Oncology quickfire

Question 1

Carcinoid syndrome
a) First line therapy
b) 2nd line therapy (risk of this Rx)

Answer 1

a) Octreotide

b) Methysergide
- risk of retroperitoneal fibrosis (which is why it is no longer used in migraines)

Question 2

Prostate Ca
a) Bone mets unlikely if PSA is less than…?
b) What value indicates referral in men aged 50-69
c) PSA false negative and false positive

Answer 2

a) 20

b) >3 should be referred 2 week wait
<50 and >69 PSA not reliable

c) - FN - 15% with prostate Ca will have normal PSA
- FP - 75% with raised PSA will have normal prostate (25% will have Ca)

Question 3

Ovarian cancer
a) Risk of malignancy score
b) Low vs high risk threshold
c) Causes of a raised CA 125
d) Krukenberg tumours

Answer 3

RMI:
- US features (multiloculated cysts, solid areas, bilateral lesions, ascites, metastatic lesions) - score 1 if 0-1 present, score 3 if 2 or more present
- x 3 if postmenopausal
- x CA-125 result

Low risk ≤200
High risk >200

c) CA-125 can be raised due to:
- Gynaecological malignancy: ovarian*, endometrial, cervical, fallopian, germ cell
- Non-gynae malignancy: breast, colon, lung, pancreas, peritoneal
- Benign gynaecological conditions: fibroids, polyps, pregnancy, cysts, benign tumours, menstruation, inflammation
- Other: liver disease, ascites, TB, inflammatory disease, CCF, diabetes, etc.

*If exceptionally high, much more likely to be ovarian Ca

d) Metastatic tumours within the ovary, usually of stomach or other GI tract origin

Question 4

Thyroid cancer
a) Which commonly causes hypercalcaemia?
b) Which commonly presents late, with cervical LN (90%), lung mets (50%) and tracheal invasion at presentation?
c) Most common
d) Measure of recurrence in follicular and papillary cancer

Answer 4

a) Medullary thyroid carcinoma - calcitonin secreting

b) Anaplastic thyroid cancer

c) Papillary (85%), then follicular (10%), then MTC (5%), then anaplastic (<0.1%)

d) Serum thyroglobulin

Question 5

Doxorubicin - side effects

Answer 5

Acute cardiac toxicity
Chronic - cardiomyopathy (dose dependent)

Question 6

Breast Ca treatment
a) HER-2 positive - ? (risk?)
b) Oestrogen receptor (ER) positive - ?
c) Triple negative

Answer 6

a) Trastuzumab (Herceptin)
- risk of cardiac toxicity. Must do ECHO before and during/after treatment

b) - Pre-menopausal: tamoxifen* (Selective ER-modulator -has antagonistic and partial agonistic properties) + ovarian suppression (GnRH analogue)
- Post-menopausal: anastrazole/letrozole** (aromatase inhibitor). Sometimes tamoxifen is used also post-menopause also but higher risk of VTE and endometrial Ca in postmenopausal women treated with tamoxifen.
N.B. Aromatase inhibitors are ineffective pre-menopause as ovaries are producing oestrogen, which aromatase is not involved in.

*Tam-oxifen (use Tam-pons)
**If they’re anastraz-old

c) - Faster growing, more common in black women, <40s and BRCA1 +ve
- Don’t respond well to hormonal therapies.
- Mainstay is chemo/radiotherapy and surgery

Question 7

Residual tumour staging

Answer 7

Rx: could not assess
R0: no residual tumour
R1: microscopic residual tumour
R2: macroscopic residual tumour

Question 8

Tumour lysis
a) MoA of rasburicase

Answer 8

a) Uric acid oxidation

Question 9

Cisplatin
a) How it works
b) Cancers used in
c) Side effects

Answer 9

a) Leads to cross-linking* of DNA which harm ability for DNA to self-repair and replicate

*cross-links are like plaits (cis-plait-in)

b) SCLC, sarcoma, head and neck cancer, ovarian, bladder

c) Nephrotoxic, neurotoxic*, ototoxic, N&V, electrolyte disturbance (hypomagnesaemia, hypokalaemia and hypocalcaemia)

*mainly affects DRG causing a sensory neuropathy

Question 10

RET proto-oncogene
a) Cancers implicated in gain of function mutations
b) Loss of function mutation - disease implicated

Answer 10

a) Gain of function mutations:
MEN-2 syndrome - MTC, phaeo, parathyroid
Papillary thyroid cancer
NSCLC

b) Hirschsprung’s

Question 11

Cyclophosphamide
a) Risks
b) What is given with it to prevent one of these risks?

Answer 11

a) Haemorrhagic cystitis
- Bladder Ca
- Lung fibrosis

b) MESNA given to prevent haemorrhagic cystitis

Question 12

5-FU
a) Cancer use
b) Risks
c) Similar oral alternative

Answer 12

a) Duke’s C or D colorectal cancer as adjuvant to surgery

b) Neutropenia, diarrhoea, hand-foot syndrome (acral redness, swelling +/- desquamation), coronary vasospasm

c) Capecitabine

Question 13

Hep C patient with cirrhosis has rapid increase in ALP

Answer 13

HCC

Question 14

Breast cancer
- prognostic index

Answer 14

Nottingham prognostic index
NPI = (0.2. x S) + N + G

S = tumour size
N = nodes
G = grade

Question 15

50 year old woman with new DVT - consider what causes

Answer 15

Cancer esp ovarian, endometrial, breast
HRT/COCP related

Question 16

55 year old woman with new onset diabetes and abdominal pain - concern?

Answer 16

Pancreatic cancer

Question 17

60 year old with renal cell carcinoma on iplimumab and nivolumab chemotherapy. Presents with T1RF. Bloods unremarkable. Differentials?

Answer 17

Checkpoint inhibitor pneumonitis
PE

Question 18

SCLC spread to hilar lymph nodes. Appropriate management?

Answer 18

Not suitable for resection
Combination chemotherapy - 75% chance of response

Question 19

Intracranial radiation effects

Answer 19

• Loss of hair, nausea
• Worsening ICP from swelling - headaches, vomiting, seizures, etc
• Post radiation somnolence - often occurs 3-6 weeks later
• SMART - Stroke like migraine attacks after radiation therapy - can present years later, T2 hyper intensity on MRI, usually self resolve but may require anticonvulsants if seizures present

Question 20

Tamoxifen
- uses
- side effects

Answer 20

a) Uses
- premenopausal ER-positive cancer (acts as an oestrogen antagonist)
- Post surgery to reduce risk of recurrence
- Prophylaxis in women at high risk due to family history
- generally taken for 5 years only, or longer if metastatic BC

b) side effects: (related to oestrogen)
- hot flushes, sweats, vaginal dryness
- VTE risk
- Endometrial Ca risk
- Fluid retention and weight gain
- Positive: lower risk of IHD, lower risk of osteoporosis

Question 21

Renal cell carcinoma management

Answer 21

• Nephrectomy first line even if distant mets as removal of tumour can cause regression of mets and improve symptoms related to anaemia/Pain etc. Partial neph if poor renal function or needing bilateral nephrectomy
• Radiotherapy has little value
• Chemotherapy can be considered.
• Kinase inhibitors used eg pazopanib
• Checkpoint inhibitors used eg iplimumab

Question 22

Refractory loin pain from bladder cancer - management option

Answer 22

Obturator nerve block. Responds much better to this than opiates

Question 23

MSCC (in patients with known cancer)
a) Symptoms and signs to suspect spinal mets
b) Symptoms and signs to suspect MSCC
c) Imaging
d) Treatments for spinal mets without MSCC
e) Treatments for MSCC

Answer 23

a) Any of the following symptoms and signs of spinal mets should be discussed with MSCC coordinator within 24h:
- Cervical or thoracic pain*
- Progressive or severe/unremitting lumbar pain
- Localised tenderness
- Nocturnal pain preventing sleep
- Pain worse on straining e.g. during defecation/ coughing /sneezing

*Thoracic mets the classic spread from breast Ca due to lymphatic drainage

b) Any of the following signs or symptoms should prompt immediate discussion with MSCC:
- Radicular pain
- Difficulty walking, leg weakness
- Bladder or bowel dysfunction
- Signs on examination of cord compression/CES

c) Urgent whole-spine MRI

d) - Pain ladder
- Bisphosphonates in myeloma, breast or prostate Ca to prevent fracture and treat pain (not for any other causes of spinal mets)
- Consider radiotherapy for pain resistant to the above
- Consider vertebroplasty (cement injection) if refractory pain or collapse
- Consider stabilising surgery for unstable spine to prevent MSCC or for refractory pain
- Consider orthoses if unstable spine but unsuitable for surgery

e) - Bed rest, log rolling, ulcer prevention, VTE prophylaxis, bladder/bowel care, etc.
- Dexamethasone 16mg OD until surgery/RT, then gradually taper over 5-7 days. Increase dose if any worsening neurology. Monitor glucose.
- Surgery for cord decompression and spinal stabilisation, ideally before they lose ability to walk
- If unsuitable for surgery, for RT unless tetra/paraplegic for >24h with good pain control, or very poor prognosis

Question 24

Traztuzumab (herceptin)
- cardiac toxicity

Answer 24

ECHO monitoring must be done due to risk of cardiomyopathy
If EF drops by 10% and below 50%, it must be stopped with a re-Echo in 3 weeks

Question 25

SVC obstruction - management

Answer 25

• Dexamethasone stat
• Endovascular stenting asap (if bronchial Ca cause)