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
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
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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