Oncology / palliative Flashcards
What are the 6 broad N&V syndromes?
- Reduced gastric mobility (e.g. due to opioids)
- chemically mediated (e.g. secondary to hypercalcaemia, opioids or chemotherapy)
- visceral/serosal (e.g. constipation, oral thrush)
- raised ICP (e.g. brain mets)
- vestibular (e.g. opioid, motion or base of skull tumours)
- cortical (e.g. anxiety, fear, pain and/or anticipatory nausea)
N&V caused by reduced gastric mobility first line drug?
metoclopramide OR domperidone
When should metoclopramide not be used?
When pro-kinesis may negatively affect the gastrointestinal tract, particularly in complete bowel obstruction, gastrointestinal perforation, or immediately following gastric surgery
N&V caused by ‘chemically mediated’ drug options?
Ondansetron OR haloperidol OR levomepromazine
N&V caused by ‘visceral/serosal’ causes drug options?
Cyclizine and levomepromazine - first-line
N&V caused by ‘raised ICP’ causes drug options?
Cyclizine
Dexamethasone can also be helpful
N&V caused by ‘vestibular’ causes drug options?
Cyclizine - first line
metoclopramide or prochlorperazine - can be used if refractory vestibular causes
N&V caused by ‘cortical’ causes drug options?
- may not be needed if short lasting
- benzodiazapines e.g. lorazepam can be tried
- cyclizine may be useful
How do you convert oral codeine to oral morphine dose?
divide by 10
How do you convert oral tramadol to oral morphine dose?
divide by 10
Oral morphine to subcut morphine conversion factor?
divide by 2
Oral morphine to subcut dimorphine conversion factor?
divide by 3
Oral oxycodone to subcut dimorphine conversion factor?
divide by 1.5
Oral morphine to oral oxycodone conversion factor?
divide by 1.5 or 2 (depending on guidelines)
Mild-moderate renal failure in palliative patients - which pain drug preferred?
oxycodone (instead of morphine)
Severe renal failure in palliative patients - which pain drug preferred?
Alfentanil OR buprenorphine OR fentanyl
Which tumour marker is associated with pancreatic cancer?
CA 19-9
Which tumour marker is associated with breast cancer?
CA 15-3
What is the tumour marker S-100 associated with?
Melanoma, schwannomas
What is the tumour marker bombesin associated with?
Small cell lung carcinoma, gastric cancer, neuroblastoma
How to calculate breakthrough dose of morphine?
1/6th of daily morphine dose
Management of secretions in a palliative setting?
Hyoscine hydrobromide OR hyoscine butylbromide
In palliative care, if pain is not controlled on current dose of morphine then by how much do you increase dose?
30-50%
What is a sarcoma?
A group of malignant tumours originating from mesenchymal tissue.
can be either bone or soft tissue
Presentation of sarcoma?
- Pain - more common in bone sarcoma
- Swelling/ palpable mass - more common in soft tissue sarcoma
- impaired function
- pathological fracture
- systemic features - weight loss, fever, fatigue
Investigations for sarcoma?
Imaging - CT, XRAY, PET, MRI
biopsy
Management of sarcoma?
Surgery - complete resection
radiation therapy
chemotherapy
Targeted therapy - depends on type
Immunotherapy
Child with unexplained bone pain +/- swelling management?
very urgent direct access xray within 48 hours -> if features suggestive of sarcoma then urgent assessment within 48 hours.
X-RAY shows codman triangle + ‘sun-burst’ appearance = ?
osteosarcoma
Pre-menopausal woman + oestrogen receptor +ve breast cancer drug treatment?
Tamoxifen
Post-menopausal woman + oestrogen receptor +ve breast cancer drug treatment?
Anastrozole
Drug treatment in HER2 receptor +ve breast cancer?
Trastuzumab (Herceptin)
X-RAY shows ‘onion skin’ appearance = ?
Ewing’s sarcoma
Risk factors for bowel cancer?
- FH
- Familial adenomatous polyposis (FAP)
- Hereditary nonpolyposis colorectal cancer (HNPCC), (Lynch syndrome)
- IBD
- Increased age
- Diet (high in red and processed meat and low in fibre)
- Obesity and sedentary lifestyle
- Smoking
- Alcohol
What is Familial adenomatous polyposis (FAP)?
An autosomal dominant condition involving malfunctioning of the tumour suppressor genes called adenomatous polyposis coli (APC). It results in many polyps (adenomas) developing along the large intestine. These polyps have the potential to become cancerous (usually before the age of 40).
How is FAP usually managed?
Patients have their entire large intestine removed prophylactically to prevent the development of bowel cancer (panproctocolectomy).
What is HNCPP?
It is an autosomal dominant condition that results from mutations in DNA mismatch repair (MMR) genes. Patients are at a higher risk of a number of cancers, but particularly colorectal cancer. Unlike FAP, it does not cause adenomas and tumours develop in isolation.
NICE ‘two week’ referral guidelines on suspicion of bowel cancer include?
> 40 years with abdominal pain and unexplained weight loss
50 years with unexplained rectal bleeding
60 years with a change in bowel habit or iron deficiency anaemia
Presentation of bowel cancer?
- Change in bowel habit (usually to more loose and frequent stools)
- Unexplained weight loss
- Rectal bleeding
- Unexplained abdominal pain
- Iron deficiency anaemia (microcytic anaemia with low ferritin)
- Abdominal or rectal mass on examination
Which test could you do in GP to screen for bowel cancer?
FIT (Faecal immunochemical tests)
What is the screening program for bowel cancer (scotland)?
FIT test every 2 years from ages 50-74y
Investigations for bowel cancer?
- colonoscopy +/- biopsy - GOLD STANDARD
- sigmoidoscopy (if rectal bleeding only)
- CT colonography (if patient unfit for colonoscopy)
- staging CT - CT thorax, abdomen and pelvis (checks for metastases)
- CEA - useful for checking risk of relapse or staging disease (NOT SCREENING)
Classification system for bowel cancer?
TNM (previously Duke’s)
Management of bowel cancer?
Depends on patient but:
- surgery - most common
- chemotherapy
-radiotherapy
- palliative care
Which surgical operation if cancer is affecting caecum, ascending and proximal transverse colon?
Right hemicolectomy
Which surgical operation if cancer is affecting distal transverse and descending colon?
Left hemicolectomy
Which surgical operation if cancer is affecting sigmoid colon?
High anterior resection (sigmoid colectomy)
Which surgical operation if cancer is affecting sigmoid colon and upper rectum?
Low anterior resection
Which surgical operation if cancer is affecting anal verge?
Abdomino-perineal resection (APR)
What is a Hartmann’s procedure + indications?
An emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date. Common indications are acute obstruction by a tumour, or significant diverticular disease.
Most common type of anal cancer?
Squamous cell carcinoma (80%)
Most common cause of anal cancer?
HPV 16 and 18 (85%)
Presentation of anal cancer?
- Perianal pain, perianal bleeding
- A palpable lesion
- Faecal incontinence
- A neglected tumour in a female may present with a rectovaginal fistula.
What cancers is tumour lysis syndrome associated with?
lymphomas
germ cell tumours (testes)
prophylaxis for tumour lysis syndrome?
hydration (3L a day) +/- Allopurinal 300mg (max 7 days)
Presentation of tumour lysis syndrome?
- oliguria / AKI
- cardiac arrhythmia
- seizure
- high K+
- high phosphate
- high urate
- low calcium
Management of tumour lysis syndrome?
- Fluid resus (IV, 3-4L a day)
- correct cardiac arrhythmia + hyperkalaemia (calcium gluconate)
- monitoring + allopurinol
- if resistant then consider dialysis
Most common type of malignancy to cause bone invasion?
prostate
thyroid
breast
myeloma
lung
Which cancer can produce PTH as a paraneoplastic syndrome?
Squamous cell carcinoma of the lung
Management of hypercalcaemia?
IV fluids (1-3L)
Then check calcium…
- if between 2.5 to 3 mmol/l - disodium pamidronate
- if >3mmol/l then zoledronic acid
(bisophonates)
Presentation of malignant spinal cord compression?
- back pain
- pain worse on coughing / straining
- new difficulty walking
- bladder/bowel issues
investigations for MSCC?
- full neuro exam
- MRI full spine
Management of Metastatic spinal cord compression?
analgesia + PT/OT
- steroids (dexamethasone) - START AS SOON AS POSSIBLE
- radiotherapy or neurosurgery
What needs to be co-prescribed with dexamethasone and what should be monitored?
PPI and monitor BM
presentation of raised ICP?
- headache with nausea
- weakness / vague symptoms
- vomiting
- personality changes / memory loss
- visual disorders
- seizures
Investigations for raised ICP?
- neuro exam
- imaging - URGENT CT head and MRI
Management of raised ICP?
- steroids as soon as possible
- surgery or radiotherapy
presentation of SVCO?
haemodynamic compromise
redness of face
facial swelling
JVP distension
cynanosis
syncope
coma
Investigations for SVCO?
CXR - widened mediastinum, mass lesion
CT chest
Treatment for SVCO?
stent or radiotherapy - only if stridor or respiratory compromise
dexamethasone - initial
Presentation of neutropenic sepsis?
7-14 days after chemotherapy
fever
low neutrophils
antibiotic for neutropenic sepsis
Tazocin (within 1 hour)
if allergic to penicillin then teicoplanin and aztreonam
symptoms of opioid overdose?
pinpoint pupils
drowsy
resp depression
choking / gurgling sounds
pale, blue, cold skin
hallucinations
vivid dreams
myclonic jerks
symptoms/signs of carcinoid syndrome?
- Flushing
- diarrhoea
- hypotension
- bronchospasm
- right heart valve stenosis (can also occur on left side if tumour originating in lungs)
- cushings syndrome - if ACTH and GHRH is also released
Investigations for carcinoid syndrome?
urinary 5-HIAA
plasma chromogranin A y
Management of carcinoid syndrome?
- somatostatin analogues e.g. octreotide
- diarrhoea: cyproheptadine may help
Which areas of the body are not typically reached by chemotherapy?
CNS and testes
Neck lump + pain when drinking alcohol?
Hodgkins lymphoma
Cancers which commonly metastasis to the bone?
breast, lung, prostate, kidney and thyroid
Carcinoid syndrome management?
somatostatin analogue (e.g. octreotide) + surgery
