Oncology - Sheffield Peer Teaching Society

Oncology - Sheffield Peer Teaching Society

Oncology 17/10/2019 MLT2 Rosalind Simpson Plan

Pathology + staging of common malignancies Oncological emergencies Screening theory and screening programmes

Pain management and palliative care in terminal disease Breast Breast ~80% ductal

~15% lobular ~5% other eg medullary mucinous, papillary Classification by histology Oestrogen + progesterone HER2 (human epidermal growth factor

receptor 2) Triple negative Proliferative markers eg ki67 Oestrogen receptor

Premenopausal = Tamoxifen SERM = antagonist at breast, agonist at bone Postmenopausal = aromatase inhibitors Block conversion of adrenal androgens to

oestrogens in fatty tissues Anastrozole Her2 receptor Trastuzumab (aka Herceptin) Humanized monoclonal antibody

Nomenclature of monoclonal antibodies

-umab = hUMAn -zumab = hUMAniZed -ximab = x = chi = chimeric -imab = primate -omab = mouse MAB Monoclonal Anti Body

Ki67 + triple negative Aggressive. Adjuvant chemo indicated Ki67 positive tumours are chemosensitive Staging

Nottingham Prognostic Index tumour grade [1 3] + lymph node status [1 3] + 0.2 x tumour size [cms] Result between 0 and 7 Less than 2.4 = same survival >5.4 less than 20% 5 year survival

Lung Lung 15% small cell lung cancer Metastasise early Chemosensitive but poor prognosis Can produce ACTH, SIADH, cause LEMS

85% non small cell 42% squamous 39% adenocarcinoma commonest in non smokers 8% large cell 7% carcinoid

Colorectal Colorectal Two thirds colon one third rectum Adenocarcinomas that arise from polyps Prostate cancer

Adenocarcinoma Multi-focal (different foci have different properties) Mostly indolent but minority are aggressive Metastasise to bone Presents

Bone pain, erectile dysfunction, lower back pain, lethargy, anorexia, wt loss, haematuria LUTS less commonly Raised or rising PSA not particularly sensitive or specific Hard and nodular prostate on DRE

Diagnosis + gleason grade TRUS biopsy 10-12 cores taken Commonest and second most common tumour patterns identified Each graded from 1 (normal tissue) to 5 (completely undifferentiated

Sum them Get a number between 2 and 10 Low grade = 6 or less, intermediate = 7, high grade = 8+ Goals of treatment Radical = with curative intent Palliative = to reduce symptoms/prolong life

WITHOUT curative intent Adjuvant = alongside/after definitive (normally surgical therapies) implies curative intent Neo-adjuvant = before definitive treatment to eliminate micrometastases Goals of treatment

Watchful waiting = postponing palliative treatment Active surveillance = postponing radical treatment and involves re-biopsy Radical Therapy External Beam Radiotherapy

Prostatectomy Adjuvant therapies Androgen withdrawal surgery, LHRH agonist or LHRH antagonist LHRH agonists eg gosrelin Agonists can cause a flare which you can block

with bicalutaide LHRH antagonists eg cyproterone acetate Also be ready for

melanoma cervical

endometrial bladder kidney liver pancreas Oncological emergencies

Tumour lysis syndrome

Spinal cord compression SVC obstruction Neutropenic sepsis Hypercalcaemia Tumour Lysis Syndrome The abrupt release of large quantities of

cellular components into the blood following rapid lysis of malignant cells Who gets it Cancers with large tumour bulk (more tumour to lyse) Cancers that are very chemosensitive (more of the tumour lyses at once)

Leukaemias and lymphomas especially aggressive lymphomas Poor renal function (cannot clear the toxic cell contents) What happens Proteins are released -> hyperuricaemia

Electrolytes that are more concentrated in the cells are released -> hyperphosphataemia and hyperkalaemia The phosphate complexes with calcium -> hypocalcaemia The uric acid and calcium phosphate crystals deposit in the renal tubules -> acute renal failure

Presentation Weakness Paralytic ileus - Constipation, vomiting, abdo pain Cardiac arhythmias - Palpitations, chest pain, collapse

Acute kidney injury - reduced UO, lethargy, nausea Investigations FBC U+E - raised urea, raised creatinine (AKI(, hyperkalaemia

Serum LDH - high Serum phosphate - high Serum calcium - low Serum urate - high Management

Awareness, identification of high risk patients,

implementation of prophylaxis, monitoring patient during chemotherapy Starting active treatment when necessary Prevention for high risk patients IV fluids, Rasburicase: recombinant urate oxidase catalyses the oxidation of uric acid to more

soluble allantoin, Allopurinol: xanthine oxidase inhibitor - blocks conversion of xanthines to uric acid Active treatment Vigourous hydration Correct hyperkalaemia

Protect the myocardium with 10mls of 10% calcium gluconate Drive potassium into cells with 10 units of rapid acting insulin and 50mls of 50% glucose Salbutamol neb Remove the potassium with oral calcium resonium

Active treatment Rasburicase (stop allopurinol) Acetazolomide = alkalinize urine make uric acid more soluble Phosphate binders If above fails dialyse

Neutropenic sepsis Neutropenia of ** AND a fever >38 OR other signs or symptoms suggestive of sepsis Neutropenia = neuts <1 Nice guidance = <.5 Some hospitals = <.7 to <1

At risk of neutropenic sepsis Current or recent anticancer treatment Most commonly chemo for blood cancers But also lung, breast, ovarian, colorectal Investigations FBC !!!

Identify source or pathogen = CXR, Urine M C + S, blood culture Treatment ABCDE Sepsis six

IMMEDIATE commencement of empiric abx DO NOT wait for the fbc NICE piperacillin with tazobactam

Some hospital guidelines add gentamicin prevention If considered high risk = fluroquinolone monotherapy NOT recommended routinely by NICE but important to know about = GCSF

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