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oncology Flashcards

1
Q

what is the WHO performance status

A

0 - fit and well, no restrictions
1=restricted in physcially streneuous activity but ambulatory and able to carry out light work
2=ambulatory and capable of self care but unable to carry out any work activities. up and about 50% of waking hours
3=capable of limited selfcare, confined to bed or chair for more than 50% of time
4=completely disabled, cannot carry out selfcare, completely confined to bed/chair
5=dead

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2
Q

how does chemo work

A

damages dna
direct - binds
indirect - affects dna replication/mitosis

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3
Q

e.g. chemo agents

A

alkylating
antimetbaolites
anthracyclines
taxanes
platinums
topoisomerase i

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4
Q

how does radiotherapy work

A

use of high energy XR to destroy cancer cells

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5
Q

how does immunotherapy work

A

systemic agents that aim to stimulate a patiejts own immune system to attack cancer cells
e.g. checkpoint i, monoclonal ab

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6
Q

how do targeted agents work and e.g.

A

systemic therapoy
inhibit specific targets involved in cell replication etc
e.g. tyrosine kinase i

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7
Q

what are tx related oncological emergencies

A

cytopenia - neutropenic sepsis
electrolyte disturbance - hypercalcaemia
tumour lysis syndrome
diarrhoea
vomiting
anaphylaxis
extravasation
radiotherapy se

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8
Q

what are tumou related oncological emergencies

A

spinal cord compression
SVCO
upper airway obstruction
brain mets
bowel obstruction

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9
Q

what are cancer cells

A

undergo uncontrolled and unregulated cell proliferation with the abiliity to move to other places in theo body

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10
Q

cell cycle

A

G0 = rest
G1 = pre DNA synthesis
S= DNA synthesis
G2 = post DNA synthesis
M = mitosis

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11
Q

systemic anticancer tx

A

chemo
hormone
molecular - inhibitors, monoclocal ab, immunotherapy

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12
Q

SE chemo

A

HF
immune supprssion
alopecia
renal impairment
skin rashes
bowel upset
peripheral neuropathy
taste changes
hepatic impairment
nasuea

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13
Q

diagnosis neutropenic sepsis

A

temp >38 and neutrophil count <1 x10 to the 9

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14
Q

presentation neutropenic sepsis

A

Any infective symptoms or signs, with or without fever
 Asymptomatic yet febrile
 Suspect in any patients presenting with a new clinical deterioration9 within 6 weeks
of cytotoxic chemotherapy
 Associated risk factors; poor nutritional, mucosal barrier defect, central venous lines,
abnormal host colonisation

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15
Q

ix neutropenic sepsis

A

U+E, creatinine, LFT, CRP/ESR, coag screen
 Septic screen; Blood cultures, clinically relevant swabs or cultures, CXR

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16
Q

mx neutropenic sepsis

A

Initial Antibiotic Therapy: initial empirical antibiotics (Piperacillin with tazobactam) to all patients within 1hr. Do not wait for the results of blood tests before administering antibiotics.

Switch to oral antibiotics after 24-48 hours of IV treatment if the patient is clinically
improving.

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17
Q

prevention neutropenmic sepsis

A

prophylaxis with a fluoroquinolone antibiotics, anti-
fungals or Granulocyte colony-stimulating factor (G-CSF).

 In the palliative setting chemotherapy doses may be reduced with subsequent cycles

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18
Q

causes malignant hypervcalcaemia

A

Osteolysis (lytic bone metastases)
 Humoral (PTHrP in squamous cell lung ca)
 Dehydration
 Other tumour specific mechanisms

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19
Q

presnetation malignant hypercalcaemia

A

BONES, STONES, GROANS AND PSYCHIC MOANS
 GI: abdominal pain, vomiting, constipation, anorexia, weight loss
 GU: polyuria, polydipsia
 Neuro: fatigue, weakness, confusion
 Psych: depression

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20
Q

ix malignant hypercalcaemia

A

Repeat blood sample, PTH
 ECG (shortened QT interval)
 Imaging for bone mets if appropriate

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21
Q

mx malignant hypercalcaemia

A

0.9% saline 4-6L
IV bisphosphonates-zolendronic acid

For persistent or relapsed hypercalcaemia of malignancy
o Denosumab: human monoclonal antibody that inhibits RANK ligand.

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22
Q

causes malignant spinal cord compression

A

Malignancy
o Primary
o Secondary – most common cause e.g. Prostate, Lung, Breast
 Mechanism = Crush fracture, soft tissue tumour extension

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23
Q

presentation malignant spinal cord compression

A

Worsening back pain
 Limb weakness below level of compression
 Sensory loss (sensory level present) below level of compression
 Bowel or bladder dysfunction - LATE sign, do not wait for this
 Radicular pain
 Abnormal neurological examination
o Causes lower motor neurone signs at the level of the lesion and upper motor
neurone signs below that level.14

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24
Q

ix malignant spinal cord compression

A

MRI WHOLE Spine; patient may have multiple levels of compression which require
treatment

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25
mx malignant spinal cord compression
High-dose corticosteroids, analgesia, VTE prophylaxis definitive: surgfery, radio, chemo,
26
causes superior vena cava obstruction
Inside the vessel o Thrombus o Intravascular device  Inside the vessel wall o Direct tumour invasion  Outside the vessel o Tumour; Lung cancer, Lymphoma, Germ cell tumours o Fibrosing mediastinitis
27
sx SVCO
Dyspnoea Chest pain, often at rest Cough Neck and face swelling Arm swelling Others – dizziness, headache, visual disturbance, nasal stuffiness, syncope
28
signs SVCO
Dilated veins over arms, neck and anterior chest wall Oedema of upper torso, arms, neck and face Severe respiratory distress Cyanosis Engorged conjunctiva Convulsions and coma
29
ix SVCO
May be clinical diagnosis  CXR (widened mediastinum or a mass on the right side of the heart)  CT scan
30
mx SVCO
High-dose steroids can be useful in acute SVCO  Endovascular stenting  Also consider: Chemotherapy, Radiotherapy, Anticoagulation; if central vein thrombosis is present
31
what is ionising radiation
enough energy to detach electrons damages DNA
32
what is radiotherapy
use of high energy XR/ionising radiation in carefully measured doses to damage and destroy cancer cells
33
what is a neo-adjuvant
aims to decrease the size or extent of disease prior to radical tx
34
what is an adjunvant
aims to target micro-meastatic disease reduce risk of local recurrnce
35
what is radical tx
aiming for cure sometimes refers to high/curative dose
36
general SE radiotherpay
sunburn type effects late = scarring
37
SE head and neck radiotherapy
acute: stomatitis, odynophagia, dysphagia, sore and red broken skin, xerostomia, dysgeusia, fatigue late: long term xerostomia, dysphagia, skin fibrosis/telangiectasia, dental problems
38
SE prostate cancer radiotherpay
acute: dysuria, urinary freq/urg. diarrhoea, fatigue late: long term bladder/rectile/erectile dysfunt,
39
preventing anaphylaxis with chemo
high dose steroid IV/PO antihitamine slower rate of infusion
40
mx coronary artery spasm due to chemo
stop infusion nitrates
41
features coronary artery spsm due to chemo
features ACS
42
common antiemetics used for N+V in chemo
metoclopramide, ondansetron
43
mx constipation caused by chemo
excude infection/obstruction loperamide, laxatives
44
features bone marrow suppression
thrombocytopenia anaemia neutropenia
45
mx fatigue/reduced appetite due to chemo
can give steroids but risk
46
mx alopecia due to chemo
cold caps wigs
47
late effects of chemo
infertility early menopase atherosclerosis heart failure lung damage chemo brain secondary cancers
48
TNM staging
T=tumour size, 1-4 N=nodes M=metastases
49
multiple myeloma
neoplastic proliferation of bone marrow plasma cells
50
characteristics multiple myeloma
monoclonal protein in serum or urine lytic bone lesions/CRAB end organ damage excess plasma cells in bone marrow
51
common presenting features myeloma
tired bone/back pain +/- fractures infections lab: anaemia, renal failure, hypercalcaemia, raised globulins, rasied esr, serum/urien paraprotein
52
myeloma blood film
rouleaux
53
tx myeloma
cytotoxic: radiotherapy, chemo supportive
54
what is acute leukaemia
proliferation primitve precursor cells usually only found in bone marrow proliferation without differentiation replaces normal bone marrow cells
55
what is acute lymphoblastic leukaemia
malignant proliferation of lymphoblasts in bone marrow affects mainly children
56
tx acute lymphoblastic leukaemua
induction chemo consolidation chemo +/- craniospinal irradiation maintenance chemo bone marrow transplant if relapse
57
what is acute myeloid leukaemia
malignant proliferation of myeloblasts in bone marrow affects mainly adults
58
chronic lymphocytic leukaemia
proliferation mature lymphocytes, usually B cels affects elderly
59
chronic myeloid leukaemiakey features
high white cell count and splenomegaly philadelphia chromosome chronic, accelerate, blast crisis
60
tx chronic myeloid leukaemia
imatinib allogeneic stem cell transplant
61
myelodysplasia
premalignant condition of haemopoietic precursors disease of elderly can be asx or anaemia can transform to acute myeloid leukaemia
62
tx myelodysplasia
support bone marrow transplant in young
63
presentation hodkin lymphoma
painless lymphadenopathy B sx: sweats, wt loss, fever 15-35y, >55y reed sternberg cells
64
mx hodgkins lymphoma
chemo, radiotherapy, stem cell transplant
65
features low grade non hodgkin lymphoma
e.g. follicular gradual onset may be asx incurable
66
features high grade non hodgkin lymphoma
e.g. diffuse large B cell rapidly progressive sx potentially curable
67
sx myeloma
lytic lesions in bones - pain hypercalcaemia- thirst, polyurea, confusion, constipation hyperviscosity renal failure anaemia infections
68
what is lymphoma
malignant growth wbc usually in lymph nodes also in blood, bone marrow, liver, spleen
69
diagnosing lymphoma
blood film and bone marrow lymph node biopsy immunophenotyping PET for staging
70
common presentation acute leukaemia
anaemia: tired, fatigue, lightheaded, palpitaiton,s sob thrombocytopenia: bruising, bleeding WCC: infection extramedullary disease coagulopathy -DIC
71
blood film on acute myeloid leukaemia
increased blast cells
72
ix in leukaemia
FBC blood film haematinics, haemolysis screen, LFTs, U+Es
73
how are brain tumours classified
not using tnm use WHO based on histology grades using morphology into 4 grades of malignancy
74
most common primary brain tumour
gliomas
75
symptoms of brain tumours
headache - worse in morning/lying down seizures focal neuro sx: weakness, sensory loss, visual/speech disturbance, ataxia non-focal: personality change/behaviour, memory disturbance, confusion
76
signs of a brain tumour
papilloedema focal neuro deficit - hemiparesis, hemisensory loss, vidual field defect, dysphasia
77
brain tumour red flags
headache: features raised ICP or focal neurology new onset focal seiaure rapidly progressive focal neurology past hx cancer
78
ix for brain tumours
CT with contrast MRI brain biopsy
79
tx brain tumours
non curative except grade 1 steroids - reduce oedema surgery - biopsy or resection radiotherapy chemo: temozolamide, pcv
80
effects of pituitary tumours
excess hormone production local effects inadequate hormone production by remianing pituitary usually benign and curable
81
neuroepithelial tumours - histological classification 1
astrocytic, oligodendrological, ependymal, neuronal and neuro-glial, pineal, embryonal, choroid plexus
82
brain tumours in histological classification 2
cranial and spinal nerve tumours meningeal tumours lymphomas germ cell tumours metastatic tumours
83
astrocytoma grading
I-4, worsening prognosis IV=gliobastoma
84
common cancers that metastasise to the brain
lung breast melanoma GI tract kidney
85
anatomical effects of a mass lesion
local deformity and shift of structures decreased vol CSF pressure gradients - internal herniation
86
RF bladder cancer
smoking environemnt: petroleum, phenacetin, cadmium occupational: leather tanners, shoe workers, asbestos hormonal: obesity, diethyrlstillbestrol genetic: VHL, BHD
87
presentation renal cancer
triad: mass, haematuria, pain incidental haematuria sx metastatic disease paraneoplastic sx: PTH, erythropoietin, prolactin variocele rare
88
upper tract TCC
CT CAP not really curable if gone beyonf kidney nephroureterectomy
89
tx options for renal cancer
surveillance radical nephrectomy partial nephrectomy radiofrequency ablation cryotherapy tyrosine kinase inhibitors cytoreductive nephrectomy palliative care
90
presentation bladder cancer
painless haematuria LUTS
91
pathology bladder cancer
transitional cell carcinoma increased number epithelial cell layers
92
ix bladder cancer
CT cystoscopy- felxible under LA
93
tx options bladder cancer
TURBT intravesical chemo or immunotheraoy cystectomy radiotherapy chemo palliative
94
RF testicualr cancer
cryptorchidism germ cell neoplasia - klinefelters HIV genetic maternal oestrogen exposure
95
pathology testicular cancer
germ cell tumours - seminomatous and non seminomatous
96
presntation testicular cancer
scrotal lump (hard, irregular, non-transilluminable)- painless scrotal pain due to haemorrhage sx metastasis - wt loss, lumps in neck, bone main secondary hydrocele
97
ix testicualr cancer
USS staging - CT CAP tumour markers - AFP, LDH, hCG, before tx
98
what are sarcomas?
Sarcomas are rare tumours of mesenchymal tissue.
99
early SE chemo
Anaemia, thrombocytopenia, neutropenia Mouth ulcers, thrush N&V Constipation Neurotoxicity – peripheral neuropathy, encephalopathy Nephrotoxicity – also haemorraghic cystitis Hair loss Tiredness
100
late SE chemo
Cardiotoxicity Nephrotoxicity Neurotoxicity Osteopenia Fertility Second malignancies
101
mx localised sarcomas
surgery Addition of radiotherapy improves local control rates,
102
mx advanced sarcomas
usually palliative surgery, chemo, radiotherapy
103
back pain red flags
thoracic pain, non mechanical, Hx of malignancy, saddle anaesthesia, incontinence, leg weakness, systemic features <20 or >55 years
104
mx spinal metastases
Analgesia (pain ladder, specialist pain teams) Palliative radiotherapy Vertebroplasty/spinal stabilisation surgery Bisphosphonates – only if involvement from breast or prostate cancer or myeloma
105
mx spinal cord compression
Refer to neurosurgery for MRI whole spine Give IV dexamethasone and VTE prophylaxis
106
pathophysiology humoralhypercalcaemia of malignancy
Humoral is caused by secretion of parathyroid hormone related peptide by tumour, activating osteoclasts suppressing osteoblasts, releasing Ca
107
causes hypercalcaemia of malignancy
Ca renal, ovarian, breast, endometrial, squamous cell Release of factors by bony mets increasing osteoclasts: Myeloma, Breast bony mets Calcitriol production: Lymphoma Ectopic hyperparathyroidism: Small cell lung cancer
108
hypercalcaemia sx
Dehydration! Bones, stones, groans, thrones and psychic moans: Bone pain, Increased risk of kidney stones, Abdominal pain, nausea, Constipation, polyuria (+polydipsia), Confusion, fatigue
109
hypercalcaemia mx
REHYDRATE, MONITOR U+ES Treat malignancy, support and monitor, avoid meds that worsen hypercalcaemia (Thiazides, calcitriol/calcium supps, antacids, lithium) If severe: IV bisphosphonates/denosumab, Furosemide
110
what is tumour lysis syndrome
Metabolic and electrolyte abnormalities and renal impairment – due to lysis of rapidly dividing cancer cells, releasing intracellular contents into circulation Usually hours/days into chemotherapy Usually chemosensitive lymphoma/leukaemia Cancer cells have high turnover, produce lots of uric acid and phosphate, renal ability for excretion is saturated
111
who is at risk of tumour lysis syndrome
dehydrated, renal impairment, prechemo high urate and lactate
112
what does renal saturation in tumour lysis syndrome cause
Hyperuricaemia – can cause uric acid nephropathy and AKI Hyperphosphataemia – can cause calcium phosphate deposition and obstruction Secondary hypocalcaemia (from high phosphate) Hyperkalaemia (from cell degradation)
113
presentation tumour lysis syndrome
Syncope/chest pain/dyspnoea Seizures Nausea, D+V Muscle weakness and cramps
114
ix tumour lysis syndrome
25% INCREASE in uric acid, phosphate, potassium 25% DECREASE in calcium High creatinine and LDH
115
mx tumour lysis syndrome
Prevention is key Prechemotherapy IV fluids, avoid nephrotoxic meds, use allopurinol (blocks conversion to uric acid) Treating – hydrate, correct high potassium, give rasburicase (oxidises uric acid), give aluminium hydroxide (phosphate binder)
116
benign tumours
can put pressure on structures, obstruct flow, produce hormones Localised, non invasive Closely resemble normal structures Circumscribed Normal morphology
117
malignant tumours
destroy tissue, cause blood loss Invasive, metastatic Rapid growth down and in Variable resemblance to normal structures Poorly defined border, increased mitosis
118
papilloma
benign epithelial neoplasm
119
adenoma
benign epithelial neoplasm of glandular/secretory
120
carcinoma
malignant tumour of epithelial cells
121
adenocarcinoma
malignant tumour of glandular/secretory epithelium
122
tumour invasion steps
Normal tissue Carcinogenesis Dysplasia In situ neoplasia Invasive malignancy Metastatic cascade (intravasation, evasion, adherence, angiogenesis) Metastatic disease Death
123
tumour grading
1 – looks like normal cells, growing slowly 2 – less like normal cells, quicker growth 3 – abnormal fast growing cells T0-3 (extent of tumour) N0-3 (presence/extent of regional lymph nodes) M0-1 (presence of metastases)
124
cancer and thrombosis
Cancers are prothrombotic so VTE prophylaxis important Can cause higher number of platelets and clotting factors Surgery/chemo can damage vessels and cause increased clots Cancer and chemo can also lead to low platelets Cancer can directly erode blood vessels Clotting factors decrease with chemo or liver involvement
125
endocrine paraneoplastic syndromes
Syndrome of inappropriate antidiuretic hormone (SIADH): Mostly small cell lung cancer Cushing’s syndrome – overproduction of ACTH precursors: Mostly small cell lung cancer, non SCLC, carcinoids Hypercalcaemia – most caused by bony mets, this is humoral hypercalcaemia of malignancy: Squamous cell – NSCLC, head/neck, renal
126
neuro paraneoplastic syndromes
Peripheral neuropathy: SCLC, myeloma, Hodgkin’s, breast, GI Encephalomyelopathies: SCLC Cerebellar degeneration: SCLC, breast, Hodgin’s Lambert-Eaton myasthenic syndrome : SCLC
127
haem paraneoplastic syndromes
anaemia, leukocytosis, thrombocytosis – mostly renal, lymphomas, leurkaemias, lung squamous cell
128
derm paraneoplstic syndromes
pruritus, pigmentation, erythema, bullous pemphigus – mostly lymphoma/leukaemia, some GI
129
what is carcinoid syndrome
Due to secretion of serotonin and kinins from neuroendocrine tumours : Gastric carcinoma, bronchial adenoma, pancreatic carcinoma – often liver mets
130
features carcinoid syndrome
Flushing, diarrhoea, wheeze, abdo pain
131
mx carcinoid syndrome
resection, octreotide (somatostatin analogue)
132
what are neuroendocrine tumours
Neoplasms arising from endocrine or nervous system Commonly in the intestine (can be called carcinoid tumours), Also in pancreas, lung (SCLC)
133
what is a sarcoma
Cancer of connective tissue, some associated with specific gene mutations
134
presentation sarcoma
soft tissue swelling and pain
135
types of sarcoma
Liposarcoma Leiomyosarcoma (uterine bleed) Fibrosarcoma GIST (acute abdomen, bleed) Synovial sarcoma Kaposi’s sarcoma (AIDS related)
136
ix sarcoma
Ix: CT/MRI of the mass shows heterogeneous mass with central necrosis, patchy contrast enhancement CT chest for mets, HIV test, biopsy and histology, genetic testing
137
mx sarcoma
wide local excision with pre and post of radiotherapy Possible chemo but not very sensitive
138
what is lymphoedema
Chronic progressive swelling of tissue with protein rich fluid as a consequence of developmental or acquired disruption of lymphatic system Majority malignancy or cancer treatment
139
mechanisms lymphoedema
Inflammation and increased vascular permeability Lymphatic obstruction of drainage Hypoalbuminaemia decreased oncotic pressure Venous oedema from increased venous pressure
140
mx lymphoedema
Skin care, compression bandaging, elevation, exercise, weight loss, psych support If filiariasis = diethylcarbamazine or albendazole

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