Oncology

Question 1

Features of spinal cord compression

Answer 1

• 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
  *

Question 2

Management of spinal cord compression

Answer 2

• high-dose oral dexamethasone → 18 mg PO
• urgent oncological assessment for consideration of radiotherapy or surgery

Question 3

Features of superior vena cava obstruction

Answer 3

• 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
• Pemberton’s sign → venous congestion in neck, dilated veins in the upper chest and arms

Question 4

Management of superior vena cava obstruction

Answer 4

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

Question 5

Hypercalcaemia treatment

Answer 5

• IV fluids (3-4 l a day)
• IV bisphosphonates → Pamidronate or Zolendronate
• Denosumab and calcitonin → in some difficult causes

Question 6

Causes of hypercalcaemia in ca patient

Answer 6

• metastasis to bone (due to osteolysis)
• PTHrP from squamous cell lung cancer

Question 7

Features of hypercalcaemia

Answer 7

• ‘bones, stones, groans and psychic moans’
• corneal calcification
• shortened QT interval on ECG
• hypertension

Question 8

Features of ICP

Answer 8

• headache
• nausea
• vomiting
• papilloedema → occurs very late in disease
• possible slower onset with non specific symptoms e.g. drowsiness, mental deterioration

Question 9

Management of increased ICP

Answer 9

• MRI
• high dose dexamethasone
• gamma-knife radiotherapy may be needed

Question 10

What’s the definition of hyperviscosity?

Answer 10

Either of:

• Hb >18
• high WCC
• high platelets

Cause:

• untreated leukaemia
• myeloma (high level of immunoglobulins)
• Waldenstrom’s macroglobulinemia (high level of immunoglobulins)

Question 11

Clinical features of hyperviscosity

Answer 11

• hypoxia
• pulmonary infiltrates
• confusion
• headaches
• visual disturbances
• papilloedema
• retinal venous dilation
• cardiac failure
• priapism

Question 12

Management of hyperviscosity

Answer 12

• plasmapheresis
• leukopheresis
• treat underlying malignancy

Question 13

Definition of neutropenic sepsis

Answer 13

• neutrophil count of < 0.5 * 10⁹

^​ in a patient who is having anticancer treatment and has one of the following:

• a temperature higher than 38ºC or
• other signs or symptoms consistent with clinically significant sepsis

Question 14

The timeframe in which neutropenic sepsis usually occurs?

Answer 14

7-14 days post chemo

Question 15

Prophylaxis of neutropenic sepsis

Answer 15

if it is anticipated that patients are likely to have a neutrophil count of < 0.5 * 10⁹ as a consequence of their treatment they should be offered a fluoroquinolone

Question 16

Treatment of neutropenic sepsis

Answer 16

• antibiotics must be started immediately
• start with empirical antibiotic therapy with piperacillin with tazobactam (Tazocin) immediately
• add vancomycin if the patient has central venous access
• assessment by a specialist and risk-stratified to see if they may be able to have outpatient treatment
• if patients are still febrile and unwell after 48 hours an alternative antibiotic such as meropenem is often prescribed +/- vancomycin
• if patients are not responding after 4-6 days do investigations for fungal infections (e.g. HRCT)
• there may be a role for G-CSF in selected patients

Question 17

(6) Hallmarks of cancer (pathophysiology)

Answer 17

The Hallmarks of Cancer (Weinberg):

1. Autonomy from growth signals
2. Insensitivity to growth inhibitory signals
3. Avoidance of programmed cell death
4. unlimited replicative potential
5. sustained angiogenesis
6. invasion and metastasis

Question 18

(3) genetic syndromes (+ a bit of info) predisposing to colorectal cancer

Answer 18

Question 20

Difference between adjuvant vs neo-adjuvant rafiotherapy

Answer 20

• adjuvant → given after the surgery/ alongside other treatment
• neo-adjuvant → given before the surgery to shrink the tumour size

Question 21

Types of radiotherapy (4) + describe

Answer 21

• External beam radiotherapy/teletherapy → high dose x-ray (radiation produce by the machine and given to the pt)
• Brachytherapy → source of radiation near tumour (via needle, scope etc)
• Radionucleotide therapy → injection of radiation source into the pt e.g. radioiodine therapy in thyroid ca
• Proton beam therapy → used mostly in paediatrics (charged particles leave their energy at a certain point) so less radiation left behind= less long term side effects

Question 22

MoA of radiotherapy (2)

Answer 22

MoA:

• DNA of cancer cells is damaged → decreased cancer cells ability to reproduce
• ability of the cancer cell repair is decreased → ca cell death

Question 23

What’s:

• cancer
• carcinoma
• sarcoma

Answer 23

• cancer → solid malignancy
• carcinoma → malignancy growing from the epithelium
• sarcoma → malignancy growing from mesenchymal tissue

Question 24

What does it mean:

• Disease-free survival
• Progression-free survival
• Overall survival

Answer 24

• Disease- free survival → time after e.g. that ‘cured’ cancer to death
• Progression-free survival → period when the cancer is not growing
• Overall survival → takes into account also different causes of death (e.g. cancer + other conditions)

Question 25

Other causes (than neutropenic sepsis) of fever in chemotherapy pt

Answer 25

• malignancy related fever
• PE
• chemo-induced fever (e.g. Bleomycin)

Question 26

What scoring system do we use for neutropenic sepsis patients

Answer 26

MASCC score

score of >/ 21 indicates low risk ⇒ pt can be managed as an outpatient on oral antibiotics

*of course, clinical judgement should be used

* social situation, frailty etc is also considered

Question 27

What does ‘fraction’ mean in terms of radiotherapy?

Answer 27

Fraction = dividing total dose into small fractions given over several weeks

• it allows differentiating between repairability of normal and cancer tissues
• SEs usually appear bu the end of the treatment course and
• it takes same time to recover from SEs (e.g. side effects happened after 5 weeks of the treatment course → it will take 5 weeks to recover from them)

Question 28

SEs of radiotherapy to breast

Answer 28

• swelling
• redness

Question 29

SEs of radiotherapy to abdo

Answer 29

• nausea
• vomiting
• diarrhoea

Question 30

SEs of radiotherapy to chest

Answer 30

• cough
• SOB
• reflux

Question 31

SEs of radiotherapy to head and neck

Answer 31

• taste changes
• dry mouth
• red skin

Question 32

SEs of radiotherapy to brain

Answer 32

• hair loss
• scalp redness

Question 33

SEs of radiotherapy to pelvis

Answer 33

• diarrhoea
• cramps
• vaginal irritation
• urinary frequency

Question 34

SEs of radiotherapy to prostate

Answer 34

• impotence
• urinary symptoms
• diarrhoea

Question 35

SEs of chemotherapy related to a reaction to the drug

Answer 35

• N/V
• thromboembolism
• rash

Question 36

SEs of chemotherapy related to early/cyclical effects on organs

Answer 36

• dysguesia
• mucositis
• rash
• myelosuppression
• diarrhoea
• cramps
• fatigue

Question 37

SEs of chemotherapy re to late/cumulative effects

Answer 37

• alopecia
• nail changes
• peripheral neuropathy
• fatigue

Question 38

Secondary SEs of chemotherapy that can be avoided by prompt management

Answer 38

• AKI (dehydration)
• respiratory failure
• sepsis
• malnutrition
• acute abdo
• neuro disability
• disfiguring rash
• poor QoL
• death