PASSMEDICINE TEXT BOOK (DOWNLOADED 28/01/2022)

ONCOLOGY

Bone metastases

Most common tumour causing bone metastases (in descending order)

 prostate
 breast
 lung

Most common site (in descending order)

 spine
 pelvis
 ribs
 skull
 long bones

Other than bone pain, features may include:

 pathological fractures
 hypercalcaemia
 raised ALP

© Image used on license from Radiopaedia

Isotope bone scan (using technetium-99m labelled diphosphonates which accumulate in the bones) from a patient with metastatic prostate cancer. The scan
demonstrates multiple, irregular, randomly distributed foci of high grade activity involving the spine, ribs, sternum, pelvic and femoral bones. The findings are
in keeping with multiple osteoblastic metastasis.

Cancer in the UK

The most common causes of cancer in the UK are as follows*

 1. Breast
 2. Lung
 3. Colorectal
 4. Prostate
 5. Bladder
 6. Non-Hodgkin's lymphoma
 7. Melanoma
 8. Stomach
 9. Oesophagus
 10. Pancreas
The most common causes of death from cancer in the UK are as follows:

 1. Lung
 2. Colorectal
 3. Breast
 4. Prostate
 5. Pancreas
 6. Oesophagus
 7. Stomach
 8. Bladder
 9. Non-Hodgkin's lymphoma
 10. Ovarian

*excludes non-melanoma skin cancer

Chemotherapy side-effects: nausea and vomiting

Nausea and vomiting are common side-effects of chemotherapy. Risk factors for the development of symptoms include:

 anxiety
 age less than 50 years old
 concurrent use of opioids
 the type of chemotherapy used
For patients at low-risk of symptoms then drugs such as metoclopramide may be used first-line. For high-risk patients then 5HT3
receptor antagonists such as ondansetron are often effective, especially if combined with dexamethasone

Cyclophosphamide

Cyclophosphamide is an alkylating agent used in the management of cancer and autoimmune conditions. It works by causing
cross-linking of DNA

Adverse effects

 haemorrhagic cystitis: incidence reduced by the use of hydration and mesna

 myelosuppression
 transitional cell carcinoma

Mesna

 2-mercaptoethane sulfonate Na
 a metabolite of cyclophosphamide called acrolein is toxic to urothelium
 mesna binds to and inactivates acrolein helping to prevent haemorrhagic cystitis

Cytotoxic agents
The tables below summarises the mechanism of action and major adverse effects of commonly used cytotoxic agents.

Alkylating agents

Mechanism
Cytotoxic of action Adverse effects

Cyclophosphamide Alkylating Haemorrhagic

agent - cystitis, myelosuppression, transitional
causes cell carcinoma
cross-linking
in DNA

Cytotoxic antibiotics

Cytotoxic Mechanism of action Adverse effects

Bleomycin Degrades preformed DNA Lung fibrosis

Anthracyclines (e.g Stabilizes DNA-topoisomerase II Cardiomyopathy

doxorubicin) complex inhibits DNA & RNA
synthesis
Antimetabolites

Mechanism of
Cytotoxic action Adverse effects

Methotrexate Inhibits Myelosuppression, mucositis, liver

dihydrofolate fibrosis, lung fibrosis
reductase and
thymidylate
synthesis

Fluorouracil (5- Pyrimidine Myelosuppression, mucositis, dermatitis

FU) analogue
inducing cell
cycle arrest
and apoptosis
by blocking
thymidylate
synthase
(works during
S phase)

6- Purine Myelosuppression
mercaptopurine analogue that
is activated by
HGPRTase,
decreasing
purine
synthesis

Cytarabine Pyrimidine Myelosuppression, ataxia

 Mechanism of
Cytotoxic action Adverse effects

antagonist.
Interferes
with DNA
synthesis
specifically at
the S-phase of
the cell cycle
and inhibits
DNA
polymerase

Acts on microtubules

Cytotoxic Mechanism of action Adverse effects

Vincristine, Inhibits formation of Vincristine: Peripheral

vinblastine microtubules neuropathy (reversible) , paralytic
ileus
Vinblastine: myelosuppression

Docetaxel Prevents microtubule Neutropaenia

depolymerisation &
disassembly, decreasing
free tubulin
Topoisomerase Inhibitors

Cytotoxic Mechanism of action Adverse effects

Irinoteca Inhibits topoisomerase I which prevents Myelosuppression

n relaxation of supercoiled DNA

Other cytotoxic drugs

Mechanism of
Cytotoxic action Adverse effects

Cisplatin Causes cross- Ototoxicity, peripheral

linking in DNA neuropathy, hypomagnesaemia

Hydroxyurea Inhibits Myelosuppression

(hydroxycarbamide) ribonucleotide
reductase,
decreasing DNA
synthesis

Neoplastic spinal cord compression

Spinal cord compression is an oncological emergency and affects up to 5% of cancer patients. Extradural compression accounts for
the majority of cases, usually due to vertebral body metastases. It is more common in patients with lung, breast and prostate cancer

Features

 back pain
o the earliest and most common symptom
o may be worse on lying down and coughing
 lower limb weakness
 sensory changes: sensory loss and numbness
 neurological signs depend on the level of the lesion. Lesions above L1 usually result in upper motor neuron signs in the legs
and a sensory level. Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness. Tendon
reflexes tend to be increased below the level of the lesion and absent at the level of the lesion

Investigation

 urgent MRI: the 2019 NICE guidelines recommend a whole MRI spine within 24 hours of presentation

Management

 high-dose oral dexamethasone

 urgent oncological assessment for consideration of radiotherapy or surgery
Superior vena cava obstruction

Superior vena cava (SVC) obstruction is an oncological emergency caused by compression of the SVC. It is most commonly
associated with lung cancer.

Features

 dyspnoea is the most common symptom

 swelling of the face, neck and arms - conjunctival and periorbital oedema may be seen
 headache: often worse in the mornings
 visual disturbance
 pulseless jugular venous distension

Causes

 common malignancies: small cell lung cancer, lymphoma

 other malignancies: metastatic seminoma, Kaposi's sarcoma, breast cancer
 aortic aneurysm
 mediastinal fibrosis
 goitre
 SVC thrombosis

Management is dependant on the individual patient and malignancy and advice should be taken from the oncology team. Options
include:

 endovascular stenting is often the treatment of choice to provide symptom relief

 certain malignancies such as lymphoma, small cell lung cancer may benefit from radical chemotherapy or chemo-
radiotherapy rather than stenting
 the evidence base supporting the use of glucocorticoids is weak but they are often given

Tumour markers

Tumour markers may be divided into:

 monoclonal antibodies against carbohydrate or glycoprotein tumour antigens

 tumour antigens
 enzymes (alkaline phosphatase, neurone specific enolase)
 hormones (e.g. calcitonin, ADH)

It should be noted that tumour markers usually have a low specificity

Monoclonal antibodies

Tumour marker Association

CA 125 Ovarian cancer

 Tumour marker Association

CA 19-9 Pancreatic cancer

CA 15-3 Breast cancer

Tumour antigens

Tumour marker Association

Prostate specific antigen Prostatic carcinoma

(PSA)

Alpha-feto protein (AFP) Hepatocellular carcinoma, teratoma

Carcinoembryonic antigen Colorectal cancer

(CEA)

S-100 Melanoma, schwannomas

Bombesin Small cell lung carcinoma, gastric

cancer, neuroblastoma