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Haematology, Oncology and Palliative Medicine Eva Kerr, FY1 UoE ~ Salford Royal Foundation Trust Eva.Kerr@srft.nhs.uk Finals Checklist GMC’S Medical Licensing Assessment Content Map 01 Haematology hyposplenism, leukaemia, lymphoma, myeloma, myeloproliferative disorders, pancytopaenia, anticoagulants + antiplatelets, polycythaemia, PE, sickle cell disease, transfusion reactions Palliative Medicine 02 Pain management, end-of-life care/ symptoms of terminal illness, nausea, neuromuscular illness, cardiac failure, metastatic disease, multi-organ dysfunction syndrome Oncology 03 ovarian, pancreatic, prostate, SCC, testicular, leukaemia, lymphoma, myeloma, . Hypercalcaemia ofageal, malignancy, spinal cord compression, tumour lysis syndrome 04 Breast Breast lump / tenderness, nipple discharge, breast abscess, mastitis, breast cyst, breast cancer,Questions ● 1 min per question ● Please try not to put the answer in the chat!01 you that pain is starting to bother him for the first time, and simple analgesia at home isn’t helping. His latest bloods are; Hb 97, PLT 650, Na 138, K 4.9, urea 15, creatinine 270, eGFR 31. What do you give him? 1. Morphine MR, 10mg 3-hourly PRN 2. Oxycodone MR 5-7.5mg BD plus 1-2mg IR PRN 3. Morphine MR 15mg BD plus 2.5mg IR PRN 4. Oxycodone IR 10mg BD 5. Morphine MR 60mg OD plus 10mg IR PRN01 you that pain is starting to bother him for the first time, and simple analgesia at home isn’t helping. His latest bloods are; Hb 97, PLT 650, Na 138, K 4.9, urea 15, creatinine 270, eGFR 31. What do you give him? 1. Morphine MR, 10mg 3-hourly PRN 2. Oxycodone MR 5-7.5mg BD plus 1-2mg IR PRN 3. Morphine MR 15mg BD plus 2.5mg IR PRN 4. Oxycodone IR 10mg BD 5. Morphine MR 60mg OD plus 10mg IR PRN Pain Management in Palliative Care https://www.nice.org.uk/guidance/cg140 • Initiation of opioid analgesia: -start with PO, regular modified or immediate-release opioid depending on preference; plus immediate-release for breakthrough -regular total daily dose 20-30mg morphine, with 5mg breakthrough if no renal / hepatic comorbidities -prescribe laxatives for all patients initiating strong opioids, consider anti-emetics if nausea which is persistent -if persistent moderate-severe drowsiness; if pain controlled, reduce dose / if pain not controlled, switch med • Titration; add regular plus PRNs, have this as new regular dose plus 1/6 of this for breakthrough • If analgesic needs are stable but PO analgesia is not suitable, switch to transdermal or subcutaneous • If pain is due to bone mets, can consider bisphosphonates / palliative radiotherapy02 A 65-year old gentleman presents with 5kg weight loss and diarrhoea over the past 3 months. He has a past medical history of hypertension and depression. You do some baseline bloods, which are as follows; Hb 134, WCC 8.9, PLT 430, BM 18.4 What is your next step with this patient? 1. 2ww CT abdomen 2. 2ww colonoscopy 3. Non-urgent OGD 4. 2ww ultrasound abdomen 5. Reassure and discharge02 A 65-year old gentleman presents with 5kg weight loss and diarrhoea over the past 3 months. He has a past medical history of hypertension and depression. You do some baseline bloods, which are as follows; Hb 134, WCC 8.9, PLT 430, BM 18.4 What is your next step with this patient? 1. 2ww CT abdomen 2. 2ww colonoscopy 3. Non-urgent OGD 4. 2ww ultrasound abdomen 5. Reassure and discharge Suspected Cancers Cancer Signs/ Symptoms Investigation Type Oesophageal Dysphagia, or >55 with weight loss plus upper abdo pain / reflux / 2ww OGD / Gastric dyspepsia Treatment-resistant dyspepsia / upper abdominal pain with anaemia Non-urgent OGD / nausea / vomiting / weight loss / reflux / dyspepsia / upper abdo pain / haematemesis / thrombocytosis Lung 2 symptoms for never-smokers, 1 for smokers/ pts with asbestos 2ww CXR exposure; (followed by 2ww cough, fatigue, SOB, chest pain, weight / appetite loss appointment if CXR OR 1 of; persistent / recurrent chest infection, finger clubbing, suggestive of cancer) supraclavicular / cervical lymphadenopathy, thrombocytosis, malignant chest signs CXR findings suggestive of cancer / 2ww appointment >40 + unexplained haemoptysis Pancreatic 40+ with jaundice 2ww appointment 60+ with weight loss and; diarrhoea / back pain / abdominal pain / 2ww CT (or US if CT nausea / vomiting / constipation / new onset diabetes unavailable) Suspected Cancers Cancer Signs/ Symptoms Investigation Type Gall bladder Enlarged upper abdominal mass consistent w/ GB 2ww USS Liver Hepatomegaly 2ww USS Colorectal 40+, unexplained weight loss + abdo pain 2ww 50+, unexplained rectal bleeding appointment* 60+, iron-deficiency anaemia / bowel habit changes Consider for; rectal/ abdominal mass, any of above symptoms <50, anal ulceration / mass Breast 30+ with unexplained breast lump 2ww appointment 50+ with unilateral nipple changes Consider if any red flag skin changes / 30+ with axillary lump Ovarian 2ww appointment if ascites or pelvic / abdominal mass Investigate in primary care (Ca-125 +/- US) if any other red flag ovarian Ca symptoms; persistent bloating, early satiety, appetite loss, pelvic/ abdominal pain, lower urinary tract symptoms, weight loss, fatigue, bowel changes Beware IBS symptoms in women >50yo; always exclude ovarian Ca *Pts who don’t meet criteria for 2ww appointment should have faecal immunochemical testing Suspected Cancers Cancer Signs/ Symptoms Investigation Type Endometrium Post-menopausal bleeding (refer if >55, consider referring if <552ww appointment >55 and; 2ww USS -vaginal discharge and thrombocytosis / haematuria, or -haematuria and anaemia / thrombocytosis / hyperglycaemia Vulva/ vagina Unexplained lump / ulceration / bleeding 2ww appointment Prostate Lower urinary tract infections / erectile dysfunction / visible PSA + PR haematuria PSA above age-specific threshold / concerning PR findings 2ww appointment02 A 67-year old woman presents to the GP feeling tired all the time. She reports low mood and recurrent coughs and colds. Baseline bloods are below; Hb 89, WCC 4.0, PLT 100, urea 13.0, creatinine 170, Ca 3.0, PO4 0.8 What is the definitive investigation for the most likely diagnosis, and what is the finding associated with this diagnosis? 1. Serum protein electrophoresis + serum-free light chain assay; increased 2. Blood film – Rouleaux cells 3. FDG-PET-CT; focal areas of increased uptake 4. Bone marrow aspirate + trephine biopsy- increased plasma cells 5. Bone marrow aspirate + trephine biopsy- Reed-Sternberg cells02 A 67-year old woman presents to the GP feeling tired all the time. She reports low mood and recurrent coughs and colds. Baseline bloods are below; Hb 89, WCC 4.0, PLT 100, urea 13.0, creatinine 170, Ca 3.0, PO4 0.8 What is the definitive investigation for the most likely diagnosis, and what is the finding associated with this diagnosis? 1. Serum protein electrophoresis + serum-free light chain assay; increased 2. Blood film – Rouleaux cells 3. FDG-PET-CT; focal areas of increased uptake 4. Bone marrow aspirate + trephine biopsy- increased plasma cells 5. Bone marrow aspirate + trephine biopsy- Reed-Sternberg cells Myeloma- CRABBI Malignancy of the plasma cells that produce immunoglobulin Calcium Renal Anaemia Bleeding Bones Infection Impairment • Myeloma cells • Light chain • Bone marrow • Bone marrow • Bone marrow • Reduced release local deposition in crowding crowding infiltrated by production of cytokines tubules suppresses suppresses plasma cells normal Ig • Increases • Also erythropoiesis platelet • Increased osteoclast amyloidosis + prouction osteoclast bone renal tract activity resorption stones • Leads to lytic • Also, renal lesions + impairment, pathological increased fractures renal tubular calcium absorption, PTHrP Myeloma https://www.nice.org.uk/guidance/ng35/chapter/Recommendations Diagnosis • Test for serum paraproteins first; -serum (+ urine) protein electrophoresis + serum-free light chain assay -indicate possible myeloma, but can’t exclude diagnosis • Confirm diagnosis with bone marrow aspirate + trephine biopsy -FISH analysis on selected bone marrow plasma cells helps with prognostication/ risk abnormality • Serum-free light chain assay + ratio also helps assess prognosis • First-line imaging = whole-body MRI -if contraindicated, whole-body low-dose CT / FDG-PET-CT Myeloma https://www.nice.org.uk/guidance/ng35/chapter/Recommendations Management Myeloma is incurable, but treatments improve survival + QoL • First line = high-dose chemotherapy with haematopoietic stem cell transplantation -bortezomib + dexamethasone + thalidomide -stem cell transplantation can be autologous or allogeneic • If this is inappropriate, consider either thalidomide or bortezomib with alkylating agent + steroid Managing Complications of Myeloma Renal Bone Disease Infection Risk Peripheral Anaemia Disease Neuropathy Responds Dental referral Test for BBVs before chemo Consider reducing If to chemo dose/ frequency or symptomatic, Bisphosphonates Flu + pneumococcal changing route of consider EPO vaccination bortezomib analogue Surgical stabilisation of If hypo- Consider pathological gammaglobulinaemia suspending chemo fractures / spinal contributing to infections, for moderate instability consider IVIg neuropathy with pain / severe Radiotherapy Consider antiviral neuropathy prophylaxis Myeloma https://www.nice.org.uk/guidance/ng35/chapter/Recommendations Monitoring • After recovery, follow-up 3-monthly bloods incl serum immunoglobulins + protein electrophoresis • If bloods suggest relapse → MRI / FDG PET-CT03 PMH; IUD insertion 2020, infectious mononucleosis 2019. She denies weight loss, night sweats and is afebrile. Bloods; Hb 90, WCC 11, PLT 450, urea 6, creatinine 80 Which aspect of this patient’s history is most likely to confer a poor prognosis? 1. Previous EBV infection (infectious mononucleosis) 2. Age 3. Anaemia 4. Being female 5. Absence of B symptoms03 PMH; IUD insertion 2020, infectious mononucleosis 2019. She denies weight loss, night sweats and is afebrile. Bloods; Hb 90, WCC 11, PLT 450, urea 6, creatinine 80 Which aspect of this patient’s history is most likely to confer a poor prognosis? 1. Previous EBV infection (infectious mononucleosis) 2. Age 3. Anaemia 4. Being female 5. Absence of B symptoms Lymphoma Staging; Ann Arbor System Classed as ‘A’ or ‘B’ depending if B symptoms present; -temperature >38’Cin last 6 months -night sweats Stage 1 Stage 2 Stage 3 Stage 4 Lymph In >1 region, Lymph Widespread, nodes but only nodes both including involved are either above/ above + non- confined to below below lymphatic one region diaphragm diaphragm organs Hodgkin’s Lymphoma https://www.nice.org.uk/guidance/NG52/chapter/Recommendations#diagnosis Aetiology • Unknown • RFs; infectious mononucleosis, HIV, autoimmune, FHx Clinical Features • Painless, asymmetrical lymphadenopathy (usually cervical / supraclavicular) • Lymphnode pain after alcohol • Mediastinal lymphadenopathy → chest symptoms (SOB, pain, dry cough) • Constitutional ‘B’ symptoms; fever, sweats, weight loss • Spread tends to be node → node; organ metastasis rare • May have hepatosplenomegaly, doesn’t necessarily indicate spread to liver / spleen Hodgkin’s Lymphoma https://www.nice.org.uk/guidance/NG52/chapter/Recommendations#diagnosis Investigations Bloods + FBC- may be normal; normochromic normocytic anaemia carries poor prognosis + Blood Film multifactorial; hyposplenism, bone marrow replaced with lymphoma, haemolysis Raised ESR, LDH = poor prognosis Eosinophilia = production of cytokines e.g. IL-5 Blood film; Reed-Sternberg cells Radiology CXR- may show mediastinal mass CTCAP- staging PET-CT- allows identification of involved nodes, more accurate staging, monitoring LN Biopsy Definitive Hodgkin’s Lymphoma https://www.nice.org.uk/guidance/NG52/chapter/Recommendations#diagnosis Diagnosis • Histology → Reed-Sternberg cells (large malignant lymphoid cells of B-cell origin) Subtypes Based on appearance of Reed-Sternberg cells and surrounding cells; • Nodular sclerosing (70%) • Mixed cellularity (20%) • Lymphocyte rich (5%) • Lymphocyte deplete (rare) Management • Stage I + II → chemo-radiotherapy; ABVD commonly used in UK, followed by radiotherapy • NB long term risks of radiotherapy; secondary cancers, heart + lung problems • Stage III + IV → chemotherapy alone • Monitoring with PET-CT • Role for stem cell transplantation if recurs; autologous if responds to chemo, allogeneic if resistant to chemo Non-Hodgkin’s Lymphoma https://www.nice.org.uk/guidance/NG52/chapter/Recommendations#diagnosis • Subtypes; -diffuse large B cell; most common (40%), high-grade and aggressive but typically responds well to treatment -follicular (16%)- low-grade -cutaneous T cell (5%)- skin changes -Burkitt- typically in immune-compromised pts -mantle cell (<1%) Lymphoma https://www.nice.org.uk/guidance/NG52/chapter/Recommendations#diagnosis Investigation • Lymph node excisional biopsy -if benefits < risks of excisional biopsy, consider needle core biopsies (as many and as large as possible) • Biopsies sent for histology + immunohistochemistry • FDG-PET-CT offered for kinds of lymphoma where results would affect management; mainly early-stage diffuse large-B cell, follicular and Burkitt lymphomasNon-Hodgkin Lymphoma- Management https://www.nice.org.uk/guidance/NG52/chapter/Recommendations#diagnosis Subtype Management Follicular Localised → radiotherapy Advanced → rituximab, plus chemo if symptomatic (CVP/ CHOP/ MCP/ CHVPi) After induction of remission, maintenance w/ rituximab Gastric MALT Localised → H. pylori eradication therapy (consider even if H. pylori negative); if residual high- risk disease after this, consider gastric radiotherapy or chemo + ritux Disseminated → H. pylori eradication therapy; if symptomatic / impaired organ function, consider gastric radiotherapy, or chemo + rituximab Non-gastric Localised → radiotherapy MALT Disseminated → chemotherapy + rituximab Consider watch + wait if non-progressive, asymptomatic, not impairing organ function Mantle cell Localised → radiotherapy Advanced disease, symptomatic → chemotherapy + rituximab If can tolerate intensive regime, consider immunochemotherapy (cytarabine) If pt responds to chemotherapy, consider consolidation with stem cell transplantation Maintenance w/ rituximab Diffuse large B- Chemotherapy +/- consolidation with autologous stem cell transplantation cell If responds to immunochemotherapy, consider radiotherapy to bulk areas If relapsed / refractory and fit enough , consider multi-agent immunochemotherapy Burkitt Intensive immunochemotherapy if high-risk and fit If lower risk or not fit for intensive regime, consider less intensive chemo plus MTX Peripheral T-cell CHOP chemo +/- consolidation with stem cell transplantation Essentially… https://www.nice.org.uk/guidance/NG52/chapter/Recommendations#diagnosis Most Non-Hodgkins (except peripheral T-cell) If disease is localised → radiotherapy If disease is advanced → chemotherapy plus rituximab Consider consolidation with autologous stem cell transplantation if they respond to chemotherapy Peripheral T-Cell CHOP chemotherapy +/- autologous stem cell transplantation04 Two parents bring their five-year-old child into the surgery with them. She has been falling asleep in school and coming home with bumps and bruises. FBC; Hb 80, PLT 40, WBC 18. You also notice hepatic and splenic enlargement. What is the most likely diagnosis? 1. AML 2. CML 3. Hodgkin lymphoma 4. CLL 5. ALL04 Two parents bring their five-year-old child into the surgery with them. She has been falling asleep in school and coming home with bumps and bruises. FBC; Hb 80, PLT 40, WBC 18. You also notice hepatic and splenic enlargement. What is the most likely diagnosis? 1. AML 2. CML 3. Hodgkin lymphoma 4. CLL 5. ALL Leukaemia Symptoms Malignancy of haematopoietic stem cells (precursor cells); excessive production of one type of abnormal WBC, and suppressed production of normal WBCs, RBCs and platelets Lack of Red Cells Lack of Platelets Lack of Normal White Cells Fatigue, pallor, shortness Bruising, bleeding, Recurrent / atypical / of breath, dizziness, petechiae serious infections palpitations Also; bone pain, hepatosplenomegaly Acute leukaemias → stem cells are still primitive when they proliferate (blasts) Chronic leukaemias → stem cells have time to develop (mature cells) Diagnosis; -AML, ALL, CML → bone marrow aspirate + trephine biopsy -CLL → BM analysis not essential, can be diagnosed from blood film Leukaemias; Average Ages ALL CLL CML AML Under 5, Over 55 Over 65 Over 75 Over 45 Leukaemias; Management AML ALL CML CLL Chemotherapy → BM Tyrosine kinase inhibitorsTreat only if BM failure, transplant if fail to respond (Imatinib, nilotinib, massive organomegaly/ dasatinib) lymphadenopathy, systemic symptoms, If fail TKI therapy, stem autoimmune haemolysis cell transplant Chemo + rituximab Supportive therapy; -transfusion -prophylactic abx / antivirals / antifungals -leucopheresis (WCC removal) before chemo -radiotherapy for obstructing lymphadenopathy / splenomegaly Leukaemias; Exam Buzzwords AML ALL Blast cells and Auer rods on blood smear Young (80% of childhood leukaemias) Auer = hour >20% blasts on BM aspirate CML CLL Philadelphia chromosome Older (BCR-ABL 9;22) Philadelphia = cream (CM) cheese Splenomegaly (present in 90%)05 A 75-year-old man comes to see you with 2 months of night sweats and weight loss. PMH; total knee replacement, T2DM, CLL, HTN, BPH. What is most likely to help you diagnose what is happening? 1. Blood film 2. Bone marrow aspirate + trephine biopsy 3. PET-CT 4. CTCAP 5. Lymph node biopsy05 A 75-year-old man comes to see you with 2 months of night sweats and weight loss. PMH; total knee replacement, T2DM, CLL, HTN, BPH. What is most likely to help you diagnose what is happening? 1. Blood film 2. Bone marrow aspirate + trephine biopsy 3. PET-CT 4. CTCAP 5. Lymph node biopsySpread / Transformation of Blood Cancers Large B-Cell CLL Polycythaemia Vera Lymphoma CNS Spread Richter’s transformation → Transformation to AML / large cell non-Hodgkin myelofibrosis lymphoma Emergencies in HOPB Emergency Presentation / Diagnosis / Management Tumour Lysis Chemo → uric acid release from cancer cells → AKI, high electrolytes except Ca Syndrome Treatment → allopurinol, rasburicase MSCC First presentation of cancer in 23%; lung, breast, myeloma, lymphoma, prostate Radicular sciatic-like back pain, localised tenderness, weakness (UMN if above L2, LMN if below), altered sensation, urinary retention / constipation Oral dexamethasone and omeprazole and send for urgent MRI whole spine Definitive management; surgery +/ radiotherapy Plus; analgesia, tapering steroid course, thromboprophylaxis, catheterisation, TEDS Hypercalcaemia >2.7mmol/L; PTHrP > skeletal involvement > tumour calcitriol production Stones, thrones, abdominal groans, bones, psychiatric moans, cardiac overtones Treatment → discontinue exacerbating meds + nephrotoxics, IV saline 3L/24h, calcitonin / bisphosphonates, haemofiltration Emergencies in HOPB Emergency Presentation / Diagnosis / Management Neutropaenic 80% caused by gut flora; chemotherapy inhibits gut mucosal division → breakdown → Sepsis infiltration of gut flora Criteria; -systemic cytotoxic therapy within last 6 weeks -neutrophils <1.0 (but don’t wait for FBC; treat as neutropaenic sepsis) -temperature >38 / <36, or signs / symptoms of sepsis Cultures ONLY → then piptaz plus gent → then rest of septic screen) Plus rest of sepsis six +/- filgrastim (GCSF) to stimulate neutrophil production SVCO Usually lung cancers / lymphomas SOB, facial / arm swelling worse when flat, cough, chest pain, vein distention, non- pulsatile JVP, positive Pemberton’s test, hoarseness/ stridor → laryngeal + cerebral oeema → cardiorespiratory arrest CTPA is gold standard Management; emergency stenting + radiotherapy if unstable, contact oncology for specific cancer management if stable Thanks! Any questions- feel free to ask now, or email me- Eva.Kerr@srft.nhs.uk x CREDITS: This presentation template was created by Slidesgo, including icons by Flaticon, and infographics & images by Freepik.