Oncology Flashcards
What 2 hormones control calcium?
PTH
Calcitonin
How is serum calcium increased?
thyroid gland releases calcitonin
- this causes reduced calcium uptake in the kidneys
- stimulates calcium deposition in bones
how is serum calcium decreased?
parathyroid gland releases PTH
- calcium release from bones
- calcium uptake in kidneys increased (via active Vit D causes increase in ca uptake in intestines as well)
causes of hypercalcaemia?
Normal PTH:
direct bone destruction i.e. cancer
PTHrP- released by some cancers e.g. breast, kidney, lung, head and neck
High PTH:
- primary hyperparathyroidism
- sarcoidosis
- vit D intoxication
- lithium
- dehydration
features of hypercalcaemia?
bones, stones, groans and moans
GI groans-pain, constipation, N&V, weight loss, dehydration
Moans- depression, fatigue, weakness, confusion
Ix of hypercalcaemia?
corrected calcium levels ECG- shortened QT interval U&Es Bone profile CXR- sarcoidosis Isotope bone scan 24hr urinary Ca excretion
what blood features should make you think of malignancy with hypercalcaemia?
low albomin, Cl and K
high phosphate, alk phos
alkalosis
PTH normal
tx of hypercalcaemia?
treat cause
correct dehydration- IV 0.9% saline, 3L over 24 hours
bisphosphonates- inhibits osteoclasts e.g. pamidronate, zoledronic acid (monthly via IV)
chemotherapy
steroids in sarcoidosis
denosumab- inhibits osteoclast maturation
SEs of bisphosphonates?
flu, oesophagitis, osteonecrosis of the jaw, bone pain, myalgia, reduced phosphate levels, N&V
what levels does the spinal cord end?
L1
forms cauda equina
what spinal nerves cause knee jerk reflex?
l3/l4
what spinal nerve causes ankle jerk reflex?
S1
causes of spinal cord compression?
malignancy- primary or secondary trauma disc prolapse inflammatory disease e.g. RA spinal infection epidural or subdural haematoma
presentation of SCC?
back pain radicular pain leg or arm weakness sensory level bladder and bowel dysfunction ED abnormal neuro exam
Ix of SCC?
MRI whole spine
bloods- FBC, U&E, LFTs (could indicate lever mets)
tx of SCC?
Analgesia dexamethasone 8mg BD PPI surgery radiotherapy chemo
cause of superior vena cava obstruction?
90% due to small cell lung cancer
non-SCLC
lymphoma
features of SVCO?
Dyspnoea, chest pain, cough, neck arm and face swelling, dizziness, headache, blurred vision
visual compensatory collaterals
Pemberton’s sign= raising arms up to face worsen SOB, cyanosis and facial congestion
Ix of SVCO?
clinical diagnosis CXR- widened mediastinum or mass on RHS of heart CT scan biopsy of any masses doppler studies invasive studies- venography
mx of SVCO?
elevation of the head and oxygen therapy may provide symptomatic relief High dose- dexamethasone endovascular stenting radiotherapy chemo diuretics for breathlessness anticoagulation
what is neutropenic sepsis?
oral temp >38 degrees or 2 consecutive readings of >37.5 degrees AND
an absolute neutrophil count <1x 10^9/L or expected to fall below 1x10^9/L
presentation of neutropenic sepsis?
any infective symptoms
asymptomatic yet febrile
can follow cytotoxic chemotherapy
Ix of neutropenic sepsis?
as per local guidelines
IV Piperacillin with Tazobactam (tazocin) (don’t wait for results of blood tests)
Assess risk of septic complications- AKI, DIC, organ failure
Oral abx for low risk patients
prophylaxis of neutropenic sepsis?
fluoroquinolone while undergoing chemotherapy
G-CSF (granulocyte colony- stimulating factor)
Side effects of radiotherapy?
N&V, anorexia, mucositis, oesophagitis, diarrhoea, skin rashes
types of chemotherapy?
1) cytotoxic:
- alkylating agents e.g. cisplastin
- anti-metabolites- e.g. methotrexate
- natural products e.g. bleomycin
2) hormonal therapy
3) molecular targeted therapy
SEs of chemotherapy?
HF, nausea, taste change, hepatic impairment, immune suppression, peripheral neuropathy, constipation, hair loss, skin rashes, renal impairment, infertility
palliative care drug for resp secretions?
hyoscine hydrobromide
palliative care drug for bowel colic?
hyoscine butylbromide
pain relief for palliative care?
regular oral (MR) morphine with immediate release (MR) morphine for breakthrough pain- should be 1/6th dose of maintenance dose
- laxatives should be co-prescribed
- anti-emetic if nausea persists
alternatives to morphine for pain relief?
diamorphine oxycodone alfentanil buprenorphine fentanyl
conversion between: oral codeine/tramadol-> oral morphine oral morphine -> oral oxycodone oral morphine -> sub cut morphine oral morphine -> sub cut diamorphine oral oxycodone -> sub cut diamorphine
oral codeine/tramadol-> oral morphine (divided by 10)
oral morphine -> oral oxycodone (divided by 1.5-2)
oral morphine -> sub cut morphine (divided by 2)
oral morphine -> sub cut diamorphine (divided by 3)
oral oxycodone -> sub cut diamorphine (divided by 1.5)
what pain relief is used for palliative care if oral treatments aren’t suitable?
transdermal opioid patch
SE morphine?
constipation nausea sedation dry mouth psychomimetic effects confusion myoclonus allergy resp depression pruritis
what are the different neurotransmitters causing in N&V?
5HT3- serotonin
H2
D2
what factors influence vomiting centre in the brain?
fear pain -> cerebral cortex -> VC
motion sickness/cerebral tumours -> vestibular apparatus-> VC
gastric irritation/GI distension -> vagus/ splanchnic nerves -> VC
GI tract-> VC
drugs/ metabolic -> chemoreceptor trigger zone -> VC
what types of anti-emetic is a 5HT3 receptor antagonist?
e.g. ondansetron
acts at chemoreceptor trigger zone and GI tract
Useful in CTZ stimulation e.g. drugs, gut infection, radiotherapy
SEs of 5HT3 receptor antagonist?
constipation, diarrhoea, headaches, prolonged QT interval
what types of anti-emetic is a D2 receptor antagonist?
metoclopramide, domperidone
acts at CTZ and upper GIT
prokinetic: relaxes the pylorus, reduces lower oesophageal sphincter tone, increases gastric peristalsis
useful in long-term opioid use
SE of D2 receptor antagonist?
diarrhoea, extrapyramidal side effects with metoclopramide- acute dystonia- more common in young females
(domperidone doesn’t cross BBB so doesn’t cause EPSE)
CI- GI obstruction, perforation
what types of anti-emetic is a H2 receptor antagonist?
cyclizine, promethazine
acts at vomiting centre, vestibular system
SE of H2 receptor antagonist?
drowsiness, dry mouth and blurred vision (anti-cholinergic side effects)
transient tachycardia after IV
useful in motion sickness and vertigo
CI of H2 receptor antagonist?
prostatic hypertrophy as it can cause urinary retention
what anti-emetics are best used for post op N&V?
ondansetron
cyclizine
name some PONV risk factors?
female prev PONV history of travel sickness non-smoker surgeries- ENT, gynae, GI peri-operative opioid use gastric insufflation during intubation duration of anaesthesia
investigating metastatic disease of unknown primary?
FBC, U&E, LFT, Ca, LDH urinalysis CXR CT of chest, abdo, pelvis AFP and hCG
what are the human rights related to health?
2- the right to life
3- the prohibition of torture or inhumane or degrading treatment or punishment
8- the right to respect for private or family life
what is the pain ladder?
simple analgesia- paracetamol and NSAIDs
weak opioids- codeine, dihydrocodeine, tramadol
strong opioids- morphine, oxycodone, fentanyl, buprenorphine, diamorphine
how do NSAIDs work?
inhibits COX
need to monitor renal function and platelet count
how does paracetamol work?
inhibits CNS prostaglandins
5 drugs essential for palliative care?
pain- morphine 1.25-2.5mg SC or 2.5-5mg PO breathlessness- morphine secretions- hycosine butylbromide SC agitation- midazolam nausea- haloperidol
signs and symptoms of opioid overdose?
sudden improvement in pain reduced conscious level reduced resp rate/SpO2 myoclonic jerks pinpoint pupils confusion hallucinations
mx of opioid overdose?
naloxone 400mg STAT if live threatening
close observation
review dosing
what are the different types of breast cancer?
- invasive ductal carcinoma
- invasive lobular carcinoma
- ductal carcinoma-in-situ
- lobular carcinoma-in-situ
what is paget’s disease of the nipple?
eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer
what is inflammatory breast cancer?
where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast
RFs for breast cancer?
BRCA1/BRCA2 genes- lifetime risk of breast/ovarian cancer 1st premenopausal relative with breast cancer Nulliparity, 1st pregnancy, >30 years Early menarche, late menopause COCP, HRT Not breastfeeding Ionising radiation p53 gene mutation Obesity
features of breast cancer?
lump nipple inversion nipple discharge skin contour changes peau d'orange dimpling of the breast
when to refer for 2ww?
age >30 and have an explained breast lump with or without pain OR
age >50 with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
who is offered breast cancer screening?
women aged 47-73 years
women are offered a mammogram every 3 years
diagnosis of breast cancer?
mammogram
USS
core needle biopsy/fine needle aspiration
examination
staging of breast cancer?
TNM
mx of breast cancer?
surgery- either wide local excision or mastectomy
radiotherapy
hormonal therapy
chemotherapy
when to do a mastectomy for breast cancer?
Multifocal tumour
central tumour
large lesion in small breast
DCIS >4cm
SEs of radiotherapy for breast cancer?
pneumonitis rib fracture pericarditis lymphoedema brachial plexus injury
when is hormonal therapy used?
ER positive- tamoxifen (pre or peri-menopausal women)or aromatase inhibitors (post-menopausal women)
when is biological therapy used?
HER2 positive disease e.g. Herceptin (transtuzumab)
