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Oncology Flashcards

1
Q

What cancers is HPV associated with?

A

Cervical
Anal
Head and neck

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2
Q

What subtypes of HPV are cancerous?

Pathophysiology?

A

HPV16 and HPV18

HPV16 produces E6 protein, which binds to and inactivates p53 protein leading to dysregulation of cell cycle and apoptotic pathways

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3
Q

What cancer is Epstein Barr Virus associated with?

A

non-Hodgkin’s lymphomas (Burkitts lymphoma)

(Epstein Barr Nuclear Antigens)- 8:14 translocation

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4
Q

What cancer is HTLV1 infection associated with?

A

HTLV1 is a retrovirus associated with T-cell lymphomas

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5
Q

What specific type of cancer is H. Pylori associated with?

A

MALT (mucosal associated lymphoid tissue) tumours. Irradication of the H pyloric may lead to a regression of the tumour

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6
Q

When would you use hormone therapy in prostate cancer?

What hormone therapies can be used in prostate cancer?

A

-Hormonal treatments are used for treating advanced disease OR alongside radiotherapy for localised disease.

• Luteinising hormone release hormone agonists (LHRH) (relins)

e. g. leuprorelin, goserelin
- interferes with release of gonadotropins from pituitary
- decreases testosterone
- depot injection
- tumour flare occurs on initiation of treatment (prior to the down regulation of gonadotropin) and is avoided by short-term concomitant anti-androgen therapy

• Anti-androgens (amides)

  • e.g. bicalutamide, enzalutamide
  • compete with androgens at androgen-receptor

• Gonadotrophin-releasing hormone antagonist -(e.g. degarelix)

  • depot injection
  • reduces testosterone without risk of tumour flare (good for when tumour flare is really bad (MSCC)

• Oestrogen therapy
-inhibit LHRH production but rarely used due to SE (impotence, loss of libido, gynaecomastia, myocardial infarction, stroke and pulmonary emboli)

• Bilateral orchidectomy (countries without easy access to medical therapy)

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7
Q

What presentation defines neutropenic sepsis?

A

NEUTROPHIL COUNT less than 1×109 per litre (normal is 4-10) and who have either:

  1. a temperature higher than 38 degrees or
  2. other signs or symptoms consistent with clinically significant sepsis
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8
Q

What microorganism are most neutropenic sepsis cases caused by?

A

Gram positive bacteria (70%)

  • Staphylococcus aureus
  • Coagulase-negative staphylococcus
  • alpha and beta haemolytic streptococcus

Gram negative organisms (30%)

  • Escherichia coli
  • Klebsiella pneumoniae
  • Pseudomonas aeruginosa

Fungi
Candida , Aspergillus, PCP

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9
Q

What is the main risk factor for neutropenic sepsis?

What is the prognosis for neutropenic sepsis?

A
  • Chemotherapy (especially within 6 weeks of receiving chemo)
  • Typically occurs between 7 and 14 days post chemotherapy
  • Neutropenic sepsis has overall mortality of 5%
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10
Q

What is the management for neutropenic sepsis?

A 
Ato E assessment 
Bloods 
-FBC (WCC) 
-UsEs
-LFTs and albumin 
-Clotting 
-CRP

Septic screen

  • chest X ray
  • Urine, stool, sputum cultures

Serology
-atypical pneumonia serology if indicated

BUFALO
Blood cultures (paired-anerobic and aerobic at lines and peripheral)
Urine output - put catheter in
Fluids
Antibiotics - start IV broad spectrum WITHIN 1 HOUR (piperacillin/tazobactam)
Lactate
Oxygen

Handover- call oncology, side room

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11
Q

What can you give to a patient with severe neutropenia (neutrophils < 0.1) and multi-organ failure?

A

Colony stimulating factors e.g. filgrastim/lenograstim

  • They are haematopoietic growth factors that promote stem cell proliferation and shorten duration of neutropenia
  • can also give for prophylaxis in order to maintain high chemo dose (curative intent)
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12
Q

What is the MASCC score?

A

Assesses risk of complications during febrile neutropenic episode

-Looks at burden infection, co-morbidities, BP, COPD, tumour type, haematological/ solid tumour, fluid status, age <60 yrs, in-patient vs outpatient

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13
Q

What cancers are most commonly associated with spinal mets/MSCC?

A

Common cancers for MSCC

  • Lung (bronchus)
  • Prostate (COMMON)
  • Breast
  • Myeloma
  • Melanoma

Less common:

  • Renal
  • Thyroid
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14
Q

What are some signs of metastatic spinal cord compression? (4)

A

Signs of MSCC
•Weakness/paraparesis/paraplegia (limbs or sadle)
•Changes in sensation occur below level of compression.
•Reflexes are usually INCREASED below level of compression
•Clonus and painless bladder distension may be present- retention

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15
Q

How does spinal cord compression present?

Where are most compassions found?

A
  • Back pain (95%) exacerbated by movement, coughing and lying flat
  • Limb weakness
  • abnormal walking
  • Changes in sensation of limbs (walking cotton wool)
  • Bowel/urine changes (unable to go-early, loss of control-late)
  • Male sexual dysfunction

Majority 75% in the thoracic spine (C1-7, Th1-12, L1-5)

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16
Q

How do you investigation a spinal cord compression?

A

Whole spine MRI within 24 hours
Neurological examination
PR to assess sphincter tone

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17
Q

What is the acute management for spinal cord compression?

A
  1. Lie flat
  2. Urgent MRI of spine within 24 hours
  3. Give Dexamethasone 16mg + PPI (make sure to measure glucose) within 24 hours
  4. Refer to on call oncologists (they will decide whether patient should have neurosurgery/radiotherapy/chemotherapy)

Other things

  • Catheter if loss of bladder control
  • VTE prophylaxis
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18
Q

What is the prognosis of spinal cord compression?

A

If treated within 24 hours, 57% will be able to walk again

Patients with loss of motor function after >48h are unlikely to recover function

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19
Q

symptoms and signs of cauda equina syndrome?

What level is Cauda equina?

A 
SYMPTOMS
Back pain
Radiating pain down legs
Asymmetrical, atrophic, areflexic, flaccid paralysis of legs
Saddle anaesthesia
Decreased sphincter tone

SIGNS
-palpable bladder, reduced anal tone, bony tenderness, PNS changes

Cauda equina is below L1

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20
Q

What is the most common cause of hypercalcaemia?

A

Primary Hyperparathyroidism

-cancer is second most common

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21
Q

What cancers most commonly cause hypercalcaemia?

A

Lung cancer (particularly squamous cell)
Multiple myeloma
Breast carcinoma
Prostate caner
Squamous cell carcinomas (lung, renal, head and neck)

(can get hypercalceamia without bone mets- tumours produce TGFa and PTH related peptide)

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22
Q

How does hypercalcaemia present? (think about different systems)

A

Symptoms of hypercalceamia
CNS : temperature, tiredness, confusion, drowsiness, fits, can cause comas
GI: nausea, vomiting, constipation, loss of appetite, weight loss
GU: thirsty, polyuria, kidney failure
Bones: achy
Stones: kidney stones
MSK: weakness muscles (proximal)
Cardiac: bradycardia, short QT (T wave comes early), wide T waves, prolonged PR, BBB, arrhythmia, arrest

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23
Q

What blood results would indicate hypercalcaemia of malignancy rather than primary hyperparathyroidism?

A 
Low albumin
High ALP (high bone turnover)
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24
Q

How do you investigate and manage hypercalcaemia?

A

Managment hypercalceamia
-A to E assessment with full observations, senior help

Investigations
• Serum calcium corrected for serum albumin (hypercalcaemia can actually be normal if albumin is low - binds to albumin) 
• FBC 
• LFT, TFT, UsEs 
•Urine calcium
  1. IV FLUIDS 0.9% saline 1L every 4 hours for 24h then every 6 hours for 48-72h with adequate K+ (consider giving furosemide if at risk of fluid overload)
  2. IV BISPHOSPHONATES (inhibit osteoclastic bone reabsorption) Zolendronic acid 4mg IV or IV pamidronate
  3. SPECIALIST
    Calcitonin and Corticosteroids:
    Salmon calcitonin is given S/C or IM with oral prednisolone
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25
Q

What should you avoid in hypercalcaemia?

A

Thiazide diuretics

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26
Q

What can cause a high ALP with hypercalcaemia?

A

(higher bone turnover)

  • Bone metastases
  • Sarcoidosis
  • Thyrotoxicosis
  • Lithium
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27
Q

What most commonly causes superior vena cava obstruction?

A

Extensive lymphadenopathy in upper mediastinum from lung cancer or lymphoma

Other causes
Germ cell tumours
Thymoma
Oesphageal
Tumour associated thrombus
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28
Q

What are some possible benign causes of SVCO?

A
  • Non-malignant tumours e.g. goitre
  • Mediastinal fibrosis e.g. post-radiotherapy
  • Infection e.g. TB
  • Aortic aneurysm
  • Thrombus associated with indwelling catheters
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29
Q

How does superior vena cava obstruction present (symptoms and signs)

A 
Symptoms
• Headache/feeling of fullness in head 
• Facial/upper limb swelling 
• Dyspnoea – worse on lying flat
• Cough
• Hoarse voice 
•  Visual disturbance 
Signs
• Oedematous face/neck
• Dilated blue veins in neck, chest, arms
• Stridor
•Cyanosis
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30
Q

How would brachiocephalic artery obstruction present?

A

Arm swelling

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31
Q

What is the management of SVCO?

A

Acute management SVCO

  • Dexamethasone 16mg + PPI to relieve symptoms
  • Vascular stenting is treatment of choice. (followed by radiotherapy or che motherapy depending on primary tumour type)
  • LMWH (if thrombus confirmed)

Afterwards-find the cause

  • Chest Xray and full body CT
  • Bronchoscopy
  • Biopsy (e.g. EBUS)
  • OGD (if oesophageal ca suspected)
  • Tumour markers (e.g. especially if suspect germ cell)
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32
Q

What tumour markers are associated with germ cell/testicular cancers?

A 
Alpha fetoprotein (aFP) 
hCG
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33
Q

What benign conditions are relevant to aFP?

A

Liver cirrhosis
Pregnancy
Neural tube defects

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34
Q

What cancer is relevant to calcitonin?

A

Medullary thyroid

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35
Q

What cancer is relevant to CA-125?

A

Ovarian

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36
Q

What conditionsalso increase CA-125?

A

Raised Ca-125

  • Endometriosis
  • PID
  • menstruation
  • pregnancy
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37
Q

What cancer is relevant to CA19-9?

What about Ca15-3?

A

Pancreatic

Breast

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38
Q

What use does measuring CA19-9 have in pancreatic cancer?

A

Monitoring the disease only

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39
Q

What tumour marker is associated with breast cancer?

A

CA15-3

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40
Q

What tumour marker is associated with colorectal cancer?

What other things cause raise in CEA

A

CEA
Normal <5,
-raised in smokers and itis conditions (IBD, hepatitis, pancreatitis or gastritis)

41
Q

What else is CEA raised in?

A

Smoking
Chronic kidney disease
Chronic liver disease
IBD

42
Q

What tumour marker is the most sensitive to the prostate cancer

A

PSA in prostatic carcinoma

43
Q

What cancer do raise immunoglobulins suggest?

A

Myeloma

44
Q

What are tumour markers?

A

Substances produced either by, or in response to, tumour and are present in the blood or other tissue fluids and can be quantified

45
Q

What 2 cancers is aFP raised in?

A

afp> 500 ng/ml

  • Hepatocellular cancer
  • Germ cell cancers
46
Q

What are UMN signs?

A

Hypertonia
Hyper-reflexia
Upgoing plantars

47
Q

What type of scan is a PET scan?

A

Positron emission tomography (PET)

  • Nuclear imaging that uses fluorodeoxyglucose (FDG18)
  • the glucose is rapidly taken up in very metabolically active cells such as malignant cells or neurons
  • Creates a 3D functional image of metabolic activity
  • Good for finding other lymph nodes with disease that might not have been picked up by CT
48
Q

What is Pemberton’s sign?

A

Ask patient to raise their arms until they touch the side of their face
If they develop cyanosis, worsening of their shortness of breath or facial congestion, it is positive for venous congestion

49
Q

How does ovarian cancer often present?

A

Non-specific abdominal symptoms
E.g.
- Bowel disturbance
- Abdominal distention and discomfort

50
Q

What is the most common origin of bony mets? (M vs F)

A

In men: prostate

In women: breast

51
Q

What cancer are women who have HNPCC at risk of other than colorectal cancer?

A

Endometrial cancer

52
Q

What is Li-Fraumeni syndrome caused by?

A

Germline mutations to p53 tumour suppressor gene

53
Q

What malignancies is Li-Fraumeni syndrome particularly associated with?

A

Sarcomas - it is diagnosed when an individual develops sarcoma under 45 years
Leukaemias

54
Q

What kind of bone lesions are most common in prostate cancer? (how do these look of X-ray)

What about myloma? (and x ray findings)

A

Prostate cancer - sclerotic bone lesions (white x ray)

Myeloma - lytic bone lesions (black x ray)

Therefore, myeloma often causes hypercalcaemia, whereas prostate cancer does not

55
Q

What is the dose of radiation defined as in radiotherapy?

A

Irradiation absorbed by each kilogram of tissue expressed as Grays (Gy)

1 Gy = 1J/kg

56
Q

Briefly summarise how radiotherapy works

A
  • High energy X rays
  • Kills cells (healthy ones can recover and regenerate, cancer ones cannot
  • Fractions allow for this recovery

X-Rays have very high energy and very short wavelength (they deliver energy through photons), which are produced by accelerating a stream of electrons and colliding them with a metal targets

The X-Rays are generated and delivered by a linear accelerator (LINAC)

High-energy photons produce secondary electrons in human tissue (whilst sparring the skin), causing DNA damage and leads to apoptotic or mitotic cell death

57
Q

What is a fraction (in radiotherapy)?
Why are they given in fractions?
When are cells most sensitive to radiotherapy?

A

One treatment session of radiotherapy
Fractions allow healthy cells to recover
Cells in G2 and mitosis (M-phase) are most sensitive to radiotherapy

58
Q

What is the most common method to deliver radiotherapy?

A

External beam radiation therapy

This can be:

  • Image-guided radiotherapy = CT/MRI is used to target tumours while minimising radiation exposure of healthy tissues
  • Stereotactic radiosurgery (e.g. gamma knife) = multiple radiation beams converge on the tumour e.g. brain tumours
59
Q

What is the most common acute adverse effect of radioetherapy?

A

General fatigue - 80% patients

60
Q

What is a common complication after head/neck irradiation, particularly if the parotids have been irradiated?

A

Loss of salivary flow leading to dry mouth

61
Q

In radiotherapy, what does fractionating mean? What is the purpose of it?

A

A course of radiotherapy is spread over days or weeks.

Fractionating allows normal tissues to repair from the radiation damage, while tumour cells, which are less efficient to repair, do not recover

62
Q

In radiotherapy, what is a beam of radiation called?

A

A field

63
Q

Which tissues are most acutely damaged by radiotherapy?

A

Fast proliferating tissues

e. g.
- Skin
- Mucosa of GI tract
- Hair
- Bone marrow

64
Q

Generally, what is the mechanism of action of chemotherapy?

A

Most agents target DNA either directly or indirectly

Therefore, chemo agents are preferentially toxic towards actively proliferating cells

65
Q

How are chemotherapy doses calculated? (what formula)

A

According to the patient’s body surface area
Most commonly used formula is DuBois formula

Carboplatin dose is calculated from renal function

Monoclonal antibody dose is calculated based on body weight

66
Q

What acute/immediate complications can be experienced from chemotherapy agents?

A

Nausea/vomiting
Myelosuppression - neutropenia, anaemia, thrombocytopenia
Mucositis - aphthous ulcers, diarrhoea
Alopecia
Neuropathies - PNS (burning, tingling), ANS, CNS, ototoxicity
Acute arrhythmias
Transient rise of liver enzymes
Skin and soft tissue
- Palmar plantar erythema (hand-foot syndrome)
- Photosensitivity
- Nail changes - bow’s lines

67
Q

What long term complications can be experienced from chemotherapy agents?

A

Infertility
Pulmonary fibrosis or pneumonitis
Secondary malignancies
Cardiac fibrosis

68
Q

What are some carcinogenic chemical? (what cancers are they assosiated with?

A
  • Cigarette smoke - carcinogens present in cigarette smoke cause specific mutations in the p53 tumour suppressor gene.
  • Aromatic amines - associated with bladder cancer
  • Benzene - leukaemia
  • Wood dust - nasal adenocarcinoma
  • Vinyl chloride (PVC) - angiosarcomas
69
Q

What increases risk of hepatocellular cancer?

A

Hepatitis B virus more than 100 times more likely to get
hepatocellular cancer
(αFP tumour marker is used to screen this high risk group of patents with cirrhosis)

70
Q

when is MRI used to stage rather than CT?

A

MRI is gold standard for the following tumours:

  • neurospinal
  • rectal
  • prostate
  • musculoskeletal
  • staging some subtypes of head and neck cancer
71
Q

What is the RECIST system? (Response evaluation criteria in solid tumors)

A

RECIST is a system for assessing response.

  • Complete Response (CR)-no disease detectable radiologically
  • Partial Response (PR)-all lesions have shrunk by at least 30%, but disease still present
  • Stable Disease (SD)-less than 20% increase in size or less than 30% decrease in size

Progressive Disease (PD)-new lesions or lesions that have increased in size by more than 20%

72
Q

Things to make sure before requesting CT/MRI?

A

CT scan

  • are you pregnant
  • do you have kidney problems (contract)

MRI

  • do you have a pacemaker/implantable cardiac defibrillates?
  • have you had past surgery?
  • have you ever had trauma where metal went into eye or anywhere else?
73
Q

What is a bone scan (scintography) and whats it used for?

A
  • Bone scans are a type of nuclear medicine
  • used to detect bone mets
  • radioisotope labelled drugs are given and distribution measured by emittited photons
  • e.g. technetium (Tc99m DTPA) given IV used for isotope glomerular filtration rate (GFR) or radioiodine given orally
74
Q

What is sensitivity

A

The sensitivity of a marker describes its ability to detect those with a certain disease (true positives). If 100 people have the disease and the marker is elevated in only 95, its sensitivity is 0.95

-a tumour marker with high sensitivity means that few people with the disease are missed- low false negative rate

75
Q

What is specificity

A

The specificity of a marker describes its ability to accurately define those who are disease free (true negetives). If in 100 disease-free people the marker is negative in only 90 (i.e. there are 10 false positives) the specificity of the test is 0.90.

-a tumour marker with high specificity means that few people are falsely labeled as having the disease when they don’t-low false positive rate

76
Q

What are Bence Jones

A

Bence Jones is immunoglobulin associated with myeloma

77
Q

If someone has hearing problems which chemotherapy drug should be avoided?

A

Cisplatin is ototoxic-avoid with patients with hearing loss

78
Q

if CXR shows a mass what should you do next?

A

CXR>full body CT> FDG PET scan to highlight suspicious nodes> EBUS of suspicious nodes to look at cancer (if negative then do a CT guided biopsy)

79
Q

What happens when calcium levels in the body are too high?

A

Thyroid produces calcitonin

  1. Promotes osteoblasts to put calcium back into bones
  2. Reduces absorption of calcium by the kidneys
80
Q

What happens when calcium levels in the body are too low?

A

Parathyroid gland releases parathyroid hormone

  1. Promotes osteoclasts to release calcium from the bones
  2. Increased absorption of calcium by the kidneys
  3. Kidneys convert 25-hydroxy Vitamin D to 1-25 dihydroxy Vitamin D which stimulates the bowels to absorb calcium
81
Q

Treatment of major haemorrhage?

A

major haemorrhage

  • IM or subcutaneous midazolam, as a sedative and amnesic can be given
  • stay with patient and help keep calm
82
Q

In palliative care what is the purpose of radiotherapy?

A

palliative radiotherapy is great for bleeding (e.g. heamoptysis) and pain

83
Q

Young man with widespread mets, what should you test for?

A
  • serum LDH, αFP, and βHCG (pregnancy test) will probably show chemosensitive and curable germ cell tumour
  • continue to monitor during chemo to assess response
84
Q

What is the cervical cancer screening program?

A

Cervical cancer screening

  • most effective screening programme
  • 25 to 49 years have smears every three years (
  • 50 to 64 every five years
85
Q

Surgery can be useful for some metastatic tumours, which ones?

A

The following mets can be surgically treated:

  • Solitary lung metastases from sarcomas
  • Localized liver metastases from colon cancer
86
Q

What drug causes acniform rash?

A

EGFR inhibitors (biological therapy) cause acniform rash and diarrhoea (much less myelosuppression)

87
Q

What tumours can be treated with hormone therapy?

A

Hormone therapy

  • prostate, breast and endometrium (sex hormones)
  • lymphocytic malignancies (lymphoma, leukaemia and myeloma, hodjkins) (corticosteroids)
88
Q

Uses of megestrol acetate

A
  • It is a Progestogen
  • given in high doses for cancer arising in progesterone-sensitive tissues (breast, endometrium).
  • Produce negative feedback on the pituitary/gonadal axis
  • also stimulate appetite in palliative care
89
Q

When can chemo be curative?

A

Chemo can be curative:

  • Germ cell tumours
  • Hodjkins
  • Non Hodjkins
  • childhood leukemias
90
Q

When is chemo given prophylactically ?

A

Hormonal treatments may be given before overt malignancy appears. For instance tamoxifen may be used for in-situ breast cancer before invasive carcinoma is recognised.

91
Q

Give examples of when chemo can be delivered via

a) intravesically
b) intraperitoneal
c) intra-arterial

A
  • Intravesical- superficial bladder cancer
  • Intraperitoneal- tumours that spread trans-coelomically (e.g. ovarian cancer)
  • Intra-arterial- Any tumour that has a well-defined blood supply (e.g. hepatic artery infusion for liver metastases).
92
Q

If a patient is ventilated and immunocompromised what type of infection should you consider? how would you investigate AND treat?

A

Immunocompromised patient on ICU

INVESTIGATIONS
-Blood tests to look for fungal infection
• Fungal beta-D-glucan (any fungal)
• Aspergillus galactomannan ELISA (aspergillus only)
-Do bronchalveolar lavage and PCR if unsure what organism it is

TREATMENT

  • Voriconazole is particularly good for aspigillus infection
  • Cotrimoxazole (trimethoprim/sulfamethoxazole) used for PCP (Pneumocystis jiroveci)
93
Q

What are the long term effects of chemotherapy?

A

Chemotherapy long term effects

  1. Fertility-sperm storage/ freeze eggs/embryo
  2. Second Malignancies
  3. Scarring/fibrosis of heart and lungs
  4. Psychological and social
94
Q

What type of anemia is caused by blood loss from tumour?

What type of anemia is caused by repeated chemotherapy?

A

Blood loss from tumour: iron defficinecy anaemia

Repeated chemotherapy treatment: macrocytic anaemia (not megaloblastic)

95
Q

How do you investigate prolongued/ excessive myelosuppression in cancer patient?

A

Myelosuppresion investigations

  • blood film
  • FBC and heamotinics
  • Bone marrow aspirate and trephine (biopsy)
96
Q

How do you treat myelosuppression in cancer patient?

A

Cancer myelosuppression managment

Anemia
-Hb <10 g/dl could impair QoL. Recombinant erythropoietin or blood transfusion

Thrombocytopenia

  • platelets less than 10 x 109/L high risk of spontaneous bleeds (eyes, brain,skin) URGENT platelet transfusion
  • platelets between 10 x 109/L and 20 x 109/L often treated with platelet transfusion
  • high dose chemo will require transfusions

*give HLA matched platelets of single donor platelets to reduce risk of failure

Neutropenia

  • WCC <1
  • broad spectrum antibiotics within 1 hour (if not responded within 48 hours change to second line)
  • full septic screen
97
Q

Wan would you give prophylactic AB for a cancer patient on chemo

A

Prophylactic antibiotics with chemo

  • e.g. for COPD patients
  • patients with lymphoma at risk of PCP (co-trimoxazole)
98
Q

Most common cancers to met to bone?

A

My BLT and kosher pickle

  • Multiple myeloma
  • Breast
  • Lung cancer and lymphoma
  • Thyroid
  • Kidney
  • Prostate

CCC (15 decks)

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