Oncology Flashcards
Definition of carcinogenesis
Transformation of normal cells to neoplastic cells through permanent genetic alterations or mutations
Carcinogen definition
Mutagenic agent which causes cancer. (environmental, hormones, radiation)
Papilloma
Benign epithelial neoplasm of non-glandular, non-secretory cells.
Adenoma
Benign epithelial neoplasm of glandular or secretory cells.
Carcinoma
Malignant tumour of epithelial cells
Adenocarcinoma
Malignant tumour of glandular or secretory cells.
Sarcoma
Malignant connective tissue tumour
Metastatic cascade events
1) detachment
2) invasion
3) intravasation (blood or lymph)
4) evasion of the host’s defence system
5) adherence
6) extravasation
7) angiogenesis
Adverse effects of radiotherapy
Fatigue Diarrhoea Nausea and vomiting Erythema Infertility Lymphoedema Hypothyroidism Poor wound healing.
Adverse effects of chemotherapy
Mylosuppresion = Anaemia, Increased infections, bleeding.
Alopecia
Infertility
Nausea, vomiting and diarrhoea.
Fatigue
EXTRAVASATION when medicine leaks out of veins into surrounding tissue - pain, red, blisters.
Name some oncology emergencies
Anaphylaxis to chemo agent. Spinal cord compression Neutropenic sepsis DVT/PE Hypercalcaemia of malignancy Haemorrhage SVC obstruction Tumour lysis syndrome Lambert-Eaton Myasthenic Syndrome Carcinoid syndrome Emergencies from paraneoplastic syndromes
Common malignancies to cause spinal cord compression
Breast Prostate Lung Myeloma Lymphoma
S+S of spinal cord compression
Severe, radicular back pain. Weakness of limb Sensory loss Urinary retention, dribbling, incontinence. Faecal incontinence.
O/E:
Pain and tenderness of local area.
Sensory and motor loss below level of compression.
Where does the spinal cord end and what happens if there is a compression below this level
L1
Cauda equina syndrome.
S+S of cauda equina syndrome/compression
Sciatic pain (bilateral) Bladder dysfunction (incontinence, retention) Sacral or saddle paraesthesia Loss of anal sphincter tone. Gluteal muscle wasting and weakness.
Ix for spinal cord compression
START TREATMENT BEFORE ANYTHING!!
MRI of whole spinal cord
Mx of spinal cord compression
IV dexamethasone + PPI
Contact neurosurgery.
Definition of febrile neutropenia
Neutrophils = 0.5 x 10^9 per litre or lower
+
temperature higher than 38 degrees.
Ix for neutropenic sepsis
START TREATMENT FIRST!! Blood culture FBC U+E ABG and lactate LFT CRP Creatinine Urine analysis Clotting screen
Mx for neutropenic sepsis
Piperacillin + tazobactam.
IV fluid bolus
Monitor urine output.
Differential diagnosis for patient presenting with: Dyspnoea Cough Swelling of face and facial oedema. Raised JVP Collateral veins on chest Cyanosis
Superior vena cava obstruction
Heart failure (JVP will pulsate)
Cardiac tamponade
External jugular vein compression.
Malignancies which are more likely to cause SVC obstruction
Involving medistinal lymph nodes e.g. NSC and SC lung cancers, non-hodkin’s lymphoma.
S+S of SVC obstruction
Dyspnoea
Cough
Swelling of face
Headache
O/E: facial oedema and plethora fixed raised JVP collateral veins on chest wall cyanosis papilloedema
Ix for SVC obstruction
For many will be first presentation of the cancer so image to get clear diagnosis.
CXR or CT thorax.
US of upper extremities.
Mx of SVC obstruction
If acute airway obstruction: Secure airway (A-->E) Radiotherapy Dexamethasone. Loop diuretic
Treat malignancy.
Endovascular stenting is a symptomatic/pallative option.
Causes of raised ICP in a cancer patient
Neoplasm e.g. glioma, meningioma)
Haemorrhage (increased risk of bleed from myelosuppresion)
CNS infection e.g encephalitis (myelosuppresion = immunocompromised)
S+S of raised ICP
Headache Nausea and vomiting Worse on sneezing, coughing and in morning (after lying down). Drowsy Gait abnormality
O/E:
Papilloedema
Focal neurology signs
Ix of raised ICP
Head CT or MRI
Mx of raised ICP
High dose dexamethasone to reduce oedema for cancer cause only!!!.
Alternative to dex or for all other causes = Mannitol.
Contact oncology team :)
Consider neurosurgical intervention, chemotherapy.
When to intervene ASAP in hypercalcaemia
If free calcium is greater or equal to 3.0mmol/L.
Aetiology of hypercalcaemia in cancer patients
Humoral = systemic release of factors which activate oestoclasts. e.g. secretion of parathyroid hormone in squamous cell carcinoma of lungs.
Osteolytic metastasise = increased bone resorption due to bone metastases e.g. breast, multiple myeloma and lymphoma + calcitriol production.
Over-production of 25-hydroxyvitamin D = tumour secretes osteoclast activating hormone e.g lymphoma
Dehydration
S+S of hypercalcaemia
Bones - boney pains.
Moans - loss of appetite, nausea + vomiting, malaise, fatigue.
Stones - renal colic.
Thrones - polyuria, polydipsia, dehydration (dry mucus membranes, constipation).
Psych undertones - depression, cognitive dysfunction, drowsy.
Cardiac - arrythmias
Ix in hypercalcaemia
U+E FBC Albumin Parathyroid hormone levels ECG Serum calcitriol and 25-hydroxyvitamin D
Mx of hypercalcaemia
Rehydration - 0.9% normal saline resuscitation.
Monitor U+Es
Bisphosphonates e.g. Pamidronate
Loop diuretic e.g. furosemide to avoid overload.
If recurrent can use Denosumab (inhibits RANK ligand)
Bisphosphonate to use in hypercalcaemia of malignancy
Pamidronate
Tumour lysis syndrome pathophysiology
Combination of metabolic and electrolyte abnormalities occurring after cytotoxic treatment in patients with cancer.
Excessive cell lysis
Renal impairment
Electrolyte imbalances in tumour lysis syndrome
Hyperuricaemia
Hyperphosphataemia
Hyperkalaemia
Hypocalcaemia
AKI
Metabolic acidosis
S+S in tumour lysis syndrome
Nausea and vomiting Anorexia Diarrhoea Muscle cramps and weakness Lethargy Confusion Haematuria, flank pain, oligouria/anuria Arrythmia Syncope
Name of the definition of tumour lysis syndrome
Cairo-Bishop definition =
2 or more serum biochemistry results increase by 25% from baseline levels (uric acid, potassium, phosphate or calcium) occurring 3 days prior to treatment or 7 days after commencing treatment.
Mx of tumour lysis syndrome
PROPHYLAXIS:
Optimise renal function pre-treatment.
Correct pre-existing electrolyte imbalances.
Adequate fluid intake - may use IV fluids and also loop diuretic to maintain high urine output.
Drugs = Allopurinol or if higher risk Rasburicase, these specfically help hyperuricaemia.
Name a recombinant urate-oxidase enzyme used to manage tumour lysis syndrome
Rasburicase.
Cancers commonly associated with paraneoplastic syndromes
Lung (SC and NSC) Pancreatic Lymphoma Breast Prostate Ovary
SIADH as a paraneoplastic syndrome
Small cell lung cancer most commonly.
Inappropriate secretion of anti-diuretic hormone.
S+S: gait disturbance + falls, headache, nausea, muscle cramps, anorexia, seizures.
Ix: low sodium, high urine osmolality.
Rx: Fluid restriction, Demeclocycline antibiotics
Cushing’s as a paraneoplastic syndrome
Inappropriate/ectopic overproduction of ACTH precursors.
Common malignancies = NC and NSC lung Ca, pancreatic, thymic.
High 24hr urinary cortisol.
High plasma ACTH
Poor dexamethasone suppresion test
Hypercalcamia as a paraneoplastic syndrome
Bony metastases.
Tumour production of parathyroid hormone e.g squamous cell lung carcinoma (humour hypercalcaemia of malignancy) or TNF
Hypoglycaemia as a paraneoplastic syndrome
Insulinoma
Non-islet cell pancreatic tumours secreting IGF-2.
Lambert-Eaton myastheic syndrome
Decrease in pre-synaptic calcium dependent acetylcholine release.
Commonest malignancy = SCLC.
S+S = Insidious onset of fatigue, weakness and dry mouth, areflexia, diplopia, ptosis, impotence.
Ix = EMG, anti-P/Q voltage-gated calcium channel antibodies.
Rx = IV immunoglobulins
Common neurological paraneoplastic syndromes
Peripheral neuropathy
Proximal myopathy.
Hypo-osmotic, euvolemic hyponatraemia
SIADH secretion
2 dermatology Paraneoplastic syndromes
Acanthosis Nigricans (commonest = gastric adenocarcinoma) Dermatomyositis
Dermatomyosistis as a paraneoplastic syndrome
Skin changes + proximal muscle weakness.
Skin changes = Heliotrope rash on eyelids, facial erythema, phalangeal scaliness (similar to psoriasis).
Ix = High creatinine phosphokinase, EMG, mule biopsy.
Haematological Paraneoplastic syndrome
Polycythaemia due to Erythropoietin secretion of tumour. Commonly renal malignancies.
Carcinoid syndrome
Neuroendocrine tumours secrete serotonin and other vasoactive peptides (histamine etc).
S+S: flushing, diarrhoea, bronchial constriction (wheeze, SOB), RHF, abdomen cramps, palpitations.
Ix: high 5-HIAA, Chromogranin A.
Rx: surgical. Somatostatin analogue e.g. Octreotide
Staging of gynae cancers
FIGO
Staging of lymphoma
Ann Arbor classification
Staging of colon cancer
TMN or Duke’s Classification
Examples of staff in a cancer MDT
Medical oncologist Clinical/radiation oncologist Pallative care team Dietician Physio OT Psychologist Cancer nurses
Symptom management for pain
Analgesia
Symptom management for nausea
Metoclopramide
Ondansetron
Symptom management for anorexia
Steroids e.g. prednisolone or dexamethasone
Symptom management for cough
Opioids
Cancers which commonly metastasise to bone
Prostate cancer Breast cancer Lung cancer Kidney cancer Thyroid cancer
Level of serum correct calcium for hypercalcaemia
Greater or equal to 2.6mmol/L
What is corrected calcium?
As approximately 4% of calcium is bound to albumin need to account for that in serum levels.
Add 0.1mmol/L to calcium level for every 4g/L that albumin levels are below 40g/L
Acute presentation of SIADH secretion treatment
Slow infusion of 1.8% NaCl
What is Pemberton’s sign
Patient raises arms up to the sides of their face so that the arm touches the ear. Hold for 2-3mins.
+ve if: cyanosis, SOB or facial congestion occur on arm raise.
Indicates venous obstruction
Normal ICP
<15mmHg
Chemotherapy agent associated with reversible peripheral neuropathy
Vincristine and sometimes cisplatin
Side effect of cisplatin
Ototoxicity and renal impairment
The hallmarks of cancer
Self-sufficiency of growth signals. Evade apoptosis. Insensitive to anti-growth factors. Invasion and metastasis. Limitless replicative potential. Sustained angiogenesis.
Purpose of adjutant therapy
Shrink tumour before surgery
Eradicate any residual micro tumour post surgery
Tumour marker raised in pancreatic cancer
CA19-9
Tumour marker raised in ovarian cancer
CA125
