Oncology Flashcards
1
Q
Discuss the presentation, investigations, diagnosis and management of multiple myeloma
A
- neoplastic proliferation of plasma cells which produce monoclonal antibodies
Presentation - CRAB
- Hypercalcemia: n/v, confusion, constipation, polyuria
- Renal failure
- Anemia: weakness, fatigue
- Bone lesions: pain, pathologic fracture
- lytic lesions present in skull, spine, ribs, proximal long bones - bleeding due to thrombocytopenia
- hyperviscosity leading to headache, stroke, angina
Investigation - CBC: normocytic anemia, thrombocytopenia, leukopenia
- Rouleax formation on blood film
- high creatinine
- high beta2-microglobulin
- serum protein electrophoresis: Monoclonal protein
- urine protein electrophoresis: light chains
- Bone marrow aspirate: >10% plasma cells
- Skeletal x-ray: lytic lesions
Diagnosis - all of the following
- serum or urinary monoclonal protein
- clonal plasma cells in bone marrow or plasmacytoma
- end organ damage by >=1 of CRAB
Management - <65 then autologous stem cell transplant
- > 65 chemotherapy with Melphalan, Prednisone, Bortezomib
- bisphosphonate for hypercalcemia and osteopenia
- local radiotherapy for bone pain or spinal cord compression
- EPO
2
Q
List the oncologic emergencies
A
- Hypercalcemia
- Superior vena cava syndrome
- Cerebral metastasis
- Spinal Cord compression
3
Q
Discuss the presentation, investigation and treatment for superior vena cava syndrome
A
- occur with lung cancer and lymphoma
- have obstruction of blood flow through SVC caused by tumour invasion or external compression
Presentations - facial swelling
- head fullness
- dyspnea, cough
- dysphagia
- distended neck and chest wall veins
- arm edema
Investigation - CXR
- CT chest with contrast
Management - treat underlying cause
- relieve SVC obstruction: radiotherapy, urgent stent placement
- supportive therapy
- raise head
4
Q
Discuss the grading for superior vena cava syndrome
A
Grade 0
- asymptomatic
Grade 1
- mild: edema in head and neck, cyanosis
Grade 2
- moderate: edema in head and neck with functional impairement
- dysphagia
- visual disturbance
Grade 3
- severe: mild/mod cerebral edema or laryngeal edema
- decreased cardiac reserve
Grade 4
- life threatening: significant cerebral edema or laryngeal edema
- hemodynamic compromise
5
Q
Discuss the presentation, investigation and management for cerebral metastasis
A
- lung, breast, kidney, colorectal and melanoma most common
Presentation - headache: early morning and worsened with valsava
- n/v
- cognitive dysfunction
- seizure, focal neurological deficit
Investigation - MRI head with contrast
Management - treat underlying malignancy
- treat brain metastasis if favourable prognosis
- symptomatic with dexamethasone 10mg to 4-8mg Q12H
- Seizure treatment and prophylaxis
- epival 15/mg/kg for prophylaxis
6
Q
Discuss the presentation, investigation and management for spinal cord compression from metastasis
A
- invade epidural space and compromise spinal cord Presentation - severe and progressive back pain - pain radiating down limb - progressive motor weakness - ascending numbness, paresthesia - urinary retention, fecal incontinence - gait ataxia Investigation - MRI Management - dexamethesone 10mg followed by 16mg OD - urgent referral to spine surgery or radiation oncologist
7
Q
Discuss the criteria for critically significant weight loss
A
- > 5% of baseline body weight
- 10lbs (4.5kg) in <6 months
8
Q
List the 9 D’s of decreased food intake
A
- Dentition
- Dysgeusia
- Dysphagia
- Diarrhea
- Depression
- Dementia
- Disease
- Dysfunction
- Drugs
9
Q
List the differential for weight loss
A
Weight Loss with Increased Appetite - Endocrine: diabetes, hyperthyroidism - GI: malabsorption - increased physical activity Involuntary Weight Loss with Decreased Appetite - Neoplastic - GI: peptic ulcer, diabetic enteropathy, IBD - Endocrine: hyperhyroidism, diabetes - Infection: HIV, hepatitis, TB - Organ: severe heart, lung or kidney disease - Neurologic: stroke, Parkinson - Inflammatory: RA, sarcoidosis - Psychiatric - Medication: alcohol, opiates, cocaine
10
Q
Discuss the approach to cancer pain management
A
Mild Pain
- non-opioid
- NSAID, acetaminophen
Moderate Pain (4-6/10)
- weak opioid analgesic
- tramadol or low dose opioid
Severe Pain (7-10/10)
- opioid
- morphine, hydromorphone, oxycodone
11
Q
Discuss contraindication to oral opioids
A
- Bowel obstruction
- severe pain requiring urgent intervention
- dysphagia
- intractable n/v
- diminished GI absorption
- terminal
12
Q
Discuss the conversion between opioids
A
10 Morphine: 5 Oxycodone: 2 Hydromorphone
- peak in 1.5hrs PO, SC in 45 minutes
- IV to PO divide PO by 2
- usually start daily dose of Morphine 5mg Q4H straight
- PRN would be 10% of total daily dose
- PRN dose for above would be 3mg PO Q2H PRN
- if pain not well controlled or using PRN >=3x/day then increase straight dose by 25-50% - renal failure use smaller dose due to risk of accumulation and neurotoxicity
13
Q
List the common side effects of opioids
A
- n/v that improve over 3-7d
- constipation
- sedation/somnolence, improve after 3-7d
- opioid neurotoxicity
- confusion - dry mouth
Uncommon - pruritis
- urinary retention, improves
- myoclonus
- respiratory depression
- postural hypotension
14
Q
Discuss strategies to reduce opioid side effects
A
Constipation
- Senna 1 tab PO OD (bowel stimulant) or lactulose 10mL PO OD (osmotic)
- RPN dulcolax suppository as well
- bowel movement every 3 days
Nausea and Vomiting
- metoclopramide 5-10mg Q4H PRN
Sedation
- not to drive
- switch opioid
Urinary Retention
- can wait until it improves
- Foley catheter
Opioid Neurotoxicity
- rule out organic cause to delirium
- hydrate
- treat symptomatically
Respiratory depression
- naloxone
15
Q
Discuss how to switch opioid
A
- start new opioid with 30-50% lower morphine equivalent dose with appropriate breakthrough
