Rx
Senna
->lactulose / docusate
Biggest cause of cancer death in women
lung ca
[breast Ca is most common Dx and second most death]
Biggest cause of cancer death in men
Lung Ca
then Prostate
Jaundice and painless enlargement of gall bladder. Where is Ca?
Ampulla of vata
[Gallbladder usually has pain]
What is removed in whipples procedure
Gallbladder, head of pancreas and duodenum
Rx of chronic pancreatitis related pain eg Cancer if already on high dose morphine
coeliac plexus block
Imatinib used for what 2 cancers? Mechanism?
CML
GIST
[Both BCR-ABL translocation]
Tyrosine kinase inhibitor
Small cell lung ca which chemo regime
cisplatin and etoposide
Tumor lysis syndrome electrolytes
HyperK
HyperUrate
HyperPO4->HypoCa
No capacity. No POA. Who can make a decision about surgery
Doctor performing the operation
hypnagogic vs hypnapompic
Off to the land of gog
(when fall asleep = hypnagogic)
Patient doesn’t want to know if they are dying can you tell them?
No
Mutation of APML? which chromosome?
Key drug for Rx
retinoic-acid receptor alfa (RARa) mutation
t (15:17)
all-trans-retinoic acid [ATRA]
Most common single place for neuro endocrine tumours (carcinoid)
Ileum
[somatostatin analogues (ocretide) key for symptom Rx]
Most common single place for neuroendocrine tumours (carcinoid)
Ileum
[somatostatin analogues (octreotide) key for symptom Rx]
Which thyroid cancer produces calcitonin
Medullary
c cells produce calcitonin
Method of monitoring for recurrence of papillary/medullary thyroid Ca
Serum thyroglobulin levels
What % thyroid Ca are papillary
85%
What is R in tumour classification
R0 - no residual tumour
R1 - microscopic residual tumour
R2 - macroscopic residual tumour
Quiet heart sounds and raised JVP which immediate Ix
Echo
Risk factors for depression in palliative care
Which symptom?
Which blood finding?
Age?
PMH?
Pain
Hypercalcaemia
Young
Prev depression
SOB end stage heart failure already on furosemide and morphine without clinical significant pulm oedema
Lorazepam
Mycobacterium avium infection Rx
Ethambutol + rifabutin +clari/azithro
[macrolide + quinolone should be avoided due to risk of developing resistance]
Bladder Ca that has invaded muscle rx? Which chemo in bladder cystectomy / metastatic disease
Radical cystectomy
+cysplatin chemo
Where are glioblastomas found
Cerebral hemispheres - white matter
Bone pain in metastatic breast Ca already on para/ibu/morphine
Bisphosphonates (usually IV zoledronate)
Bisphosphonates shown to improve bone pain and delay further mets
Most common met to bone?
Bronchial
[Breast
Prostate]
Classic chemo choice in Dukes colon ca
5-fluorouracil
Weight loss lethargy nighsweats. Progressive kidney disease + proteinuria.
Green birefringence after congo red staining. Positive for lambda light chains?
Myeloma with renal amyloidosis
NF2 most common tumour
Acoustic neuroma
Most common lung Ca in non smokers
Adenocarcinoma
What is the mutation that allows imatinib to work for GIST and CML?
Philadelphia
t (9:22)
[assoc with bcr-abl overexpression]
Imatinib - what is it inhibitng when used for GIST
c-kit inhibitor
[bcr-abl TK inhibition in CML]
fev1 requirement ability to tolerate pneumectomy
> 2L
[1.5L for lobectomy]
Conversion of morphine to fentanyl patch
100mg oral morphine
25ug/hr fent
150mg
37ug fent
Approx dive by 4 and convert to ug/hr
Subacute bowel obstruction in pal first line
Hyoscine
Do you need to start senna with opiate analgesia in pal care
Yes according to NICE
Cones and rods for dark / light vision? Retinitis pigmenosa has deficiency of what?
Rods - Dark
-Rhodopsin (night blindness)
Cones - light
[-Protein is coneopsin]
What is the gold standards framework
For patients with life limiting conditions
when fent over morphine
GFR <30
Most common site for lymphoma that isnt lymp node
Upper gi - Stomach