Oncology

Question 1

A 72-year-old lady presents with a complaint of a unilateral mass in the right upper quadrant of the breast, which is hard in consistency and associated with enlarged axillary lymph nodes, which are fixed.

Answer 1

Carcinoma
Breast cancer is around a hundred times more common in women than men. Its incidence increases with age. The main features include a painless, firm to hard mass, with irregular borders fixed to adjacent tissues, nipple retraction and discharge, breast asymmetry and skin changes. Features of advanced disease include bone pain weight loss and arm swelling. Definite diagnosis is by biopsy.

Question 2

A 21-year-old lady attends with a firm mass in the upper quadrant of the left breast. This mass is mobile, no axillary nodes are palpable.

Answer 2

Fibroadenoma
Fibroadenomas are the most common benign female breast tumours. They occur most often during the reproductive years. They usually have a rubbery feel on palpation and are mobile. They are not tender and do not become malignant. The diagnosis is confirmed by biopsy.

Question 3

A 32-year-old woman complains of lumps and discomfort in her left breast. Her symptoms are intermittent and peak just before her periods.

Answer 3

Fibrocystic disease
Fibrocystic changes can occur in either or both breasts, and are most common in the upper, outer quadrants. These changes are benign and do not increase the risk of breast cancer. Symptoms, especially discomfort, are related to, and peak before, the menstrual periods. The breast tissue has a cobblestone feel on palpation.

Question 4

A 58-year-old woman attends with excoriation of the skin of her right nipple and has been aware of a bloody discharge.

Answer 4

Intraduct carcinoma in situ
Intraductal carcinoma in situ and carcinoma may present primarily with bloody, painless, nipple discharge. The nipple may be deformed or retracted and itchy - Paget’s disease. In the absence of a mass, 70% have carcinoma in situ and 30% invasive carcinoma.

Question 5

A 24-year-old woman, who has been breast feeding her infant, develops a painful swelling in her left breast. She is pyrexial and has a erythematous, tender and swollen left breast with a vague mass underlying the nipple.

Answer 5

Breast abscess
Breast abscesses are common in lactating women, and are associated with all the features of inflammation as demonstrated in this case - redness, pain, heat and tenderness.

Question 6

A 70-year-old male receiving treatment for metastatic bronchial carcinoma complains of deteriorating dyspnoea. He is noted to have compromised respiratory function.

Answer 6

Start oxygen therapy

The patient with bronchial carcinoma and dyspnoea would most appropriately be treated with oxygen.

Question 7

A 72-year-old male diagnosed with metastatic bowel carcinoma is being treated for bone pain with high doses of oral morphine sulphate. Recently he has become aware of increasing constipation and lower abdominal pain.

Answer 7

Macrogol
The patient with metastatic bowel carcinoma has typical opioid side effects of constipation. The most appropriate treatment is macrogol in the first instance.

Question 8

A 75-year-old patient treated with tramadol for control of pain related to metastatic malignant melanoma. The patient still feels that the pain is unbearable.

Answer 8

Escalate opioid therapy
The patient with the metastatic malignant melanoma has pain despite tramadol. Consequently escalation of opioid analgesia is required with the introduction of oramorph as the next appropriate step.

Question 9

A 66-year-old female with carcinoma of the breast associated with multiple metastases is receiving palliative care. She develops severe nausea and vomiting and bone pains. Investigations reveal a serum calcium concentration of 3.5 mmol/l.

Answer 9

Pamidronate IV
The patient with breast carcinoma has symptoms of symptomatic hypercalcaemia and the most appropriate therapy is IV rehydration and pamidronate therapy. Pamidronate, a bisphosphonate may also be associated with the relief of bone pain.

Question 10

An 80-year-old male receiving treatment for prostate carcinoma complains of pelvic pain and is noted to have pelvic metastases on radiological investigation.

Answer 10

Palliative radiotherapy

The patient with prostate carcinoma may well respond to palliative radiotherapy which should be considered in this case.

Question 11

A 65-year-old female is receiving treatment for colon cancer with a combination chemotherapy regime that includes irinotecan.
Which of the following best describes the action of irinotecan?
(Please select 1 option)
	 Alkylating agent
	 DNA antimetabolites
	 Inhibition of protein synthesis
	 RNA/DNA antimetabolites
	 Topoisomerase inhibitor

Answer 11

Topoisomerase inhibitor This is the correct answerThis is the correct answer
Irinotecan is a chemotherapy agent that is a topoisomerase 1 inhibitor. Chemically, it is a semisynthetic analogue of the natural alkaloid Camptothecin.

Its main use is in colon cancer, particularly in combination with other chemotherapy agents. This includes the regimen FOLFIRI which consists of infusional 5-fluorouracil, leucovorin, and irinotecan.

Question 12

A 69-year-old gentleman presents with loin pain and frank haematuria.
After investigation he is diagnosed with a renal cell carcinoma.
Which is the most common mode of initial dissemination of renal cell carcinoma?
(Please select 1 option)
Along the renal vein
Multiple lung metastases that regress after resection of the primary
Solitary lung metastases
To the IVC
To the ureter

Answer 12

Along the renal vein

Renal cell carcinomas are prone to spread into the renal vein from where they can grow into the IVC.

Tumour thrombi may also be swept into the circulation where they lodge in the lungs as cannon ball metastases.

Question 13

A 31-year-old male is receiving treatment for testicular carcinoma with cisplatin based chemotherapy.
Which of the following best describes the action of cisplatin?
(Please select 1 option)
	 Alkylating agent
	 DNA antimetabolites
	 Inhibition of protein synthesis
	 RNA/DNA antimetabolites
	 Topoisomerase inhibitor

Answer 13

Alkylating agent

Cisplatin is a platinum based chemotherapy used in the treatment of testicular tumours, ovarian tumours and lymphomas. It functions through crosslinking DNA preventing the division required for rapid mitosis. Although it does not have an alkyl group, it is classed as an alkylating agent.

Question 14

A 30-year-old woman has a right mastectomy and axillary lymph node dissection for a carcinoma diagnosed by fine needle aspiration cytology.
The histological pattern is that of a poorly differentiated carcinoma that is negative for oestrogen and progesterone receptors, but is positive for HER2/neu. One axillary lymph node demonstrates micro-metastases.
Her 32-year-old sister is found to have a similar lesion.
Which of the following statements regarding risk factors for this lesion is the most appropriate?
(Please select 1 option)
A history of late menarche is likely to be present in females in this family
Fibrocystic changes were present for many years
She had a history of exposure to hydrocarbon compounds
She has a positive antinuclear antibody test
These findings suggest a BRCA-1 mutation

Answer 14

These findings suggest a BRCA-1 mutation This is the correct answerThis is the correct answer
A small number of breast cancers are the result of an inherited BRCA-1 mutation (or BRCA-2) but the family history of breast cancer at a young age makes this more likely.

Early menarche and late menopause and nulliparity are risks for breast cancer.

Autoimmune diseases do not appreciably increase the risk for breast cancer.

Question 15

A 24 year man with 47XXY karyotype is found to have an anterior mediastinal mass which on histology shows a germ cell tumour

Answer 15

AFP
Klinefelter syndrome is associated with the development of non-seminomatous germ cell tumours. Non seminomatous germ cell tumours are associated with elevated AFP or beta subunit Human chorionic gonadotrophin.

Question 16

A 45-year-old woman attends follow up; she previously had a total thyroidectomy and radioiodine therapy as management of her papillary thyroid cancer.

Answer 16

Serum thyroglobulin
Well differentiated thyroid cancer comprises 1% of all malignancies. It is the most common endocrine malignancy. Serum thyroglobulin is an important monitoring tool, useful in detecting relapse of well differentiated thyroid cancer, following complete removal of thyroid tissue surgically and radioiodine ablation.

Question 17

A 60-year-old man presents with weight loss, symptoms of obstructive uropathy and low back pain.

Answer 17

Prostate specific antigen (PSA)
This patient has symptoms suggestive of prostate cancer. PSA is a glycoprotein that is expressed by normal and neoplastic prostatic epithelium. Its major use is for monitoring response following treatment of prostatic cancer. Its use for screening for prostatic cancer is still being evaluated. A high PSA of more than 4 ng/ml will require investigation to exclude cancer, benign prostatic hypertrophy, prostatitis and perineal trauma.

Question 18

A 50-year-old man who attends gastroenterology follow up for cirrhosis of the liver has been found to have a large dominant nodule in the right lobe of liver on his recent CT scan.

Answer 18

AFP
In cirrhotic patients, a dominant nodule which is not clearly a haemangioma should be considered as hepatocellular cancer until proven otherwise. A markedly elevated serum AFP is diagnostic of hepatocellular cancer.

Question 19

A 40-year-old man presents with a thyroid nodule. Five years he underwent adrenal surgery to remove a phaeochromocytoma. Also, he mentions that his mother has had parathyroid surgery.

Answer 19

Serum calcitonin
Medullary thyroid cancer (MTC) needs to be excluded. MTC is inherited in an autosomal dominant fashion, in about 20% of cases. Serum calcitonin which is secreted by the parafollicular cells of the thyroid may be elevated in MTC and is useful tumour marker.

Question 20

A 60-year-old woman with advanced breast cancer complains of thirst and is dehydrated. Her ECG shows a short QT interval.

Answer 20

Hypercalcaemia
Hypercalcaemia is relatively common in patients with cancer, occurring in approximately 10 - 20% of cases. It occurs in patients with both solid tumors and leukaemia. The most common cancers associated with hypercalcaemia are breast and lung cancer and multiple myeloma. Administration of bisphosphonates has been used to treat the hypercalcaemia of malignancy. In addition, bisphosphonate therapy may prevent skeletal complications and perhaps improve survival in patients with multiple myeloma or breast cancer.

Question 21

A 42-year-old woman who is followed by an oncology clinic has noticed that her left arm does not fit into her favourite jacket sleeve. She has some discomfort in that arm but no signs of inflammation on examination.

Answer 21

Lymphoedema
Lymphoedema is due to the disruption of lymphatic drainage. Where the underlying cause is malignancy this disease is often first noticed by the patient as an asymmetry or increased circumference of an extremity. As swelling slowly progresses, patients may have difficulty fitting into clothing. Once well established, lymphoedema may cause fatigue related to the size and weight of the extremity, embarrassment in public, and severe impairment of daily activities.

Question 22

A 42-year-old woman who is known to have advanced breast cancer presents with progressive breathlessness and weight loss. Chest examination reveals stony dull percussion note over the left lower lung.

Answer 22

Pleural effusion
Malignant pleural effusion from pulmonary spread. Diagnosis would be confirmed by chest x ray and diagnostic aspiration. If the patient is in respiratory distress, therapeutic aspiration must be performed.

Question 23

A 60-year-old woman has had persistent low back pain for the previous three months, unrelieved by lying down. Physical examination reveals intact sensation in both lower limbs.

Answer 23

Cord compression
Spinal cord compression usually follows haematogenous dissemination of malignant cells to the vertebral bodies, thoracic spine (70% of cases), lumbar spine (20%), cervical spine (10%) and multiple spinal levels (30%).

Systemic cancers with a tendency for spinal cord metastasis include the following:

Breast
Prostate
Renal or lung neoplasms
Lymphoma
Sarcoma
Multiple myeloma
Early symptoms are often nonspecific and include local pain or stiffness. Gradually worsening back pain is the classic initial feature of spinal cord neoplastic disease in about 90% of adult patients who are affected.

Paraplegia and bowel or bladder disturbances (for example, constipation, urinary hesitancy, retention, incontinence) are usually late findings except in conus medullaris syndrome, in which sphincter dysfunction and saddle anesthesia may emerge early in the course.

Question 24

A 60-year-old woman presents with weight loss of two stones and poor appetite of three months duration. She complains of shoulder tip pain. On clinical examination, she is jaundiced and has ascites.

Answer 24

Liver metastases
Sixty per cent of breast cancers metastasise to the liver. The only physical sign may be hepatomegaly, sometimes with nodularity of the free edge. About 30% of patients with liver metastases have a normal-sized liver. The patient may have weight loss with malaise and abdominal enlargement secondary to hepatomegaly and/or ascites. The presence of ascites usually indicates widespread tumours in the liver, and it is regarded as a grave prognostic sign.

Question 25

A 65-year-old woman is admitted with left leg pain and weight loss which have developed over the last one month.
On examination she is found to have a left flank mass associated with a deep vein thrombosis (DVT) and further investigations confirm a renal cell carcinoma with lung metastases. She is treated for her DVT with low molecular weight heparin followed by warfarin.
Which of the following is the most appropriate treatment for her renal carcinoma?
(Please select 1 option)
Interleukin 2
Nephrectomy
Palliative therapy alone
Platinum based chemotherapy
Radiotherapy

Answer 25

IL-2
This is stage IV renal carcinoma and the prognosis is poor.

There is no evidence to support nephrectomy in this situation, but drugs such as interferon, and more recently, interleukin 2 show promise with reported carcinoma response rates with reduction in tumour bulk of approximately 15%.

Question 26

A 62-year-old male undergoes surgery for caecal carcinoma.
Which of the following tumour markers is most appropriate for the continued surveillance of this patient?
(Please select 1 option)
	 AFP
	 CA 19-9
	 CA 27-29
	 CA 125
	 CEA

Answer 26

CEA This is the correct answerThis is the correct answer
CEA is the most appropriate tumour marker for the monitoring of potential recurrence of colonic cancer.

CEA is also elevated in breast, melanoma and pancreatic malignancy to name but a few.

The value of CA 19-9 is higher concentrations often reflect more advanced pancreatic cancer.

Question 27

Glucagonoma

Answer 27

Necrolytic Migratory erythema
Glucagonoma, a rare pancreatic malignancy is typically associated with necrolytic migratory erythema, an erythematous, scaling, and sometimes bullous and erosive dermatitis occurring irregularly in plaques chiefly on the lower trunk, buttocks, perineum, and thighs.

Question 28

Peutz Jegher’s syndrome

Answer 28

Circumoral pigmentation
Peutz Jegher’s syndrome an autosomal dominant condition consisting of numerous small bowel hamartomas is characterisied by circumoral pigmentation/freckling.

Question 29

Phaeochromocytoma

Answer 29

Café-au-lait patches
Phaeochromocytoma is a feature of many conditions such as von Hippel-Lindau disease, Neurofibromatosis (axillary freckling, café-au-lait patches and neurofibromas) as well as MEN type 2 (Medullary thyroid cancer, hyperparathyroidism and Phaeo).

Question 30

Gastric adenocarcinoma

Answer 30

Acanthosis Nigricans is a cutaneous manifestation of typically Gastric malignancy but is also associated with conditions such as Insulin-resistance (Type 2 diabetes/Polycystic Ovarian Syndrome) and drug therapy such as Nicotinic acid.

Question 31

Acute myeloid leukaemia

Answer 31

Pyoderma gangrenosum
Pyoderma Gangrenosum is associated with TB, Inflammatory bowel disease and internal malignancy such as Myeloid Leukaemias.

Question 32

Carcinoid syndrome

Answer 32

Pellagra
Carcinoid syndrome, a neuroendocrine tumour produces 5-hydroxytryptophan (5HT) with increased tryptophan consumption creating niacin deficiency and Pellagra.

Question 33

Ovarian carcinoma

Answer 33

Hirsutism

Ovarian malignancy may be associated with excessive testosterone production and hence virilisation with hirsutism.

Question 34

Multiple hamartomas and thyroid cancer

Answer 34

Cowden’s disease
Cowden’s disease is an autosomal dominant inherited condition characterised by multiple hamartomas and neoplasms of ectodermal, mesodermal and endodermal origin. It occurs mainly in white persons and the mean age at the time of the diagnosis is 41 years.

Question 35

Microprolactinoma

Answer 35

Galactorrhoea
A microprolactinoma is associated with hypogonadism. Gynaecomastia is not a feature of microprolactinomas in males, but galactorrhoea is certainly a common presenting complaint associated with prolactinoma.

Question 36

A 55-year-old female presents with diarrhoea and flushing and is diagnosed with Carcinoid syndrome.

Answer 36

Pellagra
Carcinoid syndrome is associated with depletion of tryptophan required in the synthesis of 5HT and this is associated with the dermatological condition, pellagra.

Question 37

A 68-year-old male presents with flank heaviness and is diagnosed with a renal carcinoma.

Answer 37

Polycythaemia

Renal carcinoma is well recognised to produce erythropoietin and this is associated with polycythaemia.

Question 38

A 57-year-old male presents with weight loss and haemoptysis and is diagnosed with squamous cell carcinoma of the lung.

Answer 38

Hypercalcaemia
Squamous cell carcinoma of the lung is associated with the synthesis of PTH-related peptide and hence hypercalcaemia as a non-metastatic manifestation.

Question 39

A 61-year-old male presents with weight loss and haemoptysis and is found to have an oat cell carcinoma of the lung.

Answer 39

Eaton-Lambert syndrome
Oat cell carcinoma of the lung is associated with a number of non-metastatic manifestations which include syndrome of inappropriate antidiuretic hormone (SIADH), Cushing’s syndrome (ectopic ACTH), cerebellar degeneration and Eaton-Lambert syndrome which is akin to myasthenia gravis (MG), except that weakness tends to be more distal.

Hypercalcaemia is due to ectopic PTHrp release due to squamous cell Ca of the lung.

Question 40

A 55-year-old female presents with dysphagia and weight loss. She is diagnosed with a thymoma.

Answer 40

Myasthenia gravis
Thymoma is associated with myasthenia gravis and is found in approximately 15% of all cases of MG and MG is found in approximately 50% of all cases of thymoma.

Question 41

A 65-year-old male presents with back pain and weight loss. He is diagnosed with pancreatic carcinoma.

Answer 41

Migratory thrombophlebitis

Pancreatic carcinoma is classically associated with a migratory thrombophlebitis.