ONCOLOGY Flashcards
1
Q
What are the big and serious side effects of chemotherapy
A
Neutropenic sepsis
2
Q
What is radical treatment
A
Curative treatment (usually)
3
Q
What is neo adjuvant treatment
A
Things you do before giving curative treatment to optimise this working (eg to reduce burden of metastatic disease)
Aim is to improve longer term survival before having curative treatment (eg surgery, radiotherapy etc)
4
Q
What is adjuvant treatment
A
Treatment you give after your curative intent treatment
Intent is to reduce the risk of cancer coming back in the future - eg to kill little cancer cells floating around that you dont see on scans etc - would give chemo for this
5
Q
What are palliative treatments
A
Shrink and control (not get rid of it)
Improve QOL
Improve symptom control
6
Q
What is radiotherapy
A
Use of high energy x rays to destroy cancer cells
7
Q
What is brachytherapy
A
internal radiation therapy - directed at a specific place
8
Q
Difference between chemo and radiotherapy
A
Radiotherapy - local therapy
Chemo - systemic therapy
9
Q
Difference between chemo and radiotherapy
A
Radiotherapy - local therapy
Chemo - systemic therapy (deals with micro-metastatic disease)
10
Q
Time frame for neutropenic sepsis in chemo
A
In a 3 weeks cycle of chemo
7-10 days lowest for neutrophils
11
Q
Risk factors for breast cancer
A
Atypical ductal hyperplasia Lobular carcinoma in situ Age Alcohol - even moderate intake Obesity (post menopaural) HRT (5 years plus) COCP Late first child (>35 years), no breastfeeding Early menarche
12
Q
Red flags for breast cancer
A
Hard painless lump Irregular Tethered Skin tethering - pathognomic Lump and enlarged node - pathognomic Positive family hx, breast, prostate, pancreas (ductal)
13
Q
Breast lump differentials
A
Fibroadenoma - younger pts (puberty - 30), breast tissue proliferation - benign and leave unless very large. Breast mouse - feels smooth and moveable.
Cyst - most similar to cancer as can feel hard if dense and irregular - 35-55
Papilloma
Benign breast changes - cyclical, tender, rubbery, nodules
Mastitis
Sarcoma
14
Q
Nipple discharge differentials
A
Physiological - colour - yellow/ creamy
Hormonal - pregnancy/ hormone profile - milky large volume
Duct ectasia (dilation) - green/ brown, multi duct (can get blood sometimes)
Papilloma - blood, uniduct
DCIS - clear or bloody, uniduct
15
Q
Red flags for nipple discharge
A
Red - blood
Uniduct
If these, probably papiloma or DCIS
16
Q
Breast pain differentials
A
Hormonal (pre meno and post on HRT)
MSK (non cyclical)
17
Q
Outline the management of breast lumps
A
> 40 - mammography then US and biopsy
25-40 - US and biopsy
<25 - free hand biopsy
Positive result - sentinal node biopsy
18
Q
what is the inheritance pattern of lynch syndrome
A
autosomal dominant
19
Q
what is the criteria for 2 week wait referral for ?breast cancer
A
age (>30), unexplained lump in breast
age (>50),
no lump but nipple discharge or retraction
consider urgent referral for unexplained lump in axilla
<30 unexplained lump - non urgent referral
20
Q
what 2 clinical features in over 50s require 2 week wait referral for suspected breast cancer
(regardless of breast lump or pain)
A
nipple discharge
nipple retraction
21
Q
what are the common gene syndromes associated with breast cancer
A
brca 1 and 2 (2 associated with other ductal cancers - prostate and pancreatic)
tp53 - li-fraumeni (brain, gastric)
cowdens - thyroid, endocrine
22
Q
what should you ask about in a ?cancer hx to identify any possible gene penetrance/ syndromes
A
family hx of ANY cancers
any fhx of cancers <50 years
23
Q
what age of women are screened for breast cancer, how, what are pros and cons
A
47-73, every 3 years, mammogram
pros picks up dcis, lcis
cons - lead time bias about whether improvement in survival is real or artifact
24
Q
how are pts with cancer penetrance genes monitored for breast cancer
A
mri from >30 years - more sensitive than mammogram
25
what investigations are done for suspected breast cancer
>40 years - mammogram then uss and biopsy
25 - 40 - uss and biospy
<25 - free hand biopsy
26
What are the main imaging tools for breast cancer
mammography (xr)
ultrasound
mri (if young and dense breasts, or discrepancy between clinical findings and other imaging)
27
what are the indications for mri in breast cancer
dense breasts <30 years and cancer genes in family
discrepancy in other imaging used and clinical findings
if needed to quantify tumour size in breast conserving surgery (i.e. need to know more precise detail of tumour size)
28
which breast cancer has the worst prognosis
her 2 positive
| 50% will get brain mets vs 20% in her 2 negative
29
what are patients with lynch syndrome recommended to take for prevention of colorectal cancer
aspirin
30
what is difference between men and women re follow up anaemia
men should not be anaemic - always needs investigating
| women can be anaemia due to menstruation - once post menopausal would investigate as a man
31
indications for transfusion
depends on symptoms - not based on hb
32
how do you give iron for iron deficiency anaemia
oral
if cant tolerate this iv
give for 3 months to replace iron stores
33
how often would you prescribe iron for iron deficiency anaemia
od - 200mg od
| tds - get less iron absorption because of symptoms
34
causes of thrombocytosis
inflammation, bleeding, cancer
35
what exam do you for constipation
rectal and abdo
| to see where constipated
36
what exam do you need to do for confusion
neurological, gcs
37
what is a blood disorder than increases dvt risk
factor v leiden
38
what is factor v leiden
mutation of one of the clotting factors in the blood. This mutation can increase your chance of developing abnormal blood clots, most commonly in your legs or lungs.
39
first line for pe in cancer patients
dalteparin
40
what should you co prescribe with dexamethasone
ppi, antiemetic
41
what is first line treatment for neutropaenic sepsis
piperacillin/ tazobactam
42
what days are greatest risk for neutropenic sepsis
7-14
43
dexamethasone dose in spinal cord compression
8mg dex bd
44
outline current bowel cancer screening in uk
>55 - one off scope (flexisig) in some areas
60-74 - fit test every 2 years - faecal immunochemical test
looks for small amounts of blood with antibodies for human blood (eg dont get false positive by detection of ingested blood from meat)
45
what is curative treatment
definitive treatment
| usually surgery or radiotherapy
46
what is palliative treatment
treatment aimed at reducing symptom burden
47
what is concurrent treatment
treatment given at same time as definitive treatment
48
how does chemotherapy work
mechanisms that damage rapidly dividing cells and cause them to die.
Works mainly on cancer cells rather than healthy tissue as cancer cells are less developed cells and so have less defences. Health tissue has better mechanisms/ defences to deal with damage from chemo, although damage still happens.
49
How is toxicity graded with chemotherapy, and what levels of serious/ life-threatening
```
1-5 (5 is death)
1 = mild
2 = moderate
3,4 = serious, hospital admission, life threatening, need change in chemo regime
5 = death
Graded based on speed of toxicity
```
50
Management of anaphylaxis
```
Stop drug infusion
High flow oxygen (12-15L, bag valve mask)
IV adrenalin (0.5 ml of 1:1000 IM)
IV fluids
IV antihistamine (eg chlorphenamine)
IV steroid (eg hydrocortisone)
Continuous monitoring
```
51
What dose and route of adrenalin should you give in anaphylaxis
0.5 mls of 1:1000 adrenaline IM
52
What blood test do you need to do before starting gentamicin
UandE - can cause renal failure
53
List some of the common side effects of chemotherapy
```
Anaphylaxis
Neutropenic sepsis / neutropenia
Extravasation
Coronary spasm
Nausea/ vomiting
Constipation/ diarrhoea
Bone marrow suppression
Fatigue
Alopecia
Stomatitis
Skin toxicity (rash, itching etc)
Cognitive impairment
Lung toxicity
Peripheral neuropathy
Late effects
```
54
Difference between chemotherapy and immunotherapy
Chemo - drugs that kill cancer cells by toxic mechanisms
| Immunotherapy - antibodies that help to activate (upregulate) immune system to respond to cancer
55
Commonest side effects of immunotherapy
Autoimmune damage to liver (derranged LFTs), lungs (SOB, cough, chest pain), colon (diarrhoea, constipation), thyroid
56
Currently, what are immunotherapies used for
Palliative treatment only
57
When should you suspect neutropenic sepsis and how would you proceed with assessment / management
Neutrophils <1.0 and any symptoms of infection (does not have to be fever)
Consider it in ANY patient on chemo with temp of >37.5
CLINICAL DIAGNOSIS AND MANAGEMENT
Do not wait to for blood results to confirm
Any infection symptom - treat as per sepsis protocol, stat IV broadspectrum antibiotics
Check hx for blood cultures and any known resistant organisms - may mean you need to speak to microbiology about this
Contact oncall oncologist
58
How is anaphylaxis prevented when starting a new chemotherapy
High dose steroids day before
IV/ PO antihistamines day before
Slow infusion
59
What is extravasation, what are the complications and how is it prevented
When cannula tissues - cytotoxic drug accumulates into tissue and can cause necrosis
Prevent by small cannula and insert away from joints to reduce serious damage if tissues
Management - stop infusion and seek help
Of bad, ?plastics
60
What chemotherapy can cause coronary artery spasm and what is the management
Flurouracil
Capecitabine
Management is nitrates
61
What antiemetics are prescribed for nausea and vomitting
Metoclopramide - D2 antagonist
Ondansetron - 5HT
Aprepitant - only licenced for chemo
Cyclizine - antihistamine
62
What is the management of diarrhoea and constipation in patients on chemotherapy
Loperamide (diarrhoea)
| Laxatives (constipation)
63
What should you always consider when a patient on chemotherapy presents with constipation
Bowel obstruction
64
What are the features of bone marrow suppression in a patient on chemotherapy
Anaemia
Thrombocytopenia
Neutropenia
65
What is dose limiting toxicity determined by with chemotherapy
Bone marrow suppression
| So basically - toxicity level acceptable is when marrow is still functioning
66
What is pancytopenia, what does it represent
Low red cells
Low white cells
Low platelets
Represents aplastic anaemia, which is the term used for bone marrow failure
67
What is the management of aplastic anaemia in chemotherapy patients
Lower threshold for transfusion, want a Hb target of 100-120 - discuss with oncologist
Platelet transfusion when <10
68
What would make you suspicious of bone marrow suppression in a patient undergoing chemotherapy
Signs of anaemia
Pallor
Fatigue
69
When should you suspect neutropenic sepsis and how should it be managed
Suspect and treat based on clinic symptoms and very low threshold
Fever (>37.5) OR any infection symptom - cough, feeling unwell, dysuria, abdo pain, diarrhoea - ANYTHING
CHECK ALLERGIES then:
IV broadspectrum antibiotics - tazobactam / pipercillin
Speak to on call oncologist
Bloods and monitor
Neutrophils <1
Do not treat based on neutrophils
TREAT BASED ON SYMPTOMS
70
Presentation and management of stomatitis
```
Sore, dry, red, inflamed oral mucosa
Ask about oral intake (if preventing this need to consider dehydration)
Supportive:
Oral anti-inflammatory gels/ mouthwash/ toothpaste
Difflam mouthwash (numbs mouth)
Antacid ozetocaine
Aspirin gargle/ mouthwash
Last resort: systemic analgesia
ALCOHOL free oramorph
```
71
What can you give for the management of fatigue in cancer patients
steroids - although only if end of life/ poor prognosis as not good long term
72
What can you give for management of dry skin/ itch in cancer patients
emollients
| antihistamines
73
What should you include in differential of SOB in patients on chemotherapy
Lung toxicity - rare but potentially life threatening remember in differential
Bleomycin
74
What neurological symptoms are common with chemotherapy
Peripheral neuropathy
| Platinum in chemo is cause
75
What are the late effects associated with chemotherapy
```
Infertility
Early menopause
Atherosclerosis
Heart failure / lung damage
Chemo brain
secondary cancers
```
76
What should you always check on examination when suspecting cancer
lymph nodes
77
what is the 2 ww referral guidelines for breast cancer
>30 unexplained breast lump
| >50 nipple retraction, discharge or lump in axilla
78
what is the 2 ww referral guidelines for bowel cancer
>40 unexplained weight loss + abdo pain
>50 unexplained rectal bleeding
>60 iron deficiency anaemia or change in bowel habit
79
what is the 2 ww referral guidelines for lung cancer
>40 unexplained haemoptysis
| CXR changes suggestive of cancer
80
what is the 2 ww referral guidelines for prostate cancer
>50 and PSA >3
| Hard craggy mass on DRE
81
List some red flags for bowel cancer
```
Change in bowel habit
Anaemia
Abdominal mass
Abdominal pain
Blood in stool
Weight loss
Change in appetite
Anal mass/ ulceration
DVT
```
82
What should you include in differential for an unprovoked DVT
Cancer
83
How long should a patient who has had a PE and who has cancer be anticoagulated for (as a minimum)
3-6 months
| usually 6 months
84
List red flags for lung cancer
```
Haemoptysis
Cough, chest pain + smoker
Dysphagia
Hoarse voice
SOB
Head, neck, arm swelling (SVCO obstruction)
```
85
Most common symptoms of lung cancer
Cough
Chest pain
Haemoptysis
86
Site of lung cancer mets
```
lymph glands
bone
brain
liver
adrenal glands
```
87
Symptoms of lung cancer metastatic disease
```
bone pain
headache
seizures
neurological deficit
hepatic pain
abdominal pain
```
88
What are paraneoplastic syndromes
| Which cancers most commonly have paraneoplastic syndromes
Symptoms caused by the effects of a tumour rather than tumour itself (eg secreting high ACTH - Pituitary tumour/ lung tumour, or tumour acts as antigen that causes immune system to produce antibody that cross reacts eg Eaton Lambert syndrome, or tumour secretes protein that interacts with normal physiology eg parathyroid hormone related protein and hypercalcaemia)
Lung, breast, ovarian, pancreas, stomach, kidney, lymphoma, leukaemia
89
Investigations for lung cancer
```
CXR
CT thorax
Bronchoscopy +/- US guided biopsy
Percutaneous (CT guided) needle biopsy
US guided aspirate or biopsy
Surgical biopsy
```
90
List the common paraneoplastic syndromes and their symptoms/ presentations
Eaton Lambert - weakness, fatigue, similar to MG
SIADH - hyponatraemia - headache, lethargy, weakness, confusion
Hypercalcaemia - parathyroid related protein (check PTH (high in primary HPT), phosphate (low in primary HPT), protein (normal to low in cancer), ALP (bone turnover)
Hypertropic osteoarthropathy - joint pain, bone pain
Clubbing
Weight los
91
What questions should you ask about in cancer hx to probe for paraneoplastic syndromes
```
Weakness
Balance/ stumbling
Bone/ joint pain
Thirst / polyuria
Nausea/ sickness / vomitting
```
92
presentation of paraneoplastic ACTH producing lung tumour
Cushing's symptoms
93
what are carcinoid tumours
Tumours of neuroendocrine cells (enterochromaffin in gut that releases serotonin and histamine; and PNEC - pulmonary neuroendocrine cells that release serotonin)
94
how do carcinoid tumours present
Features of high plasma serotonin and bradykinin
Flushing
Low BP
Palpitation
Diarrhoea
Bronchospasm
Can get symptoms of R sided heart disease bc of metastatic spread from gut to liver to heart. Get tricuspid valve regurge, endocardial fibrosis
Can get retroperitoneal fibrosis from retroperitoneal spread - eg hydro nephrosis
Peyronies
95
how would you investigate carcinoid tumours
Plasma chromaffin A - screening test
24 hour urinary excretion of 5HIAA
Bloods for tumour marks including FBC, LFTs, TFTs, parathyroid hormone, calcium, calcitonin, prolactin. alpha-fetoprotein, carcinoembryonic antigen (CEA) and beta-hCG.
96
What radiation is used in radiotherapy and why
Gamma waves
| Higher energy, more ionising, affect nucleus of cell
97
What is the difference between a bone scan and a DEXA scan
DEXA is X rays - looks at density
| Bone scan is nuclear medicine - uses a radioisotope to look as bone activity
98
How does a bone scan work
Uses a radioactive tracer - usually technetium 99 - attaches it to a compound that is metabolically active with bone (medronic acid - is taken up by blasts). The tracer is then taken up more in areas of bone clast activity and turn over, eg mets or fractures and generates 'hot spots'
99
What is the difference between X-rays/CT and nuclear medicine scans
XRays/ CT - anatomical scans
| Nuclear medicine - functional - have a tracer that gives some index of physiology
100
What is the difference between PET and SPECT vs Bone scan (gamma camera)
Bone scan - 2D image
| PET and SPECT - 3D image (combined with CT for anatomy)
