Oncology Flashcards
What are the presenting features of prostatic cancer
Frequently asymptomatic Prostatic symptoms: poor stream, nocturia, dribbling, frequency Metastatic symptoms: bone pain, pathological fracture
Where would a cancerous prostate feel like?
Craggy Hard Enlarged Obliteration of median sulcus
What Duke’s stage CR Ca does this picture illustrate?
Stage A
(Innermost lining of bowel or SLIGHTLY growing in to muscle layer)
What are the features of a colorectal cancer of Duke’s stage A?
Innermost lining of bowel only
OR
SLIGHTLY growing in to muscle layer
What are the features of a Duke’s stage B colorectal cancer?
Cancer has grown through muscle layer of bowel
What Duke’s stage colorectal cancer does this picture illustrate?
Stage B
(Grown through muscle layer of bowel)
What Duke’s stage colorectal cancer does this picture illustrate?
Stage C
(Spread to one or more lymph nodes close to bowel)
What Duke’s stage colorectal cancer does this picture illustrate?
D
(Spread to somewhere else in body - eg. liver or lungs)
What are the features of Duke’s Stage C colorectal cancer?
Cancer has spread to one or more local lymphnodes (close to bowel)
What are the features of Duke’s Stage D colorectal cancer?
Cancer has spread to somewhere else in body (eg. liver or lungs)
Where does Colon cancer metastasise to through invasion?
Urinary bladder
Small bowel
Duodenum
Internal genitals
Abdominal wall
Retroperitoneum
Where are the common sites of metastases when colon cancer spreads haematogenically?
Lung and liver (most common)
Can also (rarely) go to brain, skeleton and kidnets
Once colorectal cancer has invaded lymph nodes, what other common lymphnodes can the cancer spread to?
Aortic lymphnodes
Liver ligament
Mediastinal lymph nodes
Supraclavicular lymph nodes
Inferior mesenteric lymph nodes (rectal)
Pelvic wall lymph nodes (rectal)
Which is more common, colon or rectal cancer?
Colon
What is the most common histology for a colorectal cancer?
adenocarcinoma (90-95%)
How does colorectal cancer spread?
Local invasion
Lymphatic
Venous spread
Coelomic
List the less common types of colorectal cancer
Squamous cell
Carcinoid
GI stromal tumour
Primary malignant lymphoma
List presentation of bowel cancer
Altered bowel habit
Weight loss
Rectal bleeding
Abdo pain
Anaemia symptoms
What investigations would you do to a pt if you suspected colorectal cancer?
RECTAL EXAM
Bloods: FBC (looking for anaemia)
Us and Es (?nutrition)
LFTs (detect abnormal liver function)
CEA (carcinogenic-embryonic antigen)
Sigmoidoscopy ((rigid/flexible) catches about 60% tumours) or Colonoscopy (gold standard)
Biopsy
CT (for staging)
Liver ultrasound/MRI (to detect liver mets)
What is the 5 year survival rate for a Stage A CRCa?
80%
What is the 5 year survival rate for a Stage B CRCa?
50%
What is the 5 year survival rate for a Stage C CRCa?
15-40%
What is the 5 year survival rate for a Stage D CRCa?
6%
What investigations would be useful for looking for mets in CRCa?
LFTs
Liver ultrasound
MRI (more specific for showing liver mets)
What are the risk factors for colorectal cancer?
Diet (high in fat (animal), meat and low in fibre, calcium and folate)
Inflammatory disease (UC and Crohn’s)
FHx of bowel cancer (under 60s)
Hereditary bowel cancers: HNPCC (hereditary non-polyposis colon cancer) and FAP (Familial adenomatous polyposis)
PMHx of small bowel, endometrial, breast and ovarian Ca
obesity, smoking, alcohol
Diabetes
What are the most common presentating features of a R-sided colon cancer?
weight loss
anaemia
occult bleeding
mass in right iliac fossa
disease more likely to be advanced at presentation.
What are the most common presenting features of a L-sided colon cancer?
often colicky pain
rectal bleeding
bowel obstruction
tenesmus
mass in left iliac fossa
early change in bowel habit
less advanced disease at presentation
What are the most common (general) presenting features of colorectal cancer?
rectal bleeding
change in bowel habit
anaemia (more common in R-sided tumour)
weight loss
vague abdo pain
what are the differentials for someone presenting with:
rectal bleeding, altered bowel habit, abdominal pain, weight loss and anaemia (ie. main presenting features of colon cancer)
Divreticular disease
IBS
IBD
Haemorrhoids
Anal cancer
Ischaemic colitis
Pneumatosis coli
How quickly should a patient be seen when an emergency referral is made?
Patient should be seen within 2 weeks (max)
What are the urgent referral criteria for colorectal cancer?
40 or under: rectal bleeding + altered bowel habit (looser, more frequent) for 6/52 or more
60 or under with EITHER: rectal bleeding 6/52 OR altered bowel habit 6/52
Any age pt: palpable rectal mass, R lower abdo mass
Any age man or woman (non-menstruating): unexplained iron-deficiecy anaemia with Hb of 11 and 10 (respectively)
What are the ‘T’ classifications for colorectal cancer in the TNM staging system?
TX: primary cannot be assessed.
T0: no evidence of primary carcinoma in situ (Tis) - intraepithelial or lamina propria only.
T1: invades submucosa.
T2: invades muscularis propria.
T3: invades subserosa or non-peritonealised pericolic tissues.
T4: directly invades other tissues and/or penetrates visceral peritoneum.
What are the ‘N’ classifications for colorectal cancer in the TNM staging system?
NX: regional nodes cannot be assessed.
N0: no regional nodes involved.
N1: 1-3 regional nodes involved.
N2: 4 or more regional nodes involved
What are the ‘M’ classifications for colorectal cancer in the TNM staging system?
MX: distant metastasis cannot be assessed.
M0: no distant metastasis.
M1: distant metastasis present (may be transcoelomic spread)
What are the stages of colorectal cancer (non-Duke’s staging)?
Stage 0: carcinoma in situ (CIS).
Stage 1: T1/T2, N0, M0
Stage 2: further spread, but no lymph node involvement
Stage 2a: T3, N0, M0
Stage 2b: T4, N0, M0
Stage 3: lymph node involvement:
Stage 3a: T1/T2, N1, M0
Stage 3b: T3/T4, N1, M0
Stage 3c: any T, N2, M0
Stage 4: Cancer has spread to other parts of the body. Any T, any N, M1
What are the three levels of colorectal cancer grading?
Grade 1 (low grade): well differentiated.
Grade 2 (moderate grade): moderately differentiated.
Grade 3 (high grade): poorly differentiated
How can response to treatment be measured in patietns with colorectal cancer?
CT
What is the first-line of treatment of localised colorectal cancer?
Surgery to resect localised disease
(usually cures)
What is the most recommended treatment for colorectal primary with liver met(s)?
Surgery to remove affected colon and liver mets
How might radiotherapy be used in colorectal cancer?
Rectal carcinoma
Pre-operative or adjuvant therapy in high-risk rectal carcinomas
Why isn’t radiotherapy recommended in colon cancers?
risks toxicity to adjacent organs
What are the palliative therapeutical options to consider for patients with late-stage colorectal cancer?
Surgery or stenting (manage/prevent obstruction by lesion)
When might chemotherapy be used in patients with colorectal cancer?
adjuvant therapy for high-risk (stage D) patients
What chemotherapy agents are recommended in colorectal cancer?
5-FU
Oxiplatin
Irinotecan
What colorectal screening schemes are available in UK?
Faecal occult blood testng in general population
What treatments can be considered for patients with colorectal cancer?
Surgery (resect primary and met(s))
Radiotherapy (pre-operative and adjuvant) for rectal cancers (before/after total resection)
Chemotherapy: adjuvant for high-risk (stage D) cancers
5-FU
Oxiplatin
Irinotecan
Palliative: stenting/surgery to prevent/remove blockage
What are the risk factors for breast cancer?
Increasing age
Increased periods of oestrogen exposure (nuliparity, late/early menarche, late menopause, obesity)
Ionising radiation
Family history (1st degree relatives)
BRCA mutations
What are the risks associated with BRCA mutations?
Increased susceptibility to breast and ovary cancer
Early onset Ca (breast only) - INCLUDES MALE BREAST Ca
Which type of breast cancer is more common (ductal or lobar)?
Ductal (70/80% (lobar: 10%))
How might breast cancer present?
lump (painless = more likely to be cancer)
Nipple discharge and inversion
Lymphadenopathy
Skin changes
Erythema
Symptoms of met disease: bone pain and lung/liver/brain symptoms
(men may not have nipple and skin changes)
What are the differentials when a patient presents with potential breast Ca symptoms?
Ductal papilloma
Fibrocystic disease
Cyst/abscess
Mastitis
DCIS
How would you start investigating for breast cancer?
TRIPPLE ASSESSMENT:
Physical examination
Imaging: bilateral mammography (35 ultrasound (35>)
Fine needle aspiration or biopsy
After tripple assessment, what other investigations might you do for breast cancer?
Liver ultrasound or CT
Isotopic bone scan (bisphosphonates)
In pts with suspected mets
What are the ‘T’ classifications for breast cancer in the TNM staging system?
T0: no primary tumour
Tis: in situ (non-invasive)
T1: invasive tumour (<2 cm)
T2: 2-5cm
T3: >5cm
T4: skin involvement
What are the ‘N’ classifications for breast cancer in the TNM staging system?
N0: no lymph nodes
N1: mobile axiallry nodes
N2: fixed axillary nodes
N3: internal mammary nodes
What are the ‘M’ classifications for breast cancer in the TNM staging system?
M0: no mets
M1: mets
What are the different stages of breast cancer?
Stage 0: Tis, N0, M0
Stage 1: T1, N0, M0
Stage 2: T2/3, N0, M0 OR T0/1/2, N1, M0
Stage 3: T or N >2, M0
Stage 4: T and N any, M1
What are the recommended treatments for breast cancer?
Surgery: mastectomy or wide local excision (survival equivalent in correctly selected pts)
Remove all lymp glands if invaded or high risk of recurrence (these pts do not have radiotherapy)
Radiotherapy (depends on location and size)
Systemic therapy in specific circumstances
What systemic treatments are available for breast cancer?
Endocrine treatments: Herceptin (trastuzumab)
Tamoxifen
Anastrazole
Ovarian ablation
Cytotoxic therapy: Chemotherapy
When can herceptin be used?
Breast cancer: metastatic and lcal disease
WHERE CANCER EXPRESSES HER-2
When can tamoxifen be used?
Breast cancer - adjuvant treatment
tumours that are oestrogen receptive (ER +ve)
Pts who are pre-menopause
must be taken for 2-5 years
What are the benefits of tamoxifen?
Reduced risk of death and recurrent
Also decreased incidence in contralateral women (irrespective of ER status)
When can anastrazole be used?
Breast cancer
ER +ve tumours
Post-menopausal pts.
What are good predictors of response to endocrine treatments in breast cancer?
Pt has local disease
Response to previous endocrine treatment
Greater duration of previous disease-free interval
What proportion of patients with metastatic breast cancer respond to endocrine therapies?
1/3
How can ovarian ablation take place?
surgical
radiotherapy
LHRH (leutenizing hormone release hormone)
When would chemotherapy be considered in breast cancer?
Adjuvant therapy: high stage/spread (reduces risk of recurrence)
More effective in women 50<
Benefit is percentage of risk (benefit is lower in better prognosis, higher in poorer)
Higher dose = more effective (combination therapy > single-agent therapy)
Palliative: improve QoL
What is the 5-year survival for a patient with stage 1 Breast Ca?
84%
What is the 5-year survival for a patient with stage 2 Breast Ca?
71%
What is the 5-year survival for a patient with stage 3 Breast Ca?
48%
What is the 5-year survival for a patient with stage 4 Breast Ca?
18%
What age women does the breast cancer screening scheme include?
47-73
What are tumour markers and why are they useful in oncology?
Substances produced BY or IN RESPONSE TO tumour
Present in blood or other tissues
can be quantified
What are the two desired qualities of a tumour marker?
Highly specific: few people FALSELY LABELLED
Highly sensitive: few people MISSED
What are the uses of tumour markers?
diagnosis
detect relapse/trend of disease
response to treatment
indication of prognosis
screening (not routinely used)
How can tumour markers be used for diagnosis? And what is the problem?
High levels can be indicative of disease. If you increase the threshold needed to confirm the presence of a disease, the test becomes more sensitive.
If the marker is not specific, then it could be raised due to another condition, therefore isn’t conclusive.
How can tumour markers be used to indicate relapse of cancer?
If pt. had high levels when ill, and they decrease through treatment, a subsequent increase could be indicative of relapse (or tumour activity)
How can tumour markers be used to measure response to treatment?
levels may reduce with treatment
How can tumour markers be indicative of prognosis?
Rising values could indicate decline of patient’s state. High levels could suggest a worse prognosis (depends on specificity of test)
What are the different types of tumour markers?
hormones: thyroglobulin, ADH, adrenocorticotrophic hormone
immunoglobulins
intermediate metabolites
cell surface proteins: CEA, CA125, CA19.9
enzymes: APT, ALT, LDH
oncofetal proteins: HCG, alpha-feta protein
Nucleic acid
What can cause raised CEA (carcino-embryonic antigen)?
colorectal ca
gastric ca
breast ca
lung ca
smoking
Gastro problems: IBD, hepatits, pancreatitis and gastritis
What cancer is CEA most commonly used to investigate?
colorectal carcinoma
A 67-year-old man with metastatic colon cancer and multiple liver mets complains of vomiting. He is eating and drinking normally but vomits once or twice a day often undigested food, but has little nausea.
What is the most likely cause for these symptoms?
What is the most suitable first-line anti-emetic?
Gastric stasis
Metaclopramide
A 54-year-old woman with metastatic breast cancer complan of vomiting, usually in a morning. She also complains of increasing frontal headaches.
What is the likely cause of these symptoms?
What is the most suitable first-line anti-emetic?
Cyclizine (for vomiting and ICP)
(+ dexamethasone (to reduce ICP))
A 29-year-old man with a testicular tumour is having chemotherapy after an orchidectomy. He complains of severe nausea and vomiting when he enters the oncology day unit?
What is the likely cause of these symptoms?
What is the most suitable first-line anti-emetic?
Anticipatory
Lorazepam
A 47-year-old woman with advanced cervical cnacner complains of drowsiness persistent nausea, intermittent small vomits and reduced urine production?
What is the likely cause of these symptoms?
What is the most suitable first-line anti-emetic?
Renal failure (Could also suspect hypercalcaemia, but usually get polyuria and polydipsia before these symptoms in hypercalcaemia)
Haliperidol
A 71-year-old man with prostate cancer is started on zomorph 20mg twice daily for pain control. Two days later he complains of nausea and reduced appetite. His bowels are open daliy and he has no new urinary symptoms.
What is the likely cause of these symptoms?
What is the most suitable first-line anti-emetic?
Opiods
Haliperidol (drug-related vomiting counts as toxic vomiting)
A 65-year old man with lung cancer compains of difficulty passing hard stool.
What drug is most likley to have caused his constipation?
a) fybogel
b) gabapentin
c) metaclopramide
d) ondansatron
e) paracetamol
Ondansatron
VERY CONSTIPATING
A 71-year old woman with advanced breast cancer is having difficulty passing hard stool and is prescribed lactulose.
What best describes the mechanism of action of lactulose?
a) bulk forming agent
b) contrast irritant
c) softner and stimulant
d) stimulant
e) stool softener
Stool softener
A 47-year-old man with recurrent renal cancer and bone mets, complains of increasing back pain, difficulty poassing urine and constipation.
What is the most likely cause of his symptoms?
a) hypocalcaemia
b) NSAIDS
c) poor fluid intake
d) spinal cord compression
e) urinary retention
Spinal cord compression
A 69-year old woman with advanced ovarian cancer complains of reduced appetite and constipation and is commenced on codanthramer.
What is the most appropriate advice about this medication to give to the patient?
a) codanthramer is carcinogenic if taken long term
b) codanthramer should be administered orally
c) codanthramer may cause an orange discolouration of the urine
d) codanthramer may cause a severe peri-anal rash
e) codanthramer can cause excessive flatulence
c) Orange urine
(only causes peri-anal rash if incontinent)
What are the most common causes of pleural effusion:
chest infection
cancer
What is the most common cause of a bilateral pleural effusion?
Heart failure
When might a PSA level be raised?
when is PSA used?
Investigate prostate Ca (indicate whether a biopsy is needed)
To monitor response to hormonal/cytotoxic treatment or surgery
Detect relapse/more active cancer (eg. trend of rising PSA)
What are immunoglobulins used to detect in oncology?
myeloma
Waldenstrom’s macroglobinaemia (a type of non-hodgkins lymphoma)
Non-hodgkins lymphoma
What is the difficulty in using CA125 to detect for ovarian cancer?
Can also be raised in: normal women (1%) benign conditions (6%) Ovarian cancer (82%)
Doesn’t detect all cancers (remaining 18%)
At what level is CA125 only indicative of malignant disease?
Greater than 200U/mL
What cancer is CA125 most commonly used to detect for?
Ovarian
What cancers can cause raised level of CA125?
OVARIAN
Pancreatic*
Lung*
Colorectal*
Breast*
*Especially when these have spread into abdominal cavity
Where can immunoglobulins be detected?
blood or urine
What causes mildly raised levels of alpha-fetoprotein?
Hepatitis
What causes high levels of alpha-fetoprotein?
Hepatocellular carcinoma
Teratoma
What do higher levels of alpha-fetoprotein indicate about prognosis?
Poor prognosis
When does alpha-fetoprotein stop being detectable in normal adults?
after the age of 1
What can human chorionic gonadotrophin levels be used to detect?
hydatiform mole and choriocarcinoma
Non-seminomatous testicular cancers (some seminomatous)
Pregnancy
What are the usual sites for a syringe driver?
chest
abdomen
upper arm
thigh
What features indicate that it is not approprite to administer SC medication at this site (when using a syringe driver)?
oedematous areas
broken skin
What can be done to try and prevent problems with syringe driver sites?
Check for redness, soreness, induration, precipitation
Move sites every day/every few days
Provide a very small dose of dexamethasone (to prevent any problems occuring with the site)
How long does a syringe driver take to establish a stable dose in the patient? What can be done to provide pain relief during this time?
3-4 hours
Can give a stat SC injection of appropriate medicines (eg. pain killers, anti-emetics etc.)
Which drugs are too irritant to use in the syringe driver?
diazepam
chlorpromazine
prochlorperozine
What should you use to dilute drugs in syringe driver?
Water
(saline can be used if there is a problem with site irritation)
When can you dilute drugs with saline when using a syringe driver?
when there are problems with site irritation
what drug should not be diluted by saline? why?
cyclizine
the combination can cause precipitation
How do you work out the rate per hour of drug when setting up a syringe driver?
Calculate the total dose needed in 24 hours.
Divide it by 24.
What is the dose of hyosine butylbromide (buscopan) given in a syringe driver?
60-120mg
What is the dose of cyclizine given in a syringe driver?
100-150mg over 24 hours
What is the dose of halloperidol given in a syringe driver?
3-10 mg (for vomiting)
10-30mg (for terminal agitation/confusion)
*Risk of dyskinesia at doses higher than 10mg
What is the dose of metaclopramide given in a syringe driver?
30-60mg over 24 hours
What is the dose of levomepromazine given in a syringe driver?
6.25mg-100mg over 24 hours
What is the dose of hyoscine hydrobromide given in a syringe driver?
400 micrograms - 2.4mg
What is the dose of midazolam given in a syringe driver?
10-60mg
What are the two different types of morphine?
Immedite release (oromorph liquid)
Modified release (zomorph, MST - two different preparations)
What are the key features of immediate-release morphine?
Takes 30 mins to work
Lasts for 4 hours
What are the features of modified release morphine?
BD (released over 12 hours)
Continuous dose
How do you determine the dose of oromorph to prescribe for someone on morphine?
oromorph dose = 1/6th of background dose of morphine (either zomorph or MST)
How regularly can oromorph be used (if calculated as 1/6 of background morphine dose)?
PRN - hourly if needed
Max of 6 doses in 24 hours
NOTE THIS ON THE DRUG CHART
What are the main side-effects of morphine?
Drowsiness
Constipation
Nausea and vomiting
(Respiratory depression: Not a problem if doses are correct)
How long would you expect a patient to experience drowsiness for when prescribed morphine?
If it persists longer than this, what could cause this?
48-72 hours
dose
renal function
A patient on morphine experiences constipation, what do you do?
prescribe laxative
A patient on morphine experiences nausea and vomiting, what would you do?
anti-emetic (or reduce dose)
A patient on morphine experiences respiratory depression, what do you do?
Prescribe naloxone
How do you convert oromorph in to MST/zomoprh?
Work out daily total dose of what is being given, divide it by two (as it will be given BD) and then add this to MST dose.
Is there a maximum dose of morphine that can be described?
NO MAXIMUM DOSE
Titrate up in 30% dose
Depends on: side effect
Pain relief level
Mr Williams is a 67 year old man with lung cancer. He is in pain. His medical notes show that he was diagnosed with an inoperable sqamous cell carcinoma of the R lung 2 months ago and received two fractions of palliative radiotherapy. He was admitted 3 days ago with increasing shortness of breath. He was found to have a pleural effusion. The respiratory team are due to drain this tomorrow.
You find his drug chart and see he is on regular paracetamol (1gm qds), salbutamol nebuliser (2.5mg qds) and furosemide (40mg od)
What are the differentials?
PE
MI
Angina
Pneumonia
Pleural invasion
Pneumothorax
Rib fracture
GORD
MSK
Neuropathic pain
What is the definition of neuropathic pain?
Pain in an area of sensory information
How do you convert the dose of codeine into doses of oromorph?
Work out how much codein is being given:
eg. 30mg BD = 60mg over 24hrs
Divide this by 10 (as oromorph is 10x stronger than codeine)
60/10= 6mg.
6mg of oromorph can be given PRN. MAXIMUM OF 4 TIMES. MAX DOSE 24mg - WRITE THIS ON THE DRUG CHART.
What are the three main causes of pain?
Disease itself
Treatment
Concurrent disease (resulting from first disease)
How do you treat pain related to an infection?
Treat underlying infection
Treat pain (depending on what patient is already on and where they are on pain ladder)
What are the features of neuropathic pain?
Pain in an area of abnormal sensation
Localised (eg. dermatome) or widespread
Numbness or hyperaesthesia
Autonomic changes: pallor, sweating
Pins and needles or burning
How do you treat neuropathic pain?
TCA: amitriptyline
Anti-convulsants: gabba-pentin (cheaper)
Pre-gabbalin
(compression of nerve may be helped by corticosteroids)
What can help with pain associated with compression of a nerve?
corticosteroids
How should you manage the pain caused by a headache related to raised ICP?
Corticosteroids (dexamethasone - to reduce oedema)
NSAIDS
Paracetamol
What are the features related to a headache caused by raised ICP?
Dull, oppressive pain
Usually worse on coughing, waking and sneezing
Nausea and vomiting
What are the features of visceral pain?
Dull, deap seated pain
Poorly localised
May be tenderness over organ
Spasmodic - bladder spasm, bowel colic.
How would you manage visceral pain?
Suspected dull visceral pain: analgesia ladder
Pain due to visceral stretch (eg. liver capsule pain): NSAIDS and corticosteroids (reduce inflammation)
Colic/spasmodic pain: anticholinergic drugs
What are the main features of bone pain?
Dull ache over a large area
OR
Localised tenderness over bone
How would you manage bone pain?
What is stage one of the analgesia ladder?
Paracetamol
What is stage two of the analgesic ladder?
WEAK opioids - eg. co-codamole (Paracetamol and codeine)
What dose of co-codamol would you start someone on if moving from step 1 to step 2 of the analgesic ladder?
30/500 (UNLESS ELDERLY: reduce the dose)
What is step three of the analgesic ladder?
Strong opioids: morphine
diamorphine
buprenorphine
oxycodon
phentanil
methadone
Can paracetamol be continued in to step 3 of the analgesic ladder?
yes
What are the adjuncts of the analgesic ladder?
NSAIDS: can be used at any stage
Anti-epileptics: Gabapentin, pre-gabalin
Anti-depressants: amitriptyline
Corticosteroids: prednisilone, dexamethasone
TENS machine
What medication should you give to patients who are on terminal care?
ONLY THINGS THAT MANAGE Sx
What are 4 things you can/should prescribe for terminal care patients?
Analgesia
Anti-emetics
Antisecretories
Anxiolytics
(all SC)
What should be done about food and fluids during terminal care?
Support oral intake for as long as possible
?do not commence articficial food/hydration
What are the problems with artificial hydration in terminal care?
Causes pulmonary and peripheral oedema
What are the benefits of withdrawing artificial fluid/food?
reduced vomiting and incontinence
reduced barriers between patient and carer
prevents need for venepuncture
What are nursing care needs likley to be in terminal care patients?
Mouth care for dry mouth
Special bed
Catheter/incontinence pads
Bowel care (if pt. uncomfortable)
Fast track/continuing care (to get pt. in correct place to die)
Things to discuss with family when patient is on terminal care:
Check understanding of situation (incl. decision not to artificially feed etc.)
Negotiate treatment
Explore fears and concerns
Check re. any unfinished business and whether they may benefit from help
Identify those at risk of bereavement
Involved faith leader (if pt. wishes)
DNACPR!!!
Give some examples of distressing terminal events:
haemorrhage
fits
tracheal obstruction
(these are rare, need to anticipate them and agree a management plan)
How might you recognise someone who is coming towards the end of their life?
Rapid deterioration of condition
Weakness
Confined to bed most of time
Extended periods of drowsiness
Disorientated
Severely limited attention span
Losing interest in food and drink
Too weak to swallow meds
What is a death rattle? How would you treat it?
Noise made by secretion in URT (pt too weak to expectorate)
Re-position pt to be more upright. Prescribe hyoscine (buscopan)
How would you manage terminal restlessness?
Elliminate reveersible causes: pain, urinary retention, respiratory secretions, faecal impaction
Sedation: midazolam (SC/IV)
What needs to be considered after death?
Pt. religion - do they have any special requirements
Prompt provision of death certificate (family cannot do anything until they have this)
Inform GP within 24 hours
Warn relatives re. involvement with the coroner
Provide family with info on: role of a funeral director, how to register death, sommon feelings of grief and support available
Which tumours are most likely to cause major haemorrhage in terminal care?
Head and neck
Tumours that may erode major vessels
How would you manage a patient who suffeers a major haemorrhage in palliative care?
Green towels close by: absorb blood and reduce visual impact of blood
IM/SC midazolam: sedative and amnesic effect
MEMBER OF STAFF TO STAY WITH PATIENT
What cancers are most associated with SCC?
Prostate
Breast
Lung
Myeloma and lymphoma
(less common: renal and thyroid)
Where in the spine are the majority of SCCs?
2/3 thoracic
1/3 cervical or lumbar
How might SCC present?
Back/nerve root pain. Worse when: lying flat, movement, cough (may be first sign OR absent)
Leg/motor weakness (can be subtle, rapid or slow onset)
Difficulty controlling bladder/bowels
Urinary retention
Saddle anaesthesia
Loss of anal tone
Paraparesis and paraplegia
Hyper-reflexia (below level of lesion)
Clonus
AUTONOMIC DYSREFLEXIA (injuries T6 and above)
How would you manage pt with suspected SCC?
- Lie flat
- Prescribe 16mg dexamethasone (with PPI cover)
- URGENT MRI SPINE - WITHINT 24 HOURS
What treatment is available for SCC?
Steroids (dexamethasone 16mg)
Neurosurgical intervention +/- radiotherapy
Radiotherapy
Chemotherapy
Why is it important to catch SCC early?
If motor function lost for 48 hours, unlikley to regain.
Noticing it early = prevent or partiall reverse problems
What are the two most common causes of hypercalcaemia?
Hyperparathyroidism
Cancer
Which cancers are most associated with hypercalcaemia?
Non-small cell lung (squamous cell)
Breast
Myeloma/lymphoma
Renal cell
Head and neck
*can occur without bone mets*
How can cancer cause hypercalcaemia?
Can cause imbalance between bone reabsoprtion and calcium:
Factors produced by tumours eg.
Transforming growth factos alpha
Parathyroid hormone related peptides
Increase bone reabsorption, Increase renal tubule calcium reabsorption
How can hypercalcaemia present?
General: dehydration, weakness and fatigue
CNS: confusion, drowsiness, seizures, coma (LATE FEATURES)
Proximal neuropahty and hyporeflexia
GI: weight loss, nausea and vomiting, abdo pain, constipation, ileus, dyspepsia, pancreatitis
Urinary: polyuria
Cardio: brady, ECG changes, BBB, arrhythmia arrest
What ECG changes might you expect to see in pt with hypercalcaemia?
Reduced QT interval
Wide T wave
Increased PR interval
BBB
Arrhythmia
What are the late feartues of hypercalcaemia?
confusion
drowsiness
seizures
coma
How would you investigate a patient with suspected hypercalcaemia?
SERUM CALCIUM
FBC (check for infection markers to elliminate infection)
Hep/Renal function tests: LFTs, U&Es, Serum creatinine
Urinalysis
Abdo exam
ECG
Blood glucose (elliminate DKA)
ABG: late stages, sepsis screen
How would you manage a patient with Hypercalcaemia?
- PAIN RELIEF (if necessary)
- FORCEFUL DIURESIS TO PROMOTE CALCIUM EXCRETION
Normal saline:
1L over 4hrs for 24hours
1L over 6 hours for next 48-72 hours (with adequate K)
3. INHIBIT BONE REABSORPTION IV Bisphosphonates (pamidronate or zaledronic acid)
- RAPID ACTING REDUCTION OF SERUM CALCIUM
Calcitonin and corticosteroids
Salmon calcitonin (SC/IM) and oral presnisilone
How might a patient with neutropenic sepsis present?
Sepsis symptoms: pyrexia/sub-optimal temperature
Flu-like symptoms
Rigor
Malaise
Specific infection (eg. UTI)
Diarrhoea
Vomiting/nausea
Confusion/altered mental state
What examinations might you perform on someone with suspected neutropenic sepsis?
Temp (<38 or 38.5=< for more than one hour)
ABC
MEWS
Look for potential site of infection:
lungs, wounds, cannulation/central line sites, bowel/perianal, UTI
DO NOT DO VAGINAL OR RECTAL EXAM: RISK OF CAUSING BACTERAEMIA
What elements of a pts history might point you in the direction of neutropenic sepsis?
Recent chemotherapy
Previous episodes of neutropenic sepsis
Localising symptoms of infection
(also need to find out about allergies for sake of ABX prescribing)
What score might you think about using to calculate a pts risk of complications during a febrile neutropenic episode?
MASCC score
What kinds of criteria does the MASCC score include?
Burden of illness (extent of symptoms)
BP
COPD
Tumour type (solid/not solid)
Previous infection
Presence of haematolgic malignancy
Dehydration
Age (60
What investigations might you do on someone with suspected neutropenic sepsis?
FBC (paying particular attention to ANC)
CRP
Lactate
LFTs, U&Es, Serum creatinine
Blood culture (x2: aerobes and anaerobes) from lines or peripheral
Swabs
Sputum culture
Urinalysis and culture
Stool analysis and culture (if diarrhoea)
CXR (if resp Sx, lung ca or mets)
Only if indicated: atypical pneumonia serology
urine for legionella
(ANC <= 1 x 109/L)
How would you manage a patient with neutropenic sepsis?
Antibiotics: ASAP.
Straight AFTER blood cultures
5 day course
Add in secondary ABX if no response to first-line within 48 hours.
After 5 days, continue on ABX if ANC <= 1 x 109/L AND:
Fever
Hypotensive
Tachycardic
Symptoms of systemic infection
EVEN IF PT IS AFEBRILE
Call Senior: oncologist, microbiologist
What is an alternative treatment for neutropenic sepsis? When would this be considered appropriate to use?
G-CSF (filgastrim and lenogastrim) = colony stimulating factors
Haemopeoitic growth factors that promote stem cell proliferation and reduce duration of neutropenia
Not routinely prescribed unless ANC neutropenic for 10< or risk of multi-organ failure
What organisms most commonly cause neutropenic sepsis?
Gram +ve: Staph. A
Coagulase -ve staph
alpha and beta haemolytic strep
Gram -ve: E coli
Klebsiella
Pseudomonas
Fungi: candida and aspergillus
If a patient has neutropenic sepsis, what might this mean for their chemotherapy? Are there any exceptions?
May need to reduce dose being given (especially in palliative patients)
Exception: Hodgkins and testicular cancer - try to maintain dose (as good cure rates with high dose, therefore ?greater benefit than risk)
What malignancies most commonly cause SVCO?
Lung
Lymphoma
Mediatinal tumours: lymphadenopathy and germ cell tumours
Thymoma
Oesophageal
THROMBUS (tumour-associated)
What are some benign causes of SVCO?
Non-malignant tumours: goiter
Mediastonal fibrosis
Infection (TB)
Aortic aneurysm
Thrombus from catheter
How might SVCO present?
Dyspnoea (worse on lying flat)
Headache (worse on coughing)
Facial/neck/arm swelling
Distended chest/neck veins
Cough
Hoarse voice
Cyanosis (head, neck. worse when raise arms of lying flat)
Visual disturbance
What investigations would you do for a pt if you suspected SVCO?
CXR
Contrast CT thorax
If not diagnosed with cancer: Tumour markers
Bronchoscopy
Mediastinoscopy
Biopsy
How would you manage someone with SVCO?
- 16mg dexamethasone (plus PPI)
- Depends on cause: Vascular stenting of SVCO
Chemotherapy
Radiotherapy
LMWH (if thrombus)
How does chemotherapy work?
Tries to: erradicate occult cancer cells
treat the natural progression of cancer
Chemotherapy agents are preferentially toxic to more actively proliferating cells ie. cancer cells
Tumours with more rapid proliferation = more effected
What are the different uses for chemotherapy?
Adjuvant
Primary
Neo-adjuvant
Currative
Palliative
Prophylactic
What is neo-adjuvant chemotherapy and when is it used?
Pre-operative treatment
Used in operable tumours to cure:
Make tumour smaller (allow less radical surgery)
treats occult mets
eg. osteosarcoma
What is primary chemotherapy and when is it used?
Initial treatment for tumour that is inoperable (or operability is uncertain)
Aim: make curative surgery feasible and reduce tumour bulk
Increases cure rates
What is adjuvant chemotherapy and when is it used?
After surgery
Aim: treats occult mets
Increase cure rates
eg. breast and colorectal ca
What is palliative chemotherapy and when is it used?
In pts where cure isn’t possible:
Alleviate symptoms
Prolong life
S/E should not be > negative impact on QoL
What is prophlyactic chemotherapy and when is it used?
Hormonal treatment before overt malignancy appears
eg. tamoxifen (in in-situ breast cancer before invasice carcinoma occurs)
What is curative chemotherapy and when is it used?
Sometimes this works even in presence of mets (eg. germ cell tumours, hodgkins, non-hodgkins, childhood cancers)
Justifies use of more aggressive treatment
Give some examples of oral chemotherapy
Tamoxifen
Capecitabine
Etoposide
Cyclosphamide
What are the benefits of oral chemotherapy?
Less invasive
Less hospital visits
What are the issues with oral chemotherapy?
variation of drug levels in blood
still needs regular check ups at hospital
What are the three types of systemic administration of chemotherapy?
bolus injection
infusion (short)
continuous infusion
What is the most common route of administration for chemotherapy?
Systemic
When might intravesical chemotherapy be used? What is the benefit of this?
superficial bladder cancer
Higher dose at site of tumour, negligable systemic absorption (limit toxicity)
When might intraperitoneal chemotherapy be used?
For cancers that spread trans-coelomically eg. ovarian cancer
When might intra-arterial chemotherapy be used? What is the benefit of this?
Tumours that have good blood supply eg. hepatic artery infusion (for liver mets)
Higher does at site: reduced toxity
Why is chemotherapy given cyclically?
Allows normal cells to recover from treatment
Need repeated cycles to get tumour clearance (but no point giving excessive number of cycles (increased toxicity))
How long does chemotherapy take to reach maximum effect?
after 6-months
How is the dose of chemotherapy calculated?
Surface area
(except carboplatin: this is done using renal function)
Why is chemotherapy administered in combinations?
Different classes of chemo have different actions, therefore maximise cell kill.
Less chance of drug-resistance: either in initial malignancy or developing mets
Different drugs cause different toxicity, therefore allows high dose of treatment, without high s/e
When might single agent chemo be appropriate?
Case-specific
Palliaive care
What are the short term side-effects of chemotherapy?
Cardio: arrhythmias, coronary artery spasm (ischaemia)
Alopecia
Peripheral neuropathy
GI: oral mucositosis, diarrhoea, constipation, paralytic ileus (rare)
Myelosupression
Nausea and vomiting
Genitourinary: haemorrhage cystitis, nephrotoxicity
Skin and soft tissue: extrasation, palmer plantar erythema, photosensitivity, pigmentation
Myalgia and arthralgia
Allergic reaction
Lethargy
How can alopecia be prevented in pts undergoing chemotherapy?
Cold cap - reduces blood flow to scalp, therefore reducing effect drugs can have
Which chemotherapy agents are most likely to cause peripheral neuropathies?
Platinum-containing drugs
esp. cisplatin
taxanes
vinka alkaloids
Which nerves are usually effected in chemoherapy-induced peripheral neuropathy?
Mostly sensory nerves
(autonomic and CNS can also be effected)
Usually recover, but can have a small remaining deficit
Ototoxicity: permanent damage to cochlea
What GI side effects can occur with chemotherapy?
oral mucositosis
diarrhoea (due to collitis and small bowel inflammation)
constipation (due to dehydration, nausea and analgesics)
Rarely:
paralytic ileus (due to autonomic neuropathy - RARE. Most commonly associated with platinums and vinka-alkaloids)
How common are GI side effects in chemotherapy?
common
When does myelosupression usually occur after chemotherapy?
How long does this last for?
10-14 days after the start of each cycle
Recover: 3-4 weeks (therefore allowing a further cycle)
What neutrophil count represents a serious risk of infection for patients?
<0.5 x 109/L
Which chemotherapy drugs cause nausea and vomiting?
Most cytotoxic drugs (therefore prescribe anti-emetics)
due to: direct stimulation of vomiting centre
peripheral stimulation
anticpatory causes
What risk does chemotherapy present to the bladder? How can this be treated if it occurs?
haemorrhagic cystitis
antidote: MESNA
What risk does chemotherapy present to the kidneys? How would you assess whether it was appropriate to start/continue this treatment?
Nephrotoxicity
Occurs especially with platinum agents
Due to the renal excretion of drugs
Therefore: need to check renal function regularly (?before each cycle of treatment)
How would you treat palmar-plantar erythema in a patient receiving cytotoxic treatment?
Stop treatment
Prescribe emollient
What psychological and social side effects of chemotherapy should you consider?
employment
relationships
insurance
social adaptation
(usually all effected, worse in young people)
What are the long-term side effects of chemotherapy?
Fertility problems
Pyschological and social issues
Secondary malignancies
Pulmonary s/e: fibrosis, pneumonitis
Cardiac problems: fibrosis
How would you manage chemotherapy-related myalgia and arthralgia?
NSAID analgesics
How can fertility be effected by chemotherapy? What can you suggest to patients?
Reduced fertility (with most drugs) Alyklating agents: infertility-inducing at standard dose Other agents: infertility-inducing at high doses
Males: sperm storage
Females: fertilised ova storage (be aware of ethical implications)
Which patients are more susceptible to cariac fibrosis secondary to chemotherapy treatment?
Younger patients
Which drugs are most likley to cause DNA damage (therefore present higher risk of secondary malignancies)?
aklylating agetns and procarbazine
(Higher dose of drug = increased risk)
What is myelosuppression?
A condition in which bone marrow activity is decreased, resulting in fewer red blood cells, white blood cells, and platelets.
What can cause myelosupression in cancer patients?
(cytotoxic) treatment
interferon and interleukin-2
bone marrow infiltration
paraneoplastic syndromes (= pancytopenia)
blood loss from tumour (= anaemia)
anaemia of chronic disease
How long after chemotherapy treatment does the nadir of myelosupression usually take place?
10-12 days
How is chemo-dose related to myelosuppression?
Higher the dose, the higher the fall in total leucocyte count.
Also, decrease is more sustained.
What is a paraneoplastic syndrome?
This is a syndrome (collection of symptoms) that occurs as a result of chemicals produced by a mass - not the mass itself. It can also occur as a result of the immune response to the tumour.
What is pancytopenia?
Deficiency of all three cellular components of blood: red blood cells, white blood cells and platelets
What form of myelosupression can paraneoplastic syndromes cause?
pancytopenia
What is bone marrow infiltration and what form of myelosupression can it cause?
Bone marrow replacement by malignant infiltration
Can cause pancytopenia
What malignancies cause higher risk of bone marrow infiltration?
haematological malignancies
breast
lung
prostate
How do you treat bone-marrow infiltration?
anti-tumour therapy (cytotoxic agents - which are myelosupressive)
What is a feature of anaemia resulting from chemotherapy?
Macrocytic NOT megaloblastic
What is thrombocytopenia? What are the risks associated with it?
Deificiency of platelets in the blood
Causes bleeding in to tissues, bruising and slow blood clotting after injury
What are the common causes of anaemia in cancer?
blood loss from tumour
anaemia of chronic disease (not iron-deficiency)
What are the signs of thrombocytopenia?
Petchial haemorrhage
Spontaneous nose bleeds
Corneal haemorrhage
Haematuria
How would you investigate suspected myelosupression?
FBC
blood film
bone marrow aspirate
trephine (bone marrow biopsy)
Other than a blood transfusion, how else can we treat/prevent anaemia in patients on chemotherapy? What are the benefits of this over transfusion?
Prescribe recombinant erythropoeitin
(prevents symptomatic anaemia)
reduced risk compared to transfusion and viral transmission
How do we treat anaemia resulting from chemotherapy?
Hb < 10: blood transfusion
How can we try and prevent patients developing antibodies to blood products that are given in thrombocytopenia?
Give a single dose of blood products only
OR
HLA match the platelets
What is the risk when providing repeated blood products to a patient for thrombocytopenia?
Antibodies to products are developed
May begin to see failure to increase in platelet count after transfusion
How would you treat thrombocytopenia?
Platelets < 10 x 109/L: URGENT PLATELET TRANSFUSION
Platelet count 10-20 x 109/L: platelet transfusion (esp in the presence of transfusion)
Platelets > 20 x 109/L and no spontaneous bleeding: do not require platelet transfusion
What is CT best used for imaging in oncology?
Bowel obstruction
Intra-luminal pathology
Mass lesions
Vascular structures
What is important to consider when thinking about using a contrast CT?
Pts renal function
IV contrast can be nephrotoxic, therefore should be used with caution in AKI and CKD
What is the level of radiation to the patient in CT scanning?
Low, but still at risk of developing radiation-related problems
*ASK ABOUT PREGNANCY*
In what cancers is MRI the gold standard imaging tool?
Neurospinal
Rectal
Prostate
MSK tumours
Head and neck cnacers
What is MRI good for viewing?
high soft tissue contrast
What other types of MRI are useful in cancer imaging?
MR angiography: cardio vessels
MR cholangiopancreatograms: gall bladder and pancreas
Real-time MRI: breast cancer
What is one of the main benefits of MRI over CT?
No radiation risk
Which patients cannot undergo MRI?
Pts with metalwork eg. pacemakers or defibrillators
*THESE PTS MUST NOT ENTER MRI UNIT*
Eye and brain foreign bodies eg. vascualr clips, surgical staples, metalic shards
Which metal work is okay in MRI?
Prosthetic joints (as they are very firmly fixed in patient)
When can ultrasound be used in oncology?
Detecting masses in solid visceral organs (eg. liver)
Assessing blood flow (eg. in DVT or when assessing tumour blood flow)
Real-time guidance in biopsy
What are the benefits of using ultrasound to image?
Low cost
Easily available
Painless
Non-invasive
No ionisation at all
Why aren’t US investigations reliable for serial measurements?
They are operator dependent, therefore there may be individual variation between images produced and conclusions drawn.
Give two uses of nuclear medicine in oncology
Technetium: GFR
Bone scintography: principle investigation for detection of skeletal mets
What is PET scanning useful for in cancer imaging?
Can differentiate benign tumours from malignant: FDG-18 usually taken up in areas of high glucose metabolism
Can be used when radical treatment appears possible but has high risk of morbidity/mortality. HELPS DECIDE WHAT TO DO (whether worth the risk)
How are PET and CT usually combined in imaging?
PET usually combined with CT to map findings on to anatomy
Which imaging techniques are best for staging in cancer?
Depends where you’re looking to stage:
CT - chest and abdo
MRI - bone and soft tissue
How can imaging be used in oncology?
Diagnosis (eg. identify and guide biopsy for diagnosis)
Staging (presence and extent of mets)
Treatment (response)
How can imaging be used to assess response to treatment?
CT, MRI and CXR: measure changes in tumour dimensions
How do you classify response to treatment?
Stable disease: <20% increase or <30% decrease in size
Progressive: new lesions or lesion increase by 20%<
Partial response: all lesions decreased by 30% BUT disease still present
Which cancers have a good cure rate with chemo?
hodgkins
testicular
acute lymphoblastic LEUKAEMIA
Choriocarcinoma
Paediatric cancers
Which cancers which have okay cure rates (<50%) with chemotherapy?
non-hodgkins
ovarian
paediatric neuroblastoma
sarcomas
Which cancers have few cures in advanced disease (but are used to prolong survival)?
NSCLC
Colorectal
Gastric
Breast
Bladder
Prostate
For which cancers can chemotherapy produce remission in most patients?
breast cancers (in early stages)
SCLC
Ovarian cancer
In which cancers is chemotherapy used for palliation (but with limited response?)
Renal
Melenoma
Head and neck
Pancreatic
Biliary tract
Which cancers have an increased cure rate in high risk local regional disease if chemotherapy is used?
breast
colorectal
NSCLC
oesophageal and gastric
bladder
What forms can modified release morphine come in?
tablets, granules and capsules
What is the starting dose of morphine you would use?
if on max co-codamol: 20 mg MST BD is usually fine
When would you condsider a reduced initial dose of morphine?
Elderly
Frail
Reduced renal function
Opiate niave
What would you prescribe someone who was constipated due to opioid use?
co-danthramer if palliative
other laxatives (eg. movicol, senna) if not palliative
Which anti-emetic would you prescribe for someone who was nauseated/vomiting due to opioids?
Haloperidol
nausea should settle after a couple of days
If a patient who is on morphine is confused or had visual hallucinations, what should you do?
check dose
check renal function
consider alternative opioid
What are the features of opioid toxicity?
Nausea, vomiting
persistent drowsiness
confusion
visual hallucination
myoclonic jerks
respiratory depression
What can surgery be used for in oncology?
Resection of primary tumour
Reduce bulk of residual disease
Curative surgery for mets
Palliative
Prevention of cancer
Diagnosis and staging
What are the conditions for surgical resection of a primary tumour?
must be localised
(some lymphnodes)
adequate margins of clearance required
+/- adjuvant radiotherapy or chemotherapy
Why is curative surgery not usually recommended in metastatic disease?
There is usually a presence of occult mets, therefore only recommended in: solitary lung mets (sarcomas), localised liver mets (colorectal)
Combined with adjuvant therapy
What types of surgery could be used to palliate a cancer patient?
Bowel obstruction removal
Stents
Pleurodesis
Pathalogical fracture pinning
How can surgery be used to prevent cancer?
Remove body parts if high-risk:
eg. double mastectomy
colectomy in patient with FAP
What is an incisional biopsy?
Taking a sample of a tumour at surgery
What’s a wide local excision?
Removal of whole tumour
What are the risk factors for testicular cancer?
maldescended testes
testicular atrophy
family history
Kleinfelter’s syndrome
infertility
What are the main classifications of testicular cancer?
germ cell tumours: seminomatous (40%)
non-seminomatous (60%)
teratomas
yolk sac
(Most testicular cancers are germ cell tumours)
What is the prognosis like in testicular cancer?
Highly metastatic BUT highly curable
In which population is testicular cancer most common?
Males 15-45
White
How does testicular cancer spread? Where does it commonly spread to?
Early spread is common (via lymphatics)
Haematogenic spread: lungs, liver, bone, brain
How might testicular cancer present?
Painless testicular lump
Testicular or abdomen pain
Dragging sensation
Hx of trauma (pt. may have examined self after trauma)
Hydrocele
Gynaecomastia
Less sensitive testes
Symptoms of mets: bone pain, lung problems etc.
Inguinal lymphadenopathy
What differential diagnoses might you make in someone who presents symptoms similar to testicular cancer?
Epididymo-orchitis.
Torsion.
Other scrotal lumps - eg, hydrocele, haematocele, epididymal cyst, hernia.
Infection - eg, tuberculosis, syphilis, mumps.
How would you investigate a suspected testicular cancer?
Examine scrotum
Assess tumour markers: BHCG (raised in up to 75% of patients - seminomatous and non-seminomatous). PREGNANCY TEST.
AFP (rasied in non-seminomatous)
Lactate dehyrogenase
ULTRASOUND of testes
CT chest, abdo and pelvis (or CXR) to detect mets
Orchidectomy (definitive diagnosis. Biopsy contralateral testivle if crypto or madescended as increased risk of bilateral disease)
What are other common sites of germ cell tumours?
retroperitoneum
mediastinum
Why is trans-scrotal biopsy contra-indicated in investigating testicular cancer?
Biopsy increases risk of disseminating tumour
How do you stage testicular cancer?
Royal Marsden staging:
- Confined to testicle
- Involves para-aortic lymph nodes below diaphragm
- Involved para-aortic lymph nodes above diaphragm
- Involves visceral metastases
What are the prognostic factors for testicular cancers?
bulky sites = worse prognosis
PULMONARY METS HAVE NO IMPACT ON PROGNOSIS
Adverse markers: yolk sac elements, vascular invasion, lymph invasion
Tumour size >4cm
Rete involvement
= both poor markers for relapse
How would you manage testicular cancer?
VERY SENSITIVE TO RADIOTHERAPY AND CHEMOTHERAPY
Destinction between seminomatous and non-seminomatous determines treatment
Orchidectomy (done at diagnosis through inguinal canal)
Seminoma: carboplatin + adjuvant radiotherapy
Non-seminoma: BEP
High dose stem cell support is used in pts with poor prognosis
How would you manage metastatic teratoma?
Surgery after chemo (to take away the residual mass)
Further systemic treatment might be needed: radiotherapy
What are the palliative care options for someone with testicular cancer?
Radiotherapy to specific areas: bone, brain and nodes
How many cycles of BEP would you suggest for someone with testicular cancer?
3-4 cycles of intense dose.
High dose given to maximise response
A 63-year-old man with NSCLC is dying in hospital. His pain is well controlled on a syringe pump infusin diamorphine 20mg/24hrs. The nursing staff are concerned that he is occasionally agitated with no obvious cause.
Select the most appropriate treatment from those listed below:
Diazepam 5mg SC
Diamorphine 30mg/24hours SC
Furosemide 40mg PO
Ibuprofen 400mg TDS PO
Lorazepam 0.5mg PO
Midazolam 5mg SC
Oramorph 2.5mg PO
Oxygen 2L/min
Pregabalin 75mg BD
Tramadol 100mg QDS
Midazolam 5mg SC
(Diazepam can’t be given SC as it’s too irritant)
A 73-year-old man with advanced renal cancer and multiple lung mets complains of progressive breathlessness. He is struggling with day-to-day activities at home. He is not for any further disease-modifying treatment. On examination his pulse is 80 regular, oxygen sats 95% on air, no oedema and chest auscultation normal.
Select the most appropriate treatment from those listed below:
Diazepam 5mg SC
Diamorphine 30mg/24hours SC
Furosemide 40mg PO
Ibuprofen 400mg TDS PO
Lorazepam 0.5mg PO
Midazolam 5mg SC
Oramorph 2.5mg PO
Oxygen 2L/min
Pregabalin 75mg BD
Tramadol 100mg QDS
Oramorph 2.5mg PO (PRN)
(Other opiate choice on here is diamorphine SC. As this is a first presentation of a need for opiates, wouldn’t start on SD immediately. Better to start on immediate-release, small dose and PRN).
A 67-year-old man with prostate cancer and bone mets complains of increasing pain in his right thigh despite paracetamol 1gm QDS. He describes it as a dull ache radiating down his leg which is worse on standing and walking. No abnormalities are detected on examination and an xray is requested.
Select the most appropriate treatment from those listed below:
Diazepam 5mg SC
Diamorphine 30mg/24hours SC
Furosemide 40mg PO
Ibuprofen 400mg TDS PO
Lorazepam 0.5mg PO
Midazolam 5mg SC
Oramorph 2.5mg PO
Oxygen 2L/min
Pregabalin 75mg BD
Tramadol 100mg QDS
Ibuprofen 400mg TDS PO
(description sounds like bone pain, therefore would prescribe anti-inflammatory. Tramadol is not very good and pre-gabbalin is usually used as an adjuvant/for neuropathic pain)
A 78-year-old woman with heart failure is diagnosed with non-small cell lung cancer. Her main symptom is distressing haemoptysis. She has a 3x5cm mass in the right upper lobe, multiple enlarged mediastinal lymph nodes and a solitary adrenal metastasis. She has a performance status of 3.
Select the most appropiate treatment from the answers below:
Adjuvant chemo
Palliative chemo
Palliative radiotherapy
Palliative systemic hormone treatment
Primary chemotherapy
Radical radiotherapy
Surgical excision
Surveillane
Symptom management alone
Palliative radiotherapy - really good for treating bleeding.
(Can only give chemo to patients with performance status of 2 and above. Would consider symptom control only if you thought she was in her final days and would prescribe tranexamic acid and midazolam)
A 66 year old man presented with a change in bowel habit. Subsequent investigations show a right-sided colonic mass but no metastatic disease. He undergoes a colectomy and histology confirms a Duke’s C adenocarcinoma.
Select the most appropriate treatment from the following list:
Adjuvant chemo
Palliative chemo
Palliative radiotherapy
Palliative systemic hormone treatment
Primary chemotherapy
Radical radiotherapy
Surgical excision
Surveillane
Symptom management alone
Adjuvant chemotherapy (because he has already had a colectomy and has high-stage colorectal cancer)
A 67-year old lady presents to her GP with hip pain. Xray shows mixed sclerotic/lytic lesions in the iliac blade and subsequent imaging and biopsy confirm small primary HER2- ER+ breast cancer.
Select the most appropriate treatment from the list below:
Adjuvant chemo
Palliative chemo
Palliative radiotherapy
Palliative systemic hormone treatment
Primary chemotherapy
Radical radiotherapy
Surgical excision
Surveillane
Symptom management alone
Palliative systemic hormone treatment. This solves all of the problems (including the pain)
(Whilst you might consider radiotherapy for bone pain, doesn’t solve other problems. You would probably leave the small primary in place as it doesn’t have much bearing on prognosis and can be used as a marker of treatment success)
A 64-year-old woman with hyperthyroidism and alcohol dependence complains of episodes of palpitations associated with fatigue and breathlessness. She is a non-smoker and is otherwise well. On examination her pulse is 88bpm (regular), her heart sounds are normal, chest clear and she has no ankle oedema.
Select the most appropriate diagnosis from the list below:
anaemia
asthma
COPD
Heart failure
Hyperventilation
Paroxysmal AF
Pleural effusion
Pneumonia
Paroxysmal AF. Key clues: episodic presentation, paroxysmal AF is also associated with hyperthyroidism and alcoholism.
A 73-year-old man is breathless when he climbs stairs or walks uphill. He sleeps on 3 pillows. He is an ex-smoker. On examination he has mild ankle oedema and basal crackles in the lungs.
Please select the most appropriate diagnosis from the list below:
anaemia
asthma
COPD
Heart failure
Hyperventilation
Paroxysmal AF
Pleural effusion
Pneumonia
Heart failure. He has bilateral crackles (likley to be due to oedema. He also has ankle oedema, is breathless on exertion and sleeps with three pillows).
A 45-year-old woman who has recetnly had chemotherapy for breast cancer complains of sudden onset pain in R-side of her chest, breathlessness and a dry cough. On examination her temperature is 36.4oc, pulse 110bpm and respiratory rate 24/min. Auscultation of the chest is clear.
Please select the most appropriate diagnosis from the list below:
anaemia
asthma
COPD
Heart failure
Hyperventilation
Paroxysmal AF
Pleural effusion
Pneumonia
PE.
Breast cancer can lead to increased risk of PE. whilst her pulse and RR are raised (which might indicate infection), her lungs are clear and her cough is dry. Pain was also sudden in onset (an infection may be more insidious)
A 64-year-old main comes to see his GP complaining of painless intermittent haematuria. He has no other urinary symptoms. On examination he has a smoothly enlarged prostate gland.
Please select the most appropriate investigation from the list below:
Bronchoscopy
CT chest scan
CT scan abdo
MRCP
MRI abdo
Spirometry
Sputum culture and cytology
Urine dipstick
USS abdo
X-ray abdo
X-ray chest
Urine dipstick.
You’re looking for the least sinister cause so that you can rule this out. (Would potentially refer for 2-week appointment with specialist anyway, as painless haematuria)
A 73-year-old man presents to his GP with a 3-week history of persistent cough and increased sputum production. He has a Hx of COPD and type 2 diabetes.
Please select the most appropriate investigation from the list below:
Bronchoscopy
CT chest scan
CT scan abdo
MRCP
MRI abdo
Spirometry
Sputum culture and cytology
Urine dipstick
USS abdo
X-ray abdo
X-ray chest
CXR.
This would allow us to differentiate between infection, COPD and cancer. His Hx is 3 weeks long, therefore would definitely want to rule out cancer.
(sputum cultures not that commonly done in practice now)
A 69-year old man presents to his GP with a 6-week Hx of right upper quadrant pain and reduced appetite. Examination is normal. Blood tests reveal bilirubin 18µmol/L (1-22), alanine aminotransferase 51 U/L (5-35), alkaline phosphatase 673 U/L (45-105) and gamma glutamyl transferase 90 U/L (<50).
Please select the most appropriate investigation from the list below:
Bronchoscopy
CT chest scan
CT scan abdo
MRCP
MRI abdo
Spirometry
Sputum culture and cytology
Urine dipstick
USS abdo
X-ray abdo
X-ray chest
USS abdo.
Quick, cheap, easily available. No radiation risk to the patient. Would probably need to do this before could refer for CT/MRI.
(X-ray abdo is only really useful for bowel obstruction)
An 82-year old woman who is in a residential home following a stroke has a UTI. She has mild renal impairment and is on simvastatin 40mg nocte and felodipine 2.5mg OD.
Please select the most appropriate tretment from the list below:
amoxicillin
cephalexin
ciprofloxacin
co-amoxiclav
erythromycin
flucloxacillin
metronidazole
nitrofurantoin
oxytetracycline
Nitrofurantoin. This is a second-line treatment for UTI (given to people who have renal impairment)
A 28-year-old man with a history of testicular cancer has been bitten by a dog on the lower leg. He is worried that his immunity may be low because of recent chemotherapy.
Please select the most appropriate tretment from the list below:
amoxicillin
cephalexin
ciprofloxacin
co-amoxiclav
erythromycin
flucloxacillin
metronidazole
nitrofurantoin
oxytetracycline
Co-amoxiclav.
This is given to people who have been bitten by an animal.
A 68-year old woman has an infected in-growing toenail. She has Type 2 diabetes and high blood pressure for which she takes ramipril 5mg od and metformin 500mg tds. She is allergic to penicillin.
Please select the most appropriate tretment from the list below:
amoxicillin
cephalexin
ciprofloxacin
co-amoxiclav
erythromycin
flucloxacillin
metronidazole
nitrofurantoin
oxytetracycline
Erythromycin
She has a sub-cutaneous skin infection, but is allergic to peniciilin, therefore you cannot use flucloxacillin.
(might use clarithromycin over erythromycin as less stomach s/e, but this is not an option in this question)
A 71-year old woman complains of fatigue. She has a history of osteoarthiritis and a hiatus hernia. She does not have any repeat prescriptions but buys painkillers from the chemist for her knees. Heart sounds normal and chest clear.
Select the most appropriate diagnosis from the list below:
Anaemia
Alcoholism
Cancer
Chronic fatigue syndrome
Depression
Diabetes
Heart failure
Hypothyroidism
Insomnia
Obstructive sleep apnoea
Anaemia.
She may have been taking NSAIDS, which increase risk of bleed. Hiatus hernia also increases pts risk of GI bleeds.
A 34-year-old woman complains of a sore tongue, cystitis symptoms, recurrent boils and tiredness. She has a BMI of 48.
Select the most appropriate diagnosis from the list below:
Anaemia
Alcoholism
Cancer
Chronic fatigue syndrome
Depression
Diabetes
Heart failure
Hypothyroidism
Insomnia
Obstructive sleep apnoea
Diabetes.
Increased susceptibility to infections and boils, tiredness are key clues.
A 58 year old man with obesity complains of poor concentration at work and is always nodding off at his desk. He denies feeling stressed but his relationship is ‘on the rocks’ because of his snoring. Blood shows HbA1c 39, TSH 3.0.
Select the most appropriate diagnosis from the list below:
Anaemia
Alcoholism
Cancer
Chronic fatigue syndrome
Depression
Diabetes
Heart failure
Hypothyroidism
Insomnia
Obstructive sleep apnoea
Sleep apnoea.
Obese, snoring and day-time sleeping
A 70-year-old woman with hypertension is taking felodipine and valsartan but her BP remains persistently raised. She is adamant that she is taking her medications regularly.
Select the most appropriate treatment from the list below:
Amiodarone
amlodipine
atenalol
bisoprolol
Furosemdie
Indapamide
Losartan
Ramipril
Verapamil
Indapamide
A+C+D (indapamide is a thiazide diuretic)
A 42-year-old caucasian man checked his own BP at home for a week and his average was 168/102 mmHg
Select the most appropriate treatment from the list below:
Amiodarone
amlodipine
atenalol
bisoprolol
Furosemdie
Indapamide
Losartan
Ramipril
Verapamil
Ramipril
ACE inhibitor - first line treatment for caucasian male under 50
A 69-year-old man with myeloma is admitted to the oncology ward with constant nausea. He has vomited small amounts of bile stained fluid for the last 3 days and feels thirsty. What is most suitable first-line anti-emetic?
Cyclizine
Haloperidol
Levomepromazine
Metoclopramide
Ondansetron
Haloperidol
Cause of vomiting: hypercalcaemia. Myeloma is a very common cause of hypercalcaemia. Pt is also thirsty, which is a sign of hypercalcaemia.
Haloperidol>Levomepromazine (in terms of safety)
A 71-year-old woman with advanced lung cancer complains of passing hard stool. She is opening her bowels once a day as previously, but this is now painful.
What is the most suitable laxative to prescribe?
Bisacodyl suppositories
Co-danthramer suspension
Docusate capsules
Fybogel
Senna
Docusate
Stool softner.
A 63-year-old man undergoing treatment for prostate cancer complains of left leg ‘gave way’ yesterday and feels odd. He denies back pain.
What is the most appropriate investigation?
CT scan brain
Isotope bone scan
MRI spine
PSA (prostate specific antigen)
X-ray thoracic spine
MRI spine
No pain doesn’t mean no spinal compression. Important to elliminate/ confirm this as a differential.
An 81-year-old woman presents to her GP with gradual onset of breathlessness on exertion. She has a history of angina and hypertension. On examination, she has a systolic murmur, fine crackles at both lung bases and pitting oedema of the ankles. Her ECG shows left ventricular hypertrophy.
What are the most appropriate investigations to perform?
CXR and coronary angiogram
CXR, echocardiogram and bloods for BNP
Exercise tolerance test
Spirometry and bloods for FBC, U&E
24 hour ECG and echocardiogram
CXR, echo and bloods for BNP
Suspect HF, therefore BNP is useful, CXR may show cardiomegaly and echo to show which part myocardium is dysfunctional.
You review a 50-year-old woman in a primary care diabetes clinic. She had an ischaemic stroke 30 years previously following open heart surgery.
What would you expect to find when examining her gait?
Bilateral increased tone with scissoring
Broad-based rolling gait
Dystonic, writhing movements
Extended lower limb and flexed upper limb
Festinant gait
Extended lower limb and flexed upper limb
Bilateral increased tone with scissoring: cerbral palsy
Broad-based rolling gait: cerebellar problems (eg. ataxia)
Dystonic, writhing movements: Huntingtons
Festinant gait: Parkinsons
A 69-year-old man with SCLC and brain mets was dying at home but had a tonic-clonic seizure and a paramedic ambulance brought him to the ED. He remained unconscious and died 18 hours later.
What is the most appropriate cause of death to wtie on the medical cause of death certificate?
1a metastatic lung cancer
1a brain mets 1b lung cancer
1a brain metastases 1b small cell lung cancer
1a seizure 1b brain mets 1c small cell lung cancer
Do not issue a certificate and refer to HM coroner
Do not issue a certificate and refer to HM coroner
Pt. has been in hospital for less than 24 hours.
(if you were to issue the certificate, option D would be the most correct)
A 46-year old publican has recently been diagnosed with type 2 diabetes. He is unable to tolerate metformin because of the diarrhoea. His most recent HbA1c is 86 mmol/mol (ideal control <59 mmol/mol) and his blood sugars are raised at 16-18 mmol/L.
What is the next most appropriate alternative treatment?
Gliclazide
Insulin
Lingagliptin
Pioglitazone
Orlistat
Gliclazide
This is a second-line treatment for somone who is on one agent
A 60-year-old man visits the practice nurse to discuss life style modification after a friend died of cancer. The patient’s BMI is 30.
What cancer is a man who is obese more at risk of?
Bladder cancer
Colon cancer
Lung cancer
Melanoma
Prostate cancer
Colon cancer
A 75-year olf man is admitted following a sudden onset of right sided weakness. A swallowing assessment is commenced by the fonudation year doctor on the stroke uni. The patient swallows a teaspoon of water without any problems.
What is the most appropriate next step?
Allow a normal diet and re-assess swallowing in 24 hours
Ask the patient to drink half a glassful of water
Give the patient a further two teaspoons of water
refer to speech and language therapist for formal swallowing assessment
videofluroscopy
Give the patient a further two teaspoons of water
A 70-year-old woman complains that soon after waking she had a fleeting loss of vision in her left eye followed by a change in sensation affecting the right side of her body. Neurological examinatino later that day shows no abnormalities.
What is the most likley diagnosis?
Acute anxiety
Bell’s palsy
Migraine
MS
TIA
TIA
Clue: fleeting loss of vision - amarosis fugax
A 73-year-old man with prostate cancer and multiple done and lymph node mets is admitted to MAU with increasing fatigue and swollen ankles. He is currently taking paracetamol 1mg QDS, oxycodone 20mg BD and dexamethasone 0.5mg daily.
His blood tests on admission show: sodium 141 mmol/L (137-144), potassium 5.9 mmol/L (3.5-4.9), urea 39 mmol/L (2.5-7.0) and creatinine 487 µmol/L (60-110).
What is the most-likley cause of his renal failure?
Dehydration
Hypercalcaemia
Medication
Obstructive uropathy
Polycystic kidney disease
Obstructive uropathy
Lymphatic mets from prostate cancer can obstruct ureters.
Fatigue fits with uraemia.
Swollen legs fits with lymphadenopathy.
A 10-year-old boy with asthma comes to surgery for his routine review. He is using his salbutamol inhaler every day about 2-3 times but more when he is playing football. He wakes up coughing most nights and occasionally has to sit out of PE due to wheezing.
What is the most appropriate additional treatment?
Anti-muscarinic (eg. ipratropim bromide)
Leukotriene receptor antagonist (eg. monkelukast)
Oral theophylline
Regular long-acting B-2 agonist (eg. salmetrol)
Regular standard dose inhaled corticosteroids (eg. beclametasone)
Beclametasone/clenil (corticosteroids)
An 81 year old lady has her annual review for hypertension. Her BP is 100/60 and U&Es show the following: sodium 128 (NR 135-145), potassium 4.5 (NR 3.5-5.0), urea 7.0 (NR 3.0-8.3), creatine 78 (NR 44-133).
Which of her medications would you stop?
Amlodipine
Atenalol
Bendroflumethiazide
Paracetamol
Ramipril
Bendroflumethiazide
Sodium is low - which is commonly caused by thiazide diuretics
Where are the majortiy of lung cancers?
Bronchi
Which cancers commonly metastasise to the lung?
kidney
prostate
breast
bone
GI
cervix and ovary
Where are the majority of lung mets?
lunch parenchyma
relatively asymptomatic
What classification are the majority of lung cancer?
Non-small-cell lung cancer
What proportion of cancers fall in to NSCLC and SCLC?
85% and 15% respectively
