Oncology Flashcards
1
Q
What is thrombocytopenia?
A
Reduced platelet count < 150x10^9/L
2
Q
Causes of thrombocytopenia
A
Chemotherapy, paraproteins (multiple myeloma), bone marrow infiltration (leukaemia, lymphoma, myeloma)
3
Q
Presentation of thrombocytopenia
A
Epistaxis, bleeding gums, haemoptysis, haematemesis, haematuria, haematochezia, malaena, metromenorrhagia, PPH, bruising/petechiae/purpura
4
Q
What is Ca27.29 a tumour marker for?
A
Breast cancer
5
Q
What tumour marker can be used for breast cancer?
A
Ca27.29
6
Q
What is CEA a tumour marker for?
A
Colorectal cancer
7
Q
What tumour marker can be used for colorectal cancer?
A
CEA
8
Q
What is Ca19-9 a tumour marker for?
A
Pancreatic + biliary tree cancer
9
Q
What tumour marker can be used for pancreatic and biliary tree cancer?
A
Ca19-9
10
Q
What is AFP a tumour marker for?
A
Hepatocellular carcinoma
Non-seminomatous germ cell cancer
11
Q
What tumour marker can be used for Hepatocellular carcinoma?
A
AFP
12
Q
What is Beta-hCG a tumour marker for?
A
Non-seminomatous germ cell cancer
Gestational trophoblastic disease
13
Q
What tumour marker can be used for non-seminomatous germ cell cancer?
A
AFP + B-hCG
14
Q
What is Ca125 a tumour marker for?
A
Ovarian cancer
15
Q
What tumour marker can be used for ovarian cancer?
A
Ca125
16
Q
Define screening
A
A process of identifying apparently healthy people who may be at increased risk of a disease
17
Q
What is grading of a cancer?
A
The extent to which the neoplasm resembles its cell or tissue of origin
- Well-differentiated- closely resembles, grows slowly
- Poorly-differentiated- do not resemble, grows rapidly
18
Q
Describe the TNM cancer staging system
A
Size and extent to which is had spread
T- tumour size
N- nodal status
M- metastatic disease (4: mets to distant organs)
19
Q
What is the most common cancer in women?
A
Breast cancer
20
Q
Types of breast cancer
A
Mostly ductal or lobular, also Paget’s
21
Q
Risk factors for breast cancer
A
BRCA1+2, TP53 mutation Age, previous Hx breast ca, FH breast ca Nulliparity/1st child>30, not breast-feeding Early menarche/late menopause Radiation to chest HRT/COCP Cirrhosis
22
Q
Presentation of breast cancer
A
Lump in breast or axilla, mostly painless
Nipple change- discharge, retraction, inversion, bloody discharge
23
Q
Differentials of breast lump
A
Breast cancer Fibroadenoma Fat necrosis Cysts Breast abscess Intraductal papilloma
24
Q
What makes up the assessment of a breast lump?
A
Triple assessment:
- History and examination
- Imagine- mammogram/USS
- Biopsy- fine needle aspiration/core needle biopsy/excision biopsy/incisional
25
How is breast cancer staged/grouped?
```
Sentinel lymph node biopsy
ER + Progesterone receptor status
HER2 status
CT/PET for mets
TNM
```
26
Management of breast cancer
```
Radiotherapy
Hormonal- Premenopausal- Tamoxifen; Postmenopausal- Letrozole
HER-2 +ve- Trastuzumab (Herceptin)
ER+ve- Docetaxel
Chemotherapy, Surgery
```
27
Screening for breast cancer
Women aged 50-71 every 3 years
28
What is the most common cancer in men?
Prostate cancer
29
What is the most common type and location of prostate cancer?
Mostly adenocarcinomas from peripheral zone of the prostate
30
Name the 4 zones of the prostate
Transitional, Anterior, Peripheral and Central
31
Where are the most common sites of metastasis of prostate cancer?
Bone & Lymph nodes
32
Risk factors for prostate cancer
Age, Black Afro-Caribbean, Family history
33
What is the main differential of prostate cancer?
Benign Prostatic Hyperplasia
34
Presentation of prostate cancer
Lower urinary tract symptoms (LUTS)- weak stream, hesitancy, sensation of incomplete emptying, urinary frequency, urgency/incontinence, dysuria
UTI, haematuria, haematospermia, tenesmus
35
What is found on DRE in prostate cancer?
Hard irregular prostate, asymmetry, nodule within lobe, induration, lack of mobility, palpable seminal vesicles
36
Investigations of suspected prostate cancer
PSA
Transrectal prostate biopsy
TNM staging
Gleason grading
37
What grading system is used for prostate cancer?
Gleason grading 1-5
38
Management of prostate cancer
```
Active surveillance
Surgery
Radiotherapy- external beam/brachytherapy
Cryotherapy
Chemotherapy- Docetaxel, Cabazitaxel
Hormonal- androgen deprivation
- LNRH analogue- eg goserelin
- Anti-androgen- eg Cyproteroneacetate
- Bilateral orchidectomy
```
39
What are the adverse effects of androgen deprivation therapy for prostate cancer?
'Flare phenomenon'- hot flushes, sexual dysfunction, loss of libido, osteoporosis, gynaecomastia, fatigue
40
Oncology causes of stridor
Head/neck tumour, lung/upper GI tumour
41
How is stridor diagnosed?
Clinically
| Can use upper airway visualisation/imaging (CT)
42
Management of stridor
- O2
- Dexamethasone 16mg OD
- Urgent ENT review
- Stenting/Tracheostomy
- Radiotherapy
43
Definition of hypercalcaemia
Corrected calcium >2.6mmol/L
44
Causes of hypercalcaemia
- With raised PTH- Hyperparathyroidism
- With low PTH- bone mets, ectopic PTHrp (esp SCLC), drugs (thiazides, vit D, lithium), thyrotoxicosis, adrenal insufficiency, TB, sarcoidosis
45
ECG finding in hypercalcaemia
Prolonged QT
46
Management of hypercalcaemia
Immediate IV fluids
IV Bisphosphonates- Zolendronate/Pamidronate
Steroids
Denosumab if resistant to bisphosphonates
Treat underlying cause
47
What types of malignancy predispose to massive haemorrhage?
Head and neck tumours, lung/GI tumours with history of bleeding
48
How might massive haemorrhage present?
Rapid loss of consciousness
49
Management of massive haemorrhage
Stop anticoagulation
ABCDE if for treatment
Or dark towels, remain with patient, Midazolam 10mg stat
50
What is the most common type of brain tumour?
Brain metastases
51
Where do brain mets most commonly arise from?
Lung, breast, melanoma
52
Presentation of brain mets
Headache worse in morning/coughing, N&V, seizures, cognitive/behavioural symptoms, papilloedema, progressive focal neurology (diplopia, visual field defect, upper/lower limb defect)
53
What symptoms would specifically present in mets in..
- frontal lobe;
- parietal lobe?
Frontal- personality change
| Parietal- Dysarthria
54
What investigation should be done in suspected brain mets?
Urgent MRI brain
55
Management of brain mets
Steroids
| Surgery/chemo/radiotherapy
56
What is the normal physiology of ADH production?
Hypothalamus --> posterior pituitary releases ADH in response to increased serum osmolality --> in kidneys water reabsorbs into blood stream --> increased urine osmolarity --> reduced plasma osmolality
57
What is the aetiology of Syndrome of inappropriate ADH secretion (SiADH)?
Tumour cells may secrete ADH especially SCLC
| This causes hyponatraemia
58
Presentation of Syndrome of inappropriate ADH secretion (SiADH)
Depression, lethargy, N&V, headache, irritability, muscle cramps, weakness, ataxia, confusion, seizures, coma
59
What neuro sign is often seen on examination of Syndrome of inappropriate ADH secretion (SiADH)
Impaired deep tendon reflexes --> pseudobulbar palsy
60
What is needed for diagnosis of Syndrome of inappropriate ADH secretion (SiADH)?
Hyponatraemia
Low plasma osmolality
Inappropriately elevated urine osmolality
Urine sodium >40mmol/L with normal salt intake
Euvolaemia
Normal thyroid and adrenal function
61
Management of Syndrome of inappropriate ADH secretion (SiADH)
Fluid restriction
| Sodium replacement
62
What is Tumour Lysis Syndrome?
Severe metabolic disturbance caused by abrupt release of large quantities of cellular components into the blood following rapid lysis of malignant cells
63
What electrolyte abnormalities are seen in Tumour Lysis Syndrome?
Hyperuricaemia
Hyperkalaemia
Hyperphosphataemia
Hypocalcaemia
64
Risk factors for Tumour Lysis Syndrome
Haematological malignancies
Treatment-sensitive tumours
Renal impairment
Volume depletion
65
Presentation of Tumour Lysis Syndrome
Onset 1-5 days post-chemo
Weakness, constipation, vomiting, abdo pain, paralytic ileus, seizures, gout
Cardiac arrhythmias: palpitations, chest pain, collapse
AKI: reduced urine output, lethargy, nausea
66
Prevention of Tumour Lysis Syndrome
Low/intermediate risk- monitoring, hydration, allopurinol
| High risk- Rasburicase (catalyses oxidation of uric acid to allantoin) + hydration
67
Management of Tumour Lysis Syndrome
Prevention
Correct hyperkalaemia- IV calcium gluconate, IV insulin + dextrose, salbutamol nebs
Cardiac monitoring
Dialysis if severe
68
How is performance status measured?
ECOG/WHO
0 = Normal function
1 = Light work, independent ADLs
2 = Limited function, up and about > 50% of waking hours
3 = Limited ADLs, in bed/chair > 50% of waking hours
4 = Bed bound
5 = Dead
69
What are the hallmarks of cancer?
1. Sustained proliferative signalling
2. Evading tumour suppressors
3. Activating invasion and metastasis
4. Resisting cell death
5. Inducing angiogenesis
6. Enabling replicative immortality
70
What are the enabling hallmarks of cancer?
1. Dysregulating cellular energetics
| 2. Avoiding immune destruction
71
What are the enabling characteristics of cancer?
1. Genetic instability and mutation
| 2. Tumour promoting inflammation
72
What is i) neoadjuvant and ii) adjuvant chemotherapy?
NEOADJUVANT: prior to potentially curative treatment
ADJUVANT: following potentially curative treatment, to prevent relapse
73
What is ionising radiation?
Radiation energetic enough to displace an electron from its orbit around a nucleus- this electron goes on to interact with other atoms to create free radicals
Used to damage cancer cells whose repair mechanisms are inadequate, causing cell death
74
What is particle radiation?
Alpha and Beta
75
What is i) direct and ii) indirect radiation?
DIRECT: x-rays directly breaking DNA bonds
INDIRECT: creation of free radicals which break the bonds
76
What is stereotactic radiotherapy?
Highly focused radiotherapy delivering radical doses to small areas with surrounding normal structures
77
Give an example of stereotactic radiotherapy
Gamma knife
78
What is proton therapy?
Better directs the radiotherapy eg to a certain depth
79
Give 2 examples of alkylating agents used for chemotherapy
Cisplatin, Cyclophosphamide
80
Give 2 examples of antimetabolites used for chemotherapy
Fluorouracil, Methotrexate, Hydroxyurea
81
Define pharmacokinetics
What the body does to the drug
82
Define pharmacodynamics
What the drug does to the body
83
What 3 features need to be present for a chemotherapy drug to be effective?
1. Drug must reach cancer cells
2. Cell must be sensitive to the cytotoxic drug
3. Toxic effect must be minimal to the effect of the drug
84
Side effect of Cisplatin
Nephrotoxicity
85
Side effect of Doxorubicin
Cardiomyopathy
86
General side effects of chemotherapy
Heart failure, nausea, taste changes, infertility, hepatic impairment, renal impairment, immune suppression, peripheral neuropathy, alopecia, constipation, rashes
87
Give an example of immunotherapy used to treat cancer
Ipilimumab for metastatic melanoma
| --> activates T cells that recognise and kill cancer
88
What is Cancer of Unknown Primary Origin (CUPO)?
Metastatic malignant disease without an identifiable primary site
89
Investigations of Cancer of Unknown Primary Origin (CUPO)
```
History and examination- breast, nodes, skin, genital, rectal, pelvic
Bloods- FBC, U&E, LFT, calcium, LDH
Urinalysis
Myeloma screen
CTTAP
Tumour markers- Ca125, PSA, AFP, BhCG
Testicular USS
Biopsy + histology/immunohistochemistry
```
90
Presentation of Cancer of Unknown Primary Origin (CUPO)
Malaise, fatigue, weakness, weight loss
91
At what point does the spinal cord become the cauda equina?
T1
92
What are the commonest primary sites of bone mets?
Breast, lung, prostate, myeloma, kidney, thyroid
93
Causes of cauda equina/spinal cord compression
Primary malignancy, bony mets, trauma, disc prolapse, RA, spinal infection, epidural/subdural haematoma
94
How do signs of cauda equina syndrome and those of spinal cord compression differ?
Spinal cord compression - UMN signs
| Cauda equina syndrome - LMN signs
95
Presentation of Spinal cord compression/Cauda equina syndrome
```
Spinal cord compression - UMN signs
Cauda equina syndrome - LMN signs
Back pain/radicular pain
Limb weakness + sensory loss below level
Bladder/Bowel retention (UMN) or incontinence (LMN)
```
96
Symptoms of spinal mets without compression
Spinal pain aggravated by straining, localised spinal tenderness, nocturnal spinal pain
97
Investigation of Spinal cord compression/
| Cauda equina syndrome
MRI whole spine
98
Management of Spinal cord compression/
| Cauda equina syndrome
```
Dexamethasone 8mg BD
Analgesia
Bed rest
Surgical decompression
Radiotherapy/Chemo
```
99
Describe UMN signs
Hypertonia
Weakness
Brisk reflexes
No wasting or fasciculations
100
Describe LMN signs
```
Hypotonia
Weakness
Absent reflexes
Wasting
Fasciculations
```
101
Define neutropenic sepsis
Temperature > 38 or any symptoms or signs of sepsis, in a person with neutrophila < 0.5 x10^9/L
102
Define Sepsis
Life-threatening organ dysfunction due to a dysregulated host response to infection
103
Causes of neutropenic sepsis
Cytotoxic chemotherapy, haematopoeitic stem cell transplant, immunosuppressive drugs, infections, autoimmune disease, bone marrow failure (aplastic anaemia, myelodysplastic syndromes, acute leukaemia), B12/Folate deficiency
104
Investigations in neutropenic sepsis
FBC, U&E, LFT, CRP/ESR, coagulation screen
Blood cultures
Septic screen
105
Management of neutropenic sepsis
If on high risk chemo- prophylactic GCSF
IV antibiotics- Tazocin + Gentamicin
Fluids + O2
106
Causes of Superior vena cava obstruction
- Inside vessel- thrombus, intravascular device
- Inside wall- direct tumour invasion
- Outside vessel- tumour (lung, lymphoma, germ cell, ALL), fibrosing mediastinitis
107
Presentation of superior vena cava obstruction
Facial swelling + redness, periorbital oedema, engorged conjuctivae, arm swelling, breathlessness, cough, distended veins on chest, visual disturbance, headache, syncope, cyanosis
108
Diagnosis of superior vena cava obstruction
Clinical diagnosis
109
Investigations in Superior vena cava obstruction
CXR- widened mediastinum, mass on right side of heart
| CT, Doppler, invasive contrast venography
110
CXR findings in Superior vena cava obstruction
Widened mediastinum, mass on right side of heart
111
Management of Superior vena cava obstruction
Dexamethasone 16mg OD
Elevate head, O2
Endovascular stenting
Radio/chemotherapy
112
Screening programme for prostate cancer
None currently
113
2-week wait criteria for prostate cancer
DRE hard nodular prostate
| PSA above normal age range eg Age 50-69 >3
114
What lymph nodes drain into the bladder?
Obturator, external iliac, internial iliac, common iliac
115
What is the blood supply to the bladder?
Vesical arteries- branch from internal iliac arteries
| Superior vesical artery branches from umbiliac artery from internal iliac
116
Risk factors for bladder cancer
Male, age, smoking, aromatic amines in dyes, pelvic irradiation, cyclophosphamide, Schistosomiasis
SCC- stones/indwelling catheter
117
Types of bladder cancer
90% transitional cell carcinoma in developed countries
| Rest squamous cell carcinoma
118
How does bladder cancer present?
Painless gross or microscopic haematuria
| Voiding symptoms in advanced disease
119
Investigations in bladder cancer
Urinalysis + culture to exclude infection
CT/MRI
Cystoscopy
120
2 week wait criteria for bladder cancer
Age > 45- unexplained visible haematuria without UTI or after UTI has been treated
Age > 60- unexplained non-visible haematuria and either dysuria or raised WCC
121
Management of bladder cancer
TURBT +/- lymph nodes
Intravesical Mitomycin C
Cisplatin combo chemotherapy
External beam radiotherapy
122
Types of lung cancer
95% bronchial carcinomas
- 15% Small cell- rapidly growing, highly malignant, poor prognosis, respond to chemo
- 85% Non-small-cell- squamous, adenocarcinoma, large cell, bronchoalverolar cell
- Secondaries- kidney, prostate, breast, bone, GI tract, cervix, ovary
123
Risk factors for lung cancer
Smoking, COPD, Age, previous Hx cancer, industrial dust diseases, asbestos exposure, EGFR mutation
124
Presentation of lung cancer
Cough, dyspnoea, weight loss, chest pain, haemoptysis, clubbing, wheeze, pneumonia
Hoarseness- recurrent laryngeal nerve involvement
125
CXR findings in lung cancer
Peripheral circular opacity, hilar enlargement, consolidation, pleural effusion, bony mets
126
Investigations in lung cancer
CXR
CT/PET
Bronchoscopy for histology
127
How is lung cancer staged?
NSCLC- TNM
| SCLC- limited stage disease or extensive stage disease
128
Management of lung cancer
Smoking cessation
Surgical resection
Chemo/radiotherapy
129
Complications of lung cancer
Recurrent laryngeal/phrenic nerve palsy
Pancoast's syndrome
Mets
SIADH, Cushing's
130
Types of testicular cancer
95% germ cell tumours- seminoma or non-seminomatous (teratoma)
Other 5% Leydig or Sertoli cell
131
Risk factors for testicular cancer
Cryptorchidism/testicular maldescent, Klinefelter's syndrome, FH, male infertility, low birth weight, infantile hernia, testicular microlithiasis
132
Presentation of testicular cancer
Usually painless lump in body of testes, testicular/abdominal pain, dragging sensation, hydrocele
Gynaecomastia from BhCG production
133
Where do testicular cancers metastasise to?
Seminomas to para-aortic nodes
| Teratomas to liver, lung, bone and brain
134
Investigations of testicular cancer
USS confirms diagnosis
Tissue histology after inguinal orchidectomy
Tumour markers- AFP, BhCG
135
Tumour markers for testicular cancer
AFP
| BhCG
136
What staging system is used for testicular cancer?
Royal Marsden Staging I-IV
137
Management of testicular cancer
Surgery- Inguinal orchidectomy
Chemo/Radiotherapy
Sperm storage
