Malignant disease

Question 1

What is the meaning of ‘opsoclonus’ and does it always indicate
malignancy?

Answer 1

Opsoclonus is characteristic of the paraneoplastic syndrome. It describes
rapid, chaotic, conjugate, spontaneous eye movements that distort ocular
fixation. It is associated with ataxia and other brain stem disturbances.

Question 2

Does a greatly elevated lactate dehydrogenase (LDH) denote

malignancy?

Answer 2

It can do but a high LDH also occurs with haemolysis, liver disease and
myocardial infarction.

Question 3

Does a normal erythrocyte sedimentation rate (ESR) exclude malignancy
in a patient complaining of feeling easily fatigued?

Answer 3

No; the ESR will usually be raised but this is by no means invariable.

Question 4

Why is folic acid supplementation given just after the day of
methotrexate administration? Can we give them simultaneously on the
same day?

Answer 4

Folinic acid, not folic acid, is used to counteract the folate antagonist
action of methotrexate and should be given 24 hours after the
methotrexate and not at the same time.

Question 5

Is hydroxyurea useful in the treatment of chronic myeloid leukaemia?

Answer 5

No. Imatinib is first line therapy

Question 6

What is the treatment of choice of mucosa-associated lymphoid tissue
(MALT) lymphoma? Is the eradication of Helicobacter pylori enough?
Does the positivity of CD2 rule out MALT lymphoma?

Answer 6

Low-grade gastric MALT lymphomas restricted to the mucosa or
submucosa are often treated successfully by H. pylori eradication but others
require surgery and chemotherapy. Try eradication therapy initially.
CD2 is associated with T and natural killer (NK) cells; MALT
lymphomas are B cell lymphomas.

Question 7

Stage IIE Hodgkin’s lymphoma is the ‘involvement of one or more
lymph node regions plus an extralymphatic site’ and that stage IV is
the ‘involvement of one or more extralymphatic organs with or without lymph node involvement’. What is the difference? Is ‘site’ different from
‘organ’ and, if so, what is ‘site’?

Answer 7

‘Site’ and ‘organ’ mean the same most of the time. Sometimes, however,
the site is clear (e.g. a mass in the epigastrium) without it being very
obvious which organ is involved.

Question 8

1. What is Hodgkin’s lymphoma?
2. What is the difference between Hodgkin’s and non-Hodgkin’s
   lymphoma?

Answer 8

Lymphomas are divided histologically into:
● Hodgkin’s lymphoma: characteristically has Sternberg–Reed cells,
together with a mixture of lymphocytes and histiocytes.
● Non-Hodgkin’s lymphoma: does not have Sternberg–Reed cells but
does have lymphoid tissue of various types depending on the type of
lymphoma

Question 9

Why is serum calcium elevated in patients suffering from lymphoma?

Answer 9

Some lymphomas secrete 1,25-dihydroxycholecalciferol, which will raise
the serum calcium level.

Question 10

In a patient with suspected multiple myeloma, with pains in the back
ribs, is the skull still the most sensitive site to observe bony lesions?

Answer 10

No; an X-ray of the area of pain, e.g. the spine, would be the best test but
a full skeletal survey, which would of course include the skull, is usually
carried out in a patient suspected of having myeloma

Question 11

Please explain why the incidence of ovarian cancer (surface epithelial
type)/carcinoma is low in women who take the oral contraceptive pill
and who have undergone tubal ligation, compared with the general
population?

Answer 11

The “Incessant ovulation theory” suggests that continuous ovulation
in a nulliparous woman is associated with high frequency of malignant
change. Ovulation is reduced by oral contraceptive treatment and
is incomplete with tubal ligation, perhaps explaining the reduced
frequency of ovarian cancer in these patients

Question 12

What is the treatment of Kaposi’s sarcoma?

Answer 12

Treatment of Kaposi’s sarcoma depends very much on the site. Many
do not need treatment but some need surgical treatment and others
chemotherapy. This lesion is now much less common in patients with
AIDS since the introduction of highly active antiretroviral therapy.

Question 13

How effective is a paracetamol and codeine phosphate combination
in cancer pain therapy and ordinary pain therapy, and what is the
difference in using them in cancer pain therapy?

Answer 13

Paracetamol and codeine phosphate as a combination at an adequate
dosage is sometimes helpful in pain control. It is important that the drugs
are given regularly. They can be useful in cancer pain when this is mild,
making opiates unnecessary.

Question 14

What is meant by co-analgesic drugs in palliative care?

Answer 14

These are drugs used in addition to opioids. Examples include NSAIDs,
which are used with an opioid for bone pain, and anticonvulsant drugs,
e.g. gabapentin, carbamazepine and pregabalin for neuropathic pain.

Question 15

Is trastuzumab useful in all patients with metastatic breast cancer?

Answer 15

No. It is only useful in patients who overexpress HER2 receptors. It is
now being used in patients following surgery for early breast cancer, and
in patients with metastatic disease. Trastuzumab is a member of the
epidermal growth factor family.

Question 16

I have heard that Imatinib is useful in stromal cell tumours. Can you
explain the mechanism?

Answer 16

Stromal tumour cells have a mutation in the proto-oncogene, which leads
to activation and cell surface expression of the tyrosine kinase KIT
(CD117). Imatinib is a tyrosine kinase inhibitor and is also used in chronic
myeloid leukaemia.

Question 17

Does monoclonal gammopathy of unknown significance (MGUS)

progress to multiple myeloma?

Answer 17

Yes. Patients with a serum monoclonal protein concentration of
1.5 g/dL that is IgA or IgM, and an abnormal serum free light chain
ratio (k: chains), are the most likely to develop multiple myeloma

Question 18

Why do some cancers particularly metastase to bone?

Answer 18

Bone is a frequent site of metastasis due to its high blood flow. Tumour
cells also produce adhesins that bind them to marrow stromal cells. Bone
also contains growth factors, e.g. tumour growth factor beta (TGFβ).

Question 19

What is the difference between lead time bias and length time bias.

Answer 19

In ‘lead’ time bias, the diagnosis is made early, e.g. by screening so that
‘survival time’ appears longer. Death still occurs at the same time from
the genesis of the cancer.
With ‘length’ time bias, a greater number of slowly growing tumours
are detected when screening asymptomatic individuals.

Question 20

Could lymphocytosis (lymphocytes: 4.4 109/L, representing 56%
of total lymphocytic count) and not accompanied by any other
haematological or systemic symptoms or signs except for mild weight
loss (5–10% previous body weight) some 12 years ago, with no
progression until now, be chronic lymphocytic leukaemia?

Answer 20

Answer 20
Yes; chronic lymphocytic leukaemia can have a good prognosis

Lymphocytosis only has a median survival of
10 years.

Question 21

What is the sensitivity of a prostate-specific antigen (PSA) in detecting
prostatic carcinoma?

Answer 21

Using a cut-off level of 4 mg/mL, the sensitivity is 70–80% and specificity
60–70%.