Oncology Flashcards
1
Q
What is the definition of an oncological emergency?
A
-An acute medical problem related to cancer or it’s treatment which may result in serious morbidity or mortality if not treated quickly
2
Q
What are the categories of oncological emergency?
A
- Metabolic
- Structural/obstructive
- Treatment related
3
Q
What are the main oncological emergencies?
A
- Hypercalcaemia
- SIADH
- Spinal cord compression
- SVC obstruction
- Raised ICP
- Airway obstruction
- Neutropenic sepsis
- Anaphlaxis
- Tumour lysis syndrome
- Extravasation
- Tamponade
4
Q
What is the definition of hyercalcaemia?
A
-Serum corrected calcium >2.6mmol/L
5
Q
What are the causes of hypercalcaemia?
A
- Direct bone destruction ie bone tumour, bony mets, myeloma
- Parathyroid hormone related protein
- Non-cancer causes ie primary hyperparathyroidism
- Sarcoidosis
- Vit D intoxication
- Lithium
- Dehydration
6
Q
What is the cause of hypercalcaemia if PTH is high normal or raised?
A
-Hyperparathyroidism
7
Q
What are the possible causes if PTH is low or low/normal?
A
- Malignancy
- Drugs ie thiazides, high dose vit d, lithium
- Thyrotoxicosis
- Adrenal insufficiency
- Sarcoid or TB
8
Q
How does hypercalcemia present? (useful rhyme)
A
-STONES, BONES, GROANS, MOANS
9
Q
What are the GI symptoms caused by hypercalcaemia?
A
- Abdominal pain
- Constipation
- Nausea/vomiting
- Anorexia
- Weight loss
- Dehydration
10
Q
What are the Gu symptoms caused by hypercalcaemia?
A
- Renal stones
- Renal failure
- Polyuria
- Polydipsia
11
Q
What are the neuro symptoms caused by hypercalcaemia?
A
- Fatigue
- Weakness
- Confusion
12
Q
What are the psych symptoms caused by hypercalcaemia?
A
-Depression
13
Q
What investigations should be done for hypercalcaemia?
A
- Corrected calcium levels
- ECG (shortened QT level)
- Chloride levels
- ABG
- K+
- Phosphate
- Alk phos
- PTH
- CXR (sarcoidosis)
- 24hr urinary calcium excretion (for familial hypocalciuric hypercalcaemia)
14
Q
What suggests that hypercalcaemia is caused by malignancy?
A
- Low albumin
- Low chloride
- Alkalosis
- Low potassium
- Raised phosphate
- Raised alk phos
- PTH normal
15
Q
What are side effects of bisphosphonates?
A
- Flu like symptoms
- Oesophagitis
- Osteonecrosis of the jaw
- Bone pain
- Myalgia
- Reduced phosphate levels
- Nausea and vomiting
16
Q
What drug can be used for persistent/relapsed hypercalcaemia of malignancy?
A
- Denosumab
- Chemotherapy
17
Q
What is SIADH?
A
-Syndrome of inappropriate ADH secretion
>excess ADH
18
Q
What does ADH do?
A
-Stops urine output by acting on the collecting duct
>water retention and low serum sodium
>high urine osmolarity
19
Q
What are the malignant causes of SIADH?
A
-Paraneoplastic syndrome >SCLC >Pancreatic -NHL -Hodgkins lymphoma Prostate
20
Q
How does SIADH present?
A
- Fatigue
- N + V
- Confusion
- Coma
21
Q
Investigations for SIADH?
A
- Serum sodium (low, dilutional)
- Plasma osmolarity (low)
- Urine sodium (high, concentrated)
- Urine osmolarity (high)
- Look for underlying cause ie CT scan
22
Q
Management of SAIDH?
A
Fluid restirct (0.5-1l in 24hrs)
- Demeclocycline (abx which is known to cause reversible nephrogenic diabetes insipidus)
- ADH receptor antagonists
23
Q
How is SIADH managed in an emergency? (ie coma/fitting)
A
-Slow infusion of NaCl 1.8%
24
Q
Why is it important to correct SIADH slowly?
A
-Avoid precipitating central pontine myelinolysis
damage to the myelin sheath of the nerve cells in the Pons
25
What is spinal cord compression caused directly by malignancy?
- Pressure from tumour in between the vertebral bodies
| - Collapsed vertebral bodies on the spinal cord or cauda equina
26
Which spinal nerves are responsible for the knee and ankle jerk reflexes?
- Knee jerk: L3, L4
| - Ankle jerk: S1
27
What are the causes of spinal cord compression?
- Malignancy (2ndry is most common)
- Trauma
- Disc prolapse
- Inflammatory disease
- Spinal infection
- Epidural or subdural haematoma
28
Which types of cancer most commonly cause spinal cord compression?
- Breast
- Lung
- Thyroid
- Prostate
- Kidney
- Bowel
- Melanoma
- Myeloma
- Lymphoma
29
How does spinal cord compression present?
- Back pain
- Radicular pain (radiates to the lower extremity of that nerve root)
- Leg or arm weakness below level of compression
- Difficulty walking
- Sensory loss below level of compression
- Bladder and bowel dysfunction
- ED
- Abnormal neurological examination
30
On a neurological examination, what would LMN and UMN signs be for someone with a spinal cord compression?
- UMN: signs below the level of the compression
| - LMN: signs at the level of examination
31
How is spinal cord compression managed acutely?
- Analgesia
- High dose corticosteroids ie dexamethasone 8mg BD
- PPi cover whilst on steroids
- Bed rest if spinal instability
- Definitive treatment depends on site and extent of lesions and fitness
32
When would surgery be indicated for spinal cord compression?
-Single area of SCC - decompress then radiotherapy (allows spinal column stability)
33
What is the role of radiotherapy in management of spinal cord compression?
- Shrink the tumour
- Prevents deterioration of neurology
- Pain control
34
Other methods to treated spinal cord compression?
- Chemotherapy
- Hormone deprivation (in newly diagnosed prostate cancer causing mets)
- Bisphosphonates for bone pain
- VTE prophylaxis
- Pressure sore prevention
- Manage bladder and bowel dysfunction
35
What is superior vena cava obstruction?
-Compression, invasion or occasionally intra-luminal obstruction of the SVC
36
Describe the anatomy of the SVC?
- Provides venous drainage for the head, neck upper limbs and upper thorax
- From right atrium to the junction of the right and left innominate veins
- Surrounded by the sternum, trachea, right bronchus, aorta, PA, perhihilar and peritracheal lymph nodes
- IF svc obstructed, collateral pathways drain blood to return to the RA
37
What are the main causes of SVCO?
- Small cell lung cancer
- Non-small cell lung cancer
- Lymphoma
38
What are some other causes of SVCO?
- Thymoma
- Germ cell tumours
- Thrombus
- Direct tumour invasions
- Pressure outside of the vessel
39
Symptoms of SVCO?
- Dyspnoea
- Chest pain at rest
- Cough
- Neck, face and arm swelling - including conjunctival and periorbital oedema
- Dizziness
- Headache - worse in the morning
- Visual disturbance
- Syncope
40
Signs of SVCO?
- Visual compensatory collaterals ie dilated veins over neck, arms, anterior chest wall
- Oedema of upper torso, arms, neck and face
- Severe resp. distress
- Cyanosis
- Engorged conjunctiva
- Convulsions and coma
41
What is Pemberton's sign?
-Raising arms to touch over head
-If develop cyanosis, worsening SOB, or facial congestion
+ve for SVCO
42
Investigations for SVCO?
- Clinical diagnosis
- CXR - wide mediastinum, mass on right side of heart
- CT
- Doppler studies
- Invasive contrast-venography
43
How is SVCO managed?
- Symptomatic relief ie elevation of head and oxygen therapy
- Steroids 8mg BD po
- Endovascular stenting
- ?Anticoagulation
- Ultimate treatment depends on cause ie radio, chemo
44
What is the normal value for intracranial pressure?
-Normal ICP <15mmHg
45
Causes of raised ICP?
- Primary metastatic tumours
- Head injury
- Haemorrhage (subdural, extradural, subarachnoid, intracerebral, intraventricular)
- Infection
- Hydrocelphalus
- Cerebral oedema
- Status epilepticus
- Idiopathic intracranial hypertension
46
How does raised ICP present?
- Headache (worse when coughing, in morning, leaning forwards)
- Vomiting
- History of trauma
- Reduced GCS - drowsiness, irritability, coma
- Falling pulse
- Rising BP
- Cheynes-stokes respiration (deeper and quicker breathing followed by apnoeic episodes)
- Pupil changes
- Visual disturnaces
- Papilloedema
47
What investigations need doing for raised ICP?
- Fundoscopy
- U&E, FBC, LFT, glucose, clotting, blood cultures
- Consider tox screen
- CXR
- CT head
- LP if safe: measure opening pressure
48
Immediate management for raised ICP?
-ABCDE
-Correct hypotension
-Elevate bed to 30-40*
-Restrict fluids: 1.5l/day
-Diagnose and treat underlying cause
>?meningococcal rash, previous cancer
49
What's the role of mannitol in raised ICP?
-Osmotic agent used to suck out water from the brain
>20% solution IV over 10-20 mins
-May lead to rebound raised ICP after prolonged use
50
What is the role off corticosteroids in raised ICP?
- Only useful if raised ICP is due to cancer
- Dexamethasone 10mg IV
- Reduces oedema surrounding tumours
51
What are the 3 main herniation syndromes associated with raised ICP?
- Uncal herniation
- Cerebellar tonsil herniation
- Subfalcian (cingulate) herniation
52
What is uncal hernation?
- Lateral supratentorial mass causes the uncus to push against the midbrain
- 3rd nerve palsy: dialted ipsilateral pupil, ophthalmoplegia
- followed by contralateral hemiparesis due to pressure on cerebral peduncle
53
Why does uncal herniation result in a coma?
-Coma is a result of the pressure on the ascending reticular activation system in the midbrain
54
What is cerebellar tonsil herniation?
-Caused by increased pressure in the posterior fossa > forces the cerebellar tonsilts through the foramen magnum
55
What are the symptoms/signs of cerebellar tonsil herniation?
- Ataxia
- 6th nerve palsies
- Upgoing plantars
- LOC
- Irregular breating
- Apnoea
56
What is subfalcian (cingulate) herniation?
- Caused by a frontal mass
| - The cingulate gyrus is forced under the rigid falx cerebri
57
Why may a subfalcian herniation be silent?
-If the anterior cerebral artery is not compressed there many be no symptoms
-If compressed, symptoms of an anterior circulation stroke
>contralateral leg weakness
>abulia (inability to make decisions)
58
What may be the cause of airways obstruction in cancer?
-Can occur due to pressure from the tumour ie bronical carcinoma compressing the trachea
59
What is neutropenic sepsis?
-A treatment related eergency that occurs due to chemotherapy
60
What is the clinical definition of neutropenic sepsis?
- Neutrophil count <1.0x10^9 with a fever >37.5
| - or unwell in absence of fever
61
What treatments cause neutropenic sepsis?
- Any traditional chemotherapy regime >where agents act against all rapidly dividing cells ie bone marrow.
- Targeted/biological agents do not cause neutropenic sepsis
62
Risk factors for neutropenic sepsis?
-Current chemotherapy
63
How does neutropenic sepsis present?
- Pyrexia
- Hypotensive
- Poor urine output
- Confusion
- Any infective symptoms or signs ie headache, vomiting, productive cough
64
What is septic shock?
-Hypotension despite adequate fluid resuscitation along with perfusion abnormalities leading to end-organ dysfunction due to an increased systemic response to infection
65
Investigations for neutropenic sepsis
- Blood cultures
- ABG (lactate)
- FBC and platelet count
- U&Es
- LFTs
- Creatinine
- CRP/ESR
- Clotting (?DIC)
- Glucose
- CXR and other parts of septic screen for other sources of infection
66
How is neutropenic sepsis managed?
- ABCDE
- HDU
- Iv access: 500ml NaCl fluid challenge
- O2 if hypoxic
- Iv Abx
67
Which antibiotics could be used to treat neutropenic sepsis?
- Tazcoin 4.5g QDS
- Teicoplanin IV 400mg
- Of penicillin allergic: Ciprofloxacin
68
How is neutropenic sepsis prevented?
- Prophylaxis for pts at high risk with fluoroquinolone
- GCSF (to stimulate bone marrow)
- Reduced chemotherapy in susbsequent cycles if palliative
69
What is anaphylaxis?
- An acute mutli-system type 1 hypersensitivity reaction
| - Life threatening overreaction of the body's immune system
70
What causes anaphylaxis?
- When someone is exposed to a trigger substance to which they have already been sensitised
- Commonly occurs in response to chemotherapy
71
What are some conditions which may mimic anaphylaxis?
- Carcinoid
- Phaeochromacytoma
- Systmemic mastocytosis
- Hereditary angioedema
72
How does anaphylaxis present?>
- Acute onset
- CVS: tachy, hypotension
- Cutaneous: red skin, uticaria
- Bronchospasm: tight chest, cough, wheeze
- Non specific: agitation, D+V, abdo pain, unwell
73
How is anaphylaxis managed?
- Stop the drip of the offending agent
- ABCDE
- Resuscitate with o2 and IV
- 1:1000 0.5mg epinephrine IM
- Iv piriton 10mg
- IV hydrocortisone 100mg
74
What is tumour lysis syndrome?
-Sudden tumour necrosis due to cancer treatment
>causes metabolic abnormalities
>caused by an abrupt release of large quantities of cellular components into the blood following rapid lysis of the malignant cell
75
What are the electrolyte abnormalities that would be seen on tumour lysis syndrome?
- Hyperkalaemia
- Hyperphosphateaemia
- Hypocalcaemia
- Hyperuricaemia
- Raised lactate
- Raised LDH
- AKI
76
What causes tumour lysis syndrome?
- Spontaneous or treatment mediated (most often after initiation of treatment)
- Commonly occurs in haematological malignancies ie Burkitt's lymphoma, ALLA
77
Risk factors for tumour lysis syndrome?
-Volume depletion ie dehydration, bleeding
-Renal impairment
-Treatment-sensitive tumours
-High pre-treatment urate, lactate, LDH levels
>increased LDH - ^ risk of tumour breakdown
78
How does tumour lysis syndrome present?
- weakness
- Constipation and vomiting
- Abdominal pain,
- Palpitations, chest pain, collapse
- Seizures
- Reduced urine out put, lethargy, nausea
- AKI
79
Why can tumour lysis syndrome lead to AKI?
- Deposition of uric acid and calcium phosphate cyrstals in renal tubules = acute renal failure
- can be exacerbated by concomitant intravascular depletion
80
What investigations need to be done for tumour lysis syndrome?
- FBC
- U&E
- Serum LDH
- Serum phosphate
- Serum Urate
- Calcium profile
81
What are some key points to be aware of in prevention of tumour lysis syndrome?
- Awareness of its causes
- Identificaiton of high risk pts
- Implementation of appropriate prophylaxis-
- Monitoring of ts during chemo
- Starting active treatment when necessary
82
How can tumour lysis syndrome be prevented?
- Iv fluids
- Rasburicase (catalyses the oxidation of uric acid to allantion = more soluble)
- Allopurinol (xanthine oxidase inhibitor blocks conversion of xanthines to uric acid)
83
How is tumour lysis syndrome treated?
- Vigorous hydration with IV fluids
- Correct hyperkalaemia
- Rasburicase
- Acetazolamide
- Phosphate binders
- Dialysis in severe cases)
84
How do you treat hyperkalaemia?
- 10mls of calcium gluconate 10%
- Iv insulin and dextrose
- Salbutamol nev
- Oral calcium resonium 15g/6hrs
85
What is extravasation?
- Leakage of IV administered medication out of a vein into surrounding tissues
- Can cause severe tissue damage when given to surrounding tissues if the agent causes blistering
86
What causes extravasation?
-IV medication specifically chemo
87
How does extravasaion present?
- Pain, redness, swelling and blistering (at or near a cannula site)
- Absence of blood return
88
How is extravasation treated?
- Stop drip and disconnect from cannula
- Aspirate from cannula and then remove
- May require surgical debridement and skin grafting
89
What is cardiac tamponade?
-Pericardial fluid (or blood) collecting causing the intra-pericardial pressure to rise
-Heart can not fill and so pumping stops
=Obstructive shock
90
What causes tamponade?
- Trauma
- Breast/lung cancer
- Pericarditis
- MI
- Bacteria ie TB
91
Signs of tamponade?
```
-Beck's triad:
>falling BP
>rising JVP
>muffled heart sounds
-Increased JVP on inspiration
-Pulsus paradoxus (pulse fades on inspiration)
```
92
Investigations for a tamponade?
- ECHO
- CXR: globular heart, left heartborder: convex or straight
- ECG: electrical alternans (specific for pericardial effusion)
93
What does an ECG of electrical alternans show?
-Alternating QRS amplitudes due to fluid wobbling the heart, and mot being able to contract efficiently
94
How is cardiac tamponade treated?
- Pericardiocentesis
- O2, ECG monitoring, IVI, G&S
- May need cardiothoracic surgery
95
What are some examples of complimentary therapies that can be used alongside traditional cancer treatment?
- Aromatherapy
- Reflexology
- Western Herbal medicine
- Healing includin Reiki
- Manipulative therapies ie osteopathy and chiropractic
- Acupuncture
- Shiatsu
- Homeopathy
- Clinical hypnosis
96
What is the legal position with regard to complimentary medicine?
-Legally free to practice at their level of qualification/experience
-Regulation is important. Identification of competent and safe therapists is required
-Osteopaths and chiropractors have to register
>if unregistered: criminal offence
97
What is the relationship between complementary medicine and the NHS?
- Becoming more open minded about potential benefits
- Some forms available on the NHS
- Some primary health sectors can have team trained in complementary therapy to provide within a practice. Need registration from the regulatory body
98
What is the conversion factor between codeine and morphine?
-Morphine is 10x stronger
99
What chemotherapy medication is commonly associated with peripheral neuropathy?
- Vincristine
| - Urinary hesitancy may also develop secondary to bladder atony
100
What treatment options are there for a pt who is experiencing bone pain from bony mets?
- NSAIDs (diclofenac)
- Bisphosphonates
- Radiotherapy
101
Where are the most common sites for bony mets?
1. Spine
2. Pelvis
3. Ribs
4. Skull
5. Long bones
102
Which is the most common cancer causing bony mets?
-Prostate
103
What are the side effects associated with cyclophosphamide?
- Haemorrhagic cystitis
- Myelosuppression
- Transitional cell carcinoma
104
What are the side effects associated with bleomycin?
lung fibrosis
105
What cancers is cyclophosphamide chemotherapy used for?
- lymphoma
- multiple myeloma
- leukemia
- ovarian cancer
- breast cancer
- small cell lung cancer
- neuroblastoma
- sarcoma.
106
What is bleomycin used for?
- Hodgkin's lymphoma
- non-Hodgkin's lymphoma
- testicular cancer
- ovarian cancer
- cervical cancer
107
What are the side effects associated with doxorubicin?
-Cardiomyopathy
108
What is doxorubicin used for?
- Usually used in a combination of chemotherapy agents
- breast cancer
- bladder cancer
- Kaposi's sarcoma
- lymphoma
- acute lymphocytic leukemia
109
What are the side effects associated with methotrexate?
- Myelosuppression
- Mucositis
- Liver fibrosis
- Lung fibrosis
110
What are the side effects associated with 5-fluorouracil?
- Myelosuppression
- Mucositis
- Dermatitis
111
What is 5-fluorouracil used to treat?
-colon cancer, esophageal cancer, stomach cancer, pancreatic cancer, breast cancer, and cervical cancer
112
What are the side effects associated with 6 mercaptopurine?
-Myelosuppression
113
What conditions are 6 meracaptopurine used to treat?
- acute lymphocytic leukemia
- chronic myeloid leukemia
- Crohn's disease
- ulcerative colitis
114
What are the side effects associated with cytarabine?
- Myelosuppression
| - Ataxia
115
What are the side effects associated with vincristine and vinblastine?
- Vincristine: peripheral neuropathy, paralytic ileus
| - Vinblastine: myelosuppression
116
What are the side effects associated with docetaxel?
-Neutropenia
117
What are the side effects associated with cisplatin?
- Ototoxicity
- Peripheral neuropathy
- Hypomagneseamia
118
What are the side effects associated with hydroxycarbamide?
-Myelosuppression
119
Which tumour marker is raised in pancreatic cancer?
-CA19-9
120
What should be the breakthrough morphone dose for breakthrough pain compared to the normal daily dose?
-1/6th
ie if someone is taking 30mg BD = 60mg
therefore breakthrough dose is 10mg
121
Which opioids are safest to use in pts with CKD?
- Alfentanil
- Buprenorphone
- Fentanyl
122
Define neoplasm
-A new and abnormal growth of tissue in the body
123
What are the 6 characteristics of cancer cells that underline their behaviour?
1. Self-sufficiency in growth signals
2. Evades apoptosis
3. Insensitivity to anti-growth signal
4. Tissue invasion and metastasis
5. Limitless replicative potential
6. Sustained angiogenesis
124
Define pharmacodynamics?
-What a drug does to the body
125
Define pharmacokinetics
What the body does to the drug
126
What are the 3 features of chemotherapy that must be present for a treatment to be effective?
1. The drug must reach the cancer cells
2. The cell must be sensitive to the cytotoxicity of the drug
3. The toxic effect must be minimal to the benefit of the drug
127
Define screening
-A process to identify apparently health people who may be at increased risk of a disease or condition
128
Who is involved in a cancer care MDT?
- Oncologist
- Surgeon specific to body system affected
- Clinical nurse specialist
- Macmillan team
- Pt and their family
129
What is the purpose of neoadjuvant chemotherapy?
- Given before surgery/radical treatment to shrink the tumour to make it easier to operate on
- Can eradicate micro-metastatic disease and allow some tumours to be downstaged before the definitive/curative treatment
130
What are the -ves of neoadjuvant chemotherapy?
- Delays definitive treatment
- Adds the risk of potentially fatal chemo related complications
- May cause a decrease in pts performance status and then they may no longer be fit for surgery
131
What is the purpose of adjuvant chemotherapy?
- Given after surgery
- To ensure any margins/micrometastatic sites are free from disease
- Can improve survial in some cancers (breast, colorectal)
132
What are some disadvantaged os adjuvant chemotherapy?
-Morbidity from surgery may mean pts aren't fit for chemo within an appropriate timeframe
133
What are some side effects of radiotherapy?
- Nausea
- Vomiting
- Anorexia
- Mucositis
- Oesophagitis
- Diarrhoea
- Skin rash
* Early SE = local inflammation
* Late SE = local fibrosis
134
What are 3 different groups of systemic anti-cancer treatment?
- Cytotoxic chemotherapy
- Hormone therapy
- Molecularly targeted therapy
135
What are the 3 main groups of cytotoxic chemotherapy agents?
- Alkylating agents
- Antimetabolites
- Natural products
136
What are some examples of alkylating agents?
- Cisplastin
- Cyclophosphamide
- Melphalan
- Chlorambucil
- Isosfamide
137
What are some examples of antimetabolites?
- Fluorouracil
- MTX
- Capecitabine
- Gemcitabine
- Mercaptopurine
- Hydroxyura/hydroxycarbamide
138
What are some examples of natural product chemotherapy agents?
- Bleomycin and doxorubicin
- Mitomycin C
- Vinca alkaloids ie vincristine, vinblastine
- Taxanes ie docotaxel
139
What are some general side effects of chemotherapy?
- HF
- Nausea
- Taste changes
- Hepatic impairment
- Immune suppression
- Peripheral neuropathy
- Constipation
- Hair loss
- Skin rashes
- Renal impairment
- Infertility
140
What chemotherapy agent specifically causes renal impairment?
-Cisplatin
