Oncology Flashcards
4 most common cancers?
Top 4 cancers with highest mortality?
Breast- Lung- CRC- Prostate
Lung- CRC- Breast- Prostate
Examples of uninterrupted oestrogen exposure increasing breast cancer risk
Late childbearing, Nullparity, Early menarche, Late menopause, Obesity, HRT
2 week referral guidelines for ?breast cancer
30+= Unexplained lump 50+= unilateral discharge/retraction/nipple sign
Consider if skin changes/ Axilla lump
If <30 + unexplained lumo then non-urgent referral
Describe breast cancer screening in the UK
50-70 years
Mammogram every 3 years
What is the breast cancer triple assessment?
What is added if there is a discrepancy?
1- Clinical Dx
2- Bilateral mammography
3- Targeted US biopsy (FNAC)
MRI
Isotopic bone scan or CT if ?Disseminated disease
What is triple -ve breast cancer?
ER -ve HER2 -ve and PR-ve
HARDER TO TREAT
When does BRCA1/2 status impact treatment?
if <50 and triple -ve
Broad indication for surgery in breast cancer?
Wen is neo-adjuvant chemo given?
Number one choice if localised
+/- Post op RT
+/- Neo-adjuvant Chemo if HER-2 +VE or Triple -ve or need to reduce size to enable surgery
How does ER/PR status impact prognosis in breast cancer?
Better if +ve
How does HER2 status impact prognosis in breast cancer?
Worse if +ve
In what breast cancer group is chemotherapy most effective in?
<50
+ Oncotype Dx can help predict extent of benefit
Tumour marker used in breast cancer?
CA15.3
When is RT required to treat breast cancer?
Following conservative surgery by all residual tissue to decrease recurrence
Post-mastectomy if high recurrence risk (mets or >4cm or deep resection margin)
When is endocrine therapy the primary treatment in breast cancer?
ER/PR +ve and slowly progressive
Indications for tamoxifen in breast cancer?
ER/PR +VE
PRE-MENOPAUSAL
taken for 5 years as adjuvant
Indications for Herceptin (Trastuzamab) in breast cancer?
HER2 +VE
12 months but need regular cardiac testing
Indications for Aromatase inhibitors (Anastrazole) in breast cancer?
What are the complications?
POST-MENOPAUSAL and ER/PR +VE
Osteoporotic events therefore do DEXA baseline
Median response to endocrine therapy if breast cancer with metastatic disease?
1-2 years
What factors are considered during management of metastatic breast cancer?
What is not part of the treatments for the above?
Extent, hormone status, HER2 status, symptoms, preferences, performance status
If mets or S4 post-assessment then surgery only has a palliative role. Metastatic solid breast cancer tumour= Wholly palliative.
Information and support available to breast cancer patients
Breast cancer nurse specialist
Psychological support
Lymphedema risk
Early menopause (iartrogenic)
What factors impact the response to endocrine therapy in breast cancer?
Dominant site of the disease- greater response if soft tissue; much reduced if bony or visc mets
An objective response to prior endocrine therapy
Greater duration of previous disease free interval
Most common type of prostate cancer?
Where in the prostate is cancer likely to be?
95% Adenocarcinoma
Peripheral or posterior (BPH likely centric)
Gold standard imaging of choice in ?Prostate cancer
MRI
What do patients with an abnormal PR usually get if ?Prostate cancer?
Transrectal biopsy under US guidance
Side effects of Transrectal biopsy under US guidance?
Blood in urine/semen, infection, discomfort
Ideal imaging method to detect bone mets from prostate cancer?
Radionucleotide bone scan
Describe the The Gleason System of Grading
Sample from the two most predominant areas of prostate neoplasm
Histological grading ranging 2-10
“4+3” Main area is graded as 4 and second area 3
Higher number= Less differentiation= More aggressive
What are the following scores on the Gleason System of Grading: 6 7 8 10 What ISUP grade is high risk?
6- Low (LOWEST POSSIBLE)
7- Intermediate
8- Aggressive
10- Highest
ISUP 4/5 is high risk
Advantages of ISUP score over other Gleason classification scores?
The classification simplified the number of grading categories from Gleason scores 2 to 10, with even more permutations based on different pattern combinations, to Grade Groups 1 to 5
The lowest grade is 1 not 6 as in Gleason, with the potential to reduce overtreatment of indolent cancer
Many classification systems consider Gleason score 7 as a single score without distinguishing 3+4 versus 4+3, despite studies showing significantly worse prognosis for the latter
Cancers commonly causing Bony mets?
Prostate, Kidneys, Lung, Thyroid, Breast (All midline)
Where does prostate cancer commonly metastasise to?
Spine +/- Pelvis
Classic appearance of prostate cancer related bony mets?
Sclerotic
Important discussion points with a patient who has ?Prostate cancer
Sexual function Urinary function Fertility Asymptomatic Comorbidities
When is surgery considered for treatment of prostate cancer?
What iatrogenic side effects can this have?
Radical prostatectomy with curative content if T2 (confined to prostate) or less
Impotence
What is the intent of Transurethral resection of the prostate?
Palliative
Side effects of Radiotherapy treatment in prostate cancer?
Dysuria, rectal bleeds, diarrhoea, impotence, incontinence
General role of radiotherapy in prostate cancer treatment?
Can be alternative to surgery if T1/T2
Adjuvant
Palliative if persistent bone pain
What is brachytherapy?
When should this be avoided in prostate cancer?
Interstitial implantation of radioisotopes (form of radiotherapy)
Best if fewer comorbidities as less risk of impotence
Avoid if significant urinary symptoms (can exacerbate)
Indications for hormone therapy to treat Prostate cancer?
Advanced disease (or with radiotherapy if localised)
General side effects of using hormone therapy to treat Prostate cancer?
Reduced muscle bulk
Wx gain
Sexual dysfunction
Increased risk of DM
How do LHRH and GnRH antagonists work to treat prostate cancer?
Side effects?
Reduce testosterone
Medical castration
Can exacerbate symptoms if there is a tumour flare
What hormone therapy is rarely the best option to treat prostate cancer?
Oestrogen induced LHRH inhibition
Prognosis of prostate cancer if:
1) Local
2) Radical surgery/RT
3) Metastatic
1) Local- 4.5 years
2) Radical surgery/RT- 85% live 10 years if treated
3) Metastatic- 3.5 years
Role of chemotherapy in prostate cancer treatment?
Example regimen?
Adjuvant to increase QoL and Survival Cytotoxic Docetaxel (+prednisolone)
Is small cell or non-small cell the most common type of lung cancer?
Non-small cell 82%
Most common types of NSCLC?
Squamous cell -> Adenocarcinoma -> Large cell -> Other (Carcinoid, mesothelioma, sarcoma etc)
General features to differentiate between squamous cell and adenocarcinoma lung neoplasms?
SCC- Central, close to bronchi, SMOKERS GET THIS, Secrete PTHpp therefore hypercalcaemia
Adeno- Peripheral, EGFR and ALK mutations (drug targets!), non-smokers, women, asbestos
General features of small cell lung cancer?
How responsive are they to chemo/RT?
Aggressive, rapid growth, mets likely before Dx, neuroendocrine cells (SIADH, ACTH-Cushing’s, Lambert-Eaton), marker= Bombesin
Good response to Chemo/RT but relapse quickly
Indications for a 2 week lung cancer referral
Unexplained haemoptysis in >40
CXR suggesting cancer
> 40 + 2 of cough/fatigue/SOB/Chest pain/Wx loss/Smoker
Role of bronchoscopy in lung cancer Dx?
Biopsy
End brachial US to biopsy lymph nodes in the mediastinum
What investigation is essential for lung cancer staging?
CT as allows an assessment of disease extent
When is PET indicated in ?Lung cancer?
If thought to be operable
Usually after CT to make sure distant mets arent missed
Role of pulmonary function tests in assessing lung cancer
Important in deciding whether an individual is fit for lung cancer surgery (alongside cardiopulmonary exercise training)
Role of sputum cytology in assessing lung cancer
Malignant cells in ~80%
In terms of TMN staging, when is trimodality treatment indicated in lung cancer?
Ipsilat bronchopul and hilar nodes (N1)
Ipsilateral mediastinal or subcranial (N2)
What Nodal involvement would usually indicate inoperable lung cancer?
Contralateral mediastinal/hilar/supraclavicular
S4 lung cancer prognosis
6 months
Role of Chemotherapy in treating SCLC
Good response. Usually palliative though as relapse is v common within 12 months
Common mets in SCLC? What is done to ameliorate this?
Brain mets therefore receive prophylactic cranial irradiation
Role of RT in treating SCLC
Treat primary tumour
Prophylactic cranial irradiation to prevent brain mets following good chemo response
Palliative id advanced
Role of surgery in treating SCLC
Inappropriate in vast majority.
Needs adjuvant CT/RT if used.
Role of surgery in NSCLC
S1 or S2
Adjuvant RT if +ve surgical markings
Adjuvant CT if nodal/larger
General CI for surgery in NSCLC
Mediastinal involvement
When is RT a good choice for NSCLC?
If not suitable for surgery or palliative
What is Continuous hyperfractionated accelerated RT?
What is Stereotactic ablative RT?
CHART- 3X a day for 12 days
SABR v large doses to a small area; good if peripheral and not suitable for surgery
Examples of when to use palliative RT in Lung cancer
SC compression, Painful mets, central disease symptoms (blood, cough)
Role of chemotherapy in NSCLC
Mainstay if metastatic or locally advanced
Also palliative role
Example of an EGFR inhibitor used to treat NSCLC
Gefitinib
Example of an ALK inhibitor used to treat NSCLC
Crizotinib
What is Pembrolizumab?
Immunotherapy used to treat NSCLC with high PDL1 expression
SE of prophylactic intracranial irradiation?
Memory loss
Functional deficit
Dementia
What is the 1/3rd rule for CRC?
1/3rd rectum, 1/3rd left side, 1/3rd rest of colon
Most common type of CRC?
Adenocarcinoma= 90%
CRC screening- what blood test is used? Who for?
Faecal occult blood test
60-74 every 2 years
3X separate samples
When is sigmoidoscopy screening done for CRC?
55
if normal then bowel screening at 60
What is Faecal Immunological Blood testing for CRC? Any advantages?
One sample
Home test kit
60-74 yrs
What age is a RF for CRC?
95% in >50s
Dont forget IBD and acromegaly
What imaging is used for CRC staging?
CT scan
Essential bed side investigation for CRC?
Rectal exam! 3/4 felt on this
What is Carcinoembryonic antigen (CEA)?
Tumour marker for CRC
Role in monitoring treatment response/disease progression
Describe Duke’s staging for CRC
A- Bowel wall only B- Invasion through wall C1- Apical/high tide node clear but other nodal involvement C2- Apical node involved D- Distant mets
What treatment can be curative in CRC?
Surgery- radical CR resection
Indications for palliative surgery in CRC?
Stenting etc to manage or prevent obstruction
Role of RT in:
- Rectal carcinomas
- Colonic cancers
- Palliation in CRC
- Rectal carcinomas= Pre-op or adj in high risk before resection
- Colonic cancers= NOT USUALLY INDICATED DUE TO RADIATION RISK TO OTHER ORGANS
- Palliation- Bone mets
When is adj chemotherapy accepted practice in CRC?
High risk CRC
More effective in DUKES C THAN B in increasing survial
Example of genetic factors that impose ‘high risk’ status on individuals with CRC?
HNPCC (lynch), Gardener’s (APC gene), P53, DCC, RAS mutation
What is the most active chemotherapy agent in CRC with the highest response rate?
5-FU with a response rate of 25%
Standard screening process for CRC?
Faecal occult blood test followed by endoscopic intervention if +ve
General principles of CRC follow up
CT 18 months/3 yrs/5yrs
Endoscopic intervention at 12 months and 3 years
CEA tumour marker
Specialist nurse led
When does RT generally have curative potential?
No mets
Especially useful if H+N cancer
Units of RT?
Grays
Smaller doses= Fractions
How many RT fractions are usually given?
1 fraction a day for Mon-Fri
If radical then large doses over many fractions
How does concurrent chemotherapy impact the efficacy of RT?
Acts as a radiosensitiser so increases effectiveness
BUT ALSO INCREASES TOXICITY
What is Gross tumour volume?
What you see on the scan
What does the Clinical target volume include?
Microscopic parts not seen on the scan so you add margins for ?spread
What is the planning target volume?
Add margins for variation in pt and tumour position whilst also considering other organs at risk of RT-related damage
When are the acute RT side effects usually seen?
What are the common acute SE?
After first 5-10 fractions (usually 2 weeks)
Reversible TRANSIENT damage to normal tissue
Localised hyperpigmentation/skin reaction/Dermatitis
Oral mucositis
Diarrhoea
‘‘-itis’’
Late often irreversible SE of RT?
3 months to years after
Infertility, blood vessel damage, fibrosis, dry mouth, urethral/oesophageal strictures, skin atrophy, telangectasia, secondary malignancy, teratogenic!
What is brachytherapy?
Interstitial/cavity based radioactive source near tumour
used in prostate/H&N/Gyane/Oesophageal
Localised dose to small volume! But pt is radioactive…
What is stereotactic RT? When can it be used?
Delivers a large dose to a small margin, small Number of large fractions, minimal SE
Used if well defined & small tumour
When are Radioisotopes used to treat cancer?
Cancerous tissue takes up decaying isotope, useful if thyroid cancer, must stay isolated for 4 days though
What does a ‘course’ of chemotherapy mean?
A planned number of cycles
Immediate adverse effects of chemotherapy
N&V Myelosuppression- Thrombocytopenia/Leucopenia/Neutropenia Oral mucositis Diarrhoea/Constipation Alopecia Nephrotoxicity Peripheral neuropathy Skin Extravasation /Erythema /Pigmentation/Photosensitivity Myalgia Lethargy Clots deafness
Long term consequences of chemotherapy
Secondary malignancy (via DNA damage) Infertility Pulmonary fibrosis Cardiac fibrosis Osteoporosis Psychosocial Toxicity to major organ systems- important to consider PMHx
What is the nadir in relation to chemotherapy?
The most profound point of haemopoetic stem cell deficit
Signs of chemotherapy related thrombocytopenia?
Petechial haemorrhage, Spontaneous nose bleeds, corneal haemorrhage, haematuria
When is a platelet transfusion indicated in thrombocytoepenia?
Platelet count <10 X 10^9
consider if 10-20, but need evidence of spont bleeding
Definition of neutropenic sepsis?
Absolute neutro count <1X 10^9
plus single temp >38.5 or sustained temp of >38 for 1 hour
What investigations are indicated if ? Neutropenic sepsis
2X peripheral cultures
2x line cultures (Both within 30 mins)
BUFALO
Site of infection? Lines? Catheters?
Key Q if ? Neutropenic sepsis
Chemotherapy timeline and drugs
Previous episodes
Localising symptoms
Most common causes of neutropenic sepsis?
70% G+ve S.Aureus, Staph Epidermis/Haemolyticus, strep pyogenes
30% G-ve like E.coli/Klebsiella/Pseudomonas
Also consider candida and aspergillosis
Key management principles for neutropenic sepsis
Start IV broad spec Abx immediately (E.G Tazocin or meropenem)
Continue if ANC<1 +Fever/Hypotension/Tachycardia
Review past microbiology
Fluid resus
What is s MASCC score?
Risk of neutropenic sepsis complications
If penicillin allergic what initial Abx would you try in neutropenic sepsis
Vancomycin or Aztreonam
When would you consider changing the intial Abx in neutropenic sepsis
If Microbiology results come back
or if no response in 48 hours try a second broad spec and then if no response after another 48 hours ?Antifungal or antiviral
How can you prevent neutropenic sepsis?
Prophylactic Abx if high risk e.g COPD
Dose modification; although may need to keep this high if radical therapy
What are the top 3 cancers most likely to metastasise to the vertebral bodies/spine
Prostate -> Breast -> Lung
Also consider Myeloma and lymphoma
Most common sign of MSCC?
90% Back pain
Aggravated by coughing/moving/Lying
Can be worst at night
Minus pain what are other signs of MSCC?
Motor change- weakness/parapesis Gait change Sensory loss Incontinence saddle anaesthesia Hyperreflexia UMN signs- Inc tone inc reflexes, up going plantars
If you ?MSCC what do you do?
Whole spine MRI within 24 hours 16mg Dex with PPI cover Lay flat RT (Think about treatment goals) Neurosurgery if limited/good prognosis/structural failure
When is presentation of MSCC with complete paralysis almost never reversible?
> 48 hours from onset
57% reversibility if treated within 24 hours
Signs of SVCO
SOB exacerbated by lying Headache worse on coughing Upper body swelling Venous distension in the neck Cyanosis Visual disturbance
Investigations for SVCO
First do CXR- LOOK FOR WIDE MEDIASTINUM
If above is +ve thenarrange a CT to confirm
+/- Tumour markers, Bronchoscopy, Biopsy, Mediastinoscopy
When would you start treating SVCO?
How would you do this?
If the SVCO is obvious on the CXR then treat with 16mg Dex + PPI cover
The next step is cause dependent- Stenting/Chemo/RT/LWMH if thrombus
+/- Morphine if severe SOB
Brief outline of calcium homeostasis
low Ca2+= Inc PTH release= Osteoclast bone resorption= inc ca2+
Kidneys also activate Vit D
What are PTH related peptides?
What is transforming growth factor alpha?
PTHrp- Mimic PTH to stimulate osteoclast bone resorption
TGFA- Produced by tumour cells, act directly to stimulate osteoclasts
Normal calcium levels?
Severely high calcium?
2.1-2.6 mmol/L
> 3.4 (Mod if >3)
Most common cancers to cause hypercalcaemia
Myeloma,SCLC, NSCLC, Renal cell, lymphoma, H&N
Hypercalcaemia... General symptoms? CNS? GI? GU? CV? Late?
General symptoms- Dehydration (Ca is a diuretic), Weakness, Fatigue
CNS- Confusion, Seizure, Hyporeflexia, coma, neuropathy
GI- Wx loss, N&V, Constipation, Pain
GU- Polyuria
CV- Bradycardia, ECG changes, Arrest, Arrhythmia
Late- Coma
Hypercalcaemia ECG changes
Bradycardia Short QT Wide T wave Prolonged PR BBB
J WAVES
(Extra little wave on S wave)
How do you rehydrate someone with hypercalcaemia?
Saline 1L 4 hourly for 24 hours
Then 1L 6 hourly for 48-72 hours
Make sure K+ is adequate
How do bisphosphonates work in hypercalcaemia?
Examples of drugs used?
Inhibit osteoclastic bone resorption
IV Zolendronic acid or IV Pamidronate
N/B Repeat many times before intensifying
If someone with hypercalcaemia has an arrhythmia/Seizure what do you intervene with?
SC or IM Salmon calcitonin with oral prednisolone
Tumour markers- HCG
Oncofetal protein
Seminoma/Non-seminomatous testicular cancers, pregnancy
PSA
Prostate pathology
Good for monitoring
Ca19.9
Pancreatic cancer
Ca15.3
Breast cancer
Immunoglobulins are tumour markers in what?
Myelomas, NHL
AFP tumour marker
Oncofetal protein
Hepatocellular carcinoma
Teratoma
Hepatitis
(High levels= Poor prognosis)
Cell surface glycoproteins (CEA)
Colorectal cancer
Pancreatic/Breast/Gastric lung cancer
Also raised in: Smokers, pancreatitis, IBD, hepatitis, Gastritis
CA-125
Ovarian cancer +/- Panc/lung/CRC/Breast
Not v sens/spec
Performance status
Explain 0-5
0- Normal 1- Symptomatic but self-care 2- Ambulatory >50% time 3- Ambulatory <50% time needs nursing care 4- Bed ridden
SE of prostatic RT
Cystitis, prostatitis, Proctitis (Diarrhoea, Haematemesis)
Haematuria, Abd pain, nausea
SE of pulmonary RT
Pneumonitis (6-8 weeks post RT) Therefore always make sure there is good residual lung function before
Progressive SOB
Cough
Oesophagitis
When is mammography not viable for Breast cancer screening?
How can USS be used?
When is MRI good?
Dense breast tissue in pre-menopausal breast
USS good if confirmed lump
MRI good if V young and V high risk. Not very specific so wont tell you if it is malignant
Tamoxifen SE
Vasomotor, mood changes, reduced libido, vag discharge, VTE risk
USED PRE OR POST-MENOPAUSAL
Aromastase inhibitors SE
Vag dryness, vasomotor, mood, reduced libido, arthralgia, Reduced bone density
POST-MENO ONLY
Benefits of PSA testing
Catch cancer early
If left than cancer can present too late
Reassurance
Disadvantages of PSA testing
75% of abnormal PSAs arent cancer so uncecessary worry
80% OF abnormal ones will go and have TRUS
15% of normal tests still have prostate cancer
How is prostate cancer diagnosed
Pre-biopsy MRI followed by TRUS
what will you do if the PSA is
> 20
10-20
Low risk
> 20= HIGH RISK ALWAYS TREAT
10-20= ?Radical treatment
Low risk= Monitor
Indications for androgen deprivation therapy in prostate cancer?
Any side effects?
Advanced disease/spread/recurrence
Hot flushes, sexual dysfunction, loss of muscle, mood disturbance, Wx inc, DM, osteoprosis
What treatments would you give for CRC if…
Low risk?
Mod risk?
High risk?
Low risk- Anterior resection/other surgery
Mod risk- RT then surgery
High risk- RT + Chemotherapy + Surgery
N.B If higher risk (T3, N2, V1, M0) then more benefit from the triple therapy
Side effects of immunotherapy drugs
Autoimmune disease and endocrinopathies
Thryoid, Glomerulonephritis, Vasculitis, Pneumonitis, Hepatitis, Cystitis, Encephalitis, Addisons, Cushings, Arthralgia
PEAK 6-8 WEEKS POST TREATMENT
How do you manage immunotherapy SE?
Steroids
Lifelong hormone replacement if endocrinopathies
When prescribing controlled drugs what do you always have to write?
THE SUPPLY
“MORPHINE SULPHATE 10mg/5ml TWICE A DAY. SUPPLY: ONE HUNDERED MILIMETRES”
2 week referral for ? Oesophageal cancer if
Dysphagia
or
Wx loss + > 55 + Pain/Reflux/dyspepsia
(Urgent endoscopy)
2 week referral for ? Pancreatic cancer if
> 40 + Jaundice
or
60 + Wx loss + Back pain/N&V/Bowel habit change/New DM
2 week referral for ? Gastric cancer if
Upper abd mass or Dysphagia or Wx loss + > 55 + Pain/Reflux/dyspepsia
(Urgent endoscopy)
2 week referral for ? Anal cancer
Unexplained anal mass or ulceration
2 week referral for ? CRC
What can you do if the 2 week referral criteria aren’t met but you are still suspicious?
> 40 + Wx loss + Abd pain
50 + rectal bleeding
60 + Fe deificency anaemia/Change in bowel habit
Occult blood in faeces + mass
<50 + rectal bleeding + Pain/Change in bowel habit/Wx loss/Fe deficiency anaemia
If above not met but still suspicious then offer faecal occult blood testing
