JC Block C - Clinical Oncology Teaching Clinic I and II (all)

Question 1

Hallmarks of cancer

Answer 1

o Sustaining proliferative signaling
o Evading growth suppressors
o Activating invasion and metastasis
o Enabling replicative immortality
o Inducing angiogenesis
o Resisting cell death

Question 2

Reasons of growing cancer incidence

Answer 2

 Aging population (exposed to more risk factors; decreased immunity)

 Westernised lifestyle: high fatty intake, sedentary lifestyle without exercise

 Unfavourable habits: smoking, alcoholism, unprotected sun-tanning, unsafe sex (cervical cancer, HPV-associated oropharyngeal
cancer)

 Improved cancer screening

Question 3

5 leading behavioral and dietary risks of cancer development

Answer 3

1. High body mass index
2. Low fruit and vegetable intake
3. Lack of physical activity
4. Tobacco use (= most important risk factor for cancer)
5. Alcohol use

Question 4

Outline WHO’s Comprehensive cancer control strategy & action plan

Answer 4

Aims:
o Reduce cancer incidence and mortality
o Improve quality of life of cancer patients and their families

Plan:
o Prevention (e.g. HPV vaccine)
o Early detection (screen high-risk group)
o Diagnosis and treatment
o Rehabilitation
o Palliative care, survivorship:

Question 5

Incidence rate of cancer in HK

Mortality rate

Answer 5

1 in 4 men and 1 in 5 women will develop cancer before age of 75

Median age at diagnosis of cancer:
 68 years in men
 62 years in women

(~1/3) of all deaths
1 in 9 men and 1 in 15 women will die from cancer before age of 75

Question 6

Most common cancers in male and female in HK

Answer 6

Question 7

Cancers with increasing incidence rate in HK

Answer 7

o Female: breast, corpus uteri, pancreas

o Male: prostate, kidney (RCC), non-Hodgkin lymphoma, thyroid, pancreas

Question 8

Top 5 cancer in incidence and mortality rate in HK (both sex)

Answer 8

Incidence:
- Colorectal, Lung, Breast, Prostate, Liver

Mortality:
- Lung, colorectal, liver, breast, pancreas

Question 9

Effect of cancer growth

Answer 9

Local effects: 
o Mechanical (e.g. bone, spine collapse)
o Disturbance of functions:
 Anatomical (e.g. metastasis to humerus)
 Physiological
 Irritation/infiltration of nerves
 Hormonal disturbance

Systemic constitutional effects

Paraneoplastic manifestations

Question 10

List examples of paraneoplastic manifestations

Answer 10

 Dermatomyositis (e.g. breast, lung, NPC)

 Lambert-Eaton myasthenic syndrome (LEMS) (e.g. small cell lung cancer)

 Hypercalcaemia of malignancy (e.g. SCC lung, breast, lymphoma, prostate (sic))

 SIADH (e.g. small cell lung cancer (oat cell), breast, pancreatic)

 Cushingnoid features (etopic ACTH production) (e.g. small cell lung cancer)

 Hypoglycaemia (e.g. HCC)

 Polycythaemia (e.g. RCC: erythropoietin production)

 Vasculitis

Question 11

Causes of finger clubbing

Answer 11

 Respiratory system: CA lung, fibrosis, bronchiectasis, lung abscess

 Cardiovascular system: infective endocarditis, cyanotic heart disease

 GI: liver cirrhosis, inflammatory bowel disease

 Thyrotoxicosis (traditionally called pseudoclubbing) due to soft tissue proliferation

 Idiopathic

Question 12

Key presenting features of colorectal CA

Answer 12

 Per rectal bleeding
 Constipation/ change in bowel habit
 Tenesmus (= most specific: tumor in sigmoid/ rectum)
 Abdominal pain
 Abdominal distension: ascites, IO or liver met.
 Other local symptoms (e.g. hematochezia, passing mucus)

Question 13

Workup investigations for colorectal CA

Answer 13

 Proctoscopy/ colonoscopy – biopsy of lesion

 AXR: IO features

• Proximal dilatation of bowel
• Multiple air-fluid level
• Perforation

 CT abdomen and pelvis (for staging, metastasis, complications)

• Obstructing lesion (white solid arrow)/ mural thickening of rectosigmoid junction
• Liver met.
• Ascites

Question 14

Workup investigation for rectal CA

Answer 14

 Endorectal US (for local staging: depth of invasion)

 Pelvic MRI:
o Mural thickening
o Enlarged mesorectal lymph nodes

Question 15

Ddx colorectal cancer

Answer 15

Differential diagnoses – benign:
 Benign polyp (can be pre-malignant)
 Haemorrhoid
 Inflammatory bowel diseases
 Infective colitis
 Diverticulitis +/- abscess

 Adhesions
 Paralytic ileus

Question 16

Key presenting features of lung cancer

Answer 16

 Chronic cough, no regression

 Haemoptysis

 Shortness of breath, new wheezing, recurrent chest infection (tumor obstruction)

 Hoarseness

 Lower neck mass

(pleuritic chest pain)

Question 17

3 syndromes a/w lung cancer **

Answer 17

Superior vena cava syndrome* (SVCO)
 Dilated veins at neck and chest wall, facial & neck swelling (including lips), edematous arms and hands, dyspnea

Horner syndrome* (compression of sympathetic trunk usually at C7-T1)
 4 major features: partial ptosis, miosis, anhidrosis, enophthalmus

Pancoast syndrome (invades adjacent ribs & vertebrae)
- Brachial plexus:
o Severe pain at shoulder radiating toward axilla, scapula, ulnar aspect of hand
o Atrophy of small muscles of hand
- Cervical sympathetic nerves (Stellate ganglion): Horner’s syndrome

Question 18

Paraneoplastic syndromes of lung cancer

Answer 18

 SIADH (hyponatremia)

 Cushing syndrome (ectopic ACTH production in small cell lung cancer)

 Lambert-Eaton syndrome* (production of IgG antibodies binding to voltage-gated Ca2+ channels):
o Proximal muscle weakness
o Autonomic disturbance

 Hypercalcaemia (PTHrP)

 Hypertrophic osteoarthropathy

 Cerebellar ataxia

 Peripheral neuropathy

Question 19

Workup investigations for lung cancer

Answer 19

CXR

CT thorax

Sputum cytology, C/ST, AFB (if suspect carcinomatosis or TB)

Biopsy:
 CT or EBUS (endobronchial US) guided
 Bronchoscopy
 Mediastinoscopy

Staging Ix: TNM/ limited or extensive staging

Metastatic:
 CT/ MRI brain for distant metastasis
 PET-CT
 Blood tests: LFT, RFT (includes creatinine, urea, K+ , Na+), Ca2+, CEA (tumor marker for adenocarcinoma), LDH (prognosis)

Question 20

Ddx lung cancer

Answer 20

Question 21

Key features of breast cancer

Answer 21

 Breast lump, Fungating mass
 Skin changes (redness/ dimpling)
 Nipple retraction
 Nipple discharge
 Axillary/ neck swelling
 Upper limb – lymphedema due to LN met. or radiotherapy 

 Signs of metastasis (bone, liver, lung, brain)

Question 22

Workup investigations for breast cancer

Answer 22

 Mammogram/ USG
 MRI breast
 FNAC/ core biopsy

Question 23

Ddx breast cancer

Answer 23

Question 24

Prostate cancer

Key presenting features

Answer 24

Common presenting symptoms:
 Problem in passing urine (but seldom painful)
 Haematuria
 Haemaspermia
 Bone metastases: Bone pain, spinal cord compression, hypercalcemia S/S

Clinical signs:
 DRE: hard prostatic nodules, loss of middle sulcus
 Bony tenderness (cord compression in advanced cases)

Question 25

Workup investigations for prostate cancer

Answer 25

 Tumour marker: PSA

 MRI pelvis

• Prostate cancer (e.g. involving peripheral, transition zone)
• Extracapsular spread, e.g. invasion to seminal vesicles, neurovascular bundle, anterior wall of rectum
• Lymph nodes

 Transrectal ultrasound (TRUS) guided biopsy

 MRI spine

Question 26

Ddx prostate cancer

Answer 26

 Benign: benign prostate hyperplasia

 Malignant: direct invasion from bladder or rectum cancers

Question 27

Liver cancer

Key presenting features

Answer 27

Presentation
 Abdominal distension (hepatomegaly, ascites)
 Abdominal pain especially at RUQ
 Jaundice, HE, Hypoglycaemia

Signs:
 Jaundice
 Signs of chronic liver diseases(clubbing, palmar erythema, Dupuytren’s contracture, flapping tremor, spider naevi, gynaecomastia, testicular atrophy)
 Lower limb edema
 Hepatomegaly – hard, irregular
 Ascites
 Splenomegaly

Question 28

Workup investigations for liver cancer

Answer 28

 HBV and HCV serology
 Tumor marker: alpha fetoprotein for HCC
 Imaging:
Ultrasound liver
Triphasic CT scan – if hepatocellular carcinoma
CT angiography
MRI liver

Question 29

Ddx HCC

Answer 29

Question 30

NPC

Risk factors

Answer 30

EBV infection

genetic predisposition : HLA A2 + BW 46

Environmental factors: salted fish (nitrosamines), alcohol, poor oral hygiene

Question 31

NPC Key presenting features

Answer 31

Neck mass (LN involvement)

Nasal obstruction, bleeding, epistaxis, post-nasal drip, blood-stained saliva, discharge

Aural (tinnitus, deafness, pain, discharge) due to blockage of Eustachian tube:

Headache

Cranial nerve palsy spread further up to cavernous sinus - Compress on CN III, IV, V1, V2, VI

Dermatomyositis* (paraneoplastic)

Question 32

Workup investigations for NPC

Answer 32

 Tumour marker: EBV-DNA, IgA anti-EBV

 Nasopharyngoscopy & biopsy at fossa of Rosenmuller

 MRI with gadolinium from skull base to clavicle, i.e. nasopharyngeal & cervical regions, and/or CT with contrast

 FDG-PET/CT for systemic workup + supplement locoregional assessment

Question 33

Prognosis of NPC

Answer 33

Prognosis – survival by stage (5-year):
 I: 100% (very good)
 II: 95% (very good)
 III: 90% (regional LN; amenable to radical chemoirradiation)

 IVA: 67%
 IVB: 68%
 IVC: 18%

Question 34

General Constitutional and metastatic symptoms of all cancers

Answer 34

Question 35

Modalities of pathological diagnosis of cancer

Answer 35

Modalities:
 Cytology
 Histopathology
 Liquid-based biopsy (blood, pleural effusion, pericardial effusion) for circulating tumour cells or circulating tumour DNA
 Biological and genetic characteristics: e.g. ER/ PR/ EGFR/ ALK…etc

Question 36

Examples of hormonal therapy for cancer treatment

Examples of immunotherapy

Answer 36

Hormonal:
o Breast cancer: tamoxifen, aromatase inhibitors
o Prostate cancer: abiraterone
o Neuroendocrine tumors: octreotide

Immuno:
o Anti-PD-1: nivolumab, pembrolizumab, pidilizumab
o Anti-PD-L1: atezolizumab, durvalumab, avelumab

Question 37

Key presenting features of gastric cancer

Answer 37

Epigastric discomfort/ pain - “indigestion”, dyspepsia, early satiety

Obstructive symptoms: vomiting, dysphagia

 Melena, coffee ground vomiting
 Systemic: anemia, weight loss

Question 38

Workup investigations for gastric cancer

Answer 38

Endoscopy: OGD and biopsy

CT abdomen and pelvis: metastasis, LN involvement, ascites, adnexal masses, complications e.g. GOO, Perforation

Barium meal (e.g. nodular, markedly thickened folds)

Question 39

Ddx gastric cancer

Answer 39

Question 40

Skin cancer

Key presenting features
Most common types

Answer 40

Presenting symptoms:
 Lump, nodules
 Non-healing ulcer
 Bleeding, pain (late stage)

Different histology:
 Basal cell carcinoma
 Squamous cell carcinoma
 Merkel cell carcinoma
 Cutaneous lymphoma
 Kaposi’s sarcoma
 Angiosarcoma
 Dermatofibroma protuberans

Question 41

Ddx skin cancer

Answer 41