Onc Ix Mx

Question 1

Basal cell carcinoma (most common type of cancer in the Western world)

Answer 1

Ix = Lesions are also known as rodent ulcers

Characterised by slow-growth and local invasion

Metastases are extremely rare.

The most common type is nodular BCC at sun-exposed sites

Initially a pearly, flesh-coloured papule with telangiectasia, may later ulcerate leaving a central ‘crater’

Mx = refer for surgery/cryo/radio/cream etc

Question 2

Bladder cancer

‘painless haematuria’

Answer 2

Ix = biopsy, pelvic MRI + PET-CT

Needs referral to urology for investigations if suspected

Mx:

Superficial lesions = TURBT* in isolation.

Recurrences or higher grade/risk on histology = intravesical chemotherapy

Stage T2 disease = surgery (radical cystectomy and ileal conduit) or radical radiotherapy

*(transurethral resection of the bladder tumour)

Question 3

Breast cancer

Answer 3

Ix:

USS (<35yo)
Mammogram (>35)
and mammogram 47-73, every 3 years

Triple assessment = history, scan, FNA/core biopsy*

Referral

2ww;
>30yo + unexplained lump in breast/axilla
>50yo + SLANT

<30yo + no pain = non-urgent referral

Assessed for Oe-Receptor+, P-Receptor+, HER-2

Mx:

HER-2 = trastuzumab (HERceptin)

Oe-R+ = pre/peri-menopause = tamoxifen, post = letrozole

Solitary nodule = Wide-local excision

post-excision of high risk cancer/Stage T3/t4 or >4 LN = Radio

Chemo is adjuvant pre-surgery

Axillary node clearance is indicated if there is any lymph node involvement

*Biopsy will show “atypical ductal hyperplasia”

Question 4

Central nervous system (CNS) tumours

Answer 4

Ix = MRI

Mx = surgery

Resection of Gliomas is nearly always incomplete as they invade the brain tissue

Question 5

Cholangiocarcinoma

Answer 5

Ix = LFTs (abnormal)

Incidental = USS
Suspected = CT

GS = ERCP!! then MRI for staging

Mx = remove

or chemo+stent is it’s non-resectable

Question 6

Colorectal carcinoma

Ix (>55 and 60-74?)

It is currently thought there are three types of colon cancer:

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

What are the amsterdam criteria for HNPCC?

Answer 6

Ix = sigmoid/colonoscopy

> 55yo = flexisig once

60-74 = FIT every 2 years

if either are +ve -> colonoscopy

Mx = surgery resection

The Amsterdam criteria are sometimes used to aid diagnosis of HNPCC;

1. at least 3 family members with colon cancer
2. the cases span at least two generations
3. at least one case diagnosed before the age of 50 years

Question 7

Gastric cancer

associated with acanthosis nigricans

Pernicious anaemia predisposes pt to developing gastric cancer

Answer 7

Ix = OGD (oesophago-gastro-duodenoscopy) + biopsy

signet ring cells may be seen in gastric cancer. (more=worse)

Staging: CT

Mx: surgeries;

endoscopic mucosal resection
partial/total gastrectomy

chemotherapy

Question 8

Head & neck cancer (oral cavity, laryngeal,

Answer 8

Laryngeal cancer 2ww criteria:
>45yo + (persistent unexplained hoarseness) or
(an unexplained lump in the neck)

Oral cancer 2ww criteria:

Unexplained ulceration in the oral cavity lasting for more than 3 weeks

a persistent and unexplained lump in the neck, lip, oral cavity,

a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

Thyroid cancer 2ww criteria = unexplained lump in neck

Question 9

Hepatocellular carcinoma

Accounts for 90% of liver tumours!

Answer 9

Ix:
USS + alpha-fetoprotein for high risk groups;

ie. Patients liver cirrhosis secondary to hepatitis B & C or Haemochromatosis or alcohol

Mx: surgery

early disease: surgical resection
liver transplantation
radiofrequency ablation
transarterial chemoembolisation

sorafenib: a multikinase inhibitor

Question 10

Lung cancer

Gynaecomastia is associated with adenocarcinoma

Answer 10

IX: 1st = Chest X-Ray

Suspected = CT

Bronchoscopy (guided by USS) used for biopsy

PET scanning = to see if there’s enough neuroplastic tissue for 18-fluorodeoxygenase to work as a treatment

Bloods = raised platelets

2ww referral criteria:

> 40yo + (2symptoms, or 1symptom w smoking)

Cough, chest pain, SOB, appetite loss, WL, fatigue

> 40yo + 1 symptom of: clubbing, recurrent chest infection, lymphadenopathy, thrombocytosis)

Mx = surgery/chemo?

Question 11

Neutropenic sepsis

most common cause = Staph epidermidis

Answer 11

Ix = 7-14 days post-chemo, neutrophil count < 0.5 * 109 + >38ºC or other signs of sepsis

after ab’s, send for blood cultures

Mx:

Immediate ab’s! (pip+taz) - given as soon as suspected (ie. 8days post chemo + pyrexic)

if still pyrexic after 48hrs, add (meropenem+vanc)

If this doesn’t work, consider fungal cause

prophylaxis for high-risk pt = fluroquinolone (floxacins e.g. cipro)

Question 12

Oesophageal cancer

Most common oesophageal cancer?

Answer 12

Ix = Upper GI endoscopy with biopsy

Endoscopic-ultrasound = locoregional staging

CT CAP = initial staging

FDG-PET CT = occult metastases if metastases are not seen on the initial staging CT scans

Mx = Ivor-Lewis type oesophagectomy + adjuvant chemo

The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis resulting in mediastinitis

Most common = lower1/3rd = adenocarcinoma
upper2/3rds = scc

Question 13

Pancreatic cancer

‘painless jaundice’

Answer 13

Ix =
ultrasound has a sensitivity of around 60-90%
high-resolution CT scanning is the investigation of choice if the diagnosis is suspected
imaging may demonstrate the ‘double duct’ sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts

Mx:
<20% suitable for surgery at diagnosis

Head of pancreas = a Whipple’s resection (pancreaticoduodenectomy)

Palliation = ERCP with stenting

SE’sWhipple’s = dumping syndrome and peptic ulcer disease

Question 14

Prostate cancer

Answer 14

Ix = PSA, 1st = multi-parametric MRI

TRUS-guided biopsy is less used

Mx = localised = watch/remove/radiotherapy

advanced = hormonal, remove, radio,

metastatic = GnRH agonist (goserelin) + 3wks of antiandrogen

Question 15

Renal cell carcinoma

Answer 15

Ix = CT-CAP

Mx = nephrectomy

Question 16

Squamous cell carcinoma

(what 3 things does histology show for any carcinoma)

who gets urgent referral?

Answer 16

Histology for ANY carcinoma shows:
1. nuclear enlargement,
2. hyperchromasia
3. and pleomorphism

Squamous cell carcinomas are more common in patients who are immunosuppressed, and may present atypically and grow rapidly.

NICE therefore advises all patients who have received organ transplants are referred urgently to a dermatologist if they present with any new or growing skin lesions.

Question 17

Testicular cancer

Answer 17

Ix: 1st = ultrasound

• a painless lump is the most common presenting symptom, some have pain
• hydrocele
• gynaecomastia (due to an 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

Tumour markers for germ-cell tumour;

seminomas = hCG (in 20%)
non-seminomas = AFP/beta-hCG are elevated in 80-85%

LDH is elevated in around 40% of germ cell tumours

Mx:

Treatment depends on whether the tumour is a seminoma or a non-seminoma

orchidectomy

+ chemo if there’s lymph node involvement

chemotherapy and radiotherapy may be given depending on staging and tumour type

5yr survival-rate = >95%

Question 18

Thyroid cancer

Answer 18

Thyroid cancer 2ww criteria = unexplained lump in neck

Question 19

Tumour lysis syndrome

Answer 19

Ix: Also recent chemo (similar to neutropenic sepsis)

hyperkalaemia/phosphataemia, but hypocalcaemia

K>6, PO4>1.125, Ca<1.75 and uric acid>475

If suspicious, test for urate to confirm!

then 1 from: increased creatinine, arrhymthia or seizure

Mx: prophylaxis before/during chemotherapy

high-risk = IV (allopurinol + rasburicase)
low-risk = PO allopurinol

Question 20

Parotid gland disease passmed

Question 21

Hodgkin’s lymphoma

signs of poor prognosis:

• B-symptoms,
• increasing age,
• male sex,
• stage IV disease
• lymphocyte depleted subtype

Answer 21

Hodgkin’s lymphoma is a malignant proliferation of lymphocytes characterised by the presence of the Reed-Sternberg cell. It has a bimodal age distribution being most common in the third and seventh decades.

Ann-Arbor staging of Hodgkin’s lymphoma
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)

Management
chemotherapy is the mainstay of treatment. Two combinations may be used
ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine): considered the standard regime
BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone): alternative regime with better remission rates but higher toxicity
radiotherapy
combined modality therapy (CMT)
chemotherapy followed by radiotherapy
hematopoietic cell transplantation
may be used for relapsed or refractory classic Hodgkin lymphoma

Question 22

How to tell the difference between breast issues?

Duct ectasia
Fat necrosis
fibroadenoma
fibrocystic disease

Answer 22

Duct ectasias – green/yellow discharge

Fat necrosis – usually following trauma/injury

d) fibroadenoma – smooth mobile

Fibrocystic disease – ill defined, lumpy, responsive to oestrogen

Question 23

Which liver tumours are benign and which are malignant?

Answer 23

Benign primary liver tumours include: HALF!

H aemangiomas (most common);
A denomas;
L eiyomyomas.
F ibroma/ocal nodular

The malignant primary liver tumours include: carc/sarc/blastomas

• hepatocellular carcinoma (accounts for 90 per cent of primary liver
  tumours);
• cholangiocarcinoma;
• angiosarcoma (A);
• hepatoblastoma (D);
• fibrosarcoma (B);
• leiyomyosarcoma (E).

Question 24

SCC vs BCC vs acitinic keratosis vs Keratoacanthoma

Answer 24

SCC = hyperkeratotic, ULCERATED (may be deep), expanding nodules
with everted edges. They are commonly seen on the back of the hands, face and trunk but may also appear on the edge of scars (e.g. burns scars). Immunosuppressed patients are at risk of developing SCCs.

Basal cell carcinomas (BCCs) are slow growing and initially present as reddishcoloured, DOME-SHAPED pearly nodules with a translucent surface and visible dilated surface capillaries. As the lesions expand, the central area
tends to ulcerate, leaving a rolled-edge appearance.

Actinic keratosis (C)
are characterized by SCALY, erythematous crusting lesions which tend to occur on the scalp, face and back of hands. They are very common lesions which arise secondary to prolonged sun exposure. Actinic keratoses have
the potential to transform into metastasizing squamous carcinoma.

Keratoacanthomas (D) are RAPIDLY GROWING, and usually self-healing,
epidermal nodules which possess pathological features indistinguishable
from early SCCs. Keratoacanthomas develop as solitary lesions on the face
and grow rapidly to a size of 2–3 cm in diameter. The nodule then develops
a necrotic centre and heals spontaneously leaving a PITTED SCAR appearance.

Question 25

Hypercalcaemia mx in cancer pt’s

malignant and acute

Answer 25

malignant = IV fluids + bisphos (pamidronate)

acute = just fluids

Question 26

Whats the WHO pain relief ladder?

Answer 26

Step 1 – Non-opioid analgesia, e.g. paracetamol, NSAIDs

Step 2 – Weak opioid analgesia, e.g. codeine, tramadol

Step 3 – Strong opioids, e.g. morphine, diamorphine, fentanyl

ie. if paracetamol doesn’t work then step up to give paracetamol + codeine

Question 27

How do you calculate morphine breakthrough doseage?

Answer 27

Once a 24-hour requirement of morphine
is established, the dose can be given as a modified release preparation
(morphine sulphate tablets) in 2 divided doses.

A sixth of the total daily
morphine dose should be given as required (used a maximum of every 4
hours) for breakthrough pain.

So if the patient has used 60 mg of oral morphine solution in 24 hours. This can be divided into the 2 doses of 30 mg of modified release preparation of morphine given with 12-hour
intervals.

A sixth of the total daily dose of morphine for breakthrough
pain is 10 mg

So 60 mg would be 2 lots of 30mg plus 10mg as required

Question 28

Carcinoid Tumours Px and Ix

Answer 28

Carcinoid tumours arise from enterochromaffin cells (APUD cells). They most commonly occur in the appendix, ileum or rectum but can occur
elsewhere, including other areas of the gastrointestinal tract, ovary, testis
or lung.

It is often difficult to histologically determine whether carcinoid
tumours are benign or malignant.

Carcinoid tumours of the
gastrointestinal tract are usually asymptomatic but may cause appendicitis,
intussusception or obstruction.

Carcinoid syndrome refers to carcinoid tumours with liver metastases.

These patients are usually symptomatic and
may present with spontaneous facial flushing, abdominal pain and watery diarrhoea. Fifty per cent of patients develop cardiac abnormalities, such as
tricuspid regurgitation or pulmonary stenosis. Symptoms are produced by the tumours secreting substances such as 5-hydroxytryptamine, bradykinin
and histamine.

Ix = radiological imaging of the liver metastases and 24-hour urine 5-hydroxyindoleacetic acid.

Question 29

Non-hodgkins differentiators from hodgkins?

Answer 29

non is mostly elderly whereas HL is 30s and 70s

HL has Reed-sternberg owl eye cells

Lymphadenopathy in Hodgkin’s lymphoma can experience alcohol-induced pain in the node

‘B’ symptoms typically occur earlier in Hodgkin’s lymphoma and later in non-Hodgkin’s lymphoma

Extra-nodal disease is much more common in NHL than in HL