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OPB Flashcards

1
Q

Incidence of breast cancer

A

1 in 8 women

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2
Q

Most common cancer in women

A

Breast cancer

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3
Q

2 most common cancers overall

A

1) Lung

2) Breast

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4
Q

Risk factors for breast cancer

A
  • Age >50
  • Benign breast disease
  • Proliferative types of hyperplasia
  • Exposure to ionising radiation
  • Later first child birth
  • History of breast cancer
  • Family history of breast or ovarian cancer in a 1st degree relative
  • Hormone therapy use
  • Nulliparity
  • Obesity
  • Alcohol
  • No breast-feeding
  • Elevated endogenous oestrogen levels
  • Hormonal contraceptive use
  • Increased mammography density of breast tissue
  • Menarche <12
  • Menopause >45
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5
Q

Features which may make you suspect inflammatory breast cancer

A
  • Erythema
  • Oedema
  • Peau d’orange
  • Nipple retraction
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6
Q

Clinical features of breast cancer

A
  • Breast lump
  • Change in shape of breast
  • Nipple discharge
  • Skin changes
  • Pain
  • Ulceration
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7
Q

Most common sites of metastasis for breast cancer

A
  • Bone
  • Lung
  • Liver
  • Pleura
  • Adrenal glands
  • Skin
  • Brain
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8
Q

Investigations to consider in a patient with ?breast cancer

A
  • Mammogram (>40 years old)
  • US (<40 years old)
  • MRI
  • FNA/core biopsy/vacuum assisted biopsy
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9
Q

Factors influencing choice of surgical management option in breast cancer patients

A
  • Patient age
  • Comorbidities
  • Patient preference
  • Tumour stage (size, lymphovascular invasion, nodal involvement, location)
  • Tumour biomarkers
  • Tumour: breast size ratio
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10
Q

Contra-indications for breast conservation surgery/wide local incision/lumpectomy in breast cancer patients?

A
  • Large primary tumour
  • Central primary tumour
  • Small breast size
  • Patient unfit for surgery/follow up radiotherapy
  • Severe lung/heart disease
  • Pes excavatum
  • Chronic lack of mobility at ipsilateral shoulder
  • Kyphoscoliosis
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11
Q

Indications for mastectomy (rather than WLE) in breast cancer patients

A
  • Multifocal disease
  • Bilateral disease where it is not possible to conserve the breasts
  • Extensive DCIS
  • Patients unsuitable for breast radiotherapy
  • Significant family history of risk regarding procedures
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12
Q

Indications for axillary sampling (rather than axillary clearance)

A
  • Negative findings on US of the axilla +/- biopsy

- High upper quadrant tumour (avoid irradiation of ‘cleared’ axilla)

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13
Q

Indications for axillary clearance (rather than axillary sampling)

A
  • Histologically confirmed invasive breast cancer/ >1 node axilla biopsy confirmed malignant
  • Patient preference
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14
Q

Main complication of axillary clearance

A

Lymphoedema

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15
Q

Aim of adjuvant therapy in breast cancer patients

A

Aim to reduce risk of recurrence locally or systemically

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16
Q

Indications for breast adjuvant radiotherapy in breast cancer patients

A
  • No lymph node metastases in an adequate axillary node sample (4 nodes)
  • <4 nodes involved in an adequate axillary node clearance (10 nodes)
  • Invasive disease with inadequate excision margins unsuitable for re-excision
  • Conserved breast unsuitable for excision
  • T4 disease at presentation
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17
Q

Indications for chest wall radiotherapy after mastectomy in breast cancer patients

A
  • Tumour size >5cm
  • 4 or more involved nodes
  • Involved resection margins
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18
Q

Indications for adjuvant chemotherapy after surgery in breast cancer patients

A
  • High-risk early breast cancer
  • Grade 3
  • LVI
  • Nodal involvement
  • Triple negative
  • HER2+
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19
Q

Main hormonal treatment of breast cancer in pre-menopausal women

A
  • 5 years Tamoxifen

OR

  • 5 years tamoxifen + another 5 years (if still pre-menopausal) or 5 years of letrozole (if post-menopausal)
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20
Q

Main hormonal treatments of breast cancer in post-menopausal women

A
  • 5 years tamoxifen

OR

  • 5 years tamoxifen + 5 years letrozole

OR

  • 5 years letrozole
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21
Q

Indications for 5 years of tamoxifen treatment in pre-menopausal women with breast cancer

A
  • Grade 1-2
  • T1 <2cm
  • Node -
  • ER+
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22
Q

Indications for 10 years of tamoxifen or 5 years or tamoxifen + 5 years letrozole in pre-menopausal women with breast cancer

A
  • T2-4
  • Grade 3
  • Node +
  • HER2+
  • ER poor
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23
Q

Indications for 5 years of treatment with tamoxifen in post-menopausal women with breast cancer

A
  • Grade 1-2
  • T1 <2cm
  • Node -
  • ER+
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24
Q

Indications for 5 years of treatment with tamoxifen + 5 years with letrozole in post-menopausal women with breast cancer

A
  • Grade 2
  • T2 >2cm
  • Node -
  • ER+
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25
Q

Indications for 5 years of treatment with letrozole in post-menopausal women with breast cancer

A
  • Grade 3
  • T3-4
  • Node +
  • HER2+
  • ER poor
  • Response to neo-adjuvant aromatase inhibitors
  • Tamoxifen contra-indicated
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26
Q

What scan needs to be done before starting a breast cancer patient on letrozole

A

DEXA scan

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27
Q

How would you check menopausal status in patients on tamoxifen?

A

Check hormone levels after 6 weeks off tamoxifen

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28
Q

How would you confirm menopause in a women <50 on tamoxifen?

A
  • FSH >30 on 2 occasions >6 weeks apart
    AND
  • Amenorrhoeic for 24 months
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29
Q

How would you confirm menopause in a women 50-54 on tamoxifen?

A
  • FSH >30 on 2 occasions >6 weeks apart
    AND
  • Amenorrhoeic for 12 months
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30
Q

Which group of breast cancer patients should be offered immunotherapy, and what treatment would you offer?

A
  • HER2 + patients

- Herceptin for 6-12 months

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31
Q

Features that increase risk of breast cancer recurrence

A
  • Tumour size >1cm
  • ER-
  • Involvement of lymph nodes
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32
Q

Long-term follow up of ‘cured’ breast cancer patients

A

YEAR 1

  • Clinical examination and mammogram
  • Check family history and consider genetic testing

YEAR 2-4

  • Mammogram
  • Clinical examination if bilateral mastectomy performed

YEAR 5

  • Clinical examination and mammogram
  • Consider changing endocrine therapy

YEAR 6-10
- Mammogram

Year 10

  • Mammogram with clinical examination
  • Stop endocrine therapy as appropriate
  • Discharge to breast screening programme
  • Contact genetics if high risk patient
  • Reassess family history and consider genetic referral
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33
Q

Define neutropenic sepsis

A

WCC <1 + pyrexia as a potential complication of systemic anti-cancer treatment

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34
Q

When are patients on SACT at risk of neutropenic sepsis?

A

Days 7-21 post-treatment

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35
Q

Risk factors for neutropenic sepsis

A
  • Age >65
  • Poor performance status
  • Previous neutropenic sepsis
  • Combined chemotherapy + radiotherapy
  • Poor nutrition
  • Advanced disease
  • Co-morbidities
  • Active infection
  • Central venous catheters
  • Surgical wounds
  • Previous MRSA colonisation
  • Unwell contacts
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36
Q

Clinical features of neutropenic sepsis

A
  • Pyrexia (temp >37.5 or <36)
  • Malaise
  • Infective symptoms e.g. cough
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37
Q

What scoring assessment is used for initial assessment of patients with ?neutropenic sepsis

A

Formal risk assessment - combines NEWS score and MASCC score (maximum score is 26 - patients <21 or with NEWS Score >6 are high risk)

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38
Q

What investigations would you carry out in a patient with ?neutropenic sepsis?

A
  • Clinical examination (including mouth and perineum) for signs of infection
  • Daily bloods (CRP, FBC, U&Es, LFTs) while on antibiotics - must be requested URGENTLY on admission and following day
  • Peripheral (and central) blood cultures
  • Viral throat swabs
  • Urine dipstick and MSU
  • CXR
  • Consider abdominal x-ray and CT or stool cultures for C. diff
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39
Q

Antibiotic choice in patients with standard risk neutropenic sepsis

A

1) IV piperacillin/tazobactam 4.5g qds

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40
Q

Antibiotic choice in patients with high risk neutropenic sepsis

A

1) IV piperacillin/tazobactam 4.5g qds + IV gentamicin

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41
Q

Side effects of Tazocin

A
  • GI upset
  • Rash, pruritis
  • Phlebitis
  • Insomnia
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42
Q

Side effects of Gentamicin

A
  • Neurotoxicity (vertigo, gait instability)
  • Ototoxicity
  • Nephrotoxicity
  • Oedema
  • Rash, pruritis
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43
Q

What does dose regime of Tazocin depend on

A

Renal function - creatinine clearance determines if Tazocin is given bd, td or qds

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44
Q

Antibiotic management of a patient with neutropenic sepsis with previous MRSA or presumed central line infection

A

1) IV Tazocin + Vancomycin

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45
Q

Antibiotic management of a patient with neutropenic sepsis with suspected atypical pneumonia

A

1) IV Tazocin + Clarithromycin

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46
Q

Side effects of Vancomycin

A
  • Anaphylactic reaction
  • ‘Red man’ syndrome
  • Back pain
  • Bradycardia
  • Chest pain
  • Dyspnoea
  • Hearing loss
  • Hypotension
  • Muscle pain
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47
Q

Side effects of clarithromycin

A
  • Decreased appetite
  • GI upset
  • Dizziness
  • Headache
  • Insomnia
  • Pancreatitis
  • Skin reactions
  • Vasodilation
  • Vision disorders
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48
Q

What would you recommend in regards to chemotherapy treatment in a patient recovering from neutropenic sepsis?

A
  • Reduce dose of chemotherapy

OR

  • Delay chemotherapy cycle by a week
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49
Q

Clinical features of malignant spinal cord compression

A
  • Pain (most commonly in the back, exaggerated by coughing and straining, and in a radicular pattern)
  • Weakness
  • Bowel problems
  • Altered sensation
  • Urinary incontinence
  • Faecal incontinence
  • Bilateral sciatica
  • Saddle anaesthesia
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50
Q

Radicular pain in a patient with previous/current malignancy is ??? until proven otherwise

A

malignant spinal cord compression

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51
Q

What is the 1st line investigation in a patient with ?malignant spinal cord compression

A

URGENT MRI of the WHOLE spine (within 24 hours)

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52
Q

Management options for a patient with malignant spinal cord compression

A

1) 16mg PO dexamethasone (as a ‘holding measure’) followed by 8mg bd dexamethasone + PPI cover (given in the daytime)
2) Radiotherapy (20Gy in 5 fractions) to the affected area and 1-2 vertebrae above and below

OR

Surgery (fixation of the affected vertebrae) (1st line in indicated patients)

Or

OR

Chemotherapy (for sensitive tumours)

OR

Hormone treatment (in metastatic prostate cancer)

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53
Q

Side effects of lumbar spine radiotherapy

A
  • Skin reaction
  • Fatigue
  • Cystitis
  • Diarrhoea
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54
Q

Indications for surgery in patients with malignant spinal cord compression

A
  • Single vertebral region of involvement
  • No evidence of widespread metastasis
  • Radio-resistant primary tumour (e.g. renal, sarcoma)
  • Previous radiotherapy to a affected site)
  • Unknown primary (allows us to get tissue for histology)
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55
Q

Causes of SVC obstruction

A
  • Bronchus cancer
  • Lung cancer (SCLC)
  • Lymphoma
  • Other malignancy
  • Aneurysms
  • Goitre
  • Fibrosis
  • Infection
  • Central line in situ
  • Thrombosis
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56
Q

Clinical features of SVC obstruction

A
  • Swelling of face, neck, one/both arms
  • Distended veins
  • Shortness of breath
  • Lethargy
  • Headache
  • Nasal congestion
  • Epistaxis
  • Dizziness
  • Syncope
    Symptoms are often worse on bending forward or lying down
  • Neck veins don’t collapse on compression
  • Visible veins
  • Raised JVP
  • Arm oedema
  • Plethora
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57
Q

Investigations to consider in a patient with SVC obstruction

A

1) CXR (looking for a mass)
2) CT chest with contrast (provides 3D information about the cause - contrast will accumulate in the area before the obstruction)
3) Venogram
4) Routine bloods and coagulation screen

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58
Q

Management of a patient with malignant SVC obstruction

A

Dexamethasone is often given first line (although there is limited evidence for this)

1) Radiological stenting
2) Chemotherapy (in SCLC, lymphoma, teratoma)
OR
Radiotherapy (in other malignant causes)

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59
Q

Define malignant hypercalcemia

A

Corrected serum calcium >2.65 mmol/L on two occasions in patients with malignancy

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60
Q

3 most common causes of malignant hypercalcemia

A
  • Lung cancer
  • Breast cancer
  • Multiple myeloma
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61
Q

Differentials for malignant hypercalcemia

A
  • Brain/bony metastasis
  • Delirium
  • Paraneoplastic syndrome
  • Electrolyte imbalances
  • Infection
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62
Q

Clinical features of malignant hypercalcemia

A

May be asymptomatic (particularly in mild cases)

  • Bone pain, pathological fractures
  • Delirium, drowsiness, coma
  • Fatigue
  • Muscle weakness
  • Impaired concentration and memory
  • Depression
  • GI upset
  • Polyuria, polydipsia and dehydration
  • Renal colic, renal stones, renal impairment
  • Hypertension
  • Shortened QT on ECG
  • Pruritus
  • Eye infections, corneal calcifications
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63
Q

Investigations to consider in a patient with ?malignant hypercalcemia

A
  • General infection screen e.g. MSU
  • Routine bloods including calcium and PTH
  • CT head (rule out brain metastasis)
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64
Q

Management of a patient with malignant hypercalcemia

A

1) Adequate rehydration to correct dehydration
- Oral rehydration if appropriate
- 3L of 0.9% NaCl over 24 hours

2) IV zolendronate 4mg over 15 mins in 100ml 0.9% NaCl (if eGFR >30)
OR
Pamidronate (if eGFR <30)

3) Review medications affecting renal function (e.g. NSAIDs, diuretics, ACE inhibitors)
4) Check U&Es in 3-4 days

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65
Q

Management of a patient with neutropenic sepsis with a penicillin allergy

A

1) IV Vancomycin + Metronidazole + PO Ciprofloxacin

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66
Q

Side effects of metronidazole

A
  • Dry mouth
  • Myalgia
  • GI upset
  • Metallic taste
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67
Q

Side effects of ciprofloxacin

A
  • Tendon damage
  • Arthralgia, myalgia
  • GI upset
  • Dizziness
  • Dyspnoea
  • Fever
  • Headache
  • QT prolongation
  • Skin reactions
  • Sleep disorders
  • Altered taste
  • Tinnitus
  • Vision disorders
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68
Q

Oral antibiotic stepdown in patients with neutropenic sepsis

A

Co-amoxiclav + ciprofloxacin

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69
Q

Indications for GCS-F in patients with neutropenic sepsis

A
  • Profound neutropenia (<0.1)
  • Prolonged neutropenia (> 10 days)
  • Pneumonia
  • Hypotension
  • Multi-organ dysfunction
  • Uncontrolled primary disease
  • Invasive fungal infection
  • Age >65
  • Hospital inpatient at time of developing fever
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70
Q

Most common malignant causes of spinal cord compression

A
  • Breast
  • Lung
  • Prostate
  • Multiple myeloma
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71
Q

What is the scoring system used to consider surgery in patients with malignant spinal cord compression, and what factors does it take into account?

A

Tokuhasi score:

  • Patient’s general condition
  • Number of extra-spinal bone metastasis
  • Number of spinal bone metastasis
  • Metastasis in major organs
  • Primary site of cancer
  • Neurological deficit
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72
Q

What blood tests should you request to monitor a patient on bisphosphonates

A
  • Renal function
  • Calcium
  • Phosphate
  • Potassium
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73
Q

Side effects of bisphosphonates

A
  • GI upset
  • Flu-like symptoms
  • Osteonecrosis of the jaw
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74
Q

Mechanism of action of Tamoxifen

A

Oestrogen receptor antagonist

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75
Q

Route of administration of Tamoxifen

A

Oral

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76
Q

Indications for Tamoxifen

A
  • ER+ breast cancer (as adjuvant or neb-adjuvant therapy) post-surgery/radiotherapy in pre- or peri-menopausal women
  • Breast cancer patients for 5 years after tumour removal
  • Primary prevention of breast cancer (in women >30 with moderate/high risk)
  • Gynaecomastia in males
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77
Q

Contraindications for tamoxifen

A
  • Family/personal history of idiopathic VTE
  • Pregnancy
  • Concurrent anastrozole therapy
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78
Q

Side effects of tamoxifen

A

MOST IMPORTANT:

1) endometrial changes (hyperplasia, polyps, cancer, uterine sarcoma)
2) Increased risk of thromboembolism

  • Alopecia
  • Anaemia
  • Cataracts
  • Cerebral ischaemia
  • Fatigue
  • Fluid retention
  • Headache
  • Hot flushes
  • Nausea
  • Retinopathy

Tamoxifen DOES NOT affect bone mineral density

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79
Q

Route of administration of aromatase inhibitors

A

Oral

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80
Q

Indications for letrozole

A
  • Adjuvant treatment of ER+ invasive early breast cancer in post-menopausal women
  • 1st line treatment in ER/PR+ or ER/PR status unknown locally advanced or metastatic breast cancer in post-menopausal women
  • Extended adjuvant therapy of early breast cancer in post-menopausal women who have received 5 years of adjuvant tamoxifen
  • Treatment of advanced breast cancer in post-menopausal women where other anti-oestrogen therapy has failed
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81
Q

Indications for exemestane

A
  • Adjuvant treatment of ER+ early breast cancer in post-menopausal women following 2-3 years of tamoxifen
  • Advanced breast cancer in post-menopausal women where anti-oestrogen therapy has failure
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82
Q

Indications for anastrozole

A
  • Adjuvant treatment of ER+ early invasive breast cancer in post-menopausal women
  • Adjuvant treatment of ER+ early breast cancer in post-menopausal women following 2-3 years of tamoxifen
  • Advanced breast cancer in post-menopausal women which is ER+ or responsive to Tamoxifen
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83
Q

Contra-indications for aromatase inhibitors

A
  • Pre-menopausal women

- Pregnancy and breast feeding

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84
Q

Side effects of aromatase inhibitors

A

MOST IMPORTANT:
1) Decreased bone mineral density/osteoporosis

  • Alopecia
  • Arthralgia
  • Hot flushes
  • Vaginal dryness
  • Oedema
  • Bone pain
  • Headache
  • GI upset
  • Carpal tunnel syndrome
  • Insomnia
  • Leucopenia
  • Thrombocytopenia
  • Skin reactions
85
Q

Monitoring required during aromatase inhibitor treatment

A
  • Bone mineral density
86
Q

Mechanism of action of Goserelin

A

GnRH receptor antagonist

87
Q

Route of administration of Goserelin

A

SC injection into anterior abdominal wall

88
Q

Indications for Goserelin

A
  • Locally advanced prostate cancer (as an alternative to surgery)
  • Adjuvant/neoadjuvant treatment to radiotherapy/radical prostatectomy in patients with high-risk localised or locally advanced prostate cancer
  • Metastatic prostate cancer
  • Advanced breast cancer
  • ER+ early breast cancer
89
Q

Contra-indications for Goserelin

A
  • Undiagnosed vaginal bleeding

- Use for >6 months in endometriosis

90
Q

Side effects of Goserelin

A
  • Alopecia
  • Pain
  • Breast abnormalities
  • Altered mood, depression
  • Impaired glucose tolerance
  • Gynaecomastia
  • Headache
  • Heart failure
  • Hot flushes
  • Hyperhidrosis
  • MI
  • Neoplasm complications
  • Parasthesia
  • Sexual dysfunction
  • Skin reactions
  • Spinal cord compression
  • Vulvovaginal disorders
  • Weight gain
91
Q

Monitoring required on Goserelin

A
  • Men at risk of ‘tumour flare’ (temporary worsening of disease) should be closely monitored during first month of treatment for prostate cancer
  • Monitor for QT-prolongation and ventricular arrhythmia (in patients on QT-prolonging agents)
92
Q

Drug interactions of Goserelin

A

Goserelin interacts with QT-prolonging agents

93
Q

Mechanism of action of Herceptin

A

Monoclonal antibody which down-regulates HER2

94
Q

Route of administration of Herceptin

A

SC injection or IV infusion

95
Q

Indications for Herceptin

A
  • Early HER2+ breast cancer
  • Metastatic HER2+ breast cancer in patients who have not received chemotherapy and where Anthracyclines treatment is inappropriate (given in combination with paclitaxel or docetexal)
  • Monotherapy for metastatic breast cancer patients who have previously received at least 2 chemotherapy agents
  • Metastatic HER2+, ER/PR+ breast cancer in post-menopausal women not previously treated with Herceptin
  • Metastatic HER2+ gastric cancer
96
Q

Contra-indications for Herceptin

A
  • Severe dyspnoea at rest

- Pregnancy, breast-feeding

97
Q

Side effects of Herceptin

A

MOST IMPORTANT:
1) Decreased ejection fraction and congestive heart failure

  • Headache
  • GI upset
  • Insomnia
  • Cough
  • Rash
  • Cardiac disorders
  • Infection (including neutropenic sepsis)
  • Pancytopenia
  • Fatigue, malaise, pain
  • Tremor
  • Dizziness
  • Parasthesia
  • Altered sense of taste
  • Hot flushes
  • Respiratory symptoms
  • Swollen face
  • Alopecia
  • Nail disorders
  • Hand-foot syndrome
  • Peripheral oedema
98
Q

Monitoring required when on Herceptin

A

Regular echocardiograms to assess ejection fraction

99
Q

Mechanism of action of Imatinib

A

Tyrosine kinase inhibitor - inhibits BCR-ABL in the Philadelphia chromosome and c-Kit

100
Q

Route of administration of Imatinib

A

Orally with food

101
Q

Indications for Imatinib

A
  • Philadelphia+ CML
  • Philadelphia+ ALL
  • C-KIT+ GIST
102
Q

Side effects of Imatinib

A

MOST IMPORTANT:

1) Hepatotoxicity
2) Cardiac toxicity

  • Pancytopenia
  • Fluid retention
  • GI upset
  • Photosensitivity
  • Alopecia
  • Myalgia, arthralgia
  • Blurred vision
  • Taste alteration
  • Skin changes
103
Q

Monitoring required when on Imatinib

A
  • FBC
  • LFTs
  • Monitor for GI haemorrhage
  • Monitor for fluid retention
  • Monitor for growth retardation (in children)
104
Q

Drug interactions with Imatinib

A
  • CYPA34 inhibitors (erythromycin) and inducers (carbamazepine, St JOhn’s wort)
  • Warfarin
105
Q

Mechanism of action of Capecitabine

A

Anti-metabolite - converted into fluorouracil in the tumour to inhibit DNA synthesis and slow tumour growth

106
Q

Route of administration of Capecitabine

A

Orally after a meal, bi-daily

Given for 14 days followed by a 7 day interval (course of 6 months)

107
Q

Indications for Capecitabine

A
  • Monotherapy is first line treatment of advanced colorectal cancer
  • Adjuvant therapy of patients with stage III colon cancer
  • Advanced gastric cancer
  • In combination with Docetexal in locally advanced or metastatic breast cancer
  • Monotherapy in advanced breast cancer after failure or taxmen and anthracyclines chemotherapy
108
Q

Contra-indications for Capecitabine

A
  • Dihydropyrimidine dehydrogenase deficiency
  • Severe liver dysfunction
  • Severe renal impairment
  • Thrombocytopenia
  • Neutropenia
  • Pregnancy/breast feeding
109
Q

Side effects of Capecitabine

A
  • GI upset and appetite suppression
  • Eye irritation
  • Fever
  • Alopecia
  • Stomatitis
  • Myelosuppression
  • Headache
  • Fatigue
  • Shortness of breath
  • Hand-foot syndrome
  • Weakness
  • Dermatitis
  • Pain
  • Peripheral oedema
110
Q

Monitoring required when on Capecitabine

A
  • Serum calcium
  • Monitoring for eye disorders
  • Monitoring for severe skin reactions e.g. Stevens-Johnson syndrome and toxic epidermal necrosis - discontinue permanently if these occur
111
Q

Mechanism of action of Rituximab

A

Anti-lymphocytic monoclonal antibody - causes apoptosis of B lymphocytes

112
Q

Route of administration of Rituximab

A

IV (or SC for non-Hodgkin’s lymphoma)

113
Q

Indications for Rituximab

A
  • Non-Hodgkin’s lymphoma
  • CLL
  • Autoimmune disease e.g. RA, SLE
114
Q

Contra-indications for Rituximab

A
  • Severe infection

- Severe heart failure, severe uncontrolled heart disease (when used for autoimmune disease)

115
Q

Side effects of Rituximab

A

MOST IMPORTANT:

1) Reactivation of Hepatitis B and TB infection
2) Induced serum sickness (triad of arthralgia, fever and rash)
3) Cytokine-releasing syndrome

Transient hypotension occurs frequently during infusion.

  • Angioedema
  • Anxiety
  • GI upset
  • Arrhythmia
  • Bone marrow disorders
  • Bursitis
  • Cancer pain
  • Cardiac disorders
  • Chest pain
  • Infection
  • Dizziness
  • Dysphagia, throat pain
  • Ear pain
  • Electrolyte imbalance
  • Hypercholesterolaemia
  • Hyperglycaemia
  • Hyperhidrosis
  • Insomnia
  • Lacrimation disorders
  • Malaise
  • Migraine
  • Multi-organ failure
  • Myalgia
  • Increased muscle tone
  • Nerve disorders
  • Oedema
  • Oral disorders
  • OA
  • Respiratory disorders
  • Abnormal sensation
  • Skin reactions
  • Tinnitus
116
Q

Screening required before starting Rituximab

A

Hepatitis B and TB screen

117
Q

Management steps for pain

A

1) Mild pain
- Paracetamol 1g qds
OR
- NSAID
(Reduce dose of paracetamol in poor nutritional status, low body weight, hepatic impairment, chronic alcohol abuse)

2) Mild-moderate pain
- ADD a weak opioid (codeine or dihydrocodeine 30-60mg qds)
OR
- Switch to a combined paracetamol codeine preparation (co-codamol 30/500, 2 tablets qds)
(Consider prescribing a laxative or anti-emetic)

3) Moderate-severe pain
- Switch from a weak to a strong opioid (24mg oral morphine in 24 hours)

118
Q

Adjuvant therapies available for pain management in palliative care

A
  • NSAID (bone pain, liver pain, soft tissue infiltration inflammatory pain)
  • Anti-depressants/anti-convulsants (nerve pain) - should be started at a low dose and titrated slowly
  • Dexamethasone (raised ICP, neuropathic or liver capsule pain)
  • TENS
  • Nerve block
  • Radiotherapy
  • Surgery
  • Bisphosphonates
  • Ketamine
  • Smooth/skeletal muscle relaxants
119
Q

NSAID side effects

A
  • GI ulcers/bleeding
  • Renal impairment
  • Fluid retention
  • Adverse cardiac events
120
Q

Amitryptilline side effects

A
  • Confusion
  • Hypotension
  • Dry mouth
  • Use with caution in CVD or risk of seizures
121
Q

Gabapentin side effects

A
  • Sedation
  • Tremor
  • Confusion
  • Use with caution in renal impairment
122
Q

Dexamethasone side effects

A
  • Insomnia
  • GI ulcer
  • Hyperglycaemia
  • Fluid retention
  • Infection e.g. candida
  • Myopathy
123
Q

Dose of breakthrough pain relief (compared to daily pain relief)

A

1/6th-1/10th (given as immediate release form)

124
Q

When should you seek specialist advice regarding pain control in palliative care patients

A
  • > 3 doses breakthrough pain relief given but patient still in pain
  • > 6 doses breakthrough pain relief in 24 hours
125
Q

Opioid management ladder

A

1) Mild-moderate pain:
- Codeine
- Dihydrocodeine
- Tramadol
- Buprenorphine patches

2) Moderate-severe pain:
- Morphine
- Diamorphine

  • Oxycodone
  • Fentanyl patch
  • Alfentanil
  • Fentanyl sublingual/buccal/intra-nasal
  • Hydromorphone
  • Methadone
126
Q

Analgesics to avoid in stage 4/5 CKD

A
  • Codeine
  • Dihydrocodeine
  • Morphine (titrate slowly and monitor in stages 1-3)
  • Diamorphine (titrate slowly and monitor in stages 1-3 and liver impairment)
  • Modified release Oxycodone
127
Q

Contra-indications/cautions for using Tramadol

A
  • Caution in stage 4/5 CKD
  • Caution in severe liver failure
  • CI with Monoamine oxidase inhibitors
  • CI in epilepsy
  • Avoid/use with caution in those on SSRIs or tricyclic antidepressants (risk of serotonin syndrome and lower seizure threshold)
128
Q

Drug of choice for high-dose SC breakthrough pain control injections

A

Diamorphine

129
Q

CIs for oxycodone

A
  • Severe liver impairment
  • Titrate slowly and minter in stages 1-3 CKD
  • CI in stage 4/5 CKD (for modified release form)
130
Q

Indications for fentanyl patch

A

Tolerant to opioids and chronic/stable pain

131
Q

Contra-indications/cautions for fentanyl patch

A
  • Monitor carefully in renal impairment
  • Reduce dose in liver impairment
  • Don’t initiate at end of life if oral route unavailable (can take too long to reach a steady state)
132
Q

Drug of choice for pain control in palliative care if eGFR <30 and a syringe driver is indicated

A

Alfentanil

133
Q

How would you convert a patient from immediate release morphine to modified release morphine?

A

Divide dose of 24 hour morphine by 2 and prescribe 12 hourly

134
Q

How would you convert a dose of an oral weak opioid to oral morphine?

A

Oral codeine/dihydrocodeine/tramadol –> oral morphine: divide dose by 10

135
Q

How would you convert a dose of an oral morphine to SC morphine?

A

Divide dose by 2

136
Q

How would you convert a dose of an oral morphine to SC Diamorphine?

A

Divide dose by 3

137
Q

How would you convert a dose of an oral morphine to oral oxycodone?

A

Divide dose by 2

138
Q

How would you convert a dose of an oral morphine to SC oxycodone?

A

Divide dose by 4

139
Q

How would you convert a dose of an oral oxycodone to SC oxycodone?

A

Divide by 2

140
Q

Precipitating factors for opioid toxicity

A
  • Rapid dose escalation
  • Renal impairment
  • Sepsis
  • Electrolyte abnormalities
  • Drug interactions
141
Q

Symptoms of opioid toxicity

A
  • Persistant sedation
  • Vivid dreams/hallucinations
  • Shadows at edge of visual fields
  • Delirium
  • Muscle twitching/myoclonus/jerking
  • Abnormal skin sensitivity to touch
142
Q

How to manage a patient with opioid toxicity

A
  • Reduce opioid dose by 1/3rd

- Ensure patient is well hydrated

143
Q

4 types of medication that can be prescribed using anticipatory care planning?

A

1) Opioids (for pain or breathlessness) e.g. morphine sulphate
2) Anxiolytic sedative (for anxiety, agitation or breathlessness) e.g. midazolam
3) Anti-secretory (for respiratory secretions) e.g. hyoscine butylbromide
4) Anti-emetic (for nausea and vomiting) e.g. levomepromazine

144
Q

Most common malignant causes of cachexia

A
  • Gastric
  • Pancreatice
  • NSCLC
  • SCLC
  • Prostate
  • Colon
  • NHL
  • Sarcoma
  • Acute non-lymphocytic leukaemia
  • Breast
145
Q

Reversible causes of anorexia

A
  • Pain
  • Breathlessness
  • Depression
  • Ascites
  • Nausea and vomiting
  • Constipation
  • Dysphagia
  • Heartburn
  • Gastritis
  • Anxiety
  • Medication
  • Oral problems
  • Odours
  • Delayed gastric emptying
  • Fatigue
146
Q

Symptoms of cachexia

A
  • Weight loss
  • Anorexia
  • Fatigue
  • Muscle wasting
  • Aesthesia
  • Anaemia
  • Oedema
147
Q

Pharmacological management of anorexia/cachexia

A
  • Corticosteroids (PO dexamethasone or prednisolone for 1 week then review) - may improve appetite and help nausea, energy levels and malaise. Effect is usually rapid but wears off after a few weeks.
  • Progestogens (megestrol acetate) - may stimulate appetite and weight gain. Onset of effect is slower but more prolonged than steroids.
148
Q

Side effects of progestogens

A
  • Nausea
  • Fluid retention
  • Increased risk of thromboembolism
149
Q

Pharmacological management of breathlessness in palliative care

A

1) Opioids (morphine)
2) Dexamethasone 8-16mg/daily (indicated in lymphangitis or tumour-associated airway obstruction)
3) Benzodiazepines
4) Oxygen
5) Nebulised saline

150
Q

Define delirium

A

Disturbed consciousness and inattention with cognitive impairment of acute onset and fluctuating course as a consequence of disease or treatment.

151
Q

Causes of delirium

A
  • Drugs e.g. opioids, anti-cholinergics, corticosteroids, benzodiazepines, antidepressants, sedatives
  • Drug withdrawal e.g. alcohol, sedatives, antidepressants, nicotine
  • Dehydration
  • Constipation
  • Urinary retention
  • Uncontrolled pain
  • Liver or renal impairment
  • Electrolyte imbalance
  • Infection
  • Hypoxia
  • Cerebral tumour
  • Cerebrovascular disease
152
Q

Pharmacological management of delirium in palliative care patients

A

1) Haloperidol PO or SC

2) Benzodiazepines

153
Q

Risk factors for depression in palliative care

A
  • Personal/family history of depression
  • Concurrent life stresses
  • Multiple losses
  • Unfulfilled life aspirations
  • Absence of social support
  • History of substance misuse/abuse
  • Oropharyngeal, pancreatic, breast and lung cancers
154
Q

Pharmacological management of depression in palliative care patients

A

1) SSRIs
2) Mirtazapine (well tolerated in elderly patients and heart failure)
3) Amitryptilline

155
Q

Side effects of SSRIs

A
  • GI upset
  • Risk of GI bleeding
  • Insomnia
  • Sweating
  • Impaired sexual function
  • Vivid dreams
  • Agitation
  • Hyponatremia
  • Risk of serotonin syndrome
156
Q

Investigations to consider in a palliative patient with nausea and vomiting

A
  • U&Es
  • LFTs
  • Calcium
  • Blood glucose
157
Q

Non-pharmacological management of a patient with nausea and vomiting

A
  • Regular mouth care
  • Regularising bowel habit
  • Regular, small, palatable meals
  • Avoid food preparation and cooking meals
  • Acupressure bands
  • Acupuncture
  • Psychological approaches
158
Q

Management of nausea/vomiting caused by chemical stimulation (e.g. drugs, malignancy, metabolic upset)

A

1) Dopamine receptor antagonist (metroclopramide, haloperidol, levomepromazine)

159
Q

Management of nausea/vomiting caused by motility disorders (e.g. gastric paresis)

A

1) Pro kinetic (metroclopramide)

160
Q

Management of nausea/vomiting caused by raised ICP or stimulation of the vestibular nerve

A

1) Cyclizine/hyoscine hydrobromide + dexamethasone
2) Levomepromazine
3) Prochloperazine

161
Q

Management of nausea/vomiting caused by cranial nerve irritation (oral, pharyngeal or oesophageal causes)

A

1) Cyclizine
2) Hyoscine hydrobromide
3) Levomepromazine

162
Q

Dopamine receptor antagonists used to treat nausea

A

Haloperidol

163
Q

5HT3 receptor antagonists used to treat nausea

164
Q

Anti-muscarinics used to treat nausea

A

Hyoscine hydrobromide

165
Q

Histamine 1 receptor antagonists used to treat nausea

166
Q

5HT2 receptor antagonists used to treat nausea

A

Levomepromazine

167
Q

Factors leading to fatigue in cancer patients

A
  • Anaemia
  • Cancer treatment
  • Tumour bulk
  • Cytokine release
  • Depression and anxiety
  • Difficulty sleeping
  • Low degree of physical functioning
168
Q

Non-pharmacological management of fatigue in palliative care patients

A
  • Energy conservation/restoration plans
  • Exercise regimes
  • Stress reduction and increased psychological support
  • Sleep pattern advice
  • Recombinant EPO (may stimulate tumour progression in head and neck cancer)
169
Q

Pancreatic cancer tumour marker

170
Q

Breast cancer tumour marker

171
Q

Hepatic cancer tumour marker

172
Q

Colorectal cancer tumour marker

173
Q

Ovarian cancer tumour marker

174
Q

Testicular cancer tumour markers

175
Q

Clinical features of a fibroadenoma

A
  • Young woman (18-25)

- Painless, mobile, firm breast lump

176
Q

Management of a fibroadenoma

A

None required usually

Surgical removal if >3cm or patient wants it removed

177
Q

Clinical features of duct ectasia

A
  • Women >50
  • Cheesy/white or thick green nipple discharge from single or multiple ducts
  • Slit like nipple retraction
  • Doughy palpable mass
178
Q

Risk factors for mastitis

A
  • Breast-feeding
  • Smoking
  • Diabetes
179
Q

Is lactational or non-lactational mastitis more serious?

A

Lactational - infection is usually more generalised and the patient is more systemically unwell so requires IV antibiotics

180
Q

Most common bacterial cause of breast abscess

181
Q

Clinical features of mastitis

A
  • Usually affects one breast
  • Symptoms develop quickly
  • Red, swollen area/lump on breast
  • Hot and painful to touch
  • Area of hardness or tender fluctuating mass
  • Burning pain
  • Nipple discharge (white or blood-stained)
  • Malaise
182
Q

Indications for referral of a mastitis patient

A
  • Mastitis or breast inflammation which does not settle after 1 course of antibiotics
  • Abscess suspected
  • Breast inflammation in patient >35
183
Q

Management of lactational mastitis

A

1) Continue breast feeding
2) Antibiotics (if systemically unwell, nipple fissure present or symptoms don’t improve after 24-48 hours)
- 10-14 days Flucloxacillin 500mg QDS
OR
- Erythromycin 500mg BD

184
Q

Management of non-lactating mastitis

A

1) Co-amoxiclav 375mg TD
OR
2) Erythromycin 500mg WDS + Metronidazole 400mg TD

185
Q

Clinical features of intra-ductal papilloma

A
  • Clear or bloodstained nipple discharge originating from a single duct
186
Q

Clinical features of a breast cyst

A
  • Peri-menopausal women
  • Soft, fluctuant breast swelling
  • ‘Halo’ appearance on mammography
187
Q

Management of symptomatic breast cysts

A

Aspiration then re-examine the breast to ensure cyst has gone.

188
Q

Most common lung cancer in non-smokers

A

Adenocarcinoma

189
Q

Clinical features of lung cancer

A
  • Persistent cough
  • Haemoptysis
  • Dyspnoea
  • Chest pain
  • Weight loss and anorexia
  • Hoarseness
  • SVC syndrome
  • Fixed, monomorphic wheeze
  • Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
  • Finger clubbing
190
Q

Paraneoplastic features of SCLC

A
  • ADH - hyponatremia
  • ACTH - hypertension, hyperglycaemia, hypokalemia, alkalosis, muscle weakness
  • Lambert-Eaton syndrome
191
Q

Paraneoplastic features of squamous cell lung cancer

A
  • PTHrP - hypercalcemia
  • Finger clubbing
  • Hypertrophic pulmonary osteoarthropathy
  • Hyperthyroidism
192
Q

Paraneoplastic features of adenocarcinoma

A
  • Gynaecomastia

- Hypertrophic pulmonary osteoarthropathy

193
Q

Indications for an URGENT CXR in suspected lung cancer

A

Patients >40 with 2 or more of the following symptoms OR 1 symptom + smoking history:

  • Cough
  • Fatigue
  • Shortness of breath
  • Chest pain
  • Weight loss
  • Appetite loss

OR patients >40 with ANY of the following:

  • Persistent or recurrent chest infections
  • Finger clubbing
  • Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
  • Chest signs consistent with lung cancer
  • Thrombocytosis
194
Q

Investigations to consider in a patient with suspected lung cancer

A
  • CXR
  • CT
  • Bronchoscopy
  • PET scanning
  • FBC
195
Q

Indications for urgent referral for lung cancer work up

A
  • CXR findings that suggest lung cancer

- >40 with unexplained haemoptysis

196
Q

Management of SCLC

A

Chemotherapy + radiotherapy

197
Q

Contra-indications for surgery in NSCLC patients

A
  • Poor general health
  • Metastatic disease
  • FEV <1.5L
  • Malignant pleural effusion
  • Tumour near hilum
  • Vocal cord paralysis
  • SVC obstruction
198
Q

3 ‘types’ of colon cancer

A

1) Sporadic
2) HNPCC-associated
3) FAP-associated

199
Q

Mode of inheritance for HNPCC and FAP

A

Autosomal dominant

200
Q

Clinical features of colorectal cancer

A
  • Persistant changes in bowel habit
  • Rectal bleeding
  • Persistent abdominal discomfort
  • Tenesmus
  • Weakness or fatigue
  • Unexplained weight loss
201
Q

Indications for urgent referral for colorectal cancer work up

A
  • Patients >40 with unexplained weight loss and abdominal pain
  • Patients >50 with unexplained rectal bleeding
  • Patients >60 with iron deficiency anaemia OR change in bowel habit

Consider referral in:

  • Rectal or abdominal mass
  • Unexplained anal mass or anal ulceration
  • Patients <50 with rectal bleeding AND abdominal pain/change in bowel habit/weight loss/iron deficiency anaemia
202
Q

Screening programme for colorectal cancer

A

Faecal Immunochemical testing offered every 2 years to men and women 60-74 in England and 50-74 in Scotland

203
Q

Follow up for patients with a positive FOB test

A

Colonoscopy

204
Q

Indications for FOBT (outside normal screening criteria)

A
  • Patients >50 with unexplained abdominal pain OR weight loss
  • Patients <60 with changes in bowel habit or iron deficiency anaemia
  • Patients >60 with anaemia
205
Q

Risk factors for ovarian cancer

A
  • Family history - BRCA1/2 mutations

- Many ovulations e.g. early menarche, late menopause, nulliparity

206
Q

Clinical features of ovarian cancer

A
  • Age >60
  • Abdominal distention and bloating
  • Abdominal and pelvic pain
  • Urinary symptoms e.g. urgency
  • Early satiety
  • Diarrhoea
207
Q

Investigations to consider in a patient with suspected ovarian cancer

A

1) Ca125 (not to be used to screen asymptomatic women)
2) Urgent abdo/pelvis US (if Ca125 >35)
3) Diagnostic laparotomy

208
Q

Causes of an increased Ca125

A
  • Endometriosis
  • Menstruation
  • Benign ovarian cysts
209
Q

Management of ovarian cancer

A

Combination of surgery and platinum-based chemotherapy

Year 5 (9 decks)

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