Oncology Flashcards
Name 3 causes of new confusion in a patient on the ward
Sepsis hypercapnia hypercalcaemia raised ammonia AKI -> dehydration -> reduced opiate excretion steroids low Na Brain mets
Mx of hypercalcaemia
saline -> bisphosphonates [zoledronate]
2- calcitonin
Adverse effects of zolendonic acid
osteonecrosis of jaw
gastritis
oesophagitis
Mx of raised ammonia
phosphate enemas
How does AKI cause confusion in patient on opiates?
Dehydration -> decreased opiate excretion -> increased levels of opiates -> confusion and sedation
mx - naloxone
Mechanism of steroid psychosis
- > reduced Na and increased K
- > reduced BP (due to low Na)
2 Drug causes of reduced NA
steroids PPI - omeprazole / lanzoprazole ssri Carbamazepine fluids (Eg 5% dextrose)
(rinitidine is good to change PPI)
What happens in the metastatic cascade
DIIE AEA [like someone shouting it]
Detachment Invasion Intravasation (blood or lymph) Evasion of host defence Adherence Extravasation Angiogenesis
When might you use radiotherapy - 3 indications
Pt medically unfit surgery,
anatomically unresectable, close proximity to vital structures,
neo-adjuvant to shrink structure,
adjuvant to decrease risk of recurrence,
palliative for bone/brain mets + spinal cord compression
2 main types of radiotherapy
External beam radiation therapy - using CT/MRI to target tumour
Internal radiation therapy - brachytherapy - radiation source placed near target tumour
Name 2 acute and 2 chronic comps of radiotherapy
Acute (during treatment or <2-3 weeks)
Fatigue (80%)
Skin - Erythema, dry and moist desquamation, irritation
GI - loss of taste, oral mucositis (complicated by yeast/bacterial superinfection), diarrhoea, nausea, vomiting
BM - cytopenias
Lungs - pneumonitis, fever, cough, dyspnoea
Chronic Infertility Lymphoedema Delayed healing Loss of salivary flow Transverse myelitis, Lhermitte’s Increased risk CV events/stroke Hypothyroidism
Name 3 SEs of chemo
Myelosuppression - anaemia, infection, bleeding
One week after, FBC prior to admission
Alopecia
Infertility
Nausea, vomiting and diarrhoea
-Major cause of distress - use domperidone or metoclopramide
Fatigue
Teratogenicity
Mouth ulcers
What is extravasation
Problem with chemo -
pain, redness and inflammation -> may lead to skin necrosis + amputation (dissolving soft tissue).
May see brown demarcation of veins
Mx of extravasation
Topical agents e.g. dimethyl sulfoxide, heat, cold,
debridement and grafting may be required
Common severe reaction to chemo
Anaphlaxis - T1 hypersensitivity
What is the risk with chemo induced myelosupression
Neutropenic sepsis
Ix in anyone who has fever and recent chemo
FBC, LFT, U + Cr, CRP, lactate, blood cultures (multiple sites), urine culture, NOT LP (may introduce infx), swabs and cultures from central line (each part)
Worry about neutropenic sepsis
Pt presents with Sx of spinal cord compression (in onc) what exam should you do?
peripheral nerve
precuss spine
mets -> spinal cord compression
Ix for Dx?
Mx?
MRI whole spine,
- > refer to neurosurgery/spinal surgery
- > Or if more widespread give radiotherapy
+ IV DEXAMETHASONE + prevention VTE + PPI
- Analgesia
- Lay flat
Dexamethasone
Just god shit keep it in the brain for all onc
Mx painful spine mets
Analgesia (NSAID/non-opiate/opiate)
Bisphosphonates if myeloma/breast cancer (lytic lesions)
Palliative radiotherapy
Vertebroplasty
3 precipitating factors for DVT in Ca
cancers tend to be prothrombotic
Surgery and chemotherapy may damage vessel walls (increased clots)
Patients tend to be less active
Describe 1 way malignancy can cause hyperCa
Secretion of PTH related peptide by tumour (humoral hypercalcaemia)
Local release of factors increasing osteoclast proliferation (local osteolytic hypercalcaemia) - including PTH-rP
Boney mets
Autonomous production of calcitriol by lymphoma
Name 3 Ix in HyperCa of malignancy
Total calcium
Elevated but influenced by albumin and calcium binding Igs (MM)
Serum ionised calcium
If abnormal albumin
Serum albumin
Adjusted serum calcium is (0.02 x [normal albumin - pt albumin]) + serum calcium
Resting ECG
?Shortened QT
Serum PTH
Elevated in PTH mediated i.e. primary hyperparathyroid/ ectopic hyperparathyroid
Serum phosphorus
Low in humoral
Serum calcitriol - high in calcitriol mediated
Skeletal survey - osteopenia, osteolytic lesions, pathological fractures + CXR lung cancer, TB, sarcoidosis
Name 2 medications that worsen hypercalcaemia
Thiazide diuretics Calcitriol Calcium supplementation Antacids Lithium
Mx of mod/severe hyoer Ca
IV saline
(dehydration)
IV bisphosphonates (block bone reabsorption)
Furosemide
-avoid fluid overload
Most common cause of SVCS? What happens
Malignancy - its in the onc deck idiot
75% - lung ca
Venous return from head, thorax and upper extremities is obstructed leading to an increased venous pressure
Name 3 sx/signs of SVC obstruction
FIXED (non-pulsatile) + RAISED JVP
Oedema of face and upper extremities (80%)
Dyspnoea (60%) - worse leaning forward
Facial plethora (venous engorgement)
Cough
Distended neck veins + chest veins - worse leaning forward
Hoarse voice
Ix in SVCO
Chest x-ray (widened mediastinum or mass in lung)
CT thorax with contrast (collat vess, loc, sev, path),
USS upper extremities (dilated SVC, thrombu
2 Options Mx of acute airway obstruction (comp of SVCO)
Secure airway (intubate/surgical) + local radiotherapy + corticosteroids (dexamethasone)
OR
Secure airway + percutaneous endovascular stent (bleeding risk, patency)
What is tumour lysis syndrome? most common Ca to get it with?
Combination of metabolic and electrolyte abnormalities occurring spontaneously following initiation of cytotoxic treatment in patients with cancer.
Characterised by excessive cell lysis.
Lymphoma
Lab findings in tumour lysis
hyperuricaemia, hyperphosphataemia, hyperkalaemia,
->Arrhythmia
hypocalcaemia
-> muscle cramps / tetany
Why do you get AKI in TLS
uric acid nephropathy
(+ calcium phosphate deposition)
[will also cause K to go up higher]
What is lambert-eaton myasthemic syndrome ? which Ca common?
AI disorder of NM junction
SCLC
How does lambert-eaton present?
Limb weakness (proximal legs + arms)
Dry mouth ( + metallic taste)
Weakness
Dysarthria, ptosis, diplopia, impotence
Name 3 Ix in lambert eaton
Nerve conduction studies - doubling of compound muscle action potential post exercise
Anti VGCaC - positive
Anti AChR - negative
Chest CT - ? malignancy
Serial LuFT - low FVC - ? resp crisis
Mx of lambert eaton if no resp weakness?
resp weakness
-> treat cause + amifampridine ± pred
intubation and ventilation + plasma exchange/IVIG
How does carcinoid syndrome present
flushing/diarrhoea (± wheeze, palpitations, telangiectasia, abdo pain)
What causes sx in carcionoid
serotonin
(+ kinins)
from neuroendocrine tumours
Dx of carcinoid
elevated urinary-5-hydroxyindoleacetic acid (24 hr)
Mx of carcinoid
octreotide - somatostatin analogue) + surgical resection
Name 3 Ca that met to bone
Breast - C Prostate - P Bronchus - M Myeloma - Thyroid
What is a sanctuary site?
an area that chemotherapy does not reach well e.g. brain and scrotum in ALL
period between chemo and becoming neutropenic
1-2 weeks
When would tazosin not be good for neutropenic sepsis? What could you give
if on high dose methotrexate - both act on folic acid
give meropenem
What increases risk of becoming neutropenic on chemo
age
more cytotoxic chemos
multiple courses
Hx of becoming neutropenic
What might you give with pts high risk becoming neutropenic
GCSF - boosts bone marrow to produce more
[granulocyte stimulating factor]
moans bones stones and groans is?
Bone pain, vomiting diarrhoea, abdo pain, seizures, arrhythmias, Kidney stones
5 ca mets to bone
breast lung kidney prostate thyroid
Mx of TLS
allopurinol
rasburicase
Mx of HyperK
Fluids
[Consider dialysis]
