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CCC > Oncology > Flashcards

Oncology Flashcards

1
Q

What are the presenting features of prostatic cancer

A

Frequently asymptomatic Prostatic symptoms: poor stream, nocturia, dribbling, frequency Metastatic symptoms: bone pain, pathological fracture

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2
Q

Where would a cancerous prostate feel like?

A

Craggy Hard Enlarged Obliteration of median sulcus

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3
Q

What Duke’s stage CR Ca does this picture illustrate?

A

Stage A

(Innermost lining of bowel or SLIGHTLY growing in to muscle layer)

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4
Q

What are the features of a colorectal cancer of Duke’s stage A?

A

Innermost lining of bowel only

OR

SLIGHTLY growing in to muscle layer

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5
Q

What are the features of a Duke’s stage B colorectal cancer?

A

Cancer has grown through muscle layer of bowel

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6
Q

What Duke’s stage colorectal cancer does this picture illustrate?

A

Stage B

(Grown through muscle layer of bowel)

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7
Q

What Duke’s stage colorectal cancer does this picture illustrate?

A

Stage C

(Spread to one or more lymph nodes close to bowel)

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8
Q

What Duke’s stage colorectal cancer does this picture illustrate?

A

D

(Spread to somewhere else in body - eg. liver or lungs)

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9
Q

What are the features of Duke’s Stage C colorectal cancer?

A

Cancer has spread to one or more local lymphnodes (close to bowel)

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10
Q

What are the features of Duke’s Stage D colorectal cancer?

A

Cancer has spread to somewhere else in body (eg. liver or lungs)

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11
Q

Where does Colon cancer metastasise to through invasion?

A

Urinary bladder

Small bowel

Duodenum

Internal genitals

Abdominal wall

Retroperitoneum

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12
Q

Where are the common sites of metastases when colon cancer spreads haematogenically?

A

Lung and liver (most common)

Can also (rarely) go to brain, skeleton and kidnets

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13
Q

Once colorectal cancer has invaded lymph nodes, what other common lymphnodes can the cancer spread to?

A

Aortic lymphnodes

Liver ligament

Mediastinal lymph nodes

Supraclavicular lymph nodes

Inferior mesenteric lymph nodes (rectal)

Pelvic wall lymph nodes (rectal)

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14
Q

Which is more common, colon or rectal cancer?

A

Colon

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15
Q

What is the most common histology for a colorectal cancer?

A

adenocarcinoma (90-95%)

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16
Q

How does colorectal cancer spread?

A

Local invasion

Lymphatic

Venous spread

Coelomic

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17
Q

List the less common types of colorectal cancer

A

Squamous cell

Carcinoid

GI stromal tumour

Primary malignant lymphoma

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18
Q

List presentation of bowel cancer

A

Altered bowel habit

Weight loss

Rectal bleeding

Abdo pain

Anaemia symptoms

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19
Q

What investigations would you do to a pt if you suspected colorectal cancer?

A

RECTAL EXAM

Bloods: FBC (looking for anaemia)
Us and Es (?nutrition)
LFTs (detect abnormal liver function)
CEA (carcinogenic-embryonic antigen)

Sigmoidoscopy ((rigid/flexible) catches about 60% tumours) or Colonoscopy (gold standard)

Biopsy

CT (for staging)

Liver ultrasound/MRI (to detect liver mets)

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20
Q

What is the 5 year survival rate for a Stage A CRCa?

A

80%

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21
Q

What is the 5 year survival rate for a Stage B CRCa?

A

50%

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22
Q

What is the 5 year survival rate for a Stage C CRCa?

A

15-40%

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23
Q

What is the 5 year survival rate for a Stage D CRCa?

A

6%

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24
Q

What investigations would be useful for looking for mets in CRCa?

A

LFTs

Liver ultrasound

MRI (more specific for showing liver mets)

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25
Q

What are the risk factors for colorectal cancer?

A

Diet (high in fat (animal), meat and low in fibre, calcium and folate)

Inflammatory disease (UC and Crohn’s)

FHx of bowel cancer (under 60s)

Hereditary bowel cancers: HNPCC (hereditary non-polyposis colon cancer) and FAP (Familial adenomatous polyposis)

PMHx of small bowel, endometrial, breast and ovarian Ca

obesity, smoking, alcohol

Diabetes

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26
Q

What are the most common presentating features of a R-sided colon cancer?

A

weight loss

anaemia

occult bleeding

mass in right iliac fossa

disease more likely to be advanced at presentation.

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27
Q

What are the most common presenting features of a L-sided colon cancer?

A

often colicky pain

rectal bleeding

bowel obstruction

tenesmus

mass in left iliac fossa

early change in bowel habit

less advanced disease at presentation

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28
Q

What are the most common (general) presenting features of colorectal cancer?

A

rectal bleeding

change in bowel habit

anaemia (more common in R-sided tumour)

weight loss

vague abdo pain

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29
Q

what are the differentials for someone presenting with:

rectal bleeding, altered bowel habit, abdominal pain, weight loss and anaemia (ie. main presenting features of colon cancer)

A

Divreticular disease

IBS

IBD

Haemorrhoids

Anal cancer

Ischaemic colitis

Pneumatosis coli

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30
Q

How quickly should a patient be seen when an emergency referral is made?

A

Patient should be seen within 2 weeks (max)

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31
Q

What are the urgent referral criteria for colorectal cancer?

A

40 or under: rectal bleeding + altered bowel habit (looser, more frequent) for 6/52 or more

60 or under with EITHER: rectal bleeding 6/52 OR altered bowel habit 6/52

Any age pt: palpable rectal mass, R lower abdo mass

Any age man or woman (non-menstruating): unexplained iron-deficiecy anaemia with Hb of 11 and 10 (respectively)

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32
Q

What are the ‘T’ classifications for colorectal cancer in the TNM staging system?

A

TX: primary cannot be assessed.

T0: no evidence of primary carcinoma in situ (Tis) - intraepithelial or lamina propria only.

T1: invades submucosa.

T2: invades muscularis propria.

T3: invades subserosa or non-peritonealised pericolic tissues.

T4: directly invades other tissues and/or penetrates visceral peritoneum.

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33
Q

What are the ‘N’ classifications for colorectal cancer in the TNM staging system?

A

NX: regional nodes cannot be assessed.

N0: no regional nodes involved.

N1: 1-3 regional nodes involved.

N2: 4 or more regional nodes involved

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34
Q

What are the ‘M’ classifications for colorectal cancer in the TNM staging system?

A

MX: distant metastasis cannot be assessed.

M0: no distant metastasis.

M1: distant metastasis present (may be transcoelomic spread)

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35
Q

What are the stages of colorectal cancer (non-Duke’s staging)?

A

Stage 0: carcinoma in situ (CIS).

Stage 1: T1/T2, N0, M0

Stage 2: further spread, but no lymph node involvement
Stage 2a: T3, N0, M0
Stage 2b: T4, N0, M0

Stage 3: lymph node involvement:
Stage 3a: T1/T2, N1, M0
Stage 3b: T3/T4, N1, M0
Stage 3c: any T, N2, M0

Stage 4: Cancer has spread to other parts of the body. Any T, any N, M1

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36
Q

What are the three levels of colorectal cancer grading?

A

Grade 1 (low grade): well differentiated.

Grade 2 (moderate grade): moderately differentiated.

Grade 3 (high grade): poorly differentiated

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37
Q

How can response to treatment be measured in patietns with colorectal cancer?

A

CT

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38
Q

What is the first-line of treatment of localised colorectal cancer?

A

Surgery to resect localised disease

(usually cures)

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39
Q

What is the most recommended treatment for colorectal primary with liver met(s)?

A

Surgery to remove affected colon and liver mets

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40
Q

How might radiotherapy be used in colorectal cancer?

A

Rectal carcinoma

Pre-operative or adjuvant therapy in high-risk rectal carcinomas

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41
Q

Why isn’t radiotherapy recommended in colon cancers?

A

risks toxicity to adjacent organs

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42
Q

What are the palliative therapeutical options to consider for patients with late-stage colorectal cancer?

A

Surgery or stenting (manage/prevent obstruction by lesion)

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43
Q

When might chemotherapy be used in patients with colorectal cancer?

A

adjuvant therapy for high-risk (stage D) patients

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44
Q

What chemotherapy agents are recommended in colorectal cancer?

A

5-FU

Oxiplatin

Irinotecan

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45
Q

What colorectal screening schemes are available in UK?

A

Faecal occult blood testng in general population

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46
Q

What treatments can be considered for patients with colorectal cancer?

A

Surgery (resect primary and met(s))

Radiotherapy (pre-operative and adjuvant) for rectal cancers (before/after total resection)

Chemotherapy: adjuvant for high-risk (stage D) cancers
5-FU
Oxiplatin
Irinotecan

Palliative: stenting/surgery to prevent/remove blockage

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47
Q

What are the risk factors for breast cancer?

A

Increasing age

Increased periods of oestrogen exposure (nuliparity, late/early menarche, late menopause, obesity)

Ionising radiation

Family history (1st degree relatives)

BRCA mutations

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48
Q

What are the risks associated with BRCA mutations?

A

Increased susceptibility to breast and ovary cancer

Early onset Ca (breast only) - INCLUDES MALE BREAST Ca

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49
Q

Which type of breast cancer is more common (ductal or lobar)?

A

Ductal (70/80% (lobar: 10%))

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50
Q

How might breast cancer present?

A

lump (painless = more likely to be cancer)

Nipple discharge and inversion

Lymphadenopathy

Skin changes

Erythema

Symptoms of met disease: bone pain and lung/liver/brain symptoms

(men may not have nipple and skin changes)

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51
Q

What are the differentials when a patient presents with potential breast Ca symptoms?

A

Ductal papilloma

Fibrocystic disease

Cyst/abscess

Mastitis

DCIS

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52
Q

How would you start investigating for breast cancer?

A

TRIPPLE ASSESSMENT:

Physical examination

Imaging: bilateral mammography (35<)
ultrasound (35>)

Fine needle aspiration or biopsy

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53
Q

After tripple assessment, what other investigations might you do for breast cancer?

A

Liver ultrasound or CT
Isotopic bone scan (bisphosphonates)

In pts with suspected mets

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54
Q

What are the ‘T’ classifications for breast cancer in the TNM staging system?

A

T0: no primary tumour

Tis: in situ (non-invasive)

T1: invasive tumour (<2 cm)

T2: 2-5cm

T3: >5cm

T4: skin involvement

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55
Q

What are the ‘N’ classifications for breast cancer in the TNM staging system?

A

N0: no lymph nodes

N1: mobile axiallry nodes

N2: fixed axillary nodes

N3: internal mammary nodes

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56
Q

What are the ‘M’ classifications for breast cancer in the TNM staging system?

A

M0: no mets

M1: mets

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57
Q

What are the different stages of breast cancer?

A

Stage 0: Tis, N0, M0

Stage 1: T1, N0, M0

Stage 2: T2/3, N0, M0 OR T0/1/2, N1, M0

Stage 3: T or N >2, M0

Stage 4: T and N any, M1

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58
Q

What are the recommended treatments for breast cancer?

A

Surgery: mastectomy or wide local excision (survival equivalent in correctly selected pts)

Remove all lymp glands if invaded or high risk of recurrence (these pts do not have radiotherapy)

Radiotherapy (depends on location and size)

Systemic therapy in specific circumstances

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59
Q

What systemic treatments are available for breast cancer?

A

Endocrine treatments: Herceptin (trastuzumab)
Tamoxifen
Anastrazole
Ovarian ablation

Cytotoxic therapy: Chemotherapy

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60
Q

When can herceptin be used?

A

Breast cancer: metastatic and lcal disease

WHERE CANCER EXPRESSES HER-2

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61
Q

When can tamoxifen be used?

A

Breast cancer - adjuvant treatment

tumours that are oestrogen receptive (ER +ve)

Pts who are pre-menopause

must be taken for 2-5 years

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62
Q

What are the benefits of tamoxifen?

A

Reduced risk of death and recurrent

Also decreased incidence in contralateral women (irrespective of ER status)

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63
Q

When can anastrazole be used?

A

Breast cancer

ER +ve tumours

Post-menopausal pts.

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64
Q

What are good predictors of response to endocrine treatments in breast cancer?

A

Pt has local disease

Response to previous endocrine treatment

Greater duration of previous disease-free interval

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65
Q

What proportion of patients with metastatic breast cancer respond to endocrine therapies?

A

1/3

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66
Q

How can ovarian ablation take place?

A

surgical

radiotherapy

LHRH (leutenizing hormone release hormone)

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67
Q

When would chemotherapy be considered in breast cancer?

A

Adjuvant therapy: high stage/spread (reduces risk of recurrence)

More effective in women 50<

Benefit is percentage of risk (benefit is lower in better prognosis, higher in poorer)

Higher dose = more effective (combination therapy > single-agent therapy)

Palliative: improve QoL

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68
Q

What is the 5-year survival for a patient with stage 1 Breast Ca?

A

84%

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69
Q

What is the 5-year survival for a patient with stage 2 Breast Ca?

A

71%

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70
Q

What is the 5-year survival for a patient with stage 3 Breast Ca?

A

48%

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71
Q

What is the 5-year survival for a patient with stage 4 Breast Ca?

A

18%

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72
Q

What age women does the breast cancer screening scheme include?

A

47-73

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73
Q

What are tumour markers and why are they useful in oncology?

A

Substances produced BY or IN RESPONSE TO tumour

Present in blood or other tissues

can be quantified

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74
Q

What are the two desired qualities of a tumour marker?

A

Highly specific: few people FALSELY LABELLED

Highly sensitive: few people MISSED

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75
Q

What are the uses of tumour markers?

A

diagnosis

detect relapse/trend of disease

response to treatment

indication of prognosis

screening (not routinely used)

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76
Q

How can tumour markers be used for diagnosis? And what is the problem?

A

High levels can be indicative of disease. If you increase the threshold needed to confirm the presence of a disease, the test becomes more sensitive.

If the marker is not specific, then it could be raised due to another condition, therefore isn’t conclusive.

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77
Q

How can tumour markers be used to indicate relapse of cancer?

A

If pt. had high levels when ill, and they decrease through treatment, a subsequent increase could be indicative of relapse (or tumour activity)

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78
Q

How can tumour markers be used to measure response to treatment?

A

levels may reduce with treatment

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79
Q

How can tumour markers be indicative of prognosis?

A

Rising values could indicate decline of patient’s state. High levels could suggest a worse prognosis (depends on specificity of test)

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80
Q

What are the different types of tumour markers?

A

hormones: thyroglobulin, ADH, adrenocorticotrophic hormone

immunoglobulins

intermediate metabolites

cell surface proteins: CEA, CA125, CA19.9

enzymes: APT, ALT, LDH

oncofetal proteins: HCG, alpha-feta protein

Nucleic acid

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81
Q

What can cause raised CEA (carcino-embryonic antigen)?

A

colorectal ca

gastric ca

breast ca

lung ca

smoking

Gastro problems: IBD, hepatits, pancreatitis and gastritis

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82
Q

What cancer is CEA most commonly used to investigate?

A

colorectal carcinoma

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83
Q

A 67-year-old man with metastatic colon cancer and multiple liver mets complains of vomiting. He is eating and drinking normally but vomits once or twice a day often undigested food, but has little nausea.

What is the most likely cause for these symptoms?

What is the most suitable first-line anti-emetic?

A

Gastric stasis

Metaclopramide

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84
Q

A 54-year-old woman with metastatic breast cancer complan of vomiting, usually in a morning. She also complains of increasing frontal headaches.

What is the likely cause of these symptoms?

What is the most suitable first-line anti-emetic?

A

Cyclizine (for vomiting and ICP)

(+ dexamethasone (to reduce ICP))

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85
Q

A 29-year-old man with a testicular tumour is having chemotherapy after an orchidectomy. He complains of severe nausea and vomiting when he enters the oncology day unit?

What is the likely cause of these symptoms?

What is the most suitable first-line anti-emetic?

A

Anticipatory

Lorazepam

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86
Q

A 47-year-old woman with advanced cervical cnacner complains of drowsiness persistent nausea, intermittent small vomits and reduced urine production?

What is the likely cause of these symptoms?

What is the most suitable first-line anti-emetic?

A

Renal failure (Could also suspect hypercalcaemia, but usually get polyuria and polydipsia before these symptoms in hypercalcaemia)

Haliperidol

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87
Q

A 71-year-old man with prostate cancer is started on zomorph 20mg twice daily for pain control. Two days later he complains of nausea and reduced appetite. His bowels are open daliy and he has no new urinary symptoms.

What is the likely cause of these symptoms?

What is the most suitable first-line anti-emetic?

A

Opiods

Haliperidol (drug-related vomiting counts as toxic vomiting)

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88
Q

A 65-year old man with lung cancer compains of difficulty passing hard stool.

What drug is most likley to have caused his constipation?

a) fybogel
b) gabapentin
c) metaclopramide
d) ondansatron
e) paracetamol

A

Ondansatron

VERY CONSTIPATING

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89
Q

A 71-year old woman with advanced breast cancer is having difficulty passing hard stool and is prescribed lactulose.

What best describes the mechanism of action of lactulose?

a) bulk forming agent
b) contrast irritant
c) softner and stimulant
d) stimulant
e) stool softener

A

Stool softener

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90
Q

A 47-year-old man with recurrent renal cancer and bone mets, complains of increasing back pain, difficulty poassing urine and constipation.

What is the most likely cause of his symptoms?

a) hypocalcaemia
b) NSAIDS
c) poor fluid intake
d) spinal cord compression
e) urinary retention

A

Spinal cord compression

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91
Q

A 69-year old woman with advanced ovarian cancer complains of reduced appetite and constipation and is commenced on codanthramer.

What is the most appropriate advice about this medication to give to the patient?

a) codanthramer is carcinogenic if taken long term
b) codanthramer should be administered orally
c) codanthramer may cause an orange discolouration of the urine
d) codanthramer may cause a severe peri-anal rash
e) codanthramer can cause excessive flatulence

A

c) Orange urine

(only causes peri-anal rash if incontinent)

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92
Q

What are the most common causes of pleural effusion:

A

chest infection
cancer

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93
Q

What is the most common cause of a bilateral pleural effusion?

A

Heart failure

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94
Q

When might a PSA level be raised?

A
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95
Q

when is PSA used?

A

Investigate prostate Ca (indicate whether a biopsy is needed)

To monitor response to hormonal/cytotoxic treatment or surgery

Detect relapse/more active cancer (eg. trend of rising PSA)

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96
Q

What are immunoglobulins used to detect in oncology?

A

myeloma
Waldenstrom’s macroglobinaemia (a type of non-hodgkins lymphoma)
Non-hodgkins lymphoma

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97
Q

What is the difficulty in using CA125 to detect for ovarian cancer?

A 
Can also be raised in: normal women (1%)
benign conditions (6%)
Ovarian cancer (82%)

Doesn’t detect all cancers (remaining 18%)

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98
Q

At what level is CA125 only indicative of malignant disease?

A

Greater than 200U/mL

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99
Q

What cancer is CA125 most commonly used to detect for?

A

Ovarian

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100
Q

What cancers can cause raised level of CA125?

A

OVARIAN

Pancreatic*

Lung*

Colorectal*

Breast*

*Especially when these have spread into abdominal cavity

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101
Q

Where can immunoglobulins be detected?

A

blood or urine

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102
Q

What causes mildly raised levels of alpha-fetoprotein?

A

Hepatitis

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103
Q

What causes high levels of alpha-fetoprotein?

A

Hepatocellular carcinoma
Teratoma

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104
Q

What do higher levels of alpha-fetoprotein indicate about prognosis?

A

Poor prognosis

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105
Q

When does alpha-fetoprotein stop being detectable in normal adults?

A

after the age of 1

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106
Q

What can human chorionic gonadotrophin levels be used to detect?

A

hydatiform mole and choriocarcinoma

Non-seminomatous testicular cancers (some seminomatous)

Pregnancy

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107
Q

What are the usual sites for a syringe driver?

A

chest

abdomen

upper arm

thigh

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108
Q

What features indicate that it is not approprite to administer SC medication at this site (when using a syringe driver)?

A

oedematous areas

broken skin

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109
Q

What can be done to try and prevent problems with syringe driver sites?

A

Check for redness, soreness, induration, precipitation

Move sites every day/every few days

Provide a very small dose of dexamethasone (to prevent any problems occuring with the site)

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110
Q

How long does a syringe driver take to establish a stable dose in the patient? What can be done to provide pain relief during this time?

A

3-4 hours

Can give a stat SC injection of appropriate medicines (eg. pain killers, anti-emetics etc.)

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111
Q

Which drugs are too irritant to use in the syringe driver?

A

diazepam

chlorpromazine

prochlorperozine

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112
Q

What should you use to dilute drugs in syringe driver?

A

Water

(saline can be used if there is a problem with site irritation)

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113
Q

When can you dilute drugs with saline when using a syringe driver?

A

when there are problems with site irritation

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114
Q

what drug should not be diluted by saline? why?

A

cyclizine

the combination can cause precipitation

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115
Q

How do you work out the rate per hour of drug when setting up a syringe driver?

A

Calculate the total dose needed in 24 hours.

Divide it by 24.

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116
Q

What is the dose of hyosine butylbromide (buscopan) given in a syringe driver?

A

60-120mg

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117
Q

What is the dose of cyclizine given in a syringe driver?

A

100-150mg over 24 hours

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118
Q

What is the dose of halloperidol given in a syringe driver?

A

3-10 mg (for vomiting)

10-30mg (for terminal agitation/confusion)

*Risk of dyskinesia at doses higher than 10mg

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119
Q

What is the dose of metaclopramide given in a syringe driver?

A

30-60mg over 24 hours

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120
Q

What is the dose of levomepromazine given in a syringe driver?

A

6.25mg-100mg over 24 hours

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121
Q

What is the dose of hyoscine hydrobromide given in a syringe driver?

A

400 micrograms - 2.4mg

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122
Q

What is the dose of midazolam given in a syringe driver?

A

10-60mg

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123
Q

What are the two different types of morphine?

A

Immedite release (oromorph liquid)

Modified release (zomorph, MST - two different preparations)

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124
Q

What are the key features of immediate-release morphine?

A

Takes 30 mins to work

Lasts for 4 hours

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125
Q

What are the features of modified release morphine?

A

BD (released over 12 hours)

Continuous dose

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126
Q

How do you determine the dose of oromorph to prescribe for someone on morphine?

A

oromorph dose = 1/6th of background dose of morphine (either zomorph or MST)

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127
Q

How regularly can oromorph be used (if calculated as 1/6 of background morphine dose)?

A

PRN - hourly if needed

Max of 6 doses in 24 hours

NOTE THIS ON THE DRUG CHART

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128
Q

What are the main side-effects of morphine?

A

Drowsiness

Constipation

Nausea and vomiting

(Respiratory depression: Not a problem if doses are correct)

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129
Q

How long would you expect a patient to experience drowsiness for when prescribed morphine?

If it persists longer than this, what could cause this?

A

48-72 hours

dose
renal function

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130
Q

A patient on morphine experiences constipation, what do you do?

A

prescribe laxative

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131
Q

A patient on morphine experiences nausea and vomiting, what would you do?

A

anti-emetic (or reduce dose)

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132
Q

A patient on morphine experiences respiratory depression, what do you do?

A

Prescribe naloxone

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133
Q

How do you convert oromorph in to MST/zomoprh?

A

Work out daily total dose of what is being given, divide it by two (as it will be given BD) and then add this to MST dose.

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134
Q

Is there a maximum dose of morphine that can be described?

A

NO MAXIMUM DOSE

Titrate up in 30% dose

Depends on: side effect
Pain relief level

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135
Q

Mr Williams is a 67 year old man with lung cancer. He is in pain. His medical notes show that he was diagnosed with an inoperable sqamous cell carcinoma of the R lung 2 months ago and received two fractions of palliative radiotherapy. He was admitted 3 days ago with increasing shortness of breath. He was found to have a pleural effusion. The respiratory team are due to drain this tomorrow.

You find his drug chart and see he is on regular paracetamol (1gm qds), salbutamol nebuliser (2.5mg qds) and furosemide (40mg od)

What are the differentials?

A

PE
MI
Angina
Pneumonia
Pleural invasion
Pneumothorax
Rib fracture
GORD
MSK
Neuropathic pain

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136
Q

What is the definition of neuropathic pain?

A

Pain in an area of sensory information

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137
Q

How do you convert the dose of codeine into doses of oromorph?

A

Work out how much codein is being given:
eg. 30mg BD = 60mg over 24hrs

Divide this by 10 (as oromorph is 10x stronger than codeine)
60/10= 6mg.

6mg of oromorph can be given PRN. MAXIMUM OF 4 TIMES. MAX DOSE 24mg - WRITE THIS ON THE DRUG CHART.

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138
Q

What are the three main causes of pain?

A

Disease itself

Treatment

Concurrent disease (resulting from first disease)

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139
Q

How do you treat pain related to an infection?

A

Treat underlying infection

Treat pain (depending on what patient is already on and where they are on pain ladder)

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140
Q

What are the features of neuropathic pain?

A

Pain in an area of abnormal sensation

Localised (eg. dermatome) or widespread

Numbness or hyperaesthesia

Autonomic changes: pallor, sweating

Pins and needles or burning

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141
Q

How do you treat neuropathic pain?

A

TCA: amitriptyline

Anti-convulsants: gabba-pentin (cheaper)
Pre-gabbalin

(compression of nerve may be helped by corticosteroids)

142
Q

What can help with pain associated with compression of a nerve?

A

corticosteroids

143
Q

How should you manage the pain caused by a headache related to raised ICP?

A

Corticosteroids (dexamethasone - to reduce oedema)

NSAIDS

Paracetamol

144
Q

What are the features related to a headache caused by raised ICP?

A

Dull, oppressive pain

Usually worse on coughing, waking and sneezing

Nausea and vomiting

145
Q

What are the features of visceral pain?

A

Dull, deap seated pain

Poorly localised

May be tenderness over organ
Spasmodic - bladder spasm, bowel colic.

146
Q

How would you manage visceral pain?

A

Suspected dull visceral pain: analgesia ladder

Pain due to visceral stretch (eg. liver capsule pain): NSAIDS and corticosteroids (reduce inflammation)

Colic/spasmodic pain: anticholinergic drugs

147
Q

What are the main features of bone pain?

A

Dull ache over a large area

OR

Localised tenderness over bone

148
Q

How would you manage bone pain?

A
149
Q

What is stage one of the analgesia ladder?

A

Paracetamol

150
Q

What is stage two of the analgesic ladder?

A

WEAK opioids - eg. co-codamole (Paracetamol and codeine)

151
Q

What dose of co-codamol would you start someone on if moving from step 1 to step 2 of the analgesic ladder?

A

30/500 (UNLESS ELDERLY: reduce the dose)

152
Q

What is step three of the analgesic ladder?

A

Strong opioids: morphine
diamorphine
buprenorphine
oxycodon
phentanil
methadone

153
Q

Can paracetamol be continued in to step 3 of the analgesic ladder?

A

yes

154
Q

What are the adjuncts of the analgesic ladder?

A

NSAIDS: can be used at any stage

Anti-epileptics: Gabapentin, pre-gabalin

Anti-depressants: amitriptyline

Corticosteroids: prednisilone, dexamethasone

TENS machine

155
Q

What medication should you give to patients who are on terminal care?

A

ONLY THINGS THAT MANAGE Sx

156
Q

What are 4 things you can/should prescribe for terminal care patients?

A

Analgesia

Anti-emetics

Antisecretories

Anxiolytics

(all SC)

157
Q

What should be done about food and fluids during terminal care?

A

Support oral intake for as long as possible

?do not commence articficial food/hydration

158
Q

What are the problems with artificial hydration in terminal care?

A

Causes pulmonary and peripheral oedema

159
Q

What are the benefits of withdrawing artificial fluid/food?

A

reduced vomiting and incontinence

reduced barriers between patient and carer

prevents need for venepuncture

160
Q

What are nursing care needs likley to be in terminal care patients?

A

Mouth care for dry mouth

Special bed

Catheter/incontinence pads

Bowel care (if pt. uncomfortable)

Fast track/continuing care (to get pt. in correct place to die)

161
Q

Things to discuss with family when patient is on terminal care:

A

Check understanding of situation (incl. decision not to artificially feed etc.)

Negotiate treatment

Explore fears and concerns

Check re. any unfinished business and whether they may benefit from help

Identify those at risk of bereavement

Involved faith leader (if pt. wishes)

DNACPR!!!

162
Q

Give some examples of distressing terminal events:

A

haemorrhage

fits

tracheal obstruction

(these are rare, need to anticipate them and agree a management plan)

163
Q

How might you recognise someone who is coming towards the end of their life?

A

Rapid deterioration of condition

Weakness

Confined to bed most of time

Extended periods of drowsiness

Disorientated

Severely limited attention span

Losing interest in food and drink

Too weak to swallow meds

164
Q

What is a death rattle? How would you treat it?

A

Noise made by secretion in URT (pt too weak to expectorate)

Re-position pt to be more upright. 
Prescribe hyoscine (buscopan)
165
Q

How would you manage terminal restlessness?

A

Elliminate reveersible causes: pain, urinary retention, respiratory secretions, faecal impaction

Sedation: midazolam (SC/IV)

166
Q

What needs to be considered after death?

A

Pt. religion - do they have any special requirements
Prompt provision of death certificate (family cannot do anything until they have this)
Inform GP within 24 hours
Warn relatives re. involvement with the coroner

Provide family with info on: role of a funeral director, how to register death, sommon feelings of grief and support available

167
Q

Which tumours are most likely to cause major haemorrhage in terminal care?

A

Head and neck

Tumours that may erode major vessels

168
Q

How would you manage a patient who suffeers a major haemorrhage in palliative care?

A

Green towels close by: absorb blood and reduce visual impact of blood

IM/SC midazolam: sedative and amnesic effect

MEMBER OF STAFF TO STAY WITH PATIENT

169
Q

What cancers are most associated with SCC?

A

Prostate
Breast
Lung
Myeloma and lymphoma

(less common: renal and thyroid)

170
Q

Where in the spine are the majority of SCCs?

A

2/3 thoracic

1/3 cervical or lumbar

171
Q

How might SCC present?

A

Back/nerve root pain. Worse when: lying flat, movement, cough (may be first sign OR absent)

Leg/motor weakness (can be subtle, rapid or slow onset)

Difficulty controlling bladder/bowels

Urinary retention

Saddle anaesthesia

Loss of anal tone

Paraparesis and paraplegia

Hyper-reflexia (below level of lesion)

Clonus

AUTONOMIC DYSREFLEXIA (injuries T6 and above)

172
Q

How would you manage pt with suspected SCC?

A
  1. Lie flat
  2. Prescribe 16mg dexamethasone (with PPI cover)
  3. URGENT MRI SPINE - WITHINT 24 HOURS
173
Q

What treatment is available for SCC?

A

Steroids (dexamethasone 16mg)

Neurosurgical intervention +/- radiotherapy

Radiotherapy

Chemotherapy

174
Q

Why is it important to catch SCC early?

A

If motor function lost for 48 hours, unlikley to regain.

Noticing it early = prevent or partiall reverse problems

175
Q

What are the two most common causes of hypercalcaemia?

A

Hyperparathyroidism

Cancer

176
Q

Which cancers are most associated with hypercalcaemia?

A

Non-small cell lung (squamous cell)

Breast

Myeloma/lymphoma

Renal cell

Head and neck

*can occur without bone mets*

177
Q

How can cancer cause hypercalcaemia?

A

Can cause imbalance between bone reabsoprtion and calcium:

Factors produced by tumours eg.
Transforming growth factos alpha
Parathyroid hormone related peptides

Increase bone reabsorption, Increase renal tubule calcium reabsorption

178
Q

How can hypercalcaemia present?

A

General: dehydration, weakness and fatigue

CNS: confusion, drowsiness, seizures, coma (LATE FEATURES)
Proximal neuropahty and hyporeflexia

GI: weight loss, nausea and vomiting, abdo pain, constipation, ileus, dyspepsia, pancreatitis

Urinary: polyuria

Cardio: brady, ECG changes, BBB, arrhythmia arrest

179
Q

What ECG changes might you expect to see in pt with hypercalcaemia?

A

Reduced QT interval

Wide T wave

Increased PR interval

BBB

Arrhythmia

180
Q

What are the late feartues of hypercalcaemia?

A

confusion

drowsiness

seizures

coma

181
Q

How would you investigate a patient with suspected hypercalcaemia?

A

SERUM CALCIUM

FBC (check for infection markers to elliminate infection)

Hep/Renal function tests: LFTs, U&Es, Serum creatinine

Urinalysis

Abdo exam

ECG

Blood glucose (elliminate DKA)

ABG: late stages, sepsis screen

182
Q

How would you manage a patient with Hypercalcaemia?

A
  1. PAIN RELIEF (if necessary)
  2. FORCEFUL DIURESIS TO PROMOTE CALCIUM EXCRETION
    Normal saline:
    1L over 4hrs for 24hours
    1L over 6 hours for next 48-72 hours (with adequate K)
3. INHIBIT BONE REABSORPTION
IV Bisphosphonates (pamidronate or zaledronic acid)
  1. RAPID ACTING REDUCTION OF SERUM CALCIUM
    Calcitonin and corticosteroids
    Salmon calcitonin (SC/IM) and oral presnisilone
183
Q

How might a patient with neutropenic sepsis present?

A

Sepsis symptoms: pyrexia/sub-optimal temperature
Flu-like symptoms
Rigor
Malaise
Specific infection (eg. UTI)
Diarrhoea
Vomiting/nausea
Confusion/altered mental state

184
Q

What examinations might you perform on someone with suspected neutropenic sepsis?

A

Temp (<38 or 38.5=< for more than one hour)

ABC

MEWS

Look for potential site of infection:
lungs, wounds, cannulation/central line sites, bowel/perianal, UTI

DO NOT DO VAGINAL OR RECTAL EXAM: RISK OF CAUSING BACTERAEMIA

185
Q

What elements of a pts history might point you in the direction of neutropenic sepsis?

A

Recent chemotherapy

Previous episodes of neutropenic sepsis

Localising symptoms of infection

(also need to find out about allergies for sake of ABX prescribing)

186
Q

What score might you think about using to calculate a pts risk of complications during a febrile neutropenic episode?

A

MASCC score

187
Q

What kinds of criteria does the MASCC score include?

A

Burden of illness (extent of symptoms)
BP
COPD
Tumour type (solid/not solid)
Previous infection
Presence of haematolgic malignancy
Dehydration
Age (60<)

188
Q

What investigations might you do on someone with suspected neutropenic sepsis?

A

FBC (paying particular attention to ANC)

CRP
Lactate
LFTs, U&Es, Serum creatinine
Blood culture (x2: aerobes and anaerobes) from lines or peripheral
Swabs
Sputum culture
Urinalysis and culture
Stool analysis and culture (if diarrhoea)
CXR (if resp Sx, lung ca or mets)

Only if indicated: atypical pneumonia serology
urine for legionella

(ANC <= 1 x 109/L)

189
Q

How would you manage a patient with neutropenic sepsis?

A

Antibiotics: ASAP.
Straight AFTER blood cultures
5 day course
Add in secondary ABX if no response to first-line within 48 hours.

After 5 days, continue on ABX if ANC <= 1 x 109/L AND:
Fever
Hypotensive
Tachycardic
Symptoms of systemic infection
EVEN IF PT IS AFEBRILE

Call Senior: oncologist, microbiologist

190
Q

What is an alternative treatment for neutropenic sepsis? When would this be considered appropriate to use?

A

G-CSF (filgastrim and lenogastrim) = colony stimulating factors

Haemopeoitic growth factors that promote stem cell proliferation and reduce duration of neutropenia

Not routinely prescribed unless ANC neutropenic for 10< or risk of multi-organ failure

191
Q

What organisms most commonly cause neutropenic sepsis?

A

Gram +ve: Staph. A
Coagulase -ve staph
alpha and beta haemolytic strep

Gram -ve: E coli
Klebsiella
Pseudomonas

Fungi: candida and aspergillus

192
Q

If a patient has neutropenic sepsis, what might this mean for their chemotherapy? Are there any exceptions?

A

May need to reduce dose being given (especially in palliative patients)

Exception: Hodgkins and testicular cancer - try to maintain dose (as good cure rates with high dose, therefore ?greater benefit than risk)

193
Q

What malignancies most commonly cause SVCO?

A

Lung

Lymphoma

Mediatinal tumours: lymphadenopathy and germ cell tumours

Thymoma

Oesophageal

THROMBUS (tumour-associated)

194
Q

What are some benign causes of SVCO?

A

Non-malignant tumours: goiter

Mediastonal fibrosis

Infection (TB)

Aortic aneurysm

Thrombus from catheter

195
Q

How might SVCO present?

A

Dyspnoea (worse on lying flat)

Headache (worse on coughing)

Facial/neck/arm swelling

Distended chest/neck veins

Cough

Hoarse voice

Cyanosis (head, neck. worse when raise arms of lying flat)

Visual disturbance

196
Q

What investigations would you do for a pt if you suspected SVCO?

A

CXR
Contrast CT thorax

If not diagnosed with cancer: Tumour markers
Bronchoscopy
Mediastinoscopy
Biopsy

197
Q

How would you manage someone with SVCO?

A
  1. 16mg dexamethasone (plus PPI)
  2. Depends on cause: Vascular stenting of SVCO
    Chemotherapy
    Radiotherapy
    LMWH (if thrombus)
198
Q

How does chemotherapy work?

A

Tries to: erradicate occult cancer cells
treat the natural progression of cancer​

Chemotherapy agents are preferentially toxic to more actively proliferating cells ie. cancer cells
Tumours with more rapid proliferation = more effected

199
Q

What are the different uses for chemotherapy?

A

Adjuvant
Primary
Neo-adjuvant
Currative
Palliative
Prophylactic

200
Q

What is neo-adjuvant chemotherapy and when is it used?

A

Pre-operative treatment

Used in operable tumours to cure:
Make tumour smaller (allow less radical surgery)
treats occult mets

eg. osteosarcoma

201
Q

What is primary chemotherapy and when is it used?

A

Initial treatment for tumour that is inoperable (or operability is uncertain)

Aim: make curative surgery feasible and reduce tumour bulk
Increases cure rates

202
Q

What is adjuvant chemotherapy and when is it used?

A

After surgery

Aim: treats occult mets
Increase cure rates

eg. breast and colorectal ca

203
Q

What is palliative chemotherapy and when is it used?

A

In pts where cure isn’t possible:

Alleviate symptoms
Prolong life

S/E should not be > negative impact on QoL

204
Q

What is prophlyactic chemotherapy and when is it used?

A

Hormonal treatment before overt malignancy appears

eg. tamoxifen (in in-situ breast cancer before invasice carcinoma occurs)

205
Q

What is curative chemotherapy and when is it used?

A

Sometimes this works even in presence of mets (eg. germ cell tumours, hodgkins, non-hodgkins, childhood cancers)

Justifies use of more aggressive treatment

206
Q

Give some examples of oral chemotherapy

A

Tamoxifen

Capecitabine

Etoposide

Cyclosphamide

207
Q

What are the benefits of oral chemotherapy?

A

Less invasive

Less hospital visits

208
Q

What are the issues with oral chemotherapy?

A

variation of drug levels in blood

still needs regular check ups at hospital

209
Q

What are the three types of systemic administration of chemotherapy?

A

bolus injection

infusion (short)

continuous infusion

210
Q

What is the most common route of administration for chemotherapy?

A

Systemic

211
Q

When might intravesical chemotherapy be used? What is the benefit of this?

A

superficial bladder cancer

Higher dose at site of tumour, negligable systemic absorption (limit toxicity)

212
Q

When might intraperitoneal chemotherapy be used?

A

For cancers that spread trans-coelomically eg. ovarian cancer

213
Q

When might intra-arterial chemotherapy be used? What is the benefit of this?

A

Tumours that have good blood supply eg. hepatic artery infusion (for liver mets)

Higher does at site: reduced toxity

214
Q

Why is chemotherapy given cyclically?

A

Allows normal cells to recover from treatment

Need repeated cycles to get tumour clearance (but no point giving excessive number of cycles (increased toxicity))

215
Q

How long does chemotherapy take to reach maximum effect?

A

after 6-months

216
Q

How is the dose of chemotherapy calculated?

A

Surface area

(except carboplatin: this is done using renal function)

217
Q

Why is chemotherapy administered in combinations?

A

Different classes of chemo have different actions, therefore maximise cell kill.

Less chance of drug-resistance: either in initial malignancy or developing mets

Different drugs cause different toxicity, therefore allows high dose of treatment, without high s/e

218
Q

When might single agent chemo be appropriate?

A

Case-specific

Palliaive care

219
Q

What are the short term side-effects of chemotherapy?

A

Cardio: arrhythmias, coronary artery spasm (ischaemia)

Alopecia

Peripheral neuropathy

GI: oral mucositosis, diarrhoea, constipation, paralytic ileus (rare)

Myelosupression

Nausea and vomiting

Genitourinary: haemorrhage cystitis, nephrotoxicity

Skin and soft tissue: extrasation, palmer plantar erythema, photosensitivity, pigmentation

Myalgia and arthralgia

Allergic reaction

Lethargy

220
Q

How can alopecia be prevented in pts undergoing chemotherapy?

A

Cold cap - reduces blood flow to scalp, therefore reducing effect drugs can have

221
Q

Which chemotherapy agents are most likely to cause peripheral neuropathies?

A

Platinum-containing drugs

esp. cisplatin
taxanes
vinka alkaloids

222
Q

Which nerves are usually effected in chemoherapy-induced peripheral neuropathy?

A

Mostly sensory nerves
(autonomic and CNS can also be effected)
Usually recover, but can have a small remaining deficit

Ototoxicity: permanent damage to cochlea

223
Q

What GI side effects can occur with chemotherapy?

A

oral mucositosis

diarrhoea (due to collitis and small bowel inflammation)

constipation (due to dehydration, nausea and analgesics)

Rarely:

paralytic ileus (due to autonomic neuropathy - RARE. Most commonly associated with platinums and vinka-alkaloids)

224
Q

How common are GI side effects in chemotherapy?

A

common

225
Q

When does myelosupression usually occur after chemotherapy?

How long does this last for?

A

10-14 days after the start of each cycle

Recover: 3-4 weeks (therefore allowing a further cycle)

226
Q

What neutrophil count represents a serious risk of infection for patients?

A

<0.5 x 109/L

227
Q

Which chemotherapy drugs cause nausea and vomiting?

A

Most cytotoxic drugs (therefore prescribe anti-emetics)

due to: direct stimulation of vomiting centre
peripheral stimulation
anticpatory causes

228
Q

What risk does chemotherapy present to the bladder? How can this be treated if it occurs?

A

haemorrhagic cystitis

antidote: MESNA

229
Q

What risk does chemotherapy present to the kidneys? How would you assess whether it was appropriate to start/continue this treatment?

A

Nephrotoxicity

Occurs especially with platinum agents

Due to the renal excretion of drugs

Therefore: need to check renal function regularly (?before each cycle of treatment)

230
Q

How would you treat palmar-plantar erythema in a patient receiving cytotoxic treatment?

A

Stop treatment

Prescribe emollient

231
Q

What psychological and social side effects of chemotherapy should you consider?

A

employment

relationships

insurance

social adaptation

(usually all effected, worse in young people)

232
Q

What are the long-term side effects of chemotherapy?

A

Fertility problems

Pyschological and social issues

Secondary malignancies

Pulmonary s/e: fibrosis, pneumonitis

Cardiac problems: fibrosis

233
Q

How would you manage chemotherapy-related myalgia and arthralgia?

A

NSAID analgesics

234
Q

How can fertility be effected by chemotherapy? What can you suggest to patients?

A 
Reduced fertility (with most drugs)
Alyklating agents: infertility-inducing at standard dose
Other agents: infertility-inducing at high doses

Males: sperm storage
Females: fertilised ova storage (be aware of ethical implications)

235
Q

Which patients are more susceptible to cariac fibrosis secondary to chemotherapy treatment?

A

Younger patients

236
Q

Which drugs are most likley to cause DNA damage (therefore present higher risk of secondary malignancies)?

A

aklylating agetns and procarbazine

(Higher dose of drug = increased risk)

237
Q

What is myelosuppression?

A

A condition in which bone marrow activity is decreased, resulting in fewer red blood cells, white blood cells, and platelets.

238
Q

What can cause myelosupression in cancer patients?

A

(cytotoxic) treatment
interferon and interleukin-2

bone marrow infiltration

paraneoplastic syndromes (= pancytopenia)

blood loss from tumour (= anaemia)

anaemia of chronic disease

239
Q

How long after chemotherapy treatment does the nadir of myelosupression usually take place?

A

10-12 days

240
Q

How is chemo-dose related to myelosuppression?

A

Higher the dose, the higher the fall in total leucocyte count.

Also, decrease is more sustained.

241
Q

What is a paraneoplastic syndrome?

A

This is a syndrome (collection of symptoms) that occurs as a result of chemicals produced by a mass - not the mass itself. It can also occur as a result of the immune response to the tumour.

242
Q

What is pancytopenia?

A

Deficiency of all three cellular components of blood: red blood cells, white blood cells and platelets

243
Q

What form of myelosupression can paraneoplastic syndromes cause?

A

pancytopenia

244
Q

What is bone marrow infiltration and what form of myelosupression can it cause?

A

Bone marrow replacement by malignant infiltration

Can cause pancytopenia

245
Q

What malignancies cause higher risk of bone marrow infiltration?

A

haematological malignancies

breast

lung

prostate

246
Q

How do you treat bone-marrow infiltration?

A

anti-tumour therapy (cytotoxic agents - which are myelosupressive)

247
Q

What is a feature of anaemia resulting from chemotherapy?

A

Macrocytic NOT megaloblastic

248
Q

What is thrombocytopenia? What are the risks associated with it?

A

Deificiency of platelets in the blood

Causes bleeding in to tissues, bruising and slow blood clotting after injury

249
Q

What are the common causes of anaemia in cancer?

A

blood loss from tumour

anaemia of chronic disease (not iron-deficiency)

250
Q

What are the signs of thrombocytopenia?

A

Petchial haemorrhage
Spontaneous nose bleeds
Corneal haemorrhage
Haematuria

251
Q

How would you investigate suspected myelosupression?

A

FBC
blood film
bone marrow aspirate
trephine (bone marrow biopsy)

252
Q

Other than a blood transfusion, how else can we treat/prevent anaemia in patients on chemotherapy? What are the benefits of this over transfusion?

A

Prescribe recombinant erythropoeitin

(prevents symptomatic anaemia)

reduced risk compared to transfusion and viral transmission

253
Q

How do we treat anaemia resulting from chemotherapy?

A

Hb < 10: blood transfusion

254
Q

How can we try and prevent patients developing antibodies to blood products that are given in thrombocytopenia?

A

Give a single dose of blood products only

OR

HLA match the platelets

255
Q

What is the risk when providing repeated blood products to a patient for thrombocytopenia?

A

Antibodies to products are developed

May begin to see failure to increase in platelet count after transfusion

256
Q

How would you treat thrombocytopenia?

A

Platelets < 10 x 109/L: URGENT PLATELET TRANSFUSION

Platelet count 10-20 x 109/L: platelet transfusion (esp in the presence of transfusion)

Platelets > 20 x 109/L and no spontaneous bleeding: do not require platelet transfusion

257
Q

What is CT best used for imaging in oncology?

A

Bowel obstruction
Intra-luminal pathology
Mass lesions
Vascular structures

258
Q

What is important to consider when thinking about using a contrast CT?

A

Pts renal function

IV contrast can be nephrotoxic, therefore should be used with caution in AKI and CKD

259
Q

What is the level of radiation to the patient in CT scanning?

A

Low, but still at risk of developing radiation-related problems

*ASK ABOUT PREGNANCY*

260
Q

In what cancers is MRI the gold standard imaging tool?

A

Neurospinal

Rectal

Prostate

MSK tumours

Head and neck cnacers

261
Q

What is MRI good for viewing?

A

high soft tissue contrast

262
Q

What other types of MRI are useful in cancer imaging?

A

MR angiography: cardio vessels

MR cholangiopancreatograms: gall bladder and pancreas

Real-time MRI: breast cancer

263
Q

What is one of the main benefits of MRI over CT?

A

No radiation risk

264
Q

Which patients cannot undergo MRI?

A

Pts with metalwork eg. pacemakers or defibrillators
*THESE PTS MUST NOT ENTER MRI UNIT*

Eye and brain foreign bodies eg. vascualr clips, surgical staples, metalic shards

265
Q

Which metal work is okay in MRI?

A

Prosthetic joints (as they are very firmly fixed in patient)

266
Q

When can ultrasound be used in oncology?

A

Detecting masses in solid visceral organs (eg. liver)

Assessing blood flow (eg. in DVT or when assessing tumour blood flow)

Real-time guidance in biopsy

267
Q

What are the benefits of using ultrasound to image?

A

Low cost

Easily available

Painless

Non-invasive

No ionisation at all

268
Q

Why aren’t US investigations reliable for serial measurements?

A

They are operator dependent, therefore there may be individual variation between images produced and conclusions drawn.

269
Q

When can nuclear medicine be used?

A

Technetium: GFR

Bone scintography: principle investigation for detection of skeletal mets

270
Q

What can PET scanning be used for in cancer imaging?

A

Can differentiate benign tumours from malignant: FDG-18 usually taken up in areas of high glucose metabolism

Can be used when radical treatment appears possible but has high risk of morbidity/mortality. HELPS DECIDE WHAT TO DO (whether worth the risk)

271
Q

How are PET and CT usually combined in imaging?

A

PET usually combined with CT to map findings on to anatomy

272
Q

Which imaging techniques are best for staging in cancer?

A

Depends where you’re looking to stage:
CT - chest and abdo
MRI - bone and soft tissue

273
Q

How can imaging be used in oncology?

A

Diagnosis (eg. identify and guide biopsy for diagnosis)

Staging (presence and extent of mets)

Treatment (response)

274
Q

How can imaging be used to assess response to treatment?

A

CT, MRI and CXR: measure changes in tumour dimensions

275
Q

How do you classify response to treatment?

A

Stable disease: <20% increase or <30% decrease in size

Progressive: new lesions or lesion increase by 20%<

Partial response: all lesions decreased by 30% BUT disease still present

276
Q

Which cancers have a good cure rate with chemo?

A

hodgkins

testicular

acute lymphoblastic LEUKAEMIA

Choriocarcinoma

Paediatric cancers

277
Q

Which cancers which have okay cure rates (<50%) with chemotherapy?

A

non-hodgkins

ovarian

paediatric neuroblastoma

sarcomas

278
Q

Which cancers have few cures in advanced disease (but are used to prolong survival)?

A

NSCLC

Colorectal

Gastric

Breast

Bladder

Prostate

279
Q

For which cancers can chemotherapy produce remission in most patients?

A

breast cancers (in early stages)

SCLC

Ovarian cancer

280
Q

In which cancers is chemotherapy used for palliation (but with limited response?)

A

Renal

Melenoma

Head and neck

Pancreatic

Biliary tract

281
Q

Which cancers have an increased cure rate in high risk local regional disease if chemotherapy is used?

A

breast

colorectal

NSCLC

oesophageal and gastric

bladder

282
Q

What forms can modified release morphine come in?

A

tablets, granules and capsules

283
Q

What is the starting dose of morphine you would use?

A

if on max co-codamol: 20 mg MST BD is usually fine

284
Q

When would you condsider a reduced initial dose of morphine?

A

Elderly

Frail

Reduced renal function

Opiate niave

285
Q

What would you prescribe someone who was constipated due to opioid use?

A

co-danthramer if palliative

other laxatives (eg. movicol, senna) if not palliative

286
Q

Which anti-emetic would you prescribe for someone who was nauseated/vomiting due to opioids?

A

Haloperidol

nausea should settle after a couple of days

287
Q

If a patient who is on morphine is confused or had visual hallucinations, what should you do?

A

check dose

check renal function

consider alternative opioid

288
Q

What are the features of opioid toxicity?

A

Nausea, vomiting

persistent drowsiness

confusion

visual hallucination

myoclonic jerks

respiratory depression

289
Q

What can surgery be used for in oncology?

A

Resection of primary tumour

Reduce bulk of residual disease

Curative surgery for mets

Palliative

Prevention of cancer

Diagnosis and staging

290
Q

What are the conditions for surgical resection of a primary tumour?

A

must be localised

(some lymphnodes)

adequate margins of clearance required

+/- adjuvant radiotherapy or chemotherapy

291
Q

Why is curative surgery not usually recommended in metastatic disease?

A

There is usually a presence of occult mets, therefore only recommended in: solitary lung mets (sarcomas), localised liver mets (colorectal)

Combined with adjuvant therapy

292
Q

What types of surgery could be used to palliate a cancer patient?

A

Bowel obstruction removal

Stents

Pleurodesis

Pathalogical fracture pinning

293
Q

How can surgery be used to prevent cancer?

A

Remove body parts if high-risk:
eg. double mastectomy
colectomy in patient with FAP

294
Q

What is an incisional biopsy?

A

Taking a sample of a tumour at surgery

295
Q

What’s a wide local excision?

A

Removal of whole tumour

296
Q

What are the risk factors for testicular cancer?

A

maldescended testes

testicular atrophy

family history

Kleinfelter’s syndrome

infertility

297
Q

What are the main classifications of testicular cancer?

A

germ cell tumours: seminomatous (40%)
non-seminomatous (60%)

teratomas

yolk sac

(Most testicular cancers are germ cell tumours)

298
Q

What is the prognosis like in testicular cancer?

A

Highly metastatic BUT highly curable

299
Q

In which population is testicular cancer most common?

A

Males 15-45

White

300
Q

How does testicular cancer spread? Where does it commonly spread to?

A

Early spread is common (via lymphatics)

Haematogenic spread: lungs, liver, bone, brain

301
Q

How might testicular cancer present?

A

Painless testicular lump
Testicular or abdomen pain
Dragging sensation
Hx of trauma (pt. may have examined self after trauma)
Hydrocele
Gynaecomastia

Less sensitive testes

Symptoms of mets: bone pain, lung problems etc.
Inguinal lymphadenopathy

302
Q

What differential diagnoses might you make in someone who presents symptoms similar to testicular cancer?

A

Epididymo-orchitis.

Torsion.

Other scrotal lumps - eg, hydrocele, haematocele, epididymal cyst, hernia.

Infection - eg, tuberculosis, syphilis, mumps.

303
Q

How would you investigate a suspected testicular cancer?

A

Examine scrotum

Assess tumour markers: BHCG (raised in up to 75% of patients - seminomatous and non-seminomatous). PREGNANCY TEST.
AFP (rasied in non-seminomatous)
Lactate dehyrogenase

ULTRASOUND of testes

CT chest, abdo and pelvis (or CXR) to detect mets

Orchidectomy (definitive diagnosis. Biopsy contralateral testivle if crypto or madescended as increased risk of bilateral disease)

304
Q

What are other common sites of germ cell tumours?

A

retroperitoneum
mediastinum

305
Q

Why is trans-scrotal biopsy contra-indicated in investigating testicular cancer?

A

Biopsy increases risk of disseminating tumour

306
Q

How do you stage testicular cancer?

A

Royal Marsden staging:

  1. Confined to testicle
  2. Involves para-aortic lymph nodes below diaphragm
  3. Involved para-aortic lymph nodes above diaphragm
  4. Involves visceral metastases
307
Q

What are the prognostic factors for testicular cancers?

A

bulky sites = worse prognosis

PULMONARY METS HAVE NO IMPACT ON PROGNOSIS

Adverse markers: yolk sac elements, vascular invasion, lymph invasion

Tumour size >4cm
Rete involvement
= both poor markers for relapse

308
Q

How would you manage testicular cancer?

A

VERY SENSITIVE TO RADIOTHERAPY AND CHEMOTHERAPY

Destinction between seminomatous and non-seminomatous determines treatment

Orchidectomy (done at diagnosis through inguinal canal)

Seminoma: carboplatin + adjuvant radiotherapy

Non-seminoma: BEP

High dose stem cell support is used in pts with poor prognosis

309
Q

How would you manage metastatic teratoma?

A

Surgery after chemo (to take away the residual mass)

Further systemic treatment might be needed: radiotherapy

310
Q

What are the palliative care options for someone with testicular cancer?

A

Radiotherapy to specific areas: bone, brain and nodes

311
Q

How many cycles of BEP would you suggest for someone with testicular cancer?

A

3-4 cycles of intense dose.

High dose given to maximise response

312
Q

A 63-year-old man with NSCLC is dying in hospital. His pain is well controlled on a syringe pump infusin diamorphine 20mg/24hrs. The nursing staff are concerned that he is occasionally agitated with no obvious cause.

Select the most appropriate treatment from those listed below:

Diazepam 5mg SC
Diamorphine 30mg/24hours SC
Furosemide 40mg PO
Ibuprofen 400mg TDS PO
Lorazepam 0.5mg PO
Midazolam 5mg SC
Oramorph 2.5mg PO
Oxygen 2L/min
Pregabalin 75mg BD
Tramadol 100mg QDS

A

Midazolam 5mg SC

(Diazepam can’t be given SC as it’s too irritant)

313
Q

A 73-year-old man with advanced renal cancer and multiple lung mets complains of progressive breathlessness. He is struggling with day-to-day activities at home. He is not for any further disease-modifying treatment. On examination his pulse is 80 regular, oxygen sats 95% on air, no oedema and chest auscultation normal.

Select the most appropriate treatment from those listed below:

Diazepam 5mg SC
Diamorphine 30mg/24hours SC
Furosemide 40mg PO
Ibuprofen 400mg TDS PO
Lorazepam 0.5mg PO
Midazolam 5mg SC
Oramorph 2.5mg PO
Oxygen 2L/min
Pregabalin 75mg BD
Tramadol 100mg QDS

A

Oramorph 2.5mg PO (PRN)

(Other opiate choice on here is diamorphine SC. As this is a first presentation of a need for opiates, wouldn’t start on SD immediately. Better to start on immediate-release, small dose and PRN).

314
Q

A 67-year-old man with prostate cancer and bone mets complains of increasing pain in his right thigh despite paracetamol 1gm QDS. He describes it as a dull ache radiating down his leg which is worse on standing and walking. No abnormalities are detected on examination and an xray is requested.

Select the most appropriate treatment from those listed below:

Diazepam 5mg SC
Diamorphine 30mg/24hours SC
Furosemide 40mg PO
Ibuprofen 400mg TDS PO
Lorazepam 0.5mg PO
Midazolam 5mg SC
Oramorph 2.5mg PO
Oxygen 2L/min
Pregabalin 75mg BD
Tramadol 100mg QDS

A

Ibuprofen 400mg TDS PO

(description sounds like bone pain, therefore would prescribe anti-inflammatory. Tramadol is not very good and pre-gabbalin is usually used as an adjuvant/for neuropathic pain)

315
Q

A 78-year-old woman with heart failure is diagnosed with non-small cell lung cancer. Her main symptom is distressing haemoptysis. She has a 3x5cm mass in the right upper lobe, multiple enlarged mediastinal lymph nodes and a solitary adrenal metastasis. She has a performance status of 3.

Select the most appropiate treatment from the answers below:

Adjuvant chemo
Palliative chemo
Palliative radiotherapy
Palliative systemic hormone treatment
Primary chemotherapy
Radical radiotherapy
Surgical excision
Surveillane
Symptom management alone

A

Palliative radiotherapy - really good for treating bleeding.

(Can only give chemo to patients with performance status of 2 and above. Would consider symptom control only if you thought she was in her final days and would prescribe tranexamic acid and midazolam)

316
Q

A 66 year old man presented with a change in bowel habit. Subsequent investigations show a right-sided colonic mass but no metastatic disease. He undergoes a colectomy and histology confirms a Duke’s C adenocarcinoma.

Select the most appropriate treatment from the following list:

Adjuvant chemo
Palliative chemo
Palliative radiotherapy
Palliative systemic hormone treatment
Primary chemotherapy
Radical radiotherapy
Surgical excision
Surveillane
Symptom management alone

A

Adjuvant chemotherapy (because he has already had a colectomy and has high-stage colorectal cancer)

317
Q

A 67-year old lady presents to her GP with hip pain. Xray shows mixed sclerotic/lytic lesions in the iliac blade and subsequent imaging and biopsy confirm small primary HER2- ER+ breast cancer.

Select the most appropriate treatment from the list below:

Adjuvant chemo
Palliative chemo
Palliative radiotherapy
Palliative systemic hormone treatment
Primary chemotherapy
Radical radiotherapy
Surgical excision
Surveillane
Symptom management alone

A

Palliative systemic hormone treatment. This solves all of the problems (including the pain)

(Whilst you might consider radiotherapy for bone pain, doesn’t solve other problems. You would probably leave the small primary in place as it doesn’t have much bearing on prognosis and can be used as a marker of treatment success)

318
Q

A 64-year-old woman with hyperthyroidism and alcohol dependence complains of episodes of palpitations associated with fatigue and breathlessness. She is a non-smoker and is otherwise well. On examination her pulse is 88bpm (regular), her heart sounds are normal, chest clear and she has no ankle oedema.

Select the most appropriate diagnosis from the list below:

anaemia
asthma
COPD
Heart failure
Hyperventilation
Paroxysmal AF
Pleural effusion
Pneumonia

A

Paroxysmal AF. Key clues: episodic presentation, paroxysmal AF is also associated with hyperthyroidism and alcoholism.

319
Q

A 73-year-old man is breathless when he climbs stairs or walks uphill. He sleeps on 3 pillows. He is an ex-smoker. On examination he has mild ankle oedema and basal crackles in the lungs.

Please select the most appropriate diagnosis from the list below:

anaemia
asthma
COPD
Heart failure
Hyperventilation
Paroxysmal AF
Pleural effusion
Pneumonia

A

Heart failure. He has bilateral crackles (likley to be due to oedema. He also has ankle oedema, is breathless on exertion and sleeps with three pillows).

320
Q

A 45-year-old woman who has recetnly had chemotherapy for breast cancer complains of sudden onset pain in R-side of her chest, breathlessness and a dry cough. On examination her temperature is 36.4oc, pulse 110bpm and respiratory rate 24/min. Auscultation of the chest is clear.

Please select the most appropriate diagnosis from the list below:

anaemia
asthma
COPD
Heart failure
Hyperventilation
Paroxysmal AF
Pleural effusion
Pneumonia

A

PE.
Breast cancer can lead to increased risk of PE. whilst her pulse and RR are raised (which might indicate infection), her lungs are clear and her cough is dry. Pain was also sudden in onset (an infection may be more insidious)

321
Q

A 64-year-old main comes to see his GP complaining of painless intermittent haematuria. He has no other urinary symptoms. On examination he has a smoothly enlarged prostate gland.

Please select the most appropriate investigation from the list below:
Bronchoscopy
CT chest scan
CT scan abdo
MRCP
MRI abdo
Spirometry
Sputum culture and cytology
Urine dipstick
USS abdo
X-ray abdo
X-ray chest

A

Urine dipstick.
You’re looking for the least sinister cause so that you can rule this out. (Would potentially refer for 2-week appointment with specialist anyway, as painless haematuria)

322
Q

A 73-year-old man presents to his GP with a 3-week history of persistent cough and increased sputum production. He has a Hx of COPD and type 2 diabetes.

Please select the most appropriate investigation from the list below:
Bronchoscopy
CT chest scan
CT scan abdo
MRCP
MRI abdo
Spirometry
Sputum culture and cytology
Urine dipstick
USS abdo
X-ray abdo
​X-ray chest

A

CXR.
This would allow us to differentiate between infection, COPD and cancer. His Hx is 3 weeks long, therefore would definitely want to rule out cancer.

(sputum cultures not that commonly done in practice now)

323
Q

A 69-year old man presents to his GP with a 6-week Hx of right upper quadrant pain and reduced appetite. Examination is normal. Blood tests reveal bilirubin 18µmol/L (1-22), alanine aminotransferase 51 U/L (5-35), alkaline phosphatase 673 U/L (45-105) and gamma glutamyl transferase 90 U/L (<50).

Please select the most appropriate investigation from the list below:
Bronchoscopy
CT chest scan
CT scan abdo
MRCP
MRI abdo
Spirometry
Sputum culture and cytology
Urine dipstick
USS abdo
X-ray abdo
​X-ray chest

A

USS abdo.
Quick, cheap, easily available. No radiation risk to the patient. Would probably need to do this before could refer for CT/MRI.

(X-ray abdo is only really useful for bowel obstruction)

324
Q

An 82-year old woman who is in a residential home following a stroke has a UTI. She has mild renal impairment and is on simvastatin 40mg nocte and felodipine 2.5mg OD.

Please select the most appropriate tretment from the list below:
amoxicillin
cephalexin
ciprofloxacin
co-amoxiclav
erythromycin
flucloxacillin
metronidazole
nitrofurantoin
oxytetracycline

A

Nitrofurantoin. This is a second-line treatment for UTI (given to people who have renal impairment)

325
Q

A 28-year-old man with a history of testicular cancer has been bitten by a dog on the lower leg. He is worried that his immunity may be low because of recent chemotherapy.

Please select the most appropriate tretment from the list below:
amoxicillin
cephalexin
ciprofloxacin
co-amoxiclav
erythromycin
flucloxacillin
metronidazole
nitrofurantoin
oxytetracycline

A

Co-amoxiclav.
This is given to people who have been bitten by an animal.

326
Q

A 68-year old woman has an infected in-growing toenail. She has Type 2 diabetes and high blood pressure for which she takes ramipril 5mg od and metformin 500mg tds. She is allergic to penicillin.

Please select the most appropriate tretment from the list below:
amoxicillin
cephalexin
ciprofloxacin
co-amoxiclav
erythromycin
flucloxacillin
metronidazole
nitrofurantoin
oxytetracycline

A

Erythromycin
She has a sub-cutaneous skin infection, but is allergic to peniciilin, therefore you cannot use flucloxacillin.

(might use clarithromycin over erythromycin as less stomach s/e, but this is not an option in this question)

327
Q

A 71-year old woman complains of fatigue. She has a history of osteoarthiritis and a hiatus hernia. She does not have any repeat prescriptions but buys painkillers from the chemist for her knees. Heart sounds normal and chest clear.

Select the most appropriate diagnosis from the list below:
Anaemia
Alcoholism
Cancer
Chronic fatigue syndrome
Depression
Diabetes
Heart failure
Hypothyroidism
Insomnia
Obstructive sleep apnoea

A

Anaemia.
She may have been taking NSAIDS, which increase risk of bleed. Hiatus hernia also increases pts risk of GI bleeds.

328
Q

A 34-year-old woman complains of a sore tongue, cystitis symptoms, recurrent boils and tiredness. She has a BMI of 48.

Select the most appropriate diagnosis from the list below:
Anaemia
Alcoholism
Cancer
Chronic fatigue syndrome
Depression
Diabetes
Heart failure
Hypothyroidism
Insomnia
​Obstructive sleep apnoea

A

Diabetes.
Increased susceptibility to infections and boils, tiredness are key clues.

329
Q

A 58 year old man with obesity complains of poor concentration at work and is always nodding off at his desk. He denies feeling stressed but his relationship is ‘on the rocks’ because of his snoring. Blood shows HbA1c 39, TSH 3.0.

Select the most appropriate diagnosis from the list below:
Anaemia
Alcoholism
Cancer
Chronic fatigue syndrome
Depression
Diabetes
Heart failure
Hypothyroidism
Insomnia
​Obstructive sleep apnoea

A

Sleep apnoea.
Obese, snoring and day-time sleeping

330
Q

A 70-year-old woman with hypertension is taking felodipine and valsartan but her BP remains persistently raised. She is adamant that she is taking her medications regularly.

Select the most appropriate treatment from the list below:
Amiodarone
amlodipine
atenalol
bisoprolol
Furosemdie
Indapamide
Losartan
Ramipril
Verapamil

A

Indapamide
A+C+D (indapamide is a thiazide diuretic)

331
Q

A 42-year-old caucasian man checked his own BP at home for a week and his average was 168/102 mmHg

Select the most appropriate treatment from the list below:
Amiodarone
amlodipine
atenalol
bisoprolol
Furosemdie
Indapamide
Losartan
Ramipril
Verapamil

A

Ramipril
ACE inhibitor - first line treatment for caucasian male under 50

332
Q

A 69-year-old man with myeloma is admitted to the oncology ward with constant nausea. He has vomited small amounts of bile stained fluid for the last 3 days and feels thirsty. What is most suitable first-line anti-emetic?

Cyclizine
Haloperidol
Levomepromazine
Metoclopramide
Ondansetron

A

Haloperidol
Cause of vomiting: hypercalcaemia. Myeloma is a very common cause of hypercalcaemia. Pt is also thirsty, which is a sign of hypercalcaemia.

Haloperidol>Levomepromazine (in terms of safety)

333
Q

A 71-year-old woman with advanced lung cancer complains of passing hard stool. She is opening her bowels once a day as previously, but this is now painful.

What is the most suitable laxative to prescribe?

Bisacodyl suppositories
Co-danthramer suspension
Docusate capsules
Fybogel
Senna

A

Docusate
Stool softner.

334
Q

A 63-year-old man undergoing treatment for prostate cancer complains of left leg ‘gave way’ yesterday and feels odd. He denies back pain.

What is the most appropriate investigation?
CT scan brain
Isotope bone scan
MRI spine
PSA (prostate specific antigen)
X-ray thoracic spine

A

MRI spine

No pain doesn’t mean no spinal compression. Important to elliminate/ confirm this as a differential.

335
Q

An 81-year-old woman presents to her GP with gradual onset of breathlessness on exertion. She has a history of angina and hypertension. On examination, she has a systolic murmur, fine crackles at both lung bases and pitting oedema of the ankles. Her ECG shows left ventricular hypertrophy.

What are the most appropriate investigations to perform?
CXR and coronary angiogram
CXR, echocardiogram and bloods for BNP
Exercise tolerance test
Spirometry and bloods for FBC, U&E
24 hour ECG and echocardiogram

A

CXR, echo and bloods for BNP
Suspect HF, therefore BNP is useful, CXR may show cardiomegaly and echo to show which part myocardium is dysfunctional.

336
Q

You review a 50-year-old woman in a primary care diabetes clinic. She had an ischaemic stroke 30 years previously following open heart surgery.

What would you expect to find when examining her gait?

Bilateral increased tone with scissoring
Broad-based rolling gait
Dystonic, writhing movements
Extended lower limb and flexed upper limb
Festinant gait

A

Extended lower limb and flexed upper limb

Bilateral increased tone with scissoring: cerbral palsy
Broad-based rolling gait: cerebellar problems (eg. ataxia)
Dystonic, writhing movements: Huntingtons
Festinant gait: Parkinsons

337
Q

A 69-year-old man with SCLC and brain mets was dying at home but had a tonic-clonic seizure and a paramedic ambulance brought him to the ED. He remained unconscious and died 18 hours later.

What is the most appropriate cause of death to wtie on the medical cause of death certificate?

1a metastatic lung cancer
1a brain mets 1b lung cancer
1a brain metastases 1b small cell lung cancer
1a seizure 1b brain mets 1c small cell lung cancer
Do not issue a certificate and refer to HM coroner

A

Do not issue a certificate and refer to HM coroner
Pt. has been in hospital for less than 24 hours.

(if you were to issue the certificate, option D would be the most correct)

338
Q

A 46-year old publican has recently been diagnosed with type 2 diabetes. He is unable to tolerate metformin because of the diarrhoea. His most recent HbA1c is 86 mmol/mol (ideal control <59 mmol/mol) and his blood sugars are raised at 16-18 mmol/L.

What is the next most appropriate alternative treatment?

Gliclazide
Insulin
Lingagliptin
Pioglitazone
Orlistat

A

Gliclazide
This is a second-line treatment for somone who is on one agent

339
Q

A 60-year-old man visits the practice nurse to discuss life style modification after a friend died of cancer. The patient’s BMI is 30.

What cancer is a man who is obese more at risk of?

Bladder cancer
Colon cancer
Lung cancer
Melanoma
Prostate cancer

A

Colon cancer

340
Q

A 75-year olf man is admitted following a sudden onset of right sided weakness. A swallowing assessment is commenced by the fonudation year doctor on the stroke uni. The patient swallows a teaspoon of water without any problems.

What is the most appropriate next step?

Allow a normal diet and re-assess swallowing in 24 hours
Ask the patient to drink half a glassful of water
Give the patient a further two teaspoons of water
refer to speech and language therapist for formal swallowing assessment
videofluroscopy

A

Give the patient a further two teaspoons of water

341
Q

A 70-year-old woman complains that soon after waking she had a fleeting loss of vision in her left eye followed by a change in sensation affecting the right side of her body. Neurological examinatino later that day shows no abnormalities.

What is the most likley diagnosis?
Acute anxiety
Bell’s palsy
Migraine
MS
TIA

A

TIA
Clue: fleeting loss of vision - amarosis fugax

342
Q

A 73-year-old man with prostate cancer and multiple done and lymph node mets is admitted to MAU with increasing fatigue and swollen ankles. He is currently taking paracetamol 1mg QDS, oxycodone 20mg BD and dexamethasone 0.5mg daily.

His blood tests on admission show: sodium 141 mmol/L (137-144), potassium 5.9 mmol/L (3.5-4.9), urea 39 mmol/L (2.5-7.0) and creatinine 487 µmol/L (60-110).

What is the most-likley cause of his renal failure?
Dehydration
Hypercalcaemia
Medication
Obstructive uropathy
Polycystic kidney disease

A

Obstructive uropathy

Lymphatic mets from prostate cancer can obstruct ureters.
Fatigue fits with uraemia.
Swollen legs fits with lymphadenopathy.

343
Q

A 10-year-old boy with asthma comes to surgery for his routine review. He is using his salbutamol inhaler every day about 2-3 times but more when he is playing football. He wakes up coughing most nights and occasionally has to sit out of PE due to wheezing.

What is the most appropriate additional treatment?

Anti-muscarinic (eg. ipratropim bromide)
Leukotriene receptor antagonist (eg. monkelukast)
Oral theophylline
Regular long-acting B-2 agonist (eg. salmetrol)
Regular standard dose inhaled corticosteroids (eg. beclametasone)

A

Beclametasone/clenil (corticosteroids)

344
Q

An 81 year old lady has her annual review for hypertension. Her BP is 100/60 and U&Es show the following: sodium 128 (NR 135-145), potassium 4.5 (NR 3.5-5.0), urea 7.0 (NR 3.0-8.3), creatine 78 (NR 44-133).

Which of her medications would you stop?

Amlodipine
Atenalol
Bendroflumethiazide
Paracetamol
Ramipril

A

Bendroflumethiazide
Sodium is low - which is commonly caused by thiazide diuretics

345
Q

Where are the majortiy of lung cancers?

A

Bronchi

346
Q

Which cancers commonly metastasise to the lung?

A

kidney

prostate

breast

bone

GI

cervix and ovary

347
Q

Where are the majority of lung mets?

A

lunch parenchyma

relatively asymptomatic

348
Q

What classification are the majority of lung cancer?

A

Non-small-cell lung cancer

349
Q

What proportion of cancers fall in to NSCLC and SCLC?

A

85% and 15% respectively

350
Q
A

CCC (3 decks)

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