oncology

Question 1

side effectsof bisphosphonates

Answer 1

osetonecrosis of jaw/hip: pain, fever

GI symptoms

Question 2

side effects of prostate ca injections

Answer 2

Leuprolide is known to cause osteoporosis and flushing. It is known to cause generalised body pain

Question 3

ovarian ca chemo

Answer 3

NICE recommends that if patients are of a good performance status then they should be offered combination carboplatin and paclitaxel chemotherapy as this offers approximately an 8% increased response from single agent carboplatin chemotherapy alone.

Question 4

bladder ca causes

Answer 4

bladder cancer which is associated with smoking, occupational exposure to rubber and advancing age.

Cystoscopy and biopsy are required for diagnosis.

Question 5

SVCO management

Answer 5

1. The best initial treatment in SVCO is with high dose steroids.
   2, radio/stent

Question 6

opiods for bone mets

Answer 6

Boluses of IV opioids, morphine or fentanyl, will provide the best pain management strategy acutely

Question 7

gatric ca and rash

Answer 7

acanthosis nigricans

Question 8

hnpcc/lynch syndrome

Answer 8

colorectal ca, ovarian ca (psamomma bodies), renal pelvis, pancreatic, small bowel, liver and biliary tract, stomach, brain, breast
MSH

Question 9

treatment of LEMS

Answer 9

The clinical description is typical of Lambert-Eaton myasthenic syndrome (LEMS) - a paraneoplastic disorder associated with small cell lung cancer.

As the syndrome is autoimmune, mediated treatments such as IV immunoglobulin, plasma exchange and high dose steroids may help, as well as treating the underlying small cell lung cancer, which is often very responsive to appropriate chemotherapy.

As LEMS is a non-metastatic phenomenon, whole brain radiotherapy would not be helpful.

Question 10

FAP

Answer 10

APC
multiple colon polyps
small intestine, brain, bone, stomach, skin

Question 11

FAP

Answer 11

APC
multiple colon polyps
small intestine, brain, bone, stomach, skin

Question 12

Li fraumeni

Answer 12

Breast ca
Sarcoma, osteosarcoma, leukemia, brain, adrenal
TP53

Question 13

Cowden syndrome

Answer 13

PTEN

Harmatomas and breast, thyroid, endometrial

Question 14

Hereditary breast and ovarian ca

Answer 14

BRCA 1 and 2

Men - breast and prostate

Question 15

management of pain and renal impairment in palliative care

Answer 15

Fentanyl is a synthetic opioid extensively metabolised by cytochrome P450 enzymes in the liver and gastrointestinal tract, thus it is unaffected by renal impairment. Due to its extensive first pass metabolism, it can only be given parenterally (that is, transmucosal, transdermal, intramuscular, intravenous or subcutaneous).

Question 16

stage II rectal cancer : rectal tumor no lymph node involvement

Answer 16

stage II rectal cancer and is likely to benefit from a combined modality treatment with surgery and adjuvant chemoradiation therapy.

Preoperative chemoradiation with low anterior resection is the treatment of choice to reduce the need for permanent colostomy and local recurrence.

Question 17

causes of brain mets

Answer 17

Brain metastases usually originate from tumours via neoplastic emboli and therefore most often affect the ‘watershed areas’ at the end of the arterial supply.

Lung cancer, melanoma and breast cancer are the primary tumours most frequently associated with metastatic spread to the brain, therefore malignant melanoma is the correct answer in this case.

Melanoma usually causes multiple metastases whereas breast cancer tends to cause solitary lesions. The most common effect of a metastatic deposit is to cause oedema of the surrounding tissue leading to raised intracranial pressure and displacement, rather than infiltration, of the brain.

Treatment of brain metastases is generally dictated by the type of cancer, the neurological status of the patient and the extent of systemic disease. General measures include high dose corticosteroids and palliation of any distressing symptoms such as agitation.

Question 18

PE treatment in palliative care

Answer 18

Patients with malignancy are at higher risk of deep venous thrombosis (DVT) and pulmonary embolism (PE) and complications of anticoagulation. This makes management decisions tricky.

Daily low molecular weight heparin has been demonstrated to be efficacious in this setting, with low bleeding risks and is acceptable to most patients. It avoids regular blood tests and has fewer interactions. Therefore in the palliative care setting, daily low molecular weight heparin is the treatment of choice for most palliative patients.

Answer 19

A patient with a high grade glioma (that is, WHO grade 3 or 4) such as a glioblastoma will be unable to drive for at least two years following completion of treatment. After the two years have elapsed the DVLA will consult with the physicians involved in the patient’s care and a decision is made regarding return of the licence.

Question 20

acute dystonic reaction

Answer 20

Common presentations include protrusion of the tongue, trismus, facial grimacing, difficulty speaking, torticollis and oculogyric crisis. The patient’s mental status and basic observations (for example, heart rate and blood pressure) remain unaffected.

The most common drug causes of acute dystonia are neuroleptics (for example, haloperidol, levomepromazine), antiemetics (for example, metoclopramide) and antidepressants (for example, amitriptyline, trazodone).

Management is dominated by the need to stop the causative drug, followed by administration of either benztropine or diphenhydramine. Both of these medications block striatal cholinergic receptors which may help to balance cholinergic and dopaminergic activity and resolve the dystonia. Benzodiazepines may also be helpful.

Question 21

treatment for metastatic prostate ca

Answer 21

Surgical castration or gonadotropin hormone-releasing hormone (GnRH) agonists are first line therapies for an asymptomatic patient with metastatic prostate cancer.

As the patient is asymptomatic, hormonal therapy with surgical castration or gonadotropin hormone-releasing hormone (GnRH) agonists is the treatment of choice. Patients may experience tumour-flare reactions with the use of GnRH agonists which cause a transient increase in testosterone, which can exacerbate prostate cancer symptoms.

Question 22

hypercalcemia in malignancy

Answer 22

Hypercalcaemia is the most common life-threatening metabolic disorder associated with malignancy and should be treated as an oncological emergency.

Ten per cent of cancer patients develop hypercalcaemia, most of whom have disseminated disease and 80% die within a year. The cancers most frequently associated with hypercalcaemia are breast cancer, lung cancer, renal cell carcinoma and (most commonly) myeloma.

There are three main mechanisms by which malignancy leads to hypercalcaemia:

Osteolytic metastases with local release of cytokines (including osteoclast activating factors)
Tumour secretion of parathyroid hormone-related protein (PTHrP) and
Tumour production of 1,25-dihydroxyvitamin D (calcitriol).
Treatment usually involves intravenous fluid rehydration followed by administration of a bisphosphonate (for example, pamidronate). Denosumab can be used as an anti-resorptive in patients who cannot take a bisphosphonate

Question 23

leptomeningeal carcinomatosis

Answer 23

Lithium toxicity is more common when renal excretion of lithium is reduced, for example, concomitant use of diuretics or non-steroidal anti-inflammatory drugs (NSAIDs), or dehydration.

Cardiovascular adverse effects are more likely to occur in the presence of underlying cardiac disease.

In acute or chronic toxicity, a lithium level of greater than 4 mmol/L or features of central nervous system toxicity or cardiac instability are indications for haemodialysis.

Whole bowel irrigation should be considered in adults who have ingested a slow release preparation of lithium of greater than 4 g.

Question 24

Testicular ca

Answer 24

90% germ cell tumors (GCTS) divided into seminomal or non seminomal GCTs. Nongerm cell malignancies (Leydig and Sertoli cell tumours, gonadoblastomas) make up less than 10% of all testicular tumours.

Patients with history of cryptorchidism have a 10- to 40-times increased risk of testicular cancer and this risk is greater for the abdominal versus inguinal location of undescended testis. Orchidopexy does not reduce the risk of subsequently developing a malignancy. An abdominal testis is more likely to be seminoma, while a testis surgically brought to the scrotum by orchiopexy is more likely to be NSGCT.

The classical presentation for testicular tumours is that of a healthy male in the third or fourth decade of life with a painless, swollen, hard testis. NSGCT has some yolk sac/embryoloigcal elements which produced AFP so this will be elevated. Choriocarcinoma also produces B-HCG.

Choriocarinomas , NSGCT, are usually small and non-palpable so present late often with signs of mets. it is the most aggressive. On ultrasound scanning, choriocarcinoma is associated with haemorrhage and necrosis and may appear more cystic, inhomogeneous, and calcified than a seminoma. Calcifications and cystic areas are less common in seminomas than in nonseminomatous tumours.

Question 25

hormonal treatment breast ca

Answer 25

Patients with oestrogen receptor (ER)-positive tumours are managed with endocrine therapy with either anastrozole or tamoxifen, and patients whose tumours are ER-negative or are refractory to endocrine treatment should receive chemotherapy.

Patients with HER2 overexpression warrant treatment with trastuzumab in addition to the chemotherapy.

Bevacizumab is indicated only in patients with HER2-negative metastatic breast cancer and has not been studied in the adjuvant setting.

Question 26

bony mets and brest ca treatment

Answer 26

In patients with bony metastases hormonal therapy is usually combined with bisphosphonate therapy; the combination of anastrozole and zoledronic acid is the most appropriate therapy for this patient at this time.