Oncology Flashcards
What is hodgkins lymphoma?
malignant tumour of lymphatic system - characterised histologically by Reed Sternburg Cells
Describe the histology of Hodgkin’s lymphoma
Reed Sterburg cells (multinucleated giant cells)
abnormal and smaller mononuclear cells originating from B lymphocytes
Risk factors for Hodgkins lymphoma
EBV
previous mononucleosis
HIV
immunosuppression
Presentation of Hodgkins lymphoma
- enlarged but asymptomatic lymph node in lower neck or supraclavicular region (pain with alcohol)
- cyclical fever
- chest discomfort - cough dyspnoe (mediastinal lymph node involvement)
- B symptoms - night sweats, fever, weight loss
Staging of Hodgkins lymphoma
Ann Arbor
- one lymph node region or structure (spleen, thymus, waldeyers ring)
- >1 lymph node region on same side
- involvement both sides
- splenic, hilar, coeliac or portal
- para-aortic iliac or mesenteric
- extranodal
Modifying features of Hodgkins lymphoma
A: no symptoms
B: night sweats, fever, weight loss
X: > 1/3rd mediastium widening or >10cm diameter of mass
E: extranodal site
Potential examination findings of Hodgkins lymphoma
Lymphadenopathy
Hepatomegaly
Splenomegaly
Superior VC syndrome (facial swelling associated with SOB)
Hodgkins lymphoma investigations
FBC (leukamia, mono)
ESR (>70 bad prog)
LFT (low albumin bad prog)
HIV
CXR (lymphadenopathy and mediastinal expansion)
Lymph node and bone marrow biopsy (staging)
CT thorax and abdo (staging)
ABVD chemo
Doxorubicin
Bleomycin
Vinblastine
Dacarbazine
BEACOPP chemo
Bleomycin
Etoposide
Doxorubicin
Cyclophosphamide
Vincristine
Procarbazine
Prednisolone
What can additional things can you give with chemo
- Abx to any pt with severe neutropenia
- Recombinant human granulocyte colony - stimulating factor stimulates neutrophil production so could reduce duration of chemo induced neutropenia reducing incidence of associated sepsis
Management of Hodgkins lymphoma
Early: ABVD then radio (preceeded by BEACOPP in unfavourable prog)
Advanced: ABDV/BEACOPP
ASCT= autologous stem cell transplant
follow up for Hodgkins lymphoma
OPD 2-5 years
TFT if radio to neck and upper mediastinum
made aware theyre increased risk of secondary mags, CVD, pulmonary disease and infertility
Prognosis of Hodgkins lymphoma
80-90% patients achieve permanent remission
poor prognostic indicators
- increasing age
- male
- B symptoms
*
what are the oncological emergencies?
- neutropenic sepsis
- spinal cord compression
- SVC obstruction with airway compromise
- hypercalaemia
- tumour lysis syndrome
- raised ICP
- SIADH
- Haemorrhage
- Anaphylaxis
Causes and presentation of neutopenic sepsis
Bone marrow suppression due to chemo
usually presents 5-12 days after chemo
generally unwell, confusion or drowsiness
HR>90 RR>20
Investigations and management of neutropenic sepsis
- Septic screen
- neutrophils <0.5 with either temp>38 or Sx sepsis
Mx: immediate empirical Abx - IV Tazosin
Cause and presentation of spinal cord compression
causes: extradural mets, direct extension of tumour, crush fracture
Presentation: back pain, weakness, sensory loss, bowel and bladder dysfunction
Investigations and management of spinal cord compression
Ix: URGENT MRI whole spine
Mx: dexa, radio, decompression surgery
SVC obstruction causes
malignancy
- lung
- thymus
- lymphoma
- mediastinal enlargement
thrombotic disorders
thrombus around IV Central line
SVC obstruction presentation
Dyspnoea, orthopnoea
cyanosis
face/arm swelling
cough
headache
engorged veins
SVC obstruction test, investigations and management
Pembertons test: hold arm about head for more than 1min = cyanosis, increased JVP, insp stridor
Ix: URGENT contract CT
Mx: dexo, SVC stent, balloon venoplasty
Raised ICP causes and presentation
Causes: Primary CNS tumour, mets (breast, bowel, kidney, lung, skin)
Px: headache, focal neuro, N&V, papilloedema, fits
Raised ICP investigations and management
Ix: URGENT MRI/CT
Mx: dexa, radio or surgery, mannitol for symptomatic
Tumour lysis syndrome cause
rapid cell death after starting chemo causes release of cell contents
rise in serum urate K+ and phosphate precipitating renal failure
seen 12-72 hours after chemo
Presentation of tumour lysis syndrome
- fatigue
- N&V
- diarrhoea
- weakness and cramps
- seizures
Tumour lysis syndrome investigations
increased uric acid
increased K+ and phosphorus
decreased calcium
Tumour lysis syndrome prophylaxis
hydration
low risk: allopurinol 7 days before chemo
high risk: Rasburicase stat dose
Neutropenic sepsis prophylaxis
Ciprofloxacin (fluroquinolone) during expected period of neutropenia
Hypercalaemia causes
lytic bone mets
myeloma
tumour producing osteoclast activating factor or PTH like hormones
hypercalaemia presentation
- bones
- stones
- abdo groans (and constipation)
- fatigue
- N&V
Investigations and management of hypercalaemia
Ix: high serum calcium >2.6
Mx: rehydrate IV bisphosphonate
Patho behind non-hodgkins lymphoma
Genetic mutation causes B/T cells to divide uncontrollably producing a neoplastic cell.
This can be
1) nodal lymphoma
2) extranodal lymphoma
- GI tract
- Bone Marrow
- Spinal cord
What types of B cell lymphoma are there?
Indolent e.g. follicular lymphoma and marginal zone lymphoma
aggressive e.g. Diffuse large B cell lymphoma
mantle cell lymphoma
highly aggressive e.g. Burkitts lymphoma (chromosomal translocation 8->14) associated with EBV
Types of T cell lymphoma
adult T cell lymphoma
mycosis fungoides
Non-Hodgkins lymphoma symptoms
gastric MALT: GORD + constitutional symptoms
Burkitts: abdo swelling, nausea and diarrhoea
NHL investigations
Lymph node biopsy
CT - staging
NHL Management
localised - Radiotherapy
High grade - R-CHOP
Rituximab
Cyclophosphamide
Hydroxydaunomycin
Vincristine
Prednisolone
Which cancer is associated with coeliac disease?
small bowel T cell lymphoma
What is bacteria is assoicated with Burkitts lymphoma?
H. pylori
how do you treat h.pylori?
PPI
clarithromycin
metronidazole or amoxicillin
What are the possible causes of a mediastial tumour?
Terrible lymphoma (Hodgkins)
Teratoma
Thymoma
Thyroid Mass
Tumour Lysis Management
- Hydration, 10mls 10% calcium gluconate (lowers potassium, protects the heart)
- 10 units rapid acting insulin and 50mls 50% glucose
- Calcium polystyrene sulfonate (reduces K+ )
- ±furosemide
- Rasburicase (reduces Uric acid)
- Aluminium hydroxide (reduces phosphate)
- Haemodialysis
Causes of SIADH
- Produced by SCLC
- Brain: Meningitis
- Lung: Pneumonia, TB
- Alcohol withdrawal
- Drugs: opiates, carbamazepine, vincristine, cyclophosphamide
Presentation of SIADH
Mild – nausea, vomiting, headache, anorexia, lethargy
Moderate – muscle cramps, weakness, confusion
Severe – drowsiness, seizures, coma
Signs of SIADH
Signs: hyporeflexia, ataxia, tremour
Investigations of SIADH
- High ADH
- Urine: Hyperosmolar and hypernatraemic
- Plasma: Hypo-osmolar and hyponatraemic, low uric acid
- Normal BP, thyroid and adrenal function
Test: give saline - Na depletion responds, SIADH doesn’t
SIADH management
Treat cause
Fluid restriction - maybe lifelong
Tolvaptan - V2 receptor antagonist which stops aquaporins
What is anaphylaxis?
Type 1 hypersensitivity reaction
IgE mediated
How do you manage anaphylaxis?
- ABCDE
- High flow 02
- IM adrenaline 0.5MG (1in 1000)
- Repeat after 5 mins X3 then switch to IV
- IV fluid - 500ml bolus in 5/10 mins
- Chlorphenamine 10mg IM
- Hydrocortisone 200mg IM
