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High Yield Neurosurgery FRCS Part 2 > Oncology (WM) > Flashcards

Oncology (WM) Flashcards

1
Q

What’s the mechanism of action of Temozolamide?

A

Temozolamide is an oral alkylating agent
The cytotoxic effect is due to adding an alkyl group (methyl is the smallest alkyl group) to DNA primarily at the O6 and N7 positions on guanine.

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2
Q

With reference to Temozolamide, what’s the significance of MGMT?

A

Temozolamide adds an alkyl group to DNA, most cells repair this damage using the protein O6-methylguanine-DNA methyltransferase. Temozolamide is more effective against tumours with subnormal MGMT activity. MGMT promotor methylation reduces MGMT activty.

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3
Q

What’s the difference in the relationship to the nerve between neurofibromas and schwannomas?

A

Schwannomas displace axons (centrifugal)

Neurofibrommas are unencapsulated and engulf the nerve of origin (centripetal)

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4
Q

What’s the incidence of NF1 and NF2?

A

1: 3000 live births (NF1)
1: 40,000 live births (NF2)

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5
Q

What’s are the gene product in NF1 and NF2?

A

neurofibromin (NF1)

schwannomin (NF2)

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6
Q

Where’s the gene locus for NF1 and NF2?

A

NF1 ch17

NF2 ch22

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7
Q

What are the 7 diagnostic features of NF1? (2 of more needed for diagnosis)

A 
3 skin:
>6 cafe au lait spots
>2 neurofibromas (or one plexiform neurofibroma)
Freckling (axillary or intertriginous)
3 head:
>2 lisch nodules (iris hamartomas)
Osseous abnomality (sphenoid dysplasia or thinning of long bone cortex)
Optic pathway glioma:
1 other:
First degree relative
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8
Q

What’s the function of neurofibromin?

A

It’s a negative regulator of the RAS oncogene

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9
Q

What are the diagnostic criteria for NF2?

A

Bilateral VS
OR
A combination of unilateral VS +/ first degree relative +/- 2 of meningioma, schwannoma, glioma, posterior subcapsular lens opacity, cortical wedge cataract
OR
multiple meningioma and two of the following

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10
Q

What is the effect of pregnancy of 8th nerve tumours?

A

It can accelerate the rate of growth

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11
Q

What is the classic clinical triad of tuberous sclerosis?

A

Seizures
Mental retardation
Facial angiofibromas

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12
Q

What’s the incidence of tuberous sclerosis?

A

1:6000 live births

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13
Q

Give a differential for benign skull lesions

A

Sclerotic:
Fibrous dysplasia
Osteoma
Intraosseous meningioma

Lytic:
Epidermoid cyst
Dermoid cyst
Calvarial sarcoid
Langerhans cell histiocytosis

Not easily classified above:
Ossifying fibroma
Paget disease
Haemangioma (osseous venous vascular malformation)

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14
Q

Give a differential for malignant skull lesions

A

Primary
Osteosarcoma
Chordoma
Chondrosarcoma

Secondary
Multiple myeloma
Mets

(All lytic except sclerotic mets)

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15
Q

What’s survival in GBM?

A

In the stummer study 5-ALA resection group
Total resection ~16.5 months
Partial resection ~12

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16
Q

What’ the survival benefit of temozamide + RTX and RTX alone?

A

Stupp with RTX + temo 14.6months (25% improvement)

vs 12.1 (10% improvement) RTX alone

17
Q

What’s the stupp protocol?

A

5 days a week RTX for 6 week with temozolamide
(60Gy total)
then four week break then up to 6 further cycles (5 days one 23 days off)

18
Q

What’s impact of 5-ALA on resection?

A

Improves complete resection 36%-65%

19
Q

What’s second line chemo for GBM?

A

PCV (procarbazine, lomustine, vincristine)

20
Q

What’s the evidence for resection LGG?

A

Jakkola cohort study 2017

6 years vs 14 years for intention to treat by surgical strategy

21
Q

What are the oncological options for LGG?

A

If residual and oliogo –> PCV and RTX
Non-codeleted –> consider PCV and RTX
No residual –> active monitoring
If intractable seizure and progression –> also an indication for PCV and RTX

22
Q

What are the grade I tumours?

A 
Astrocytic:
pilocytic
SEGA
Ependymal:
subependymoma
Myxopallipllary
Neuronal and mixed neuronal-glial tumours:
gangliocytoma (lhermitte duclos)
reosetter forming
DNET
others
Anything ganglio
23
Q

Describe MRS changes in glioma

A

Gliomas - increase in choline, relative fall in NAA

creatine is middle value

24
Q

How would you distinguish post fossa medulloblastoma, ependymoma and pilocytic astrocytoma on imaging? (1 classic feature of each)

A

Medulloblastoma - high density on CTH

Ependymoma - Grows through 4th ventricle foramina Pilocytic - nodule with cyst

25
Q

How does meningioma grade affect recurrence?

A

3* grade 2

5* grade 3

26
Q

What is 2 year control for acoustics with gamma knife vs microsurgery?

A

94% Gamma knife

97% surgery

27
Q

Describe House-Brackman scale?

A 
1 - normal
2 - normal at rest
3 - obvious but complete eye closure
4 - incomplete eye closure
5 - flickers
6 - no movement
28
Q

What tumour markers do you send of for pineal region?

A

alpha fetoprotein
bHCG
PALP

(Also remember to image whole spine for seeding)

29
Q

What’s the classification of germ cell tumours?

A 
Geminoma (weakly bhCG+ve)
Non-germinomatous germ cell tumours
  - embryonal carcinoma (AFP)
  - yolk sac tumour (AFP)
  - choriocarcinoma (bHCG)
  - teratoma
  - mixed germ cell tumour

Teratomas - don’t express markers

30
Q

Pineal origin tumours

A

Grade I - pineocytoma
Grade II-III - intermediate differentiation
Grade IV - pineoblastoma

31
Q

Describe approaches to pineal

A 
Infratentorial supracerebellar
Occipital transtentorial
Stereotactic
Endoscopic through third ventricle
(Interhemispheric transcallosal - if predominantly within third ventricle)
32
Q

What do you do for air embolism and what end tidal C02 changes occurs?

A

Fall in end tidal CO2

Flat
Flood field
Right side up if possible
100 percent 02

33
Q

What’s the classification for middle cranial fossa arachnoid cysts?

A

Galassi

I-III (small, medium, large)

34
Q

What are the criteria for brainstem testing?

A 
Exclude reversible (drugs, electrolytes)
Then
GCS 3
No response to CO2 challenge
Pupillary reflex 
Corneal reflex
Caloric reflex (COWS)
Gag reflex
Cough reflex
35
Q

What are features of acromegaly?

A 
Large hands
Sweaty palms
Carpal tunnel syndrome
Hypertension
Prominent supra-orbital ridge
Increased interdental spaces
Large nose
Macroglossia
Prognathism
Displaced apex beat
OSA
Increased risk of bowel Ca
DM
36
Q

How do you diagnose acromegaly?

A

glucose tolerance test

Give glucose and growth hormone should suppress

37
Q

Describe the knosp classification?

A 
0 - Intrasellar
1 - abutting cav sinus
2 - infiltrating cav sinus but not beyond carotid
3 - beyond carotid
4 - encasing carotid

High Yield Neurosurgery FRCS Part 2 (18 decks)

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