Oncology Flashcards
A 2-year-old boy presents with abdominal distension, haematuria and vague pain. Examination reveals a large nodular mass on the left kidney. A. Kaposi's sarcoma B. Hodgkin's lymphoma C. Grawitz's tumour D. Wilm's tumour E. Ewing's sarcoma F. Pancoast tumour G. Brodie's tumour H. Burkitt's lymphoma
D
Question 1 Wilms’ tumour (a.k.a. nephroblastoma) is the commonest intra-abdominal tumour in children, rarely occuring in adults. It is a malignant tumour derived from embryonic mesodermal tissues. Patients present with a loin mass, weight loss, anorexia and fever. Although the tumour is rapidly growing an behaves aggressively, it has an 80% survival rate at 5 years.
A 32-year-old male architect arrives in your clinic accompanied by his husband. He complains of a 2-week history of indigestion and dysphagia. On examination you notice multiple purple bruise-like lesions on his right arm. There is no pain or itching. A. Kaposi's sarcoma B. Hodgkin's lymphoma C. Grawitz's tumour D. Wilm's tumour E. Ewing's sarcoma F. Pancoast tumour G. Brodie's tumour H. Burkitt's lymphoma
A
Question 2 Kaposi’s sarcoma is a malignant tumour of the vascular endothelium consisting of spindle cells and small blood vessels. It is very rare in patients without HIV infection or those who are immunosuppressed. It gives rise to multiple lesions in the skin that appear like purple bruises and are not painful to touch. In about 40% of cases (such as this one) there is gastrointestinal involvement.
A 55-year-old gentleman complains of progressive weakness in his left hand. On examination, you notice that there is wasting of the intrinsic muscles of the hand innervated by the T1 nerve root. There is also mild ptosis and meiosis on the left hand side of his face. A. Kaposi's sarcoma B. Hodgkin's lymphoma C. Grawitz's tumour D. Wilm's tumour E. Ewing's sarcoma F. Pancoast tumour G. Brodie's tumour H. Burkitt's lymphoma
F
Question 3 Pancoast tumours are lung tumours located at the apex of the lung. They typically extend to involve the sympathetic ganglion resulting in ipsilateral Horner’s syndrome (ptosis, meiosis, anhydrosis). In some cases, the lower roots of the brachial plexus are also involved, resulting in pain and weakness in the muscles of the arm and hand, specifically in the T1 distribution.
A 6-year-old Ethiopian boy presents with a 4-week history of a swelling in his jaw, which has been progressively enlarging. He has a history of EBV infection. Examination of the oral cavity reveals minor disruption of the teeth with no laryngeal obstruction. A. Kaposi's sarcoma B. Hodgkin's lymphoma C. Grawitz's tumour D. Wilm's tumour E. Ewing's sarcoma F. Pancoast tumour G. Brodie's tumour H. Burkitt's lymphoma
H
Question 4 Burkitt’s lymhpoma is a high-grade B-cell lymphoma endemic in some parts of Africa. It frequently involves the jaw and is most often seen in African children with previous EBV infection (there is a strong association between the two) Other associations include chronic malarial infection and translocation of chromosome 8 on the c-myc gene with chromosome 14.
A 35-year-old woman comes to see you in the clinic. She is noticeably distressed and complains of a bulky mass in her left breast which has grown rapidly over the past month. On examination you notice that the contour of the breast has been distorted and the overlying skin is red and tender. Core biopsy reveals mixed connective tissue and epithelial elements. A. Kaposi's sarcoma B. Hodgkin's lymphoma C. Grawitz's tumour D. Wilm's tumour E. Ewing's sarcoma F. Pancoast tumour G. Brodie's tumour H. Burkitt's lymphoma
G
Question 5 Brodie’s tumour (a.k.a. phyllodes tumour) are rare tumours of the fibroepithelial stroma of the breast. The history of a rapidly growing mass that distorts the shape of the breast points towards this disease. Most of these tumours are benign and the prognosis after surgery is excellent.
A 45-year-old woman presents with an irregular 4cm firm lump in the left breast. O/E the lump is fixed to the overlying skin and their is bloody discharge from the left nipple. A. CA 15-3 B. CA 19-9 C. α-Fetoprotein D. Tyrosinase E. Prostate-specific antigen F. Prostatic acid phosphatase G. BRCA-1 H. Carcinoembryonic antigen
A
Question 1 High Ca 15-3 levels suggest metastatic breast disease. However, it has poor sensitivity and is therefore not used as a screening procedure to detect breast carcinoma. This tumour marker has recently been superseded by Ca 27-29, which is claimed to be more sensitive and specific. However, CA 27-29 lacks predictive value in the earliest stages of breast cancer and thus has no role in screening for or diagnosing the malignancy.
A 56-year-old man presents with anorexia and jaundice. He reports losing weight over the past month. He has a bilirubin of 350 umol/L, AST of 55 IU/L and an ALP of 750 IU/L. O/E the gallbladder is palpable. A. CA 15-3 B. CA 19-9 C. α-Fetoprotein D. Tyrosinase E. Prostate-specific antigen F. Prostatic acid phosphatase G. BRCA-1 H. Carcinoembryonic antigen
B
Question 2 Ca 19-9 is used to confirm the diagnosis of malignant pancreatic tumours, differentiating them from chronic pancreatitis. However, it should not be used as a stand-alone diagnostic tool, rather as an adjunct to CT, U/S and ERCP. It is also used for monitoring the response to therapy. Levels can also be elevated in hepatbiliary disease, but it is not used in this setting.
A 70-year-old man presents with difficulty passing urine, haematuria and back pain. A hard irregular mass is palpable anterior to the rectum. A. CA 15-3 B. CA 19-9 C. α-Fetoprotein D. Tyrosinase E. Prostate-specific antigen F. Prostatic acid phosphatase G. BRCA-1 H. Carcinoembryonic antigen
E
Question 3 This patient’s histroy is suggestive of metastatic prostate cancer. Prostate-specific antigen (PSA) is used as a screening test, a diagnostic test, a measure of treatment success and a marker of recurrence. It has replaced the use of prostatic acid phosphatate (PSA). However, PSA lacks the required specificity as it is raised in patients without prostatic cancer (i.e. a high false positive rate). Therefore, it should be used alongside other methods of investigation, and not by itself, to make a diagnosis.
An 82-year-old woman presents with constipation, lower abdominal pain and a feeling of incomplete emptying. She looks emaciated and has lost 5 kgs over the past month. A. CA 15-3 B. CA 19-9 C. α-Fetoprotein D. Tyrosinase E. Prostate-specific antigen F. Prostatic acid phosphatase G. BRCA-1 H. Carcinoembryonic antigen
H
Question 4 Although carcinoembryonic antigen (CEA) lacks the sensitivity and specificity to be a diagnostic test for colorectal cancer, it has found a valuable application in the detection of recurrence of malignant disease following treatment.
A 50-year-old IVDU with a history of hepatitis C infection presents with jaundice and RUQ pain. He has lost weight over the past 2 months and claims he has no desire to eat food. A. CA 15-3 B. CA 19-9 C. α-Fetoprotein D. Tyrosinase E. Prostate-specific antigen F. Prostatic acid phosphatase G. BRCA-1 H. Carcinoembryonic antigen
C
Question 5 This patient is likely to have hepatocellular carcinoma (HCC) on a background of chronic hepatitis C infection. α-Fetoprotein (AFP) is one of the most widely used tumour markers for HCC, but may also be raised in patients with germ cell tumours, cirrhosis and hepatitis.
A 60-year-old gentleman with known lung cancer complains of a four-week history of facial swelling, intermittent blackouts, a tightness around the collar and headache which is worst when he first wakes up in the morning.
A. Meningitis B. Anaphylaxis C. Superior vena caval obstruction D. Raised intracranial pressure E. Tumour lysis syndrome F. Spinal cord compression G. Chemotherapy complication H. Ectopic PTH secretion I. SIADH
C
Question 1 This is a classic description of SVC obstruction. This occurs when the SVC is subjected to pressure from a tumour in the superior mediastinum or from thrombosis. The most common cause is lymph node metastases from bronchial carcinoma. The main clinical features are due to venous congestion, and there may even be stridor due to obstruction of the trachea or main bronchi. Initial treatment is with oral dexamethasone to reduce oedema around the tumour followed by long-term radiotherapy/chemotherarpy.
A 62-year-old man with known metastatic prostate cancer complains of sudden-onset weakness in both legs. O/E you notice significantly reduced power in the legs bilaterally, brisk knee and ankle reflexes and bilateral upgoing plantar reflexes.
A. Meningitis B. Anaphylaxis C. Superior vena caval obstruction D. Raised intracranial pressure E. Tumour lysis syndrome F. Spinal cord compression G. Chemotherapy complication H. Ectopic PTH secretion I. SIADH
F
Question 2 Metastasis to the spine has lead to compression of this patient’s spinal cord (a medical emergency). Spinal cord compression usually causes LMN signs at the level of the lesion and UMN signs below that level. If not recognised immediately and treated, the damage will become permanent.
A 45-year-old woman presents to A&E complaining of a secere headache that has been getting worse over the past 2 months. She claims it is worse whe nshe wakes up in the morning and coughs or sneezes.
A. Meningitis B. Anaphylaxis C. Superior vena caval obstruction D. Raised intracranial pressure E. Tumour lysis syndrome F. Spinal cord compression G. Chemotherapy complication H. Ectopic PTH secretion I. SIADH
D
Question 3 This lady’s symptoms are suggestive of raised ICP secondary to a mass lesion such as a brain tumour. Actions such as coughing, sneezing and laughing make the pain worse as they all lead to temporary increases in ICP. Patients often report the headache as being worst when they wake up in the morning. This is because ICP increases during sleep, probably from vascular dilatation due to CO2 retention.
A 70-year-old lady is brought into A&E after being found unconscious in her home. When examined she is found to be extremely drowsy and agitated when attempts are made to rouse her. Routine observations show that her BP is 160/100 mmHg and pulse 80 bpm. Her U&Es reveal: Na+ 119 mmol/l, K+ 3.0 mmol/l, urea 6.5 mmol/l, Cr 92 mmol/l; corrected Ca2+ 2.45 mmol/l; plasma osmolality: 255 mosmol/kg.
A. Meningitis B. Anaphylaxis C. Superior vena caval obstruction D. Raised intracranial pressure E. Tumour lysis syndrome F. Spinal cord compression G. Chemotherapy complication H. Ectopic PTH secretion I. SIADH
I
Question 4 There are many causes of SIADH, however in this case it is due to ectopic ADH secrtion from tumour cells, most commonly small cell lung carcinoma. The clinical features are due to the resulting dilutional hyponatraemia. Severe hyponatraemia may lead to convulsions, seizures, coma and even death. Characteristic the patient with SIADH will persistently excrete concentrated urine (with a higher urine osmolairity than serum), have normal renal and adrenal function and will have no oedema or hypovolaemia. When treating hyponatraemia take care not to correct the serum Na+ too quickly as this may lead to central pontine myelinolysis (as you may remember from your IBFD lectures!).
A 65 year old male undergoing chemotherapy for acute myeloid leukaemia starts to deteriorate on the ward. He complains of a tingling sensation in his fingers and around his lips. He also complains of muscle weakness and appears confused. His biochemistry reveals that he is hyperkalaemic, hyperphosphataemic, hyperuricaemic and hypocalcaemic. His creatinine is also elevated to 300 umol/L.
A. Meningitis B. Anaphylaxis C. Superior vena caval obstruction D. Raised intracranial pressure E. Tumour lysis syndrome F. Spinal cord compression G. Chemotherapy complication H. Ectopic PTH secretion I. SIADH
E
Question 5 Tumour lysis syndrome usually occurs in patients undergoing chemotherapy for lymphoproliferative malignancies, who have just initiated treatment. Lysis of tumour cells leads to the release of large amounts of potassium, phosphate and uric acid into the circulation. The excess phosphate binds to calcium, leading to hypocalcaemia and its clinical features. Patients are also at risk of developing acute renal failure due to the deposition of uric acid and calcium phosphate crystals in the renal tubules.
