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Imperial Medicine Year 3 > 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-> this is the most common by far
  • 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

HNPCC is more common than the other 2 causes of colon cancer.

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 -> piperacillin with tazobactam
  • 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.

Start Dexamethasone and continue if CT shows SVCO. If dexamethasone is unsuccessful then other options inc radiotherapy

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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 -> immediate ix
CT-> most useful for establising diagnosis
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
Cytotoxic Classes?
``` Alkylating agents Antimetabolitis Vinca alkaloids Cytotoxic ABx Taxanes Immune modulators MAbs ```
26
What are the alkylating agents
Cyclophosphamide, chorambucil, busulfan
27
What are the antimetabolities?
Methotrexate, 5-FU
28
What are the vinca alkaloids
Vincristine and Vinblastine
29
What are the cytotoxic antibiotics
Doxorubicin, bleomycin, actinomycin D
30
What are the taxans?
Paclitaxel
31
What are the immune modulators?
Thalidomide | Lenalidomide
32
What does Trastuzumab treat?
anti-Her2 breast Ca
33
What does Bevacizumab treat
Anti-VEGF: RCC, CRC, Lung
34
What does Cetuximab treat?
Anti-EGFR: RCR
35
What does Rituximab treat?
Anti-CD20 : NHL
36
What are the TK inhibitors?
Erlotinib: Lung cancer Imatinib: CML
37
What are the endocrine modulators?
Tamoxifen | Anastrazole
38
What are the common side effects of Chemo?
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
What specific problems does cyclophosphamide cause?
Hemorrhagic cystitis, myelosuppression, transitional cell carcinoma Hair loss BM suppression
40
What specific problems does Doxorubicin cause?
Cardiomyopathy
41
What specific problems does bleomycin cause?
Pulmonary Fibrosis
42
What specific problems does Vincristine cause?
Peripheral neuropathy (reversible) Paralytic ileus Vinblastine: Myelosuppression
43
What specific problems does Carboplatin cause?
Peripheral neuropathy N/v nephrotoxic
44
What specific problems does paclitaxel cause?
Hypersensitivty
45
What is Radial Radiotherapy treatment
- Curative intent - 40-70Gy - 15-30 daily fractions
46
What is palliation radiotherapy ?
Symptoms relief - Bone pain, haemoptysis, cough, dyspnoea, bleeding 8-30 Gy 1-10 fractions.
47
What are the early reactions to radiotherapy?
``` Tiredness Skin reaction: erythema --> ulceration Mucositis (painful ulceration and damage to mucous membranes) N/V Diarrhoea Cystitis BM suppression ```
48
Late reactions for radiotherapy?
Brachial plexopathy - follows axillary radiotherapy - Numb, weak, painful arm Lymphoedema Pneumonitis - Dry cough ± dyspnoea - manage: prednisolone ``` Xerostomia Benign strictures Fistulae Decreased fertility Panhypopituitarism ```
49
Surgery for cancer therapy
Diagnostics: tissue biopsy Excision: GI, soft-tissue sarcoma, gynae Palliation: Bypass procedure, stenting.
50
What malignant cancers is AFP used for?
Hepatocellular carcinoma | Teratoma
51
What non- malignant conditions is AFP a marker for?
Hepatitis Cirrhosis Pregnancy
52
What malignant cancers is CA125 used for?
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
What non-malignant conditions is CA125 used for?
Cirrhosis | Pregnancy
54
What malignant cancers is Ca15-3 used for?
Breast
55
What non-malignant conditions is Ca15-3 used for?
Benign breast diseaase
56
What malignant cancers is Ca19-9 used for?
Pancreas Cholangiocarcinoma CRC
57
What non-malignant cancers is Ca19-9 used for?
Cholestatis | Pancreatitis
58
What malignant cancers is Ca 27-29 used for?
Breast
59
What malignant cancers is Neuron-Specific enolase used for?
SCLC
60
What malignant cancers is CEA used for?
CRC - colorectal cancer
61
What non-malignant conditions is CEA used for?
Pancreatitis | Cirrhosis
62
What malignant cancers is B-HCG used for?
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
What malignant cancers is PSA used for?
Prostate (non-malignant = BPH)
64
What malignant cancers is mono Ig used for?
Multiple Myeloma
65
What malignant cancers is S-100 used for?
Melanoma (benign in Sarcoma)
66
What malignant cancers is PLAP used for?
Seminoma
67
What malignant cancers is acid phosphatases used for?
Prostate
68
What malignant cancers is thyroglobulin used for?
Thyroid cancer
69
Bombesin
Small cell lung carcinoma Gastric cancer Neuroblastoma
70
Spinal cord compression
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
Irinotecan (Topoisomerase I)
Myelosuppression
72
Cisplatin SE
Ototoxicity, peripheral neuropathy, Hypomagnesaemia
73
Hydroxyurea SE
Myelosuppression
74
Toxicity Bear?
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
Nivolumab MOA and use?
Immune checkpoint inhibitor = PD-1. Treatments for melanoma, Hodgkin's lymphoma, NSCLC, uro cancers
76
Ipilimumab MOA and use?
CTLA-4 (cytotoxic T lymphocyte-associated protein 4 for melanoma. Given via injection/IV infusion.
77
Atezolizumab, Avelumab, Durvalumab use?
PD-L1 - treat lung cancer and urothelial cancer.
78
Side effects of checkpoint inhibitors?
``` 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
Woman with bone mets causes?
Most likely to come from breast cancer. Likelihood = Prostate Breast Lung Most common site - Spine - Pelvis - ribs - Skull - Long bones
80
Most common cancers?
1. Breast 2. Lung 3. Colorectal 4. Prostate 5. Bladder 6. Non-Hodgkin's lymphoma 7. Melanoma 8. Stomach 9. Oesophagus 10. Pancreas
81
Most common cause of death from cancer?
1. Lung 2. Colorectal 3. Breast 4. Prostate 5. Pancreas 6. Oesophagus 7. Stomach 8. Bladder 9. Non-Hodgkin's lymphoma 10. Ovarian
82
For patients at low-ris of symptoms of nausea and vomiting?
Use metaclopramide For high-risk patients - 5HT3 receptor antagonist such as ondansetron - especially if combined with dexamethasone. For intracranial tumours -> dexamethasone
83
Features of spinal mets?
- 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
Commonest lung cancer in non-smokers?
Adenocarcinoma - typically peripheral - commonest cancer in non smokers
85
Calcitonin a marker for?
Medullary thyroid cancer (MaiCa)
86
Thyroglobulin a marker for?
Follicular/ papillary cancer (fthapad)
87
Features of Gardner's syndrome?
- 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
Features of Li Fraumeni syndrome?
- 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
Features of lynch syndrome?
- 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
Investigating an unknown primary?
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)

Imperial Medicine Year 3 (35 decks)

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