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Cancer care > Oncology > Flashcards

Oncology Flashcards

1
Q

What are the properties of cancer?

A
  • Self sufficiency in growth signals
  • Evading growth suppressors
  • Avoiding immune destruction
  • Enabling replicative immortality
  • Tissue invasion and metastasis
  • Inducing angiogenesis
  • Resisting apoptosis
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2
Q

What are some mechanisms of cancer cell resistance?

A 
Increased efflux
Decreased uptake
Increased drug metabolism
Alter drug targets
Inhibition of apoptosis
Alter cell cycle checkpoints
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3
Q

What cancers are AFP associated with?

A

Hepatocellular and testicular

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4
Q

What else can raise AFP apart from cancer?

A

Pregnancy and cirrhosis

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5
Q

What is the tumour marker for ovarian cancer?

A

CA125

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6
Q

What else can raise CA125 apart from cancer?

A

Liver disease, pancreatitis, pregnancy, heart failure, cystic fibrosis

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7
Q

What is CA19-9 associated with?

A

Pancreatic cancer, acute cholangitis, cholestasis, jaundice

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8
Q

What is the tumour marker for breast?

A

CA15-3

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9
Q

What else apart from prostate cancer can raise PSA?

A

BPH, DRE, recent ejaculation, UTI, BMI <25

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10
Q

What is the tumour marker for colorectal cancer?

A

CEA

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11
Q

What else can increase CEA levels?

A

Smoking, liver disease, CKD, diverticulitis, jaundice

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12
Q

Give 5 principles of screening

A
  • Important health problem
  • Recognisable latent or early symptomatic stage
  • Accepted treatment available
  • Cost effective
  • Acceptable to population
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13
Q

What is lead time bias?

A

Screening leads to earlier identification so there’s a longer perceived survival

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14
Q

What is length time bias?

A

Screening picks up less severe disease so there’s an improved perceived prognosis

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15
Q

What is a female’s risk of breast cancer?

A

1 in 8

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16
Q

What is the second most common cause of death from cancer?

A

Colorectal

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17
Q

Which is the most common invasive breast cancer?

A

Ductal carcinoma (around 70%)

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18
Q

What percentage of breast cancers are oestrogen receptor positive?

A

60-70% (better prognosis)

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19
Q

What percentage of breast cancers express HER2?

A

Around 30% (worse prognosis)

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20
Q

What are the risk factors for breast cancer?

A 
Female
Family history - BRCA1/BRCA2 mutations
Obesity
Nulliparity
Early menarche/late menopause
COCP/HRT use
Previous benign breast disease
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21
Q

What are the clinical features of breast cancer?

A 
Lump - painless, non mobile, hard, irregular
Nipple retraction
Nipple discharge
Skin tethering or dimpling
Axillary lump
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22
Q

What are some differentials for breast lumps other than cancer?

A

Fibroadenoma, lipoma, cyst

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23
Q

What is the triple assessment?

A

1) Clinical examination
2) Radiology - USS/mammography
3) Histology from US guided core biopsy or cytology from aspirate

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24
Q

Describe the TNM staging for breast cancer

A 
T1 = <2cm
T2 = 2-5cm
T3 = >5cm
T4 = skin/chest wall involved
N1 = 1-3 LNs
N2 = 4-9 LNs
N3 = >9 LNs

M0 =.no mets, M1 = mets

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25
Q

What is the surgical management of breast cancer?

A

Wide local excision (1cm margin) or mastectomy with reconstruction

Axillary node sampling or clearance or sentinel node biopsy

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26
Q

When is mastectomy preferred over WLE?

A
  • Multifocal disease
  • High tumour:breast tissue ratio
  • Disease recurrence
  • Patient choice
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27
Q

What are some chemotherapy agents used in breast cancer?

A

CMF - cyclophosphamide, methotrexate, 5FU

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28
Q

What hormone treatment can be used in breast cancer?

A

Tamoxifen in ER+ in premenopausal

Aromatase inhibitors eg anastrazole in postmenopausal

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29
Q

What immunotherapy can be used in certain breast cancers?

A

Herceptin (Trastuzumab) in HER2 positive (can cause cardio toxicity)

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30
Q

What is the Nottingham prognostic index?

A

NPI = (size*0.2) + nodal status + histological grade

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31
Q

Where can breast cancers metastasise?

A

Axillary nodes, bone, lung, liver, brain, adrenals, ovaries

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32
Q

What are some risk factors for prostate cancer?

A

Increasing age, afro-caribbean ethnicity, family history, BRCA2/BRCA1 gene, obesity, smoking, diabetes

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33
Q

What are the clinical features of prostate cancer?

A 
Hesistancy
Frequency
Urgency
Nocturia
Poor urinary stream
Terminal dribbling
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34
Q

What is the normal upper limit of PSA in people >70 years?

A

6.5ng/ml

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35
Q

What other investigations apart from bloods are required in prostate cancer diagnosis?

A

TRUS biopsy, MRI prostate

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36
Q

What is active surveillance in prostate cancer management?

A

3 monthly PSA, 6m-1 yearly DRE and rebiopsy at 1-3 yearly intervals

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37
Q

What is a radical prostatectomy?

A

Removal of the prostate gland, resection of the seminal vesicles and pelvic lymph node dissection

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38
Q

What are some side effects of radical prostatectomy?

A

Erectile dysfunction (60-90%)
Stress incontinence
Bladder neck stenosis

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39
Q

What radiotherapy options are available for prostate cancer?

A

External beam radiotherapy or brachytherapy

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40
Q

What are some side effects of radiotherapy to the prostate?

A

Urinary frequency, fatigue, cystitis, proctitis, problems with ejaculation, erectile dysfunction, skin irritation

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41
Q

What hormone therapies can be used in the treatment of prostate cancer?

A

Anti-androgens - GnRH antagonists eg goserelin

Enzalutamide and abiraterone

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42
Q

What is the most common cause of cancer deaths?

A

Lung cancer

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43
Q

What is the 5 year survival for lung cancer?

A

13%

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44
Q

What percentage of lung cancers are small cell?

A

20%

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45
Q

What is Lambert-Eaton syndrome?

A

Proximal arm and leg weakness due to autoimmune destruction of voltage gated calcium channels at the neuromuscular junction

Associated with small cell lung cancer

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46
Q

What paraneoplastic syndromes are associated with small cell lung cancer?

A

Cushings, SIADH, Lambert eaton

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47
Q

Which lung cancer cavities?

A

Squamous cell

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48
Q

What is squamous cell lung cancer associated with?

A

Hypercalcaemia due to secretion of PTHrp

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49
Q

Which lung cancer is more common in non smokers and asian females?

A

Adenocarcinomas

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50
Q

What is hypertrophic pulmonary osteoarthropathy and which cancer is it associated with?

A

Clubbing + arthritis + symmetrical periosteal formation

In 1% of those with adenocarcinoma of lung

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51
Q

What paraneoplastic syndrome is large call lung cancer associated with?

A

GnRH secretion - gynaecomastia

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52
Q

What do you see on CXR of mesothelioma?

A

Pleural thickening/plaques

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53
Q

What are the main risk factors for developing lung cancer?

A 
Smoking
Asbestos exposure
Increasing age
Male
Radon exposure
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54
Q

How does lung cancer present?

A 
Cough
Haemoptysis
Dyspnoea
Chest pain
Weight loss
Anaemia
Hoarse voice
Finger clubbing
Lymphadenopathy
Slow resolving pneumonia
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55
Q

What are some complications of lung cancer?

A 
Horners syndrome
Recurrent laryngeal nerve palsy
SVC obstruction
Pericarditis
Paraneoplastic syndromes
VTE
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56
Q

What is Horners syndrome?

A

Miosis, ptosis and anhydrosis

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57
Q

What would trigger the 2 week wait pathway for lung cancer?

A

If >40 with unexplained haemoptysis or findings on CXR

Urgent CXR if >40 with 2 red flags or one for smokers

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58
Q

What might you see on CXR with lung cancer?

A

Nodules, masses, pleural effusions, lung collapse, hilar enlargement

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59
Q

Outline the TNM staging for lung cancer

A

I - one small tumour (<4cm) localised to 1 lung
II - tumour >4cm - may have spread to local LNs
III - spread to contralateral LNs or nearby structures
IV - LNs outside chest or other organs

N1 - ipsilateral hilar
N2 - ipsilateral mediastinal
N3 - contralateral mediastinal
N4 - other side of the diaphragm

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60
Q

What chemotherapy is given in lung cancer?

A

Usually 4 cycles of cisplatin, gemcitabine

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61
Q

What immunotherapy can be given in lung cancer?

A

Pembrolizumab - targets immune checkpoint

62
Q

What is the 5 year survival for NSCLC?

A

10-13%

63
Q

What is the prognosis of small cell lung cancer

A

3 months if untreated, 1.5 years if treated

64
Q

Where does lung cancer often spread?

A

Liver, bone, pleura, brain, adrenals

65
Q

What percentage of people with colorectal cancer have a family history?

A

Around 25% (5% have identified mutations)

66
Q

What is familial adenomatous polyposis?

A

Autosomal dominant mutations in the APC tumour suppressor gene

67
Q

What cancers are implicated in Lynch syndrome?

A

Colorectal, endometrial, ovarian, urinary tract, stomach, small bowel, HPB

68
Q

What are some inherited causes of colorectal cancer?

A

FAP, Lynch syndrome, Peutz-Jeghers syndrome

69
Q

What are some risk factors for colorectal cancer?

A 
Inherited mutations
Low fibre, high fat diet
Red processed meat consumption
IBD
Smoking
Alcohol
70
Q

How does a left colon cancer present?

A

PR bleeding+mucous, altered bowel habit, tenesmus, constipation, obstruction

71
Q

How does a right colon cancer present?

A

Weight loss, Fe deficiency anaemia, abdominal pain, less likely obstruction

72
Q

How does a rectal cancer present?

A

PR bleeding, tenesmus, PR mass, obstruction

73
Q

When would a 2 week referral be appropriate in colorectal cancer?

A

> 40 and unexplained weight loss/adbominal pain
50 and PR bleeding
60 and anaemia or change in bowel habit

74
Q

When would you refer within 2 weeks in breast cancer?

A

30yo and unexplained breast lump
>50yo with one nipple discharge/retraction/other concerning changes
Consider if >30yo with unexplained lump in axilla

75
Q

What investigations could you use in colorectal cancer?

A 
FBC, LFTs, U+Es, CEA, FOB
Sigmoidoscopy or colonoscopy + biopsy
CT colon
CT C/A/P
Barium enema - apple core
76
Q

Outline the TNM staging for colorectal cancer

A 
T1 = invading submucosa
T2 = invading muscular propria
T3 = invading subserosa and beyond (not other organs)
T4 = Invasion of adjacent structures

N1 = 1-3 nodes, N2 = >3 nodes

77
Q

When would you do a right hemicolectomy?

A

Caecal tumours or ascending colon tumours

78
Q

Screening for colorectal?

A

In England and Wales, screening is offered every 2 years to men and women aged 60-75 years. For most of the UK, a faecal immunochemistry test (FIT) is used, superseding the previous faecal occult test, which utilises antibodies against human haemoglobin to detect blood in faeces

79
Q

When would you do a left hemicolectomy?

A

Descending colon tumours

80
Q

When would you do a sigmoidectomy

A

Sigmoid tumours

81
Q

When would you do an anterior resection?

A

Rectal (high) tumours

82
Q

When would you do an AP resection?

A

Low rectal tumour within 5cm of anus

83
Q

What chemotherapy regime is used in colorectal cancer?

A

FOLFOX

Folinic acid, Fluorouracil (5-FU), and Oxaliplatin

84
Q

What biological agents can be used in colorectal cancer?

A

Cetuximab, bevacizumab (anti VEGF), panitumumab (EGFR antagonist)

85
Q

What are some side effects of cetuximab?

A

Acneform rash, skin toxicity, pruritus, hair growth disorders, fatigue

86
Q

Which tumours are highly sensitive to chemotherapy?

A

Lymphomas, germ cell tumours, small cell lung, neuroblastoma, Wilm’s tumour

87
Q

Which tumours show modest sensitivity to chemotherapy?

A

Breast, colorectal, bladder, ovary, cervix

88
Q

Which tumours show low sensitivity to chemotherapy?

A

Prostate, renal cell, brain tumours, endometrial

89
Q

Give 2 examples of antimetabolites

A

Methotrexate and 5-FU

90
Q

How do antimetabolites work?

A

Interfere with DNA synthesis

91
Q

How does 5-FU work?

A

Inhibits thymidylate synthase so interrupts pyrimidine synthesis

92
Q

How does methotrexate work?

A

Inhibits dihydrofolate reductase so interferes with the folate cycle that forms purine

93
Q

Give 3 examples of alkylating agents

A

Carmustine, cyclophosphamide, chlorambucil

94
Q

How do alkylating agents work?

A

Interfere with DNA replication

95
Q

Give 3 examples of platinum compounds

A

Cisplatin, oxaliplatin, carboplatin

96
Q

How do platinum compounds work?

A

Alkylating-like – Interfere with DNA replication

97
Q

Why has oxaliplatin been more effective than cisplatin in some tumours?

A

Has a bulky DACH side group which forms covalent bonds with the cell constituents to prevent DNA replication - harder for repair processes to ligate out

98
Q

Give 2 examples of intercalating agents

A

Doxorubicin, daunorubicin - inhibit DNA replication

99
Q

Give 2 examples of spindle poisons

A

Vincristine and vibnlastine

100
Q

How do vinca alkaloids work?

A

Prevent spindle formation

101
Q

Explain some mechanisms of resistance in alkylating agents

A

Decreased entry and increased exit of drug
Inactivation of drug in the cell
Enhanced DNA repair

102
Q

List some side effects of chemotherapy

A 
Alopecia
Mucositis
Pulmonary fibrosis
Cardiotoxicity
Nausea and vomiting
Diarrhoea
Cystitis
Inferitility
Renal failure
Myalgia
Myelosuppression
Peripheral neuropathy
Fatigue
Phlebitis
103
Q

In what chemo drugs is alopecia a big side effect?

A

Doxorubicin, vincristine, cyclophosphamide

104
Q

What are the lines called on nails that are a side effect of chemo?

A

Beau’s lines

105
Q

Which chemo drugs can cause cardiomyopathy?

A

Doxorubicin, high dose cyclophosphamide

106
Q

Which chemo drugs can cause arrhythmias?

A

Cyclophosphamide, etoposide

107
Q

Which chemo drugs can cause pulmonary fibrosis?

A

Bleomycin, mitomycin c, cyclophosphamide, chlorambucil

108
Q

Certain chemotoxicity:

Cisplatin + carboplatin?

A

Ototoxicity, nephrotoxicity

109
Q

Certain chemotoxicity:

Vincristine?

A

Peripheral neuropathy

110
Q

Certain chemotoxicity:

Doxorubine and transtuzumab (Herceptin)?

A

Cardiotoxicity

111
Q

Certain chemotoxicity:

Cyclophosphamide?

A

Haemorrhage cystitis

112
Q

Certain chemotoxicity:

Methotrexate + 5FU?

A

Myelosuppression

113
Q

What can cause variability in pharmacokinetics of chemo?

A

ABNORMALITIES IN ABSORPTION
- nausea and vominting, gut problems

ABNORMALITIES IN DISTRIBUTION
- weight loss, reduced body fat, ascites

ABNORMALITIES IN ELIMINATION
- liver and renal dysfunction eg mets

ABNORMALITIES IN PROTEIN BINDING
- low albumin, other drugs

114
Q

What can vincristine and itraconazole cause?

A

More neuropathy

115
Q

What is an important drug interaction of capecitabine (oral 5FU)?

A

Warfarin, St John’s wart and grapefruit juice

116
Q

What are important drug interactions of methotrexate?

A

Penicillin and NSAIDs

117
Q

Over how long is a course of radical radiotherapy?

A

4-7 weeks

Low daily dose, high total dose

2Gy/day for 37d = 74Gy

118
Q

Over how long is a course of palliative radiotherapy?

A

1-10 daily treatments

Higher daily dose

4Gy day for 5d = 20Gy

119
Q

What are some early side effects of radiotherapy?

A 
Tiredness
Skin - erythema, desquamation, ulceration
Mucositis
N+V
Diarrhoea
Cystitis
Proctitis
Haematuria
Erectile dysfunction
\:ymphoedema
120
Q

What are some late side effects of radiotherapy?

A

Skin - pigmentation, necrosis, ulceration, telangiectasia

CNS/PNS - tsomnolence, spinal cord myelopathy, brachial plexopathy

Lung - pneumonitis, fibrosis

GI - strictures, adhesions, fistulae, mouth ulcers, dry mouth

Eyes - cataracts, sight loss

GU - frequency, dyspareunia, erectile dysfunction, infertility

SECONDARY CANCERS!

121
Q

What cancer is Ipilimumab used in?

A

Melanoma - targets CTLA-4

122
Q

Which cancer is rituxumab used in?

A

Non Hodgkins as part of RCHOP

123
Q

When is pembrolizumab used?

A

GU cancer, H+N cancer, lung?

124
Q

What does pembrolizumab block?

A

PD-1/PD-L1 checkpoint inhibitor

Restores anti tumour immunity

125
Q

What are PD-1 and PD-L1 checkpoint inhibitors?

A

Pembrolizumab, nivolumab

126
Q

What is Ipilimumab?

A

Fully human anti-CTLA-4 monoclonal antibody

  • Negative regulator of T-cell activation.
  • T-cell potentiator- blocks the inhibitory signal of CTLA-4
  • T-cell activation, proliferation, & inflammation
  • Tumour cell death
127
Q

What are side effects of immunotherapy?

A

All the itis’

Hepatitis, dermatitis, diarrhoea, abdominal pain, pruritus, Stevens Johnson syndrome, paraesthesias, conjunctivitis, episcleritis, nephritis, pneumonitis

128
Q

What are some side effects of pembrolizumab?

A 
Fatigue
• Pruritus
• Nausea
• Decreased appetite
• Peripheral oedema
• Oral mucositis
Immune-related effects:
 • Pneumonitis (2.9%)
• Colitis (1%)
• Hepatitis (0.5%)
• Nephritis (0.7%) • Hypothyroidism
129
Q

How can you manage liver mets?

A

Surgical resection
 Microwave ablation
 Radiofrequency ablation
 Radiofrequency-assisted liver resection
 Selective internal radiation therapy (SIRT)

130
Q

What is the prognosis of colorectal cancer?

A

Stage I – 85-95%
Stage II – 60-80%
Stage III – 30-60%
Stage IV – 7%

131
Q

How does neutropenic sepsis present?

A

Fever >38 or >37.5 for >1 hour

Neutrophils < 0.5

Cough, SOB, GU Sx, confusion

132
Q

In the majority of culture positive cases of neutropenic sepsis, which type of organism are responsible?

A

Gram positive cocci - staph aureus, staph epidermis, strep pneumoniae

133
Q

How do you treat neutropenic sepsis?

A

Tazocin 4.5mg TDS or meropenem 1g TDS IV stat

134
Q

What percentage of patients with cancer will present with Hypercalcaemia?

A

10-20% (40% in myeloma)

135
Q

What are the mechanisms of Hypercalcaemia in malignancy?

A
  • Tumours release humeral factors eg release of PTHrp or calcitriol
  • Tumours release cytokines which promote local osteolysis
136
Q

How does Hypercalcaemia present?

A

Polydipsia, polyuria, anorexia, N+V, costipation, abdominal pain, confusion, fatigue, bone pain

Weight loss, dehydration, bradycardia, osteopenia

137
Q

How do you investigate Hypercalcaemia?

A

Bone profile - serum calcium (adjusted >2.6), serum phosphate, ALP, albumin, total protein

U+Es

PTH/rp

Myeloma screen

ECG

138
Q

How do you manage Hypercalcaemia?

A

Rehydration with IV fluids

IV bisphosphonates eg zolendronic acid (inhibits osteoclasts)

Could also use calcitonin, octreotide, denosumab

139
Q

What percentage of cancer patients experience MSCC?

A

5%

140
Q

How does MSCC present?

A

Back pain - doesn’t relieve with rest even at night, exacerbated by exertion, thoracic or cervical spine location

Neurological deficit - muscle weakness, altered sensation, bladder/bowel dysfunction

141
Q

Which is the most common location for MSCC?

A

Thoracic (70%)

142
Q

How do you investigate MSCC?

A

Whole spine MRI

143
Q

How do you manage MSCC?

A

Lie patient flat with neutral spine

Dexamethasone 16mg stat (then 8mg BD+PPI)

Analgesia, VTE prophylaxis, surgery, radiotherapy

144
Q

What electrolyte abnormalities are seen in tumour lysis syndrome?

A

Hyperuriciaemia
Hyperkalaemia
Hyperphosphataemia
Hypocalcaemia

145
Q

How does tumour lysis present?

A

Low urine output, confusion, lethargy, muscle weakness, reduced GCS, seizures, palpitations, cardiac arrest

146
Q

What are some risk factors for tumour lysis

A

Haematological cancers, high pretreatment LDH and rate, renal impairment

147
Q

How do you investigate tumour lysis?

A

Urine dip + MSU
U+Es
LDH, urate and lactate
ECG

148
Q

How do you manage tumour lysis?

A

A-E - IV Fluids
Calcium glutinate, insulin/dextrose for high K+
Phosphate binders
Rasburicase and allopurinol for high urate

149
Q

How can SVCO present?

A 
Facial swelling, neck and arm swelling
SOB/orthopnoea/stridor/cyanosis
Distended neck and chest wall veins
Non pulsatile raised JVP
Lethargy
Headache
150
Q

How do you manage SVCO?

A 
Sit patient upright
O2 if needed
Dexamethasone 16mg/24h
Radiotherapy in some lung cancer cases
Chemotherapy in chemosensitive
Stenting
Anticoagulation

Cancer care (3 decks)

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