oncology Flashcards
what is the WHO performance status
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
how does chemo work
damages dna
direct - binds
indirect - affects dna replication/mitosis
e.g. chemo agents
alkylating
antimetbaolites
anthracyclines
taxanes
platinums
topoisomerase i
how does radiotherapy work
use of high energy XR to destroy cancer cells
how does immunotherapy work
systemic agents that aim to stimulate a patiejts own immune system to attack cancer cells
e.g. checkpoint i, monoclonal ab
how do targeted agents work and e.g.
systemic therapoy
inhibit specific targets involved in cell replication etc
e.g. tyrosine kinase i
what are tx related oncological emergencies
cytopenia - neutropenic sepsis
electrolyte disturbance - hypercalcaemia
tumour lysis syndrome
diarrhoea
vomiting
anaphylaxis
extravasation
radiotherapy se
what are tumou related oncological emergencies
spinal cord compression
SVCO
upper airway obstruction
brain mets
bowel obstruction
what are cancer cells
undergo uncontrolled and unregulated cell proliferation with the abiliity to move to other places in theo body
cell cycle
G0 = rest
G1 = pre DNA synthesis
S= DNA synthesis
G2 = post DNA synthesis
M = mitosis
systemic anticancer tx
chemo
hormone
molecular - inhibitors, monoclocal ab, immunotherapy
SE chemo
HF
immune supprssion
alopecia
renal impairment
skin rashes
bowel upset
peripheral neuropathy
taste changes
hepatic impairment
nasuea
diagnosis neutropenic sepsis
temp >38 and neutrophil count <1 x10 to the 9
presentation neutropenic sepsis
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
ix neutropenic sepsis
U+E, creatinine, LFT, CRP/ESR, coag screen
Septic screen; Blood cultures, clinically relevant swabs or cultures, CXR
mx neutropenic sepsis
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.
prevention neutropenmic sepsis
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
causes malignant hypervcalcaemia
Osteolysis (lytic bone metastases)
Humoral (PTHrP in squamous cell lung ca)
Dehydration
Other tumour specific mechanisms
presnetation malignant hypercalcaemia
BONES, STONES, GROANS AND PSYCHIC MOANS
GI: abdominal pain, vomiting, constipation, anorexia, weight loss
GU: polyuria, polydipsia
Neuro: fatigue, weakness, confusion
Psych: depression
ix malignant hypercalcaemia
Repeat blood sample, PTH
ECG (shortened QT interval)
Imaging for bone mets if appropriate
mx malignant hypercalcaemia
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.
causes malignant spinal cord compression
Malignancy
o Primary
o Secondary – most common cause e.g. Prostate, Lung, Breast
Mechanism = Crush fracture, soft tissue tumour extension
presentation malignant spinal cord compression
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
ix malignant spinal cord compression
MRI WHOLE Spine; patient may have multiple levels of compression which require
treatment
mx malignant spinal cord compression
High-dose corticosteroids, analgesia, VTE prophylaxis
definitive: surgfery, radio, chemo,
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
sx SVCO
Dyspnoea
Chest pain, often at rest
Cough
Neck and face swelling
Arm swelling
Others – dizziness, headache, visual
disturbance, nasal stuffiness, syncope
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
ix SVCO
May be clinical diagnosis
CXR (widened mediastinum or a mass on the right side of the heart)
CT scan
mx SVCO
High-dose steroids can be useful in acute SVCO
Endovascular stenting
Also consider: Chemotherapy, Radiotherapy, Anticoagulation; if central vein thrombosis is present
what is ionising radiation
enough energy to detach electrons damages DNA
what is radiotherapy
use of high energy XR/ionising radiation in carefully measured doses to damage and destroy cancer cells
what is a neo-adjuvant
aims to decrease the size or extent of disease prior to radical tx
what is an adjunvant
aims to target micro-meastatic disease
reduce risk of local recurrnce
what is radical tx
aiming for cure
sometimes refers to high/curative dose
general SE radiotherpay
sunburn type effects
late = scarring
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
SE prostate cancer radiotherpay
acute: dysuria, urinary freq/urg. diarrhoea, fatigue
late: long term bladder/rectile/erectile dysfunt,
preventing anaphylaxis with chemo
high dose steroid
IV/PO antihitamine
slower rate of infusion
mx coronary artery spasm due to chemo
stop infusion
nitrates
features coronary artery spsm due to chemo
features ACS
common antiemetics used for N+V in chemo
metoclopramide, ondansetron
mx constipation caused by chemo
excude infection/obstruction
loperamide, laxatives
features bone marrow suppression
thrombocytopenia
anaemia
neutropenia
mx fatigue/reduced appetite due to chemo
can give steroids but risk
mx alopecia due to chemo
cold caps
wigs
late effects of chemo
infertility
early menopase
atherosclerosis
heart failure
lung damage
chemo brain
secondary cancers
TNM staging
T=tumour size, 1-4
N=nodes
M=metastases
multiple myeloma
neoplastic proliferation of bone marrow plasma cells
characteristics multiple myeloma
monoclonal protein in serum or urine
lytic bone lesions/CRAB end organ damage
excess plasma cells in bone marrow
common presenting features myeloma
tired
bone/back pain +/- fractures
infections
lab: anaemia, renal failure, hypercalcaemia, raised globulins, rasied esr, serum/urien paraprotein
myeloma blood film
rouleaux
tx myeloma
cytotoxic: radiotherapy, chemo
supportive
what is acute leukaemia
proliferation primitve precursor cells usually only found in bone marrow
proliferation without differentiation
replaces normal bone marrow cells
what is acute lymphoblastic leukaemia
malignant proliferation of lymphoblasts in bone marrow
affects mainly children
tx acute lymphoblastic leukaemua
induction chemo
consolidation chemo +/- craniospinal irradiation
maintenance chemo
bone marrow transplant if relapse
what is acute myeloid leukaemia
malignant proliferation of myeloblasts in bone marrow
affects mainly adults
chronic lymphocytic leukaemia
proliferation mature lymphocytes, usually B cels
affects elderly
chronic myeloid leukaemiakey features
high white cell count and splenomegaly
philadelphia chromosome
chronic, accelerate, blast crisis
tx chronic myeloid leukaemia
imatinib
allogeneic stem cell transplant
myelodysplasia
premalignant condition of haemopoietic precursors
disease of elderly
can be asx or anaemia
can transform to acute myeloid leukaemia
tx myelodysplasia
support
bone marrow transplant in young
presentation hodkin lymphoma
painless lymphadenopathy
B sx: sweats, wt loss, fever
15-35y, >55y
reed sternberg cells
mx hodgkins lymphoma
chemo, radiotherapy, stem cell transplant
features low grade non hodgkin lymphoma
e.g. follicular
gradual onset
may be asx
incurable
features high grade non hodgkin lymphoma
e.g. diffuse large B cell
rapidly progressive
sx
potentially curable
sx myeloma
lytic lesions in bones - pain
hypercalcaemia- thirst, polyurea, confusion, constipation
hyperviscosity
renal failure
anaemia
infections
what is lymphoma
malignant growth wbc
usually in lymph nodes
also in blood, bone marrow, liver, spleen
diagnosing lymphoma
blood film and bone marrow
lymph node biopsy
immunophenotyping
PET for staging
common presentation acute leukaemia
anaemia: tired, fatigue, lightheaded, palpitaiton,s sob
thrombocytopenia: bruising, bleeding
WCC: infection
extramedullary disease
coagulopathy -DIC
blood film on acute myeloid leukaemia
increased blast cells
ix in leukaemia
FBC
blood film
haematinics, haemolysis screen, LFTs, U+Es
how are brain tumours classified
not using tnm
use WHO based on histology
grades using morphology into 4 grades of malignancy
most common primary brain tumour
gliomas
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
signs of a brain tumour
papilloedema
focal neuro deficit - hemiparesis, hemisensory loss, vidual field defect, dysphasia
brain tumour red flags
headache: features raised ICP or focal neurology
new onset focal seiaure
rapidly progressive focal neurology
past hx cancer
ix for brain tumours
CT with contrast
MRI
brain biopsy
tx brain tumours
non curative except grade 1
steroids - reduce oedema
surgery - biopsy or resection
radiotherapy
chemo: temozolamide, pcv
effects of pituitary tumours
excess hormone production
local effects
inadequate hormone production by remianing pituitary
usually benign and curable
neuroepithelial tumours - histological classification 1
astrocytic, oligodendrological, ependymal, neuronal and neuro-glial, pineal, embryonal, choroid plexus
brain tumours in histological classification 2
cranial and spinal nerve tumours
meningeal tumours
lymphomas
germ cell tumours
metastatic tumours
astrocytoma grading
I-4, worsening prognosis
IV=gliobastoma
common cancers that metastasise to the brain
lung
breast
melanoma
GI
tract
kidney
anatomical effects of a mass lesion
local deformity and shift of structures
decreased vol CSF
pressure gradients - internal herniation
RF bladder cancer
smoking
environemnt: petroleum, phenacetin, cadmium
occupational: leather tanners, shoe workers, asbestos
hormonal: obesity, diethyrlstillbestrol
genetic: VHL, BHD
presentation renal cancer
triad: mass, haematuria, pain
incidental
haematuria
sx metastatic disease
paraneoplastic sx: PTH, erythropoietin, prolactin
variocele rare
upper tract TCC
CT CAP
not really curable if gone beyonf kidney
nephroureterectomy
tx options for renal cancer
surveillance
radical nephrectomy
partial nephrectomy
radiofrequency ablation
cryotherapy
tyrosine kinase inhibitors
cytoreductive nephrectomy
palliative care
presentation bladder cancer
painless haematuria
LUTS
pathology bladder cancer
transitional cell carcinoma
increased number epithelial cell layers
ix bladder cancer
CT
cystoscopy- felxible under LA
tx options bladder cancer
TURBT
intravesical chemo or immunotheraoy
cystectomy
radiotherapy
chemo
palliative
RF testicualr cancer
cryptorchidism
germ cell neoplasia - klinefelters
HIV
genetic
maternal oestrogen exposure
pathology testicular cancer
germ cell tumours - seminomatous and non seminomatous
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
ix testicualr cancer
USS
staging - CT CAP
tumour markers - AFP, LDH, hCG, before tx
what are sarcomas?
Sarcomas are rare tumours of mesenchymal
tissue.
early SE chemo
Anaemia, thrombocytopenia, neutropenia
Mouth ulcers, thrush
N&V
Constipation
Neurotoxicity – peripheral neuropathy, encephalopathy
Nephrotoxicity – also haemorraghic cystitis
Hair loss
Tiredness
late SE chemo
Cardiotoxicity
Nephrotoxicity
Neurotoxicity
Osteopenia
Fertility
Second malignancies
mx localised sarcomas
surgery
Addition of radiotherapy improves local control rates,
mx advanced sarcomas
usually palliative
surgery, chemo, radiotherapy
back pain red flags
thoracic pain, non mechanical, Hx of malignancy, saddle anaesthesia, incontinence, leg weakness, systemic features <20 or >55 years
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
mx spinal cord compression
Refer to neurosurgery for MRI whole spine
Give IV dexamethasone and VTE prophylaxis
pathophysiology humoralhypercalcaemia of malignancy
Humoral is caused by secretion of parathyroid hormone related peptide by tumour, activating osteoclasts suppressing osteoblasts, releasing Ca
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
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
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
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
who is at risk of tumour lysis syndrome
dehydrated, renal impairment, prechemo high urate and lactate
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)
presentation tumour lysis syndrome
Syncope/chest pain/dyspnoea
Seizures
Nausea, D+V
Muscle weakness and cramps
ix tumour lysis syndrome
25% INCREASE in uric acid, phosphate, potassium
25% DECREASE in calcium
High creatinine and LDH
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)
benign tumours
can put pressure on structures, obstruct flow, produce hormones
Localised, non invasive
Closely resemble normal structures
Circumscribed
Normal morphology
malignant tumours
destroy tissue, cause blood loss
Invasive, metastatic
Rapid growth down and in
Variable resemblance to normal structures
Poorly defined border, increased mitosis
papilloma
benign epithelial neoplasm
adenoma
benign epithelial neoplasm of glandular/secretory
carcinoma
malignant tumour of epithelial cells
adenocarcinoma
malignant tumour of glandular/secretory epithelium
tumour invasion steps
Normal tissue
Carcinogenesis
Dysplasia
In situ neoplasia
Invasive malignancy
Metastatic cascade (intravasation, evasion, adherence, angiogenesis)
Metastatic disease
Death
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)
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
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
neuro paraneoplastic syndromes
Peripheral neuropathy: SCLC, myeloma, Hodgkin’s, breast, GI
Encephalomyelopathies: SCLC
Cerebellar degeneration: SCLC, breast, Hodgin’s
Lambert-Eaton myasthenic syndrome : SCLC
haem paraneoplastic syndromes
anaemia, leukocytosis, thrombocytosis – mostly renal, lymphomas, leurkaemias, lung squamous cell
derm paraneoplstic syndromes
pruritus, pigmentation, erythema, bullous pemphigus – mostly lymphoma/leukaemia, some GI
what is carcinoid syndrome
Due to secretion of serotonin and kinins from neuroendocrine tumours : Gastric carcinoma, bronchial adenoma, pancreatic carcinoma – often liver mets
features carcinoid syndrome
Flushing, diarrhoea, wheeze, abdo pain
mx carcinoid syndrome
resection, octreotide (somatostatin analogue)
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)
what is a sarcoma
Cancer of connective tissue, some associated with specific gene mutations
presentation sarcoma
soft tissue swelling and pain
types of sarcoma
Liposarcoma
Leiomyosarcoma (uterine bleed)
Fibrosarcoma
GIST (acute abdomen, bleed)
Synovial sarcoma
Kaposi’s sarcoma (AIDS related)
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
mx sarcoma
wide local excision with pre and post of radiotherapy
Possible chemo but not very sensitive
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
mechanisms lymphoedema
Inflammation and increased vascular permeability
Lymphatic obstruction of drainage
Hypoalbuminaemia decreased oncotic pressure
Venous oedema from increased venous pressure
mx lymphoedema
Skin care, compression bandaging, elevation, exercise, weight loss, psych support
If filiariasis = diethylcarbamazine or albendazole
