Oncology and palliative care
Cancer in the UK.......................................................................................................................................2
Neoplasia pathophysiology......................................................................................................................3
Presentations...........................................................................................................................................4
Lymphadenopathy.................................................................................................................................................4
Splenomegaly........................................................................................................................................................5
Malignancies............................................................................................................................................6
Respiratory............................................................................................................................................................6
Lung...............................................................................................................................................................................................6
Malignant mesothelioma..............................................................................................................................................................8
Breast....................................................................................................................................................................8
Carcinoma in situ..........................................................................................................................................................................9
Invasive cancer..............................................................................................................................................................................9
Breast cancer Management........................................................................................................................................................11
Gastric..................................................................................................................................................................12
Oesophageal cancer....................................................................................................................................................................12
Gastric cancer.............................................................................................................................................................................14
Colorectal cancer........................................................................................................................................................................15
Anal cancer.................................................................................................................................................................................18
Urological.............................................................................................................................................................19
Renal cancer................................................................................................................................................................................19
Bladder cancer............................................................................................................................................................................21
Prostate cancer...........................................................................................................................................................................23
Penile cancer...............................................................................................................................................................................25
Testicular cancer.........................................................................................................................................................................26
Head and neck.....................................................................................................................................................27
Oral cavity cancers......................................................................................................................................................................28
Cancers of the pharynx...............................................................................................................................................................28
Cancers of the larynx..................................................................................................................................................................29
Thyroid tumours.........................................................................................................................................................................30
Salivary gland tumours...............................................................................................................................................................30
Skin......................................................................................................................................................................31
Basal cell carcinoma....................................................................................................................................................................31
Squamous cell carcinoma...........................................................................................................................................................32
Malignant melanoma..................................................................................................................................................................33
Haematological....................................................................................................................................................35
Haematopoiesis..........................................................................................................................................................................36
Lymphoid - Lymphoma (Hodgkin’s, NHL)...................................................................................................................................38
Lymphoid - Myeloma..................................................................................................................................................................41
Lymphoid - Leukaemia (ALL and CLL).........................................................................................................................................44
Myeloid - Leukaemia (AML and CML).........................................................................................................................................46
Oncological emergencies........................................................................................................................48
Neutropenic sepsis...............................................................................................................................................48
Metastatic spinal cord compression.....................................................................................................................49
Hypercalcaemia...................................................................................................................................................50
Superior vena caval obstruction...........................................................................................................................51
Tumour lysis syndrome........................................................................................................................................53
Pain assessment and management.........................................................................................................54
, Types of pain........................................................................................................................................................54
WHO pain ladder and adjuvant analgesics...........................................................................................................55
Safe opioid prescribing.........................................................................................................................................56
Symptom management..........................................................................................................................57
Nausea and vomiting...........................................................................................................................................57
Intractable breathlessness...................................................................................................................................58
Constipation........................................................................................................................................................58
Diarrhoea.............................................................................................................................................................59
Respiratory secretions.........................................................................................................................................59
Oral issues...........................................................................................................................................................59
Bowel and gastric outlet obstruction...................................................................................................................59
Hiccups................................................................................................................................................................60
Fatigue.................................................................................................................................................................60
Anorexia..............................................................................................................................................................60
Depression and anxiety........................................................................................................................................60
Insomnia..............................................................................................................................................................61
Headaches, fits, and other signs of ICP
.................................................................................................................61
Confusion and delirium........................................................................................................................................61
Palliative care.........................................................................................................................................61
Structure of cancer and palliative care services...................................................................................................61
Signs that suggest a patient is dying.....................................................................................................................62
Anticipatory prescribing.......................................................................................................................................62
Procedures..............................................................................................................................................62
Blood transfusion.................................................................................................................................................62
Bone marrow examination..................................................................................................................................65
Thoracentesis.......................................................................................................................................................65
Paracentesis.........................................................................................................................................................65
Hickman lines.......................................................................................................................................................65
Apheresis procedures..........................................................................................................................................66
Cancer care interventions.......................................................................................................................66
Chemotherapy.....................................................................................................................................................68
Immunotherapy......................................................................................................................................70
Radiotherapy..........................................................................................................................................71
Tumour Markers.....................................................................................................................................71
Paraneoplastic Syndromes......................................................................................................................72
Cancer in the UK
Most common cancers in the UK:
1. Breast
2. Prostate
3. Lung
, 4. Colorectal
5. Melanoma skin cancer Most common causes of death from cancer in UK:
6. Non-hodgkin lymphoma 1. Lung
7. Kidney 2. Colorectal
8. Head and neck 3. Breast
9. Brain, other CNS and intracranial tumours 4. Prostate
10. Pancreas 5. Pancreas
11. Bladder 6. Oesophagus
12. Leukaemia 7. Stomach
13. Uterus 8. Bladder
14. Oesophagus 9. NHL
15. Cancer of unknown primary 10. ovary
16. Ovary
17. Stomach
18. Liver
19. Myeloma
20. Thyroid 6 hallmark cellular behaviours of cancer:
1. self-sufficiency in growth signals
2. resistance to growth stop signals
Neoplasia pathophysiology 3. no limit on number of times a cell can
Neoplasm = abnormal growth of cells that persists after the initial stimulus is divide (cell immortalisation)
removed. Caused by accumulated mutations in somatic cells. Mutations are 4. sustained ability angiogenesis
caused by carcinogens; initiators (mutagenic agents e.g. chemicals, infections 5. resistance to apoptosis
and radiation) and promoters (cause cell proliferation) monoclonal 6. ability to invade and produce mets
population of mutation cells.
Proto-oncogenes – become abnormally activated neoplasm formation (= oncogenes before). Only one allele of
each proto-oncogene needs to be activated neoplasm.
Tumour suppressor genes normally suppress neoplasm formation but can become inactivated neoplasm
growth. Both alleles must be inactivated – need ‘2 hits’ (Knudson 2 hit hypothesis - 2 mutations in both alleles
need to occur for TSG inactivated)
Systemic affects of neoplasms - tumour burden on host and cytokine release appetite, cachexia, malaise,
immunosuppression and thrombosis.
Malignant neoplasms = abnormal growth of cells that persists after the initial stimulus is removed and invades
surrounding tissue with the potential to spread to distant sites (colonisation = grow at secondary site to form a new
tumour). Have an irregular outer margin and shape, may show areas of necrosis and ulceration. Invasion surrounding
tissue by carcinoma cells requires altered adhesion ( E-cadherin expression to alter adhesion between malignant cells,
changes in Integrin expression to alter adhesion between malignant cells and stromal proteins), stromal proteolysis
(altered expression of MMPs degrade BM and stroma) and motility (occurs due to changes in actin cytoskeleton).
Poorly differentiated, may be anaplastic (cells have no resemblance to any tissue)
With worsening differentiation, cells have nuclear size to cytoplasmic ratio, nuclear staining (hyperchromasia),
more mitotic figures and size and shape of cells and nuclei (pleomorphism)
Can metastasise by blood vessels, lymphatic vessels, or transcoelemic spread (through fluid in body cavities)
Micrometastases can form (fail to grow into tumour at secondary site), and lay dormant.
Benign neoplasms = remain confined to site of origin, do not produce mets. Well differentiated.
Tumour = clinically detectable lump or swelling
Cancer = any malignant neoplasm
Metastasis = malignant neoplasm that has spread from its original site new non-contiguous site. Original location is
primary site, site of spread is secondary.
Dysplasia = pre-neoplastic alteration in which cells show disordered tissue organisation. Not neoplastic as changes are
reversible.
Naming neoplasms:
Benign neoplasms end in -oma.
Malignant neoplasms end in -carcinoma if epithelial (can be in-situ or invasive if penetrates through basement
membrane), or -sarcoma if stromal.
Some neoplasms end in -blastoma (occurs mainly in kids), formed from immature precursor cells.
, Presentations
Lymphadenopathy
Enlargement of LNs, most commonly occurs during benign inflammatory processes.
Causes of lymphadenopathy: (MIAMI)
Malignancy – either primary (lymphoma) or metastases of solid tumour
Infection
o Bacterial – cutaneous infection, TB, typhoid
o Viral – CMV, HZV, infectious mononucleosis, rubella
Autoimmune diseases – SLE, dermatomyositis, RA, Sjögren’s
Miscellaneous – sarcoidosis, Kawasaki disease
Iatrogenic
o Drug-induced – phenytoin, allopurinol, atenolol, hydralazine, antibiotics (penicillin, cephalosporins),
carbamazepine
Examination:
Bilateral anterior cervical LNs 2cm are often found in older healthy kids/those who have had a recent URTI
Axillary nodes 1cm and inguinal nodes 1.5cm are usually normal.
Supraclavicular nodes of any size need further investigation
Epitrochlear nodes (just above elbow crease) can indicate Hodgkin’s
Erythema, warmth, tenderness and fluctuance of a node suggest lymphadenitis of infective origin
Nodes that are firm, non-tender and matted together have possibility of being malignant
Investigations: Further Ix +/- referral if:
Bloods – FBC, blood film, ESR, plasma viscosity, CRP, LFTs (liver infiltration) Persist for 6 months or more
Infection swabs from primary infection site for culture and sensitivities LN in size
Excisional biopsy is diagnostic method of choice LNs >2cm in size
Further Ix depending on presentation Widespread nature
o Viral titres Associated splenomegaly, night
o Investigation for TB or syphilis sweats or weight loss
o Blood cultures
o Autoantibody screen – SLE or RA
o CXR – sarcoidosis, TB, primary/secondary malignancy
o US of LN
o CT/MRI
Cancer in the UK.......................................................................................................................................2
Neoplasia pathophysiology......................................................................................................................3
Presentations...........................................................................................................................................4
Lymphadenopathy.................................................................................................................................................4
Splenomegaly........................................................................................................................................................5
Malignancies............................................................................................................................................6
Respiratory............................................................................................................................................................6
Lung...............................................................................................................................................................................................6
Malignant mesothelioma..............................................................................................................................................................8
Breast....................................................................................................................................................................8
Carcinoma in situ..........................................................................................................................................................................9
Invasive cancer..............................................................................................................................................................................9
Breast cancer Management........................................................................................................................................................11
Gastric..................................................................................................................................................................12
Oesophageal cancer....................................................................................................................................................................12
Gastric cancer.............................................................................................................................................................................14
Colorectal cancer........................................................................................................................................................................15
Anal cancer.................................................................................................................................................................................18
Urological.............................................................................................................................................................19
Renal cancer................................................................................................................................................................................19
Bladder cancer............................................................................................................................................................................21
Prostate cancer...........................................................................................................................................................................23
Penile cancer...............................................................................................................................................................................25
Testicular cancer.........................................................................................................................................................................26
Head and neck.....................................................................................................................................................27
Oral cavity cancers......................................................................................................................................................................28
Cancers of the pharynx...............................................................................................................................................................28
Cancers of the larynx..................................................................................................................................................................29
Thyroid tumours.........................................................................................................................................................................30
Salivary gland tumours...............................................................................................................................................................30
Skin......................................................................................................................................................................31
Basal cell carcinoma....................................................................................................................................................................31
Squamous cell carcinoma...........................................................................................................................................................32
Malignant melanoma..................................................................................................................................................................33
Haematological....................................................................................................................................................35
Haematopoiesis..........................................................................................................................................................................36
Lymphoid - Lymphoma (Hodgkin’s, NHL)...................................................................................................................................38
Lymphoid - Myeloma..................................................................................................................................................................41
Lymphoid - Leukaemia (ALL and CLL).........................................................................................................................................44
Myeloid - Leukaemia (AML and CML).........................................................................................................................................46
Oncological emergencies........................................................................................................................48
Neutropenic sepsis...............................................................................................................................................48
Metastatic spinal cord compression.....................................................................................................................49
Hypercalcaemia...................................................................................................................................................50
Superior vena caval obstruction...........................................................................................................................51
Tumour lysis syndrome........................................................................................................................................53
Pain assessment and management.........................................................................................................54
, Types of pain........................................................................................................................................................54
WHO pain ladder and adjuvant analgesics...........................................................................................................55
Safe opioid prescribing.........................................................................................................................................56
Symptom management..........................................................................................................................57
Nausea and vomiting...........................................................................................................................................57
Intractable breathlessness...................................................................................................................................58
Constipation........................................................................................................................................................58
Diarrhoea.............................................................................................................................................................59
Respiratory secretions.........................................................................................................................................59
Oral issues...........................................................................................................................................................59
Bowel and gastric outlet obstruction...................................................................................................................59
Hiccups................................................................................................................................................................60
Fatigue.................................................................................................................................................................60
Anorexia..............................................................................................................................................................60
Depression and anxiety........................................................................................................................................60
Insomnia..............................................................................................................................................................61
Headaches, fits, and other signs of ICP
.................................................................................................................61
Confusion and delirium........................................................................................................................................61
Palliative care.........................................................................................................................................61
Structure of cancer and palliative care services...................................................................................................61
Signs that suggest a patient is dying.....................................................................................................................62
Anticipatory prescribing.......................................................................................................................................62
Procedures..............................................................................................................................................62
Blood transfusion.................................................................................................................................................62
Bone marrow examination..................................................................................................................................65
Thoracentesis.......................................................................................................................................................65
Paracentesis.........................................................................................................................................................65
Hickman lines.......................................................................................................................................................65
Apheresis procedures..........................................................................................................................................66
Cancer care interventions.......................................................................................................................66
Chemotherapy.....................................................................................................................................................68
Immunotherapy......................................................................................................................................70
Radiotherapy..........................................................................................................................................71
Tumour Markers.....................................................................................................................................71
Paraneoplastic Syndromes......................................................................................................................72
Cancer in the UK
Most common cancers in the UK:
1. Breast
2. Prostate
3. Lung
, 4. Colorectal
5. Melanoma skin cancer Most common causes of death from cancer in UK:
6. Non-hodgkin lymphoma 1. Lung
7. Kidney 2. Colorectal
8. Head and neck 3. Breast
9. Brain, other CNS and intracranial tumours 4. Prostate
10. Pancreas 5. Pancreas
11. Bladder 6. Oesophagus
12. Leukaemia 7. Stomach
13. Uterus 8. Bladder
14. Oesophagus 9. NHL
15. Cancer of unknown primary 10. ovary
16. Ovary
17. Stomach
18. Liver
19. Myeloma
20. Thyroid 6 hallmark cellular behaviours of cancer:
1. self-sufficiency in growth signals
2. resistance to growth stop signals
Neoplasia pathophysiology 3. no limit on number of times a cell can
Neoplasm = abnormal growth of cells that persists after the initial stimulus is divide (cell immortalisation)
removed. Caused by accumulated mutations in somatic cells. Mutations are 4. sustained ability angiogenesis
caused by carcinogens; initiators (mutagenic agents e.g. chemicals, infections 5. resistance to apoptosis
and radiation) and promoters (cause cell proliferation) monoclonal 6. ability to invade and produce mets
population of mutation cells.
Proto-oncogenes – become abnormally activated neoplasm formation (= oncogenes before). Only one allele of
each proto-oncogene needs to be activated neoplasm.
Tumour suppressor genes normally suppress neoplasm formation but can become inactivated neoplasm
growth. Both alleles must be inactivated – need ‘2 hits’ (Knudson 2 hit hypothesis - 2 mutations in both alleles
need to occur for TSG inactivated)
Systemic affects of neoplasms - tumour burden on host and cytokine release appetite, cachexia, malaise,
immunosuppression and thrombosis.
Malignant neoplasms = abnormal growth of cells that persists after the initial stimulus is removed and invades
surrounding tissue with the potential to spread to distant sites (colonisation = grow at secondary site to form a new
tumour). Have an irregular outer margin and shape, may show areas of necrosis and ulceration. Invasion surrounding
tissue by carcinoma cells requires altered adhesion ( E-cadherin expression to alter adhesion between malignant cells,
changes in Integrin expression to alter adhesion between malignant cells and stromal proteins), stromal proteolysis
(altered expression of MMPs degrade BM and stroma) and motility (occurs due to changes in actin cytoskeleton).
Poorly differentiated, may be anaplastic (cells have no resemblance to any tissue)
With worsening differentiation, cells have nuclear size to cytoplasmic ratio, nuclear staining (hyperchromasia),
more mitotic figures and size and shape of cells and nuclei (pleomorphism)
Can metastasise by blood vessels, lymphatic vessels, or transcoelemic spread (through fluid in body cavities)
Micrometastases can form (fail to grow into tumour at secondary site), and lay dormant.
Benign neoplasms = remain confined to site of origin, do not produce mets. Well differentiated.
Tumour = clinically detectable lump or swelling
Cancer = any malignant neoplasm
Metastasis = malignant neoplasm that has spread from its original site new non-contiguous site. Original location is
primary site, site of spread is secondary.
Dysplasia = pre-neoplastic alteration in which cells show disordered tissue organisation. Not neoplastic as changes are
reversible.
Naming neoplasms:
Benign neoplasms end in -oma.
Malignant neoplasms end in -carcinoma if epithelial (can be in-situ or invasive if penetrates through basement
membrane), or -sarcoma if stromal.
Some neoplasms end in -blastoma (occurs mainly in kids), formed from immature precursor cells.
, Presentations
Lymphadenopathy
Enlargement of LNs, most commonly occurs during benign inflammatory processes.
Causes of lymphadenopathy: (MIAMI)
Malignancy – either primary (lymphoma) or metastases of solid tumour
Infection
o Bacterial – cutaneous infection, TB, typhoid
o Viral – CMV, HZV, infectious mononucleosis, rubella
Autoimmune diseases – SLE, dermatomyositis, RA, Sjögren’s
Miscellaneous – sarcoidosis, Kawasaki disease
Iatrogenic
o Drug-induced – phenytoin, allopurinol, atenolol, hydralazine, antibiotics (penicillin, cephalosporins),
carbamazepine
Examination:
Bilateral anterior cervical LNs 2cm are often found in older healthy kids/those who have had a recent URTI
Axillary nodes 1cm and inguinal nodes 1.5cm are usually normal.
Supraclavicular nodes of any size need further investigation
Epitrochlear nodes (just above elbow crease) can indicate Hodgkin’s
Erythema, warmth, tenderness and fluctuance of a node suggest lymphadenitis of infective origin
Nodes that are firm, non-tender and matted together have possibility of being malignant
Investigations: Further Ix +/- referral if:
Bloods – FBC, blood film, ESR, plasma viscosity, CRP, LFTs (liver infiltration) Persist for 6 months or more
Infection swabs from primary infection site for culture and sensitivities LN in size
Excisional biopsy is diagnostic method of choice LNs >2cm in size
Further Ix depending on presentation Widespread nature
o Viral titres Associated splenomegaly, night
o Investigation for TB or syphilis sweats or weight loss
o Blood cultures
o Autoantibody screen – SLE or RA
o CXR – sarcoidosis, TB, primary/secondary malignancy
o US of LN
o CT/MRI
