Oncology Flashcards
Define generalised lymphadenopathy
Enlarged lymph nodes in 3 or more non-contiguous areas.
Almost always indicates presence of significant systemic disease
Where are palpable lymph notes normal in healthy children (3)
. Anterior cervical
. axillary
• inguinal
How describe characteristics of lymph nodes (7)?
- Site
- consistency
- Mobile vs fixed/matted
- tender vs painless
- clearly demarcated
- size
- duration and rate growth
When worry about size of lymph node? (3)
1,5-2 cm in size
Epitrochlear notes > 0,5cm
Inguinal > 1,5cm
Right supraclavicular lymph node significance? (3)
• Cancer in mediastinum
• lungs
• esophagus
Left supraclavicular lymph node significance? (7)
= Virchow’s node
• testes
• ovaries
• kidneys
• pancreas
• stomach
• gallbladder
• prostate
Paraumbilical lymph node significance? (2)
= sister Joseph’s
• abdominal neoplasm
• pelvic
What does lymphadenopathy of >4 weeks indicate? (3)
• Chronic infection
• collagen vascular disease
• malignancy
What do hard lymph nodes indicate?
Cancer infiltration
What do rubbery lymph nodes indicate?
Lymphoma
What do matted lymph nodes indicate?
Tb
Name 7 differences between benign and malignant lymphadenopathy
- <2 cm (1) vs >2
- soft vs hard, firm, rubbery
- <2 weeks vs > 2 weeks
- mobile vs fixed
- surroundings not attached vs attached (invasion)
- inguinal, submandibular vs supraclavicular epitrochlear or generalised
- lender vs non lender
Name 4 causes localised lymphadenopathy
- Local infection in draining area
-Metastasis - lymphoma: Hodgkin’s disease
- Scrofuloderma (TB skin)
Name 5 broad causes generalised lymphadenopathy with 2 specific examples
• Infections
→ viral: EBV, CMV, infectious mononucleosis , HIV
→ bac: tb, brucellosis,chancroid (usually localised)
→ parasite: toxoplasmosis, leishmaniasis, trypanosomiasis
→ fungal: histoplasmosis,coccidioidomycosis
→ chlamydia: lymphogranuloma venereum (usually localised),
• malignant
→ hematological: hodgkins disease, non-hodgkin’s lymphoma, acute and chronic leukaemias
→ metastatic
• connective tissue disorder: SLE,rheumatoid arthritis, mctd
• infiltrative: sarcoidosis , histiocytosis x
• other rare: drugs eg phenytoin, mucocutaneous LN disease (Kawasaki disease)
Name 4 indications for lymph node biopsy
- Increase in size over baseline in 2 weeks
- no decrease in size in 4-6 weeks
- no regression to normal in 8-12 weeks
- develop new signs and symptoms
- preferred nodes: supraclavicular, cervical, axillary
Approach to acute ( <2 week) lymphadenopathy
• low clinical risk: clinical diagnosis
• high clinical risk: FNA
→ if no diagnosis, do excision biopsy
Approach to chronic ( > 2 week) lymphadenopathy
• Low clinical risk: additional labs eg FBC, ESR, CXR, lactate dehydrogenase, uric acid, lft…
• high risk: FNA
→ if no diagnosis, do excision biopsy
Name 11 red flags for childhood cancer <15
CHILD CANCER
- contusions/ bruising, bleeding, rash
- headaches, often with vomiting - early night / morning
- inflammation/ swelling or pain in bones, joints, back, legs
- lump/mass abdomen, neck, chest,pelvis, armpits
- decreasing weight: continuous, unexplained
- colour whitish behind pupil
- anemic: constant tired or pale
- nausea that persists, or vomiting without nausea ; neurological signs
- constant infections
- eye or vision changes that occur suddenly and persists eg squint, blind, bulge
- Recurrent fevers of unknown origin
Name 2 causes febrile neutropenia and sepsis
• Disease eg leukemia, bone marrow infiltration
. Myelo suppression caused by chemo (most marked 5-10 days after admin)
Name 5 important sites of infection in neutropenia
• oral mucosa and mouth
• pharynx, lower esophagus
• lungs,
• skin, esp vascular access sites
• perineum and anus
Management febrile neutropenia and sepsis? (5)
• FBC, diff, platelets; UKE, CRP, blood culture, urine analysis
• CXR
• start empiric broad spectrum antibiotics immediately to cover g+ and esp G - (g- sepsis can be fatal within hours!)
-First line tazocin (piperacillin/tazobactam) 90 mg /kg / dose iv 6 hourly and amikacin 15 mg/kg / day iv daily.
-If evidence infection central line or no improve after 48 hours ,, add vancomycin 10 mg /kg / dose 6 hourly
Define acute and delayed nausea and vomiting post chemo
• acute 6-12 hours after admin
• delayed 24 hours or more, especially cisplatin
What nausea and vomiting prophylaxis should be given to all patients receiving ematogenic chemo and patients receiving total body, cranial and abdominal radiation?
Odansetron (zofran) 0,15 mg /kg / dose iv 8-12 hourly
Or
Granisetron (kytril) 1-3 mg iv daily before chemo
Rescue treatment for breakthrough acute and delayed nausea and vomiting post chemo?
(4)
Add stepwise:
- odansetron or kytril as with prophylaxis
- dexamethasone 10mg once daily
-Lorazepam (Ativan) 0,025 mg / kg iv 6 hourly
- metoclopramide (maxolon)
Management epistaxis in cancer children? (6)
Medical emergency!
- ABC
- insert bismuth iodoform paraffin paste (BIPP) pack
- cykclokapron 15-25 mg/kg 2-4 x/day (tranexamic acid)
-Platelet transfusion 15-20 ml/ kg over 30-60 min
-FFP transfusion as above
-Packed RBC 15-20 ml/ kg over 4h
Management epistaxis in cancer children? (6)
Medical emergency!
- ABC
- insert bismuth iodoform paraffin paste (BIPP) pack
- cykclokapron 15-25 mg/kg 2-4 x/day
-Platelet transfusion 15-20 ml/ kg over 30-60 min
-FFP transfusion as above
-Packed RBC 15-20 ml/ kg over 4h
Name 6 metabolic features tumour lysis syndrome
• HyperuricaeMia
• hyper K
• hyper p
. Hypo or hyper Ca
• renal failure , cardiac arrythmias, seizures, coma, DIC, death
Management tumour lysis syndrome?(5)
- Hydration: 3000 ml / m2/day of K free solution (grs )
- maintain urine output 3-6 ml/kg/h , strict measure input and output, lasix to induce diuresis if needed
- inotropes if indicated
- alkalanize urine to keep ph 6,5 - 7,5
- allopurinol 10 mg/kg 8 hourly
Management hyper K? (6)
• Stop all K iv and po
• nahco3 1-2 mmol/kg iv to drive k intracellular
• insulin and glucose: dextrose 0,5 g/kg /h with insulin 0,1 u / kg /h
• Ca gluconate
• kayexelate
• dialysis if fail
Management hypo k?
<3 MMOl/ L: replace iv total of 40 MMOl in 1000 ml
> 3: po
When transfuse with packed cells? (3)
15-20 ml/kg over 4 hours
- Hb <6,5 g/L in asymptomatic
- hb <8 in symptomatic eg evidence CCf, oxygen dependent, sepsis
- hb <10 in certain situations eg major surgery, AML M3 with initiation therapy
When transfuse with platelets? (2)
- Platelets <10x10 ^ 9 / L in asymptomatic
- <50 prior to procedure eg lp, tru-cut biopsy, minor surgery, active bleed (epistaxis), AML with start treatment
When transfuse with FFP?
15-20 ml/kg over 30 -60 min of leucodepleted
DIC (elevated D dimer ) secondary to severe sepsis, acute leukemia esp AML M3
What causes loss of the eye’s red reflex?
Neuroblastoma
Which enlarged lymph nodes are most suggestive of malignancy?
Supra clavicular
Name 3 warning signs intra-cranial tumour
- Acute hemiparesis
- Chronic headache
- macrocephaly in infants
- vomiting without nausea
Which viral infection causes large tender cervical lymph nodes
EBV
