22- Oncology & Transplant MSQs Only Flashcards
1 of 13
A 56-year-old man with metastatic prostate cancer comes for review. He is known to have spinal metastases but until now has not had any significant problems with pain control. Unfortunately he is now getting regular back pain despite taking paracetamol 1g qds. Neurological examination is unremarkable. What is the most appropriate next step?
Add non steroidal anti inflammatory drug
……………………………………………..
Metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy
Bone pain often responds well to NSAIDs. Both radiotherapy and bisphosphonates have a role in managing bony pain but these are not first-line treatments.
2 of 13
Which of the following group of patients are not screened for colorectal cancer?
Peutz Jeghers syndrome
Asymptomatic patients aged 45 years(Right)
Acromegaly
Ureterosigmoidostomy
Inflammatory bowel disease
…………………………………………………..
Other disorders which are screened for colorectal malignancy include: Familial adenomatous polyposis, Hereditary non polyposis colorectal cancer. The NHS screening programme starts at 60 in England (Sigmoidoscopy screening at 55 years). In Scotland it starts at 50.
3 of 13
A 50 year old lady presents with pain in her proximal femur. Imaging demonstrates a bone metastasis from an unknown primary site. CT scanning with arterial phase contrast shows that the lesion is hypervascular. From which of the following primary sites is the lesion most likely to have originated?
Renal
Renal metastases have a tendency to be hypervascular. This is of considerable importance if surgical fixation is planned.
4 of 13
A 45 year old woman with breast cancer is started on a chemotherapy regime containing epirubicin. What is the primary mode of action of this drug?
Intercalation of DNA
*=Main adverse effect cardiotoxicity
**=Irinotecan is a similar drug which works by inhibition of topoisomerase I
5 of 13
A 63 year old lady with metastatic breast cancer presents with bone pain. Radiological tests show a metastatic lytic deposit to her femoral shaft. The lesion occupies 75% of the bone diameter. What is the most appropriate management?
Fixation with intramedullary nail
……………………………………………………….
Even with surgical fixation only 30% of pathological fractures unite. The type of fixation should be chosen accordingly.
A lesion of this nature is at high risk of spontaneous fracture. Whilst radiotherapy may palliate her symptoms of pain it will not reduce the risk of fracture. In fit patients, an intramedullary nail should be inserted. Very proximal lesions may be best managed by a total hip replacement
6 of 13
A 56 year old lady presents with a pathological fracture of the proximal femur. Which of the following primary sites is the most likely source of her disease?
Breast
………………………………….
Primary site= BBRTP
Breast
Bronchus
Renal
Thyroid
Prostate
The correct answer is breast, because the question asks for the most likely primary site. Breast cancer is the commonest cause of lytic bone metastasis in women of this age, especially from amongst those options given.
7 of 13
A 43 year old lady is receiving chemotherapy for the treatment of metastatic breast cancer. You are called because it has become apparent that her doxorubicin infusion has extravasated. What is the most appropriate course of action?
Stop the infusion and apply a cold compress to the site
………………………………………………………………
The application of cold compresses is indicated in doxorubicin extravasation. Warm compresses increase the risk of doxorubicin ulceration. Hyaluronidase is indicated in the extravasation of contrast media, TPN and vinca alkaloids.
However, if administered following doxorubicin extravasation it will dramatically worsen the situation and is contra indicated.
Up to 50% of those sustaining severe injuries will require delayed surgical reconstruction.
10 of 13
In examining a biopsy of a primary tumour, the clearest evidence of malignancy is provided by:
Invasion of surrounding structures
………………………………………………………….
Invasion is the hallmark of malignancy. The others may occur in insitu disease or dysplastic lesions.
8 of 13
A lung resection is least likely to be utilized in the management of which of the following?
Small cell lung cancer(Right)
Adenocarcinoma of the lung
Squamous cell carcinoma of the lung
A solitary lung metastasis from colorectal cancer
A solitary lung metastasis from a low grade sarcoma
………………………………………………………………….
Note, the question asked for least likely. That being the case, the correct answer is small cell lung cancer as they are nearly always disseminated at diagnosis.
9 of 13
A 45 year old male is referred to clinic for consideration of resection of a lung malignancy. He reports shortness of breath and haemoptysis. Investigations reveal a corrected calcium of 2.84 mmol/l, an FEV 1 of 1.9L and histology of a squamous cell carcinoma. The patient is noted to have a hoarse voice. Which one of the following is a contraindication to surgical resection in lung cancer?
Vocal cord paralysis
…………………………………………
Contraindications to lung cancer surgery include SVC obstruction, FEV < 1.5, MALIGNANT pleural effusion, and vocal cord paralysis
Paralysis of a vocal cord implies extracapsular spread to mediastinal nodes and is an indication of inoperability.
12 of 13
A 62 year old male is found to have colorectal cancer. He has Dukes C disease. What is his 5 year prognosis?
50%
11 of 13
Chordoma may typically occur at the following sites, except?
Ribs(Right)
Clivus
Sacrum
Lumbar vertebra
Cervical vertebra
…………………………………………………..
Chordoma is a neoplasm originating from ectopic cellular remnants of the notochord and therefore arises from the midline of the axial skeleton. It accounts for 24% of all primary malignant bone tumours. Chordoma is the second commonest primary malignancy of the spine and accounts for over 50% of primary sacral tumours. The neoplasm has a predilection for the sacrococcygeal (50%) and clival (40%) regions, with other areas of the spine rarely involved. More than one vertebral body can be affected in half the cases. Chordomas most commonly present between 50 and 70 years of age. Sex incidence is equal below 40 years, but men are affected twice as often at older ages, particularly in the sacral region.
The most frequent radiographic appearance of chordoma is that of a destructive lesion of a vertebral body centered in the midline, with a large, associated soft- tissue mass.
13 of 13
What is the most prevalent type of soft tissue sarcoma?
Liposarcoma
………………………………………………
Liposarcoma (26.2% of cases), leiomyosarcoma (16.1%), and dermatofibrosarcoma protuberans (10.1%); the CIR for liposarcoma was 0.94 cases per 100,000 population per year, with dedifferentiated liposarcoma being the most common subset (0.24 cases per 100,000 per year)
1 of 23
A 43 year old lady undergoes a live related renal transplant. At the conclusion of the operation she has a good urine output and the graft appeared well perfused. On the ward she suddenly becomes anuric. What is the most likely cause?
Renal artery thrombosis
Sudden loss of urine output is most commonly due to a blocked catheter. However, if this is excluded (and is not included in the options) the most worrisome cause is arterial thrombosis. This will often be a delayed diagnosis and the rate of graft loss is high.
2 of 23
A 43 year old lady undergoes a live donor related renal transplant. Over the next few years it is noted that her renal function progressively deteriorates. What is the most likely underlying explanation?
Type IV hypersensitivity reaction
Chronic rejection of renal transplants is mediated via T lymphocytes and is therefore a type IV hypersensitivity reaction. This process can be mitigated by immunosupression.
4 of 23
A 43 year old man undergoes a live donor renal transplant. The donor’s right kidney is anastomosed to the recipient. On removal of the arterial clamps there is good urinary flow noted and the wounds are closed. On return to the ward the nurses notice that the patient suddenly becomes anuric and irrigation of the bladder does not improve the situation. What is the most likely cause?
Renal artery thrombosis
Right sided live donor transplants are extremely rare. This is because the vena cava precludes mobilisation of the right renal artery. The short right renal artery that is produced therefore presents a major challenge. The sudden cessation of urine output in this context is highly suggestive of an acute thrombosis. Delay in thrombectomy beyond 1 hour almost inevitably results in graft loss.
3 of 23
A 38 year old lady donates her kidney to her niece. What type of transplant is this?
Allograft
Though related this donor will not be genetically identical and thus this will be an allograft.
5 of 23
A 52 year old female underwent a cadaveric renal transplant and recovers well post operatively. Her immunosupression regime consists of tacrolimus. Which of the substances listed below should be avoided?
Paracetamol
Apple juice
Penicillin
Prune juice
Grapefruit juice(Right)
…………………………………………
Tacrolimus is metabolised by the P450 enzyme system. This is inhibited by a number of naturally occurring substances, these include grapefruit, watercress and St.Johns Wort. These should all be avoided in immunosupressed patients taking tacrolimus.
6 of 23
A 38 year old man is recovering following a live donor related renal transplant. The surgeon prescribes corticosteroids to reduce the risk of graft rejection. Which of the following will not occur as a result of their administration?
Suppression of macrophage activation
Reduction of expression of major histocompatibility complex antigens on the graft
Reduction in the proliferation of lymphocytes
Necrosis of activated lymphocytes(Right)
Reduction of expression of endothelial cell adhesion molecules
…………………………………………………
Corticosteroids at higher doses are able to induce apoptosis of activated lymphocytes. Necrosis is a different process and not induced by steroids.
7 of 23
A 28-year-old female undergoes a renal transplant for focal segmental glomerulosclerosis. Within hours of the operation the patient becomes unwell with features consistent with severe systemic inflammatory response syndrome. The patient is immediately taken back to theatre and the transplanted kidney is removed. What type of immunoglobulins are responsible for the graft rejection?
IgG
Hyperacute graft rejection is due to pre-existent antibodies to HLA antigens and is therefore IgG mediated
11 of 23
A 43 year old lady is recovering following a live donor related renal transplant. She has significant abdominal pain. Which of the following analgesic drugs should be avoided?
Paracetamol
Morphine
Nefopam
Diclofenac(Right)
Co-codamol
……………………………………….
Non steroidal anti inflammatory drugs may be nephrotoxic and therefore are usually avoided in patients who have undergone renal transplants. Paracetamol and morphine are metabolised predominantly in the liver. There is some renal contribution to morphine metabolism and excretion and the drug should be administered in reduced doses or avoided if the transplanted kidney stops functioning.
9 of 23
A 48 year old woman with end stage renal failure is undergoing a live donor renal transplant. The surgeon decides to implant the kidney in the left iliac fossa via a Rutherford Morrison incision. To which of the following vessels should the transplanted kidney be anastomosed?
External iliac artery and vein
First time renal tranplants and typically implanted in the left or right iliac fossae. The vessels are usually joined to the external iliac artery and vein as these are the most easily accessible. The Rutherford Morrison incision provides access to the external iliac vessels.
8 of 23
A 45 year old lady undergoes a renal transplant from a living related donor. She is well for several months, but on review in the outpatient department is noted to have persistent hypertension and a slight deterioration in renal function. What is the most likely explanation for this?
Renal artery stenosis
Renal artery stenosis typically occurs over several months and will usually result in the development of hypertension. Most cases can be assessed using duplex scanning and managed with angioplasty.
10 of 23
A 52 year old male attends renal transplant clinic for a post operative assessment. You note that he is on ciclosporin and that a recent blood test shows that the ciclosporin level is elevated. Which of the following is a recognised side effect of ciclosporin?
Nephrotoxicity
……………………………………….
Ciclosporin- nephrotoxicity
This patient is at risk of nephrotoxicity and should be referred to the renal team as soon as possible. Alopecia is associated with azathioprine and diabetes is associated with tacrolimus.