Oncology Flashcards
Management of malignant hypercalcaemia
IV 0.9% saline (4-6L, 200-300ml/hr)
Single dose IV bisphosphonates (Zoledronic acid and pamidronate)
IM/SC calcitonin (works quickly)
Causes of malignant hypercalcaemia?
Osteolysis (lytic bone metastases)
Humoral (PTHrP in breast cancer or squamous cell lung carcinoma)
Dehydration
Tumour specific mechanisms
Presentation of malignant hypercalcaemia
Bones, stone, groans and psychic moans
GI: abdo pain, constipation, vomiting, weight loss
Renal: stones, polyuria, polydipsia
Neuro: fatigue, weakness, confusion
Psych: depression
Management of malignant spinal cord compression
Corticosteroids
Surgical decompression
Radiotherapy (for pain control or if unsuitable for surgery)
Chemotherapy (if chemosensitive tumours)
Hormone deprivation (for newly diagnosed prostate cancer)
Analgesia
VTE prophylaxis and pressure sore prevention
Presentation of SCC
Worsening back pain Leg weakness Sensory loss below level of lesion Bladder and bowel dysfunction (LATE) Radicular pain
LMN signs at level of lesion, UMN below level
SVC obstruction investigations
Clinical
CXR (widened mediastinum or mass on right side of heart)
CT scan
Presentation of SVCO
Facial, neck, arm and torso oedema Dyspnoea, cough, chest pain at rest Dilated veins in arms and neck and chest wall Syncope Cyanosis Severe respiratory distress Engorged conjunctiva Convulsions
Management of SVCO
High dose steroids Stenting Raise head, give oxygen Chemo Radiotherapy Anticoagulation if central vein thrombosis present
What are the SIRS criteria?
HR >90 RR >20 BP systolic <90 Urine output less than 0.5-1ml/kg/hr Temp >38 or <36 Acute confusion
When would you get a patient with neutropenic sepsis reviewed by a senior clinician
Lactate >2
Evidence of end-organ failure
Haemodynamic instability
Abx treatment of patients with neutropenic sepsis
Piperacillin with tazobactam (Tazocin) +/- gentamycin
Switch to oral if improving after 24-48 hours
Consider 2nd line (e.g. meropenem) if no improvement after 48 hours
Consider other cause e.g. fungal (candida) or virus if no improvement after 5 days
How do you prevent neutropenic sepsis in high risk patients
Fluoroquinolones e.g. ciprofloxacin
G-CSF (granulocyte colony-stimulating factor)
What two criteria are required for diagnosis of neutropenic sepsis
> 38 fever
<0.5-1 x 10^9/L neutrophils
Most common causative organisms for neutropenic sepsis
Staph epidermidis (gram negative, coagulase negative)
Pseudomonas aeruginosa
Most common viral causes of neutropenic sepsis
Herpes zoster Varicella zoster Epstein-Barr HSV Cytomegalovirus
Acquired causes of neutropenia?
Drugs (e.g. carbimazole or chemotherapy) Infection Bone marrow disease Autoimmune disease Nutritional deficiency
Genetic cause of neutropenia
Chediak-Higashi syndrome (autosomal recessive)
Red flags for back pain
Recent infection <20 or >55 onset Thoracic pain Immunocompromise History of malignancy Fevers, chills, unexplained weight loss Night back pain, no better when supine IV drug use
Cauda equina presentation
LMN signs and symptoms Painless urinary retention and overflow incontinence Saddle anaesthesia Radicular and lower back pain Reduced anal tone Impotence Absent ankle jerk Asymmetrical weakness
Most common anatomical region of spinal cord to be affected by malignant spinal cord compression
Thoracic
Gold standard investigation for spinal cord compression
MRI whole spine
Most common malignancies to cause malignant spinal cord compression
Breast Prostate Multiple myeloma lymphoma Lung cancer
What collaterals might circumvent a SVCO
Azygous
Internal mammary
Long thoracic (femoral and vertebral)
Most common cause of SVCO
Non-Hodgkin lymphoma
Non-small cell lung carcinoma
What is Pemberton’s sign?
Raise arms for 1-2 minutes
Increased facial plethora, dilated veins and respiratory distress
Investigation of choice for SVCO
Contrast-enhanced CT scan - modality of choice
X-ray may be initially given (widening mediastinum and pleural effusion)
Superior vena cavogram (gold standard)
Causative organism of fibrosing mediastinitis
Histoplasmosis infection
Can cause SVCO
What is the most common cause of malignant hypercalcaemia?
Tumour release of PTH-related peptide
What mediastinal involvement might you see in lung carcinoma
Pancoast tumour:
Brachial plexus compression –> shoulder or arm pain, weakness and atrophy
Horner’s syndrome
Pleural effusion: dyspnoea and chest pain
Pericardial effusion
SVCO
What are the features of paraneoplastic syndrome?
Small Cell:
Ectopic cushing’s - increase in cortisol release from adrenal glands
SIADH: ADH release leading to water retention
Squamous cell:
PTH-rh leading to hypercalcaemia
Hypertrophic pulmonary osteoarthropathy (HPOA) –> clubbing and periosteal proliferation of tubular bone
Hyperthyroidism
Adenocarcinoma:
HPOA
Gynaecomastia
HPOA
What findings might you see on CXR in a patient with lung cancer?
Hilam enlargement Pleural effusion Lung collapse Rib lesions Pulmonary opacity (tumour)
Lung cancer investigations
CXR
CT
Staging:
Bronchoscopy (primary tumour visualised and sample taken)
CT-guided fine needle biopsy (more reliable)
Needle aspiration
Thomococentesis (fluid from pleural cavity)
PET scan for NSC - determines whether curative treatment
Bloods - thrombocytosis, leukocytosis
Management of lung carcinoma according to staging?
Surgery for I and II
Chemo (increases survival by a year) and radiotherapy for III
Laser therapy and stenting (managing airway obstruction)
When would you refer a patient using suspected cancer pathway>
Over 40 and unexplained haemoptysis
CXR findings suggestive of lung cancer
When would you offer a patient CXR within 2 weeks?
Over 40 and two of the following or smoked before and one of the following:
Cough Fatigue SOB Weight loss Chest pain Appetite loss
CONSIDER if: Lymphadenopathy Clubbing Thrombocytosis Chest signs consistent with lung cancer Recurrent chest infections
Which lung cancers are not related to smoking?
Adenocarcinoma and alveolar cell carcinoma +++sputum
What are the features of the three types of non-small cell carcinoma?
Squamous cell: Central PTH-rP secretion Clubbing HPOA
Adenocarcinoma:
Peripheral
Non-smokers
Large cell:
Peripheral
Anaplastic, poorly differentiated, poor prognosis
Beta hCG production
What features is small cell carcinoma associated with?
ADH –> hyponatraemia
ACTH –> Cushing’s, adrenal hyperplasia and hypokalaemic acidosis
Lambert-Eaton myasthenic syndrome
What might cause a false positive PSA?
Prostatitis
UTI
BPH
Vigorous DRE
What % of free:total PSA suggests cancer?
<20% –> biopsy advised
What nodes are most likely to be affected by prostate cancer spread?
Obturator nodes
Management of localised (T1/T2) prostate cancer?
Watchful waiting: elderly, co-morbidities, low Gleason score
Surgical: prostatectomy and obturator node excision. Risk of ED
Radiotherapy: risk of rectal malignancy and radiation proctatitis. Use of brachytherapy. Potentially curative
Active surveillance: T1c, Gleason 3+3, PSA <0.15, cancer in less than 50% of biopsy cores
Management of localised advanced (T3/T4) prostate cancer?
hormonal therapy
radical prostatectomy: risk of ED
radiotherapy: external beam and brachytherapy. risk of bladder, colon, and rectal cancer
Management of metastatic prostate cancer?
Hormonal therapy:
Synthetic GnRH agonist
e.g. Goserelin (Zoladex)
cover initially with anti-androgen to prevent rise in testosterone
Anti-androgen
cyproterone acetate
Orchidectomy
Preferred treatment for cancer associated thrombosis?
Dalteparin
Management of brain mets
Dexamethason (8g)
PPI to protect stomach
Anti-emetics
What three conditions are associated with bone sclerosis (increased density)
Metastatic prostate and breast carcinoma
Sickle cell disease
Which cancers commonly cause bony tumour deposits
Myeloma Melanoma Thyroid Renal Prostate Lung Breast
