Oncology Flashcards
What is metoclopramide contraindicated in?
bowel obstruction
What anticipatory med should you give in partial bowel obstruction?
Hyoscine butylbromide (e.g. 60mg/24 hours via a subcutaneous infusion)
useful in EOL care as it can reduce colicky abdo pain and reduce excess respiratory or gastric secretions
What is oxygen saturation recommendation from NICE for acutely unwell patients?
94-98%
What condition can be caused by cytotoxic chemotherapy?
neutropenic sepsis (temp greater than 38.5 degrees or 2 consecutive readings over 38 degrees) in a patient with a neutrophil count less than 0.5x10^9 or expected to fall to this level in the next 2 days
How is neutropenic sepsis managed?
empirical IV treatment with piperacillin and tazobactam (tazocin)
Where does lung cancer tend to spread?
bone, brain, liver and adrenals
What are areas of decreased radiolucent lesions on imaging a sign of?
osteolytic lesions (e.g. seen in thyroid, multiple myeloma, lung, renal cell cancers)
bones are broken down, become weak and easily breakable
What kind of bone lesions do prostate cancer metastasis cause?
osteoblastic metastasis (radiodense lesions)
cancer cells activate osteoblasts, increased irregular bone growth, causes dense and sclerotic hardening of bone
prostate cancer is most common cancer in males to metastasise to bones
Where does colorectal cancer tend to metastasise to?
liver, lungs, brain and peritoneum
bone mets are not common
What investigations would you do for metastasis?
imaging (CT, MRI, PET, bone scans)
biopsy (tissue samples to confirm diagnosis and identify the type of cancer cells)
What should you remember for medications with syringe drivers?
name, dosage per 24 hours (x/24hours) and via what route (subcutaneous infusion)
What are risk factors for hepatocellular carcinoma (HCC)?
chronic viral hepatitis (B + C), cirrhosis, non-alcoholic fatty liver disease, primary billiary cirrhosis, alcohol misuse, type 2 diabetes, obesity, inherited metabolic diseases, rare diseases (wilsons, porphyria cutanea tarda, alpha 1-antitrypsin deficiency)
what is HCC?
hepatocellular carcinoma (primary malignancy of the liver) which arises in patients with underlying chronic liver disease and cirrhosis
What do you offer patients at HIGH risk of HCC
Alpha-fetoprotein (AFP) tumour marker and an abdominal ultrasound every 6-12 months
What is the usual starting dose for morphine?
20-30mg/24 hours orally
What do patients with spinal cord compression present with?
upper motor neuron signs: hyperreflexia, spasticity, positive babinski’s sign
bladder incontinence or retention
sensory disturbance: typically below the level of the lesion
stabbing sensation at the level of the lesion
deep and localised back pain
pain is worse at night and when lying flat
can have a mix of sensory and upper motor neuron neurology in legs that indicate the cord is being compressed
What is the differential diagnosis for SCC?
multiple sclerosis: optic neuritis, limb weakness, sensory loss, ataxia and bladder dysfunction
transverse myelitis: acute development of limb weakness, sphincter dysfunction, sensory problems
peripheral neuropathy: sensory loss, pain and weakness in the limbs
musculoskeletal back pain: severe paain, spasms with no significant weakness
What investigation is indicated for suspected SCC or cauda equina syndrome?
whole spine MRI (show soft tissue changes)
give dexamethasone 16mg daily (divided doses) with PPIs for gastric protection
intention for surgical decompression within 48 hours,
What would brown-sequard syndrome (hemisection of the cord) present with?
causes ipsilateral (same side) weakness and proprioception/vibration loss
pain and temperature loss on the opposite side (contralaterla side)
commonly due to trauma
What does anterior cord syndrome present with?
ACS is damage to anterior 2/3s of spinal cord
usually caused by ischaemia of anterior spinal atery
present with bilateral loss of pain and temperature sensation
autonomic dysfunction
urinary incontinence
What are the causes of SCC
Trauma
Malignancy
Infection (e.g. Tuberculosis)
Disc prolapse (protruding intervertebral disc can compress the spinal cord)
epidural haematoma (accumulation of blood in epidural space can compress the spinal cord)
What are risk factors for head and neck cancers?
tobacco use, alcohol consumption, human papillomavirus (HPV) and Epstein-Barr virus (EBV) infection
What are common clinical features of head and neck cancers?
dysphagia
odynophagia (pain when swallowing)
dysphonia (hoarsness, abnormal voice)
ALARM symptoms (tiredness, unexplained weight loss, loss of appetite)
Lymphadenopathy
Airway compromise (stridor)
Bad breath (halitosis)
Focal neurology (VII cranial nerve palsy)
differential diagnoses for head and neck cancers?
thyroid nodules (dysphagia, dysphonia, neck swelling)
lymphadenopathy (infections, inflammatory conditions, other malignancies)
gastroesophageal reflux disease: dysphagia and odynophagia (pain when swallowing)
vocal cord polyps (dysphonia)
nasal polyps (nasal obstruction, anosmia)
What does hyoscine butylbromide do?
anti-muscarinic drug that drys out secretions and reduces noise
given subcutaneously in doses of up to 20mg every 6-8 hours
What are two functions of morphine in EOL care?
pain or breathlessness
What is Haloperidol used for?
DRUG INDUCED NAUSEA and vomiting, agitation, delirium
What is levomepromazine used for
anti-emetic to relieve nausea and vomiting at the end of life
what is prochlorperazine used for?
nausea and vomiting
What medications might you stop in EOL care?
medications that modify long term risk like atorvastatin, aspirin, bisoprolol, metformin (not eating), blood pressure reduced anyway
What marker is rasied in colorectal carcinoma?
CEA (carcinoembryonic antigen) BUT is not used for screening
What marker is raised in ovarian cancer?
CA 125 (cancer antigen 125) BUT not used in screening
What marker is raised in medullary thyroid carcinoma?
calcitonin and can be used in detecting RECURRENCE of malignant disease following treatment. NOT PART OF SCREENING
What signs can you get in hepatocellular carcinoma vs gastrointestinal cancers vs metastatic lung cancer vs germ cell tumours?
hepatocellular: abdo pain, weight loss, jaundice
Gastro: persistent abdo pain, unexplained weight loss, changes in bowel habit
metastatic lung cancer: persistent cough, breathlessness, unexplained weight loss, fatigue
germ cell: palpable mass, testicular pain or discomfort, gynecomastia in men, irregular menstruation or vaginal bleeding in women
What are other causes of increased AFP levels besides hepatocellular carcinoma?
gastro-intestinal cancers
metastatic lung cancer
pregnancy (fetal neural tube defects)
germ cell tumours
What is cyclizine used for?
nausea and vomiting associated with intracranial disease (first line anti-emetic)
What is first line for CHEMO INDUCED NAUSEA AND VOMITING?
Ondansetron
What first line is used for NAUSEA associated with delayed gastric emptying where there is NO BOWEL OBSTRUCTION?
Metoclopramide
How do you treat a patient with moderate hypercalcaemia?
IV fluids and IV bisphosphonates (alendronate, risedronate, zoledronic acid)
bisphosphonates inhibit bone resorption; risk of nausea and vomiting, difficulty swallowing, irritation of oesophagus, osteonecrosis of the jaw)
How do you treat acute hypocalcaemia?
IV calcium gluconate (can also stablise myocardium of heart in severe hyperkalaemia)
What are the differentials of confusion in oncology?
metabolic causes like hypoglycaemia or hypercalcaemia
infection (pneumonia, UTI)
metastatic spread to the brain
anaemia
intense pain
side effects of pain medication (haloperidol causes increased drowsiness, morphine, opiates)
What is tumour lysis syndrome?
serious metabolic disorder caused by rapid death of tumour cells in response to chemotherapy, causes a massive release of intracellular contents into the bloodstream causing electrolyte imbalances
hyperkalaemia
hypocalcaemia
hyperphosphatemia
hyperuricaemia
What tumours are associated with tumour lysis syndrome?
acute leukaemias and high grade lymphomas
What investigations would you do in tumour lysis syndrome?
U+Es (potassium and phosphate raised)
calcium (low)
uric acid (high)
ECG for Hyperkalaemia changes that can cause arrythmias
What signs and symptoms associated with tumour lysis syndrome?
dysuria or oliguria
abdominal pain
weakness
nausea or vomiting
diarrhoea
muscle cramps
pruritus
seizures
cardiac arrythmias
What are differentials of tumour lysis syndrome?
AKI: oliguria, fatigue, fluid retention
Hyperkalaemia: muscle weakness, fatigue, palpitations,
hyperphosphatemia: muscle cramps, itching, perioral tingling or numbness
hypocalcaemia: numbing/tingling in the hands, feet and around mouth, muscle cramps and seizures
What is management for tumour lysis syndrome?
IV fluids
dialysis in severe cases
Allopurinol or rasburicase adminstered to prevent/treat hyperuricaemia
What is the most common cause for SVCO?
Pulmonary tumour compressing on superior vena cava
worsening upper limb and facial swelling
distended neck veins
plethoric facies (facial redness and swelling)
positive pemberton’s test (raise arms over head for over a minute, will cause facial plethora and cyanosis)
how is SVCO diagnosed and managed?
CT scan of thorax
dexamethasone 8mg BD
IVC stenting
What are differentials for N + V
chemo or radiotherapy
blockage/progression of disease (e.g. bowel obstruction)
metabolic (uraemia, hypercalcaemia, hyperuricaemia)
infection
anxiety
anticipatory vomiting
What is another name for hereditary non-polyposis colorectal cancer (HNPCC)?
Lynch syndrome (strong familial link to colorectal cancer, endometrial cancer and ovarian cancer)
caused by mutations in MSH1/MSH2 DNA mismatch repair genes
autosomal dominant inheritance
increases risk by 60% for colorectal cancer and 40% for endometrial cancer
What genetic syndrome can lead to colon carcinoma and polyps in the colon
familial adenomatosis polyposis coli
mutations in APC gene
autosomal dominant
What gene is affected in retinoblastoma that happens in children?
retinoblastoma gene (Rb)
What germline mutation of what tumour supressor gene leads to Li Fraumeni syndrome that increases the risk of sarcoma and cancer of breast, brain and adrenal glands?
p53 tumour supressor gene
autosomal dominant disorder
What syndrome causes mutation of pituitary, parathyroid and pancreas?
MEN 1 syndrome
What syndrome causes mutations in the RET oncogene that leads to medullary thyroid cancer, phaeochromocytoma and parathyroid adenoma?
MEN 2A syndrome
What syndrome causes mutations in the RET incogene that leads to gastro-intestinal complaints, mucosal neuroma, medullary thyroid cancer and phaeochromocytoma, craniosynostosis (birth defect in which the bones in a baby’s skull join together too early. This happens before the baby’s brain is fully formed.)
MEN 2B rhymes with baby which causes craniosynostosis
What are differentials for masses in the liver?
hepatocellular carcinoma (chronic liver disease like hep B and C and cirrhosis)
lymphoma (primary liver lymphoma or secondary mets)
cholangiocarcinoma (comes from bile ducts in liver)
haemangioma (benign blood vessel tumours)
hydatid cyst (infection with echinococccus granulosus tapeworm)
hepatic abscess
metastatic lesions
common signs and symptoms of liver lesions
abdominal pain
jaundice
weight loss
fatigue
loss of appetite
nausea and vomiting
What is haemochromatosis?
most common inherited liver disease that leads to iron overload.
causes cirhossis and diabetes as excess iron deposits in the liver and the pancreas
does not present with jaundice, weight loss or changes to stool/urine
What is Gilbert syndrome?
inherited metabolic disorder that causes excess unconjugated bilirubin because the conjugating enzymes in the liver cells (hepatocytes) dont work.
presents as painless jaundice during times of stress
What is the triad for acute cholangitis?
fever
jaundice
right upper quadrant pain
What are signs and symptoms for cholangiocarcinoma
painless jaundice
weight loss
itching (excoriations)
PMH of ulcerative colitis and primary sclerosising cholangitis
What are the 3 steps to the WHO analgesic ladder?
Step 1: non-opoid: paracetamol, NSAIDs
step 2: weak opoid: codeine and tramadol
step 2: strong opoid: morphine, oxycodone, fentanyl, buprenorphine
can have adjuvants for neuropathic pain
amitryptyline: TCA
duloxetine: SNRI antidepressant
gabapentin: CCB for epilepsy and neuropathic
pregabalin: CCB for epilepsy and neuropathic pain
capsaicin cream (topical)
What are common subtypes of lung cancer?
small cell and non-small cell tumours
non small cell lung cancer is most common
most common type is squamous cell, then adenocarcinoma
What are key signs and symptoms of thyroid cancer?
mass in neck, dysophonia (hoarseness), difficulty swallowing, breathing problems, persistent cough, pain in neck of throat
What is the most common neoplasm in the thyroid gland?
papillary thyroid cancer (80% of thyroid cancer)
show orphan-annie cells (optically clear nuclei)
‘cold’ nodule: does not take up iodine which is suggestive of papillary or follicular carcinoma
other types:
follicular adenoma (15%)
medullary thyroid (3%)
anaplastic thyroid (2%)
What are differentials for thyroid cancer?
benign thyroid nodules: non cancerous growths in thyroid
thyroiditis: inflammed thyroid causing pain/swelling
hyperthyroidism or hypothyroidism
goitre: non cancerous enlargement of thyroid gland
What do iodine uptake tests in radionuclide scan help distinguish between in thyroid disease?
functioning toxic nodules and thyroid mets from follicular and papillary carcinomas
cold nodules: do not uptake iodine in follicular/papillary carcinoma of thyroid
thyroid mets/toxic nodules would take up iodine
Why is tazocin given in neutropenic sepsis?
broad spect; covers staphs, streps, anaerobes, problem gram positives (coagulase negative staph) and problem gram negatives (pseudomonas)
What is G-CSF? (granulocyte colony stimulating factor)
given in some chemo regimes to reduce risk of neutropenic sepsis
What are side effects of morphine
hallucination, confusion, drowiness
opiates can also cause respiratory depression in patients with lung disease and hypoxia is another cause of delirium
What are side effects of haloperidol?
dry mouth, urinary retention, restlessness, drowsiness
What are side effects of metoclopramide?
drowsiness, headache, nausea and diarrhoea
What can levomepromazine cause?
drowsiness, dry mouth, postural hypotension, constipation
What drugs can accumulate in renal failure with patients that need pain medications
tramadol
codeine
Which pain medication is less likely to accumulate in renal impairment?
oxycodone (twice as potent as oral morphine so half the dose of oral morphine is needed)
What are side effects of dexamethasone
poor healing, skin thinning, hypertension, poor glycaemic control, increased appetite, salt and water retention, increased predisposition to infection, osteopenia and cushing’s syndrome
What are side effects of anti-muscarinic drugs like hyoscine hydrobromide?
dry mouth, constipation and urinary retention
Differentials for SOB in oncology
pneumonia
anxiety
lung collapse due to tumour or narrowing of airway
pleural effusion (malignant; cancer cells can spread into pleura, causing irritation and fluid build up)
radiation pneumonitis
anaemia
oncological emergency (superior vena cava obstruction)
