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Year 4 cancer care > Oncology > Flashcards

Oncology Flashcards

1
Q

What can PSA be raised by?

A
  • Benign prostatic hyperplasia (BPH)
  • Prostatitis (NICE recommend to postpone the PSA test for at least 1 month after treatment)
  • Urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)
  • Ejaculation (ideally not in the previous 48 hours)
  • Vigorous exercise (ideally not in the previous 48 hours)
  • Urinary retention
  • Instrumentation of the urinary tract
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2
Q

When should one be referred urgently to urology?

A

‘If a hard, irregular prostate typical of a prostate carcinoma is felt on rectal examination, then the patient should be referred urgently. The PSA should be measured and the result should accompany the referral.’

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3
Q

Lung cancer : small cell - features?

A
  • usually central
  • arise from APUD* cells
    *an acronym for
    Amine - high amine content
    Precursor Uptake - high uptake of amine precursors
    Decarboxylase - high content of the enzyme decarboxylase
  • associated with ectopic ADH,
    ACTH secretion
  • ADH → hyponatraemia
  • ACTH → Cushing’s syndrome
  • ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis
  • Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenic like syndrome
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4
Q

Lung cancer : small cell - Management?

A
  • usually metastatic disease by time of diagnosis
  • patients with very early stage disease (T1-2a, N0, M0) are now considered for surgery. NICE support this approach in their 2011 guidelines
  • however, most patients with limited disease receive a combination of CHEMOTHERAPY and RADIOTHERAPY
    patients with more extensive disease are offered palliative chemotherapy
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5
Q

What is the most important risk factor for developing cervical cancer?

A
  • Human papilloma virus (HPV)

- Subtypes 16,18 & 33 are particularly carcinogenic.

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6
Q

Which are the non-carcinogenic subtypes of HPV? What are they associated with?

A

Subtypes 6 and 11

Associated with GENITAL WARTS.

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7
Q

What characteristics do koliocytes have?

A
  • enlarged nucleus
  • irregular nuclear membrane contour
  • the nucleus stains darker than normal (hyperchromasia)
  • a perinuclear halo may be seen
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8
Q

What are koliocytes?

A

Infected endocervical cells may undergo changes resulting in the development of koilocytes

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9
Q

What is the most common colorectal cancers?

A

Adenocarcinomas

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10
Q

Colorectal cancer screening - what is available?

A
  • Faecal Immunochemical Test (FIT)

- Flexible sigmoidoscopy screening

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11
Q

At what age are people offered screening tests for colorectal cancer?

A

Age 55

One-off flexible sigmoidoscopy at age 55 aims to detect and treat polyps, reducing future risk of colorectal cancer

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12
Q

What is the FIT screening test?

A

Faecal Immunochemical Test (FIT) screening

  • national screening programme offering screening every 2 years to all men and women aged 60 to 74 years in England. Patients aged over 74 years may request screening
  • eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post
  • a type of faecal occult blood (FOB) test which uses antibodies that specifically recognise human haemoglobin (Hb)
  • used to detect, and can quantify, the amount of human blood in a single stool sample
  • patients with abnormal results are offered a colonoscopy
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13
Q

Why is FIT screening better than conventional FOB (faecal occult blood) tests

A
  • advantages over conventional FOB tests is that it ONLY DETECTS HUMAN HAEMOGLOBIN, as opposed to animal haemoglobin ingested through diet
  • only one faecal sample is needed compared to the 2-3 for conventional FOB tests
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14
Q

What is flexible sigmoidoscopy screening?

A
  • screening for bowel cancer using sigmoidoscopy is part of the NHS screening program
  • the aim (other than to detect asymptomatic cancers) is to allow the detection and treatment of POLYPS, reducing the future risk of colorectal cancer
  • this is being offered to people who are 55-years-old
  • NHS patient information leaflets refer to this as ‘bowel scope screening’
  • patients can self-refer for bowel screening with sigmoidoscopy up to the age of 60, if the offer of routine one-off screening at age 55 had not been taken up
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15
Q

Endometrial cancer - risk factors

A
  • obesity
  • nulliparity
  • early menarche
  • late menopause
  • unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
  • diabetes mellitus
  • tamoxifen
  • polycystic ovarian syndrome
  • hereditary non-polyposis colorectal carcinoma
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16
Q

Features of endometrial cancer

A
  • POSTMENOPAUSAL BLEEDING is the classic symptom
  • premenopausal women may have a change intermenstrual bleeding
  • pain and discharge are UNUSUAL features
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17
Q

Investigations for endometrial cancer

A
  • women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
  • first-line investigation is TRANS-VAGINAL ULTRASOUND - a normal endometrial thickness (< 4 mm) has a high negative predictive value
  • hysteroscopy with endometrial biopsy
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18
Q

Management of endometrial cancer

A
  • localised disease is treated with TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPINGO-OOPHOTRECTOMY. Patients with high-risk disease may have post-operative radiotherapy
  • progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery
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19
Q

What are the protective factors for endometrial cancer?

A
  • Combined oral contraceptive pill

- Smoking

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20
Q

How often are faecal immunochemical tests (FIT) sent to people’s houses?

A

Every 2 years

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21
Q

What supports a diagnosis of adenocarcinoma?

A
  • gynaecomastia (particularly associated with lung adenocarcinoma- but is an infrequent manifestation)- thought to be caused by an increased oestrogen/androgen ratio, or the tumouritself produces a substance causing hormonal change
  • hypertrophic pulmonary osteoarthropathy (HPOA)
  • most common lung malignancy in non-smokers
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22
Q

What is mesothelioma?

A

is a type of cancer that can develop years after exposure to asbestos

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23
Q

What are the paraneoplastic features of small cell carcinoma?

A
  • ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc
  • Lambert-Eaton syndrome
  • Syndrome of inappropriate anti-diuretic hormone (SIADH) secretion.
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24
Q

What is the most likely lung cancer found in smokers?

A

Squamous cell carcinoma

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25
Q

Squamous cell carcinoma is associated with?

A
  • Hypertrophic pulmonary oesteoarthropathy (HPOA)
  • Parathyroid hormone -related protein secretion - causing hypercalcaemia, and hyperthyroidism due to ectopic thyroid stimulating hormone secretion.
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26
Q

Lung cancer - features

A
  • persistent cough
  • haemoptysis
  • dyspnoea
  • chest pain
  • weight loss and anorexia
  • hoarseness- seen with Pancoast tumours pressing on the recurrent laryngeal nerve
  • superior vena cava syndrome
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27
Q

Lung cancer - Examination findings

A
  • a fixed, MONOPHONIC wheeze may be noted
  • supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
  • clubbing
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28
Q

Paraneoplastic features -Squamous cell lung cancer

A
  • parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
  • clubbing
  • hypertrophic pulmonary osteoarthropathy (HPOA)
  • hyperthyroidism due to ectopic TSH
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29
Q

Paraneoplastic features of adenocarcinoma of the lungs

A
  • gynaecomastia

- hypertrophic pulmonary osteoarthropathy (HPOA)

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30
Q

Complications of lung cancer

A

Hoarseness
Stridor
(thrombocytosis?)

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31
Q

What is the first line investigation in suspected prostrate cancer?

A

Multiparametric MRI (has replaced TRUS biopsy)

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32
Q

Prostate cancer - investigations

A

Multiparametric MRI as a first-line investigation - for clinically localised prostate cancer

  • the results are reported using a 5-point Likert scale
  • If the Likert scale is >=3 a multiparametric MRI-influenced prostate biopsy is offered
  • If the Likert scale is 1-2 then NICE recommend discussing with the patient the pros and cons of having a biopsy.
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33
Q

Breast cancer management- what are the possible options (not going into detail)

A

The management of breast cancer depends on the staging, tumour type and patient background. It may involve any of the following:

  • surgery
  • radiotherapy
  • hormone therapy
  • biological therapy
  • chemotherapy
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34
Q

Who is eligible for a surgical management for breast cancer?

A

The vast majority of patients who have breast cancer diagnosed will be offered surgery. An exception may be a very frail, elderly lady with metastatic disease who may be better managed with hormonal therapy.

Prior to surgery, the presence/absence of AXILLARY LYMPHADENOPATHY
- determines management:
women with NO palpable axillary lymphadenopathy at presentation should have a PRE-OPERATIVE AXILLARY ULTRASOUND before their primary surgery
===if positive then they should have a sentinel node biopsy to assess the nodal burden

  • in patients with breast cancer who present with clinically PALPABLE lymphadenopathy, AXILLARY NODE CLEARANCE is indicated at primary surgery
  • this may lead to arm lymphedema and functional arm impairment

Depending on the characteristics of the tumour women either have a WIDE-LOCAL EXCISION or a MASTECTOMY. Around two-thirds of tumours can be removed with a wide-local excision.

Women should be offered breast reconstruction to achieve a cosmetically suitable result regardless of the type of operation they have. For women who’ve had a mastectomy this may be done at the initial operation or at a later date.

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35
Q

Why choose a mastectomy or wide local excision? Factors about them

A

Mastectomy

  • multifocal tumour
  • central tumour
  • large lesion in small breast
  • DCIS >4cm (Ductal carcinoma in situ)

Wide local excision

  • Solitary lesion
  • Peripheral tumour
  • Small lesion in large breast
  • DCIS <4cm
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36
Q

Radiotherapy treatment in breast cancer - when it given?

A
  • WHOLE BREAST radiotherapy is recommended AFTER a woman has had a WIDE -LOCAL EXCISION as this may reduce the risk of recurrence by around two-thirds.
  • For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes
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37
Q

Hormonal therapy - when is it given?

breast cancer

A

Adjuvant hormonal therapy is offered if tumours are POSITIVE FOR HORMONE RECEPTORS.

  • Tamoxifen is used in PRE- and PERI-menopausal women.
  • In POST-menopausal women, AROMATASE inhibitors such as ANASTROZOLE are used for this purpose. This is important as aromatisation accounts for the majority of oestrogen production in post-menopausal women and therefore anastrozole is used for ER +ve breast cancer in this group.
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38
Q

What are side effects of Tamoxifen?

A
  • an increased risk of endometrial cancer
  • venous thromboembolism
  • menopausal symptoms.
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39
Q

When is biological therapy used in the treatment of breast cancer?

A

The most common type of biological therapy used for breast cancer is TRASTUZUMAB (HERCEPTIN). It is only useful in the 20-25% of tumours that are HER2 positive.

Trastuzumab cannot be used in patients with a history of heart disorders.

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40
Q

When can trastuzumab not be used?

A

Patients with history of heart disease

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41
Q

When in chemotherapy used in the treatment of breast cancer?

A

CYTOTOXIC THERAPY may be used either prior to surgery (‘neoadjuvanant’ chemotherapy) to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation.

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42
Q

What is the treatment post breast conserving surgery for breast cancer?

A

Breast conserving is - wide local excision

Radiotherapy is routine following breast conserving surgery

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43
Q

What is the treatment for the elderly with breast cancer?

A
  • Elderly patients may be managed using ENDOCRINE THERAPY ALONE.
  • Eventually most will escape hormonal control.
  • In post menopausal women oestrogen are produced by the peripheral aromatisation of androgens aromatase inhibitors are therefore the most popular agent in this age group
  • E.g. of treatment - endocrine therapy using letrozole
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44
Q

What treatment would you give for a grade 3 tumour and axillary node metastasis in a young female with breast cancer?

A
  • Cytotoxic chemotherapy

- Some may also add Herceptin (if they are HER2 positive)

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45
Q

What type of lung cancer is most commonly found near large airways?

A

Squamous cell lung cancer

Small cell lung cancer

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46
Q

What type of lung cancer is most commonly found in peripheral airways?

A

adenocarcinoma

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47
Q

What are the features of squamous cell cancer?

A
  • typically central
  • associated with parathyroid hormone-related protein (PTHrP) secretion → hypercalcaemia
  • strongly associated with finger clubbing
  • hypertrophic pulmonary osteoarthropathy (HPOA)
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48
Q

What are the features of adenocarcinoma?

A
  • typically peripheral
  • most common type of lung cancer in non-smokers, although the majority of patients who develop lung adenocarcinoma are smokers
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49
Q

What are the features of large cell carcinoma?

A
  • typically peripheral
  • anaplastic, poorly differentiated tumours with a poor prognosis
  • may secrete β-hCG
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50
Q

What happens next if a routine smear shows ‘borderline changes’?

A

If a smear is reported as borderline or mild dyskaryosis the original sample is tested for HPV (high-risk subtypes of HPV such as 16,18 & 33):

  • if HPV negative the patient goes back to routine recall
  • if HPV positive the patient is referred for colposcopy
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51
Q

What happens next if a routine smear shows ‘moderate dyskaryosis?

A

Consistent with Cervical Intraepithelial smears II.
Refer for urgent colposcopy (within 2 weeks)
(Women who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for ‘test of cure’ repeat cytology in the community. )

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52
Q

What happens next if a routine smear shows ‘severe dyskaryosis’?

A

Consistent with Cervical Intraepithelial smears III.
Refer for urgent colposcopy (within 2 weeks)
(Women who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for ‘test of cure’ repeat cytology in the community)

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53
Q

What do you do if a routine smear comes back as ‘Inadequate’?

A

Repeat smear - if persistent (3 inadequate samples), assessment by colposcopy

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54
Q

What is the first line investigation of a testicular mass? And why?

A

Ultrasound

- to characterise the lesion and confirm the presence of a mass

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55
Q

Testicular cancer - what are the types ?

A

Around 95% of cases of testicular cancer are germ-cell tumours.
Non-germ cell tumours include Leydig cell tumours and sarcomas.

Germ cell tumours may essentially be divided into:

  • seminomas
  • non-seminomas: including embryonal, yolk sac, teratoma and choriocarcinoma
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56
Q

What are the risk factors for testicular cancer?

A

Risk factors include:

  • infertility (increases risk by a factor of 3)
  • cryptorchidism
  • family history
  • Klinefelter’s syndrome
  • mumps orchitis
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57
Q

What are the features of testicular cancer?

A
  • a PAINLESS LUMP is the most common presenting symptom
  • pain may also be present in a minority of men
  • other possible features include hydrocele, gynaecomastia
  • AFP is elevated in around 60% of germ cell tumours
  • LDH is elevated in around 40% of germ cell tumours
  • seminomas: hCG may be elevated in around 20%
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58
Q

What is the management of testicular cancer?

A
  • treatment depends on whether the tumour is a seminoma or a non-seminoma
  • orchidectomy
  • chemotherapy and radiotherapy may be given depending on staging and tumour type
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59
Q

What is the strongest risk factor for developing anal cancer?

A

HPV infection

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60
Q

Risk factors for anal cancer

A
  • HPV infection causes 80-85% of SSCs of the anus (usually HPV16 or HPV18 subtypes).
  • Anal intercourse and a high lifetime number of sexual partners increases the risk of HPV infection.
  • Men who have sex with men have a higher risk of anal cancer.
  • Those with HIV and those taking immunosuppressive medication for HIV are at a greater risk of anal carcinoma.
  • Women with a history of cervical cancer or cervical intraepithelial neoplasia (CIN) are also at greater risk of anal cancer.
  • Immunosuppressive drugs used in transplant recipients increase the risk of anal cancer.
  • Smoking is also a risk factor.
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61
Q

What is a typical subacute onset of anal cancer?

A
  • Perianal pain, perianal bleeding
  • A palpable lesion
  • Faecal incontinence
  • A neglected tumour in a female may present with a rectovaginal fistula.
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62
Q

What are the investigations for anal cancer?

A
  • T stage assessment: examination, including a digital rectal examination, anoscopic examination with biopsy, and palpation of the inguinal nodes.
  • Imaging modalities: CT, MRI, endo-anal ultrasound and PET.
  • The patient should be tested for relevant infections, including HIV.
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63
Q

T staging for anal cancer

A

TX primary tumour cannot be assessed
T0 no evidence of primary tumour
Tis carcinoma in situ
T1 tumour 2 cm or less in greatest dimension
T2 tumour more than 2 cm but not more than 5 cm in greatest dimension
T3 tumour more than 5 cm in greatest dimension
T4 tumour of any size that invades adjacent organ(s) - for example, vagina, urethra, bladder (direct invasion of the rectal wall, perirectal skin, subcutaneous tissue, or the sphincter muscle(s) - is not classified as T4)

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64
Q

What are the types of cervical cancer?

A

It may be divided into:

  • squamous cell cancer (80%)
  • adenocarcinoma (20%)
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65
Q

Features of cervical cancer

A

May be detected during routine cervical cancer screening

  • abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
  • vaginal discharge
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66
Q

Risk factors of cervical cancer

A
  • Human papillomavirus (HPV), particularly serotypes 16,18 & 33 is by far the most important factor in the development of cervical cancer.

Other risk factors include:

  • smoking
  • human immunodeficiency virus
  • early first intercourse, many sexual partners
  • high parity
  • lower socioeconomic status
  • combined oral contraceptive pill
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67
Q

What is the mechanism by which HPV causes cervical cancer?

A
  • HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
  • E6 inhibits the p53 tumour suppressor gene
  • E7 inhibits RB suppressor gene
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68
Q

What is a complication of acute urinary retention? How would you check for this?

A

A post renal cause - ACUTE KIDNEY INJURY
Check serum creatinine

also for retention - aCatheter is inserted.
- It will be important to monitor fluid balance carefully during the next 48 hours: some patients develop a post-obstructive diuresis after insertion of the catheter.

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69
Q

What are the risk factors of prostate cancer ?

A
  • increasing age
  • obesity
  • Afro-Caribbean ethnicity
  • family history: around 5-10% of cases have a strong family history
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70
Q

Features of prostate cancer?

A

Localised prostate cancer is often ASYMPTOMATIC. This is partly because cancers tend to develop in the periphery of the prostate and hence don’t cause obstructive symptoms early on.

Possible features include:

  • bladder outlet obstruction: hesitancy, urinary retention
  • haematuria, haematospermia
  • pain: back, perineal or testicular
  • digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus
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71
Q

Where does prostate cancer metastasise to?

A

bone

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72
Q

An unresolving left varicocele - what you think is the possible cause?

A

Renal tract cancer - this is due to the embryological anatomy linking the left renal vein and the left testicular vein

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73
Q

What is the tumour marker in pancreatic cancer?

A

CA19-9

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74
Q

What is the tumour marker for ovarian cancer?

A

CA125

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75
Q

What is the tumour marker for testicular cancer?

A

Beta HCG

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76
Q

What is CA19-9 used for?

A

Used a s a tumour marker in pancreatic cancer

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77
Q

What is CA125 used for?

A

Used as a tumour marker for ovarian cancer

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78
Q

What is Beta HCG used for?

A

Used as a tumour marker for testicular cancer

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79
Q

What is renal cell cancer associated with?

A
  • more common in middle-aged - men
  • smoking
  • von Hippel-Lindau syndrome
  • tuberous sclerosis
    (incidence of renal cell cancer is only slightly increased in patients with autosomal dominant polycystic kidney disease)
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80
Q

Features of renal cell cancer?

A
  • classical triad: haematuria, loin pain, abdominal mass
  • pyrexia of unknown origin
  • left varicocele (due to occlusion of left testicular vein)
  • endocrine effects: may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH
  • 25% have metastases at presentation
  • paraneoplastic hepatic dysfunction syndrome. Also known as Stauffer syndrome. Typically presents as cholestasis/hepatosplenomegaly. It is thought to be secondary to increased levels of IL-6
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81
Q

Management of renal cell cancer?

A
  • for confined disease - a partial or total NEPHRECTOMY depending on the tumour size
  • ALPHA -INTERFERON and INTERLEUKIN-2 have been used to reduce tumour size and also treat patients with metatases
  • receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) have been shown to have superior efficacy compared to interferon-alpha
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82
Q

What is the pattern of renal cell carcinoma ?

A

Clear cell pattern

  • Clear cytoplasm
  • Small nuclei
83
Q

How long is PSA high for after ejaculation and vigorous exercise?

84
Q

what do Medullary thyroid cancers normally secrete?

A

calcitonin

85
Q

What is another name for Herceptin?

A

trastuzumab

86
Q

When is Herceptin given ?

A

When HER2+

87
Q

What can be given if a woman is ER +ve in breast cancer?

A

Tamoxifen

Aromatase inhibitors

88
Q

What is the primary treatment for ovarian cancer?

A

Stage 2 -4 - primarily by surgical excision

89
Q

Risk factors for ovarian cancer?

A
  • family history: mutations of the BRCA1 or the BRCA2 gene

- many ovulations: early menarche, late menopause, nulliparity

90
Q

Clinical features of ovarian cancer?

A

Clinical features are notoriously vague:

  • abdominal distension and bloating
  • abdominal and pelvic pain
  • urinary symptoms e.g. Urgency
  • early satiety
  • diarrhoea
91
Q

Investigations of ovarian cancer?

A

1- CA125
Is done initially.

if the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered

a CA125 should not be used for screening for ovarian cancer in asymptomatic women

2- ultrasound

92
Q

Management of ovarian cancer?

A

Usually a combination of surgery and platinum-based chemotherapy

93
Q

What are conditions that may raise CA125?

A

Ovarian cancer.Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level

94
Q

Breast cancer treatment -first line?

A

Surgery is the first line management for breast cancer.

- If the tumour is less than 4cm a wide local excision (breast conserving surgery) is favoured.

95
Q

Details about Hartmann’s procedure

A

Hartmann’s procedure involves resection of the relevant portion of bowel and formation of an end colostomy/ileostomy.

96
Q

What surgery tends to happen in emergency settings for a bowel perforation?

97
Q

What type of surgery will be performed for a cancer on the anal verge?

A

Abdomino-perineal

98
Q

If a patient comes with symptoms of colorectal cancer at Gp - what is the best investigation to be ordered at this point?

A

Colonoscopy

99
Q

When should patients be referred urgently (I.e. within 2 weeks) to colorectal services for investigations?

A
  • patients >= 40 years with unexplained weight loss AND abdominal pain
  • patients >= 50 years with unexplained rectal bleeding
  • patients >= 60 years with iron deficiency anaemia OR change in bowel habit
  • tests show occult blood in their faeces
100
Q

When should an urgent referral be CONSIDERED for colorectal cancer?

A

An urgent referral (within 2 weeks) should be ‘considered’ if:

  • there is a rectal or abdominal mass
  • there is an unexplained anal mass or anal ulceration
  • patients < 50 years with rectal bleeding AND any of the following unexplained symptoms/findings:
  • → abdominal pain
  • → change in bowel habit
  • → weight loss
  • → iron deficiency anaemia
101
Q

When is a faecal occult blood testing offered?

A

National screening programme offering screening every 2 years to all men and women aged 60 to 74 years.

In addition FOBT should be offered to:
patients >= 50 years with unexplained abdominal pain OR weight loss
patients < 60 years with changes in their bowel habit OR iron deficiency anaemia
patients >= 60 years who have anaemia even in the absence of iron deficiency

102
Q

When do you refer someone on the suspected cancer pathway referral for lung cancer?

A
  • have chest x-ray findings that suggest lung cancer

- are aged 40 and over with unexplained haemoptysis

103
Q

When should a chest x ray (to be performed within 2 weeks) be offered to assess for lung cancer?

A

In people aged 40 and over if they have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 or more of the following unexplained symptoms:

  • cough
  • fatigue
  • shortness of breath
  • chest pain
  • weight loss
  • appetite loss
104
Q

When should a chest x ray (to be performed within 2 weeks) be considered to assess for lung cancer?

A

in people aged 40 and over with any of the following:
persistent or recurrent chest infection
finger clubbing
supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
chest signs consistent with lung cancer
thrombocytosis

105
Q

What are the potential side effects for a surgery resulting in an ileostomy?

A

These patients may develop significant volume depletion, electrolyte and acid-base disturbances (metabolic acidosis) if the ileostomy output increases or if dietary intake is disrupted or altered. Hence, it is important to monitor fluid balance including stoma output in these patients.

This is because loss of bicarbonate and electrolytes in a high output stoma.

106
Q

What is the best way to assess mural invasion in oesophageal/gastric cancer?

A 
Endoscopic ultrasound (EUS)
(is better than CT or MRI)
107
Q

Oesophageal cancer

A

Risk factors:

  • smoking
  • alcohol
  • GORD
  • Barrett’s oesophagus
  • achalasia
  • Plummer-Vinson syndrome
  • squamous cell carcinoma is also linked to diets rich in nitrosamines
  • rare: coeliac disease, scleroderma

Features:

  • dysphagia: the most common presenting symptom
  • anorexia and weight loss
  • vomiting
  • other possible features include: odynophagia, melaena, cough
  • hoarseness-due to laryngeal nerve damage.

Diagnosis:
Upper GI endoscopy is the first line test
Contrast swallow may be of benefit in classifying benign motility disorders but has no place in the assessment of tumours
Staging is initially undertaken with CT scanning of the chest, abdomen and pelvis. If overt metastatic disease is identified using this modality then further complex imaging is unnecessary
If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic ultrasound
Staging laparoscopy is performed to detect occult peritoneal disease. PET CT is performed in those with negative laparoscopy. Thoracoscopy is not routinely performed.

Treatment
- Operable disease is best managed by surgical resection.
The most standard procedure is an Ivor- Lewis type oesophagectomy. This procedure involves the mobilisation of the stomach and division of the oesophageal hiatus. The abdomen is closed and a right sided thoracotomy performed. The stomach is brought into the chest and the oesophagus mobilised further. An intrathoracic oesophagogastric anastomosis is constructed. Alternative surgical strategies include a transhiatal resection (for distal lesions), a left thoraco-abdominal resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with a cervical oesophagogastric anastomosis.
The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis. With high mortality. The McKeown technique has an intrinsically lower systemic insult in the event of anastomotic leakage.
In addition to surgical resection many patients will be treated with adjuvant chemotherapy.

108
Q

What is the most common type of oesophageal cancer?

A

Adenocarcinoma is now the most common type of oesophageal cancer and is more likely to develop in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett’s.
The majority of adenocarcinomas are located near the gastroesophageal junction whereas squamous cell tumours are most commonly found in the middle third of the oesophagus.

109
Q

What increases the risk of ovarian cancer?

A

The risk factors for ovarian cancer are hormonal in nature. A woman’s risk is greater if ovulation is not suppressed. In this way, early menarche and late menopause, both of which would increase ovulation, are risk factors for ovarian cancer.

110
Q

In oesophageal cancer - is it harder to swallow solids or liquids?

A

a progressive nature of symptoms (first solids and now liquids) suggests a growing obstruction - therefore points towards a diagnosis of oesophageal malignancy

111
Q

What would a B12 and folate deficiency lead to ?

A

Increased MCV

112
Q

What type of anaemia is common in colorectal cancer?

A

Microcytic anaemia

IRON DEFICIENCY ANAEMIA

113
Q

What is the Risk Malignancy Index (RMI) for ovarian cancer based on?

A

Ultrasound findings
CA125
Menopausal status

114
Q

Risk factors for bladder cancer?

A

Risk factors for transitional cell carcinoma of the bladder include:

  • Smoking
  • Exposure to aniline dyes in the printing and textile industry: examples are 2-naphthylamine and benzidine
  • Rubber manufacture
  • Cyclophosphamide
115
Q

Risk factors for squamous cell carcinoma of the bladder?

A

Schistosomiasis

Smoking

116
Q

Who is screened for cervical cancer and how often?

A

A smear test is offered to all women between the ages of 25-64 years

  • 25-49 years: 3-yearly screening
  • 50-64 years: 5-yearly screening
  • cervical screening cannot be offered to women over 64 (unlike breast screening, where patients can self refer once past screening age)
117
Q

What happens with smears if pregnant?

A
  • cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears.
  • women who have never been sexually active have very low risk of developing cervical cancer therefore they may wish to opt-out of screening
118
Q

What are the red flag symptoms for gastric cancer?

A
  • new-onset dyspepsia in a patient aged >55 years
  • unexplained persistent vomiting
  • unexplained weight-loss
  • progressively worsening dysphagia/odynophagia
  • epigastric pain
119
Q

Features of gastric cancer?

A
  • dyspepsia
  • nausea and vomiting
  • anorexia and weight loss
  • dysphagia
120
Q

treatment of gastric cancer?

A
  • Proximally sited disease greater than 5-10cm from the OG junction may be treated by sub total gastrectomy
  • Total gastrectomy if tumour is <5cm from OG junction
  • For type 2 junctional tumours (extending into oesophagus) oesophagogastrectomy is usual
  • Endoscopic sub mucosal resection may play a role in early gastric cancer confined to the mucosa and perhaps the sub mucosa (this is debated)
  • Lymphadenectomy should be performed. A D2 lymphadenectomy is widely advocated by the Japanese, the survival advantages of extended lymphadenectomy have been debated. However, the overall recommendation is that a D2 nodal dissection be undertaken.
  • Most patients will receive chemotherapy either pre or post operatively.
121
Q

Investigations for lung cancer?

A
  1. Chest x-ray
    this is often the first investigation done in patients with suspected lung cancer
    in around 10% of patients subsequently diagnosed with lung cancer the chest x-ray was reported as normal
  2. CT
    is the investigation of choice to investigate suspected lung cancer
  3. Bronchoscopy
    this allows a biopsy to be taken to obtain a histological diagnosis sometimes aided by endobronchial ultrasound
  4. PET scanning
    is typically done in non-small cell lung cancer to establish eligibility for curative treatment
    uses 18-fluorodeoxygenase which is preferentially taken up by neoplastic tissue
    has been shown to improve diagnostic sensitivity of both local and distant metastasis spread in non-small cell lung cancer
  5. Bloods
    raised platelets may be seen
122
Q

What is Lambert Eaton syndrome associated with?

A

Small cell lung cancer

123
Q

In a postmenopausal women who is having bleeding what is the diagnosis until proven otherwise?

A

Endometrial cancer

Endometrial adenocarcinoma has a strong association with Postmenopausal bleeding

124
Q

Is BRACA genes inherited in a autosomal dominant or recessive fashion?

A

autosomal DOMINANCE

125
Q

When in cervical screening offered and how often?

A

Offer cervical screening to all women between the ages of 25 years and 64 years.
Age 25 years: first invitation.
Age 25-49 years: screening every 3 years.
Age 50-64 years: screening every 5 years.
Women 65 years of age or older if they have not had a cervical screening test since 50 years of age or a recent cervical cytology sample is abnormal.

126
Q

What makes you think something is a renal cell carcinoma rather than a bladder tumour?

A

The ballotable mass and renal angle tenderness are more in keeping with a renal cell carcinoma than a bladder tumour.

127
Q

What type of cancer does achalasia increase the risk of ?

A

Squamous cell carcinoma of the oesophagus

128
Q

what treatment be for breast cancer that is node +ve?

A

FEC-D chemotherapy

129
Q

what is the treatment for node -ve breast cancer that requires chemotherapy

A

FEC chemotherapy

130
Q

what is a common cancer in postmenopausal women ?

A

endometrial cancer

- it is important to rule this out in all women that present with post-menopausal bleeding.

131
Q

How many types of colorectal cancer are there and what are they?

A

3
It is currently thought there are three types of colon cancer:
- sporadic (95%)
- hereditary non-polyposis colorectal carcinoma (HNPCC, 5%)
- familial adenomatous polyposis (FAP, <1%)

132
Q

what is used to monitor response to treatment of colon cancer.

133
Q

what is the most common site for squamous cell carcinoma in the oropharynx?

A

The tonsil is the most common site for squamous cell carcinoma in the oropharynx and usually present at an advanced stage.

134
Q

Features of head and neck cancer

A

neck lump
hoarseness
persistent sore throat
persistent mouth ulcer

135
Q

Nasopharyngeal carcinoma - how it presents?

A

Nasopharyngeal carcinoma may present as a painless lymphadenopathy because of its tendency for early spread

136
Q

How to tell the difference between myasthenia graves and Lambert eaton syndrome?

A

The weakness from LESS typically involves the muscles of the PROXIMAL arms and legs. In contrast to myasthenia gravis, the weakness affects the LEGS more than the arms. This leads to difficulties climbing stairs and rising from a sitting position.

Weakness is often RELIEVED temporarily AFTER EXERTION or physical exercise, in contrast to myasthenia gravis.

137
Q

What is Lambert eaton syndrome

A

antibodies are formed against pre-synaptic voltage-gated calcium channels in the NEUROMUSCULAR JUNCTION.

A significant proportion of those affected have an underlying malignancy, most commonly SMALL CELL LUNG CANCER. It is therefore regarded as a

paraneoplastic syndrome.

138
Q

Stages if ovarian cancer

A

Stage 1- Tumour confined to ovary
Stage 2- Tumour outside ovary but within pelvis
Stage 3- Tumour outside pelvic but within abdomen
Stage 4- Distant metastasis

139
Q

When check CA125?

A

NICE guidelines state that serum CA125 should be performed if a woman - especially if aged 50 years old or over - has any of the following symptoms on a regular basis:

  • abdominal distension or ‘bloating’
  • early satiety or loss of appetite
  • pelvic or abdominal pain
  • increased urinary urgency and/or frequency

The guidelines also note that irritable bowel disease rarely presents for the first time in women aged 50 and over, so any symptoms suggestive of IBD should prompt appropriate tests for ovarian cancer as these two conditions can present in a similar manner.

140
Q

What should you do if a serum CA125 is raised?

A

ultrasound of the abdomen and pelvis should be arranged.

If this is suggestive of malignancy then urgent referral must be arranged.

141
Q

What is the initial investigation for post menopausal bleeding?

A

transvaginal ultrasound scan to look at the endometrial thickness.

Pipelle biopsy is used to sample the endometrium and in most cases can be used to diagnose endometrial cancer.

142
Q

What to do next if a pipette biopsy of the endometrium is inconclusive?

A

Hysteroscopy with directed sampling (dilation and curettage) can be used to detect lesions or when pipelle has been inconclusive.

143
Q

name a high grade superficial bladder cancer

A

Carcinoma in situ

-its more likely to invade to the surrounding structures

144
Q

What is the treatment for a carcinoma in situ(CIS) in bladder cancer

A

Due to the early, but high-grade nature of such cancer, patients are managed by trans-urethral removal of bladder tumour (TURBT) with adjunct intravesicle chemotherapy to reduce the risk of recurrence.

145
Q

Complication of axillary node clearance?

A

arm lymphedema and functional arm impairment

146
Q

Prior to surgery, the presence/absence of axillary lymphadenopathy determines management - if there are no palpable axillary lymphadenopathy what do you do?

A

women with no palpable axillary lymphadenopathy at presentation:

  • should have a pre-operative axillary ULTRASOUND before their primary surgery
  • if positive then they should have a sentinel node biopsy to assess the nodal burden
147
Q

Prior to surgery, the presence/absence of axillary lymphadenopathy determines management - what do you if you present with palpable lymphadenopathy?

A

axillary node clearance is indicated at primary surgery

  • this may lead to arm lymphedema and functional arm impairment
148
Q

When do you give radiotherapy recommended for breast cancer?

A
  • Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds.
  • For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes
149
Q

When should an endometrial biopsy be taken?

A

A biopsy should be taken to exclude endometrial cancer or atypical hyperplasia.
Indications for a biopsy include : - persistent intermenstrual bleeding and in women aged 45 and over treatment failure or ineffective treatment

150
Q

What is goserelin?

A
  • synthetic GnRH agonist

- prostate cancer

151
Q

Localised prostate cancer (T1/T2) management

A

Treatment depends on life expectancy and patient choice. Options include:

  • conservative: active monitoring & watchful waiting
  • radical prostatectomy
  • radiotherapy: external beam and brachytherapy
152
Q

Localised advanced prostate cancer (T3/T4) management

A

Options include:
- hormonal therapy - synthetic GnRH agonist, anti-androgen

  • radical prostatectomy: erectile dysfunction is a common complication
  • radiotherapy: external beam and brachytherapy. Patients are at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer
153
Q

Metastatic prostate cancer disease - hormonal therapy

A
  1. Synthetic GnRH agonist
    - e.g. Goserelin (Zoladex)
    - cover initially with anti-androgen to prevent rise in testosterone
  2. Anti-androgen
    - cyproterone acetate prevents DHT binding from intracytoplasmic protein complexes
  3. Orchidectomy
154
Q

A strong family history of colorectal cancer and lack of adenomatous polyposis on colonoscopy point towards a diagnosis of ?

A

hereditary nonpolyposis colorectal cancer (HNPCC)

155
Q

Hereditary nonpolyposis colorectal cancer (HNPCC) presents as?

A

A strong family history of colorectal cancer and LACK of adenomatous polyposis on colonoscopy

156
Q

what is the commonest extra-colonic malignancy of HNPCC?

A

endometrial cancer

157
Q

What is FAP- familial adenomatous polyposis?

A

rare autosomal dominant condition which leads to the formation of hundreds of polyps by the age of 30-40 years. Patients inevitably develop carcinoma.
Patients with FAP are also at risk from duodenal tumours. A variant of FAP called Gardner’s syndrome can also feature osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin

158
Q

What is anastrozole?

A

an aromatase inhibitor

159
Q

At what stage to those with endometrial cancer present with?

A

75% of patients present with stage 1 disease, which is generally treated with a hysterectomy and bilateral salpingo-oophorectomy.

160
Q

What to do if a CA125 is raised?

A

(35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered

161
Q

What is the management of ovarian cancer?

A

usually a combination of surgery and platinum-based chemotherapy

(80% of women have advanced disease at presentation)

162
Q

What is the most effective treatment for RCC?

A

Radical nephrectomy is the most effective management option in renal cell carcinoma - RCC is usually resistant to radiotherapy or chemotherapy

163
Q

What is an orchidopexy associated with?

A

An increased risk of developing testicular cancer

164
Q

What is seem histologically in gastric cancer?

A

Signet ring

165
Q

What should be also be given when GnRH analogues are given?

A

Anti- androgen treatment

e.g. cryproterome acetate

166
Q

What is the gold standard investigation for oesophageal cancer?

167
Q

In paraneoplastic Cushing’s syndrome, ectopic adrenocorticotrophic hormone (ACTH) production results in a syndrome characterised by what symptoms?

A

muscle weakness, hypertension, hypokalaemia and oedema

The classical features of buffalo hump and moon face are often absent.

168
Q

Contraindications to lung cancer surgery ?

A

SVC obstruction, FEV < 1.5, MALIGNANT pleural effusion, and vocal cord paralysis,tumour near hilum,stage IIIb or IV (i.e. metastases present)

169
Q

strong family history of breast cancer indicates possible BRCA genes involved in breast and what else?

A

ovarian cancer

170
Q

late/long-term complications of radical prostatectomy include ?

A

incontinence, erectile dysfunction and urethral stenosis

171
Q

what is the investigation of choice in diagnosing bladder cancer

A

flexible Cystoscopy

172
Q

Tumour lysis syndrome - what is it and what causes it?

A
  • Is a potentially deadly condition related to the treatment of high grade lymphomas and leukaemias. It can occur in the absence of chemotherapy but is usually triggered by the introduction of combination chemotherapy.
  • On occasion it can occur with steroid treatment alone
173
Q

What should patients at a high risk of tumour lysis syndrome be given immediately prior ro and during the first days of chemo?

A

IV allopurinol or IV rasburicase

174
Q

Why does tumour lysis syndrome occur?

A

Breakdown of the tumour cells
Subsequent release of chemicals from the cell
It leads to a high potassium and high phosphate level in the presence of a low calcium

175
Q

When should tumour lysis syndrome be suspected.

A

It should be suspected in any patient presenting with an acute kidney injury in the presence of a high phosphate and high uric acid level.
- who is on chemotherapy

176
Q

Superior vena cava obstruction - features, causes, Mx

A

Superior vena cava (SVC) obstruction is an oncological emergency caused by compression of the SVC. It is most commonly associated with lung cancer.

Features

  • 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
  • visual disturbance
  • pulseless jugular venous distension

Causes

  • common malignancies: small cell lung cancer, lymphoma
  • other malignancies: metastatic seminoma, Kaposi’s sarcoma, breast cancer
  • aortic aneurysm
  • mediastinal fibrosis
  • goitre
  • SVC thrombosis

Management
- general:
dexamethasone, balloon venoplasty, stenting
- small cell: chemotherapy + radiotherapy
- non-small cell: radiotherapy

177
Q

Cyclophosphamide- what is it? Mechanism of action? Adverse effects ?

A

Cytotoxic drug

Alkylating agent - causes cross-linking in DNA

Adverse effects:
- Haemorrhagic cystitis, myelosuppression, transitional cell carcinoma

178
Q

Anthracyclines (e.g doxorubicin). What is it? Mechanism of action? Adverse effects ?

A

Cytotoxic drug

Stabilizes DNA-topoisomerase II complex inhibits DNA & RNA synthesis

AE- Cardiomyopathy

179
Q

Methotrexate- What is it? Mechanism of action? Adverse effects ?

A

Cytotoxic drug - an antimetabolite

Inhibits dihydrofolate reductase and thymidylate synthesis

AE- Myelosuppression, mucositis, liver fibrosis, lung fibrosis

180
Q

Fluorouracil (5-FU)- What is it? Mechanism of action? Adverse effects ?

A

Cytotoxic drug - an antimetabolite

Pyrimidine analogue inducing cell cycle arrest and apoptosis by blocking thymidylate synthase (works during S phase)

AE-Myelosuppression, mucositis, dermatitis

181
Q

Docetaxel- Mechanism of action? Adverse effects ?

A

Prevents microtubule depolymerisation & disassembly, decreasing free tubulin

AE- Neutropaenia

182
Q

Cisplatin- Mechanism of action? Adverse effects ?

A

Causes cross-linking in DNA

AE- Ototoxicity, peripheral neuropathy, hypomagnesaemia

183
Q

BRCA2 mutation is associated with what in men?

A

Prostate cancer

184
Q

Neoplastic spinal cord compression - features, ix, mx

A

Spinal cord compression is an oncological emergency and affects up to 5% of cancer patients. Extradural compression accounts for the majority of cases, usually due to vertebral body metastases. It is more common in patients with lung, breast and prostate cancer

Features

  • back pain
    • -the earliest and most common symptom
    • -may be worse on lying down and coughing
  • lower limb weakness
  • sensory changes: sensory loss and numbness
  • neurological signs depend on the level of the lesion. Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level. Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion

Investigation
- urgent MRI: the 2019 NICE guidelines recommend a whole MRI spine within 24 hours of presentation

Management

  • high-dose oral dexamethasone
  • urgent oncological assessment for consideration of radiotherapy or surgery
185
Q

Chemotherapy side-effects: nausea and vomiting - risk factors, mx?

A

Nausea and vomiting are common side-effects of chemotherapy.
Risk factors for the development of symptoms include:
- anxiety
- age less than 50 years old
- concurrent use of opioids
- the type of chemotherapy used

Cyclizine - 1st line

186
Q

Anti emetics and what they work on?

A

1- Ondansetron is a 5HT-3 receptor antagonist and is useful in gastroenteritis or chemotherapy induced nausea.
2 - Haloperidol is an antipsychotic used as an anti-emetic in palliative care
4 - Cyclizine is a H1-antagonist used to treat inner-ear induced nausea
5 - Metoclopramide is a D2-antagonist used to promote bowel motility

187
Q

What are the most useful follow-up investigation(s) to detect disease recurrence for a testicular teratoma after an orchidectomy?

A

Alpha fetoprotein

Beta HCG

188
Q

Raised alpha-feto protein level can be seen in ?

A

Liver cancer

189
Q

Raised beta-human chorionic gonadotropin with a raised alpha-feto protein level is seen in?

A

Non-seminomatous testicular cancer

A raised alpha-feto protein level excludes a seminoma

190
Q

Tumour marker in breast cancer?

191
Q

What cytotoxic drug is associated with peripheral neuropathy?

A

Vincristine

Also:Urinary hesitancy may develop secondary to bladder atony

192
Q

Management for SVCO?

A

dexamethasone

193
Q

New back pain in a patient with a cancer history… think?

A

high suspicion of spinal metastasis (metastatic spinal cord compression (MSCC))

194
Q

Immune checkpoint inhibitors- what are they?

Types,SE

A

Immune checkpoint inhibitors are a type of immunotherapy that are increasingly being used to treat certain types of cancer, as an alternative to cytotoxic chemotherapy.
These targeted treatments harness the body’s natural anti-cancer immune response. They boost its ability to attack and destroy the cancer cells.

Checkpoint inhibitors block this process and reactivate and increase the body’s own T-cell population, enhancing the immune systems own ability to recognise and fight cancer cells.

Types:

  • Ipilimumab (Yervoy) is a checkpoint inhibitor that blocks CTLA-4 (cytotoxic T lymphocyte-associated protein 4). It is a treatment for advanced melanoma.
  • Nivolumab (Opdivo) and pembrolizumab (Keytruda) blocks PD-1 (programmed cell death protein 1). These are treatments for melanoma, Hodgkin’s lymphoma, non-small cell lung cancer and urological cancers.
  • Atezolizumab, Avelumab and Durvalumab block PD-L1 and is used to treat lung cancer and urothelial cancer. It is also undergoing trials as a treatment for breast cancer.

Side effects

This mechanism of action of these drugs can result in side effects termed ‘Immune-related adverse events’ that are inflammatory and autoimmune in nature. This is because all immune cells are boosted by these drugs, not just the ones that target cancer. The over-active T-cells can produce side effects such as:

  • Dry, itchy skin and rashes (most commonly)
  • Nausea and vomiting
  • Decreased appetite
  • Diarrhoea
  • Tiredness and fatigue
  • Shortness of breath and a dry cough.

Management of such side effects reflects the inflammatory nature, often involving corticosteroids.

It is important to monitor liver, kidney and thyroid function as these drugs can affect these organs.

195
Q

Features of bone metastases?

A

Other than bone pain, features may include:

  • pathological fractures
  • hypercalcaemia
  • raised ALP
196
Q

Most common tumour causing bone metastases - in order

A

in descending order

  1. prostate
  2. breast
  3. lung
197
Q

A normal bronchoscopy in lung cancer suggests?

A

a peripherally located lesion.

e.g. Lung adenocarcinoma

198
Q

Calcitonin is a tumour marker in…

A

medullary thyroid cancer

Medullary thyroid cancer is the only thyroid cancer that will cause a rise in calcitonin, as it originates from the parafollicular cells, which produce calcitonin.

199
Q

Flashes + floaters are most commonly caused by…

A

posterior vitreous detachment

where the vitreous shrinks and pulls away from the retina

200
Q

Herpes zoster ophthalmicus- features, mx

A

Herpes zoster ophthalmicus (HZO) describes the reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles.

Features

  • vesicular rash around the eye, which may or may not involve the actual eye itself
  • Hutchinson’s sign: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement

Management
- oral antiviral treatment for 7-10 days
– ideally started within 72 hours
– intravenous antivirals may be given for very severe infection or if the patient is immunocompromised
–topical antiviral treatment is not given in HZO
- topical corticosteroids may be used to treat any
secondary inflammation of the eye
- ocular involvement requires urgent ophthalmology review

Complications

  • ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis
  • ptosis
  • post-herpetic neuralgia
201
Q

What Ix should be done if orbital cellulitis is suspected >

A

CT scan with contrast of the orbits, sinuses and brain should be done if orbital cellulitis is suspected to assess the posterior spread of infection

202
Q

Orbital cellulitis - what is it, risk factors, presentation, ix , mx

A

Orbital cellulitis is the result of an infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe. It is usually caused by a spreading upper respiratory tract infection from the sinuses and carries a high mortality rate. Orbital cellulitis is a medical emergency requiring hospital admission and urgent senior review. Periorbital (preseptal) cellulitis is a less serious superficial infection anterior to the orbital septum, resulting from a superficial tissue injury (chalazion, insect bite etc…). Periorbital cellulitis can progress to orbital cellulitis.

Epidemiology
Mean age of hospitalisation 7-12 years.

Risk factors

  • Childhood
  • Previous sinus infection
  • Lack of Haemophilus influenzae type b (Hib) vaccination
  • Recent eyelid infection/ insect bite on eyelid (Peri-orbital cellulitis)
  • Ear or facial infection

Presentation

  • Redness and swelling around the eye
  • Severe ocular pain
  • Visual disturbance
  • Proptosis
  • Ophthalmoplegia/pain with eye movements
  • Eyelid oedema and ptosis
  • Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare)

Differentiating orbital from preseptal cellulitis
reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis

Investigations

  • Full blood count – WBC elevated, raised inflammatory markers.
  • Clinical examination involving complete ophthalmological assessment – Decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema.
  • CT with contrast – Inflammation of the orbital tissues deep to the septum, sinusitis.
  • Blood culture and microbiological swab to determine the organism. Most common bacterial causes – Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.

Management
- admission to hospital for IV antibiotics

203
Q

Papilloedema - fundoscopy findings, causes

A

Papilloedema describes optic disc swelling that is caused by increased intracranial pressure. It is almost always bilateral.

The following features may be observed during fundoscopy:

  • venous engorgement: usually the first sign
  • loss of venous pulsation: although many normal patients do not have normal pulsation
  • blurring of the optic disc margin
  • elevation of optic disc
  • loss of the optic cup
  • Paton’s lines: concentric/radial retinal lines cascading from the optic disc

Causes of papilloedema

  • space-occupying lesion: neoplastic, vascular
  • malignant hypertension
  • idiopathic intracranial hypertension
  • hydrocephalus
  • hypercapnia

Rare causes include
hypoparathyroidism and hypocalcaemia
vitamin A toxicity

Year 4 cancer care (1 decks)

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