Palliative and oncology Flashcards

1
Q

Neoplastic spinal cord compression

When to suspect?

A

In all lower back pain in cancer

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2
Q

Neoplastic spinal cord compression

Which cancers is it most commonly associated with?

A
  • Lung
  • Liver
  • Breast
  • Prostate
  • Myeloma
  • Melanoma
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3
Q

Neoplastic spinal cord compression

Causes

A
  • Collapse or compression of a vertebral body due to metastases (common)
  • Direct extension of a tumour into the vertebral column (rare)
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4
Q

Neoplastic spinal cord compression

Presentation

A
  • Back pain, may be worse on lying down/straining/coughing
  • Lower limb weakness
  • Sensory loss and numbness
  • Lesions > L1 –> UMN signs in leg, sensory level
  • Lesions < L1 –> LMN signs in legs, perianal numbness
  • Tendon reflexes INCREASED BELOW, ABSENT AT LEVEL
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5
Q

Neoplastic spinal cord compression

Investigations

A
  • Urgent whole spine MRI scan (within 24 hrs)
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6
Q

Neoplastic spinal cord compression

Management

A
  • High-dose dexamethasone (16 mg / 24 hrs PO)
  • With prophylactic GI protection (PPI) and blood glucose monitoring
  • Refer urgently to oncology MDT for consideration of radiotherapy or surgery
  • Radiotherapy should be given within 24 hrs of MRI diagnosis
  • May need decompressive surgery depending on the prognosis
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7
Q

Neoplastic spinal cord compression

Prognosis

A

Patients with loss of motor function after 48 hrs are unlikely to recover function

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8
Q

Neoplastic spinal cord compression

Differentiating from cauda equina

A

Cauda equina presents with lower motor neuron signs (reduced tone and reduced reflexes). The nerves being compressed are lower motor neurons that have already exited the spinal cord.
- When the spinal cord is being compressed higher up (above L1) by metastatic spinal cord compression, upper motor neuron signs (increased tone, brisk reflexes and upping plantar responses) will be seen.

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9
Q

Neutropenic sepsis

Presentation

A
  • Neutrophil count < 0.5 x 10^9/L

- Temp > 38 degrees OR other sign/symptom consistent with clinically significant sepsis

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10
Q

Neutropenic sepsis

Who should you suspect this in?

A
  • IN all patients unwell within 6 weeks of receiving chemo (most common 7-14 days after)
  • Examine indwelling catheter sites
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11
Q

Neutropenic sepsis

Management

A
  • IMMEDIATE TX
  • Treat post-chemo fever before WBC results
  • Tazocin (Piperacillin/Tazobactam)
  • If still febrile/unwell after 48 hours try meropenem +/- vancomycin
  • If not responding after 4-6 days investigate for fungal disease
  • Fluoroquinolone if suspect they might develop it as prophylaxis
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12
Q

Drugs that can cause neutropenic sepsis

A
  • Anti-cancer chemotherapy
  • Clozapine (schizophrenia)
  • Hydroxychloroquine (rheumatoid arthritis)
  • Methotrexate (rheumatoid arthritis)
  • Sulfasalazine (rheumatoid arthritis)
  • Carbimazole (hyperthyroidism)
  • Quinine (malaria)
  • Infliximab (monoclonal antibody use for immunosuppression)
  • Rituximab (monoclonal antibody use for immunosuppression)
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13
Q

Superior vena cava syndrome

Pathophysiology

A

Reduced venous return from head, neck and upper limbs

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14
Q

Superior vena cava syndrome

Causes

A

Common = extrinsic compression from malignancy (90%):

  • Lung (small cell) = most common cause
  • Others: lymphoma, metastatic, lymphoma, germ cell

Less common = venous thrombosis
- If current/past central venous access

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15
Q

Superior vena cava syndrome

Signs and symptoms

A
  • SOB = most common
  • Swelling of face, neck, arms
  • May see periorbital or conjunctival oedema
  • Headache - worse in the mornings
  • Visual disturbances - blurred vision
  • Pulseless jugular venous distension
  • Distended chest veins
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16
Q

Superior vena cava syndrome

What is Pemberton’s sign?

A
  • Raising the hands over the head –> facial congestion and cyanosis
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17
Q

Superior vena cava syndrome

Management

A
  • Prop patient up
  • High dose Dexamethasone = 16 mg OD
  • Oxygen if needed
  • CT to define anatomy of obstruction
  • SUPERIOR VENA CAVA STENTING and balloon venoplasty
  • Treat w radio/chemotherapy depending on the sensitivity of underlying cancer (e.g. SCLC, lymphoma)
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18
Q

Malignancy-associated hypercalcaemia

Epidemiology

A
  • 10-20% of cancer patients

- 40% of myeloma

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19
Q

Malignancy-associated hypercalcaemia

Causes

A

PTH-related protein produced by tumour causing local osteolysis

  • MYELOMA
  • Bone mets (lung, breast, kidney, thyroid, prostate)
  • Squamous cell lung cancer (PTHrP)
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20
Q

Malignancy-associated hypercalcaemia

Presentation

A
  • BONES (painful)
  • STONES (kidney)
  • GROANS (GI disturbance)
  • MOANS (psychiatric)
  • Shortened QT interval
  • HTN
  • Corneal calcification
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21
Q

Malignancy-associated hypercalcaemia

Management

A
  • Aggressive rehydration with normal saline
  • Bisphosphonates (if eGFR > 30) -)> IV Zolendronic acid for 3 days
  • Calcitonin - short-term, tolerance can develop
  • Long term = control of underlying malignancy
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22
Q

Malignancy-associated hypercalcaemia

Prognosis

A

`- Poor prognostic sign

- 75% mortality within 3 months

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23
Q

Brain metastases

Epidemiology

A

Up to 40% of patients with cancer

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24
Q

Brain metastases

Which cancers?

A
  • Lung = most common
  • Breast
  • Colorectal
  • Melanoma
  • Kidney
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25
Brain metastases Presentation
- Headache - worse in the morning, coughing, bending - Focal neurological symptoms - Ataxia - Fits - Nausea and vomiting - Papilloedema
26
Brain metastases Investigations
URGENT CT/MRI
27
Brain metastases Management
- High dose dexamethasone --> reduce cerebral oedema | - Stereotactic radiotherapy
28
Brain metastases Prognosis
- Poor prognosis - Median survival = 1-2 months - Better prognosis if single lesion or breast cancer
29
Tumour lysis syndrome Pathophysiology
Chemo for rapidly proliferating tumours (leukaemia, lymphoma, myeloma) leads to: - Cell death - Increased urate - Increased potassium - Increased phosphate - Decreased calcium
30
Tumour lysis syndrome Presentation
- Increased urate - Increased potassium - Increased phosphate - Decreased calcium
31
Tumour lysis syndrome Associated risks
- Arrhythmias | - Renal failure
32
Tumour lysis syndrome Management
- Hydration - Uricolytics - Rasburicase, Allopurinol - Monitor K+, Ca2+ and phosphate levels
33
Massive haemorrhage Which tumours?
- Head and neck tumours | - Lung/GI tumours with Hx of bleeding
34
Massive haemorrhage When to suspect?
- Suspect massive occult bleed if patient suddenly in shock
35
Massive haemorrhage Management
- Stop any anticoagulation - Palliative - remain with patient, dark towels - Midazolam 10 mg STAT
36
Nausea and vomiting Reduced gastric motility (gastric stasis)
- Domperidone | - Metoclopramide
37
Nausea and vomiting Bowel obstruction WITHOUT colic
- Metoclopramide
38
Nausea and vomiting Bowel obstruction WITH colic
- HYOSCINE BUTYLBROMIDE/HYDROBROMIDE - Haloperidol - Cyclizine
39
Nausea and vomiting Chemically-mediated
- Haloperidol | - Ondansetron
40
Nausea and vomiting Raised ICP
- Cyclizine | - +/- Dexamethasone
41
Nausea and vomiting Vestibular
- Cyclizine
42
Nausea and vomiting Cortical
- Benzodiazepine | - Cyclizine
43
5-HT3 antagonists Examples SEs
- Ondansetron, Granisetron | - SEs: constipation, headache, flushing
44
Anti-histamines MoA Examples SEs
- Act on H1-receptors centrally and peripherally - Cyclizine, Promethazine, Cinnarizine - SEs: anti-muscarinic effects, palpitations & arrhythmias, sleep disturbances, EPSEs
45
D2 receptor antagonists Haloperidol MoA SEs
- MoA: acts on D2 receptors in chemo-receptor trigger zone | - SEs: EPSEs, sedation, QT prolongation, depression
46
D2 receptor antagonists Domperidone MoA SEs
- MoA: Act on D2 receptors PERIPHERALLY | - SEs: QT prolongation, drowsiness, dry mouth, diarrhoea, malaise
47
D2 receptor antagonists Metoclopramide MoA SEs
- MoA: Act on D2 receptors CENTRALLY | - SEs: EPSEs, drowsiness, diarrhoea, gynaecomastia, galactorrhoea, hyperprolactinaemia
48
Levomepromazine, Prochlorperazine MoA Indications SEs
- MoA: act on dopamine, H1 and Ach-receptors - Used when non-specific or multi-factoral N+V cause - SEs: EPSEs, drowsiness, anti-muscarinic SEs, postural hypotension, QT prolongation
49
Hyoscine butylbromide/hydrobromide, Glycopyrronium bromide MoA Indications
- MoA: muscarinic receptor antagonist - Used in cases of smooth muscle spasm (bladder, GI tract), excessive secretions including sialorrhoea, drooling, death rattle and inoperable bowel obstruction)
50
Pain relief in palliative stomatitis/mucositis?
Benzydamine 0.15% mouthwash (Difflam®)
51
First-line pain relief in palliative care
- Offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference) - With oral immediate-release morphine for breakthrough pain
52
Firs-line doses of morphine
If no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain
53
Co-prescribing with opioids
- Laxatives should be prescribed for all patients initiating strong opioids - Patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered. - Drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered
54
Breakthrough dose of morphine
1/6th of total 24 hrs dose
55
Opioids in renal impairment
Mild --> Moderate: - OXYCODONE Severe (< 10): - BUPRENOPRHINE - FENTANYL (not renally excrete so less likely to cause toxicity)
56
When else might you consider using oxycodone?
Oxycodone generally causes less sedation, vomiting and pruritis than morphine but more constipation, so can be used in anyone complaining from these morphine SEs
57
Pain management in bone mets
Strong opioids Bisphosphonates Radiotherapy Denosumab
58
Oral morphine to SC morphine
Divide by 2
59
How much to increase morphine dose by?
30-50%
60
Oral morphine to SC diamorphine
Divide by 3
61
Oral oxycodone to SC diamorphine
Divide by 1.5
62
Oral codeine to oral morphine
Divide by 10
63
Oral tramadol to oral morphine
Divide by 10
64
Management of hiccups
- Chlorpromazine - Haloperidol - Gabapentin - Dexamethasone
65
Management of agitation and confusion
- Find cause and treat this - Environmental factors If require meds: - 1st line = haloperidol - Others: chlorpromazine, levomepromazine In terminal phase: - Midazolam
66
Management of secretions
- Avoid fluid overload - Educate the family that they are not likely to be troubled by them - HYOSCINE HYDROBROMIDE or HYOSCINE BUTYLBROMIDE - Also glycopyrroinum bromide
67
Which HPV subtypes are most significant RFs for cancer?
- 16 - 18 - 33 Though it should be noted that the majority of healthy women will spontaneously clear HPV within 2 years without developing cervical cancer
68
Which HPV subtypes cause warts?
- 2 - 7 - 22
69
Which lung cancer is most commonly associated with smoking?
Squamous cell carcinoma
70
Lung cancer Adenocarcinoma vs squamous cell carcinoma
- Squamous cell lung cancer is more commonly found near large airways, unlike adenocarcinoma which is more commonly peripheral - Squamous cell = most common in smokers - Adenocarcinoma = most common in non-smokers
71
Most common tumour causing bone metastases (in descending order)
- Prostate - Breast - Lung
72
Most common site (in descending order)
- Spine - Pelvis - Ribs - Skull - Long bones
73
Other than bone pain, features may include?
- Pathological fractures - Hypercalcaemia - Raised ALP
74
Cytotoxic agents Cyclophosphamide MoA
- Alkylating agent | - Causes cross-linking in DNA
75
Cytotoxic agents Cyclophosphamide Adverse effects
- Haemorrhagic cystitis - Myelosuppression - Transitional cell carcinoma
76
Cytotoxic agents Bleomycin MoA
- Degrades performed DNA
77
Cytotoxic agents Bleomycin Adverse effects
- Lung fibrosis
78
Cytotoxic agents Anthracyclines, e.g. Doxorubicin MoA
- Stabilizes DNA-topoisomerase II complex inhibits DNA and RNA synthesis
79
Cytotoxic agents Anthracyclines, e.g. Doxorubicin Adverse effects
- Cardiomyopathy
80
Cytotoxic agents Methotrexate MoA
- Inhibitis dehydrofolate reductase and thymidylate synthesis
81
Cytotoxic agents Methotrexate Adverse effects
- Myelosuppression - Mucositis - Liver fibrosis - Lung fibrosis
82
Cytotoxic agents Fluorouracil (5-FU) MoA
Pyrimidine analogue inducing cell cycle arrest and apoptosis by blocking thymidylate synthase (works during S phase)
83
Cytotoxic agents Fluorouracil (5-FU) Adverse effects
- Myelosuppression - Mucositis - Dermatitis
84
Cytotoxic agents 6-mercaptopurine MoA
Purine analogue that is activated by HGPRTase, decreasing purine synthesis
85
Cytotoxic agents 6-mercaptopurine Adverse effects
- Myelosuppression
86
Cytotoxic agents Cytarabine MoA
Pyrimidine antagonist. Interferes with DNA synthesis specifically at the S-phase of the cell cycle and inhibits DNA polymerase
87
Cytotoxic agents Cytarabine Adverse effects
- Myelosuppression | - Ataxia
88
Cytotoxic agents Vincristine/blastine MoA
Inhibits formation of microtubules
89
Cytotoxic agents Vincristine/blastine Adverse effects
- Vincristine: peripheral neuropathy (reversible), paralytic ileus - Vinblastine: myelosuppression
90
Cytotoxic agents Docetaxel MoA
Prevents microtubule depolymerisation & disassembly, decreasing free tubulin
91
Cytotoxic agents Docetaxel Adverse effects
- Neutropenia
92
Cytotoxic agents Irinotecan MoA
Inhibits topoisomerase I which prevents relaxation of supercoiled DNA
93
Cytotoxic agents Irinotecan Adverse effects
- Myelosuppression
94
Cytotoxic agents Cisplatin MoA
Causes cross-linking in DNA
95
Cytotoxic agents Cisplatin Adverse effects
- Ototoxicity - Peripheral neuropathy - Hypomagnesaemia
96
Cytotoxic agents Hydroxyurea MoA
Inhibits ribonucleotide reductase, decreasing DNA synthesis
97
Cytotoxic agents Hydroxyurea Adverse effects
- Myelosuppression
98
PET Scan
- Form of nuclear imaging which uses fluorodeoxyglucose (FDG) as the radiotracer - Allows a 3D image of metabolic activity to be generated using glucose uptake as a proxy marker - The images obtained are then combined with a conventional imaging technique such as CT to decide whether lesions are metabolically active - Used to evaluate primary and possible metastatic disease
99
Tumour markers CA 19-9
Pancreatic cancer
100
Tumour markers CA 125
Ovarian cancer
101
Tumour markers CA 15-3
Breast cancer
102
Tumour markers PSA
Prostate carcinoma
103
Tumour markers alpha-feto protein (AFP)
- Hepatocellular carcinoma | - Teratoma
104
Tumour markers Carcinoembryonic antigen (CEA)
Colorectal cancer
105
Tumour markers S-100
- Melanoma | - Schwannoma
106
Tumour markers Bombesin
- Small cell lung carcinoma - Gastric cancer - Neuroblastoma
107
BRCA 1 and 2
- Carried on chromosome 17 (BRCA 1) and Chromosome 13 (BRCA 2) - Linked to developing breast cancer (60%) risk. - Associated risk of developing ovarian cancer (55% with BRCA 1 and 25% with BRCA 2). - BRCA2 mutation is associated with prostate cancer in men
108
Gardners 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
109
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.
110
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
111
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
112
What sort of bone lesions would be seen in metastases?
focal sclerotic bony lesions