Oncology

Question 1

Bisphosphonates in bone mets

Answer 1

Mechanism of action
– Induce apoptosis of osteoclasts  inhibition of bone resorption
Administration
– Zoledronic acid(ZA): intravenous monthly (used most often)
– Pamidronate: intravenous monthly (breast only)
– Clodronate: oral daily (breast only)
Toxicities
– Acute phase reactions
– Renal insufficiency‐ contraindicated if CrCl <60mL/min
– Hypocalcemia
– Osteonecrosis of the jaw
– Ocular inflammation

Question 2

Denosumab in bone mets

Answer 2

Mechanism of action
– Inhibition of RANKL  inhibition of osteoclast
formation/activation
Administration
– Subcutaneously monthly
Toxicities
– Hypocalcemia (cf ZA)
– Osteonecrosis of the jaw (same as ZA)
– NOT renally cleared so no need to monitor renal function

Question 3

Colorectal cancer screening - average risk

Answer 3

Guidelines differ but general recommendation in
average risk aged 50‐75y:
– Colonoscopy every ten years OR
– Flexi sigmoidoscopy every 5 yrs (+/‐ 3 yearly FOBT) OR
– Annual FOBT

Question 4

Colorectal cancer screening - moderate risk

Answer 4

In those with moderate risk family history
(one 1° <55yo/ two 1° or one 1° and one 2°
any age)
– start screening 50yo or 10yrs before youngest
diagnosed
– colonoscopy 5 yearly

Question 5

Cardiotoxicity of chemo therapy

Answer 5

Anthracyclines (doxorubicin/epirubicin/etc)
• Average 3M post‐rx but can be >10years
• Acute: arrhythmias, heart block, ventricular dysfunction
• Chronic: cardiomyopathy and heart failure
• RF: cumulative dose, age, other drugs, radiotherapy,
pre‐existing heart disease
• Treatment: as per HF due to other causes
Fluorouracil/Capecitabine
• Chest pain prob dt coronary artery spasm
• RF: concomitant RT, infusional regimes, pre‐existing
cardiac disease NOT predictive
• Treatment: stop the drug, do not rechallenge
Trastuzumab
• Asx LVEF  clinical HF
• Appears mostly reversible with rechallenge feasible
• RF: age >50y, anthracycline exposure, pre‐existing
cardiac dysfunction, BMI
• Treatment: cease trastuzumab, standard rx for HF,
consider rechallenge
Bevacizumab
• Hypertension (risk of HF, but low <2%)
• Treatment: Anti‐hypertensives, cease drug if refractory
Sunitinib/Sorafenib
• LVEF, rarely clinical HF
• Treatment: Standard HF therapy, rechallenge feasible

Question 6

pumonary toxicity of chemo

Answer 6

Bleomycin
• Interstitial pulmonary fibrosis
• Less commonly organizing pneumonia, hypersensitivity
pneumonitis
• Baseline DLCO but use during treatment controversial
• RF: age, cumulative dose, renal impairment, RT
• Treatment: Cease drug, steroids if sx, do not
rechallenge
Erlotinib/Gefitinib (EGFR TKIs)
• Interstitial lung disease
• RF: smoking, preexisting lung disease
• Treatment: Cease drug, steroids if severe
• Fatal in about a third of cases

Question 7

Neurotoxicity

Answer 7

Cisplatin
• Peripheral neuropathy
– Glove & stocking sensory loss‐ damage to dorsal root ganglion
– Cease drug if functional impairment
– Usually reversible, may be permanent
• Ototoxicity
– Tinnitus and high frequency hearing loss
Carboplatin
• Peripheral neuropathy with very high doses, much less common than cisplatin
Oxaliplatin
• Acute neurotoxcicity
– Majority of patients
– Cold‐induced paresthesias and dysesthesias of
hands/feet/perioral region for up to a week following
treatment
– Pharyngolaryngeal dysesthesias
– May be motor component usually jaw tightness or cramps
– Avoid touching/consuming anything cold
– Reversible
• Chronic neurotoxicity
– Glove & stocking sensory loss, as per cisplatin
vincristine
• Axonal neuropathy sensory > motor
• Autonomic neuropathy
• Mx: Dose reduce/cease α severity
• Usually improves post‐rx but may be months
Bevacizumab (VEGF‐I):
• Reversible posterior leukoencephalopathy syndrome
(rare <1/1000)
• Headaches, confusion, visual changes, seizures
• Cause: ?endothelial dysfunc