Peer Share Flashcards
ca125
ovarian
ca19-9
pancreatic
ca15-3
breast
PSA
prostate
CEA
bowel
AFP
NSGCT (yolk sac/teratocarcinoma)
hepatocellular
HCG
germ celltumours (seminomas, NSGCT)
calcitonin
medullary thyroid cancer
tumour markers
CA125 = ovarian
CA19-9 = pancreatic
CA15-3 = breast
PSA = prostate
CEA = bowel
AFP = NSCGT (yolk-sac/teratocarcinoma) and hepatocellular
HCG = germ cell tumours (seminomas?NSCGT)
calcitonin = medullary thyroid cancer
def: radical
curative
def: neoadjuvant
before primary treatment to shrink tumour
def: adjuvant
after treatment to destroy remaining cells and reduce liklihood of recurrence
def: palliative
aims to extend life and control pain but will not cure
ECOG performance scoring
0 = fully active, able to carry on all pre-disease performance without restriction
1 = restricted in physcially strenuous activity but ambulatory and able to carry out work of light or sedentary nature (e.g light house work/office work)
2 = ambulatory and capable of all selfcare but anuable to carry out any work activities; up and about more than 50% of waking hours
3 = capable of only limited selfcare; confined to bed or chair more than 50% of waking hours
4 = completely disabled; cannot carry on any selfcare; totally confined to bef or chair
5 = dead
def: radiotherapy
- ionising radiation daages DNA
- cancer cells have poorer repair mechanisms than healthy cells
- results in increased cancer cell death
uses: radiotherapy
radical
neo-adjuvant
adjuvant
palliative
types: radiotherapy
extrenal beam = traditional rtx
brachytherapy = radioactive beads placed into tumour e/g prostate cancer
SABR = stereotactic ablative rtx (CT guided) giving higher doses in fewer fractions
def: Gy rtx
gray = the dose
def: Fr rtx
fraction = number of sessions dose is delivered over
advantages and disadvantages compared to surgery: rtx
adv:
1. no GA
2. less painful
3. treat tumour margin
dis:
1. less staging information
2. greater risk secondary mallignancy
3. less psychological benefit
short term SEs: rtx
SHORT TERM INFALMMATION
* fatigue
* nausea
* heair loss
* hoarseness
* pain/discomfort
* skin reactions: dry desquamation (skin not boken) and wet (skin broken - infection risk)
* mucositis: dysphagia/weight loss/altered bowel habit/urinary symptoms
late/long-term SEs rtx
LONG TERM FIBROSIS/SCARRING
* fatigue
* pain
* altered bowel habit
* urinary discomfort/cystitis
* dry mouth
* dry cough (pneumonitis)
* infertility
* seconday cancers
* cardiac toxicity
* skin reactions: pigmentation/talangectasia/atrophy/ulceration/permanent hair loss)
def: SACT
systemic anti-cancer therapy
1. chemotherapy
2. hormonal
3. targeted
4. biologic
def: chemotheraoy (cytotoxic)
targets DNA of cells
def: hormonal therapy
exploits oestrogen/androgen involvement
def: targeted therapy
inibits molecular pathways needed for tumour growth e.g herceptin (breast cancer)
def: biologic therapy
stimulates host response to aid tumour cell destruction
hormonal therapy: examples
tamoxifen (breast cancer)
LHRHs e.g goserelin (prostate cancer)
SEs: targeted therapy
menstrual distrubance, hot flushes, VTE and endometrial cancer
NB: lines for chemo treatment
PICC lines cannot be inserted on same side as mastectomy with lymph node clearance
if bilateral mastectomy must have centrally inserted CVC
def: chemotherapy
targets rapidly dividing cells DNA
reducing toxicity: chemotherapy
using different chemos with different MOAs reduces toxicity
SEs: chemotherapy
targets other rapidly diving cells: hair follicles/GIT cells causing change in bowel habit/ bone marrow cells (anaemia/thrombocytopenia/pancytopenia
- general fatigue
- N+V
- thrombosis
- peripheral neuropathy
- infertility
- hypersensitivity reactions
- organ toxicity
- palmar-plantar erythema (emollients rx)
extravasation: chemotherapy
leakage of fluids/medication from vein can causer tissure damage and necrosis
PICC line reduces risk
breast: screening
3 yearly mammogram from 50-70
RFs: breast
lifestyle - sedentary, high fat diet, smoking, BMI
genetic - BRCA1/2, fhx breast/ovarian ca
hormonal - nulliparity/ early menarche/ late menopause/ HRT (increased unopposed oestrogen)
ionising radiation
red flag 2 week referral criteria: breast
> =30 with unexplained breast lump
=50 unilateral nipple discharge or retraction
consider red flag: breast
skin changes suggesting breast cancer
>=30 unexplained axillary lump
non-urgent referral: breast
<30 uneplained breast lump
triple assessment: breast
- examination
- imaging (mammogram +/- USS)
- biopsy (FNA/core)
mammograms in younger patients
not as useful in younger women due to increased fibrous tissue and less fat
TNM staging: breast
T:
T1 - <2cm
T2 - 3-5cm
T3 - >5cm
T4a - chest wall
T4b - skin
T4c - both chest wall and skin
T4d - inflammatory
N:
N0 = no nodes
N1 = 1-3 nodes
N2 = 4-9 nodes
N3 = >10 nodes
M:
M0 = no mets
M1 - mets
staging scans: breast
isotope bone scan and CT abdo/thorax
primary surgical management: breast
1st line in breast cancer
CI’d - M1, T4 and unfit for surgery pts
WLE: solitary, peripheral, small lesion
mastectomy: multifocal, central, large lesion
axillary node clearance: palpable/USS +ve, SLNB indicated
if >1 node +ve on SLNB or N1-3 clinically
indication for WLE v mastectomy: breast
WLE - solitary, peripheral, small lesion
mastectomy - multifocal, large, central lesion
SE axillary node clearance: breast
- lymphadenopathy
- functional arm impairment
adjuvant radiotherapy: breast
- almost always indicated
- whole breat RT after WLE
- tumur bed boost: >=50, triple -ve, high grade, close margins
- chest wall RT after mastectomy and T>=3 or N>=2
- supraclavicular fossa >=N2
indications chest wall RT: breast
after mastectomy and T>=3 or N>=2
chemotherapy: breast
- neoadjuvant to shrink tumour
- adjuvant -ve, 2-5% risk: oncotype DX analysis
- node -ve, >5% risk = FEC chemo
- node +ve = FEC-docetaxel chemo
adjuvant SACT: breast
hormonal in ER or PR +ve for 5-10 years
pre-menopausal/perimenopausal = tamoxifen
postmenopausal = anastrazole (risk of OP)
targeted in HER2 +ve for 1 year
node -ve = trastuzumab (herceptin)
node +ve trastuzumad and pertuzumab
ER or PR +ve breast:
hormonal SACT pre/perimenopausal = tamoxifen
postmenopausal = anastrazole
for 5-10 years
HER 2 +ve: breast
targeted SACT
node -ve = trastuzumab (herceptin)
node +ve = trastuzumab (herceptin) and pertuzumab
for 1 year
primary SACT: breast
only if surgery CI’d
hormonal/targeted/chemotherapy
RFs: colorectal cancer
- age
- genetics/fhx - lynch syndrome (HPCC), FAP
- lifestyle - obesity, diet/smoking/alcohol/sedentary
- large polyp
- pelvic RT
red flag 2 week wait referral criteria: colorectal
> = 40 with weight loss + abdo pain
= 50 with rectal bleeding
=60 with iron deficiency anaemia or altered bowel habit
positive FOB/qFIT
consider red flag criteria: colorectal
rectal or abdominal mass
<50 with rectal bleeding AND
* abdo pain
* altered bowel habit
* weight loss
* iron-deficiency anaemia
offer QFIT: colorectal cancer
> =50 abdominal pain or weight loss
<60 changes to bowel habit or iron deficiency anaemia
>=60+ no iron deficiency
investigations: colorectal
1st line = colonoscopy (CT colonogram if frail/intolerant/co-morbidities)
CEA: NOT for screening - only used after diagnosis
ix mets: colorectal
CT
CT PET
if rectal: MRI rectum and endoanal USS
TNM: colorectal
T:
T1 - through mucosa into submucosa
T2 - through submucosa into muscularis proproa
T3 - through muscularis propria to subserosa
T4 - through intestinal wall and into adjacent organs
N:
N0 - no nodes
N1 - 1-3 nodes
N2 - 4+ nodes
M:
M0 - no mets
M1 - mets
staging: colorectal
stage 1 - <=T2 + N0 + M0
stage 2 - T3 or T4 + N0 + M0
stage 3 - any T + N1 or N2 + M0
stage 4 - M1
management: colorectal
stage 1 - surery alone
stage 2 - surgery + clinical trial
stage 3 - surgery + chemo
stage 4 - palliative surgery/chemo
referral criteria: prostate
- raised PSA >4
- abnormal prostate on DRE
ix: prostate cancer
- multiparametric MRI - results using 5-point LIKERT scale influence decision to biopsy
- biopsy (for Gleason) if LIKERT 3+ TRUS or transperineal biopsy if LIKERT 1 or 2 (low risk)
- isotope bone scan
Gleason score: prostate
1 = undifferentiated cells (not cancerous)
3 = cells turn cancerous
5 = undifferntiated cells
2 numbers used and most dominant cell comes first
6 = benign, 10 = highly malignant
group 1 <=6
group 2 3+4 = 7
group 3 4+3 = 7
group 4 = 8
group 5 9+
https://www.youtube.com/watch?v=T19xd3AalPs
T stage: prostate
T1 - invisible
T2 - confined to prostate (a - <1/2 lobe, b >1/2 lobe, c both)
T3 - extends through capsule
T4 - extends to other structures (excluding seminal vesicles)
prognosis and management: prostate
see table
prognosis and management: prostate
see table
adv and dis: prostate management
surgery:
ad = psych benefit and histology
dis = GA, incontinence, ED, bowel perforation
brachytherapy:
ad = fast recovery, further rx, less ED
dis = urinary obstruction and GA
external RT
ad = no GA, less ED/urinary SE
dis = proctitis and secondary malignancy
metastatic management: prostate
hormonal therapy:
LHRH (GnRH agonists) - gosereline and deslorelin
anti-androgens - abiraterone and bicalutamide
chemo - docetaxel
bone targeted therapy - zolendronic acid/radium
RT/SABR for mets
signs: spinal cord compression
LOCAL BACK PAIN AND TENDERNESS
* exacerbated by coughing/sneezing/straining/lying flat
* uncontrolled by analgesia
NEUROLOGICAL PROBLEMS (ADVANCING)
* bladder dysfunction (retention/dribbling/incontinence)
* bowel dysfx (incontinence/constipation)
* weakness i arms/legs
* hypothesia (numbness)
CAUDA EQUINA (below L1/2)
* sciatic pain (usulally bilateral)
* impotence
* baldder dysfx
* sacral aesthesia
* loss of sphincter tone
* weakness/wasting of gluteal muscles
BILATERAL MOTOR NEURONE SIGNS
GIBBUS - swelling sue to spinal angulation caused by vertebral collapse
bony mets: SCC
breast
lung
prostate
multiple myeloma
ix: SCC
neurological exam
MRI whole spine gold standard
can do XR spine
rx: SCC
- medical emergency
- IMMEDIATE DEXAMETHASONE 8m PO/IV BD
- PPI and aanalgesia
definitive management:
1. surgical decompression - gold standard (CI: unfit or complete paraplegia for >24hrs + pain well controlled)
2. radiotherapy in radiosensitive tumours - can make worse before better so give prophylactic dexamethasone
3. bisphosphonates if breast, prostate or myeloma
outcomes: SCC
strongly dependent on level of neruological dysfunction
approx 30% survive for 1 year
may have irreversible paraplegia/quadriplegia or loss of bladder/bowel fx if late diagnosis
symptoms: SVCO
gradual onset with symptoms worsening with bending over or lying down
* dyspnoea
* swelling of face/neck/arms
* cough
* headache
* visual disturbance
* dizziness
* syncope
* chest pain
* hoarseness
* nasal congestion
* epistacis
* haemoptysis
pembertons test: SVCO
raising arms over head for 1 minute will cause
facial plethora and cyanosis
signs: SVCO
- dyspnoea
- orthopnoea
- facial plethora
- dilated/engorged veins
Pemberton’s test- where lifting the arms over the head for more than 1 minute will precipitate facial plethora and cyanosis.
causes: SVCO
usually lung cancers
ymphoma 2nd most common
ix: SVCO
- CXR - right para-tracheal mass, mediastinal lymphadenopathy
CT chest gold standard diagnosis (contrast enhanced)
defines level and degree of venous blockage
identifies cause and staging
rx: SVCO
- ABCDE, high flow oxygen
- dexamethasone 8mg PO/IV BD with PPI
- tissue diagnosis
- stenting - indicated for thrombua and is bridge to chemo/radiotherapy while awaiting histo
- chemotherapy (small cell/lymphoma/germ cell)
- radiotherapy - poor performance status, previous chemo or relapse)
oucome: SVCO
prognosis dependent on underlying condition and extent of obstruction
- if untreated survival time = 30 days
- XRT tx - at least 30 months in 45% lymphoma and 10% lung
causes: raised ICP
SOL - primary brain tumour/brain mets/abscess/haematoma
hydrocephalus - CSF obstruction
benign IC hypertension
ix: raised ICP
- full clinical examination
- FBC, U+E, LFT and tumour markers
- contrast enhanced CT
- MRI if CT still ?
common tumours that met to brain: raised ICP
- lung cancer most common
- breast cancer
- melanoma
symptoms and signs: brain mets
PAPILLOEDEMA
* headache (early symptoms - worse in AM and when coughing/sneezing)
* nausea and vomiting (AM)
* cognitive impairment
* drowsiness
* seizures
* behavioural changes
* focal neurological changes
* altered gait
rx: brain mets
DEXAMETHASONE 8mg PO/IV BD with PPI
further - surgery or whole brain RT
PATIENTS CANNOT DRIVE AND MUST INFORM DVLA
outcomes: brain mets
- high morbidity
- dependent on primary tumour
- median survival without treatment is 1 month
most common cancers: hypercalcaemia
- breast
- lung
- head and neck
- renal
- lymphoma
- multiple myeloma
symptoms: hypercalcaemia
dehydration is most common finding
usually when >3.0mmol/L
bones, stones, thrones, abdominal groans and psychaitric moans
* bone pain
* stones
* polyuria and polydipsia
* N+V
* fatigue, malaise and weakness
* confusion
above 3.5mmol/Lconfusion, drowsiness and death
causes: hypercalcaemia
- bone metastases
- increased PTH protein - occurs in SCC, breast, porstate, renal, kmelanoma and neuroendocrine cancers (80%)
- calcitriol secretion from tumour
ix: hypercalcaemia
bloods - FBC, U+E, LFT, CRP, glucose, PTH, alk phos
12 lead ECG - shortened qT, severe hypercalcaemia = widerend T waves
CXR if underlying cause unknown
rx: hypercalcaemia
- immediate rehydration (IV 0.9% NaCL) - 4 to 6L in 24 hours
- IV bisphosphonate - zolendronic acid 4mg IV given after 24 hrs (moves calcium back into bones)
- discontinue thiazide diuretics/Ca/vit D supplements
outcomes: hypercalcaemia
poor prognosis if severe
def: thrombocytopenia
when chemo suppresses bone marrow
spontaneous bleeding likely when platelets <20x10^9L-1
symtpoms: thrombocytopenia
- malaise
- fatigue
- general weakness
- unexplained bleeding - epistaxis, gum bleeding
signs: thrombocytopenia
bruising
purpura
petechial rash
ix: thrombocytopenia
FBC (low plt, ?anaemia)
LFT, U+E (high urea ?upper GI bleed), coag screen
vit B12 and folic acid
rx: thrombocytopenia
- group and crossmatch
- arrange platelet Plt <10x10^9 or Plt <20x10^9 if active sepsis/bleeding
clinical triad: PE
SOB, pleuritic chest pain and haemoptysis
symptoms: PE
- triad - SOB, pleuritic chest pain and haemoptysis
- tachycardia - most common
- cough
- raised JVP
- cyanosis
- check for DVT
ix: PE
- 2-level wells score
- rotuine bloods, D-dmier, ABG, troponin, BNP
- CTPA
- CXR, ECG
rx: PE
A-E
anticoagulation - DOAC or LMWH if on chemo
thrombolysis if SBP <90mmHg
complications: PE
development of chronic thromboembolic HTN can lead to RSHF
def: TLS
caused by destruction of lage number of cancer cells
results in electrolyte abnormalities and renal failure
most common in leukaemia and lymphoma
hyperkalaemia
hyperphosphataemia
hypocalcaemia
high uric acid
symptoms: TLS
- fatigue
- N+V
- SOB
- myalgia
- syncope
- tetany
- seizures
- dark urine
- arrhythmias
- HF
ix: TLS
- hyperphosphataemia
- hyperkalaemia
- hyperuricaemia
- hypocalcaemia
- lactic acidosis
- raised serum LDH
rx: TLS
- A-E assesssment
- IV fluids
- rasburicase - clears uric acid from blood
- hyperkalaemia kit
- haemodialysis if required
prophylaxis: TLS
allopurinol
adequate hydration
