Oncology Flashcards
Super vena caval obstruction is an oncological emergency. What would cause it and what would be the patients symptoms?
Mediastinal mass causing mechanical obstruction of the SVC
Difficulty breathing and/or swallowing, stridor, oedematous face and venous congestion
A 65 year old man presents with a lump in the left side of his neck. On examination there is a firm, non tender swelling overlying the angle of the mandible. The patient has asymmetrical facial features with drooping of the angle of the mouth on the left and an inability to close his left eyelid. What is the most likely diagnosis?
Malignant parotid tumour
80% of parotid masses are benign, with 80% being benign pleomorphic adenomas and most of the remainder Warthins tumours
Involvement of the facial nerve is a feature of malignancy
A 23 year old woman noticed a lump in her right breast. It is hard, immobile and does not change with her menstrual cycle. On questioning her mother and sister were treated for breast cancer. She had genetic testing which showed she is BRCA1 positive. On biopsy, the tissue showed abnormal mitotic activity, chromosome number and was HER2 positive. What is the best treatment option for her?
Bilateral mastectomy
she has an aggressive breast cancer but also has a strong family history so removal of the affected breast is required but also prophylactically removing the other is advised as she is at high risk of recurrence
What symptoms might a prolactinoma present with?
Amenorrhoea
Bitemporal hemianopia
Reduced bone mineral density - hypooestrogenism
Hypopituitarism
72 year old man with 6 month hx 10kg weight loss. Never smoked, drinks modest alcohol, treatment for T2DM, father died of rectal carcinoma at 65. On examination pale and jaundiced, 3 finger irregular hepatomegaly. Low Hb, low MCV. What is the likely diagnosis?
Metastatic colonic neoplasia
Occult blood loss, FH
69 year old man with 6 month history 10kg weight loss. Smoker 10 cigarettes per day and has otherwise been well. On examination, polycythemic. Dipstick shows ++ blood. What is the likely diagnosis?
Renal carcinoma
Ectopic elaboration of EPO, microscopic haematuria
56 year old male with 6 month history 7kg weight loss and bone aches and pains. On examination, pale with no other signs. Urine dip shows +++ protein. What is the likely diagnosis?
Multiple myeloma
Plasma cell malignancy associated with bone marrow suppression and renal cell dysfunction/amyloid deposition
A 19 year old female presents with two month hx of weight loss and night sweats. She has left sided cervical lymphadenopathy. What is the likely diagnosis?
Hodgkin’s disease
A 55 year old male presents with 2 month history of weight loss and increasing fatigue. On examination he is pale, has bilateral cervical and axillary lymphadenopathy and splenomegaly. What is the likely diagnosis?
Chronic lymphocytic leukaemia
With carcinoid syndrome, where typically is the primary? What causes the syndrome?
Iliocaecal/appendix region
Mets to the liver
What substances are secreted by carcinoid mets?
5HT, bradykinin, histamine, substance p, prostaglandins
Which cells do carcinoid tumours arise in?
Enterochromaffin cells
What are the classic signs and symptoms of carcinoid syndrome?
Diarrhoea
Flushing with hypotension
Telangiectasia
Bronchospasm
What is diagnostic for carcinoid syndrome?
Raised urinary 5-hydroxyindoleacetic acid on a low serotonin diet
What is pellagra in relation to cancer?
Dermatological manifestation of carcinoid syndrome
Niacin deficiency
Dermatitis, diarrhoea and mental disturbance
What is a Philadelphia chromosome and what is it associated with?
T(9;22) associated with CML
What is palliative care?
Improves quality of life of patients and their families facing problem associated with life-threatening illness
Prevention and relief of suffering by early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual
What is a life limiting or terminal illness?
Illness where it is expected that death will be a direct consequence of the specified illness
What is end of life care?
Holistic care for those in the last days-weeks of life, allowing them to live as well as possible until they die
What does the gmc guidance define as end of life?
Approaching the end-of-life are likely to die in the next 12 months and those who have: Advanced, progressive, incurable conditions, General frailty and co-existing conditions that mean they are expected to die within 12 months, Existing conditions if they are at risk of dying from a sudden acute crisis in their condition, Life-threatening acute conditions caused by sudden catastrophic events
What do patients under palliative care want?
Appropriate treatment of pain and other symptoms
Achieve a sense of control
Communication regarding their care
Co-ordinated care throughout the course of illness
Avoid inappropriate prolongation of the dying process
Relieve burdens on family
Strengthen relationships with loved ones
Sense of safety in the health care system
What types of conditions are commonly seen in the palliative care specialty?
Cancer
Cardiac disease: end-stage heart failure
Respiratory disease: COPD and pulmonary fibrosis
Chronic kidney disease
Neurological illness: Parkinson’s disease and MND
Dementia
Chronic liver disease
Who should be referred for palliative care?
Patient has active, progressive and usually advanced disease for which the prognosis is limited (although it can be several years) and the focus of care is quality of life
Patient has one or more of the following needs which are unmet: Uncontrolled or complicated symptoms, Specialised nursing/therapy requirements, Complex psychological/emotional issues, Complex social/family issues, Difficult decision making about future care
What forms part of advanced care planning?
What the patient wants: advanced statement
What the patient doesn’t want: advanced decision to refuse treatment and DNAR
Who will speak for the patient: proxy spokesperson, lasting power of attorney
What are the main causes of death in England and Wales?
Circulatory disease
Cancer
What is the gold standards framework?
Systematic, evidence based approach to optimising care for all patients approaching the end of life, delivered by generalist care providers. This includes care:-
For people considered to be at any stage in the final years of life
For people with any condition or diagnosis
For people in any setting, in whichever bed they are in
Provided by anyone in health or social care
At any time needed
What is the gold standards framework surprise question?
Would you be surprised if your patient dies within the next few months, weeks or days?
If the answer is ‘no’ then check for general and specific indicators of deterioration and if present put on GSF register
What is the SPICT tool?
Supportive and Palliative Care Indicators Tool
Guide to identifying patients likely to die in the next 12 months
What are the general indicators of deteriorating health used in the SPICT tool?
Performance status poor or deteriorating, limited reversibility (Needs help with personal care, in bed/chair for 50% or more of day)
2 or more unplanned hospital admissions in past 6 months
Weight loss (5 – 10%) over past 3 – 6 months
Persistent, troublesome symptoms despite optimal treatment of any
underlying conditions
Lives in nursing care home or NHS continuing care unit, or needs care to remain at home
Patient requests supportive and palliative care, or treatment withdrawal
Why do we need to recognise when a patient is approaching the end of their life?
Prevent unnecessary tests and investigations
Advance care planning
Promote symptom control and ease suffering
Promote awareness and care of psychological and spiritual needs
Time to prepare and support family
Promote dignity and ease fears/anxieties
Why do we find it difficult to recognise that a patient is reaching the end of their life?
We want to save lives
Acceptance only when interventions fail and/or we run out of options
Pressure to provide medically futile treatment (patient/family/society)
Inadequate communication skills
Tendency to shy away from the dying and/or inability to acknowledge dying
Feelings of failure? Lack of role? Lack of experience? Lackof teaching? Fear of our own mortality?
How do you know when a patient is entering the terminal phase?
Diagnosis of advanced/end stage disease Increasing weakness (bedbound) Sleeping a lot Disoriented in time with reduced attention span Reduced interest in eating/drinking No reversible cause for deterioration
What are important factors of terminal phase management?
Symptom control Appropriate meds only Correct dose, Correct route Syringe driver often required Stop inappropriate interventions such as IV fluids, blood tests Anticipatory meds DNACPR decision and ACP Use Individual plan of care for the dying person
What things are important to communicate about to a patient and their family in the terminal phase?
Giving bad news to patient/family member
Discussing shift in management approach
Discussing important end of life decisions
Discussing home/hospice referral
Discussing DNACPR status
Discussing difficult issues (e.g. death rattle)
What is the histological feature of Hodgkin’s disease?
Reed sternberg cells: giant multinucleated cell
Which features if present with Hodgkin’s lymphoma are associated with a worse prognosis?
Night sweats
Weight loss
Pruritus
Which genetic mutations associated with CLL are bad prognostic indicators?
Trisomy 12
Del 17p
Del 11q23
How is LDH used as a prognostic marker in cancer?
Marker of tumour burden, normal level suggests less tumour bulk
If a cell has undergone somatic hypermutation and a CLL arises from this, if that a good or bad thing?
Good - more favourable prognosis
B cells in secondary lymphoid tissue undergo somatic hypermutation on recognising an antigen, process by which antibody specificity is fine tuned
In the multi step development model of colorectal carcinogenesis, loss of function of which tumour suppressor gene occurs as a late event?
p53
What role does the APC gene play in colorectal carcinogenesis?
Tumour suppressor gene involved in beta catenin pathway
One copy constitutively mutated in familial adenosis polyposis coli
Mutated relatively early in formation of colorectal cancers
What are poor prognostic factors for AML?
Age > 60 Male Secondary disease High WBC Adverse cytogenetics
What are good prognostic indicators for ALL?
Younger age
WCC
What is burkitts lymphoma?
EBV or AIDS related
Rapidly growing jaw tumour in a young child
Which paraproteins are usually present in myeloma?
Mainly IgG
Some IgA
Rarely IgM/D
What are the criteria for 2 week wait referral of a patient with suspected bladder cancer?
Age 45 and over and have unexplained visible haematuria without UTI
Age 45 and over and have visible haematuria that persists or recurs after successful treatment of UTI
What are the 2 week wait referral criteria for men with suspected prostate cancer?
Prostate feels malignant on DRE
PSA levels above age specific reference range
Which patients with lung pathology should be referred on a 2 week wait?
Have chest X-ray findings that suggest lung cancer
Are aged over 40 with unexplained haemoptysis
List some oncological emergencies
Neutropenic sepsis: fever alone enough to suspect
Spinal cord compression
SVCO
Hypercalcaemia
What is urgent management of spinal cord compression by a tumour?
Dexamethasone to reduce ICP
What is the pathogenesis of high calcium in cancer?
PTHrP stimulates osteoclast activity and Ca reabsorption
Bone marrow invasion
Increased vit D secretion by abonormal lymphocytes
Why can multiple myeloma lead to carpal tunnel syndrome?
Increased amounts of amyloid light chains that can be deposited in multiple organs including the carpal tunnel
Where typically is the primary tumour in carcinoid syndrome?
Iliocaecal/appendix
What is secreted by carcinoid mets?
5HT Bradykinin Histamine Substance P Prostaglandins
What are the classic symptoms of carcinoid syndrome?
Diarrhoea
Flushing with hypotension
Telangiectasia
Bronchospasm
What urinary measurement is diagnostic for carcinoid syndrome?
5HIAA
5 hydroxyindoleacetic acid
