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Year 4 Family and Children ANNA > Oncology > Flashcards

Oncology Flashcards

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1
Q

What are the red flags for lung cancer?

A
  • Cough that won’t clear (dry/productive)
  • Haemoptosis – remember to clarify amount
  • Dyspnoea – check if this has changed recently
  • Hoarse voice – could be a symptom of recurrent laryngeal nerve involvement which would imply mediastinal involvement with cancer
  • Chest pain – character important
  • Fatigue
  • Appetite loss
  • Weight loss
  • SVC obstruction symptoms - e.g. swelling
  • Horner’s syndrome
  • Brachial plexus involvement
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2
Q

What are paraneoplastic syndromes?

A

Symptoms and signs of cancer that are NOT due to the mass effect.

Instead, they are inflammatory or hormonal changes due to either the cancer producing things it shouldn’t, or the immune system reacting to the cancer.

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3
Q

What are the 4 most common categories of paraneoplastic syndromes?

A
  1. Endocrine
  2. Neurological
  3. Musculoskeletal
  4. Haematological
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4
Q

What information do the radiology dept need before they can perform a CT scan with contrast? And why?

A
  • Previous contrast reaction
  • Renal function - if GFR <40ml/min then increased risk of contrast-induced acute kidney injury.
  • Diabetes Mellitus – metformin therapy – (metformin may need to be stopped pre contrast if renal impairment).
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5
Q

What disease and antigen does rituximab (mabthera) treat?

A

Lymphoma CD20

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6
Q

Why do you use margins on planning radiotherapy?

A
  1. To mitigate set up error e.g. change in position
  2. To eradicate microscopic disease around tumour edge
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7
Q

What are the early-stage and late-stage side effects of radiotherapy caused by?

A

early - inflammation

late - fibrosis

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8
Q

What are chemotherapy and radiotherapy both based on?

A

Damage to DNA / cell cycle that normal tissue can recover from but cancer cells can’t

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9
Q

What is brachytherapy?

A

Radiotherapy delivered internally, e.g. prostate (PR) cervical (PV)

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10
Q

What is stereotactic radiotherapy

A

For small tumours that aren’t near critical structures. Higher doses given in fewer fractions

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11
Q

What is chemotherapy most often used for?

A

Adjuvant therapy (↓ risk of relapse, vs micrometasteses)

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12
Q

What are the red flag symptoms for back pain?

A

R - referred pain (band-like)

E - escalating pain (no response) / Exacerbated by coughing

D - different to previous / new onset

F - funny feelings - heavy legs, odd sensations

L - lying flat ↑ pain

A - agonising pain

G - gait disturbance - esp. on stairs

S - sleep disturbance - pain ↑ at night

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13
Q

What is the immediate drug for spinal cord compression (and SVC obstruction)?

A

16mg dexamethasone stat, then 8 mg BD

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14
Q

What investigation is essential in SCC?

A

MRI whole spine (lie flat until this is done! checking stability of spine)

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15
Q

Do you wait to do blood cultures if patient has ?neutropenic sepsis?

A

No! Start broad spec abx within 1hr

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16
Q

What symptoms would you get with SVC obstruction?

A
  • dyspnoea is the most common symptom
  • swelling of the face, neck and arms
    • conjunctival and periorbital oedema may be seen
  • headache: often worse in the mornings (cerebral oedema!!)
  • visual disturbance
  • pulseless jugular venous distension
  • cyanosis
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17
Q

What is Pemberton’s sign?

Who is it most commonly found in?

A

A positive Pemberton’s sign is indicative of superior vena cava syndrome (SVC), commonly the result of a mass in the mediastinum

Patients with substernal goitre

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18
Q

What is the most immediate treatment for hypercalcaemia?

A

IV rehydration and monitoring (fluid balance and electrolytes)

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19
Q

Would the PTH be high or low in a patient whose hypercalcaemia was caused by cancer?

A

Low - the Ca2+ is being produced by the cancer / hormonal effect of cancer on osteoclasts, not the PTH

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20
Q

What is the most immediate investigation for a patient with SVC obstruction?

A

Contrast CT / CXR (but manage with steroids while you wait)

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21
Q

What is the difference in the NMJ between Eaton Lambert Syndrome and myasthenia gravis?

A

Eaton Lambert - caused by an antibody directed against pre-synaptic voltage gated calcium channel channels

Myasthenia Gravis - antibodies to post-synaptic acetylcholine receptors

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22
Q

What do tendon reflexes look like in myasthenia vs LEMS?

A

Present in MG (hasn’t had time to tire yet)

Hyporeflexia in LEMS (reduced transmission of ACh, but will increase after max voluntary contraction)

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23
Q

What are the proportions of primary lung cancers?

A
  1. Small cell 24%
  2. Non-small cell 75%
    1. Squamous 48%
    2. Adenocarcinoma 13%
    3. large cell 10%
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24
Q

What are some non-metastaic / non-mass effects of lung cancer?

A
  • Clubbing / hypertrophic osteoarthropathy
  • Eaton-Lambert Syndrome (LEMS) / Myaesthenia
    • Due to autoantibodies
  • SIADH
    • Small cell cancer should be considered if Sodium is very low!
  • Cushings Syndrome
    • Due to tumour ACTH secretion
  • Hypercalcaemia
25
Q

What is an example of gene-targeted chemotherapy?

A

EGFR chemo

26
Q

What is the difference between Transudate and Exudate?

A

Transudate is fluid pushed through the capillary due to high pressure within the capillary (will not contain protein)

Exudate is fluid that leaks around the cells of the capillaries caused by inflammation (will contain protein)

27
Q

Which is likely in lung cancer? Transudate or exudate

A

Exudate

28
Q

What are the common extra-pulmonary effects with different types of lung ca?

A

Centrally

Squamous cell - clubbing, ectopic TSH, hypercalcaemia

Small cell - LEMS, vertigo/nystagmus (anti-Hu), ectopic secretion of ADH or ACTH

29
Q

What are the investigations you would do in x-ray confirmed lung cancer?

A
  • Blood tests
    • Full blood count - to check he is not anaemic as this may signal more advanced disease or co-morbidities
    • Renal function – to check fitness for chemotherapy (most Lung cancer chemotherapy is platinum- based and as this is excreted predominantly through the kidneys requires good renal function)
    • Bone profile –
      • a raised calcium could be a sign of bone metastases or
      • a paraneoplastic syndrome due to the secretion of PTH related hormone in squamous cell cancer.
    • Liver function – if abnormal may not tolerate chemotherapy of indicate Liver secondaries
  • Pulmonary Function Tests – essential before surgery and radical radiotherapy to measure Lung reserve.
  • CT scan – for staging. This should be of the thorax and abdomen with contrast. This should be done prior to the bronchoscopy so you can see where to biopsy
  • Bronchoscopy and biopsy – for histological diagnosis and staging (ie is the carina involved – inoperable) - Check not on aspirin/anti-coagulants
  • PETCT scan - as disease appears localised and may be curable
  • Other tests - only if indicated by symptoms. i.e. if bony pain – bone scan and if headaches – Brain CT/MRI
30
Q

List the 6 factors you think will be important in deciding lung cancer treatment

A
  1. The stage of his disease ie is it operable or localised for radiotherapy
  2. His fitness or performance status
  3. His co-morbidities / DH
  4. The histology and other characteristics of the tumour that may mean it would respond to specific systemic anti- cancer treatments (e.g. EGFR chemo)
  5. His preferences for treatments
  6. His social support networks
31
Q

What does SPIKES stand for?

A

Setting

Perception

Invitation

Knowledge

Emotions

Strategy/Summary

32
Q

what side effects are likely from a central lung tumour radiotherapy?

A

Oesophagitis – usually occurs within 2 weeks of commencement of radiotherapy and can require admission for nutritional support but is usually short lived and settles within 2-4 weeks of completion of treatment

Dyspnoea – due to Lung damage. This can occur 2-3 weeks into radiotherapy but can progress several months after treatment finishes and can be life-threatening.

Lung toxicity (pneumonitis) is treated with high doses of steroids if severe but may be irreversible.

33
Q

What type of lung cancer is chemotherapy effective on?

What is the exception?

A

Small cell (rapidly divides)

non-small cell can have EGFR mutation → targeted chemotherapy

34
Q

What are the characteristics of:

Small cell

Non small cell:

  • Adenocarcinoma
  • Squamous cell
A

Small cell lung cancer (15% frequency)

  • Small cell Lung cancer is typically centrally located and infiltrative on CT scan
  • Rapid growth. Doubling time is approx 29 days
  • Very chemo/radiosensitive but rarely cured
  • Without treatment median survival 2-4 months
  • With treatment median survival is 6-12 months for extensive (metastatic) disease and 16-24 months for localised disease

Adenocarcinoma (30-40%)

  • Typically peripheral location and often slower growth with a typical doubling time of 160 days.
  • However metastasise early.
  • Can occur in non smokers
  • Can respond to newer systemic agents ie tyrosine kinase inhibitors.

Squamous cell carcinoma (30%)

  • Typically centrally located and so develop symptoms early
  • Smoking related
  • Best survival due to potential operability
  • Doubling time 90 days
35
Q

What are the T stages of lung cancers?

A

T1 <3cm

T2 3-5cm or involves main bronchus but not carina

T3 5-7cm or invades chest wall or separate nodule same lobe

T4 >7cm or invading local structures e.g. mediastinum/heart/trachea – inoperable

36
Q

What are the 3 M1 categories of lung cancer?

A

M1a - separate tumour nodule(s) in opposite lobe

M1b - single extra-thoracic metastases in a single organ

M1c - multiple extra-thoracic metastases

37
Q

What symptoms aside from pain is it essential to ask about in back pain?

(x3 of MSCC metastatic spinal cord compression)

A
  1. Difficulty walking, or reduced power in any limbs.
  2. Loss of sensation, particularly in her legs or perineum.
  3. Changes in bladder or bowel function, particularly retention of urine.
38
Q

Which sites of the spine is degenerative disease found?

A

lumbar or cervical spine

39
Q

What is pain due to osteoporotic collapse like?

A
  • Site: the thoracic spine
  • Tends to be most severe at the onset and then gradually improve over time
40
Q

What is a side effect of aromatase inhibitors e.g. letrozole?

A

acts to reduce oestrogen levels -This can accelerate bone loss and patients are monitored with DEXA scans while they are on this treatment

41
Q

What blood tests would you do if you suspected bony mets?

A

FBC – bone marrow infiltration can lead to bone marrow suppression with anaemia and thrombocytopenia

Bone profile – hypercalcaemia can occur with bone metastases and may be asymptomatic

U&Es – especially important if hypercalcaemia is found (PTH)

LFTs – as a marker for other sites of metastatic disease

42
Q

What is an important side effect of denosumab?

A

Osteonecrosis of the jaw

This is a rare but important side effect. All patients planned for densumab should have a dental assessment first to reduce risk

43
Q

What tests would you perform on a suspicious cervical lymph node?

A

USS + Biopsy (FNA or core)

44
Q

What are the investigations for malignancy in order of:

  1. The cancer’s existence
  2. The cancer itself (grade)
  3. Spread of the cancer (stage)
  4. Effects of the cancer
A
  1. Confirm cancer’s presence with cheap imaging e.g. USS imaging / CXR or easy biopsy - FNA
  2. Confirm size, type and markers with core biopsy (or excision)
  3. CT, or MRI, then PET or PET-CT
  4. Bloods, history for paraneoplastic syndromes
45
Q

What 2 monoclonal antibody treatments are used for myeloma?

A

Ipilimumab and Nivolumab

46
Q

What in the PMHx is it important to check for if you are giving monoclonal antibody therapy?

A

Autoimmune conditions (immunotherapy can make these worse)

47
Q

What is the criteria used to describe side effects accross all oncological types?

A

Common Terminology Criteria (CTC) for Adverse Events

48
Q

What are the 5 grades in the Common Terminology Criteria (CTC) for Adverse Events?

A
  1. Grade 1 = mild symptoms
  2. Grade 2 = moderate symptoms limiting age appropriate instrumental ADL
  3. Grade 3 = Severe or medically significant but not immediately life-threatening. Usually requiring hospital admission
  4. Grade 4 = 4 Life-threatening consequences; urgent intervention indicated
  5. Grade 5 = Death caused by treatment toxicity
49
Q

Why is diarrhoea caused by immunotherapy treated differently from that caused by chemotherapy?

A

chemotherapy - here diarrhoea is caused by malabsorption and increased secretions from damage to rapidly-turning-over bowel cells. Stopping the chemo and steroids / rehydration is sufficient.

immunotherapy - the colitis is caused by the body attacking itself. It is more severe and will continue until immunosuppressed (removing the drugs may not help fast enough). With severe colitis patients are at risk of perforation and peritonitis. If no response to steroids, advanced immunosuppression is needed.

50
Q

50% of melanomas have this mutation. What is the treatment option?

A

BRAF V600 mutation

BRAF inhibitors (or immunotherapy)

51
Q

What are the likely side-effects for radiotherapy to cervix?

A

pelvic irradiation is likely to result in infertility due to loss of ovarian function.

It can also cause stenosis and dryness of vagina resulting in problems with sexual function. Patients are advised to use dilators to prevent stenosis and lubricants to deal with dryness.

52
Q

What are the common Cisplatin toxicities?

A
  1. Bone marrow suppression
  2. Peripheral neuropathy
  3. Renal impairment
  4. Hearing impairment
53
Q

How would you counsel and saftey net a patient receiving chemotherapy?

A
  1. Increased risk of serious infection. You are vulnerable to infection while you are having chemotherapy. Minor infections can become life-threatening in a matter of hours if left untreated. If you feel unwell, you have symptoms of an infection or your temperature is 37.5ºC or above or below 36 ºC contact The Christie Hotline straight away.
  2. Anaemia (low number of red blood cells) While having this treatment you may become anaemic. This may make you pale and feel tired and breathless. Let your doctor or nurse know if you have these symptoms. You may need a blood transfusion.
  3. Bruising or bleeding (low platelets). Rarely, this treatment can reduce the production of platelets which help the blood to clot. This means you may bruise easily or experience bleeding, such as nosebleeds or bleeding gums. If you have any of these symptoms, tell your doctor or nurse straight away. You may need a platelet transfusion.
54
Q

What lymph node biopsy should be done in suspected lymphoma?

A

Excisional lymph node biopsy

(as needle biopsies provide insufficient tissue to reliably diagnose lymphoma and define the subtype. Some types of lymphoma can look normal on FNA so false negative rate is high)

55
Q

What does Hodgkin’s lymphoma look like on biopsy?

A

Hodgkin’s lymphoma is diagnosed by the presence of Hodgkin’s cells with an appropriate background cellular milieu.

The Hodgkin’s cell can be a characteristic Reed-Sternberg cell or one of its variants, such as the lacunar cell in the nodular sclerosis sub-type.

56
Q

What staging is used for lymphoma?

A

Ann-Arbour staging

57
Q

What does WHO/ECOG Performance status mean?

A

Grade 0: fully active, able to carry on all pre-disease performance without restriction

Grade 1: Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work.

Grade 2: Ambulatory and capable of all self care but unable to carry out any work activities, up and about more than 50% of waking hours.

Grade 3: Capable of only limited self care, confined to bed or chair more than 50% of waking hours.

Grade 4: Completely disabled, cannot carry on any self care, totally confined to bed or chair.

Grade 5: Deceased.

58
Q

According to NICE how is neutropenic sepsis defined?

A

Temperature >38oC and neutrophil count <0.5 x 109/L

Year 4 Family and Children ANNA (23 decks)

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