Oncology Flashcards
List 3 tumour lysis RF:
- large tumour burden (bulky, organ)
- high tumour proliferation (high grade lymphoma like Burkitt)
- uncommon AML or other solid
- on ppt= nephropathy, dehydration, low BP
- inadequate hydration
- high K or PO4-
- delayed uric acid removal
Tumour Lysis BW
Release cell
= K++
= PO4- ++ (and low ca2+ as result)
= Uric Acid ++
Tx for Tumour Lysis Syndrome?
- **Hyperhydration
- **High K= no IV K, kayexlate, insulin + glucose, ventolin
- High uric acid= **allopurinol +/- urinary alkalization
- High phosphate= amphogel (**Aluminum OH)
- Low Ca2+= no tx unless ECG or symp
6 y.o. w/ diplopia, h/a, ataxia. Where is lesion? Two most likely brain tumour for lesion?
Posterior fossa tumour (brainstem + cerebellum)
2 most likely:
- cerebellar astrocytoma
- medulloblastoma
Impaired upward gaze. Dilated pupil. Doesn’t respond to light. What is this called and which location of brain tumour suggested?
Parineaud’s Syndrome
Midbrain
Likely germ cell tumour
- alpha-feto protein, beta HCG, AFP
- MRI
2 life threatening ppt of anterior mediastinal mass
- Airway Obstruction
- SVC syndrome
(facial, upper limb swelling from vascular compression) - Cardiac Tamponade
Treatment for Mass= Radiotherapy + Steroids
T or F: most mediastinal masses are malignant in kids.
True.
> 50%= always investigate!
What are the most common mediastinal mass CA
Lymphoma
Neuro
How do you remember ddx of anterior, posterior middle, mediastinal mass ?
Anterior Mediastinal mass= 5T’s
- Thymus (thymoma)
- Teratoma
- Terrible lymphoma
- T cell leukaemia
- Thyroid Mass
Middle= A+B
- Adenopathy (infection, Histio, TB, neoplasm, mets)
- Bronchogenic cyst
Posterior= Neuro
- neurofibroma
- neurosarcoma
- ganglioneuroma
- neuroblastoma
3 y.o. Fever, arthralgia, lethargy, lymphadenopathy, big liver. Pain w/ exertion. WBC normal. Hub 98. Plt 140. Next test:
- Bone marrow aspirate
- EBV
- follow
Bone marrow aspirate
ALL: non specific
- persistent bone pain; refusal wt bear, limp
- lymphadenopathy (> 1/2 of all kids; non tender, firm, matted)
- big liver
- big spleen
- most BW: anemia, thrombocytopenia. WBC anything.
15 y.o. M with SOB and b/l wheeze the improve w/ steroid + ventolin. One wk later radiologist say widened mediastinum. Likely cause?
= ALL
= Hodgkin’s lymphoma
= Sarcoidosis
= Thymoma
Mediastinal mass
5T’s
Teen = Hodgkin’s lymphoma
- (+) Reed Sternberg cell
= Owl’s eye in RBC
Abdo RUQ mass. Systolic murmur at LSB + RUQ. Conjugated hyperbili. Low plt. Likely Dx? And Next BW?
Kasabach Merritt Syn
= low plt + consumption coagulopathy
Next: DIC W/U
- low fibrinogen
- D dimer up
- PTT and aPTT normal or up
Which condition associated w/ childhood leukaemia?
- Electromagnetic field exposure during preg
- NF1
- FHX parent leukemia
NF1
*Certain inherited dx associated w/ higher risk leukaemia: = - Down Syndrome - NF - Fanconi anemia - Shwachman Syn - Bloom Syn - Ataxia Telangiectasia
T or F: supraclavicular lymphadenopathy associated w/ malignancy in kids
True
What workup should kids with supraclavicular adenopathy get:
CBC + diff
CXR
lymph node bx (unless abscess or cellulitis)
Poor prognosis of ALL:
a. F
b. age < 1 y.o.
c. CALLA positive
d. mediastinal mass
e. splenomegaly
Age < 1 year
When does ALL (acute lymphoblastic leukaemia) usually peak?
2-3 y.o.
What are lymphoid or myeloid cells?
Hematopoiesis==>
Lymphoid Stem= T, B
> ALL= malignant transformation of progenitor cell
Myeloid Stem= monocyte, macrophage, erythrocyte, plt (megakaryocytic), neutrophil, eosinophil, basophil
> AML
What is a “blast”?
Progenitor cell undergo malignant transformation.
Immature WBC= Blast.
These multiply and replace normal bone marrow.
List 3 Leukemia RF:
**Genetic:
- T21
- NF1
- Shwachman- Diamond Syn
- Fanconi
ALL= Klinefelter syn, Ataxia-Telangiectasia, Bloom Syn
AML= Prior Chemo
** FHX
What is the most common malignancy of childhood:
Leukemia
**ALL most common 1/4 of all kid CA= ALL 1/3 of all kid cancer= CNS 10-25%= AML Every other solid CA collectively= 1/3 of all cases
T or F: nocturnal bone pain can be non specific sign of leukaemia?
True
How is leukaemia diagnosed?
Bone marrow show > 25% cells = blast
List the three stages of chemo:
- Induction- destroy leukaemia cells (min. 29 days then test for minimal dx test)
- Consolidation- prevent growth, reduce cells present and prevent relapse
(min. 4-8 months)
+/- delayed intensification phase
- Maintenance- kill any leukaemia cells we can’t see (x 2-3 yr; BW and med q4 wk with LP q 3 mo.)
List 5 RF for poor ALL outcomes:
- Age (< 1 or > 10)
- Type (T cell)
- Initial WBC > 50
- CNS disease
- Chromosomal abnormality (philadelphia chromosome)
- Slow to respond to tx
Best prognosis in neuroblastoma associated with:
a. female
b. age < 1y.o.
c. high VMA urine
d. normal BP
e. unilateral
Age < 1 y.o. (except newborn)
What is the most common cancer in infants
Neuroblastoma
Most common solid tumour in kids
- CNS
2. Neuroblastoma
Neuroblastoma age typically
infant- 2 y.o.
T or F: Neuroblastoma is associated with paraneoplastic syndromes?
True.
- Opsoclonus-Myoclonus ataxia
- VIP secretion (diarrhea with low K)
What is the most common ppt of neuroblastoma
Adrenal glands (50%)
T or F: neuroblastoma tumour can spontaneously regress?
True.
In infants = less aggressive + may mature to benign.
But if > 1 likely aggressive and invade.
What may be neuroblastoma adrenal symptoms?
- abdo mass/fullness
- sweat
- HTN
- diarrhea (due to profound VIP)
T or F: infants may have unique bluish skin nodules (like blueberry muffin baby) as ppt for neuroblastoma.
True
T or F: Urine testing is (+) in almost ALL cases.
True.
- Urine catecholamine breakdown product (vanillylmandelic acid/ VMA , homovanillic acid / HVA)
Paraneoplastic syndrome associated with neuroblastoma:
- chorea
- athetosis
- diarrhea
- HTN
- hypercalcemia
Diarrhea
> Secretion of VIP (vasointestinal peptide)
= distend, diarrhea, low K
> Opsoclonus Myoclonus
Opsoclonus seen in which:
- AML
- ALL
- Neuroblastoma
- Medulloblastoma
- Rhabdomyosarcoma
Neuroblastoma (50% of pt)
“Dancing eyes and dancing feet”
What is the most common malignancy associated with opsoclonus myoclonus syndrome
Neuroblastoma (50% of pt)
T or F: 95% of opsoclonus myoclonus mis-dx as acute cerebellar ataxia as that comes before yes.
True.
Always have on DDx
Another name for Wilm’s Tumour
Nephroblastoma
Peak age for Wilm’s:
2-3 y.o.
14 y.o. with leg pain. XR show distal femur with sunburst pattern. Dx?
osteosarcoma (aka osteogenic sarcoma)
Poor prognosis for Langerhans Histiocytosis X associated with:
- mastoiditis
- pancytopenia
- lymphadenopathy
- chronic lung dx
- vertebral body involvement (single bony)
Pancytopenia (Marrow is high risk)
How does langerhan cell histiocytosis ppt?
- Bone (skull, other)
* * bone pain - Skin (papular seborrheic dermatitis, diaper +/- petechiae)
- lymph, HSM
Birbeck Granule. Dx?
Langerhans Cell Histiocytosis
**tennis racket granule on cytoplasm of LCH dx
What is the prognosis for langerhan cell histiocytosis?
Single-sys: usually benign
Multi-System: Chemo
Child w/ Wilm’s Tumour. Associations:
- Beckwith Weidemann
(organomegaly w/ ++ insulin, macroglossia, omph, hemihypertrophy) - WAGR (Wilms, Aniridia, GU anomalies, MR)
- Denys-Drash (RF, Pseudo hermaphroditism)
T or F: most Wilm’s tumour are asymptomatic.
True.
If symptom
= 25%= HTN
OR abdo mass
16 month old. B/L periorbital ecchymoses. Nystagmus. Palpable abdo mass. Dx?
Neuroblastoma
Note: periorbital bone mets= opsoclonus-myoclonus, periorbital ecchymosis, ptosis
Teen w/ CA palliative. 10 y.o. brother starts ignoring. Parents concerned. What to say?
Norm for siblings to experience variety of feeling (depression, anxiety, guilt, fear) which may make them pull away or may feel neglected.
Include in conversation, brother’s care and offer support (SW, psychology, child-life)
Describe the Human Body Pic for Chemo….
Human body- C look like Ear and Kidneys.
= Otoxotoxicty, Nephrotoxic
Bleomycin and Busulifan look like lungs. = Pul Fibrosis
Doxoruicin= Heart= Dilated cardiomyopathy.
CY= cyclophosphamide= Hemorrhagic cystitis
V= arm and leg = peripheral neuropathy
M= Methotrexate= Myelosuppression
List three side effects for L-asparaginase:
Allergic Rxn
Pancreatitis
High BG
Plt dysfunction
List 3 side effects Vincristine
Neuropathy
Constipation
Local cellulitis
List 3 side effects with Prednisone
HTN Cushing Cataract Diabetes Avascular necrosis Peptic Ulceration
Teen boy to get chemo + radiation. 2 factors that affect fertility:
High dose alkylating agent
High radiation Dose
Cigarette or MJ Use
Give two options to deal with possible infertility linked with chemo:
Sperm banking (for M who have gone through puberty)
Shield testicle during radiation
Choose tx regimen w/ lowest chance of infertility
List 3 tx for hyperuricemia:
- **Allopurinol (prevent forming uric acid)
- **Rasburicase (make uric acid water soluble so can pee)
- **Dialysis
- **Hyperhydration
48h after chemo has hematuria + mild dysuria. Plt 90 pre-chemo. Likely x?
Cyclophosphamide induced hemorrhagic cystitis
Neutropenic child with red central line. Abx?
Piperacillin-Tazobactam + Vancomycin
List 6 long term effects of Radiation to neck + chest, cyclophosphamide and vincristine chemo:
General Long-Term:
Infertility
Radiation:
- Growth retardation
- Hypothyroidism
- Cardiac or pul Toxicity
- Delayed Puberty
Doxorubicin:
Cardiomyopathy
Bleomycin: Pulmonary fibrosis and interstitial pneumonitis
Vincristine: Peripheral Neuropathy (sensory and motor)
Methotrexate: low BMD, neurocognitive deficits
T or F: Vincristine is lethal if given intrathecal.
True.
= paralysis, coma, death
What is lymphoma?
Solid tumour of lymphoid origin (NOT bone marrow or in circulation)
- Teens
- Hodgkin’s= Reed Sternberg cell
- Non-Hodgkin’s= lymphoblastic, burkitt’s etc.
PPT: lymph, B symptom
Dx: Bx
List 4 long term complication of curative therapy for CA:
- infertility
- hypothyroidism
- cardiomyopathy
- sensorineural hearing loss
3 long term effect of cyclophosphamide
- infertility
- delayed puberty
- bladder cancer
4 principles of opioid in palliative patient:
- individualized dosing for pt with titration as needed (no “right” dose for everyone)
- goal: relieve pain and minimize side effect
- basal level with breakthrough dose available
- give in simplest, most effective route (i.e. PO versus PCA)
- AE treated (i.e. constipation, itch, nausea)
- consider adjuvant for opioid-sparing effect (i.e. antidepressant, steroids for bone pain, sedatives)
What is tolerance in relationship to meds:
= decreasing drug effect w/ continued admin of a drug (need higher dose to get same effect)
What is dependence in relationship to drugs?
= need for continued drug dosing to prevent abstinence syndrome if abruptly d/c
** usually seen if potent opioids > 5-7 d
Teen with painless, firm rubbery cervical or supraclavicular node. Reed Sternberg cell
Hodgkin’s lymphoma
4 y.o. abdo mass. Pancytopenia. List 3 test to help differentiate dx on ddx.
Wilms Neuroblastoma Non-Hodgkin Lymphoma Hepatoblastoma Rhabdomyosarcoma
**U/S
**Urine HVA/VMA
(homovanillic aid and vanillylmandelic acid)
**alpha-fetoprotein
***CBC smear (lymphoma, rhabdo w/ bone marrow involved)
High serum Ca2+ more rhabdo
Neuroblastoma. Which associated with improved outcome?
- < 1 y.o. w/ met limited to liver, skin marrow
- age > 18 mo
- undifferentiated histology
- N-myc gene amplication
< 1 y.o. w/ met limited to liver, skin, marrow
Diabetes insipidus. MRI show two issue (pineal region, suprasellor region). beta HCG and alpha-fetoprotein negative. CNS Cytology negative for tumour. Lytic lesion on left humerus. Likely dx
- germ cell
- medulloblastoma
- langerhans cell histiocytosis
- ependymoma
LCH
Define febrile neutropenia
Fever > 38.3 or > 38 x > 1hr
ANC < 0.5 (or expected to fall below that within next 72h)
Tx: Broad spectrum Abx
Common bugs: Viral, Gram (+) (viridian’s, staph), Gram (-) (pseudomonas, E coli, Klebsiella), Fungi
Osteosarcoma vs. Ewing Sarcoma
Osteo:
- most common primary bone overall; typically middle teen
- Male
- Predisposed if Retinoblastoma, Paget Dx
- usually end of long bones + pelvis
- SUNBURST
- mets to lungs
- Chemo + Sx. No radiotherapy.
Ewing Sarcoma:
- < 10 or much older
- middle of long bone, axial skeleton or chest wall
- “onion skinning”
- mets to bunch
- Chemo +/- Sx +/- Radio
