Oncology 17/10/2019 MLT2 - PowerPoint Presentation

Slide1

Oncology

17/10/2019

MLT2

Rosalind Simpson

Slide2

Plan

Pathology + staging of common malignancies

Oncological emergencies

Screening theory and screening programmes

Pain management and palliative care in terminal disease

Slide3

Breast

Slide4

Breast

~8

0% ductal

~15% lobular

~5% other

eg

medullary

mucinous, papillary

Slide5

Classification by histology

Oestrogen

+

progesterone

HER2 (human e

pidermal

growth factor

receptor 2)

Triple negative

Proliferative markers

eg

ki67

Slide6

Oestrogen

rece

ptor

Premenopausal = Tamoxifen

SERM = antagonist at breast, agonist at bone

Postmenopausal = aromatase inhibitors

Block conversion of adrenal androgens to oestrogens in fatty tissues

Anastrozole

Slide7

Her2

rece

ptor

Trastuzumab (aka

Herce

ptin

)

Humanized monoclonal antibody

Slide8

Nomenclature of monoclonal antibodies

-

umab

=

hUMAn

-

zumab

= hUMAniZed

-

ximab

= x

= chi = chimeric

-

imab

=

primate

-

omab

=

mouse

MAB Monoclonal Anti Body

Slide9

Ki67 + tri

ple

negative

Aggressive. Adjuvant chemo indicated

Ki67

positive tumours are

chemosensitive

Slide10

Staging

Slide11

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

Slide12

Slide13

Lung

Slide14

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

Slide15

Slide16

Colorectal

Slide17

Colorectal

Two thirds colon one third rectum

Adenocarcinomas that arise from

polyps

Slide18

Slide19

Slide20

Prostate cancer

Adenocarcinoma

Multi-focal (different foci have different properties)

Mostly indolent but minority are aggressive

Metastasise

to bone

Slide21

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

Slide22

Diagnosis +

gleason

grade

TRUS biopsy

10-12 cores taken

Commonest and second most common

tumour

patterns identifiedEach graded from 1 (normal tissue) to 5 (completely undifferentiatedSum themGet a number between 2 and 10Low grade = 6 or less, intermediate = 7, high grade = 8+

Slide23

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

Slide24

Goals of treatment

Watchful waiting = postponing palliative treatment

Active surveillance = postponing radical treatment and involves re-biopsy

Slide25

Radical Therapy

External Beam Radiotherapy

Prostatectomy

Slide26

Adjuvant therapies

Androgen withdrawal – surgery, LHRH agonist or LHRH antagonist

LHRH agonists

eg

gosrelin

Agonists can cause a flare which you can block with

bicalutaideLHRH antagonists eg cyproterone acetate

Slide27

Also be ready for

melanoma

cervical

endometrial

bladder

kidney

liver

pancreas

Slide28

Oncological emergencies

Tumour

lysis syndrome

S

pinal cord compression

SVC obstruction

Neutro

penic sepsisHy

percalcaemia

Slide29

Tumour

Lysis Syndrome

The

abru

pt

release of large quantities of cellular components into the blood following rapid lysis of malignant cells

Slide30

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

lym

phomas

especially aggressive lymphomas

Poor renal function (cannot clear the toxic cell contents)

Slide31

What ha

ppens

Proteins are released ->

hyperuricaemia

Electrolytes that are more concentrated in the cells are released ->

hy

perphosphataemia

and

hyperkalaemia

The

phosphate complexes with calcium ->

hypocalcaemia

The uric acid and calcium

phosphate crystals deposit in the renal tubules ->

acute renal failure

Slide32

Presentation

Weakness

Paralytic ileus -

Consti

pation

,

vomiting,

abdo

pain

Cardiac

arhythmias

- Palpitations, chest pain, collapse

Acute kidney injury - reduced UO, lethargy, nausea

Slide33

Investigations

FBC

U+E - raised urea, raised creatinine (AKI(,

hy

perkalaemia

Serum LDH - high

Serum

phosphate - highSerum calcium - low

Serum

urate

- high

Slide34

Management

Awareness,

identification of high risk

patients,

implementation of prophylaxis,

monitoring patient during chemotherapy

Starting active treatment when necessary

Slide35

Prevention for high risk patients

IV fluids

,

Rasburicase

: recombinant urate oxidase -

catalyses

the oxidation of uric acid to more soluble allantoin

, Allo

purinol

: xanthine oxidase inhibitor - blocks conversion of

xanthines

to uric acid

Slide36

Active treatment

Vigourous

hydration

Correct

hy

perkalaemia

Protect the myocardium with 10mls of 10% calcium gluconateDrive

potassium into cells with 10 units of rapid acting insulin and 50mls of 50% glucose

Salbutamol neb

Remove the potassium with oral calcium

resonium

Slide37

Active treatment

Rasburicase

(

sto

p allopurinol)

Acetazolomide

= alkalinize urine make uric acid more soluble

Phosphate bindersIf above fails

dialyse

Slide38

Neutro

penic

sepsis

Neutro

penia

of ** AND a fever >38 OR other signs or symptoms suggestive of sepsis

Neutro

penia =

neuts

<1

Nice guidance = <.5

Some hospitals = <.7 to <1

Slide39

At risk of

neutro

penic

sepsis

Current or recent anticancer treatment

Most commonly chemo for blood cancers

But also lung, breast, ovarian, colorectal

Slide40

Slide41

Slide42

Investigations

FBC !!!

Identify source or

pathogen = CXR, Urine M C + S, blood culture

Slide43

Treatment

ABCDE

Sepsis six

IMMEDIATE commencement of

em

piric

abx

DO NOT wait for the

fbc

NICE

piperacillin with tazobactam

Some hos

pital

guidelines add gentamicin

Slide44

prevention

If considered high risk = fluroquinolone

monothera

py

NOT recommended routinely by NICE but

im

portant

to know about = GCSF