Oncology

Question 1

Cancers that spread to bone

Answer 1

Prostate
Breast
Bone

Question 2

Most common sites of bony metastases

Answer 2

spine
pelvis
ribs
skull
long bones

Question 3

Features of bony metastases

Answer 3

Bone pain
Pathological fractures
Hypercalcaemia
Raised ALP

Question 4

Features of endocervical cells that have become koilocytes

Answer 4

enlarged nucleus
irregular nuclear membrane contour
the nucleus stains darker than normal (hyperchromasia)
a perinuclear halo may be seen

Question 5

Treatment of chemotherapy induced nausea and vomiting

Answer 5

Low risk- metoclopramide 1st line

High risk- Ondansetron (5HT3 receptor antagonists), combined with dexamethasone

Question 6

Cyclophosphamide

Answer 6

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

Question 7

Adverse effects of cyclophosphamide

Answer 7

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

Mesna
-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

Question 8

Cytotoxic Agents

Answer 8

Print off pass medicine page

Question 9

Genetics and surgical disease

Answer 9

Print off pass medicine page

Question 10

Immune checkpoint inhibitors

Answer 10

T-cells are an important part of our immune system which help destroy cancer cells. Some cancer cells make high levels of proteins that turn T-cells off. Checkpoint inhibitors block this process and reactivate and increase the body’s own T-cell population, enhancing the immune systems own ability to recognise and fight cancer cells.

All CTLA-4 inhibitors and PD-1/PD-L1 inhibitors currently available are monoclonal antibodies

Question 11

Immune checkpoint inhibitor side effects

Answer 11

Dry, itchy skin and rashes (most commonly)
Nausea and vomiting
Decreased appetite
Diarrhoea
Tiredness and fatigue
Shortness of breath and a dry cough.

Management of such side effects reflects the inflammatory nature, often involving corticosteroids.

Question 12

Investigating metastatic disease on unknown primary

Answer 12

FBC, U&E, LFT, calcium, urinalysis, LDH
Chest X-ray
CT of chest, abdomen and pelvis
AFP and hCG

NB- then further imaging depending on the patient eg. mammography, PSA etc.

Question 13

Metastatic spinal deposits and location of the lesion

Answer 13

neurological signs depend on the level of the lesion. Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level. Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion

NB- whole spine MRI within 24 hours, high dose dexamethasone

Question 14

Causes of SVC obstruction

Answer 14

common malignancies: small cell lung cancer, lymphoma
other malignancies: metastatic seminoma, Kaposi’s sarcoma, breast cancer
aortic aneurysm
mediastinal fibrosis
goitre
SVC thrombosis

Question 15

Management of SVC obstruction

Answer 15

Management is dependant on the individual patient and malignancy and advice should be taken from the oncology team. Options include:
-endovascular stenting is often the treatment of choice to provide symptom relief
-certain malignancies such as lymphoma, small cell lung cancer may benefit from radical chemotherapy or chemo-radiotherapy rather than stenting
-the evidence base supporting the use of glucocorticoids is weak but they are often given

Question 16

Tumour markers

Answer 16

Print notes from pass medicine

Question 17

When is neutropenic sepsis most likely to occur?

Answer 17

7-14 days after chemotherapy

Question 18

Neutropenic sepsis prophylaxis

Answer 18

if it is anticipated that patients are likely to have a neutrophil count of < 0.5 * 109 as a consequence of their treatment they should be offered a fluoroquinolone eg. Ciprofloxacin

Question 19

Management of neutropenic sepsis

Answer 19

Sepsis 6 (take blood cultures before ABX (and any other cultures eg. catheter, central line)), CXR, ABG etc.

antibiotics must be started immediately, do not wait for the WBC
NICE recommends starting empirical antibiotic therapy with piperacillin with tazobactam (Tazocin) immediately (or meropenem)

Question 20

Causes of hypercalcaemia in malignancy

Answer 20

This may be due to number of processes, including; bone metastases, myeloma, PTHrP from squamous cell lung cancer

Question 21

Features of hypercalcaemia

Answer 21

‘bones, stones, groans (abdo pain and constipation) and psychic moans’
corneal calcification
shortened QT interval on ECG
hypertension

Question 22

Management of hypercalcaemia

Answer 22

IV fluid rehydration
Bisphosphate

Denusomab
Treat the malignancy

Question 23

What is tumour lysis syndrome

Answer 23

TLS occurs from the breakdown of the tumour cells and the subsequent release of chemicals from the cell (usually lymphomas and leukaemia’s). 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.

Question 24

Clinical diagnosis of tumour lysis syndrome

Answer 24

Clinical tumor lysis syndrome: 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

Question 25

Prophylaxis of tumour lysis syndrome

Answer 25

Patients at high risk of TLS should be given IV allopurinol or IV rasburicase immediately prior to and during the first days of chemotherapy

Question 26

Management of tumour lysis syndrome

Answer 26

IV saline (rehydration)
Phosphate binder (aluminium hydroxide)
Allopurinol (or rasburicase, not together)
Hyperkalaemia- calcium gluconate etc.

Question 27

Li-Fraumini syndrome

Answer 27

Autosomal dominant
Consists of germline mutations to p53 tumour suppressor gene
High incidence of malignancies particularly sarcomas and leukaemias

Question 28

BRCA1/2

Answer 28

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

Question 29

Lynch syndrome

Answer 29

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

Question 30

Gardner’s syndrome

Answer 30

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

Question 31

Metastatic spinal cord compression (MSCC)

Answer 31

Features;
back pain
the earliest and most common symptom
may be worse on lying down and coughing
lower limb weakness
sensory changes: sensory loss and numbness
neurological signs depend on the level of the lesion. Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level. Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion

Whole spine MRI <24 hours

Mx- high dose PO dexamethasone and urgent discussion with neurosurgeons

NB- back pain, lower limb weakness and sensory loss, needs urgent MRI