Oncology Flashcards
Cancers that spread to bone
Prostate
Breast
Bone
Most common sites of bony metastases
spine
pelvis
ribs
skull
long bones
Features of bony metastases
Bone pain
Pathological fractures
Hypercalcaemia
Raised ALP
Features of endocervical cells that have become koilocytes
enlarged nucleus
irregular nuclear membrane contour
the nucleus stains darker than normal (hyperchromasia)
a perinuclear halo may be seen
Treatment of chemotherapy induced nausea and vomiting
Low risk- metoclopramide 1st line
High risk- Ondansetron (5HT3 receptor antagonists), combined with dexamethasone
Cyclophosphamide
an alkylating agent used in the management of cancer and autoimmune conditions. It works by causing cross-linking of DNA
Adverse effects of cyclophosphamide
haemorrhagic cystitis: incidence reduced by the use of hydration and mesna
myelosuppression
transitional cell carcinoma
Mesna
-2-mercaptoethane sulfonate Na
-a metabolite of cyclophosphamide called acrolein is toxic to urothelium
-mesna binds to and inactivates acrolein helping to prevent haemorrhagic cystitis
Cytotoxic Agents
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Genetics and surgical disease
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Immune checkpoint inhibitors
T-cells are an important part of our immune system which help destroy cancer cells. Some cancer cells make high levels of proteins that turn T-cells off. Checkpoint inhibitors block this process and reactivate and increase the body’s own T-cell population, enhancing the immune systems own ability to recognise and fight cancer cells.
All CTLA-4 inhibitors and PD-1/PD-L1 inhibitors currently available are monoclonal antibodies
Immune checkpoint inhibitor side effects
Dry, itchy skin and rashes (most commonly)
Nausea and vomiting
Decreased appetite
Diarrhoea
Tiredness and fatigue
Shortness of breath and a dry cough.
Management of such side effects reflects the inflammatory nature, often involving corticosteroids.
Investigating metastatic disease on unknown primary
FBC, U&E, LFT, calcium, urinalysis, LDH
Chest X-ray
CT of chest, abdomen and pelvis
AFP and hCG
NB- then further imaging depending on the patient eg. mammography, PSA etc.
Metastatic spinal deposits and location of the lesion
neurological signs depend on the level of the lesion. Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level. Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion
NB- whole spine MRI within 24 hours, high dose dexamethasone
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 of SVC obstruction
Management is dependant on the individual patient and malignancy and advice should be taken from the oncology team. Options include:
-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
Tumour markers
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When is neutropenic sepsis most likely to occur?
7-14 days after chemotherapy
Neutropenic sepsis prophylaxis
if it is anticipated that patients are likely to have a neutrophil count of < 0.5 * 109 as a consequence of their treatment they should be offered a fluoroquinolone eg. Ciprofloxacin
Management of neutropenic sepsis
Sepsis 6 (take blood cultures before ABX (and any other cultures eg. catheter, central line)), CXR, ABG etc.
antibiotics must be started immediately, do not wait for the WBC
NICE recommends starting empirical antibiotic therapy with piperacillin with tazobactam (Tazocin) immediately (or meropenem)
Causes of hypercalcaemia in malignancy
This may be due to number of processes, including; bone metastases, myeloma, PTHrP from squamous cell lung cancer
Features of hypercalcaemia
‘bones, stones, groans (abdo pain and constipation) and psychic moans’
corneal calcification
shortened QT interval on ECG
hypertension
Management of hypercalcaemia
IV fluid rehydration
Bisphosphate
Denusomab
Treat the malignancy
What is tumour lysis syndrome
TLS occurs from the breakdown of the tumour cells and the subsequent release of chemicals from the cell (usually lymphomas and leukaemia’s). It leads to a high potassium and high phosphate level in the presence of a low calcium. It should be suspected in any patient presenting with an acute kidney injury in the presence of a high phosphate and high uric acid level.
Clinical diagnosis of tumour lysis syndrome
Clinical tumor lysis syndrome: laboratory tumour lysis syndrome plus one or more of the following:
increased serum creatinine (1.5 times upper limit of normal)
cardiac arrhythmia or sudden death
seizure
Prophylaxis of tumour lysis syndrome
Patients at high risk of TLS should be given IV allopurinol or IV rasburicase immediately prior to and during the first days of chemotherapy
Management of tumour lysis syndrome
IV saline (rehydration)
Phosphate binder (aluminium hydroxide)
Allopurinol (or rasburicase, not together)
Hyperkalaemia- calcium gluconate etc.
Li-Fraumini syndrome
Autosomal dominant
Consists of germline mutations to p53 tumour suppressor gene
High incidence of malignancies particularly sarcomas and leukaemias
BRCA1/2
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
Lynch syndrome
Autosomal dominant
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
Gardner’s 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
Metastatic spinal cord compression (MSCC)
Features;
back pain
the earliest and most common symptom
may be worse on lying down and coughing
lower limb weakness
sensory changes: sensory loss and numbness
neurological signs depend on the level of the lesion. Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level. Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion
Whole spine MRI <24 hours
Mx- high dose PO dexamethasone and urgent discussion with neurosurgeons
NB- back pain, lower limb weakness and sensory loss, needs urgent MRI
