22- Oncology & Transplant MSQs Only

Question 1

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?

Answer 1

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.

Question 2

2 of 13

Which of the following group of patients are not screened for colorectal cancer?

Answer 2

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.

Question 3

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?

Answer 3

Renal

Renal metastases have a tendency to be hypervascular. This is of considerable importance if surgical fixation is planned.

Question 4

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?

Answer 4

Intercalation of DNA

*=Main adverse effect cardiotoxicity
**=Irinotecan is a similar drug which works by inhibition of topoisomerase I

Question 5

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?

Answer 5

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

Question 6

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?

Answer 6

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.

Question 7

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?

Answer 7

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.

Question 8

10 of 13

In examining a biopsy of a primary tumour, the clearest evidence of malignancy is provided by:

Answer 8

Invasion of surrounding structures
………………………………………………………….
Invasion is the hallmark of malignancy. The others may occur in insitu disease or dysplastic lesions.

Question 8

8 of 13

A lung resection is least likely to be utilized in the management of which of the following?

Answer 8

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.

Question 9

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?

Answer 9

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.

Question 10

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?

Answer 10

50%

Question 11

11 of 13

Chordoma may typically occur at the following sites, except?

Answer 11

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.

Question 12

13 of 13

What is the most prevalent type of soft tissue sarcoma?

Answer 12

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)

Question 13

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?

Answer 13

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.

Question 14

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?

Answer 14

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.

Question 15

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?

Answer 15

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.

Question 15

3 of 23

A 38 year old lady donates her kidney to her niece. What type of transplant is this?

Answer 15

Allograft

Though related this donor will not be genetically identical and thus this will be an allograft.

Question 16

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?

Answer 16

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.

Question 17

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?

Answer 17

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.

Question 18

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?

Answer 18

IgG

Hyperacute graft rejection is due to pre-existent antibodies to HLA antigens and is therefore IgG mediated

Question 18

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?

Answer 18

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.

Question 18

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?

Answer 18

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.

Question 18

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?

Answer 18

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.

Question 19

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?

Answer 19

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.

Question 20

12 of 23

You review a 42-year-old woman six weeks following a renal transplant for focal segmental glomerulosclerosis. Following the procedure she was discharged on a combination of tacrolimus, mycophenolate, and prednisolone. She has now presented with a five day history of feeling generally unwell with anorexia, fatigue and arthralgia. On examination, she has a temperature of 37.9 and has widespread lymphadenopathy. What is the most likely diagnosis?

Answer 20

Cytomegalovirus
…………………………………………………………
Cytomegalovirus is the most common and important viral infection in solid organ transplant recipients

Primary infection with CMV typically occurs 6 weeks post transplantation in a seronegative individual who receives an organ from a seropositive donor.
Symptoms may occur as early as 20 days but can occur up to 6 months post transplant . Symptoms are often vague, retinitis can be pathognomonic, but is rarely seen in the transplant population. CMV disease is seen in 8% of renal transplant patients. Intravenous ganciclovir is the treatment of choice in such patients. Unfortunately, relapses are not uncommon.

Question 21

13 of 23

Which of the following is not true of hyper acute solid organ transplant rejection?

Answer 21

It may occur during the surgical procedure itself.
May occur as a result of blood group A, B or O incompatibility.
May be due to pre existing anti HLA antibodies.
On biopsy will typically show neo intimal hyperplasia of donor arterioles.(Right)
Complement system activation is one of the key mediators.
…………………………………………………….
These changes are more often seen in the chronic setting. Thrombosis is more commonly seen in the hyperacute phase.

Question 22

14 of 23

A 63 year old woman with severe angina undergoes a coronary artery bypass procedure and her long saphenous vein is used as a bypass conduit. Which of the types of transplant listed below best describes this?

Answer 22

Autograft

The long saphenous vein is one of the commonest autografts in surgery.

Question 23

15 of 23

Which of the following transplants is most susceptible to donor- recipient HLA mismatches?

Answer 23

Renal allograft
…………………………………………………
Autologous transplant- same individual (genetically identical)
Allograft - Genetically different

The kidney is highly susceptible to HLA mismatches and hyperacute rejection may occur in patients with IgG anti HLA Class I antibodies. The liver is at far lower risk of rejection of this nature. Although the heart is sensitive to HLA mismatches this is less than the kidney. Cardiac valves and the cornea incite little immunological response.

Question 24

16 of 23

A 39 year old lady undergoes a live related renal transplant. She progresses well. Two weeks following the transplant she is noted to have swelling overlying the transplant site and swelling of the ipsilateral limb.Urine output is acceptable and creatinine unchanged. What is the most likely cause?

Answer 24

Lymphocele

Swelling over the graft site is often due to a lymphocele and this is further suggested by the normal renal function. They cause symptoms through mass effect and limb swelling may occur. Treatment is often surgical.

Question 25

17 of 23

A 54-year-old man who has end stage diabetic nephropathy is being assessed for renal transplant. When assessing the HLA matching between donor and recipient what is the most important HLA antigen to match?

Answer 25

DR

Renal transplant HLA matching - DR is the most important

Question 25

18 of 23

A 44 year old man with end stage renal failure undergoes a live donor renal transplant. During the immediate post operative period a good urine output is recorded. However, on return to the ward the nursing staff notice that the urinary catheter is no longer draining. However, the urostomy is continuing to drain urine. Which of the interventions listed below is most likely to be required?

Answer 25

Bladder wash out

The most likely explanation for this event is a blocked catheter. This may be the result of blood clot from the ureteric anastomosis. Bladder irrigation will usually resolve the problem.

Question 26

19 of 23

A 48 year old lady with end stage renal failure receives a cadaveric renal transplant. The organ is ABO group matched only. On completion of the vascular anastomoses the surgeons remove the clamps. Over the course of the next twelve minutes the donated kidney becomes dusky and swollen and appears non viable. Which of the following is the most likely process that has caused this event?

Answer 26

IgG anti HLA Class I antibodies in the recipient

Episodes of hyperacute rejection are typically due to preformed antibodies. ABO mismatch is the best example. However, IgG anti HLA Class I antibodies are another potential cause. These events are now seen less commonly because the cross matching process generally takes this possibility into account.

Question 26

20 of 23

A 43 year old man undergoes a cadaveric renal transplant. The operation is uncomplicated. On removal of the vascular clamps the transplanted kidney immediately turns dusky and over the ensuing hours appears non viable. Which of the following best explains this event?

Answer 26

Hyper acute rejection

Immediate rejection is due to the presence of pre-existing antibodies e.g. ABO mismatch. The transplanted organ should be removed.

Question 27

22 of 23

In matching donated kidneys to the most appropriate recipient, apart from ABO matching, which of the following is most important?

Answer 27

HLA DR

The rhesus group is not important in matching donor and recipient kidneys.

Question 27

21 of 23

What type of transplant best describes a 27 year old lady donating her right kidney to her identical twin sister?

Answer 27

Isograft

Identical twin to twin donations are usually genetically identical and are therefore isografts.

Question 28

23 of 23

A 45 year old man with end stage renal failure undergoes a cadaveric renal transplant. The transplanted organ has a cold ischaemic time of 26 hours and a warm ischaemic time of 54 minutes. Post operatively the patient receives immunosuppressive therapy. Ten days later the patient has gained weight, becomes oliguric and feels systemically unwell. He also complains of swelling over the transplant site that is painful. What is the most likely cause?

Answer 28

Acute rejection
……………………………………………..
The features described are those of worsening graft function and acute rejection. The fact that there is a 10 day delay goes against hyperacute rejection. Cold ischaemic times are a major factor for delayed graft function. However, even 26 hours is not incompatible with graft survival.