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FinalsEazy Rohan VyasONCOLOGY FOR FINALS SESSION TIME : 1-1.5 HOURSONCOLOGY FOR FINALS ACUTE ONCOLOGICAL EMERGENCIES CYTOTOXIC AGENTS LUNG CANCER METASTATIC DISEASE FURTHER COMMON CANCERS Q U E S T I O1N A 72 -year-old woman presents to the emergency A CT ANGIOGRAPHY department with severe chest and back pain, described as intolerable. This has been occurring B MRI WHOLE SPINE over the past few days, usually worse at night. She has a past medical history of breast cancer, osteoporosis and an aortic dissection 6 years C X-RAY WHOLE SPINE ago. On examination, there is a noted loss of sensation in the lower limbs but increased D CHEST X -RAY reflexes. Given the likely diagnosis, what would be the E TRANSOESOPHAGEAL ECHO (TOE) most important investigation to carry out? ANSWER ON THE ZOOM POLL Q U E S T I O1N A 72 -year-old woman presents to the emergency A CT ANGIOGRAPHY department with severe chest and back pain, described as intolerable. This has been occurring B MRI WHOLE SPINE over the past few days, usually worse at night. She has a past medical history of breast cancer, osteoporosis and an aortic dissection 6 years C X-RAY WHOLE SPINE ago. On examination, there is a noted loss of sensation in the lower limbs but increased D CHEST X -RAY reflexes. Given the likely diagnosis, what would be the E TRANSOESOPHAGEAL ECHO (TOE) most important investigation to carry out? According to NICE guidelines, an urgent whole MRI spine should be done within 24 hoursSPINAL CORD COMPRESSIONA common oncological emergency due to the compression of the DEFINTION spinal cord due to vertebral metastases. SPINAL CORD COMPRESSION CAUSES CLINICAL FEATURES • Trauma • Back pain- most common symptom • Malignancy • Lung, breast, lymphoma and • Lower limb weakness prostate cancer are most • UMN signs/LMN signs in legs • Bladder and bowel incontinence common • Paraesthesia • Multiple myeloma DIAGNOSIS TREATMENT • Whole spine MRI • Dexamethasone- reduces tumour • Upper and lower limb Neuro exam size • Spinal X-ray • Radiotherapy or surgery • CT spine • Management of malignancy Spinal MRI https://pubs.rsna.org/doi/full/10.1148/rg.2019190024 Q U E S T I 2 N A 63 -year-old man presents to the emergency A MANNITOL department with facial swelling and blurred vision. Upon examination, he appears to be short B OXYGEN of breath with a RR of 28, HR 88 and a SATs of 95% on room air. He mentions that after his routine stretching in the morning, he felt worse C CHEST X -RAY off and decided to come in. He has no past medical history, aside from being a heavy D IV FLUIDS smoker. E DEXAMETHASONE Given the likely diagnosis, what would be the most appropriate management? ANSWER ON THE ZOOM POLL Q U E S T I 2 N A 63 -year-old man presents to the emergency A MANNITOL department with facial swelling and blurred vision. Upon examination, he appears to be short B OXYGEN of breath with a RR of 28, HR 88 and a SATs of 95% on room air. He mentions that after his routine stretching in the morning, he felt worse C CHEST X -RAY off and decided to come in. He has no past medical history, aside from being a heavy D IV FLUIDS smoker. E DEXAMETHASONE Given the likely diagnosis, what would be the most appropriate management? Given the prior history of smoking, the most likely diagnosis is SVCO due to lung cancer.SUPERIOR VENA VA OBSTRUCTION DEFINITION CLINICAL FEATURES SUPERIOR OBSTRUCTION OF THE SUPERIOR • DYSPNOEA VENA CAVA COMMONLY ASSOCIATED • FACIAL, ARM AND NECK VENA CA V A WITH MALIGNANCIES SUCH AS LUNG SWELLING CANCER. • BLURRY VISION OBSTRUCTION • HEADACHE • INCREASED JVP • POSITIVE PEMBERTON’S TEST CAUSES DIAGNOSIS MANAGEMENT • CT SCAN- KEY • DEXAMETHASONE • MOST COMMON- SMALL • CHEST X-RAY • STENTING CELL/NON-SMALL CELL LUNG • CHEST MRI • TREAT UNDERLYING CANCER, LYMPHOMA • ULTRASOUND MALIGNANCY • SVC THROMBOSIS • AORTIC ANEURYSMS • MALIGNANCIES Pemberton’s Test https://www.grepmed.com/images/4691/physicalexam-pembertons-clinical-photo-sign Q U E S T I O3N A 82-year-old man presents to the emergency A J WAVE department with abdominal pain. Whilst taking a history, the patient appears to be moody and B PROLONGED QT INTERVAL slightly confused. Routine investigations are ordered (e.g. ECG, bloods, electrolytes). Bloods reveal an anaemic red blood cell count with a C SHORTENED QT INTERVAL lowered eGFR. A bone marrow biopsy eventually confirms the diagnosis. D SMALL T WAVES Given the underlying condition and the current E TALL TENTED T WAVES symptoms, what would the patient’s ECG have shown? ANSWER ON THE ZOOM POLL Q U E S T I 3 N A 82-year-old man presents to the emergency A J WAVE department with abdominal pain. Whilst taking a history, the patient appears to be moody and B PROLONGED QT INTERVAL slightly confused. Routine investigations are ordered (e.g. ECG, bloods, electrolytes). Bloods C SHORTENED QT INTERVAL reveal an anaemic red blood cell count with a lowered eGFR. A bone marrow biopsy eventually confirms the diagnosis. D SMALL T WAVES Given the underlying condition and the current E TALL TENTED T WAVES symptoms, what would the patient’s ECG have shown? Due to multiple myeloma, patient is suffering from classic signs of hypercalcaemia.HYPERCALCAEMIA OF MALIGNANCY CAUSES PTHrp Metastases Vitamin D Production of PTHrp from tumourCancer metastases to bones Vitamin D production from tumour • Squamous cell carcinomas • Common in multiple myeloma • Sarcoidosis • Non-Hodgkin’s lymphoma • Tuberculosis • Lymphoma PTHrp MECHANISM https://link.springer.com/article/10.1007/s12018014-9160-y • BONES- bone pain, myalgia • STONES- renal stones SYMPTOMS • GROANS- abdominal pain • MOANS- confusion, anxiety, depression, etc • THRONES- polyuria, constipation Hypercalcaemia Criteria Diagnosis Management U+Es st PTH studies 1 line- IV fluids Elevated serum calcium of May also give loop diuretics more than 2.65mmol/l Albumin levels 2nd line- bisphosphonates Bone profile rd LFTs 3 line- calcitonin Q U E S T I O4N A 83 -year-old man presents to the emergency A OXYGEN department with a severe cough, fever and fatigue. He has known to have a past medical B CHEST X-RAY history of COPD and lung cancer for which he is undergoing chemotherapy. Patient’s basic observations include: HR: 101, BP: 87/61, RR: 27, C IV FLUIDS Temp of 38.2 ˚C and O2 sats of 94% on air. D FULL BLOOD COUNT What is the next best step in the management of this patient? E IV ANTIBIOTICS ANSWER ON THE ZOOM POLL Q U E S T I O4N A 83 -year-old man presents to the emergency A OXYGEN department with a severe cough, fever and fatigue. He has known to have a past medical B CHEST X-RAY history of COPD and lung cancer for which he is undergoing chemotherapy. Patient’s basic observations include: HR: 101, BP: 87/61, RR: 27, C IV FLUIDS Temp of 38.2 ˚C and O2 sats of 94% on air. D FULL BLOOD COUNT What is the next best step in the management of this patient? E IV ANTIBIOTICS The underlying history points towards neutropenic sepsis; IV fluids is vital for his BP.NEUTROPENIC SEPSIS A common complication of cancer therapy which lowers neutrophil count. This in turn increases the infection risk. Criteria: Fever of >38.5 degrees or two DEFINTION/ consecutive readings over 38 degrees in CRITERIA a patient with a neutrophil count of less than 0.5x10 . Other common septic symptoms are present (low B, confusion, N, etc). COMMON CAUSES GRAM-NEGATIVES FUNGAL GRAM-POSITIVES E.COLI CANDIDA STAPH AUREUS KLEBSIELLA ASPERGILLUS STAPH EPIDERMIS ENTEROBACTER SPP ENTEROCOCCUS PSEUDOMONAS AERUGINOSA STREP PNEUMONIAE ACINETOBACTER GROUP A STREPTOCOCCI Investigations Management Blood cultures Low risk- oral antibiotics (co- amoxiclav and quinolone) Blood tests (WCC, LFTs, U+Es) These individuals are haemodynamically stable with no CXR complications (leukaemia, organ failure, etc) Serology/PCR High risk- IV piperacillin and Sputum tazobactam (tazocin) Stop these when patient is afebrile Urine and blood tests have returned to normal for a full 48 hours. CT scan Prophylaxis- fluroquinolone Any further tests to identify causative organism. MASCC Risk Index https://www.researchgate.net/figure/MASCC-Risk-Index-score_tbl1_51730823 GIVE ANTIBIOTICS GIVE O2 GIVE FLUIDS SEPSIS SIX TAKE BLOOD MEASURE URINE CULTURES MEASURE LACTATE OUTPUT Q U E S T I O5N A 79 -year-old man has recently been diagnosed A IV FLUIDS with lymphoma. Around 2 days ago, he started on his chemotherapy regime. The patient starts to B LOOP DIURETICS feel weak and fatigued. There is a noted decreased urine output with signs of fluid overload. Blood tests are arranged which show C THIAZIDE -LIKE DIURETICS the following: D ALLOPURINOL E SPIRONOLACTIONE To prevent the complication above, which of the following prophylaxis would be given? ANSWER ON THE ZOOM POLL Q U E S T I O5N A 79 -year-old man has recently been diagnosed A IV FLUIDS with lymphoma. Around 2 days ago, he started on his chemotherapy regime. The patient starts to B LOOP DIURETICS feel weak and fatigued. There is a noted decreased urine output with signs of fluid overload. Blood tests are arranged which show C THIAZIDE -LIKE DIURETICS the following: D ALLOPURINOL E SPIRONOLACTIONE To prevent the complication above, which of the following prophylaxis would be given? The cause of the AKI is due to tumour lysis syndrome- prophylactic allopurinol is given. TUMOUR LYSIS SYNDROME • URAEMIA • HYPERKALAEMIA BIOCHEMICAL • HYPERPHOSPHATAEMIA CHANGES • RAISED CREATININE • HYPOCALCAEMIA CRITERIA LABORATOR Y CLINICAL REQUIRES TWO OR MORE OF THE LABORATORY TLS PLUS ONE OR FOLLOWING MORE OF THE FOLLOWING Uric acid > 475 umol/l OR 25% Increased serum creatinine (1.5 increase times upper normal limit) OR Acute Kidney Injury Potassium > 6mmol/l OR 25% increase Cardiac arrythmia Phosphate > 1.125 mmol/l OR Sudden death 25% increase Seizure Calcium < 1.75 mmol/l OR 25% decrease Cairo-Bishop TUMOUR LYSIS SYNDROME SYMPTOMS INVESTIGATIONS TREATMENT DYSURIA/OLIURIA U+Es AGGRESSIVE IV FLUIDS/CORRECTION OF ABDOMINAL PAIN BLOODS ELECTROLYTES WEAKNESS ECG TEMPORARY DIALYSIS NAUSEA+VOMITING PROPHYLAXIS High risk- IV allopurinol or IV PALPITATIONS rasburicase prior to Chemotherapy (Co-morbidities, unstable FLUID OVERLOAD clinically, neutropenia, etc) Low risk- oral allopurinol during MUSCLE CRAMPS/SPASMS during chemotherapy Q U E S T I O6N A 53-year-old woman has recently finished her A METHOTREXATE chemotherapy regime for lung cancer. She attended the oncology department for a routine B CISPLATIN blood check and explained an unusual tingling feeling in her fingers. Blood results showed the following. C VINCRISTINE D BLEOMYCIN E DOCETAXEL Which chemotherapy drug is the most likely cause of the above? ANSWER ON THE ZOOM POLL Q U E S T I O6N A 53-year-old woman has recently finished her A METHOTREXATE chemotherapy regime for lung cancer. She attended the oncology department for a routine B CISPLATIN blood check and explained an unusual tingling feeling in her fingers. Blood results showed the following. C VINCRISTINE D BLEOMYCIN E DOCETAXEL Which chemotherapy drug is the most likely cause of the above? Although vincristine can also cause peripheral neuropathy, hypomagnesaemia is the key here Q U E S T I 7 N A 46 -year-old man presents to the emergency A CISPLATIN department with increasing fatigue and shortness of breath. He has a past medical history of B DOXORUBICIN lymphoma and COPD. His lymphoma has been treated previously with chemotherapy and his COPD is well controlled with salbutamol once a C CYCLOPHOSPHAMIDE week. On examination, a heart murmur is heard. D METHOTREXATE Which of the following is the most likely cause of this presentation? E DOCETAXEL ANSWER ON THE ZOOM POLL Q U E S T I O7N A 46-year-old man presents to the emergency A CISPLATIN department with increasing fatigue and shortness of breath. He has a past medical history of B DOXORUBICIN lymphoma and COPD. His lymphoma has been treated previously with chemotherapy and his COPD is well controlled with salbutamol once a C CYCLOPHOSPHAMIDE week. On examination, a heart murmur is heard. D METHOTREXATE Which of the following is the most likely cause of this presentation? E DOCETAXEL A common drug used for lymphoma is doxorubicin- known for cardiomyopathy.CYTOTOXIC AGENTSALKYLATING AGENTS PLATINUM AGENTS CYTOTOXIC ANTIBIOTICS INHIBITION OF DNA INHIBITION OF DNA DEGRADATION OF DNA REPLICATION VIA DNA CROSS- REPLICATION AND LINKING TRNASCRIPTION VIA DNA SE: LUNG FIBROSIS, CROSS-LINKING SCLERODERMA, POOR SE: HAEMORRHAGIC CYSTITIS, CIRCULATION MYELOSUPPRESSION, SE: OTOTOXICITY, PERIPHERAL INFERTILITY, NEOPLASMS NEUROPATHY, BLEOMYCIN HYPOMAGNESAEMIA, CYCLOPHOSPHAMIDE, NEPHROTOXICITY CHLORAMBUCIL INHIBITION OF RNA AND DNA CISPLATIN, CARBOPLATIN SYNTHESIS THROUGH STABILIZATION OF DNA- TOPOISOMERASE II SE: CARDIOMYOPATHY ANTHRACYCLINES- DOXORUBICIN ANTI-METABOLITES ANTI-MICROTUBULES OTHERS/EXTRAS • 5-FLOUROURACIL- ANALOGUE OF BINDS TO TUBULIN INHIBITING • TAXANESINHIBITION OF MITOSIS PYRMIDINE NUCLEOSIDE, INDUCES CELL THROUGH STABILIZATION OF CYCLE ARREST AND APOPTOSIS MICROTUBULE ASSEMBLY DISRUPTING M-PHASE OF THE TUBULIN IN MICROTUBULES • SE- MYELOSUPPRESSION, CELL CYCLE • DOCETAXEL- SE- DERMATITIS, MUCOSITIS NEUTROPAENIA • METHOTREXATE- INHIBITS • TOPOISOMERASE INHIBITORS DIHYDROFOLATE REDUCTASE REDUCING VINCRISTINE- SE- INTESTINAL INTERFERE WITH FOLATE NEEDED FOR DNA SYNTHESIS ILEUS, PERIPHERAL NEUROPATHY TOPOISOMERASES INDUCING • SE- LIVER FIBROSIS, LUNG FIBROSIS, BREAKS IN DNA STRANDS MYELOSUPPRESSION, MUCOSITIS VINBLASTINE- SE- CAUSING CELL CYCLE ARRES • CYTARABINE- INHIBITION OF DNA MYELOSUPPRESSION • MITOXANTRONE, POLYMERASE AND HALTS DNA IRINOTECAN SYNTHESIS DURING S-PHASE OF CELL CYCLE DOCETAXEL- SE- NEUTROPAENIA • SE- ATAXIA, MYELOSUPPRESSION • ANTI-PURINES (AZATHIOPRINE) • ANTI-VIRALS (ACICOLVIR) • HYDROXYCARBAMIDE LUNG CANCER LUNG CANCER SMALL CELL NON-SMALL CELL ADENOCARCINOMA SQUAMOUS CELL LARGE CELL ALVEOLAR CELL BRONCHIAL ADENOMA ADENOCARCINOMA SQUAMOUS CELL NON- SMALL • THE MOST COMMON LUNG • STRONGLY ASSOCIATED WITH CANCER, PERIPHERAL SMOKING, CENTRAL • COMMONLY SEEN IN NON- • PTHRP LEADING TO CELL LUNG SMOKERS HYPERCALCAEMIA • ECTOPIC TSH, HYPERTHYROIDISM CANCER • GYNAECOMASTIA • CLASSIC SIGN OF CLUBBING • HYPERTROPHIC PULMONARY • HYPERTOPHIC PULMONARY OSTEOARTHROPATHY OSTEOARTHROPATHY • GLANDULAR • SQUAMOUS CELL, KERATINISED LARGE CELL ALVEOLAR CELL BRONCHIAL ADENOMA • STRONGLY ASSOCIATED WITH • NOT RELATED TO SMOKING, • ORIGINATES IN THE BRONCHUS PERIPHERAL OR CENTRAL • MOSTLY A CARCINOID SMOKING, PERIPHERAL OR • OFTEN POORLY DIAGNOSED TUMOUR, RARELY CAUSES CENTRAL • LARGE AMOUNTS OF SPUTUM CARCINOID SYNDROME • UNDIFFERENTIATED WITH POOR • ATYPICAL- FAST PROGNOSIS PRODUCED, LONG TERM • LARGE TUMOUR CELLS WITH EARLY SYMPTOM GROWING AND SPREADS METASTASES • SLOW GROWING KEY FEATURES/FACTS • Strongly associated with smoking • Centrally located • Undifferentiated with aggressive and early metastases; therefore a poor prognosis. SMALL CELL • Arise from Kulchitsky cells (endocrine cells) • siADH- euvolemic hyponatraemia LUNG CANCER • Ectopic ACTH release- Cushing’s syndrome. May also lead to bilateral adrenal hyperplasia due to increased cortisol production. • Lambert-Eaton syndrome- antibodies produced against voltage gated calcium channels, leads to muscle weakness. LUNG CANCER CLINICAL FEATURES DIAGNOSIS • Chest X-ray is usually first line • Cough • Haemoptysis • Sputum cytology • Contrast-enhanced CT scan- to • Chest pain confirm and stage • Dyspnoea • Weight loss • Bronchoscopy for histology • PET- establish metastasis MANAGEMENT COMPLICATIONS • First line curative treatment- lobectomy • SVCO, OR SCC • Contraindicated in stage 3/4, • Horner’s syndrome- from a Pancoast FEV1<1.5L, SVCO, pleural effusion, tumour near hilum, vocal cord affected tumour. Voice hoarseness also. • Second line- curative radiotherapy • Tumour in apex of lung, usually • Small cell- palliative chemotherapy, as usually adenocarcinoma or squamous cell a metastatic disease, otherwise resect (if carcinoma tumour size small) • Paraneoplastic syndromes CT SCAN CXR- PANCOAST TUMOUR https://radiopaedia/articles/pancoast-tumour?lang=us https://www.cancer.gov/news-events/cancer-currents-blog/2017/lung-cancer-screening-challenges METASTASES LOCAL DISTANT Cancerous cells spreading to Spread of cancerous cells surrounding healthy tissues, through transport systems e.g. lung cancer spreading to within the body: lymphatic nearby lobes. system or blood vessels. KEY KNOWLEDGE • Symptoms depend on the organ affected, e.g. • Bone Metastases- this leads to spinal cord compression as the spine is a common site • Bone pain, weaker leading to fractures • May get hypercalcaemia and raised ALP • Caused by many cancers, prostate and breast METASTASES are most common. • Liver (Liver failure symptoms) • Jaundice, oedema, fever, ascites, etc • Caused by colorectal cancers, breast, oesophageal, etc. • Lungs • Metastases via renal cell, breast, colorectal, etc. Lung cannonball metastases, commonly caused by renal cell cancer https://radiopaedia.orgarticles/cannonball-metastases-lungs?lang=us Q U E S T I O8N A 60-year-old woman presents to the emergency A CT SCAN - DOUBLE DUCT department with yellowing of her skin, fatigue and some mild epigastric pain. On examination, B CT SCAN - DOUBLE BARRELLED SHOTGUN there is no tenderness, aside from a palpable mass in the right upper quadrant. She has also noticed some weight loss in the past 2 months. C ULTRASOUND - DOUBLE DUCT Laboratory tests show a raised ALP, bilirubin and CRP. D MRCP - DOUBLE BARRELLED SHOTGUN Given the most likely underlying diagnosis, what investigation would be carried out and which sign E ULTRASOUND - DOUBLE BUBBLE SIGN would you expect to see? ANSWER ON THE ZOOM POLL Q U E S T I 8 N A 60-year-old woman presents to the emergency A CT SCAN - DOUBLE DUCT department with yellowing of her skin, fatigue and some mild epigastric pain. On examination, B CT SCAN - DOUBLE BARRELLED SHOTGUN there is no tenderness, aside from a palpable mass in the right upper quadrant. She has also noticed some weight loss in the past 2 months. C ULTRASOUND - DOUBLE DUCT Laboratory tests show a raised ALP, bilirubin and CRP. D MRCP - DOUBLE BARRELLED SHOTGUN Given the most likely underlying diagnosis, what investigation would be carried out and which sign E ULTRASOUND - DOUBLE BUBBLE SIGN would you expect to see? Painless jaundice, weight loss and epigastric pain point to pancreatic cancer. PANCREATIC ANCER RISK FACTORS CLINICAL FEATURES • Smoking • Painless jaundice- Courvoisier’s • Age • Chronic pancreatitis • Weight loss • Overweight • Dark urine and pale stools • Diabetes • Diabetes • Inherited syndromes- HNPCC, PJS, • Steatorrhea • Trousseau’s sign of malignancy BRCA1/2, MEN DIAGNOSIS TREATMENT • CT scan is the key • Tumour resection is curative- must not • Ultrasound is sensitive and quick involve SMA or any distant metastases • Classic ‘double duct’ sign • Usually a late presentation, so not • MRCP resectable. WHIPPLE procedure. • PET scan • Palliative treatment if metastases via • Raised bilirubin and ALP chemotherapy, radiotherapy, endoscopic • Ca19-9 and CEA stents, further surgeries, pain. PLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK! @OSCEazyOfficial @osceazyofficial OSCEazy Osceazy@gmail.com