Oncology Flashcards
An 80 year old man with spinal mets from prostate cancer complains of increasingly severe back pain despite a high dose of morphine. Spinal cord compression is ruled out by MRI scan. What could you give to help his pain?
Radiotherapy
A 91 year old woman with multiple myeloma complains of severe abdo pain, vomiting and constipation. Her serum calcium is 3.6. What could you give to improve her symptoms?
IV fluids
Bisphosphonates
A 60 year old woman has developed bowel obstruction secondary to inoperable ovarian cancer. She is complaining of colicky abdo pain not controlled by high dose morphine. What could you give to help her symptoms?
Hyoscine butylbromide 20mg SC
A 45 year old woman has fungating metastatic breast cancer and is increasingly distressed by the malodorous discharge. What could you give to alleviate this?
Oral metronidazole or gel
Charcoal dressing
A 53 year old woman with inoperable cancer has pain due to posterior abdo wall infiltration, this has been controlled well with cocodamol 30mg, two tablets, 4 times a day.
She has been admitted with n and v, the cause of which is unknown. Because she cannot retain her analgesics, she has severe loin pain. What is the best option for controlling her pain until the vomiting settles?
Subcutaneous diamorphine by continuous infusion
What treatment is used for metastatic prostate cancer? How does it work?
Gonadorelin (LHRH) analogue to switch off testosterone
Induce hypogonadotrophic hypogonadism
What treatment is used for acromegaly as alternative to surgery? How does it work?
Acromegaly due to hypersecretion of growth hormone for pituitary hormone
Synthetic somatostatin analogues - GHIH
Suppress GH secretion from tumours, effective alternative to surgery
What type of tumours are VIPomas?
Neuroendocrine
What type of treatment do you use for VIPomas?
Somatostatin therapy
In which malignancy is CA125 a helpful serum marker?
Serious carcinoma of the ovary
In which cancers might CEA (carcinoembryonic antigen) be raised?
Colon
Rectum
Stomach
Oesophagus
In which malignancy are beta human chorionic gonadotrophin and alpha fetoprotein useful tumour markers?
Testicular tumour
Which tumour markers are used in the diagnosis of testicular carcinoma, particularly germ cell?
Beta HCG
Alpha fetoprotein
Lactate dehydrogenase
Other than testicular cancer, in which cancer might alpha fetoprotein levels also be used as a tumour marker?
Hepatocellular carcinoma
What is octreotide? What is it used to treat?
Somatostatin analogue used in the treatment of acromegaly and carcinoid syndrome
What is a recognised side effect of octreotide therapy due to it altering fat absorption and decreases gall bladder motility?
Cholelithiasis
What causes carcinoid syndrome?
Overproduction and release of polypeptides, amines, prostaglandins, particularly 5HT and serotonin, histamine and bradykinin
What are the typical symptoms of carcinoid syndrome?
Flushing
Diarrhoea
Bronchospasm
Why might you get right sided valvular lesions in carcinoid syndrome?
Neurohormonal induced fibrosis
Where do carcinoid tumours usually arise?
Digestive tract, particularly small intestine
Bronchi
What is the end product of serotonin metabolism and excreted in the urine making it a useful initial diagnostic test for carcinoid syndrome?
5-hydroxyindoleacetic acid
What is the most common type of parotid tumour?
Pleomorphic adenoma
What is the most common type of parotid tumour?
Pleomorphic adenoma
Secretion of which molecule from tumour cells leads to hypercalcaemia?
Parathyroid hormone related protein (PTHrP)
Why does renal failure occur in multiple myeloma?
Hypercalcaemia Hyperuricaemia Dehydration Amyloid deposition Paraprotein excess
Why is ESR usually raised in multiple myeloma?
Presence of paraprotein in the serum
What protein is found in the urine in multiple myeloma?
Bence jones protein
How can you differentiate between multiple myeloma lesions and metastatic prostate Ca lesions on xray?
Metastatic prostate Ca - sclerotic lesions
MM - lytic lesions
What type of drug is cyclophosphamide?
DNA damaging alkylating agent
What is cyclophosphamide used to treat?
Lymphocytic leukaemia
RA
What is a rare but damaging side effect of cyclophosphamide?
Haemorrhagic cystitis
What types of cancer is cisplatin used to treat?
Lung
Bladder
Ovarian
Testicular
What is mechanism of action of cisplatin?
Platinum compound that causes DNA damage by causing cross links
What type of drug is 5-fluorouracil?
Anti metabolite which acts as a pyrimidine antagonist
What is the mechanism of action of doxorubicin?
Prevents DNA repair by acting as a topoisomerase II inhibitor - cytotoxic antibody
What is doxorubicin used to treat?
Acute leukaemia
Lymphoma
Some solid tumours
What are possible complications/side effects of radiotherapy?
Mucositis Anorexia/nausea/malaise Alopecia/epilation Skin ischaemia/ulceration Bone necrosis/fracture Mouth - xerostomia, ulceration Lung fibrosis Cardiomyopathy, pericardiofibrosis Infertility, menopause Strictures
What is the most common site for osteoclastomas (giant cell tumours)?
Around knee at distal femur
What are the cancerous causes of clubbing?
Bronchial Ca Mesothelioma Lung mets Thyroid Ca Thymus Ca Hodgkin's disease Disseminated chronic myeloid leukemia (POEMS syndrome - polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes).
What is busulfan used for in haematological malignancy? What are the limitations?
Control tumor burden but cannot prevent transformation or correct cytogenic abnormalities
What is Kaposi’s sarcoma assocaited with?
HIV - AIDS defining illness
What infection causes Kaposi’s sarcoma?
Humanherpes virus 8
How can localised Kaposi’s sarcoma be treated?
Cryotherapy Intralesional injections of vinblastine Alitretinoin gel (vit A, retinoid) Radiotherapy Topical immunotherapy (Imiquimod) Surgical excision
How does Imiquimod work?
Signals to the innate arm of the immune system through the toll-like receptor 7 (TLR7), commonly involved in pathogen recognition
Cells activated secrete cytokines IFN-alpha, IL-6, and TNF-alpha
What should be considered first line to treat AIDS related kaposi’s sarcoma?
Highly active antiretroviral therapy
What tumours are associated with EBV?
Burkitt’s lymphoma
Nasopharyngeal cancers
What is Burkitt’s lymphoma?
High-grade non-Hodgkin lymphoma that develops from B lymphocytes in the germinal center
May affect jaw, CNS, bone marrow, bowel, kidneys, ovaries
Chromosomal abnormality t(8;14) translocation
Which cancer is associated with HPV?
Cervical carcinoma
Which is the most common childhood cancer?
Acute Lymphoblastic Leukaemia
Which age groups and sex carry the worst prognosis in ALL?
Less than 2
Older than 9
Male sex
What is the chromosomal abnormality associated with ALL?
Translocation in 11q23 region
What is given prophylactically in ALL to try and prevent meningeal involvement?
Cranio-spinal irradiation
Intrathecal methotrexate
Which primary malignancies are the most common cause of bone mets?
Breast
Prostate
Bronchus
How do bone mets tend to present?
Bone pain Lump Pathological fracture Hypercalcaemia Cord compression
What is the most sensitive investigation to detect metastatic spread to bone?
Bone scintigraphy
What cancers are patients with hereditary non polyposis colonic carcinoma at risk of?
Colon
Endometrial
Ovarian
What causes the defect leading to HNPCC (lynch syndrome)?
Defect in mismatch repair genes important for DNA surveillance leading to microsatellite instability
At what age do patients with HNPCC tend to present?
40 years of age
What is Von Hippel Lindau disease?
Autosomal dominant condition associated with phaeochromocytomas, CNS haemangiomas and hypernephroma due to absence to vHL tumour suppressor gene
What is Peutz-Jeghers syndrome?
Autosomal dominant condition associated with mucocutaneous pigmentation and multiple GI hamartomas due to a defect in STK11 gene
Which cancer is acanthosis nigricans associated with?
Adenocarcinoma of the stomach
What are features of CLL?
Lymphocytosis WCC >15, 40% lymphocytes Painless lymphadenopathy Hepatosplenomegaly Anaemia (autoimmune haemolysis/bone marrow failure) Thrombocytopenia Infections (neutropenia)
What would be seen on a blood film in CLL?
Lymphocytes and smear cells
How do you treat CLL? And when?
Chlorambucil
When symptomatic, evidence of bone marrow failure, hypersplenism, automimmune haemolytic anaemia, thrombocytopenia
What do Reed Sternberg cells look like?
Multi nucleate
Polypoid
What are B symptoms of Hodgkins lymphoma?
Pel-Ebstein fever - spiking temperature
Night sweats
Weight loss of >10% body weight
What are some causes of cavitating lung lesions?
Carcinoma Abscess (staph, klebsiella, TB) Lymphoma Rheumatoid nodule Wegeners granulomatosis
What does CA stand for in tumour markers such as CA 125 and CA 19-9?
Carbohydrate antigen
What are some causes of a raised CA 125?
Ovarian cancer
Endometrial cancer
Tumour of pancreas, GI tract, lung, breast
Benign gynaecological disease such as cyst and endometriosis
Early pregnancy
Follicular phase of menstrual cycle
Cirrhosis/hepatitis
When is the peak incidence of leukaemia in childhood?
2 years in females
3 years in males
How long does treatment usually last for in children with leukaemia?
2 years in girls
3 years in boys
What are good prognostic factors for ALL?
Age 3-7 years
Female sex
What are poor prognostic factors for ALL?
Age <1 or >9
White cell count above 100 at presentation
Philadelphia chromosome (translocation 9:22)
What are the non metastatic consequences of renal carcinoma?
Synthesis of EPO - polycythemia
Hypercalcaemia through PTHrP synthesis
DIC
Leucopenia
What are risk factors for bladder cancer?
Smoking Exposure to aniline dyes in printing and textile Rubber manufacture Cyclophosphamide Schistosomiasis
What is Turcots syndrome?
Adenomatous tumours of the colon and central nervous system
Which cancer is Paget’s disease associated with?
Osteosarcoma
Which cancer are women with PCOS at increased risk of?
Endometrial
What are some characteristics of squamous cell lung cancer?
Common in smokers Centrally located Cavitate Metastasise outside thoracic cavity Ectopic PTH
What are characteristics of adenocarcinoma of the lung?
Elderly, non smoking women
Situated at periphery of lung
What are characteristics of small cell carcinoma of the lung?
Highly malignant, usually disseminated at presentation
Ectopic hormone production and paraneoplastic syndromes - ACTH and ADH
What symptoms are suggestive that a CA 125 should be checked?
Persistent abdominal distension Pelvic or abdominal pain Increased urinary urgency or frequency Feeling full/loss of appetite Symptoms suggestive of IBS
What level of CA 125 warrants referral for an ultrasound scan?
> 35
If a women presents with ascites and a pelvic mass what should you do?
Refer urgently to gynaecological oncology service
What is the classic syndrome of carcinoid?
Diarrhoea
Flushing with hypotension
Telangiectasia
Bronchospasm
What is CA15-3 a tumour marker for?
Breast cancer
What is S-100 a tumour marker for?
Melanoma, schwannomas
What is bombesin a tumour marker for?
Small cell lung carcinoma
Gastric cancer
Neuroblastoma
What is Li Fraumeni syndrome?
Sarcoma, breast leukaemia and adrenal gland syndrome
Genetic mutation of p53 so predisposes to cancer development
What class of drugs should be used to treat metastatic carcinoid syndrome?
Somatostatin analogue
What class of drug should be used to treat prolactinoma with suprasellar extension?
Bromocriptine
What are the conditions found in MEN1?
Parathyroid
Pituitary
Pancreas (insulinoma, gastrinoma)
Name some tumour suppressor genes
Von Hippel Lindau p53 Retinoblastoma 1 BRAC APC
Name some oncogenes
Myc
Erb
Ras
Ret
What is the recommended investigation for female patients over 50 presenting with IBS type symptoms in the past 12 months?
CA 125
USS abdo pelvis if this is above 35
A patient with acute leukaemia is admitted with febrile neutropenia. On day four of treatment with road spectrum antibiotics his fever deteriorates. A chest X-ray shows bilateral fluffy infiltrates. What is the likely diagnosis and what is the appropriate next step in management?
Pneumocystis jirovecii infection
Give co trimoxazole
Which drugs are commonly used in palliative care?
Nausea and vomiting: cyclizine, levomepromazine, haloperidol, metoclopramide
Resp secretions: hyoscine butylbromide
Bowel colic: hyoscine butylbromide
Agitation/restlessness: midazolam, haloperidol, levomepromazine
Pain: diamorphine
What are some different types of primary liver tumours?
Cholangiocarcinoma Hepatocellular carcinoma Hepatoblastoma Sarcoma Lymphoma Carcinoid
How is a diagnosis of Hepatocellular carcinoma made?
CT/MRI
Alpha fetoprotein
Biopsy should be avoided as it seeds tumours through resection plane
What is the management of hepatoceullar carcinoma?
Staging with liver MRI and CT chest, abdo, pelvis
Examine testis as it could account for raised alpha fetoprotein
Surgical resection
Tumour ablation
What is the main risk factor for cholangiocarcinoma?
Primary sclerosing cholangitis
What is a karnofsky performance status scale?
Used for cancer patients especially those undergoing chemo to assess functional status and ability to cope with intensive treatments
What is the most common type of ovarian epithelial cell tumour?
Serous cystadenoma
Which tumour is most commonly associated with ectopic ACTH production?
Small cell lung cancer
What is a reed sternberg cell?
Binucleate, bilobed or multinucleate with abundant amphiphilic cytoplasm and owl eyed nucleoli surrounded by clear halo
What are risk factors for ovarian cancer?
BRCA1/2
Many ovulations: early menarche, late menopause, nulliparity
What are clinical features of ovarian cancer?
Abdominal distension and bloating Abdominal and pelvic pain Urinary symptoms: urgency Early satiety Diarrhoea
What are features of SVCO?
Dyspnoea Swelling of face neck and arms Conjunctival and periorbital oedema Headache Visual disturbance Pulseless jugular venous distension
What is the management of SVCO?
Dexamethasone
Balloon venoplasty
Stenting
How are intractable hiccups managed in palliative care?
Chlorpromazine
Haloperidol
Gabapentin
What are the features of MEN1?
Pituitary adenoma
Parathyroid hyperplasia
Pancreatic tumours
What are features of MEN2A?
Parathyroid hyperplasia
Medullary thyroid carcinoma
Phaeochromocytoma
What is Li Fraumeni syndrome?
Autosomal dominant
Germline mutations to p53 tumour suppressor gene
High incidence of malignancy, particularly sarcoma and leukaemia
Under 45 years with first degree relative affected
What are features of MEN2B?
Mucosal neuroma
Marfanoid appearance
Medullary thyroid carcinoma
Phaeochromocytoma
What should be coprescribed alongside goserelin for the first 3 weeks of treatment?
Cyproterone acetate
Anti androgen
Prevent the risk of tumour flare due to increased testosterone levels
What treatment regime is employed in multiple myeloma?
Chemo: melphalan
Steroids
Thalidomide
Radiotherapy for bone pain
What are renal complications of multiple myeloma?
Bence jones cast nephropathy Light chain deposition disease Amyloidosis Nephrocalcinosis Chronic urate nephropathy Acute renal failure Renal vein thrombosis Acute and chronic pyelonephritis Tumorous infiltration of kidney tissue
Which gene is affected in familial adenomatous polyposis coli?
APC tumour suppressor gene
What are features of malignant cells on histology?
Increased nuclear size
Nuclear and cellular pleomorphism
Lack of cell differentiation
Increased nuclear DNA content with dark staining on h and E slides
Prominent nucleoli or irregular chromatin distribution
Mitotic figures
What is seen radiographically in patients with hypertrophic pulmonary osteoarthropathy?
Proliferative periostitis particularly at diaphysis of wrists, ankles, knees and elbows
Periosteal reaction
With which malignancies is hypertrophic pulmonary osteoarthropathy associated?
Intrathoracic - particularly lung cancer
Which cancers metastasise to bone?
Breast Lung Prostate Kidney Thyroid Myeloma
What is the most common site metastatic cancer spread causing cord compression?
Thoracic spine
How does metastatic spinal cord compression typically present?
Pain Motor deficit Sensory deficit Altered bowel and / or bladder control Cauda equina syndrome
In which patients should you have a high index of suspicion for metastatic spinal cord compression?
A known cancer diagnosis
Severe, unremitting pain, especially if localised to upper or middle spine
Exacerbated by increased intra-abdominal pressure
Below which spinal level can cauda equina syndrome occur?
Compression below the first lumbar vertebra
How should metastatic spinal cord compression be investigated? What should be given while waiting for this?
Suspected spinal metastases without compression: MRI whole spine within 7 days
Suspected MSCC: MRI whole spine within 24 hours
Contact MSCC co-ordinator (or acute oncology unit) to arrange urgent investigations and management)
Give dexamethasone
What is the management for metastatic spinal cord compression?
Start oral steroids: 16mg oral Dexamethasone daily
Consider adding PPI for gastro-protection
Analgesia e.g. morphine
Appropriate immobilisation e.g. nursed flat with log rolling
Consider starting LMWH for thrombo-prophylaxis if no contraindications
Radiotherapy
Surgery
Chemotherapy
Why is dexamethasone helpful in metastatic spinal cord compression?
Venous stasis leads to venous hypertension
White matter (axonal) vasogenic oedema
Decreased spinal cord blood flow leads to ischaemia and infarction
Dexamethasone reduces the oedema
In which metastatic spinal cord compression are steroids contraindicated? Why?
Lymphoma
Oncolytic effect of the steroid may impair tissue diagnosis
What are 3 goals for radiotherapy in metastatic spinal cord compression?
Prevent neurological deterioration
Improve neurological function
Pain relief
What are goals of surgery for metastatic spinal cord compression?
Circumferential decompression of the spinal cord
Reconstruct and immediately stabilise the spinal column
For which types of metastatic spinal cord compression can chemotherapy be considered?
Some haematological malignancies e.g. lymphoma, plasma cell tumours
Small cell carcinoma of the lung
What is neutropenic sepsis?
Temperature > 38°C and/ or signs of sepsis in a person with a neutrophil count of 0.5 x 109/L or less
What are causes of hypercalcaemia of malignancy?
Humoral hypercalcaemia of malignancy: secretion of parathyroid hormone-related peptide by primary tumours
Local osteolytic hypercalcaemia: local release of PTHrP and other
factors by bone metastases which increases osteoclast proliferation and activity
Calcitriol production by lymphomas
Parathyroid (PTH) secretion by primary tumours
Which cancers are commonly associated with hypercalcaemia?
Renal cancer Ovarian cancer Breast cancer Endometrial cancer Human T-lymphocytic virus-associated lymphoma Squamous cell carcinoma Multiple myeloma
What are the different grades of severity of hypercalcaemia?
Mild: total adjusted serum calcium 2.6 – 2.9 mmol/L
Moderate: total adjusted serum calcium 3.0 – 3.4 mmol/L
Severe: total adjusted serum calcium 3.5 mmol/L or above
What are signs and symptoms of hypercalcaemia?
Nausea and vomiting (often intractable) Polyuria and polydipsia Abdominal pain Constipation Confusion Tiredness/ lethargy Weakness Stone formation Corneal calcification Mild aches and pains Anorexia Weight loss Low mood
What are causes of superior vena cava obstruction?
Mainly caused by extrinsic compression of superior vena cava by upper mediastinal lymph nodes
Extension of tumour in the vessel
Blood clot obstructing the lumen
Lung cancer, Lymphoma, Breast cancer, Testicular seminoma
What are symptoms of superior vena cava obstruction?
Cough Dyspnoea Chest pain (often at rest) Headache Facial/ neck or arm swelling Dizziness
What are signs of superior vena cava obstruction?
Swelling of face/ neck or arm Fixed raised JVP Dilated veins on chest wall Engorged conjunctiva Cyanosis Made worse by raising hands above head (pembertons sign)
What investigations should be done for superior vena cava obstruction?
CXR: widened mediastinum or R sided mass in chest
CT scan (may include injection with contrast media to highlight collateral circulation)
Doppler scan: evaluate severity of the obstruction
MRI scan
Invasive contrast venography
What are medical management options for superior vena cava obstruction?
Keep head elevated, consider oxygen
In an emergency, corticosteroids and diuretics may be indicated
Radiotherapy (in some lung cancer cases)
Chemotherapy
Anticoagulation if thrombosis cause or likely complication
What are surgical treatment options for superior vena cava obstruction?
Stenting
Reconstructive surgery using autologous tissue
Insertion of a prosthesis
Which cancers are most at risk of major haemorrhage?
Lung
Head and neck
Upper GI
What are risk factors for major haemorrhage in cancer?
Local effects e.g. blood vessel invasion
Systemic effects: DIC
Drugs: LMWH, aspirin, warfarin, dexamethasone, NSAIDs
What are common side effects of morphine?
Nausea and vomiting Drowsiness Unsteadiness Delirium Constipation
What antiemetic is useful to prescribe alongside morphine?
Haloperidol 1.5mg po nocte
What are signs and symptoms of morphine toxicity?
Myoclonic jerks Agitation Hallucinations Confusion Pin point pupils Respiratory depression
What dose adjustment is required to convert a morphine dose to oxycodone?
2 times more potent than oral morphine
i.e. 20mg morphine is equivalent to 10mg oxycodone
What is the fentanyl equivalent dose to 60mg daily morphine?
25mcg/hour fentanyl equivalent to approx 60mg of morphine daily - 600mcg/day
When might parenteral analgesia be appropriate?
When oral medication not tolerated Drowsy Unable to swallow Vomiting Bowel obstruction Confused Poor absorption
How do you convert morphine and diamorphine doses for a syringe driver?
To convert oral morphine to sc morphine DIVIDE by 2
To convert oral morphine to sc diamorphine DIVIDE by 3
Which medications are considered adjuvant analgesics?
Antidepressants Anticonvulsants Corticosteroids Skeletal muscle relaxants Smooth muscle relaxants (antispasmodics) Bisphosphonates NMDA-receptor-channel blockers Anxiolytics
Which drugs should be offered initially for neuropathic pain?
Amitriptyline
Duloxetine
Gabapentin
Pregabalin
Which drug should be first line for diabetic neuropathy neuropathic pain?
Duloxetine
Which cancer problems can steroids help with?
Raised intracranial pressure (dose 8-16mg/day dexamethasone) Nerve compression (dose 4-8mg/day) Hepatomegaly, liver capsule pain (dose 4-8mg/day) Spinal cord compression (dose 16mg/day) Bone pain (dose 4-8mg/day)
What is the difference between nausea, retching and vomiting?
Nausea: Unpleasant feeling of need to vomit accompanied by autonomic symptoms (pallor, cold sweat, salivation, tachycardia, diarrhoea)
Retching: Rhythmic laboured spasmodic movements of diaphragm and abdo muscles (occurs with Nausea and results in Vomiting)
Vomiting: forceful propulsion of gastric contents through mouth
What are the mechanisms of action of Metoclopramide, Domperidone, Cyclizine and Ondansetron?
Metoclopramide: D2 antagonist, 5HT3 antagonist, 5HT4 agonist
Domperidone: D2 antagonist, doesn’t cross BBB
Cyclizine: antihistamine
Ondansetron: 5HT3 antagonist
Which antiemetic combinations should be avoided?
IV Metoclopramide + IV Ondansetron: may cause serious cardiac arrhythmias
Metoclopramide/Domperidone + Cyclizine: Metoclopramide/Domperidone are motility agents while Cyclizine slows down GI transit
Which receptors are present in the CTZ?
D2
5HT3
What are symptoms of gastric stasis?
Epigastric fullness
Early satiety
Large volume vomits (projectile)
Hiccups
Regurgitation (also if moving term ill pt)
(Minimal) Nausea quickly relieved by vomiting
What factors may precipitate gastric stasis?
Stomach emptying problems (Autonomic eg Diabetes, Gastritis, Peptic Ulcer)
Compression of gastric outflow (Tumour, Hepatomegaly, Ascites)
Drug Side-Effects (Anti-Cholinergics, Opioids)
How can gastric stasis be treated?
Reduce volume of oral intake: Little and often
Reduce Gastric secretions: PPI (Omeprazole)
Pro-kinetic agents: Dopamine D2-Antagonists: metoclopramide (also 5HT4 agonist), Domperidone
What are symptoms of visceral or serosal irritation as a cause of nausea?
According to the cause Bowel obstruction, severe constipation, faecal impaction, liver capsule stretch, mesenteric metastases, pharyngeal irritation Constant Nausea Less or variable Vomiting Fullness
Which is the most effective antiemetic to use when the cause is visceral/serosal irritation?
Anti-Cholinergic (vs Vagus): Cyclizine
What may be contributing factors to chemical or metabolic nausea and vomiting?
Chemical: Drugs (Opioids, Antibiotics, Digoxin, NSAIDs, SSRIs,
Chemotherapy)
Metabolic: Renal / Liver failure, Hypercalcaemia of Malignancy, Hyponatraemia, sepsis
How should chemical or metabolic nausea and vomiting be treated?
Dopamine D2-Antagonist: Metoclopramide [Prochlorperazine]
5HT3-Antagonist: Ondansetron
Which antiemetic should be used for motion sickness?
Cyclizine
Which receptors are important in nausea and vomiting caused by raised ICP?
Stimulation of the Vomiting Centre: H1 and AChm receptors
Which antiemetic should be used in raised ICP?
Cyclizine
What is the spikes method of breaking bad news?
Setting up the interview
Assessing the patient’s Perception
Obtaining the patient’s Invitation
Giving Knowledge and information to the patient
Addressing the patient’s Emotions with Empathetic response
Having a Strategy and Summarising
What is palliative care?
Approach that improves quality of life of patients and their families facing problems associated with life-threatening illness, through prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual
What are some non medical interventions which could be useful for a palliative care patient complaining of SOB?
Electric fan
Positioning: sitting upright
Relaxation techniques
Open windows
What are some medical interventions for SOB in palliative patients?
Saline nebulizers Salbutamol nebulisers Oxygen Low dose opioids Benzodiazepines
What are management options for noisy breathing/secretions in palliative patients?
Positioning/ suction Hyoscine butylbromide Glycopyronium Monitoring patient Reassuring relatives
What can be used for restlessness and agitation at the end of life?
Reassurance/ continuity of care and experienced staff
Careful use of oral lorazepam if needed
Sedation may be necessary in some cases e.g. midazolam or
levomepromazine
Which cancers are caused by oncogene alterations?
Philadelphia chromosome
Rhabdomyosarcomas: ras oncogene
Burkitts lymphoma: c myc translocation from chromosome 8 to 14
Neuroblastoma: N yc proto-oncogene seen in proportion of patients with poor prognosis
What blood test abnormalities are expected in multiple myeloma?
Hypercalcaemia Raised ESR High urate Renal impairment Low Hb
What are the differences between MEN1 and 2a/b?
MEN1: parathyroid hyperplasia, pituitary, pancreas
MEN2a: medullary thyroid cancer, parathyroid, phaeochromocytoma
MEN2b: medullary thyroid cancer, phaeochromocytoma, marfanoid body habitus, neuromas
What are the most common malignancies following solid organ transplant?
Skin
Cervical carcinoma in situ
Post transplant lymphoproliferative disorder (EBV driven)
