Cancer Flashcards

Question

Growth pattern of urothelial carcinomas?

Answer 1

- 70% have papillary growth pattern= superficial and better prognosis - mixed papillary and solid growth or pure solid growth= more prone to local invasion and may be higher grade, worse prognosis

Answer 2

regional or distant lymph node metastasis

Answer 3

T0= No evidence of tumour Ta= Non invasive papillary carcinoma T1= Tumour invades sub epithelial connective tissue T2a= Tumor invades superficial muscularis propria (inner half) T2b= Tumor invades deep muscularis propria (outer half) T3= Tumour extends to perivesical fat T4= Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina T4a= Invasion of uterus, prostate or bowel T4b= Invasion of pelvic sidewall or abdominal wall

Answer 4

N1= Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node) N2= Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node metastasis) N3= Lymph node metastasis to the common iliac lymph nodes

Answer 5

?bladder ca

Answer 6

- painless marcoscopic haematuria - incidential microscopic haematuria= 10% females >50yrs found to have malignancy after infection excluded

Answer 7

1) cystoscopy and biopsy or TURBT= histological diagnosis and depth of invasion 2) Pelvic MRI= locoregional spread 3) CT= distant disease 4) PET CT= nodes of uncertain significance

Answer 8

superficial lesions= TURBT in isolation recurrences or higher grade/risk on histology= intravesical chemo T2 disease= surgery (radical cystectomy and ileal conduit) or radical radiotherapy

Answer 9

T1 90% T2 60% T3 35% T4a 10-25% Any T, N1-N2 30%

Answer 10

based on origin and characteristics of the abnormal cells

Answer 11

arises from epithelial cells that line internal organs and external surfaces

Answer 12

- adenocarcinoma - SCC - BCC - transitional cel carcinoma

Answer 13

develops in glandular tissues eg. breast, prostate, colon, pancreas

Answer 14

found in squamous cells eg. skin or lining of organs, for example lungs, oesophagus

Answer 15

form of skin cancer that starts in the basal cells

Answer 16

arises in lining of the bladder, ureters and renal pelvis

Answer 17

develops in connective or supportive tissues such as bone, muscle, fat, cartilage and blood vessels less common than carcinomas but more aggressive

Answer 18

- osteosarcoma - chondrosarcoma - liposarcoma - leiomyosarcoma

Answer 19

originates in bone

Answer 20

arises in cartilage

Answer 21

develops from fat tissue

Answer 22

develops in smooth muscle tissue

Answer 23

cancers of the blood-forming tissues, incl. bone marrow and lymphatic system

Answer 24

- Acute Lymphoblastic Leukemia (ALL) - Acute Myeloid Leukemia (AML) - Chronic Lymphocytic Leukemia (CLL) - Chronic Myeloid Leukemia (CML)

Answer 25

affects lymphoid cells, common in children

Answer 26

affects myeloid cells, more common in adults

Answer 27

slow-growing form affecting lymphoid cells

Answer 28

affects myeloid cells, progresses slowly

Answer 29

ca of the lymphatic system, which is part of the immune system relatively common, esp non-Hodgkin

Answer 30

- Hodgkin Lymphoma (Hodgkin's disease) - Non-Hodgkin Lymphoma (NHL)

Answer 31

characterised by presence of Reed-Sternberg cells

Answer 32

diverse group of lymphomas that don't have Reed-Sternberg cells; including B-cell and T-cell lymphomas

Answer 33

ca of plasma cells, type of WBC in bone marrow rare form of ca, affects mainly older adults

Answer 34

multiple myeloma

Answer 35

most common form, affecting many areas of body incl. bones and kidneys (Old CRAB)

Answer 36

ca than originates in melanocytes, the cells that produce the pigment melanin in the skin less common than other skin ca (B/SCC) but more aggressive

Answer 37

- cutaneous melanoma - ocular melanoma

Answer 38

starts in skin

Answer 39

rare form that starts in the eye

Answer 40

ca that begin in brain or spinal cord can be mild or highly malignant, glioblastoma one of most severe

Answer 41

- glioblastoma - astrocytoma - meningioma

Answer 42

highly aggressive form of brain cancer

Answer 43

originates in star-shaped brain cells called astrocytes

Answer 44

affects meninges, the protective layers around brain and spinal cord

Answer 45

arises from the cells that give rise to sperm or eggs (germ cells) most common in adolescents and young adults

Answer 46

usually develop in testes (testicular ca) or ovaries (ovarian germ cell tumours) but can form in other parts of body eg. brain

Answer 47

arise from cells that release hormones into the blood in response to signals from NS rare and can be slow-growing, some can be aggressive

Answer 48

- carcinoid tumours - pheochromocytoma

Answer 49

type of neuroendocrine tumour commonly found in GI tract and lungs

Answer 50

typically arises in adrenal glands

Answer 51

typically arises in embryonic tissue or immature cells, usually seen in children

Answer 52

- retinoblastoma - neuroblastoma - hepatoblastoma

Answer 53

ca of the retina, typically in young children

Answer 54

rare liver ca in children

Answer 55

starts in immature nerve cells, often in adrenal glands

Answer 56

rare ca that affects lining of lungs, abdo or heart; often linked to asbestos exposure

Answer 57

ca that forms in thyroid gland, with types like papillary, follicular, medullary and anaplastic thyroid ca

Answer 58

- carcinoma - sarcoma - leukemia - lymphoma - myeloma - melanoma - CNS ca - germ cell tumours - neuroendocrine tumours - blastoma - mesothelioma - thyroid cancer

Answer 59

to classify and describe details about the ca size, location and degree of spread, helps in planning treatment and estimating prognosis primarily for solid tumours eg. breast, lung, colon

Answer 60

Tumour size and extent of the primary tumour

Answer 61

Nodes indicates whether the cancer has spread to nearby lymph nodes (local spread)

Answer 62

Metastasis refers to whether the ca has spread (metastasised) to distant organs or tissues (distant spread)

Answer 63

can't be assessed

Answer 64

use TNM to combine into overall stage grouping: stage I, II, III or IV some may have substage eg. IA or IIB depending on additional factors eg. tumour grade or specific molecular markers

Answer 65

0= cancer in situ (localised and not spread) I= small tumour, localised, without spread to lymph nodes II= large tumour or has spread to nearby lymph nodes, but no distant mets III= more advanced local/regional spread to lymph nodes or nearby tissues, but no distant mets IV= metastatic ca- has spread to distant parts of the body

Answer 66

N= local or regional involvement within the lymphatic system M= ca has spread beyond original area and reached distant organs or tissues so N is not considered metastasis

Answer 67

children and young people

Answer 68

new onset seizures, headaches, nausea, drowsiness, visual change, personality change

Answer 69

urgent direct access of MRI of brain or CT if MRI contraindicated, within 2w, in adults with progressive, sub-acute loss of central neurological function

Answer 70

very urgent referral (within 48hrs) in children with newly abnormal cerebellar or other central neurological function

Answer 71

brain metastases

Answer 72

advanced disease state with significant impact on morbidity and mortality

Answer 73

Lung (40-50%) Breast (15-25%) Melanoma (5-20%) Renal (5-10%) Colorectal

Answer 74

- hematogenous spread (most common)= via arterial circulation - lymohatic (less common)= typically involves leptomeningeal carcinomatosis - direct extension (rare)= from head and neck cancers

Answer 75

- headache (worse in morning) - neuro deficit (eg. hemiparesis, aphasia) - seizures - cognitive and behavioural changes - symptoms of ICP= N&V, altered consciousness

Answer 76

GOLD= MRI with contrast for number, size and location - Biopsy confirms in primary ca site is unknown or imaging inconclusive

Answer 77

controlling symptoms, reducing tumour burden and improving QOL

Answer 78

- supportive care - radiation therapy - systemic therapy - surgical resection

Answer 79

- corticosteroids eg. dexamethasone= reduce peritumoral oedema and control symptoms eg. headache - anticonvulsants= seizures - palliative care for end-of-life

Answer 80

Whole Brain Radiotherapy (WBRT)= for multiple mets but associated with notable cognitive decline Stereotactic Radiosurgery (SRS)= if 1-3 mets; offers high dose radiation with minimal damage to surrounding tissues

Answer 81

chemotherapy, targeted therapy or immunotherapy depending on primary tumour type and molecular characteristics used to better systemic control and penetration of blood brain barrier

Answer 82

for accessible lesions causing signif mass effect or when histologic diagnosis required; improves neuro function and allows more effective adjuvant therapy

Answer 83

- generally poor but improving with targeted therapies and precision medicine - median survival ranges= several months to over a yr - depends on Tx and tumour biology

Answer 84

selective oestrogen receptor modulator (SERM)= acts as an oestrogen receptor antagonist and partial agonist

Answer 85

- vaginal bleeding, amenorrhoea - hot flushes (3% stop taking due to this) - VTE - endometrial ca

Answer 86

aromatase inhibitors= reduces peripheral oestrogen synthesis

Answer 87

Anastrozole

Answer 88

it is an aromatase inhibitor that reduces peripheral oestrogen synthesis; important as aromatisation accounts for majority of oestrogen production in postmenopausal women

Answer 89

- osteoporosis (DEXA scan) - hot flushes - arthralgia, myalgia - insomnia

Answer 90

DEXA scan due to risk of osteoporosis

Answer 91

painless, but pain can occur

Answer 92

shape in shape, bleeding, tethering, peau d'orange

Answer 93

mammography and core biopsy

Answer 94

- 30yrs+ with unexplained breast lump with or without pain - 50yrs+ and any of: discharge, retraction, changes of concern; in one nipple

Answer 95

- skin changes that suggest breast ca - 30yrs+ with unexplained lump in axilla

Answer 96

<30yrs with unexplained breast lump with or without pain

Answer 97

- axillary lump (unexplained) - breast lump (unexplained) - nipple changes - skin changes - DVT

Answer 98

- immediate= acute admission or referral within few hrs - urgent= within 2w - very urgent= within 48hrs - non-urgent= general referral - suspected ca pathway= within national target for ca referral eg. 2ww

Answer 99

invasive ductal carcinoma

Answer 100

assessment of the tumour and lymph nodes- normally using sentinel lymph node biopsy (minimises morbidity of an axillary dissection)

Answer 101

- option following any resectional procedure but type tailored to age and co-morbidities - common: latissimus dorsi myocutaneous flap and sub pectoral implants - want to avoid prosthesis= TRAM or DIEP flaps

Answer 102

- multifocal tumour - central tumour - large lesion in small breast - DCIS >4cm - Pt choice

Answer 103

- solitary lesion - peripheral tumour - small lesion in large breast - DCIS <4cm - pt choice

Answer 104

mastectomy

Answer 105

breast conserving surgery where an acceptable cosmetic result may be obtained- rare in small breasts but more likely in large breast

Answer 106

5% or less at 5yrs

Answer 107

Nottingham Prognostic Index

Answer 108

Tumour Size x 0.2 + Lymph node score +Grade score

Answer 109

Score 1= 0 lymph nodes involved= Grade 1 Score 2= 1-3 lymph nodes= Grade 2 Score 3= >3= Grade 3

Answer 110

score 2-2.4= 93% 5yr survival score 2.5-3.4= 85% 3.5-5.4= 70% >5.4= 50%

Answer 111

vascular invasion and receptor status

Answer 112

presence or absence of lymphadenopathy

Answer 113

pre-op axillary USS before primary surgery if -ve then sentinel node biopsy to assess nodal burden

Answer 114

axillary node clearance at primary surgery

Answer 115

may lead to arm lymphedema and functional arm impairment

Answer 116

- all women after wide-local excision (can reduce recurrence by 2/3rds) - if had mastectomy and have T3-T4 tumours - if had mastectomy and have 4 or more +ve axillary nodes

Answer 117

if tumours are positive for hormone receptors

Answer 118

oestrogen receptor (ER), progesterone receptor (PR) or human epidermal growth factor receptor 2 (HER2)

Answer 119

Tamoxifen= men and premenopausal women with ER +ve invasive breast ca Aromatase inhibitor eg. anastrozole= postmenopausal women with ER +ve

Answer 120

Trastuzumab (Herceptin) for HER2 positive breast ca 3 w intervals for 1yr in combination to surgery, chemo, endocrine therapy and radiotherapy as appropriate

Answer 121

Regimen with a taxane and an anthracycline

Answer 122

neuropathy, neutropenia and hypersensitivity

Answer 123

zoledronic acid as adjuvant therapy to post-menopausal women with node +ve invasive breast ca or node -ve but high risk recurrence

Answer 124

external beam radiotherapy: 26Hy in 5 fractions over 1w

Answer 125

neoadjuvant chemo regimen contains a platium and an anthracycline

Answer 126

BRCA1 and BRCA2 mutations if under 50yrs with triple-negative breast ca and also those with no FHx of breast/ovarian ca

Answer 127

Offer breast-conserving surgery with removal of the nipple–areolar complex as an alternative to mastectomy for people with Paget's disease of the nipple that has been assessed as localised.

Answer 128

immediate reconstruction (during mastectomy surgery) or delayed in another operation

Answer 129

- lymphoedema= arm, breast or chest wall - arm and shoulder mobility= so carry out upper limb exercises - menopausal symptoms

Answer 130

- stop HRT - don't offer HRT if Hx of breast ca - consider SSRI to relieve symptoms if not on tamoxifen

Answer 131

ovarian function suppression to reduce risk of recurrence

Answer 132

5yrs can continue taking to reduce recurrence

Answer 133

not while taking it or within 2m of stopping

Answer 134

annual mammography for 5yrs or longer until they enter screening programme

Answer 135

- Genetic testing= BRCA1 & BRCA2 - Hormone receptor testing= ER, PR, HER2 - Pre-op= USS axilla (if abnormal then USS guided needle sampling) - Surgery= mastectomy or breast conserving surgery. Also axillary lymph node clearance or SLNB (if no evidence of LN invol on USS) - Breast reconstruction= immediate or delayed - Endocrine therapy= tamoxifen (ER) or anastrasole (PR) (and maybe extended endocrine therapy- >5yrs) - Ovarian function supression - Adjuvant chemo - Radiotherapy= after breast conserving surgery or after mastectomy who are high risk of recurrence (eg. node +ve invasive breast ca) - Biological theraoy= transtuzumab (HER2) - Bisphosphonate?

Answer 136

- BRCA1, BRCA2 genes - 1st degree relative premenopausal relative with breast cancer (e.g. mother) - nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs) - early menarche, late menopause - combined hormone replacement therapy, combined oral contraceptive use - past breast cancer - not breastfeeding - ionising radiation - p53 gene mutations - obesity - previous surgery for benign disease (?more follow-up, scar hides lump)

Answer 137

40% lifetime risk of breast/ovarian ca

Answer 138

mammography radiography- detects small changes in breast before other S&S of breast ca develop

Answer 139

every 3yrs

Answer 140

aged 50-70 should receive 1st invitation within 3yrs of 50th bday

Answer 141

excluded from programme but can get screening by self-referral to local breast screening service

Answer 142

if have increased risk eg. strong FHx

Answer 143

- benefits and harms - organisation of screening - where it is done - preparing for mammogram - what to expect during appointment

Answer 144

- early detection of breast ca - reduction in mortality

Answer 145

- over-diagnosis & unnecessary Tx - false positive mammograms - false reassurance so incorrect diagnosis - pain and discomfort - psychological distress, anxiety following a false positive

Answer 146

- one first-degree female relative diagnosed with breast cancer at younger than age 40 years, or - one first-degree male relative diagnosed with breast cancer at any age, or - one first-degree relative with bilateral breast cancer where the first primary was diagnosed at younger than age 50 years, or - two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age, or - one first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or - second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative), or - three first-degree or second-degree relatives diagnosed with breast cancer at any age

Answer 147

1) mammogram 2) USS 3) if imaging concerning then biopsy: core needle biopsy 4) Pathology report= type of ca, hormone receptor status and grade 5) Staging= sentinel lymph node biopsy, CT

Answer 148

- invasive ductal carcinoma - invasive lobular carcinoma - ductal carcinoma-in situ (DCIS) - lobular carcinoma-in-situ (LCIS)

Answer 149

Duct tissue (most) or lobular tissue (so ductal or lobular carcinoma) carcinoma-in-situ= local- hasn't spread invasive= spread

Answer 150

most common type breast ca (recently been named as No Special Type (NST); lobular and other rarer types classed as Special Type)

Answer 151

- Medullary breast cancer - Mucinous (mucoid or colloid) breast cancer - Tubular breast cancer - Adenoid cystic carcinoma of the breast - Metaplastic breast cancer - Lymphoma of the breast - Basal type breast cancer - Phyllodes or cystosarcoma phyllodes - Papillary breast cancer

Answer 152

- Paget's disease of the nipple - Inflammatory breast ca

Answer 153

Eczematoid change of nipple associated with underlying breast ca 1-2% will have breast ca 1/2 have associated underlying mass lesion and 90% have invasive carcinoma Some without mass lesion will have underlying carcinoma and some will have carcinoma in situ

Answer 154

cancerous cells block lymph drainage resulting in inflamed appearance of breast rare

Answer 155

ecto- or endocervical mucosa in the cervical transformation zone

Answer 156

low-grade dysplasia (cervical intraepithelial neoplasia 1- CIN1) but can progress to high grade dysplasia

Answer 157

when high grade dysplastic lesions extend beyond the basement membrane of the cervical epithelium

Answer 158

squamous cell carcinoma and adenocarcinoma

Answer 159

persistent infection- HPV (human papillomavirus)

Answer 160

sexual intercourse

Answer 161

16 and 18; 33 HPV detected in 99% cervical ca

Answer 162

precancerous cervical lesions

Answer 163

- increased exposure to HPV (eg. early age 1st intercourse) - impaired immune response to HPV infection eg. HIV or solid organ transplant - smoking - high parity - lower socioeconomic status - COCP

Answer 164

- psychosocial issues - sexual dysfunction - early menopause - loss of fertility - bladder & bowel dysfunction - pelvic or other pain - renal failure - haemeorrhage - fistuale - lymphoedema

Answer 165

- abnorm vaginal bleeding or discharge (not 2 to infection or other causes) - pelvic pain +/- dyspareunia - postmenopausal bleeding not due to HRT - abnorm cervix on exam= inflamed or friable, contact bleeding, visible ulcerating or necrotic lesion - symptoms of advanced disease (rare)

Answer 166

- urgent suspected ca referral (2ww) to colposcopy/gynaecology oncology - abdo, speculum and bimanual pelvic exam (may look normal) - assess for lymphadenopathy= inguinal and supraclavicular

Answer 167

- national cervical screening programme - national HPV vaccination programme - consistent use of condoms and practicing safe sex

Answer 168

- STI - Endometrial ca - endometriosis - ectropion or cervical polyp - hormonal contraception (in 1st 3m or 3-6m with coil or implant)

Answer 169

All women with unexplained postmenopausal bleeding should be referred to gynaecology for specialist assessment. Don't delay referral because a woman has had a previously normal cervical screening result Don't delay referral until after pregnancy if a woman is pregnant.

Answer 170

punch or excisional biopsy eg. electrosurgical excision and conization of suspicious lesions

Answer 171

staging using FIGO system - MRI: tumour size and extent - CXR and assessment for hydronephrosis (renal USS, CT or MRI) for pre-Tx - sentinel node biopsy + PET/CT for lymph node invol. and mets

Answer 172

lungs, liver, bone

Answer 173

- loop electrosurgical excision and conisation: aim to acheive -ve margins to both ca and dysplasia - simple hysterectomy if don't want to preseve fertility

Answer 174

- radical hysterectomy and bilateral salpingectomy ( if fertility sparing appropriate in low risk) and/or bilateral oophorectomy with bilateral pelvic lymphadenectomy - radical trachelectomy (removal of cervix) and lymphadenoectomy can be considered instead for small tumours - may have adjuvant chemo or radio if intermediate/high risk recurrence

Answer 175

tumour size, margin invl, lymph node invl

Answer 176

- external beam radio, intracavity brachytherapy (radiation source placed in uterus & vagina) and chemo 1st line - surgery not recommended as unlikely to be curative

Answer 177

systemic chemo 1st line

Answer 178

- salvage surgery= pelvic exenteration (removal of female reproductive organs, lower urinary tract, portion of rectosigmoid bowel) if chemo failed and confined to central pelvis - chemo and/or radiotherapy if surgery not controlled disease

Answer 179

resection of cervix, uterus, parametria and cuff of upper vagina

Answer 180

squamous cell cancer

Answer 181

HPV 16 & 18 produce the oncogenes E6 and E7 retrospectively E6 inhibits p53 tumour supressor gene E7 inhibits RB supressor gene

Answer 182

mutated gene that has potential to cause cancer

Answer 183

Koilocytes

Answer 184

- enlarged nucleous - irregular nuclear membrane contour - nucleus stains darker than normal (hyperchromasia) - perinuclear halo

Answer 185

FIGO staging and wishes of pt to maintain fertility

Answer 186

IA IB II III IV

Answer 187

Confined to cervix, only visible by microscopy and less than 7 mm wide: A1 = < 3 mm deep A2 = 3-5 mm deep

Answer 188

Confined to cervix, clinically visible or larger than 7 mm wide: B1 = < 4 cm diameter B2 = > 4 cm diameter

Answer 189

Extension of tumour beyond cervix but not to the pelvic wall A = upper two thirds of vagina B = parametrial involvement

Answer 190

Extension of tumour beyond the cervix and to the pelvic wall A = lower third of vagina B = pelvic side wall NB: Any tumour causing hydronephrosis or a non-functioning kidney is considered stage III

Answer 191

Extension of tumour beyond the pelvis or involvement of bladder or rectum A = involvement of bladder or rectum B = involvement of distant sites outside the pelvis

Answer 192

urine builds up in kidneys due to blockage in ureters so they swell eg. can be a Cx of advanced cervical ca

Answer 193

FIGO stage I= 99% 1yr survival; 96% 5yr II= 85%; 54% III= 74%; 38% IV= 35%; 5%

Answer 194

preterm birth in future pregnancies

Answer 195

ureteral fistula

Answer 196

diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness

Answer 197

ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema

Answer 198

25-64yrs (first invitation issued at 24.5yrs so ensure screening can be done by 25th bday)

Answer 199

25-49yrs= recall every 3yrs (invitations issued 34.5m after previous test) 50-64yrs= every 5yrs (58.5m after previous)

Answer 200

invited if recent cervical cytology abnormal or if not had screening since 50yrs and request one

Answer 201

- HPV screening= identify people with high-risk HPV (hrHPV) - Liquid based cytology (if hrHPV found)= detect early abnormalities of cervix, if untreated can lead to ca - Colposcopy= diagnose cervical intraepithelial neoplasia (CIN) and to differentiate high-grade lesions from low-grade abnormalities in people with abnormal cytology

Answer 202

cytology if this is abnormal then colposcopy

Answer 203

repeat HPV test at 12m - if -ve then return to normal recall - if +ve then repeat HPV in 12m again - if -ve at 24m then return normal recall - if +ve at 24m then refer to colposcopy

Answer 204

refer to colposcopy

Answer 205

repeat sample in <3m - if inadequate at 24m repeat text, these are exception and refer to colposcopy - 2 consecutive inadequate or unavailable tests then refer to colposcopy

Answer 206

follow up at 12m screening, if then HPV -ve then return to normal recall

Answer 207

repeat screening and colposcopy in 12m; if normal and HPV -ve then return to routine recall

Answer 208

no abnormality detected

Answer 209

- borderline changes in squamous or endocervical cells - low grade dyskaryosis - high-grade dyskaryosis (moderate) - high-grade dyskaryosis (severe) - invasive squamous cell carcinoma - glandular neoplasia

Answer 210

- taken but the cervix was not fully visualised - taken in inappropriate manner eg. using not approved sampling device - contains insufficient cells - contains obscuring element eg. lubricant, blood, inflamm - incorrectly labelled

Answer 211

any abnormal changes in cervix which may indicate pre-cancerous changes (cervical intraepithelial neoplasia [CIN]) or the presence of cancer

Answer 212

acetic acid = abnormal areas (such as CIN) tend to turn white (sometimes referred to as acetowhite). If iodine solution= normal tissue (on the outside of the cervix) stains dark brown. Pre-cancerous abnormalities may not stain with iodine. The cells on the inner part of the cervix do not stain brown.

Answer 213

- if called while pregnant, defer until 3m post-partum + - if previous test was abnormal, do not delay colposcopy (can do in late 1st or early 2nd tri; if low grade changes can delay until after delivery; if seen in early preg may need another assessment in late 2nd tri)

Answer 214

6m after Tx to test for cure

Answer 215

abnormal changes in the transformation zone of cervix

Answer 216

sometimes referred to as low-grade squamous intraepithelial lesions) — one-third of the thickness of the surface layer of the cervix is affected.

Answer 217

two-thirds of the thickness of the surface layer of the cervix is affected.

Answer 218

(sometimes called high-grade or severe dysplasia or stage 0 cervical carcinoma in situ) — the full thickness of the surface layer is affected.

Answer 219

CIN1 lesions are morphological correlates of HPV infections. CIN2/3 lesions (collectively referred to as CIN2+) are correlates of cervical pre-cancers that, if left untreated, may progress to cervical cancer.

Answer 220

annually and colposcopy at diagnosis

Answer 221

percancerous changes in cervical cells: can be early indication of cervical ca or HPV infection

Answer 222

Indicates low-grade abnormalities in the cervical cells. Often corresponds to CIN1, which is a mild change in the cells and typically linked to an HPV infection. In many cases, mild dyskaryosis can resolve on its own without treatment, especially if caused by transient HPV infections.

Answer 223

Indicates more significant abnormality. Typically corresponds to CIN2 , which is a higher risk of progression to cervical cancer than CIN1. Treatment may be needed to prevent further progression.

Answer 224

Indicates severely abnormal cells. Usually corresponds to CIN3, a precancerous stage with a significant risk of progression to cervical cancer if untreated. Requires further diagnostic testing and often surgical treatment to remove the abnormal tissue.

Answer 225

colposcopy +/- biopsy

Answer 226

- change in bowel habits: C, D or alternating; increase frequency - rectal bleeding: bright red or melena - abdo pain/discomfort - unexplained weight loss: advanced -anaemia: fatigue, weakness, SOB - bowel obstruction: advanced- severe abdo pain, N&V

Answer 227

may be due to tumour obstructing bowel or causing inflam

Answer 228

chronic bleeding from the tumour

Answer 229

rectal (40%) sigmoid (30%) descending colon (5%) transverse colon (10%) ascending colon and caecum (15%)

Answer 230

1) sporadic (95%) 2) hereditary non-polyposis colorectal carcinoma (HNPCC, 5%) 3) familial adenomatous polyposis (FAP, <1%)

Answer 231

genetic mutations

Answer 232

- allelic loss of APC gene - activation of K-ras oncogene - deletion of p53 and DCC tumour suppressor genes

Answer 233

autosomal dominant condition, most common form of inherited colon ca 90% pts develop ca, often proximal colon, poorly differentiated and highly aggressive

Answer 234

7 mutations, which affect genes invl in DNA mismatch repair leading to microsatelilite instability. Genes: - MSH2 (60%) - MLH1

Answer 235

other ca eg. endometrial ca

Answer 236

Amsterdam criteria: - at least 3 family members with colon ca - the cases span at least 2 generations - at least one case diagnosed before age of 50yrs

Answer 237

rare autosomal dominant condition which leads to formation of hundreds of polyps by age 30-40yrs pts inevitably develop carcinoma (lifetime risk near 100%)

Answer 238

mutation in tumour supressor gene called adenomatous polyposis coli gene (APC) located on chromosome 5

Answer 239

Ix= genetic testing- analyse DNA from pts WBC Mx= total proctocolectomy with ileal pouch anal anastomosis (IPAA) formation in their 20s

Answer 240

duodenal tumours

Answer 241

Gardner's syndrome- also feature osteomas of skull & mandible, retinal pigmentation, thyroid carcinoma and opidermoid cysts on the skin

Answer 242

Familial Adenomatous Polyposis

Answer 243

- carcinoembryonic antigen (CEA) - CT chest, abdo, pelvis - entire colon evaluated with colonoscopy or CT colonography - if tumour lies below peritoneal reflection then also need mesorectum evaulated with MRI

Answer 244

TNM once staging complete then MDT meeting to formulate Mx plan

Answer 245

- surgery - chemo - radio - targeted therapies

Answer 246

resectional surgery

Answer 247

eg. tumour pt from HNPCC family may be better served with panproctocolectomy rather than segmental resection

Answer 248

following resection, need decision regarding restoration of continuity for anastomosis to heal= adequate blood supply, mucosal apposition and no tissue tension

Answer 249

surgical or natural connection between 2 structures eg. blood vessels, intestine, tubes critical in many surgeries to ensure that normal flow and function are maintained after structural changes

Answer 250

stent it or resect unusual now to defunction a colonic tumour with proximal loop stoma (this differs from situation in rectum)

Answer 251

blood supply and lymphatic drainage

Answer 252

Type of resection= right hemicolectomy Anastomosis= ileo-colic

Answer 253

Type of resection= left hemicolectomy Anastomosis= colo-colon

Answer 254

Type of resection= high anterior resection Anastomosis= colo-rectal

Answer 255

Type of resection= anterior resection (TME) Anastomosis= colo-rectal

Answer 256

Type of resection= anterior resection (low TME) Anastomosis= colo-rectal (+/- defunctioning stoma)

Answer 257

Type of resection= abdomino-perineal excision of rectum Anastomosis= none

Answer 258

Colostomy: Bypass the colon, output is usually solid. Ileostomy: Bypass the small intestine, output is usually liquid. Urostomy: Bypass the bladder, output is urine. Jejunostomy and Gastrostomy: Used for feeding rather than waste diversion. (opening in jejunum or in stomach respectively)

Answer 259

Temporary Stomas: Created when the bowel or bladder needs time to heal (e.g., after an injury or surgery). They are later reversed when healing is complete. Permanent Stomas: Created when the underlying condition (e.g., cancer, severe Crohn’s disease) requires permanent removal or bypass of part of the digestive or urinary tract.

Answer 260

in neoadjuvant setting (particularly for rectal ca), adjuvant setting and for metastatic disease

Answer 261

FOLFOX and FOLFIRI

Answer 262

predominantly for rectal ca in the neoadjuvant or adjuvant setting

Answer 263

Bevacizumab (anti-VEGF) and Cetuximab (anti-EGFR), particularly for metastatic disease

Answer 264

end colostomy is safer and can be reversed - resection of sigmoid colon and end colostomy is fashioned in operation= Hartmann's procedure - left sided resections more risky, ileo-colic anastomoses are relatively safe even in emergencies and don't need to be defunctioned

Answer 265

Faecal Immunochemical Test (FIT) instead of doing colonoscopy 1st line

Answer 266

- abdo mass - change in bowel habit - iron def anaemia - 40yrs+ with unexplained weight loss & abdo pain - <50yrs with rectal bleeding + abdo pain or weight loss - 50yrs+ with rectal bleeding, weight loss or abdo pain - 60yrs+ with anaemia even in absence of iron def

Answer 267

still need another one

Answer 268

do not need FIT test, just consider referral for ?colorectal ca

Answer 269

refer on suspected ca pathway

Answer 270

- safety net - refer on suspected ca pathway if ongoing signif concern (abdo mass) - still Ix for underlying diagnosis

Answer 271

every 2yrs to people 50-74yrs (England & Scotland) Wales: 51-74 NIreland: 60-74hrs

Answer 272

Invitation letter followed by test kit: end of test tick dipped into single bowel motion, placed back in tube and returned in envelope

Answer 273

letter sent to pts home within 2 weeks of receiving the kit and GP informed electronically

Answer 274

offered colonoscopy

Answer 275

No abnormal or low-risk adenoma= return to routine recall Intermediate or high risk adenoma= invited for colonoscopic surveillance/review Cancer= refer for Tx Other pathology eg. IBD or diverticulosis= referred for Tx

Answer 276

anxiety; Cx of colonoscopy (bleeding, bowel perforation); inappropriate reassurance from -ve screening result

Answer 277

- promoting uptake - ensure that pts are aware that not all ca will be detected by screening - -ve results should not be used to guide Ix of pt presenting with symptoms of bowel ca

Answer 278

type of faecal occult blood (FOB) test which uses antibodies that specifically recognise human Hb used to detect and quantify amount of human blood in single stool sample abnormal result offered colonoscopy

Answer 279

adenomatous polyps

Answer 280

1/10 5/10 normal 4/10 polpys which may be removed (premalignant potential)

Answer 281

post-menopausal women 25% do occur before menopause

Answer 282

good due to early detection

Answer 283

XS oestrogen: - nulliparity - early menarche - late menopause - unopposed oestrogen metabolic syndrome: - obesity - DM - PCOS tamoxifen hereditary non-polyposis colorectal carinoma (HNPCC)

Answer 284

- multiparity - COCP - smoking

Answer 285

Reduces the risk addition of progestogen to oestrogen reduces the risk as oestrogen is no longer unopposed

Answer 286

endometrial ca

Answer 287

- postmenopausal bleeding, usually slight and intermittent initially before becoming heavier - premenopausal= menorrhagia or intermenstrual bleeding - pain not common, signifies extensive disease - vaginal discharge unusual

Answer 288

all women >=55yrs who present with postmenopausal bleeding consider if <55

Answer 289

trans-vaginal USS: normal endometrial thickness (<4mm) has a high negative predictive value hysteroscopy with endometrial biopsy

Answer 290

surgery - localised disease= total abdo hysterectomy with bilateral salpingo-oophorectomy high-risk disease= postop radiotherapy

Answer 291

progestogen therapy

Answer 292

unexplained vaginal bleeding more than 12m after menstruation has stopped because of the menopause

Answer 293

Unexplained symptoms of vaginal discharge who: - Are presenting with these symptoms for the first time, or - Have thrombocytosis, or - Report haematuria, or Visible haematuria, and: - Low haemoglobin levels, or - Thrombocytosis, or - High blood glucose levels.

Answer 294

older people (1/2 are >75yrs) and male

Answer 295

gastric adenocarcinoma

Answer 296

glandular epithelium of the stomach lining

Answer 297

- Helicobacer pylori - pernicious anaemic, atrophic gastritis - diet - ethnicity: Japan, China - smoking - blood group A

Answer 298

triggers inflam of the mucosa -> atrophy and intestinal metaplasia -> dysplasia

Answer 299

salt and salt-preserved foods nitrates

Answer 300

abdo pain= vague, epigastric, dyspepsia weight loss & anorexia N&V dysphagia: esp if ca arises in proximal stomach overt upper GI bleeding in minority Virchow's node & Sister Mary Joseph's node

Answer 301

left supraclavicular lymph node (Virchow's node) periumbilical nodule (Sister Mary Joseph's node)

Answer 302

oesophago-gastro-duodenoscopy with biopsy

Answer 303

may be seen in gastric ca on biopsy contain large vacuole of mucin which displaces the nucleus to one side high no. of signet ring cells= worse prognosis

Answer 304

- CT chest, abdo and pelvis= ?mets - endoscopic USS: if will guide Mx - F18 FDG-PET scan: if ? metastatic disease -pre-op staging laparoscopy: if potentially curable gastric

Answer 305

surgical options depend on extent and site, include: - endoscopic mucosal resection - partial gastrectomy - total gastrectomy - chemotherapy

Answer 306

endoscopic mucosal resection for staging

Answer 307

- definitive chemo or - surgical resection pt choice

Answer 308

open or minimally invasive oesophagectomy

Answer 309

When performing curative gastrectomy for gastric ca= consider D2 lymph node dissection Curative oesophectomy= consider two-field lymph node dissection

Answer 310

- chemo before or before & after surgery - chemoradiotherapy before surgery

Answer 311

chemo before and after surgery or chemo/chemoradiotherapy after surgery for those with curative intent and didn't have chemo before

Answer 312

- radical chemoradio or - chemoradio before surgical resection

Answer 313

palliative Mx: - chemoradio for non-metastatic that can be encompassed within a radiotherapy field if can't be encompassed, consider 1 or more: - chemo - local tumour Tx (stenting or palliative radio) - best supportive care after Tx reassess response and reconsider if surgery is an option

Answer 314

trastubzumab (in combination with cisplatin and capecitabine)

Answer 315

double Tx= 5-fluorouracil or capecitabine in combination with cisplatin or oxaliplatin triple Tx= 5-fluorouracil or capecitabine in combination with cisplatin or oxaliplatin plus epirubicin.

Answer 316

self-expanding stents or radiotherapy

Answer 317

uncovered self-expanding metal stents or palliative surgery

Answer 318

enteral or parenteral nutrition

Answer 319

Acute lymphoblastic leukaemia

Answer 320

2-5yrs boys slightly more common

Answer 321

those predictable by bone marrow failure eg. anaemia, neutropaenia, thrombocytopenia

Answer 322

- anaemia= lethargy and pallor - neutropenia= frequent or severe infection - thrombocytopenia= easily bruising, petechiae - bone pain - splenomegaly - hepatomegaly - fever in up to 50% - testicular swelling

Answer 323

secondary to bone marrow infiltration

Answer 324

- common ALL (75%), CD10 present, pre-B phenotype - T-cell ALL (20%) - B-cell ALL (5%)

Answer 325

- age <2yrs or >10yrs - WBC >20*10^9/l at diagnosis - T or B cell surface markers - non-Caucasian - male

Answer 326

acute myeloid leukaemia

Answer 327

primary disease or following a secondary transformation of a myeloproliferative disorder

Answer 328

acute myeloid leukaemia

Answer 329

related to bone marrow failure - anaemia= pallor, lethargy, weakness - neurtopenia= WBC count may be v high, functioning neutrophil levels may be low leading to frequent infections - thrombocytopenia= bleeding - splenomegaly - bone pain

Answer 330

>60yrs >20% blasts after first course of chemo cytogenetics= deletions of chromosome 5 or 7

Answer 331

French-American-British (FAB) MO - undifferentiated M1 - without maturation M2 - with granulocytic maturation M3 - acute promyelocytic M4 - granulocytic and monocytic maturation M5 - monocytic M6 - erythroleukaemia M7 - megakaryoblastic

Answer 332

associated with t(15;17) fusion of PML and RAR-alpha genes presents younger than other types of AML (average = 25 years old) Auer rods (seen with myeloperoxidase stain) DIC or thrombocytopenia often at presentation good prognosis

Answer 333

Acute promyelocytic leukaemia (APML, the M3 subtype of AML)

Answer 334

the t(15;17) translocation which causes fusion of the PML and RAR-alpha genes

Answer 335

- presents younger than other types of AML (average=25yrs) - DIC or thrombocytopenia often - good prognosis

Answer 336

all-trans retinoic acid (ATRA) to force immature granulocytes into maturation to resolve a blast crisis prior to more definitive chemo

Answer 337

APML (subtype of AML)

Answer 338

- anaemia - hypogammaglobulinaemia= recurrent infections - warm autoimmune haemolytic anaemia (in 10-15%) - transformation to high-grade lymphoma (Richter's transformation)

Answer 339

occurs when leukaemia cells enter lymph node and change into high-grade, fast-growing non-Hodgkin's lymphoma pts become unwell very suddenly

Answer 340

lymph node swelling fever without infection weight loss night sweats nausea abdominal pain

Answer 341

Ritcher's transformation

Answer 342

chronic lymphocytic leukaemia

Answer 343

monoclonal proliferation of well-differentiated lymphocytes which are almost always B-cells (99%)

Answer 344

- often asymptomatic= picked up incidental finding of lymphocytosis - constitutional: anorexia, weight loss - bleeding, infections - lymphadenopathy more marked than CML

Answer 345

- Immunophenotyping KEY - FBC - Blood film= smudge cells (smear cells)

Answer 346

most cases can be identified using panel of antibodies specific for CD5, CD19, CD20, CD23

Answer 347

anaemia (due to bone marrow replacement or autoimmune haemolyic anaemia) and thrombocytopenia (due to bone marrow replacement or immune thrombocytopenia- ITP)

Answer 348

AML (APML)

Answer 349

translocation between the long arm of chromosome 9 and 22 - t(9:22)(q34; q11). This results in part of the ABL proto-oncogene from chromosome 9 being fused with the BCR gene from chromosome 22. The resulting BCR-ABL gene codes for a fusion protein that has tyrosine kinase activity in excess of normal.

Answer 350

60-70yrs - weight loss and sweating COMMON - marked splenomegaly= abdo discomfort - increase in granulocytes at different stages of maturation +/- thrombocytosis - decrease leukocyte alkaline phosphatase - may undergo blast transformation (AML in 80%, ALL in 20%)

Answer 351

Imatinib 1st line - hydroxyurea - interferon-alpha - allogenic bone marrow transplant

Answer 352

inhibitor of the tyrosine kinase associated with the BCR-ABL defect very high response rate in chronic phase CML

Answer 353

Chronic myeloid leukaemia

Answer 354

pallor persistent fatigue unexplained fever Unexplained persistent or recurrent infection. Generalized lymphadenopathy. Unexplained bruising. Unexplained bleeding. Unexplained petechiae. Hepatosplenomegaly.

Answer 355

unexplained petechiae or hepatosplenomegaly

Answer 356

Pallor. Persistent fatigue. Unexplained fever. Unexplained persistent infection. Generalized lymphadenopathy. Persistent or unexplained bone pain. Unexplained bruising. Unexplained bleeding.

Answer 357

ALL= <5 & >45 CeLLmates= >55, smudge cells have CoMmon= >65, philadelphia chromosome AMbitions= >75, aurer rods

Answer 358

ALL= ALL children have headaches because they were doing meth (methotrexate used to Tx ALL) AML= enAML (dental problems) and when you open your mouth you go ahhhh (aurer rods) CLL= geting smudged (smudge cells) in club rituximab (used to Tx) CML= CML and gout (Cx) got married in Philidelphia (chromosome)

Answer 359

- have CXR that suggests lung ca or - 40yrs+ with unexplained haemoptysis

Answer 360

- cough - fatigue - SOB - chest pain - weight loss - appetite loss

Answer 361

- persistent or recurrent chest infection - clubbing - supraclavicular lymphadenopaty or persistent cervical lymphadenopathy - chest signs consistent of lung ca - thrombocytosis

Answer 362

pleural peritoneal can occur

Answer 363

persistent cough haemoptysis dyspnoea chest pain weight loss and anorexia hoarseness laryngeal nerve superior vena cava syndrome

Answer 364

with Pancoast tumours pressing on the recurrent laryngeal nerve

Answer 365

- fixed monophonic wheeze - clubbing - supraclavicular lymphadenopathy or persistent cervical lymphadenopathy

Answer 366

rare disorders that occur when immune system has a reaction to ca

Answer 367

- ADH - ACTH (not typical)- HTN, hyperglucaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump ect - Lamber-Eaton syndrome

Answer 368

- parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia - clubbing - hypertrophic pulmonary osteoarthropathy (HPOA) - hyperthyroidism due to ectopic TSH

Answer 369

- gynaecomastia - HPOA

Answer 370

hoarseness stridor

Answer 371

raised platelets (thrombocytosis)

Answer 372

CXR (10% sometimes CXR normal)

Answer 373

1st line= CXR Gold= CT - Bronchoscopy with biopsy using endobrachial USS - PET scan= non-small lung ca to establish eligability for cure; 18-fluorodeoxygenase if preferentially taken up by neoplastic tissue - bloods= raised platelets

Answer 374

- Squamous cell carcinoma - Adenocarcinoma - Large cell lung carcinoma

Answer 375

typically central cavitating lesions are more common than other types HPOA

Answer 376

Finger clubbing and PTHrP secretion -> hypercalcaemia

Answer 377

adenocarcinoma

Answer 378

- typically peripheral - most common in lung ca in non-smokers, but majority are still smokers

Answer 379

- typically peripheral - anaplastic, poorly differentiated tumours with poor prognosis - may secrete B-HCG

Answer 380

term used to describe ca cells that divide rapidly and have little to no resemblance to normal cells

Answer 381

- only 20% suitable for surgery - curative or palliative radiotherapy - poor response to chemo

Answer 382

mediastinoscopy as CT doesn't always show mediastinal lymph node invl.

Answer 383

assess general health stage IIIb or IV (i.e. metastases present) FEV1 < 1.5 litres is considered a general cut-off point (for lobectomy or <2 for pneumonectomy; sometimes need further lung function tests as operations may still go ahead based on results) malignant pleural effusion tumour near hilum vocal cord paralysis SVC obstruction

Answer 384

- usually central - arise from APUD* cells - associated with ectopic ADH, ACTH secretion - ADH → hyponatraemia - ACTH → Cushing's syndrome - ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis Lambert-Eaton syndrome

Answer 385

antibodies to voltage gated calcium channels causing myasthenic like syndrome

Answer 386

metastatic disease

Answer 387

pts with very early stage disease (T1-2a, N0, M0) are considered for surgery. however, most pts with limited disease receive a combination of chemotherapy and radiotherapy pts with more extensive disease are offered palliative chemotherapy

Answer 388

APUD cells: Amine - high amine content Precursor Uptake - high uptake of amine precursors Decarboxylase - high content of the enzyme decarboxylase

Answer 389

Small cell lung ca Non-small cell lung ca: - adenocarcinoma - squamous - large cell - alveolar cell carcinoma - bronchial adenoma

Answer 390

histologically as SCLC or NSCLC due to different features, Mx and prognosis

Answer 391

small cell (15%)

Answer 392

adenocarcinoma (NSCLC) often seen in non-smokers high no of cases due to increased use of low-tar cigarettes

Answer 393

Squamous (NSCLC)

Answer 394

not related to smoking ++ sputum

Answer 395

bronchial adenoma (NSCLC)

Answer 396

SCLC - 10-15% - fast growing, aggressive - often widespread at diagnosis - only one major type (small cell carcinoma) - strong association with smoking - limited stage and extensive stage - more likely to present with paraneoplastic symptoms eg. SIADH, Cushings - Tx: chemo and radio; surgery rare due to early mets - poor prognosis (12-18m limited stage; 6-12m extensive) - fewer mutations, TP53, RB1 - less responsive to immunotherapy NSCLC - 85-90% - slower growing - may be localised at diagnosis - Types: adenocarcinoma, SCC, large cell carcinoma - associated with smoking and genetic mutations - Staged I to IV - CP: cough, chest pain, weight loss like SCLC but less likely to have paraneoplastic symtpoms - surgery option in early stages; chemo, radiation and immunotherapy in advanced - better prognosis - Mutations: EGFR, ALK, ROS1 and KRAS, more common in adenocarcinoma - more responsive to immunotherapy

Answer 397

high-grade B-cell neoplasm

Answer 398

- Endemic (African) form - Sporadic form

Answer 399

typically invl. maxilla or mandible

Answer 400

abdominal eg ileo-caecal tumours are the most common form; more common in pts with HIV

Answer 401

c-myc gene translocation, usually t(8:14)

Answer 402

'starry sky' appearance= lymphocyte sheets interspersed with macrophages containing dead apoptotic tumour cells

Answer 403

Rasburicase often given before then chemotherapy

Answer 404

a rapid response which may cause tumour lysis syndrome

Answer 405

Rasburicase (a recombinant version of urate oxidase, an enzyme that catalyses the conversion of uric acid to allantoin. Allantoin is 5-10x more soluble than uric acid so excretion is more effective)

Answer 406

hyperkalaemia hyperphosphataemia hypocalcaemia hyperuricaemia acute renal failure

Answer 407

potentially life threatening Cx that occurs when ca cells break down rapidly, releasing intracellular contents into blood -> metabolic imbalances

Answer 408

ones with high cell turnover eg. leukaemia and lymphoma, occasionally highly aggressive solid tumours

Answer 409

after initiating Tx for ca eg. chemo, radio or targeted which rapidly kill large no of tumour cells can occur spontaneous when ca cells die on own, esp in rapidly growing tumours

Answer 410

Cardiac: Arrhythmias, palpitations, or even cardiac arrest (due to hyperkalemia). Renal: Acute kidney injury, leading to decreased urine output or complete kidney failure. Neurological: Muscle cramps, seizures, and altered mental status (due to electrolyte imbalances like hypocalcemia). Gastrointestinal: Nausea, vomiting, and diarrhea. General: Fatigue, weakness, and confusion.

Answer 411

Blood Tests: Monitoring of electrolyte levels (potassium, phosphate, calcium), uric acid, and kidney function (creatinine levels). Clinical Criteria: Based on the Cairo-Bishop classification, which includes both laboratory abnormalities and clinical manifestations like acute kidney failure or arrhythmias.

Answer 412

Hydration: Aggressive IV fluids to help flush out toxins and prevent kidney injury. Allopurinol: Prevents the formation of uric acid by inhibiting xanthine oxidase. Rasburicase: Converts uric acid to allantoin, a more easily excretable compound, and is used in high-risk cases. Electrolyte Management: Hyperkalemia: May require insulin, glucose, or even dialysis to reduce potassium levels. Hypocalcemia: Treated cautiously, often with calcium supplements if symptomatic. Hyperphosphatemia: May require phosphate binders. Dialysis: In severe cases of kidney failure or life-threatening electrolyte disturbances.

Answer 413

If managed quickly and appropriately, TLS can be controlled, but without timely intervention, it can lead to multi-organ failure and death.

Answer 414

Prevention is crucial in high-risk patients, and prophylactic measures (hydration, medications like allopurinol or rasburicase) are often initiated before starting cancer treatment.

Answer 415

- ca type= rapidly proliferatng ca eg. ALL and high-grade lymphomas eg. Burkitt lymphoma - tumour burden= large tumour or extensive disease - high sensitivity to Tx= ca that respond quick to chemo - pre-existing kidney issues= exacerbate inability to handle large load of metabolic byproducts released during TLS

Answer 416

Burkitt's lymphoma

Answer 417

Hodgkin's lymphoma

Answer 418

bimodal age distribution: 3rd and 7th decades most common

Answer 419

- Nodular sclerosing (70%) - Mixed cellularity (20%) - Lymphocyte predominant (5%) - Lymphocyte depleted (rare)

Answer 420

Lymphocyte predominant

Answer 421

Lymphocyte depleted

Answer 422

Mixed cellularity and nodular sclerosing Lymphocyte predominant= best

Answer 423

Nodular sclerosing

Answer 424

Mixed cellularity

Answer 425

- B symptoms - Lymphocyte depleted type - >45yrs - stage IV - Hb < 10.5 g/dl - lymphocyte count < 600/µl or < 8% - male - albumin < 40 g/l - white blood count > 15,000/µl

Answer 426

weight loss >10% in last 6m fever >38ºC night sweats

Answer 427

- lymphadenopathy (75%) - systemic B symptoms (25%) - possible: mediastinal mass- may be symptomatic (cough) or incidental on CXR

Answer 428

B-cell ALL (80%) T-cell ALL (20%)

Answer 429

1) chemoradiation 2) genetic= Down's (ALL & AML) and translocations 3) infection

Answer 430

cause mutations so increase DNA replication without lymphoblasts actually dying so not differentiating into T and B cells

Answer 431

(12:20)t= children (9:22)t= adults, Philidelphia chromosome forming BCR-ABL gene (different Tx for diff translocation)

Answer 432

hyperdiploid blast cells

Answer 433

1) increased lymphoblasts -> decreased function WBC= increase risk of INFECTION & mortality eg. pneumonia, UTI, cellulitis 2) decrease RBC (less space in BM)= ANAEMIA so pallor, fatigue, SOB 3) decrease platelets (less space)= THROMBOCYTOPENIA= bruising- petechiae, purpura and bleeding (epistaxis, GI, gums) 4) increase lymphoblasts= expand bone marrow= BONE PAIN, limping

Answer 434

1) Hepatosplenomegaly= N&V, abdo fullness 2) Lymphadenopathy= painless, common, eg. cervical 3) Meninges= Meningeal Leukaemia (meningitis features) and CN palsy eg. CN6 (so can't abduct eye) 4) Testes= Testicular enlargement 5) If T-cell ALL= Thymic enlargement (thymus overlies heart so if enlarged can compress...): - trachea- SOB, stridor - oesophagus- dysphagia - superior vena cave- vein enlargement eg. neck

Answer 435

AML or ALL AML>>> for leukostasis

Answer 436

1) FBC and blood smear 2) Definitive diagnosis= bone marrow biopsy 3) immunophenotyping 4) genetic studies 5) Tests of infiltration: - CNS= CT/MRI, LP - testis= USS - thymus= CXR, CT chest (enlargement of thymus/mediastinum) - Liver/spleen= USS, CT abdo

Answer 437

- decreased RBC and platelets - variable functional WBC (high or low) - blood smear= increased immature lymohoblasts

Answer 438

Increased lymphoblasts >20% (blast cell predominance)

Answer 439

Immunohistochemistry: - lymphoblasts high - Tdt +ve - mpo -ve Flow cytometry: - T-ALL= CD2-CD8 (CD3) - B-ALL= CD10,19,20

Answer 440

(12:21)t= children, more common (9:22)t= adults, Phil. chromosome Is it BCR-ABL +ve? If so and there is (9:22)t then Tx with tyrosine kinase inhibitors

Answer 441

as different Tx for different translocations

Answer 442

1) systemic chemo: induction -> consolidation -> maintenance (phase). Goal= complete remission 2) prophylactic intrathecal chemotherapy with methotrexate +/- cranial radiotherapy 3) AND TLS prophylaxsis If fail... 4) Advanced therapies: - TKIs - Bone marrow Transplant

Answer 443

C.yclophosphamide V.incristine A.sparaginase (+/-) D.oxorubicin D.examethasone (or pred)

Answer 444

risk of meningeal leukaemia in ALL

Answer 445

- Tyrosine kinase inhibitors eg. imatinib - Bone marrow transplant if= fail chemo, fail TKIs and poor prognosis

Answer 446

if +ve for (9:22)t and BCR-ABL

Answer 447

TLS Malignant cells hit with chemo, burst and release: - phosphates - uric acid - potassium so cause AKI

Answer 448

- IV fluids - Allopurinol - Rasburicase (all 3)

Answer 449

1) chemoradiation 2) Genetic 3) Bone marrow disorder

Answer 450

- Down's - AML subtype APL due to (15:17)t with PML-RARA gene

Answer 451

1) Myelodysplastic syndrome -> progresses to AML 2) CML -> AML

Answer 452

1) increased myeloblasts so decrease functional WBCs (don't kill pathogens or differentiate to N, B or E)= Increased risk of infection and mortality eg. pneumonia, UTI, cellulitis 2) decrease RBC as less space= anaemia: pallor, fatigue, SOB 3) decrease platelets as less space= thrombocytopenia: bruising (petechiae, purpura), bleeding (gums, GI, nose) 4) increase myeloblasts= expands bone marrow= bone pain, limping

Answer 453

1) leukostasis (AML>>ALL) if >=100,000 myeloblasts 2) Tumour lysis syndrome 3) Cutaneous/mucosal= leukaemia cutis and gingival hyperplasia 4) DIC (only in APL)= increase bleeding risk

Answer 454

if >=100,000 myeloblasts clog up blood flow due to blood vessel occlusion therefore: - hypoxaemia= headache, TIA, stroke - lungs= SOB, hypoxia so acute resp failure - retina= vision changes, vision loss

Answer 455

secondary to chemo (most common) or spontaneous secondary to high tumour burden myeloblasts burst releasing phosphate, K+ and uric acid causing AKI as uric acid forms crystals and phosphate combines with Ca to form crystals (kidney stones) causing damage to kidney SO get= low urine output, high creatinine, high BUN; high K+ can cause arrythmias

Answer 456

myeloblast releases: 1) tissue factor (III) -> increase clotting pathway -> decrease clotting factors (secondary to consumption) so can't clot when need to 2) TPA -> fibrinolysis -> can't clot therefore increase bleeding risk: - brain bleed= ICH - bleed into lungs= pulmonary haemorrhage - bruising, bleeding (eg. out of cannula)

Answer 457

1) FBC & blood smear 2) Definitive= bone marrow biopsy then to determine Tx and prognosis... 3) immunophenotyping 4) Genetic studies 5) Tests of Cx: - electrolyte panel if TLS - clotting screen if DIC - clinical exam if leukostasis or cutaneous/mucosal manifestations

Answer 458

- decreased RBC - decreased platelets - variable functional WBCs (increased or decreased) blood smear= increased myeloblasts and Auer rods (esp in APL)

Answer 459

increased myeloblasts (>20%) Auer rods

Answer 460

Immunohistochemistry: - mpo +ve (myloperoxodase) - Tdt -ve

Answer 461

for subtypes and Tx (15:17)t= APL AML-RARA +ve= APL if APL then different Tx needed compared to other AML subtypes

Answer 462

- high phosphate - high uric acid - high potassium - low Ca as combine with PO4- to form crystals - AKI so high creatinine and high BUN

Answer 463

high PTT high INR high d-dimer low fibrinogen low RBCs low platelets

Answer 464

- systemic chemo for non-APL subtype - systemic chemo for APL subtype - Bone marrow transplant - Tx of Cx: leukostasis or TLS

Answer 465

agents= Cytarabine and daunorubicin induction -> consolidation -> maintenance goal= complete remission

Answer 466

agents= ATRA +/- arsenic trioxide; may give steroids to prevent differentiation syndrome good prognosis goal= promote differentiation: myeloblast -> promyelocyte -> granulocyte

Answer 467

differentiation syndrome as goal if to promote differentiation (of undifferentiated high amounts of myeloblasts to granulocytes so good prognosis) this causes cytokine storm so can give steroids too to try prevent this

Answer 468

if: - AML with poor prognostic findings (likely to fail chemo) or - AML that failed chemo (didn't undergo complete remission)

Answer 469

1) cytoreduction= leukapheresis (take away myeloblasts blocking vessels) and hydroxyurea (reduce no. of myeloblasts) 2) then chemo

Answer 470

- allopurinol + - rasburicase + - IV fluids

Answer 471

Myeloblasts burst and release purines which convert to uric acid which then go to kidney to damage and cause AKI. Allopurinol prevents purines converting to uric acid. Rasburicase converts the uric acid into allantoin which is not toxic to kidney

Answer 472

Haemocytoblast (stem cell in bone marrow which differentiates...) into 1)Myeloid stem cells into 2) RBCs (using erythropoeitin), platelets (using TPO) or myeloblasts (CSF) 3) myeloblasts -> promylocyte 4) promylocyte -> neutrophil, basophil or eosinophil (all granulocytes) or 1) Lymphoid stem cells into 2) lymphoblast into 3) B lymphoblasts -> T-cells -> go to thymus and lymph nodes or 3) T lymohoblasts -> B-cells -> go to lymph nodes

Answer 473

APL (Acute promyelocytic leukemia)

Answer 474

Hodgkin's lymphoma

Answer 475

- common in neck (cericval/supraclavicular) > axillary > inguinal - usually painless, non-tender, asymmetrical - alcohol induced LN pain (<10% pts)

Answer 476

weight loss pruritus night sweats fever (Pel-Ebstein)

Answer 477

- normocytic anaemia - esosinophilia - LDH raised - Lymph node biopsy= Reed-Sternberg cells diagnostic

Answer 478

may be multifactorial eg. hypersplenism, bone marrow replacement by HL, Coombs-positive haemolytic anaemia

Answer 479

production of cytokines eg. IL-5

Answer 480

Lymph node biopsy= Reed-Sternberg cells large cells; multinucleated or bilobed nucleus with eosinophilic inclusion-like nuclei (giving owl's eye appearance)

Answer 481

Hodgkin's lymphoma

Answer 482

Ann-Arbor staging Stage I: single lymph node II: 2 or more lymph nodes/regions on the same side of the diaphragm III: nodes on both sides of the diaphragm IV: spread beyond lymph nodes Each stage may be subdivided into A or B A = no systemic symptoms other than pruritus B = weight loss > 10% in last 6 months, fever > 38c, night sweats (poor prognosis)

Answer 483

Lugano classification (updated version of Ann-Arbor) Stages I-IV; A/B, E, S and X

Answer 484

Stage I: invl. of a single lymph node region (I) or a single extralymphatic organ or site (IE). Stage II: invl. of 2 or more LN regions on the same side of the diaphragm (II) or localized involvement of an extralymphatic organ or site and one or more LN regions on the same side of the diaphragm (IIE). Stage III: invl. of LN regions on both sides of the diaphragm (III), which may also be accompanied by localized involvement of an extralymphatic organ or site (IIIE), involvement of the spleen (IIIS), or both (IIIE+S). Stage IV: Diffuse or disseminated involvement of one or more extralymphatic organs, with or without associated lymph node involvement.

Answer 485

A/B symptoms= no B symptoms then classed as A, if B symptoms then B E= presence of extranodal disease S= involvement of the spleen X= bulky disease (large tumour mass)

Answer 486

PET scans to determine staging- assess whether lymphoma is metabolically active in diff parts of body

Answer 487

- chemo -radiotherapy - combined modality therapy (CMT)= chemo followed by radio - hematopoeitic cell transplant= for relapsed or refractory classic Hodgkin lymphoma

Answer 488

chemotherapy followed by radiotherapy

Answer 489

ABVD= standard BEACOPP= alternative with better remission rates but higher toxicity

Answer 490

doxorubicin bleomycin vinblastine decarbazine

Answer 491

bleomycin etoposide doxorubicin cyclophosphamide vincristine procarbazine prednisone

Answer 492

most pts achieve long-term survival free of HL secondary malignancies are a risk eg. solid tumours- breast, lung

Answer 493

- higher prevalence of NHL - older mean age of diagnosis of NHL - in NHL there is non-contigous, multicentric spread - in NHL extranodal invl. is common - HL= Reed-Sternberg cells; NHL= NO R-S cells

Answer 494

malignant proliferation of lymphocytes which accumulate in lymph nodes or other organs

Answer 495

Hodgkin's lymphoma= presence of Reed-Sternberg cells Non-Hodgkins= every other type of lymphoma that is not Hodgkin's; NO Reed-Sternberg cells

Answer 496

B or T cells further classified as high or low grade

Answer 497

typically elderly, >75yrs

Answer 498

- elderly - caucasian - Hx of viral infection esp EBV - FHx - chemical agents (pesticides, solvents) - Hx of chemo or radio - Immunodeficiency (transplant, HIV, DM) - Autoimmune (SLE, Sjogren's, coeliac)

Answer 499

- painless lymohadenopathy (non-tender, rubbery, asymmetrical) - constitutional/B symptoms - extranodal disease: gastric (dyspepsia, dysphagia, weight loss, abdo pain); bone marrow (pancytopenia, bone pain); lungs; skin; CNS (nerve palsies)

Answer 500

biopsy and CP HL= can have alcohol induced LN pain B symptoms typically earlier in HL and later in NHL extra-nodal disease much MORE common in NHL

Answer 501

- weight loss - lymohadenopathy (cervical, axillary, inguinal) - palpable abdo mass: hepatomegaly, splenomegaly, lymph nodes - testicular mass - fever

Answer 502

Diagnostic= excisional node biopsy - CT chest, abdo, pelvis (staging) - HIV test (RF for NHL) - FBC and blood film - ESR (prognostic indicator) - LDH (prognostic indicator) - other if clinically indicated eg. LFTs if ?liver mets, PET CT, bone marrow biopsy (BM invl?), LP if neuro CP

Answer 503

FBC & blood film= may have normocytic anaemia; helpful to rule out other haem malignancy eg. leukaemia ESR= good prognostic indicator LDH= marker of cell turnover, useful prognostic indicator

Answer 504

Lugano staging

Answer 505

the sub-type

Answer 506

typically watchful waiting, chemo or radio Rituximab is used in combination with conventional chemo regimens (eg. CHOP) for variety of NHL types - all pts= flu/pneumococcal vaccines - neutropenia= may need Abx prophylaxis

Answer 507

CHOP: cyclophosphamide doxorubicin (hydroxydaunorubicin) vincristine (Oncovin®) prednisolone

Answer 508

Bone marrow infiltration causing anaemia, neutropenia or thrombocytopenia Superior vena cava obstruction Metastasis Spinal cord compression Complications related to treatment e.g. Side effects of chemotherapy

Answer 509

Low-grade non-Hodgkin's lymphoma has a better prognosis High-grade non-Hodgkin's lymphoma has a worse prognosis but a higher cure rate

Answer 510

present with unexplained lymphadenopathy or splenomegaly take into account associated features eg. fever, night sweats, SOB, pruritus, weight loss

Answer 511

present with unexplained lymphadenopathy or splenomegaly take into account associated features eg. fever, night sweats, SOB, pruritus, weight loss

Answer 512

either depending on age and local arrangements

Answer 513

- adult= suspected ca pathway referral (within 2w) - children/young adult= very urgent (within 48hrs)

Answer 514

presenting with unexplained lymphadenopathy take into account: fever, night sweats, SOB, pruritus, weight loss or alcohol-induced lymph node pain

Answer 515

presenting with unexplained lymphadenopathy. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus, or weight loss.

Answer 516

nodular other forms spread more slowly

Answer 517

1) Nodular 2) Superficial spreading 3) Lentigo maligna 4) Acral lentiginous

Answer 518

70% of cases Typically= arms, legs, back & chest, young people Appearance= growing mole with diagnostic features

Answer 519

second commonest Sun-exposed skin, middle aged Red or black lump or lump which bleeds or oozes

Answer 520

less common chronically sun exposed skin, older people a growing mole with diagnostic features

Answer 521

rare form nails, palms or soles; people with darker skin pigmentation subungal pigmentation (Hutchinson's sign) or on palms or feet

Answer 522

desmoplastic melanoma, amelanotic melanoma, or melanoma arising in other parts of the body such as ocular melanoma.

Answer 523

The main diagnostic features (major criteria): - Change in size - Change in shape - Change in colour Secondary features (minor criteria) - Diameter >= 7mm - Inflammation - Oozing or bleeding - Altered sensation

Answer 524

- suspicious lesions= excision biopsy: do not biopsy in primary care if suspected or uncertain- refer! - once confirmed= determine whether re-excision of margins is required (Breslow thickness) - sentinel lymph node mapping, isolated limb perfusion and block dissection of regional lymoh node groups should be selectively applied

Answer 525

Lesions 0-1mm thick= 1cm Lesions 1-2mm thick= 1- 2cm (Depending upon site and pathological features) Lesions 2-4mm thick= 2-3 cm (Depending upon site and pathological features) Lesions >4 mm thick= 3cm

Answer 526

the invasion depth of a tumour (Breslow depth)

Answer 527

< 0.75 mm= 95-100% 0.76 - 1.50 mm= 80-96% 1.51 - 4 mm= 60-75% > 4 mm= 50%

Answer 528

The lesion has a weighted 7-point checklist score of 3 or more. Dermoscopy suggests melanoma. There are nail changes, such as a new pigmented line in the nail (especially if there is associated damage to the nail), or a lesion growing under the nail. They have a new persistent skin condition, especially if growing, pigmented, or vascular in appearance and the diagnosis is unclear. There is any doubt about the lesion. A biopsy has confirmed the diagnosis of malignant melanoma. Note: if a lesion is suspected to be melanoma, an excision in primary care should be avoided.

Answer 529

prostate breast lung

Answer 530

spine pelvis ribs skull long bones

Answer 531

bone pain pathological fractures hypercalcaemia raised ALP

Answer 532

breast colorectal renal cell bladder prostate

Answer 533

multiple round well-defined lung secondaries most commonly seen with renal cell ca, may also occur 2 to choriocarcinoma and prostate ca

Answer 534

uncommon except in chondrosarcoma or osteosarcoma

Answer 535

All pts: - FBC, U&E, LFT, calcium, urinalysis, LDH - CXR - CT chest, abdomen and pelvis - AFP and hCG Specific pts: - myeloma screen (if lytic bone lesions) - endoscopy (?symptoms) - PSA (men) - CA125 (women with peritoneal malignancy or ascites) - Testicular US (men with germ cell tumours) - Mammography (features of breast ca)

Answer 536

1) primary site which will guide Tx or 2) non-epithelial malignancy, which can be Tx regardless of primary site or metastatic epithelial or neuro-endrocrien malignancy without an identifiable primary site (diagnosis of provisional CUP- carcinoma of unknown primary)

Answer 537

lymphoma other haem malignancies melanoma sarcoma germ-cell tumours

Answer 538

- tumour markers (but always do AFP and hCG, PSA, CA125 in all pts if relevant) - upper and lower GI endoscopy - mammogram - MRI breast - PET CT eg. if present with cervical lymphadenopathy - Antibodies= CK7, CK20, TTF-1, PLAP, ER, PSA with adenocarcinoma of MUO - Flexible bronchoscopy with biopsy, brushings and washing= present with intrapulmonary nodules and unsuitbale for peercutaneous biopsy - Tissue sample for histology if MUO with ascites

Answer 539

- SCC invl. upper or mid neck nodes - adenocarcinoma invl. axillary nodes - SCC invl. inguinal nodes - solitary mets

Answer 540

multiple mets incl. brain involvement- do not offer chemo unless clinical trial

Answer 541

confirmed CUP with clinical and/or laboratory features of a specific treatable syndrome and adequate performance status.

Answer 542

blastic lytic or mixed

Answer 543

osteoblastic metastatic disease lower risk compared to oestolytic lesions of similar size

Answer 544

lesions affecting peritrochanteric region because of the loading forces at that site

Answer 545

Mirel Scoring system

Answer 546

1 point= upper extremity; blastic radiographic appearance; <1/3 width of bone invloved; mild pain 2 points= lower extremity; mixed; 1/3-2/3; moderate pain 3 points= peritrochanteric; lytic; >2/3; pain aggravated by function

Answer 547

Score 9+= risk of fracture is impending (33%); Tx is prophylactic fixation Score 8= borderline risk; consider fixation Score 7 or less= not impending risk (4%); non-operative Mx

Answer 548

urgent specialist advice within 24hrs; immediate advice if neuro features unless contraindicated (signif suspicion of lymphoma) offer all pt with met spinal cord compression a loading dose of 16mg of dexamethasone asap

Answer 549

identify these pts early before any neuro symptoms develop

Answer 550

- unrelenting lumbar back pain - any thoracic or cervical back pain - worse sneezing, coughing or straining - nocturnal - associated with tenderness - wakes pt up at night

Answer 551

suspect spinal cord compression and act promptly without neuro features= whole spine MRI within 1w (whole spine imaged as pts commonly present with multi-level disease)

Answer 552

multiple myeloma (same thing)

Answer 553

progressive malignant disease characterised by proliferation of abnormal plasma cells in bone marrow and abnormal monoclonal immunoglobulins in the blood

Answer 554

bones kidneys blood immune system

Answer 555

men increases with age

Answer 556

usually incurable but can disease control can be achieved for several yrs

Answer 557

pt has high levels of serum beta-2 microglobin; high plasma cell count; diffuse multiple bone lesions; hypercalcaemia; very high levels of M protein in blood and urine; renal impairment

Answer 558

- Pathological bone fractures. - Spinal cord compression. - Renal damage. - Hypercalcaemia. - Impaired resistance to infection. - Anaemia. - Bleeding disorders. - Hyperviscosity of the blood.

Answer 559

- bone pain, often lower back - fatigue - confusion, muscle weakness, constipation, thirst and polyuria (due to hypercalcaemia) - weight loss - recurrent infection - headache, visual disturbance, cognitive impairment, mucosal bleeding, SOB (due to hyperviscosity of blood) - sensory loss, paraesthesia, limb weakness, walking difficulty, sphincter disturbance (due to spinal cord compression) - occasionally asymptomatic

Answer 560

with abnormalities on blood tests eg: - normochromic, normocytic anaemia - renal impairment - hypercalcaemia - raised ESR, plasma viscosity, serum protein or globulin

Answer 561

arrange FBC, serum Ca and plasma viscosity or ESR

Answer 562

arrange very urgent serum electrophoresis, serum-free light chain assay and Bence-Jones protein urine assessment (within 48hrs)

Answer 563

Consider very urgent serum electrophoresis, serum-free light chain assay, and Bence-Jones protein urine assessment (within 48 hours)

Answer 564

consider additional Ix: peripheral blood film, serum urea, creatinine and electrolytes, liver function tests, and for people with bone pain, X-rays of symptomatic areas (to rule out pathological fractures).

Answer 565

- for people with symptoms of spinal cord compression - if Ix reveal moderate to severe hypercalcaemia (corrected Ca 3.01mmol/L or higher) or AKI

Answer 566

urgent referral to haematologist within 2w for further Ix to confirm

Answer 567

age disease stage prognosis cormorbidities

Answer 568

Bisphosphonates to reduce bone disease and pain. eg. zolendronic acid Treatments for anaemia. eg. erythropoietin analogues or blood transfusion Chemotherapeutic drugs. High-dose drug therapy and stem cell transplantation. Immunomodulatroy drugs eg. thalidominde, lenalidomine and pomalidomide + DVT prophylaxis (aspirin or LMWH) Steroids eg. prednisolone or dexamthasone

Answer 569

bone pain, abdominal pain, depression, confusion, muscle weakness, constipation, thirst, and polyuria

Answer 570

pathological fractures and recurrent infection

Answer 571

may be normal Hepatomegaly — present in about 4% of people. Splenomegaly — present in about 1% of people. Lymphadenopathy — present in about 1% of people.

Answer 572

- depression - osteoarthritis - DM - polymyalgia rheymatica - MGUS - Waldenstrom's macroglobulinaemia - Osteosclerotic myeloma - AL amyloidosis - heavy chain disease - NHL - plasma cell leukaemia

Answer 573

Clinical features include hyperviscosity syndrome, organomegaly, and lymphadenopathy presenting in a person with an average age of 65 years. (differential for myeloma)

Answer 574

Clinical features include fatigue, weight loss, hepatomegaly, macroglossia, chronic kidney disease, heart failure, postural hypotension, carpal tunnel syndrome, and peripheral neuropathy.

Answer 575

Clinical features include weakness, fatigue, fever, lymphadenopathy and hepatosplenomegaly, with a portion of the immunoglobulin heavy chain in the serum and/or urine.

Answer 576

Clinical features include bone pain, fatigue, recurrent infection, mucosal bleeding, hypercalcaemia, renal impairment, hepatomegaly, and splenomegaly.

Answer 577

(polyneuropathy, organomegaly, endocrine disease, M protein in the blood, and skin lesions [POEMS] syndrome) Clinical features include marked polyneuropathy with widespread neurological involvement, hepatomegaly, splenomegaly, sclerotic bone lesions, endocrine disease which might manifest as gynaecomastia, M protein in the blood, and skin lesions.

Answer 578

in 1-5% who have a 'non-secretory' form of the disease that produces no serum M protein or urinary Bence-Jones protein.

Answer 579

Back pain/unexplained fracture= FBC, serum Ca, plasma viscosity or ESR Hypercalcaemia/leukopenia + CP consistent= Very urgent (within 48 hours) serum electrophoresis, serum-free light-chain assay, and Bence-Jones protein urine assessment. Additional to confirm: - peripheral blood film - serum urea, creatinine, electrolytes and LFTs - X-rays if bone pain

Answer 580

rouleaux (aggregations of red blood cells), which might suggest underlying paraproteinaemia.

Answer 581

detect renal impairment, raised uric acid from increased tumour cell turnover, and to determine total protein concentration, which is usually raised in multiple myeloma.

Answer 582

- immunofixation of serum & urine= confirm presence of paraprotein - bone marrow aspirate and trephine biopsy, with plasma cell phenotyping= confirm the presence of monoclonal plasma cells in the bone marrow. - MRI GOLD to confirm extent of myeloma bone disease; CT if contraindicaated -- Estimate tumour burden and prognosis= FISH analysis of bone marrow aspirate; Serum beta-2 microglobulin concentration; next-generation DNA sequencing.

Answer 583

Symptomatic (active)= at least every 3m Asymptomatic (smouldering)= every 3m for 1st 5yrs then depends on long-term stability of the disease

Answer 584

aminoglycosides due to risk of renal toxicity

Answer 585

cyclosphoshamide, doxirubicin, carfilozmib, bortezombin or melphalan

Answer 586

when symptoms become refractory to Tx Bone pain. Renal failure. Bone marrow failure. Infection — infection is a common cause of death in people with multiple myeloma. Increasing fatigue. Anorexia and weight loss. Changes in communication, deteriorating mobility or performance status, or social withdrawal.

Answer 587

difficult to predict, may go through multiple lines of Tx and experience periods of relapse and remission. after each line of Tx, chance of remission decreases movement from stable to late stage disease can be rapid

Answer 588

genetic mutations that occur as B-lymphocytes differentiate into mature plasma cells

Answer 589

Old CRABBI Old= age at presentation C.alcium= hypercalcaemia R.enal impairment A.naemia B.leeding= thrombocytopenia B.one lytic lesions I.nfection= more susceptible other= amyloidosis (eg. macroglossia), carpal tunnel, neuropathy, hyperviscosity

Answer 590

increased osteoclastic bone resorption caused by local cytokines (eg. IL-1, tumour necrosis factor) released by myeloma cells also less commonly: impaired renal function, increased renal tubular calcium resabsorption and elevated PTH-rP levels

Answer 591

hypercalcaemia

Answer 592

monoclonal production of immunoglobulins results in light chain deposition within the renal tubules causes renal damage which presents as dehydration and increasing thirst other causes in myeloma: amyloidosis, nephrocalcinosis, nephrolithiasis

Answer 593

bone marrow crowding suppresses erythropoiesis leading to anaemia fatigue and pallor

Answer 594

bone barrow crowding results in thrombocytopenia which puts pts at risk of bleeding and bruising

Answer 595

bone marrow infiltration by plasma cells and cytokine-mediated osteoclast overactivity creates bone lytic lesions may present as pain (esp in back) and increases risk of pathological fractures

Answer 596

a reduction in normal production of immunoglobulins

Answer 597

- bloods= FBC (anaemia), peripheral blood film (rouleaux formation), U&E (renal failure), bone profile (hypercalcaemia) - protein electrophoresis= raised conc of monoclonal IgA/IgG in serum; in urine they are known as Bence Jones proteins - bone marrow aspiration= plasma cells signif raised- confirms diagnosis - whole body MRI and X-rays. X-rays= 'rain drop skull' (random pattern of dark spots; very similar to pepperpot skull in hyperparathyroidism)

Answer 598

one major and one minor criteria or three minor criteria in an individual who has signs or symptoms of multiple myeloma. Major criteria: - Plasmacytoma (as demonstrated on evaluation of biopsy specimen) - 30% plasma cells in a bone marrow sample - Elevated levels of M protein in the blood or urine Minor criteria - 10% to 30% plasma cells in a bone marrow sample. - Minor elevations in the level of M protein in the blood or urine. - Osteolytic lesions (as demonstrated on imaging studies). - Low levels of antibodies (not produced by the cancer cells) in the blood.

Answer 599

control symptoms, reduce Cx and prolong survival

Answer 600

whether a patient may be suitable for autologous hematopoietic cell transplantation or not.

Answer 601

involves the removal of a patient's own stem cells prior to chemotherapy, which are then replaced after chemotherapy prolong both event-free and overall survival when compared with non-transplant strategies typically it is younger, healthier patients who are suitable for stem cell transplantation and rigorous chemotherapy regimes.

Answer 602

not commonly due to high rates of overall mortality and symptoms of graft-versus-host disease. It is currently only used as part of clinical trials when treating multiple myeloma.

Answer 603

autologous= transplant from same person who will get the transplant allogenic= from someone else eg. matched relative or unrelated donor

Answer 604

pain: treat with analgesia (using the WHO analgesic ladder) pathological fracture: zoledronic acid is given to prevent and manage osteoporosis and fragility fractures as these are a large cause of morbidity and mortality, particularly in the elderly. infection= receive annual influenza vaccinations they may also receive Immunoglobulin replacement therapy. VTE prophylaxis fatigue= treat all possible underlying causes, if symptoms persist consider an erythropoietin analogue.

Answer 605

extradural compression- usually due to vertebral body mets

Answer 606

lung, breast and prostate

Answer 607

back pain may be worse lying down and coughing

Answer 608

- back pain - lower limb weakness - sensory loss and numbness - neuro signs depend on level of lesion

Answer 609

UMN signs in legs and a sensory level

Answer 610

LMN signs in legs and perianal numbness

Answer 611

tend to be increased below the level of the lesion and absent at the level of lesion

Answer 612

urgent (within 24hrs of presentation) whole MRI spine

Answer 613

high dose oral dexamethasone urgent oncology assessment to consider radiotherapy or surgery

Answer 614

adenocarcinoma

Answer 615

those with Hx of GORD or Barrett's

Answer 616

A= most common type in UK/US SCC= most common type in developing world

Answer 617

A= lower third, near the gastroesophageal junction SCC= upper 2/3rds of oesophagus

Answer 618

A= GORD; Barrett's; smoking; obesity SCC= smoking, alcohol, achalasia; Plummer-Vinson syndrome; diets rich in nitrosamines

Answer 619

- dysphagia (most common): progressive - anorexia and weight loss - vomiting - odynophagia, hoarseness, malaena, cough

Answer 620

- Upper GI endoscopy with biopsy - Endoscopic USS for locoregional staging - CT chest, abdo and pelvis for initial staging: laparoscopy can be used to detect occult peritoneal disease; FDG-PET CT may be used for occult mets if mets not seen on initial CT

Answer 621

surgical resection- most common procedure is Ivor-Lewis type oesophagectomy

Answer 622

surgical resection if possible may need adjuvant chemo

Answer 623

anastomotic leak, with an intrathoracic anastomosis resulting in mediastinitis

Answer 624

Epithelial ca (90%)= serous, mucinous, endometroid, clear cell, transitional cell and squamous Non-epithelial (10%)= germ cell tumours, sex cord/stromal cell

Answer 625

Serous epithelial ca

Answer 626

ca of endometrium, breast and GI tract

Answer 627

intraperitoneal structures and organs (causing intestinal obstruction and cachexia), liver, para-aortic lymph nodes and the lungs (causing pleural effusions)

Answer 628

- high no. of pregnancies - breastfeeding - COCP

Answer 629

any persistent or frequent (>12x per month): - abdo distension (bloating) - feeling full (early satiety) and/or loss of appetite - pelvic or abdo pain - increased urinary urgency and/or frequency - symptoms suggestive of IBS within last 12m if >50yrs - unexplained symptoms: - weight loss - malaise or fatigue - change in bowel habit - abnormal or postmenopausal bleeding - GI symptoms= dyspepsia, nausea and bowel obstruction - SOB (due to pleural effusion)

Answer 630

- exam abdo and pelvis - if normal then CA125

Answer 631

urgent referral

Answer 632

urgent USS of abdo and pelvis arranged and urgent referral if this is suggestive of ovarian ca if USS and CA125 suggest ovarian ca then perform CT pelvis and abdo to establish extent of disease; + thorax if indicated

Answer 633

consider other causes of symptoms

Answer 634

due to late diagnosis

Answer 635

distal end of fallopian tube

Answer 636

- FHx= mutations of BRCA1 or BRCA2 gene - many ovulations= early menarche, late menopause, nulliparity eg. when have 'more' ovulations

Answer 637

?ovarian ca

Answer 638

35 IU/mL or greater

Answer 639

ovarian ca endometriosis menstruation benign ovarian cysts other conditions

Answer 640

NO not very specific

Answer 641

difficult, usually involves diagnostic laparotomy

Answer 642

usually combination of surgery and platinum-based chemo

Answer 643

- 80% have advanced disease at presentation - 5yr survival is <35%

Answer 644

AFP and beta-hCG

Answer 645

Confirm tissue diagnosis by histology by laparotomy or if surgery not been performed can use percutaneous image guided biopsy if feasible

Answer 646

1) retroperitoneal lymph node assessment + optical surgical staging (surgery- resection) 2) Adjuvant if high risk stage I disease (grade 3 or stage Ic)= 6 cycles of carboplatin

Answer 647

optical surgical staging involves= midline laparotomy; total abdo hysterectomy; bilateral salpingo-oophorectomy or infracolic omentectomy; biopsies of any peritoneal deposits, random biopsies of plevis and abdo peritoneal

Answer 648

1) primary surgery= complete resection of all macroscopic disease 2) chemo after surgery (debulking surgery with adjuvant chemo) or chemo before and after (neoadjuvant chemo and interval debulking surgery)

Answer 649

adenocarcinoma

Answer 650

head of the pancreas

Answer 651

late as non-specific

Answer 652

- age - smoking - DM - chronic pancreatitis (but alcohol is not independent RF) - hereditary non-polyposis colorectal carcinoma - multiple endocrine neoplasia - BRCA2 gene - KRAS gene mutation

Answer 653

pancreatic ca

Answer 654

- painless jaundice= pale stools, dark urine, pruritus, cholestatic LFTs - abdo masses: hepatomegaly, gallbladderm epigastric mass - non-specific: anorexia, weight loss, epigastric pain - loss of exocrine function eg. steatorrhoea - loss of endocrine function eg. DM - atypical back pain - migratory thrombophlebitis (Trousseaus sign)

Answer 655

cholestatic LFTs

Answer 656

- hepatomegaly= due to mets - gallbladder= Courvoisier's law - epigastric mass= from primary tumour

Answer 657

Courvoisier's law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones

Answer 658

paraneoplastic syndrome that can be associated with pancreatic cancer Recurrent episodes of thrombophlebitis in the upper and lower limbs, thoracic and abdominal wall, and major blood vessels of the abdomen. Due to coagulopathy associated with underlying malignancy.

Answer 659

- high-resolution CT scanning Ix of choice - can do USS 'double duct' sign on imaging

Answer 660

pancreatic ca presence of simultaneous dilation of the common bile and pancreatic ducts

Answer 661

<20% suitable for surgery at time of diagnosis - Whipple's resection (pancreaticoduodenectomy)= for resectable lesions in head of pancreas - Adjuvant chemo following surgery - ERCP with stenting used for palliation

Answer 662

dumping syndrome and peptic ulcer disease

Answer 663

diarrhea, nausea, and feeling light-headed or tired after a meal, that are caused by rapid gastric emptying. Rapid gastric emptying is a condition in which food moves too quickly from your stomach to your duodenum. Cx of Whipple's

Answer 664

1 or more than 1 of: gemcitabine capecitabine fluorouracil (5FU) irinotecan oxaliplatin nab-paclitaxel (Abraxane) cisplatin

Answer 665

abnormal bone due to insignificant injury

Answer 666

- metastatic tumours - bone disease= osteogenesis imperfecta; osteoporosis; metabolic bone disease; Paget's disease - local benign conditions= chronic osteomyelitis; solitary bone cyst - primary malignant tumours

Answer 667

breast lung thyroid renal prostate

Answer 668

chondrosarcoma osteosarcoma Ewing's tumour

Answer 669

lump, changes to skin or nipple, change in shape, discharge

Answer 670

persitent cough, haemoptysis, chest pain, SOB, non-resolving LRTI

Answer 671

nocturia, hesitancy, incomplete bladder emptying

Answer 672

PR bleeding, change in bowel habit, abdo pain, tenesmus

Answer 673

unexplained weight loss, fall in appetite, decreased energy levels, back pain, night sweats, unexplained anaemia, change in bowel habit (esp in elderly)

Answer 674

Presentation and age Comorbidities WHO Performance status – indicator of patient’s fitness Biopsy findings – endoscopy, histological type Radiological findings – CT, MRI, PET TNM staging for each tumour type : Tumour Nodes Metastases Radical or Palliative Intent? Surgical or Non Surgical Management? Treatment plan based on patient’s wishes Referral to appropriate team

Answer 675

0 Fully active, able to carry on all pre-disease performance without restriction 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work 2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours 3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours 4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair

Answer 676

aim to cure

Answer 677

therapy given before surgery/radiotherapy to shrink cancer down, improve outcome of resection and reduce risk of recurrence

Answer 678

aimed at reducing risk of local recurrence or distant recurrence by treating micrometastatic disease can be chemo, radio, immuno ect.

Answer 679

not curative, but aimed at improving quality of life and survival

Answer 680

- cytotoxic therapy - targeted therapy - endocrine therapy - immunotherapy - bisphosphonates

Answer 681

multiple classes of agents all affect cell cycle in some way cytotoxic agents- cause cell death

Answer 682

Tamoxifen and aromatase inhibitors for breast ca Prostate= GNRH analogues eg. zoladex

Answer 683

Act on different parts of the pathway/cascade which lead to cell proliferation, growth, transformation, angiogenesis and invasion Aim is to inhibit the pathway at various points to stop the stimulus to the cancer and cause apoptosis

Answer 684

using pts own immune system to kill ca caused activation of T cells that recognise and kill ca cells eg. ipilimumab for metastatic melanoma as lung ca autoimmune toxicities (colitis most common) which can be multisystem (as uses immune system)

Answer 685

Ionising radiation= xrays (or gamma rays); xrays can directly break DNA bonds used to damage ca cells, whose repair mechanisms are inadequate end result is cell death different dose depths dependent on energy

Answer 686

Use maximum dose for tumour control Whilst minimising dose to normal surrounding tissue

Answer 687

- IMRT - SABR

Answer 688

Stereotactic ablative body radiotherapy: - Liver - Lung - Prostate - Oligometastases: lymph nodes, spine, adrenals, bone Precise irradiation with a higher radiation dose per fraction Highly conformal dose delivery with steep dose gradients Immobilisation - Passive - 4DCT, breathing control - Active - motion tracking, compression OARs

Answer 689

produce tightly conformal plans with concave structures; needs excellent immobolisation and image guidance to allow reduced margins and reduced dose to organs at risk, while maintaining or increasing doses to the tumour

Answer 690

fatigue, nausea and vomiting, mucositis, myelosuppression, sepsis, impact on renal and liver function, alopecia, taste change, unstable BMs, blood clots, infertility, allergic reactions Some chemo agents will have a greater risk of nephrotoxicity and cardiotoxicity

Answer 691

can be multisystem inflammation, including endocrine disturbance. Usually treated with high dose steroids – SPEAK TO AOS team early

Answer 692

LOCALISED treatment and side effects are dependent on the anatomical site being treated. Subdivided into acute and late side effects. (depends on structures around area trying to treat)

Answer 693

Dexamethasone with chemo Granisetron iv (5-HT3 antagonist), PRN Ondansetron, metoclopramide Haloperidol and Levomepromazine if above fail IV fluids as needed

Answer 694

Really important to check it is not immunotherapy treatment first Loperamide, codeine – don’t always wait for MC&S stool Significant risk with 5FU/Capecitabine

Answer 695

Esp. if on 5HT3 antagonists (ondansetron) Laxatives, enema Consider bowel obstruction

Answer 696

Difflam, Bioxtra gel, analgesia Mucositis

Answer 697

5FU/Capecitabine can causes coronary spasm-chest pain/ bradycardias See UKONS for Ix and management.

Answer 698

nibs” Sunitinib Pazopanib Tivozanib SIDE EFFECTS ARE VARIED …all of them cause fatigue and GI toxicity Tyrosine Kinase Inhibitors – diarrhoea, HTN (some), hepatitis, hypothyroidism (some), QT prolongation, less likely bone marrow suppression(but may be if used in combination i.e. dabrafanib and trametinib)

Answer 699

Hepatitis Nephritis Colitis Pneumonitis MYOCARDITIS Skin, joints Hypophysitis…. But can affect any organ

Answer 700

Grade 1 – observe/monitor Grade 2 – oral Pred 1mg/kg Grade 3- 4 – IV Methyl pred If already on steroids, go back up to previous dose; if not weaning d/w specialty of organ and start additional immunosuppression – MMF, Infliximab

Answer 701

- Metastatic Spinal Cord Compression (MSCC) - Hypercalcaemia - SVC Obstruction - Seizure - Venous or Arterial - Thromboembolism - Pleural Effusion - Bowel Obstruction

Answer 702

Sepsis with neutrophils <1.0 may present with fever alone, with no obvious source chemo hotline in all ca centres door to needle time <1hr ie to delivery of Abx early discussion with on call oncology team esp if organ failure high risk regimens- prophylactic GCSF

Answer 703

Gram positive bacteraemia 70%: Staphylococcus aureus Coagulase-negative staphylococcus alpha and beta haemolytic streptococcus Gram negative bacteraemia 30%: Escherichia coli Klebsiella pneumoniae Pseudomonas aeruginosa Fungi: Candida , Aspergillus

Answer 704

ABCDE Must be given the first dose of IV Abx within one hour of presentation Do not wait for FBC or culture results before giving first dose. Piperacillin/Tazobactam (Tazocin) 4.5g QDS + Gentamicin (dose according to STHFT gentamicin chart) +/- Vancomycin - if line infection suspected (as per vancomycin dosing guidelines) See local guidelines for penicillin allergy, renal impairment Need to know local Trust policy – not always the same AB

Answer 705

1) Temperature + observations + calculate Early Warning Score (NEWS) 2) Urgent bloods: FBC, Clotting, blood cultures (peripheral +/- CVAD), U&E, LFT, CRP and serum lactate. 3) Urgent medical review and clinical examination. Assess for symptoms and signs of infection. Assess any lines (e.g., Portacath, Hickman line) History: chemo and timings, allergies, previous episodes 4) Micro/virology specimens as clinically indicated (e.g. CVAD exit site, sputum, urine, throat swab). 5) CXR if respiratory symptoms, signs or hypoxia. 6) Consider septic shock and need for fluid challenge. (EARLY) 7) Monitor fluid balance but do not catheterise routinely due to risk of infection. Do not routinely PR/PV – risk of bacteraemia 8) If Oxygen saturations less than 95% consider appropriate oxygen administration.

Answer 706

1)Monitor (NEWS) (4 hourly minimum, increase if indicated) 2) Record fluid intake and output 3) Arrange repeat blood tests including FBC, U&E’s, CRP + Gentamicin/Vancomycin levels if required. 4) Minimum once daily clinical team review Seek advice: 1) Discuss with senior member of the oncology on-call team (SpR or Consultant) via switch board or AOS team 2) Discuss and document appropriate level of escalation of care (e.g. HDU, active treatment on ward) 3) Discuss need for other treatments e.g. G-CSF.

Answer 707

Spinal cord ends at around L1 in adults Above this level – spinal cord compression Below this – cauda equina Can be caused by: Vertebral metastases Soft tissue mass Retropulsed bony fragment due to fracture WORSENING BACK PAIN is a LATE SIGN. Do NOT wait for the neurological deficit, especially in a patient known to have cancer

Answer 708

Back pain, radicular pain Common in prostate/breast/lung cancers Limb weakness – progressive, can be sudden Sensory level Bladder/bowel dysfunction Anal tone ↓

Answer 709

MRI WHOLE SPINE

Answer 710

Once established neurology- 24h to surgery or radiotherapy - Steroids (dexamethasone 8mg BD with PPI and monitor BMs) - Same day MRI scan (including out of hours) - Urgent discussion with oncology and spinal surgeons - Surgical decompression/stabilisation vs radiotherapy

Answer 711

hypercalcaemia

Answer 712

bone mets production of ectopic PTHrp (parathyroid hormone related peptide) by ca- esp SCC

Answer 713

rehydrate- manage AKI IV bisphosphonates (zolendronate, pamidronate) manage the cause if possible- treat the ca

Answer 714

bones, moans, stones, abdo groans

Answer 715

the venous drainage for the head, neck, upper limbs and the upper thorax

Answer 716

collateral pathways form to provide an alternative route for blood to return to the right atrium

Answer 717

- inside the vessel= thrombus or intravascular device - inside the vessel wall= direct tumour invasion - outside the vessel= tumour, lung ca, lymphoma

Answer 718

- dyspnoea - chest pain, often at rest - cough - neck and face swelling - arm swelling - others= dizziness, headache, visual disturbance, nasal stuffiness, syncope

Answer 719

- dilated veins over arms, neck and anteroir chest wall - oedema of upper torso, arms, neck and face - severe resp distress - cyanosis - engorged conjunctiva - convulsions and coma

Answer 720

- may be clinical diagnosis - CXR (widened mediastinum or mass on right side of heart) - May be incidental finding on CT - CTPA to define tumour extent, site of occlusion or stenosis and extent of any thrombus

Answer 721

- elevation of the head and oxygen therapy- symptomatic relief - high dose steroids if acute - endovascular stenting - consider: radio; chemo (esp in chemo-sensitive tumours eg small cell lung ca; anticoag if central vein thrombosis is present

Answer 722

- anti-inflamm/tumour effects: spinal cord compression, SVCO, brain mets (reduces oedema) ect - symptom control eg. appetite/sickness - immunotherapy related effects

Answer 723

- always check if they were taking at admission - blood glucose monitoring QDS as inpatient for all - any pts discharged on steroids needs a BM monitoring kit - all pts need gastro-protection - refer to hyperglycaemia guidlines and do diabetic nurse referral on ICE if any issues with control/starting diabetes meds

Answer 724

consider CAUSE chemo related= metoclopramide/ondansetron obstruction= avoid prokinetics, consider cyclizine/steroids instead, NBM, fluids, ryles tube brain mets= steroids, remeber metoclopramide CI in epilepsy, give alternative

Answer 725

metoclopramide and cylixine DO NOT prescribe together

Answer 726

haloperidol, olanzapine, levomepromazine

Answer 727

metoclopramide

Answer 728

brain mets primary CNS ca

Answer 729

treat like any other- lorazepam if not self-terminating, commence keppra CT initially then MRI start steroids if known brain tumour, pending scan (8mg BD, reducing over next few days to 2-4mg per day depending on neuro symptoms) consider referral to neurosurgeons (refer a pt) and add to neuro oncology MDT

Answer 730

tumour, recent steroids

Answer 731

bone mets, SCC lung

Answer 732

chemo, bisphosphonates, refeeding

Answer 733

renal failure, tumour lysis syndrome

Answer 734

chemo, refeeding, diarrhoea

Answer 735

chemo, refeeding, EGFR inhibitor

Answer 736

clinical guidelines

Answer 737

- LOW THRESHOLD to consider doppler, CTPA - check clotting/platelets before LMWH - VTE referral - start LMWH in acute setting before switching to DOAC later (as some ca pts can't have DOACs

Answer 738

DOACs= GI infiltration, rectal tumours that are bleeding, varices

Answer 739

if urgent, admit, US guided drain, check clotting (?does pt need restaging CT) if non urgent, can request as elective for future date malignant ascites can keep drain in for up to 30d, HAS not required

Answer 740

ask acute oncology team for advice

Answer 741

malignant tumour of prostate

Answer 742

adenocarcinomas

Answer 743

the different foci may be caused by different genetic mutations, which can differ greatly in growth rate and ability to metastasize

Answer 744

indolest and grow slowly- minority are aggressive and invade local structures or metastasise to remote tissues

Answer 745

in outer zone of prostate where it rarely causes symptoms

Answer 746

extends beyond the capsule of prostate and is often asymptomatic when diagnosed

Answer 747

bones- causes pain and fragility fractures

Answer 748

age black ethnicity FHx

Answer 749

unexplained... - lower back or bone pain - lethargy - erectile dysfunction - haematuria - anorexia/weight loss

Answer 750

- digital rectal exam (DRE) - prostate-specific antigen (PSA) test

Answer 751

suspected ca pathway= if prostate hard and nodular on DRE or benign enlargement consider suspected ca pathway if= PSA level above threshold for age (eg. >4.5 in pt 60-69yrs)

Answer 752

- watchful waiting= older men, slowly progressing tumour, multiple co-morbidities, low Gleason score - Active surveillance= early prostate ca to avoid over treatment (as ca unlikely to cause harm). Involves prostate biopsy at intervals and PSA. Particularly suitable for men with clinical stage T1c, Gleason score 3+3 and PSA density < 0.15 ng/ml/ml who have cancer in less than 50% of their biopsy cores, with < 10 mm of any core involved. - Radical treatements= radical prostatectomy; external beam radiotherapy; or brachytheraoy - Adjunctive and palliative= hormone therapy; chemo (for hormone relapsed metastatic disease); bisphosphonates if taking androgen deprivation therapy and have osteoporosis

Answer 753

- androgen deprivation (lowers testosterone)= bilateral orchidectomy or LHRH agonists eg. goserelin or antagonists eg. degarelix - androgen blockage= eg. cyproterone acetate, bind and block to hormone receptors of ca cells so preventing androgens stimualting growth

Answer 754

luteninizing horomone releasing hormone agonists

Answer 755

- docetaxel + prednisolone - cabazitaxel + pred (2nd line) - 3rd line: dexamethasone

Answer 756

Hot flushes= medroxyprogesterone acetate 20mg od 10w Fatigue= supervised resistance and aerobic exercise twice a w for 12w Osteoporosis= bisphosphonates Gynaecomastia= if long-term bicalutamide monotherapy (>6m) refer for prophylactic radio to both breast buds within 1st month of Tx

Answer 757

phosphodiesterase-5 (PDE-5) inhibitor eg. sildenafil

Answer 758

- PSA - Digital rectal exam - multiparametric MIR (1st line) or trans rectal USS (+/-) biopsy (2nds line) - MRI/CT and bone scan for staging

Answer 759

Gleason grading system, two grades awarded 1 for most dominant grade (on scale of 1-5) and 2 for second most dominant grade (scale 1-5). The two added together give the Gleason score. Where 2 is best prognosis and 10 the worst.

Answer 760

occurs first to the obturator nodes and local extra prostatic spread to the seminal vesicles is associated with distant disease.

Answer 761

have had at least 10 biopsy cores taken have at least one re-biopsy.

Answer 762

localised often asymptomatic - bladder outlet obstruction: hesitancy, urinary retention haematuria, haematospermia pain: back, perineal or testicular digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus

Answer 763

sepsis: 1% of cases pain: lasting >= 2 weeks in 15% and severe in 7% fever: 5% haematuria and rectal bleeding

Answer 764

multiparametric MRI: results reported using a 5-point Likert scale

Answer 765

results from multiparametic MRI are reported using a 5-point Likert scale If the Likert scale is >=3 a multiparametric MRI-influenced prostate biopsy is offered If the Likert scale is 1-2 then NICE recommend discussing with the patient the pros and cons of having a biopsy.

Answer 766

erectile dysfunction

Answer 767

develop proctitis and are also at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer

Answer 768

e.g. Goserelin (Zoladex) paradoxically result in lower LH levels longer term by causing overstimulation, resulting in disruption of endogenous hormonal feedback systems. The testosterone level will therefore rise initially for around 2-3 weeks before falling to castration leves initially therapy is often covered with an anti-androgen to prevent a rise in testosterone - 'tumour flare'. The resultant stimulation of prostate cancer growth may result in bone pain, bladder obstruction and other symptoms

Answer 769

non-steroidal anti-androgen blocks the androgen receptor

Answer 770

steroidal anti-androgen prevents DHT binding from intracytoplasmic protein complexes used less commonly since introduction of non-steroidal anti-androgens

Answer 771

androgen synthesis inhibitor option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated

Answer 772

used to rapidly reduce testosterone levels

Answer 773

serine protease enzyme produced by normal and malignant prostate epithelial cells

Answer 774

40 Use clinical judgement 40–49 > 2.5 50–59 > 3.5 60–69 > 4.5 70–79 > 6.5 > 79 Use clinical judgement

Answer 775

- BPH - prostatitis and UTI (NICE recommend to postpone the PSA test for at least 6 weeks after treatment) - ejaculation (ideally not in the previous 48 hours) - vigorous exercise (ideally not in the previous 48 hours) - urinary retention - instrumentation of the urinary tract

Answer 776

urgent urology referral (using suspected ca pathway)

Answer 777

tumour markers= AFP, hCG, LDH

Answer 778

testicular

Answer 779

germ-cell tumours

Answer 780

seminomas non-seminomas: including embryonal, yolk sac, teratoma and choriocarcinoma

Answer 781

Leydig cell tumours Sarcomas

Answer 782

T= 25yrs S= 35yrs

Answer 783

- infertility (x3 increase risk) - cryptorchidism - FHx - Klinefelter's syndrome - mumps orchitis

Answer 784

- painless lump (most common) - pain (minority) - hydrocele - gynaecomastia

Answer 785

due to increased oestrogen:androgen ratio germ-cell tumours → hCG → Leydig cell dysfunction → increases in both oestradiol and testosterone production, but rise in oestradiol is relatively greater than testosterone leydig cell tumours → directly secrete more oestradiol and convert additional androgen precursors to oestrogens

Answer 786

seminomas= hCG may be elevated in 20% non-seminomas= AFP and/or beta-hCG elevated in 80-85% LDH elevated in 40% germ cell tumours

Answer 787

depends if tumour is seminoma or non-seminoma orchidectomy chemo and radio may be given depending on staging and tumour type

Answer 788

generally excellent Seminomas= 5yrs survival 95% if stage I Teratomas= 85% if stage I

Answer 789

group of tumours that originate from germ cells- cells responsible for developing into sperm or eggs germ cells normally migrate to gonads (testes/ovaries) during fetal development but can sometimes remain in other parts of body= potential for tumour development (reproductive organs and other areas)

Answer 790

Seminomas and early-stage germ cell tumors= tend to have a high cure rate with appropriate treatment, often exceeding 90%. Non-seminomas, particularly those that are advanced or spread (metastatic), can be more challenging to treat but still have good outcomes with modern chemotherapy regimens.

Answer 791

preg= young, female, amenorrhoea obstruction= Hx malignany/prev surgery; vomiting; not opened bowel recently; tinkling bowel sounds ascites= Hx of alcohol excess, cardiac failure urinary retention= Hx of prostate problems; dullness to percussion around suprapubic area ovarian ca= older female, pelvic pain, urinary symptoms (urgency), raised CA125, early satiety, bloating

Answer 792

Develop from a whole lobule Mobile, firm, smooth breast lump - a 'breast mouse' 12% of all breast masses Over a 2 year period up to 30% will get smaller No increase in risk of malignancy If >3cm surgical excision is usual

Answer 793

umbrella term, typically includes: - oral cavity ca - ca of the pharynx (incl oropharynx, hypopharynx, nasopharynx) - ca of the larynx

Answer 794

neck lump hoarseness persistent sore throat persistent mouth ulcer

Answer 795

aged 45yrs+ with: - persistent unexplained hoarseness or - unexplained lump in neck

Answer 796

- unexplained ulceration in oral cavity lasting more than 3w or - persistent and unexplained lump in the neck

Answer 797

- lump on the lip or in the oral cavity or - red or red and white patch in oral cavity consistent with erythroplakia or erythroleukoplakia

Answer 798

unexplained thyroid lump

Answer 799

testicular torsion= most common around puberty irreducible inguinal hernia= most common in children <2yrs epididymitis= rare in prepubescent children

Answer 800

heterogenous texture with occasional ectopic tissue such as hair

Answer 801

Sheet like lobular patterns of cells with substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen.

Answer 802

Teratoma Yolk sac tumour Choriocarcinoma Mixed germ cell tumours (10%)

Answer 803

Commonest subtype Average age at diagnosis = 40 Even advanced disease associated with 5 year survival of 73%

Answer 804

Younger age at presentation =20-30 years Advanced disease carries worse prognosis (48% at 5 years) Retroperitoneal lymph node dissection may be needed for residual disease after chemotherapy

Answer 805

AFP usually normal HCG elevated in 10% seminomas Lactate dehydrogenase; elevated in 10-20% seminomas (but also in many other conditions)

Answer 806

AFP elevated in up to 70% of cases HCG elevated in up to 40% of cases Other markers rarely helpful

Answer 807

S= germ cells that are undifferentiated N-S= germ cells that are differentiated into various tissues

Answer 808

S= slow growing; may elevate b-hCG but normal AFP; highly sensitive to radio and chemo; excellent prognosis; subtypes= classic and spermatocytic seminoma N-S= faster growing & more aggressive; often elevated AFP and b-hCG; less sensitive to radio; treated with chemo; prognosis good but worse than S and varies with stage and subtype; sybtypes= embryonal carcinoma, yolk sac tumour, choriocarcinoma, teratoma

Answer 809

Aflatoxin (produced by Aspergillus)= Liver (hepatocellular carcinoma) Aniline dyes= Bladder (transitional cell carcinoma) Asbestos= Mesothelioma and bronchial carcinoma Nitrosamines= Oesophageal and gastric cancer Vinyl chloride= Hepatic angiosarcoma

Answer 810

- anxiety - <50yrs - concurrent use of opioids - type of chemo used

Answer 811

low risk of N&V= metoclopramide high risk of symptoms= 5HT3 receptor antagonists such as ondansetron are often effective, especially if combined with dexamethasone

Answer 812

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

Answer 813

haemorrhagic cystitis: incidence reduced by the use of hydration and mesna myelosuppression transitional cell carcinoma

Answer 814

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

Answer 815

Alkylating agents= cyclophosphamide Cytotoxic antibodies= bleomycin, anthracyclines (eg. doxorubicin) Antimetabolites= methotrexate, fluorouracil (5-FU), 6-mercaptopurine, cytarabine Acts on microtubules= vincritine, vinblastine, docetaxel Topoisomerase inhibitors= irinotecan Other= cisplatin, hydroxyurea (hydroxycarbamide)

Answer 816

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

Answer 817

Degrades preformed DNA Lung fibrosis

Answer 818

Stabilizes DNA-topoisomerase II complex inhibits DNA & RNA synthesis Cardiomyopathy

Answer 819

Inhibits dihydrofolate reductase and thymidylate synthesis Myelosuppression, mucositis, liver fibrosis, lung fibrosis

Answer 820

Pyrimidine analogue inducing cell cycle arrest and apoptosis by blocking thymidylate synthase (works during S phase) Myelosuppression, mucositis, dermatitis

Answer 821

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

Answer 822

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

Answer 823

Inhibits formation of microtubules Vincristine: Peripheral neuropathy (reversible) , paralytic ileus Vinblastine: myelosuppression

Answer 824

Prevents microtubule depolymerisation & disassembly, decreasing free tubulin Neutropaenia

Answer 825

Inhibits topoisomerase I which prevents relaxation of supercoiled DNA Myelosuppression

Answer 826

Causes cross-linking in DNA Ototoxicity, peripheral neuropathy, hypomagnesaemia

Answer 827

Inhibits ribonucleotide reductase, decreasing DNA synthesis Myelosuppression

Answer 828

- Autosomal dominant - Consists of germline mutations to p53 tumour suppressor gene - High incidence of malignancies particularly sarcomas and leukaemias - Diagnosed when: *Individual develops sarcoma under 45 years *First degree relative diagnosed with any cancer below age 45 years and another family member develops malignancy under 45 years or sarcoma at any age

Answer 829

- Carried on chromosome 17 (BRCA 1) and Chromosome 13 (BRCA 2) - Linked to developing breast cancer (60%) risk. - Associated risk of developing ovarian cancer (55% with BRCA 1 and 25% with BRCA 2). - BRCA2 mutation is associated with prostate cancer in men

Answer 830

Autosomal dominant Develop colonic cancer and endometrial cancer at young age 80% of affected individuals will get colonic and/ or endometrial cancer High risk individuals may be identified using the Amsterdam criteria

Answer 831

Three or more family members with a confirmed diagnosis of colorectal cancer, one of whom is a first degree (parent, child, sibling) relative of the other two. Two successive affected generations. One or more colon cancers diagnosed under age 50 years. Familial adenomatous polyposis (FAP) has been excluded.

Answer 832

Autosomal dominant familial colorectal polyposis Multiple colonic polyps Extra colonic diseases include: skull osteoma, thyroid cancer and epidermoid cysts Desmoid tumours are seen in 15% Mutation of APC gene located on chromosome 5 Due to colonic polyps most patients will undergo colectomy to reduce risk of colorectal cancer Now considered a variant of familial adenomatous polyposis coli

Answer 833

Positron Emission Tomography (PET) is a form of nuclear imaging which uses fluorodeoxyglucose (FDG) as the radiotracer. This allows a 3D image of metabolic activity to be generated using glucose uptake as a proxy marker. The images obtained are then combined with a conventional imaging technique such as CT to decide whether lesions are metabolically active. Uses - evaluating primary and possible metastatic disease

Answer 834

- monoclonal antibodies against carbohydrate or glycoprotein tumour antigens - tumour antigens - enzymes (alkaline phosphatase, neurone specific enolase) - hormones (e.g. calcitonin, ADH)

Answer 835

CA 125 CA 19-9 CA 15-3

Answer 836

PSA AFP CEA S-100 Bombesin

Answer 837

ovarain ca endometriosis, PID, menstruation, pregnancy

Answer 838

pancreatic ca, gallbladder ca gallstones, pancreatitis, liver disease

Answer 839

breast ca benign breast conditions, liver disease

Answer 840

prostate ca BPH, prostatitis

Answer 841

hepatocellular carcinoma, testicular ca, teratoma pregnancy, liver cirrhosis, hepatitis

Answer 842

colorectal ca also breast, lung, pancreatic ca smoking, IBD, liver disease

Answer 843

melanoma schwannomas

Answer 844

small cell lung carcinoma gastric ca neuroblastoma

Answer 845

testicular ca, choriocarcinoma pregnancy

Answer 846

lymphoma, leukaemia, testical ca general tissue damage, HF, anaemia, infections

Answer 847

thyroid ca thyroiditis, goiter

Answer 848

often proteins produced by body in response to ca or by ca itself found in blood, urine or tissue can help diagnosis, monitor, prognosis of ca most aren't exclusive to ca not specific or sensitive enough so used in conjunction with other diagnostic tools eg. imaging and biopsy

Answer 849

chronic hep B worldwide chronic hep c in europe

Answer 850

liver cirrhosis, eg. secondary to hep B & C, alcohol, haemochromatosis and primary biliary cirrhosis Wilson's is the exception

Answer 851

liver cirrhosis chronic hep B & C alcohol haemochromatosis primary biliary cirrhosis alpha-1 antitrypsin deficiency hereditary tyrosinosis glycogen storage disease aflatoxin drugs: oral contraceptive pill, anabolic steroids porphyria cutanea tarda male sex diabetes mellitus, metabolic syndrome

Answer 852

- tends to present late - features of liver cirrhosis/failure= jaundice, ascites, RUQ pain, hepatomegaly, pruritus, splenomegaly - possible presentation is decompensation in pt with chronic liver disease - raised AFP

Answer 853

screening with USS (+/- alpha-fetoprotein)

Answer 854

- pts with liver cirrhosis secondary to hep B&C or haemochromatosis - men with liver cirrhosis secondary to alcohol

Answer 855

early disease: surgical resection liver transplantation radiofrequency ablation transarterial chemoembolisation sorafenib: a multikinase inhibitor

Answer 856

not commonly as they rarely secrete thyroid hormones

Answer 857

- papillary (70%) - follicular (20%) - medullary (5%) - anaplastic (1%) - lymohoma (rare)

Answer 858

ca of parafollicular (C) cells, secrete calcitonin, part of MEN-2

Answer 859

anaplastic

Answer 860

lymphoma thyroid ca

Answer 861

- total thyroidectomy - followed by radioiodine (I-131) to kill residual cells - yearly thyroglobulin levels to detect early recurrent disease

Answer 862

Usually contain a mixture of papillary and colloidal filled follicles Histologically tumour has papillary projections and pale empty nuclei Seldom encapsulated Lymph node metastasis predominate Haematogenous metastasis rare

Answer 863

Usually present as a solitary thyroid nodule Malignancy can only be excluded on formal histological assessment

Answer 864

May appear macroscopically encapsulated, microscopically capsular invasion is seen. Without this finding the lesion is a follicular adenoma. Vascular invasion predominates Multifocal disease raree

Answer 865

C cells derived from neural crest and not thyroid tissue Serum calcitonin levels often raised Familial genetic disease accounts for up to 20% cases Both lymphatic and haematogenous metastasis are recognised, nodal disease is associated with a very poor prognosis.

Answer 866

Most common in elderly females Local invasion is a common feature Treatment is by resection where possible, palliation may be achieved through isthmusectomy and radiotherapy. Chemotherapy is ineffective.

Answer 867

rare malignancy that affects the penis

Answer 868

painless lesion or ulcer on glans or foreskin may get discharge or bleeding

Answer 869

phimosis poor hygiene smoking HPV infection

Answer 870

biopsy and histopathological exam of lesion

Answer 871

depends on stage surgery, radio, chemo or combination

Answer 872

painless penile lesion or ulceration, which may be accompanied by bleeding or discharge. - Changes in the colour or texture of the skin on the penis - Thickening or nodularity of the penile skin - Enlargement of regional lymph nodes - Erectile dysfunction or difficulty urinating - The location and size of the lesion may vary, with the glans and foreskin being the most commonly affected sites.

Answer 873

either - a penile mass or ulcerated lesion, where a sexually transmitted infection has been excluded as a cause, or -a persistent penile lesion after treatment for a sexually transmitted infection has been completed, or - unexplained or persistent symptoms affecting the foreskin or glans

Answer 874

- PSA at least once per yr -DRE not recommended on routine basis

Answer 875

In year 1 of active surveillance: - Every 3–4 months: measure prostate-specific antigen. - Throughout active surveillance: monitor PSA kinetics (could include PSA density and velocity). - At 12 months: perform a DRE. - At 12–18 months: multiparametric MRI. In year 2 and every year thereafter until active surveillance ends: - Every 6 months: measure PSA. - Throughout active surveillance: monitor PSA kinetics (could include PSA density and velocity). - Every 12 months: perform a DRE. If there is concern about clinical or PSA changes at any time during active surveillance, the person should be reassessed with multiparametric MRI and/or re-biopsy.

Answer 876

have their situation reviewed by uro ca specialist

Answer 877

PSA levels should be measured no earlier than 6 weeks after treatment, then at least every 6 months for 2 years, and once a year thereafter. After at least 6 months' initial follow up, consider a remote follow-up strategy for people with a stable PSA who have had no significant treatment complications, unless they are taking part in a clinical trial that needs formal clinic-based follow up. Do not routinely offer DRE to people with localized prostate cancer who are not on active surveillance while their PSA remains at baseline levels.

Answer 878

potentially deadly condition related to the treatment of high-grade lymphomas and leukaemias. It can occur in the absence of chemotherapy but is usually triggered by the introduction of combination chemotherapy. On occasion, it can occur with steroid treatment alone. Awareness of the condition is critical as prophylactic medication can be given to prevent the potentially deadly effects of tumour cell lysis.

Answer 879

occurs from the breakdown of the tumour cells and the subsequent release of chemicals from the cell. It leads to a high potassium and high phosphate level in the presence of a low calcium. It should be suspected in any patient presenting with an acute kidney injury in the presence of a high phosphate and high uric acid level.

Answer 880

IV fluids patients are higher risk should receive either allopurinol or rasburicase rasburicase= a recombinant version of urate oxidase, an enzyme that metabolizes uric acid to allantoin. Allantoin is much more water-soluble than uric acid and is, therefore, more easily excreted by the kidneys generally preferred now for patients at a higher risk of developing TLS allopurinol= generally used for patients in lower-risk groups rasburicase and allopurinol should not be given together in the management of tumour lysis syndrome as this reduces the effect of rasburicase

Answer 881

LS has been graded using the Cairo-Bishop scoring system: Laboratory tumor lysis syndrome: abnormality in two or more of the following, occurring within three days before or seven days after chemotherapy: uric acid > 475umol/l or 25% increase potassium > 6 mmol/l or 25% increase phosphate > 1.125mmol/l or 25% increase calcium < 1.75mmol/l or 25% decrease

Answer 882

laboratory tumour lysis syndrome plus one or more of the following: increased serum creatinine (1.5 times upper limit of normal) cardiac arrhythmia or sudden death seizure

Answer 883

osteosarcoma chondrosarcoma Ewing's sarcoma

Answer 884

Liposarcoma Rhabdomyosarcoma (striated muscle origin) Synovial sarcoma Fibrosarcoma Angiosarcoma Leiomyosarcoma (smooth muscle origin))

Answer 885

- pain - swelling or palpable mass (soft tissue>bone) - impaired function - pathologic fractures (bone) - systemic symptoms

Answer 886

X-ray, CT, MRI, PET biopsy= fine needle aspiration, core needle biopsy or incisional biopsy for histopath

Answer 887

- surgery= limb-sparing or amputation - radio= neoadjuvant or adjuvant or intraoperative radiation therapy (IORT) - chemo - Targeted therapy: For specific sarcoma subtypes, such as GIST, targeted therapy with tyrosine kinase inhibitors (e.g., imatinib)

Cancer Flashcards

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