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SomeOncologyTips&Tricks
OncologyTips
SVCobstructiondtlymphoma1stlinettt..IVdexamethasoneandLMWH.
SVCobstructiondtlymphoma2ndlinettt..Radio.
Radiotherapynotquickenough.
Surgery.highmorbidityandmortalityrisk.
BreastCa,Confusion..Hypercalcaemiaofmalignancy.
Usuallycorrectedcalcium>2.8beforesymptoms.
Ttt..IVBisphosphonatesandrehydrationwithnormalsaline.
Calciumtakes23daystocomedown.
Bisphosphonatesmayberequiredmonthlytokeeptheleveldown.
Cordcompression.MRI(whole)spine.
Myelography..invasiveandtakesfarlongertoperform.
Ttt..IVdexamethasonethenradiotherapyorsurgery.
Lungmassupperlobe,Ca,normaltumourmarkers.squamouscellcarcinoma.
Metastasiselate,Cavitate,Carcinoidearlyhaemoptysis,flushingisseenoncemetastases.
Adenocarcinoma..peripheral,metastasesbothtothepleuraandmediastinalLN,no
hypercalcaemia.
Smallcelltumours..metastasisedatthepointofdiagnosis.
Hodgkinsdiseaseisapotentiallycurable.
Histologically..ReedSternbergcellsinabackgroundofreactivemixedinflammatorycells.
BSymptomsTemp>38,nightsweats,unexplainedwtloss>10%within6Ms.
StageI:singleLNareaorasingleextranodalsite.
StageII:2ormoreLNareasonthesamesideofthediaphragm.
StageIII:LNareasonbothsidesofthediaphragm.
StageIV:Multipleextranodalorgans(liverorBM).
Testicularseminomagermcelltumour
Themostcommonpresentation..painlesstesticularlumppresentforseveraldaystomonths.
Testicularseminoma..hCG.
Yolksacelements..fetoprotein..ifelevatedrulesoutpureseminoma
LDHcorrelatewithtumourburden.
PlacentalikeALP..seminoma,smoking.
MMDiagnosticcriteria.symptomatic,Mproteinintheserum+/urine,>10%plasmacellsinBM
,Bxprovenplasmacytoma,myelomarelatedorgandamageincludingbonelesions.
10guidelinesbeforescreeningprogramme1
Isthediseaseanimportanthealthproblem?
Istherearecognisablelatentorearlysymptomaticstage?
Doweknowthenaturalhistoryofthedisease?
Isthereaneffectivetreatmentforpatientswithrecognizeddisease?
Isthereasuitabletestthatwillidentifythediseaseinitsearlystages?
Isthetestacceptabletothepopulation?
Doweagreeonwhotreatsthedisease?
Arefacilitiesfordiagnosisandtreatmentavailable?
Casefindingshouldbeongoing.
Thecostshouldbeeconomicallybalancedinrelationtopossibleexpendituresonmedicalcareasawhole.
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Correctedserumcalcium=Measuredcalcium(mmol/l)+[40serumalbumin(g/dl)]x0.027
Minimizingimmobilization.
DCdrugsthatinhibiturinarycalciumexcretion(thiazides).
DCdrugsthatdecreaserenalflow(NSAIDs).
DCdrudsthatcontaincalciumorvitaminD.
Biphosphonateinfusiononlyafter.2LIVfluidshasbeengiven.
Calcitonininresistanthypercalcaemia.
NOTariskfactorformalignantmelanoma.Femalesex.
Prognosisisrelatedto.type,depthandLN.
Metastasis=Poorprognosis.
Melanomaismorecommonin.fairskinned,men.
RiskfactorsFairskin,Male,UVradiation,>50yrs,1stdegreerelative,dysplastic,>50naevi2
mmormore,xerodermapigmentosum,familialatypicalmolemelanomasyndrome.
Retinoblastomagene..13q.
HNPCcancer.2pgeneMSH2,3pgeneMLH1,7pgenePMS2.
MENI.11q
NFtypeI.17qgeneNF1.
NFtype222geneNF2.
Tumourlysissyndrome..UA,K,PO4,CaARF.
HighriskidentifiedpretreatmentbyLDH
Prevention.Hydration.
Oncehyperuricaemiadevelops.urinealkalinisationandallopurinol.
DCchemotherapy.
Tamoxifen..SERM..orallyonceadayfor5yrs..metastaticdisease
continuedlonger.
Tamoxifen.riskofcancerintheotherbreast.
Ewingssarcoma..childrenandadolescentsrareafter30years.
Moreinmales
Earliestsymptomintermittentpain,Largepalpablerapidlygrowingmass.
Poorprognosis.male,>12years,LDH,anaemia,poorresponsetochemotherapy.
Themostcommonthyroidcarcinoma..Papillarycarcinoma.
Slowgrowing,welldifferentiatedcarcinoma,spreadtocervicalLN.
Moreinfemaleswithbetterprognosis.Riskfactors..iodineandradiation.
TttThyroidectomyandradioiodineablation.
Thyroglobulinusefultumourmarkerofrecurrenceonlyaftertotalthyroidablation.
Advancedmalignancypaincontrol.Laxativesandantiemeticsareoftenneeded.
Steps:
11nonopioid
22weakopioid
33strongopioid
Severepain..Step3fromthestart.
Extravasationofchemo..DCinfusion,immobilizethearm,aspirate,antidotes,Coldcompresses.
Vincaalkaloids.heatcompress.
Doxorubicinordaunorubicin.plasticsurgery.
Testiculartumours..HCGorAFP.
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Recurrence..HCG.
Ttt.orchidectomy+/radiotherapyorchemotherapy.
CIforsurgeryinLungCa..SVCobstruction.
Relativecontraindication..>65years
Inoperability.Tumourwithin2cmofeithermainbronchusdtresectionmarginsfor
pneumonectomy.
HCV,Irregularenlargedtenderliversuggest.HCC.
Splenomegaly..portalhypertension.
HightitresofAMA..primarybiliarycirrhosis.
HighALPcirrhosis.SuddenhighALPHCC.
RapidincreaseinascitesHCC.
PrognosisofbreastCadependonLNmets.
AdenomatouspolypsofGB>1cmindiameterpremalignantlesions.
IfGBisremoved&noextensionofcarcinomatouslesionstowallReassure&observe.
RCCunilateralnephrectomy.
RCCbilateralorthecontralateralKFTspoor.partialnephrectomy.
RCCwithmets.RenalBx,nephrectomy,sunitinib.
Wtloss,Asian,Ascites,Irregularenlargedtenderliver.HCC.
Amoebicliverabscess..noascites.
Hydatiddiseaseasymptomatic,dullacheandswellingintherighthypochondrium.
50yrs,SolitaryroundshadowonCXRRCC.
Primarybronchialcarcinoma.unlikelyatthisageinanonsmoker.
Gastriccancer..Bilateralshadows.
Sarcoidosis..BHL
TBPatchyornodularshadowsintheupperzones,volumeandfibrosis+/Cavitation.
Acromegaly.Somatostatinanaloguesthentranssphenoidalsurgery.
60yrs,wtloss,abdominalpainradiatetobackandbyleaningforwards.PancreaticCa(body
ortail).
PancreaticCa.ContrastenhancedspiralCT.
AbdUSSislessreliableinbodyortail.
ERCP..palliativetreatmentandconfirmthediagnosis.
CA19.9.sensitivity(80%)buthighfalsepositiverate.
ALL,TLC>100.Leucopheresis.
Ttt.Cyclicchemotherapy(vincristine,prednisolone,Lasparaginase,doxorubicin)
Beforechemo..UAlevelmustbenormalandIVfluidsorrasburicase.
57yrs,Hb12.5,PLT170,TLC2544%lympho,Nospleen,NoLN.Wait&watch.
Dx..CLLwithoutindicationforttt.
BMaspirate:lymphoplasmacytoidWaldenstromsmacroglobulinaemia.
Ptnelectrophoresisparaprotein(IgM)>20g/lhyperviscosity.
Bloodfilm.rouleauxformation.
Ttt.Oldalkylatingagents.Youngdoxorubicincontainingregimens.
Recurrenceisinevitable.
Forhyperviscosity..regularplasmapheresis.
ProstaticCa,Forstaging&sizing..TransrectalUSS.
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LungCaintheRtintermediatelobewithipsilateralhilarLN..Chemo&radio.
Combinationchemotherapy.etoposideandcisplatin.mediansurvivalfrom2to10Ms.
65yr,Smoker,wtloss,Abdpain,constipation,Ascites.SuspectovarianCa.
26yr,CervicalsmearmoderateDyskariosis.Coploscopy.
Routinescreening.at25yrsthenevery3yrstill50yrs.
From50to65.every5years.
After65nocervicalscreening.
Dyskaryosisordysplasia=Precancerouschangeincells.
Milddyskaryosis..repeatsmearin6MsIfabnormalcolposcopy.
Moderateorsevere.Colposcopy.
Tamoxifen..partialestrogenagonist/antagonist.
Weakestrogenlikepropertiescholesterol,bonedensity,riskofuterinecancer,riskof
VTE.
3rdgenerationaromataseinh(letrozole,anastrozole,andexemestane)alternativeforearlybreastcancer.
MEN1..PitPan
MEN2a.PheoMed
MEN2b..PheoMed+Neuroma+Marfanoidhabitus.
Diarrhea+HTN+Ca.SuspectMEN2
5FU,SE.diarrhoea,mucositisandmyelosuppression.
CompleteorpartialdeficiencyofDPD...severe5FUTx.
Smoker,proximalweakness,LowamplitudebyrepeatedcontractionLES.
Hypercalcaemiaofmalignancy..PTHrP.
PTHrPacton..ostoeclastssoboneresorptionandCaexcretionintheDCT.
Advancedmalignancyrecivedchemo,presentedwithrestless&Facialtwitching
Metocloprmide.
Metoclopramidedopamineantagonist.actsonthechemoreceptortriggerzone.
MetoclopramiderestingprintheLESandgastricfundus..gastricemptying.
Extrapyramidaloccurinchildren,youngwomen,impairedrenalorhepaticfunction.
Domperidone.dopamineantagonistbutdoesnotcrossbloodbrainbarrier.
Alternativeantiemetics..cyclizine,5HT3antagonists(granisetronorondansetron).
Chemo+PN..Oxaliplatin.
BPHisnotariskfactorforprostateCa.
RiskfactorsAfricanAmericans,1stdegree,70%ofmen>80yrs,Highfatdiets.
Insulinomas.Themostcommonpancreaticendocrinetumour.
areproteinsexpressedbynormalandandareMarkersofneuroendocrine
TodifferneuroendocrinecellsfromneoplasmsChromograninAandsynaptophysin.
Gleevec..tyrosinekinaseinh..targetBCRABLreceptors.
Upperandmiddleoesophagus..SqCellCa.
Loweroesophagus.AdenocarcinomaasswithGERD&Barrett
5yearsurvivalofresectabletumours..1025%.
Blueandbrownasbestos.mesothelioma.
RiskforMesothelioma..1060yrsexposuretoasbestos,exposuretoradiation.
Smokingisnotriskformesothelioma.

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PancreaticCa..CT.
(MRCP>ERCP)andendoscopicUSS.shouldnotbeperformeduntilCT.
ERCPrelatedpancreatitisimpossibletoaccuratelystageapatientandevenobscurethe
diagnosis.Resectabilityassessement.Size,invasionofSMAorPV,presenceofascites,LN,
Mwts.
85%arenotsuitableforcurativeresection.Palliationbysurgery,endoscopically,chemo
(gemcitabine).
TumourthatrarelymettothelungBrain.
CXR..hilarLN+eitherdiffuseshadowsresemblingmiliaryormultiplelargemasses(canon
balls).
Old,Backpain,anemia,RF.MM.
Bonylesionstreatment.Radioinconjunctionwithcorticosteroids.
30yrsfemale,brusing,jontspain,PLT,Autoimmuneve.ITP
CZIgGantiplateletantibodies(nottestedaspartofastandardautoimmuneprofile)
Tttoralcorticosteroidssplenectomyiffailedmedicaltherapy.
PancreaticCa,markerofrecurrence.CA199.
CA125ovariancarcinoma.
CA153..breastandlungcancers.
CEA.Bowel.
HCG..testicularandtrophoblastictumours.
AFPHCC&germcelltumoursofthetestesorovaries.
BeforeFludarabineCotrimoxazole/dorNebulisedpentamidine/MsforPCP.
Fludarabineisverysuccessfulfor..CLLresponserate>80%..completeremission
>37%.
Familialclustersofbreastcancer&malignantmelanoma..CDKN2A(p16tumoursuppressor
gene).
Familialclustersofbreastcancer&ocularmelanoma..BRCA2mutation.
Mets,Bonescan.Hotareas.
MM,Bonescan..coldareas.
PagetNohypercalcaemia.
Bonymetastasesinprostaticcarcinoma.lyticorsclerotic.
Ttt.IVBisphosphonates,localradio.
2ndfentanylpatchafter24hr,unrousable,pinpoint,RR15,BP110/60HR66,Sat95%.
Removethepatchandtitrateoralmorphineasrequired.
Fentanylpatchchangedevery3days.
Infusionofnaloxone.distressbecauseofarousal,confusionandthereturnofpain.
CLL,asymptomatic.arrangeforperiodicfollowup.
Indicationsforttt..Bsymptoms,marrowfailure,symptomaticsplenomegaly.
Ttt.Fludarabine,antiCD20rituximab.
5FU,after3wksTLC2.9,PLT72Askhimtoreturnforrepeatbloodtestinginafewdays.
5FU,after14d,TLC2<2.protectivebarriernursing.
5FU,after14d,PLT<100doseadjustment.
Cerebralradiation11dago,drowsy,lethargy..Postcranialirradiationsomnolencesyndrome
AdvacedCa(expectedtolive3Ms),Legpain,onParacetamol&morphinebupivacaineblock.

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Increasingmorphine.drowsinesswithoutnecessarilycompletelyrelievingpain.
TENS..partialrelief,usedintermittently.
Shorttermprognosis..surgicaldecompressionwouldnotbeappropriate.
49yrsfemale,AnnularsigmoidCa,2x1cmlivermetainRtlobeSurgicalresectionof1ryCa
&livermeta.
Poorprognosis.Size>5cm,>1tumour,1ryLN,markedlyelevatedCEA.
IfunfitCryotherapyorradiofrequencyablation+resectionofthe1rylesion.
MM,CKD,markerofprognosisBeta2microglobulin.
CRPisanindirectmeasureofIL6..anotherusefulmeasureofdiseaseactivity.
Orchidopexysurgeryasachild,Lungmets.TesticularUSS.
Cryptorchidism.riskofseminoma.
HCG..onlyelevatedinaround10%butlevelofelevationcorrelatewithmetastases.
AFPyolksactumours.
LDHisnonspecificfortesticulartumours.
TesticularUSS..hypoechoicmasswithareasofcalcification.
54yrs,intermittentdysuria,painonejaculation,intermittentproblemspassingurine,PR:normalsized
mildlytendernodularprostate,PSA6Chronicintermittentprostatitis.
NormalsizedprostateonPR.excludeBPH.
Nodularitywithmilddiffusetenderness..chronicinfection.
MildelevationsinPSA..chronicprostatitis.
Ttt4wktrialofciprofloxacin,ofloxacin,doxycycline.
Seversymptomsofobstruction..alphaantagonistcanbeadded.
InoperablebreastCa,cocodamol30/500DCcocodamol,giveparacetamol,titratePOmorphineto
controlpain.
MST..cannotbeeasilyuptitrated.
IfuwanttouseMST.1stcontrolpainthenintroduceMST.
Bonemetsappropriatewaytomakethediagnosiswithrespecttohismets.BoneBx.
Bleomycin.pulmonaryfibrosis.
Cisplatin.neurotoxicity.
Pancost.Horner..Pupilconistrictwithoutresponsetoatropine.
H/Ooforchidoplexy,nowBHCG9.000(<5),TSH0.05Dx:TesticularCa.Testicular
USS.
MRIprovidinglittleadditionalinformation.
BHCGresultin..hyperthyroidism.
Tttorchidectomy.
H/Ooforchidoplexy,nowBHCGmarkedly,CEA&AFPnormal,Examisnormal
Testicularchoriocarcinoma.
Ttt..cisplatincureratesupto80%eveninadvanceddisease.
Radioof4000cGy,wastedandweaksmallMsoflefthand,Clawing,lostpinprickinulnarborder..
Metsinfiltration.
Wasted&weaksmallMsofthehand,Clawingofallfingers.Lowerbrachialplexus.
Radiationplexopathy..afterdoses>6000cGy,Upperbrachialplexus,Painless,
Lymphoedema.
MRIwouldbetheinitialinvestigationofchoice.

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InformingpatientaboutCa.facetoface,privateroom,Clearlanguage,listening,Cleartreatment
options,answeringpatientsQs,nofalsereassurances,havearelativeoranurseintheroom.
KnownriskfactorforbladderCa..Exposuretoaromaticamines.
MostcommonbladderCa..transitionalcellcarcinomas.
Womenhaveworseprognosisthanmen.
RiskfactorsSmoking,Aromaticamines,Radiation,Cyclophosphamid.
17p13.1.codingforp53..highgradebladderCa.
9p15,9p16.tumoursuppressorgene..lowgradeandsuperficialtumours.
FAPHundredsofpolyps..associatedwithcongenitalhypertrophyoftheretinalpigment
epithelium.
Regularcolonoscopicscreeningisundertakeninaffectedfamilies.
Ovariancarcinomamayoccurasyoungas15years.
RiskfactorsCaucasian,earlymenarche,latemenopause,nulliparity,H/OofbreastCa,high
fatdiet.
riskinMultiparity,OCP.
Braintumour,Bx:poorlydifferentiatedsmallroundcells..Glioblastomamultiforme.
Ttt.surgicaldebulking.
Mediansurvival..1year.
LungCa,Horners.surgicalresectionisimpossible.
LungCa,Casquamouscellcarcinoma.
Ttt.Platinumbasedchemo(Cisplatin/vinblastine,cisplatin/etoposide)&radio.
RiskofHCC.HBV,HCV,HC,Dietaryaflatoxin.
PSCcholangiocarcinoma.
Tttchemicalandradioablation,embolisation.
Surgicalresectionisrarelyperformed.
Only5%aresuitableforliverTx.
ToconfirmMMDx.BMaspirate.
Endocrinalmanifestationofsmall(oat)celllungCa..hirsuitism.
Krasisthemostcommonmutationfoundinductaladenocarcinomaofbodyofpancreas.
RenalimpairmentinNHL..uretericobstructionLN.
Lowgradelymphoma.olderpeople..leadtoBMinfiltration.
Lowgradeanaemiaisamorecommonthanpancytopaenia.
Ttt.Chemo.Butriskofleukaemia5yrsafterttt.
SmallcelllungCa,proximalweakness,AntivoltagegatedCachannelAb:positiveLambert
Eaton.
LambertEaton.............improvementinweaknessafterafewminutesofmuscularcontraction.
Ttt..3,4diaminopyridineandIVIg.
LES=Goodprognosisdtallowingearlierdetection.
Mantleradiotherapy.radiotoallLNabovethediaphragm.
MantleradiotherapyriskofBreastcancerMRIbreast.
MantleradiotherapyriskofThyroiddisease..TFT.
ColorectalCa,IO.Dexa
Indicationsofsurgery..reversiblecause,goodgeneralcondition,NOascites,Nofailed
chemo/radio.
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Metoclopramideexacerbatecolicandvomiting.
CyclizineeffectiveantiemeticinmalignantIO.
Granisetronisconstipatingandthereforeideallyavoided.
ThemostcommonSEofRituximab.Flulikefever&rigors.
CertainchemoforbreastCacanczmedicalmenopause.
Hotflushescangetworsewithtamoxifen.
TttProgesteroneinlowdoses.megestrol(Megace).
HRT.Recurrenceofbreastcancer.
AFPnonseminomatousgermcelltumours.
BHCGseminomatousgermcelltumours.
CEAmonitorcolorectalmalignancies.
CA199.pancreaticcancer.
CA125..ovarianandperitonealtumours.
LDH.tumourbulkinsolidcancersaslymphomaandtesticularcancer..prognosticnot
diagnostic.
Manofanyage,unexplainedirondeficiencyanaemia,Hb<11..UpperGIendoscopyand
colonoscopy.
FaecaloccultbloodscreeningforlowerGImalignancies.
Falsenegative..largedosesofvitaminC,notcollectingmultiplesamples.
Falsepositiveredmeat,fish,turnips,horseradish,oxidisingdrugs.
DukeA(StageI)tumourconfinedtothebowelwall.
DukeB(StageII).invadesthroughthemusclewall.
DukeC(StageIII)LN.
DukeD(StageIV)Mets
DukesC,5LN,5yrsurvival..50%.
InhypercalcemiaPTHcandifferentiatebetweenparathyroidandnonparathyroidproblem.
PTH,normalALP..Hypercalcemiaofmalignancy.
Familialbreastcancer.Carrierofanunknowngermlinemutation.
Myelocytes,andnucleatedredbloodcellsLeucoerythroblasticanaemia.
ADPKD,MultipleCXRcoinshadowsCTabdomen&thorax.
LungCa,SVCobstructionSmallcellDexathenbronchoscopethenRadio.
UhavetotissueBxtodecidewhetherRadioorChemo..UsuallyRadio.
RecurrentSVCobstruction.expandablewirestents.
TerminallyillwithwidespreadmetastaticCaRelativeshavenolegalrighttodemand
resuscitation.

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