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Medicine Finals - Imperial & Quick Medical Revision > Oncology AS > Flashcards

Oncology AS Flashcards

1
Q

Familial Breast and Ovarian Cancer

A

~10% of breast Ca is familial
~5% is caused by BRCA1 or BRCA2 mutations.
- Both TSGs
- BRCA1: Breast Ca ~80%, Ovarian Ca ~40%.
- BRCA2: Breast Ca ~80%, male breast Ca + prostate cancer

May opt for prophylactic mastectomy and oophrectomy

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2
Q

Familial Prostate Ca

A
  • ~5% of those with prostate Ca have +ve fam HX
  • Multifactorial inheritance
  • BRCA1/2 –> moderately increased risk.
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3
Q

Familial CRC

A
  • ~20% of those with prostate Ca have +ve Fam history.
  • Relative risk of CRC for individual with FH related to:
    Closeness of relative
    Age of relative when Dx.
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4
Q

Types of familial CRC?

A
  • Familial Adenomatous Polyposis
  • HNPCC
  • Peutz-Jehgers
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5
Q

What is FAP?

A

Familial Adenomatous POlyposis

  • Mutation in APC gene on Chr 5
  • TSG
  • Promotes B-catenin degradation

Cells then acquire another mutation to become Ca (p53/kRAS).

  • AD transmission
  • ~100% risk of CRC by 50yrs.
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6
Q

What is HNPCC?

A 
Familial clustering of cancers 
- Lynch 1: CRC
- Lynch 2: CRC + other Ca
Ovarian
Endometrial
Pancreas
Small Bowel 
Renal pelvis

Mutations iN DNA mismatch repair gene
AD transmission
Often Right-sided CRC
Present @ young age: <50yr.

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7
Q

What is Peutz-Jegher’s

A
  • AD transmission
  • Multiple GI hamartomatous polyps
  • Mucocutaneous hyperpigmentation
    (lips, palms).
  • 10/20% lifetime risk of CRC
  • Also increased risk of other Ca
    Pancreas
    Lung
    Breast
    Ovaries and Uterus
    Testes.
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8
Q

Oncological emergencies - Febrile Neutropenia?

A

PMN < 1x10^8

  • Isolation + barrier nursing
  • Meticulous antisepsis
  • Broad-spectrum Abx, anti-fungal, anti-virals
  • Prophylaxis: co-trimoxazole.
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9
Q

Oncological emergencies - Spinal Cord compression?

A

Presentation

  • Back pain, radicular pain
  • Motor reflexes and sensory level
  • Bladder and bowel dysfunction
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10
Q

Causes of Spinal cord compression?

A
  • Usually extradural metastasis

- Crush fracture

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11
Q

Investigations of spinal cord compression

A

Urgent MRI spine

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12
Q

Spinal cord compression management?

A
  • PO Dexamethasone 8mg BD
  • Discuss with neurosurgeon and oncologist
  • Consider radiotherapy or surgery
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13
Q

SVCO with airway compromise?

A

SVCO not an emergency unless there’s tracheal compression with airway compromise.

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14
Q

Causes of SVC compression?

A
  • Usually Lung Ca
  • Thymus malignancy
  • LNs
  • SVC thrombosis: central lines, nephrotic syndrome
  • Fibrotic bands: Lung fibrosis after chemo
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15
Q

Presentation of SVC compression?

A 
Headache
Dyspnoea and orthopneoa
Plethora + thread veins in SVC distribution
Swollen face and arms
Engorged neck veins
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16
Q

What is Pemberton’s sign?

A
  • Lifting arms above head for >1min –> facial plethora, increased JVP and inspiratory stridor
  • Due to narrowing of the thoracic inlet.
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17
Q

Investigations of SVCO?

A

sputum cytology
CXR
CT
Venography

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18
Q

Management for SVCO?

A
  • Dexamethasone (dex for malignancy, mannitol for everything else)
  • Consider Balloon venoplasty + SVC stenting
  • Radical or palliative chemo/radio.
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19
Q

Hypercalcaemia in Oncology?

A

40% of those with myeloma
10-20% of those with Ca

Due to lytic bone mets
Production of PTHrP

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20
Q

Symptoms of Hypercalcaemia

A 
Confusion
Renal stones 
Polyuria and polydipsia
Abdo pain, constipation
Depression
Lethargy
Anorexia
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21
Q

Investigations of Hypercalcaemia?

A
  • Increase Ca Often >3mm
  • Decreased PTH (key to exclude increased HPT)
  • CXR
  • Isotope bone scan.
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22
Q

Management of Hypercalcaemia?

A

Aggressive hydration

  • 0.9% NS
  • Monitor volume status
  • Furosemide when full to make room for more fluid.

If primary HPT excluded, give maintenance therapy - bisphosphonate: Zoledronate is good.

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23
Q

Other oncological emergencies?

A

Raised ICP

Tumour Lysis Syndrome

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24
Q

Management of cancer - Chemotherapy?

A

Cancer must be managed in an MDT

  • Neoadjuvant (Shrink tumour to decreased need for major surgery. Control early micromets.
  • Primary therapy (sole Management in haematological cancers)
  • Adjuvant
    decreased change of relapse e.g breast and GI cancer
  • Palliative
    Provide relief from symptoms
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25
Q

Cytotoxic Classes?

A 
Alkylating agents 
Antimetabolitis
Vinca alkaloids
Cytotoxic ABx
Taxanes 
Immune modulators 
MAbs
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26
Q

What are the alkylating agents

A

Cyclophosphamide, chorambucil, busulfan

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27
Q

What are the antimetabolities?

A

Methotrexate, 5-FU

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28
Q

What are the vinca alkaloids

A

Vincristine and Vinblastine

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29
Q

What are the cytotoxic antibiotics

A

Doxorubicin, bleomycin, actinomycin D

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30
Q

What are the taxans?

A

Paclitaxel

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31
Q

What are the immune modulators?

A

Thalidomide

Lenalidomide

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32
Q

What does Trastuzumab treat?

A

anti-Her2 breast Ca

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33
Q

What does Bevacizumab treat

A

Anti-VEGF: RCC, CRC, Lung

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34
Q

What does Cetuximab treat?

A

Anti-EGFR: RCR

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35
Q

What does Rituximab treat?

A

Anti-CD20 : NHL

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36
Q

What are the TK inhibitors?

A

Erlotinib: Lung cancer
Imatinib: CML

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37
Q

What are the endocrine modulators?

A

Tamoxifen

Anastrazole

38
Q

What are the common side effects of Chemo?

A

n/v
Alopecia
Neutropenia
Extravasation of chemo agent
- Pain, burning, bruising at chemo infusion site
- Stop infusion, give steroids, apply cold pack
- Liaise early with plastics.

39
Q

What specific problems does cyclophosphamide cause?

A

Hemorrhagic cystitis, myelosuppression, transitional cell carcinoma

Hair loss

BM suppression

40
Q

What specific problems does Doxorubicin cause?

A

Cardiomyopathy

41
Q

What specific problems does bleomycin cause?

A

Pulmonary Fibrosis

42
Q

What specific problems does Vincristine cause?

A

Peripheral neuropathy (reversible)

Paralytic ileus

Vinblastine: Myelosuppression

43
Q

What specific problems does Carboplatin cause?

A

Peripheral neuropathy
N/v
nephrotoxic

44
Q

What specific problems does paclitaxel cause?

A

Hypersensitivty

45
Q

What is Radial Radiotherapy treatment

A
  • Curative intent
  • 40-70Gy
  • 15-30 daily fractions
46
Q

What is palliation radiotherapy ?

A

Symptoms relief
- Bone pain, haemoptysis, cough, dyspnoea, bleeding

8-30 Gy

1-10 fractions.

47
Q

What are the early reactions to radiotherapy?

A 
Tiredness
Skin reaction: erythema --> ulceration 
Mucositis (painful ulceration and damage to mucous membranes) 
N/V
Diarrhoea 
Cystitis 
BM suppression
48
Q

Late reactions for radiotherapy?

A

Brachial plexopathy

  • follows axillary radiotherapy
  • Numb, weak, painful arm

Lymphoedema
Pneumonitis
- Dry cough ± dyspnoea
- manage: prednisolone

Xerostomia
Benign strictures 
Fistulae
Decreased fertility
Panhypopituitarism
49
Q

Surgery for cancer therapy

A

Diagnostics: tissue biopsy
Excision: GI, soft-tissue sarcoma, gynae

Palliation: Bypass procedure, stenting.

50
Q

What malignant cancers is AFP used for?

A

Hepatocellular carcinoma

Teratoma

51
Q

What non- malignant conditions is AFP a marker for?

A

Hepatitis
Cirrhosis
Pregnancy

52
Q

What malignant cancers is CA125 used for?

A

Ovary
Uterus
Breast

Should be part of a work up for non-specific abdo pain. Ovarian can fill much of the abdominal cavity. May be hard on a CT scan to convincingly identify primary.

Screen for FBC, U+E, LFTs, Calcium, Urinalysis, LDH, AFP, hCG.

53
Q

What non-malignant conditions is CA125 used for?

A

Cirrhosis

Pregnancy

54
Q

What malignant cancers is Ca15-3 used for?

55
Q

What non-malignant conditions is Ca15-3 used for?

A

Benign breast diseaase

56
Q

What malignant cancers is Ca19-9 used for?

A

Pancreas
Cholangiocarcinoma
CRC

57
Q

What non-malignant cancers is Ca19-9 used for?

A

Cholestatis

Pancreatitis

58
Q

What malignant cancers is Ca 27-29 used for?

59
Q

What malignant cancers is Neuron-Specific enolase used for?

60
Q

What malignant cancers is CEA used for?

A

CRC - colorectal cancer

61
Q

What non-malignant conditions is CEA used for?

A

Pancreatitis

Cirrhosis

62
Q

What malignant cancers is B-HCG used for?

A

Germ cell tumours

AFP and HCG normally raised in non-seminoma but normal in seminoma

In non-seminomas (Teratoma) AFP is raised in 70% and hCG raised 40%. Man takes gfs pregnancy test and finds out he has a teratoma.

63
Q

What malignant cancers is PSA used for?

A

Prostate (non-malignant = BPH)

64
Q

What malignant cancers is mono Ig used for?

A

Multiple Myeloma

65
Q

What malignant cancers is S-100 used for?

A

Melanoma (benign in Sarcoma)

66
Q

What malignant cancers is PLAP used for?

67
Q

What malignant cancers is acid phosphatases used for?

68
Q

What malignant cancers is thyroglobulin used for?

A

Thyroid cancer

69
Q

Bombesin

A

Small cell lung carcinoma
Gastric cancer
Neuroblastoma

70
Q

Spinal cord compression

A

Oncological emergency
- 5% of cancer patients. Extradural compression accounts for majority of cases.

  • Back pain, earliest and most common symptom. Worse on lying down or coughing.
  • Lower limb weakness
  • Sensory changes: sensory loss and numbness
  • Neuro signs depend on level of lesion.
  • Lesion above L1 usually result in UMN signs in the legs + sensory level.
  • Lesions below L1 usually cause LMN signs in legs + perianal numbness
  • Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion.

Management

  • High-dose oral dexamethasone
  • Urgent oncological assessment for consideration of radiotherapy or surgery.
71
Q

Irinotecan (Topoisomerase I)

A

Myelosuppression

72
Q

Cisplatin SE

A

Ototoxicity,
peripheral neuropathy,
Hypomagnesaemia

73
Q

Hydroxyurea SE

A

Myelosuppression

74
Q

Toxicity Bear?

A

A = Asparagine (neurotoxicity)

Cisplatin = ototoxicity/ nephrotoxicity - Tx = amifostine

Vincristine = Christ my nerves (peripheral neuropathy w/ vincristine), blast my bones (myelosuppression with vinblastine)

Bleomycin = Pulmonary fibrosis

Doxorubicin = Cardiomyopathy; tx = dexrozoxane

Cyclophosphomide = Nephrotoxicity, hypomagnesaemia, bladder toxic. Tx = democycline

Methotrexate: nephrotoxicity, (tx: leucovorin), myelosuppression (tx: filgrastim), oral mucositis, liver fibrosis

75
Q

Nivolumab MOA and use?

A

Immune checkpoint inhibitor = PD-1. Treatments for melanoma, Hodgkin’s lymphoma, NSCLC, uro cancers

76
Q

Ipilimumab MOA and use?

A

CTLA-4 (cytotoxic T lymphocyte-associated protein 4 for melanoma.

Given via injection/IV infusion.

77
Q

Atezolizumab, Avelumab, Durvalumab use?

A

PD-L1 - treat lung cancer and urothelial cancer.

78
Q

Side effects of checkpoint inhibitors?

A 
Dry, itchy skin and rashes (most commonly)
Nausea and vomiting
Decreased appetite
Diarrhoea
Tiredness and fatigue
Shortness of breath and a dry cough.

Immune related problems.

79
Q

Woman with bone mets causes?

A

Most likely to come from breast cancer.

Likelihood =
Prostate
Breast
Lung

Most common site

  • Spine
  • Pelvis
  • ribs
  • Skull
  • Long bones
80
Q

Most common cancers?

A
  1. Breast
  2. Lung
  3. Colorectal
  4. Prostate
  5. Bladder
  6. Non-Hodgkin’s lymphoma
  7. Melanoma
  8. Stomach
  9. Oesophagus
  10. Pancreas
81
Q

Most common cause of death from cancer?

A
  1. Lung
  2. Colorectal
  3. Breast
  4. Prostate
  5. Pancreas
  6. Oesophagus
  7. Stomach
  8. Bladder
  9. Non-Hodgkin’s lymphoma
  10. Ovarian
82
Q

For patients at low-ris of symptoms of nausea and vomiting?

A

Use metaclopramide

For high-risk patients - 5HT3 receptor antagonist such as ondansetron - especially if combined with dexamethasone.

For intracranial tumours -> dexamethasone

83
Q

Features of spinal mets?

A
  • unrelenting lumbar back pain
  • any thoracic/ cervical back pain
  • worse with sneezing, coughing or straining
  • nocturnal
  • a/w tenderness

If any neuro sx -> consider cord compression

84
Q

Commonest lung cancer in non-smokers?

A

Adenocarcinoma

  • typically peripheral
  • commonest cancer in non smokers
85
Q

Calcitonin a marker for?

A

Medullary thyroid cancer (MaiCa)

86
Q

Thyroglobulin a marker for?

A

Follicular/ papillary cancer (fthapad)

87
Q

Features of Gardner’s syndrome?

A
  • Autosomal dominant familial colorectal polyposis
  • Multiple colonic polyps
  • Extra colonic diseases include: skull osteoma, thyroid cancer and epidermoid cysts
  • Desmoid tumours are seen in 15%
  • Mutation of APC gene located on chromosome 5
  • Due to colonic polyps most patients will undergo colectomy to reduce risk of colorectal cancer
  • Now considered a variant of familial adenomatous polyposis coli
88
Q

Features of Li Fraumeni syndrome?

A
  • Autosomal dominant
  • Consists of germline mutations to p53 tumour suppressor gene
  • High incidence of malignancies particularly sarcomas and leukaemias

Diagnosed when:

  • Individual develops sarcoma under 45 years
  • First degree relative diagnosed with any cancer below age 45 years and another family member develops malignancy under 45 years or sarcoma at any age
89
Q

Features of lynch syndrome?

A
  • Autosomal dominant
  • Develop colonic cancer and endometrial cancer at young age
  • 80% of affected individuals will get colonic and/ or endometrial cancer
  • High risk individuals may be identified using the Amsterdam criteria

Amsterdam criteria
> Three or more family members with a confirmed diagnosis of colorectal cancer, one of whom is a first degree (parent, child, sibling) relative of the other two.
> Two successive affected generations.
> One or more colon cancers diagnosed under age 50 years.
> Familial adenomatous polyposis (FAP) has been excluded.

90
Q

Investigating an unknown primary?

A

NICE recommends the following investigations for all patients:

  • FBC, U&E, LFT, calcium, urinalysis, LDH
  • Chest X-ray
  • CT of chest, abdomen and pelvis
  • AFP and hCG

NICE recommends the following investigations for specific patients:

  • Myeloma screen (if lytic bone lesions)
  • Endoscopy (directed towards symptoms)
  • PSA (men)
  • CA 125 (women with peritoneal malignancy or ascites)
  • Testicular US (in men with germ cell tumours)
  • Mammography (in women with clinical or pathological features compatible with breast cancer)

Medicine Finals - Imperial & Quick Medical Revision (29 decks)

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