Cancer

Question 1

Melanoma TNM

Answer 1

T1a - <0.8,
T1b - 0.8-1 
T2 -  1-2 mm (10%LNI) 
T3 - 2 - 4mm 
T4 - > 4mm 

N1 - 1 Node , In-transit/Microsatellite
N2 - 2-3
N3 - 4 or more

IHC S100, Melanin A

SNB

• T1b and above
• If no clinical nodes

Staging from T3b

• CT
• PET CT
• MRI Head

+ ve node
- FNA/PET/MRI brain

Question 2

Melanoma Synoptic

Answer 2

• Thickness in mm
  
  • Ulceration status
  • Dermal mitotic rate (per mm2)
  • Deep peripheral margin statue
  • Presence or absence of micro satellites
  • LVI
  • Radial or vertical growth phase
  • Tumour-infiltrating lymphocytes
  • Regression

Tumour mutation marker analysis BRAF (Stage III or IV ) - considered for adjuvant therapies of immunotherapy or targeted therapy or clinical trials

Question 3

Melanoma types

Answer 3

Nodular (15%) 
Amelanocytic 
Superficial spreading (60%) 
Acral - 1 %
Desmoplastic  
Lentigo Maligna

Question 4

MSLT 1

Answer 4

SNB vs Observation

• Initially better disease free recurrence
• but 10 year data no survival benefit

Question 5

MSLT 2

Answer 5

SNB prognosticate immediate ALND - no benefit

SNB + observe until clinically relevant

Question 6

Thyroid cancer TNM

Answer 6

T1 - <2cm
T2 - 2-4cm
T3 - >4cm
T4 - invasion more than straps

N1 a ipsilateral
b contralateral

Question 7

Investigate thyroid

Answer 7

USS (TIRADS)

• Echogenicity - hypoechoeic bad
• Shape - Taller than wide
• Composition (cystic or solid)
• Margin (smooth ill-defined, irregular)
• Echogenic foci (micro-calcification, rim calcification)

1 - Benign 
2- Not suspicious 
3 - Mild (FNA >2.5cm) 
4 - mod suspicious (FNA >1.5 follow it over 1 cm) 
5 - high (FNA) 

Bethesda
1 - Not diagnostic 
2 - benign 
3 - Atypia, FUS 
4 - Follicular 
5 - probably papillary cancer 
6 - highly likely cancer 

FNA biopsy

Question 8

Dynamic risk stratification how they respond to RAI or therapy

Answer 8

Biochemical response - thyroglobulin <0.1 (optimising suppression therapy)

• give 2mcg/kg
• 4 weeks post op (low, intermediate, high)
• Thyroglobulin levels
• Side effects - tachycardia, osteoporosis

Surgical complete excision (margins)

Radiological recurrence - structural incomplete response

Question 9

Surveillance

Answer 9

Clinical

• Examination
• no change in voice

Biochemical
- Thyroglobulin

Radiological
- I 131

Question 10

RAI, when for thyroid cancer

Answer 10

Low - no 
Intermediate - consider 
- Microscopic 
- N1 
- LVI 

High - yes

Question 11

RAI contraindication

Answer 11

Pregnant
Breast Feeding

Can’t get pregnant for 6 months after

Question 12

Medullary Thyroid cancer investigations

Answer 12

3-5 %
from parafollicular C cells
MEN 2 A or B (20%) (RET proto-oncogene -> different RET different age for prophylatic thyroidectomy)

Measure Calcitonin 
Plasma metanephrines / CT adrenal 
CEA 
USS 
Calcium and Phos

Question 13

Anal cancer Treatment

Answer 13

Nigro protocol

• Defunction
• Mitomycin/5FU
• Radiotherapy 30Gy

Complete or partial responders Followup;

• DRE, Anoscopy, and examination of 3 monthly
• 6 monthly after
• CT 3 years

No response

• APR
• Other indications
• Recurrence

ACT 2 can watch if persistent disease as can cannot to regress