Past paper questions Flashcards
A 55 year old woman being treated for triple negative breast cancer presents with pain in her spine which has progressed over the past three weeks. However, her pain today is described as excruciating and is not responsive to pain relief.
A whole spine MRI is carried out and reveals the presence of bone metastases within the thoracic spine. She has received 6 cycles of BEC chemotherapy regimen and there has been no prior surgical intervention related to her breast cancer.
What is the single most likely route of metastatic spread to the bone?
Iatrogenic
Haematogeneous
Local Invasion
Lymphatic
Inflammatory
Haematogeneous
This is the correct answer. The most common mechanism of spread of metastasis is haematogeneous through blood vessels to distant sites. The lung, liver and brain are common sites for breast cancer metastases
A 30-year-old man attends the genetics clinic after discovering that he has the BRCA2 gene mutation.
Which cancer does this increase the risk of?
Soft tissue sarcoma
Pheochromocytoma
Colorectal cancer
Cancer of the parathyroid gland
Prostate cancer
Prostate cancer
Around 20–25% of men who carry the BRCA2 gene alteration develop prostate cancer at some point, mostly when over the age of 45. It also increases the risk of breast cancer in men.
A 75-year-old man with a previous history of prostate cancer cured by external beam radiotherapy presents to A&E with a history of urinary retention. On further probing, he describes a two-month history of severe lower back pain. He describes the pain as being worse at night and while lying flat, which has significantly disturbed his sleep.
What is the most important investigation to arrange to confirm the most likely diagnosis?
Magnetic resonance imaging (MRI) of the whole spine
Whole body positron emission tomography (PET) scan
Magnetic resonance imaging of the lumbar spine
Prostate specific antigen (PSA) serum level measurement
Computed tomography (CT) scan of the whole spine
Magnetic resonance imaging (MRI) of the whole spine
This is the correct answer. This man is likely presenting with symptoms of metastatic spinal cord compression following a recurrence of prostate cancer. This occurs due to vertebral body metastases which cause extradural compression of the spinal cord. Tumours which are most likely to metastasize to the bone include prostate (most common), breast, lung, kidney and thyroid cancers.
Spinal cord compression often occurs at multiple levels. Although this patient is complaining of only lower back pain, it would be important to image the entire spine to visualise any occult metastatic deposits beyond those causing his lower back pain
A 60-year-old man attends his General Practice with unintentional weight loss, abdominal pain and leg swelling. This has occurred over the past 6 months and has been gradually getting worse. He has no past medical history and admits he rarely sees the doctor. He denies any other symptoms. He is a heavy drinker and does not smoke. On examination, his abdominal pain is most prominent in the right hypochondriac region. The patient is put on a 2-week-wait referral for suspected malignancy.
Which of these tumour markers is most likely to be useful in the diagnosis and follow up for this patient?
Ca-125
Carcinoembryonic antigen (CEA)
Beta-hCG
Alpha-fetoprotein (AFP)
5-HIAA
Alpha-fetoprotein (AFP)
AFP is often raised in liver cancer. Given this patient’s symptoms, liver cancer is the most likely malignancy. AFP can also be used in liver cancer to assess response to treatment. It can also be used in the investigation of germ-cell tumours.
A 24-year-old man presents to his general practitioner (GP) complaining of tiredness and fever. He was diagnosed with testicular cancer last month and had his first dose of chemotherapy last week.
On further questioning, he does not report any other symptoms. His blood pressure is 125/80 mmHg and his temperature is 38.3°C.
Which of the following is the next best step in management?
Prescribe oral co-amoxiclav
Provide safety-net advice and book a follow-up appointment in one week
Prescribe oral amoxicillin
Take a blood sample and request an urgent full blood count (FBC)
Send to hospital for broad-spectrum IV antibiotics
Send to hospital for broad-spectrum IV antibiotics
If they present unwell or with a fever, any patient who has recently had chemotherapy should be presumed to have neutropaenic sepsis. The neutrophil count typically reaches its lowest point 7-10 days after chemotherapy, however, this may vary.
This patient should be sent urgently to hospital to receive broad-spectrum IV antibiotics. This is usually piperacillin with tazobactam (Tazocin). In addition, his full blood count should be checked to find out if he is neutropaenic
A 55-year-old woman with breast cancer has recently been diagnosed with secondary brain metastases causing raised intracranial pressure. She has been complaining of ongoing nausea and vomiting, despite being prescribed cyclizine 50 mg three times a day.
Which medication may be added to relieve her nausea?
Betahistine dihydrochloride 8–16 mg orally three times a day
Docusate 100 mg twice a day
Domperidone 10–20 mg orally three times a day
Hyoscine butylbromide 60 mg per day
Dexamethasone 8–16 mg per day
Dexamethasone 8–16 mg per day
Dexamethasone is part of the standard treatment for people with brain metastasis. Steroids are used to reduce swelling around the tumour and thereby improve symptoms. Palliative radiotherapy to the brain may also be considered in this scenario.
A 45-year old female has end stage renal cancer. Due to her cancer she has stage 4 chronic kidney disease. Which is the best drug to prescribe in her syringe driver for pain?
Diamorphine
Morphine sulphate
Alfentanil
Oxycodone
Hydromorphone
Alfentanil
This drug is first line in those with stage 4 or 5 chronic kidney disease. This is due to limited renal excretion of parent drug or metabolites.
A 25 year old woman presents to her oncologist with abdominal pain and dysuria. She reports abdominal pain, vomiting and muscle pain as well. She had radiotherapy for a stage 3 lymphoma 2 days ago. Her NEWS score is 0. Her blood tests show a raised potassium, phosphate alongside a reduced calcium.
What is the most likely cause?
Acute Kidney Injury
Urinary tract infection
Tumour lysis syndrome
Neutropenic sepsis
Superior Vena Cava Obstruction
Tumour lysis syndrome
The patient’s recent radiotherapy and symptoms fit with a diagnosis of tumour lysis syndrome causing renal failure. Blood results for tumour lysis syndrome are characterised by hyperkalaemia, hyperphosphatemia, hypocalcaemia, hyperuricaemia and increased blood urea nitrogen (BUN.)
A 77-year-old male with a recent diagnosis of Non-Hodgkin lymphoma (NHL) presents to A&E with shortness of breath and stridor. Pemberton’s test is positive. The patient is moved into a sitting position and given high-flow oxygen (15L/min via a non-rebreathe mask). Given the likely diagnosis, what is the next step in management of the patient in the emergency department?
Radiotherapy treatment
Nebulised salbutamol
Dexamethasone
Chest X-ray
Intubation and mechanical ventilation
Dexamethasone
This is the correct answer. This patient likely has superior vena cava syndrome caused by compression of the superior vena cava by a tumour (Non-Hodgkin lymphoma can cause superior vena cava syndrome). Pemberton’s test involves asking the patient to lift their arms above their head. If this causes facial plethora, the patient has Pemberton’s sign (i.e. a positive Pemberton’s test). Dexamethasone can reduce swelling and oedema associated with the tumour, helping to reduce the external compression of the superior vena cava
A 65-year-old man with a background of multiple myeloma presents to the emergency department. He reports a 2-week history of fatigue, increased urinary frequency, thirst, constipation and weakness. His wife informs you that he also seems to be more confused than usual.
His biochemistry blood results show:
Creatinine 100 nmol/L (59–104 nmol/L)
Urea 5 mmol/L (2.5–7.8 mmol/L)
Sodium 135 mmol/L (133–146 mmol/L)
Adjusted calcium 3.1 mmol/L (2.2–2.6 mmol/L)
Potassium 3.6 mmol/L (3.5–5.3 mmol/L)
Magnesium 0.8 mmol/L (0.7–1 mmol/L)
Phosphate 101 mmol/L (98–106 mmol/L)
How should this patient be initially treated?
IV calcium gluconate
Diuretics
Fluid and salt restriction
Sando-K tablets
IV fluids and bisphosphonates
IV fluids and bisphosphonates
The case is describing a moderate malignant hypercalcaemia that is symptomatic. The patient should therefore be admitted to the hospital and given IV fluids and IV bisphosphonates.
A 55-year old female with renal cell carcinoma attends her oncology appointment. She is on chemotherapy and radiotherapy. She asks about possible metastasis of the cancer. Where would it spread to first?
Bones
Liver
Blood vessels
Lungs
Lymph nodes
Blood vessels
Most carcinomas spread to the lymph nodes first, however, renal cell carcinomas spreads to the blood first.
Multiple endocrine neoplasia type 1 (MEN1)
MEN1 is predominantly associated with tumours of the parathyroid gland, the anterior pituitary gland and the pancreas.
Multiple endocrine neoplasia type 2A (MEN2A)
Around 25% of cases of medullary thyroid cancer are associated with MEN type 2A and mutation of the RET proto-oncogene. This genetic condition is also associated with pheochromocytomas and parathyroid hyperplasia or adenomas (causing hyperparathyroidism).
Peutz–Jeghers syndrome
This is an inherited condition that leads to the growth of hamartomatous polyps within the gastrointestinal tract. It increases the risk of gastrointestinal tract, pancreatic, cervical, ovarian and breast cancers. There is no association with thyroid cancer.
von Hippel–Lindau (VHL) syndrome
VHL syndrome is an inherited disorder characterised by the formation of tumours and cysts in the brain, spinal cord, kidneys, adrenal glands and the pancreas. It is not normally associated with an increased risk of medullary thyroid cancer.
A 65-year-old man with a background of multiple myeloma attends the emergency department with pain in his back, legs and arms. After investigation, it is suspected that his symptoms are being caused by metastases to the bones. He reports that he has tried paracetamol, ibuprofen and codeine without relief.
Which medication may be added to relieve the pain?
Baclofen
Gabapentin
Hyoscine butylbromide (Buscopan)
Zoledronic acid (a bisphosphonate)
Amitriptyline
Zoledronic acid (a bisphosphonate)
According to the WHO pain ladder, adjuvants (primary indication is not for pain) can be added at any stage. In this case, a bisphosphonate would be added next as there is evidence to show that they can reduce bone pain caused by metastatic cancer.
A 54-year-old woman attends her GP complaining of back pain. There are no red-flag symptoms, investigations are all normal and she has no significant past medical history. She is diagnosed with mechanical back pain and given paracetamol for pain relief. A week later, she returns as the paracetamol is not relieving the pain.
Which analgesic would you recommend next?
Codeine phosphate
Gabapentin
Ibuprofen
Morphine
Tramadol
Ibuprofen
According to the WHO pain ladder and NICE, analgesia for mild-to-moderate pain should be added in a step-wise fashion. If paracetamol (step 1) is not relieving the pain, it should be substituted with ibuprofen (as long as nonsteroidal anti-inflammatory drugs (NSAIDs) are not contraindicated). If this does not help, paracetamol and ibuprofen can be given together.
Analgesic Ladder
The WHO developed this ladder originally to manage cancer-related pain.
In practice, it is also used for both acute and chronicp painful conditions.
There are three steps:
Step 1: Non-opioid medications e.g. Paracetamol and NSAIDs
Step 2: Weak opioids e.g. codeine and tramadol
Step 3: Strong opioids e.g. morphine, oxycodone, fentanyl and buprenorphine
A 22 year old man is currently undergoing treatment for non-Hodgkin’s lymphoma. During his chemotherapy regimen he reports that he has become increasingly nauseous. He would like to be prescribed some medication for this.
What is the single most appropriate class of anti-emetic to prescribe him?
H2 receptor antagonist
D2 receptor antagonist
5HT3 antagonist
NMDA receptor antagonist
H1 receptor antagonist
5HT3 antagonist
This is the correct answer. Ondansetron is the most frequently agent in chemotherapy to treat nausea and vomiting
An 80 year old male has been admitted to his local hospice for end of life symptom management. He has stage IV adenocarcinoma of the lung. His main symptoms were of pain and anxiety.
He has been commenced on a syringe pump with the following medications:
Morphine sulphate 40mg/24h
Midazolam 10mg/24h
Over the past few hours he has become increasingly unable to clear his secretions, and is becoming distressed by the nursing staff having to provide regular oral suction. He denies pain.
Which of the following medication changes would be most appropriate?
Addition of Haloperidol 2.5mg/24h
Increase Midazolam to 20mg/24h
Reduce Morphine Sulphate to 30mg/24h
Addition of Metoclopramide 20mg/24h
Addition of Hyoscine Butylbromide
Addition of Hyoscine Butylbromide 60mg/24h to the syringe pump
A 69-year-old man with metastatic prostate cancer on the oncology ward is complaining of worsening pain. He is currently taking modified release oral Morphine 60 mg twice daily, with 10 mg immediate release Morphine solution as required for breakthrough pain. He is currently taking two doses of immediate release morphine a day. The medical team decides to convert this to a subcutaneous administration, because he is frequently vomiting.
What is the correct dose of morphine to give over a 24 hour period using a continuous subcutaneous infusion?
70mg
40mg
65mg
140mg
80mg
70mg
This is the correct answer. This patient is requiring a daily dose of 140 mg oral Morphine (60x2 + 10x2) for adequate pain control. Morphine administered subcutaneously is twice the strength of oral Morphine, and therefore 140/2 = 70mg of subcutaneous Morphine represents an equivalent dose
An 80-year-old man with advanced prostate cancer is assessed by the palliative care team. He is currently living with his wife in a bungalow and has a package of care four times per day. He requires help with getting washed and dressed, and with cooking. He spends most of the day in his chair or in bed, but he is able to mobilise around the house and can go to the toilet unassisted.
What is his WHO performance status?
WHO performance status 4
WHO performance status 0
WHO performance status 1
WHO performance status 2
WHO performance status 3
WHO performance status 3
WHO performance status 3
means that an individual is confined to a bed or chair for more than 50% of their waking hours and that they are capable of only limited self-care. This applies to this patient.
A 60 year woman with a background of melanoma with secondary brain metastasis is bought into the emergency department. The paramedics from the ambulance inform you that she has been having a tonic–clonic seizure for the last 8 minutes with no recovery. She has already been given oxygen, intravenous access has been established and bloods have been taken to look for reversible causes. She has no allergies and no other significant past medical history.
How would this patient be managed at this stage?
IV lorazepam 4 mg as a bolus
IV phenytoin infusion at 15 mg/kg at a rate of 50 mg/minute
General anaesthesia (by the on-call anaesthetist)
Subcutaneous haloperidol 2.5 mg over 24 hours
IV Pabrinex
IV lorazepam 4 mg as a bolus
This seizure has lasted >5 minutes, which fits the definition of status epilepticus. She should therefore be given a bolus of a benzodiazepine to try to terminate the seizure. As she has intravenous access, the first-line option would be a bolus of IV lorazepam.
types of thyroid cancer
Thyroid cancer is an uncommon cancer but is the most common malignancy of the endocrine system.
Types of thyroid cancer
There are several types of thyroid cancer. It is important to appreciate the difference between them:
Features of Papillary cancer
* Most common (70%)
* Tends to present 30-40 years of age.
* Can spread locally compressing the trachea and also metastasises to bone and lung
* Small tumours have an excellent prognosis
Features of Follicular cancer
* Second most common
* More common in areas of low iodine and in women
* Tends to present 30-60 years of age.
* Is more likely to metastasise (to lung and bones) than locally invade
Features of Medullary cancer
* Relatively uncommon form of thyroid cancer (5%)
* Derived from calcitonin producing C-cells so can occasionally present with hypocalcaemia and diarrhoea secondary to raised calcitonin.
* Associated with Multiple endocrine neoplasia (MEN) syndrome type 2A and B although 75% are sporadic.
* Often metastasis to lymph nodes
* Prognosis worse than papillary and follicular carcinoma
* Disease activity can be monitored with calcitonin levels.
Features of Anaplastic cancer
* The least common form of all thyroid cancers.
* Present between 60-70 years old.
* Extremely aggressive, patients present with rapidly growing masses.
* There is often invasion of the trachea, recurrent laryngeal nerve or other local structures by the time of presentation.
* Extremely poor prognosis – median survival: 8 months
Features of Thyroid Lymphoma
* Accounts for 10% of thyroid cancers
* Almost always Non-Hodgkins lymphoma
* Mainly occurs between 50-80 years old.
* Highly associated with Hashimoto’s thyroiditis
A 42 year old lady visits her GP concerned about breast cancer. Her 43 year old friend has just been diagnosed with invasive breast cancer and she would like to know more about breast cancer screening. Which of the following statements is true?
In England a woman of any age can ask to have screening every 3 years
In England women aged 40-80 are invited to have screening every 5 years
In England all women aged 50-70 are invited to have screening every 3 years
In England only women who are 50-80 who have specifically asked to be screened are offered screening every 3 years
In England all women aged 40-80 are invited to have screening every 3 years
In England all women aged 50-70 are invited to have screening every 3 years
This is correct. Current evidence suggests that three yearly screening of all women between the ages of 50 and 70 is the most effective way of picking up breast cancer early and reducing mortality. Some areas of the country as currently trialing extending this age window but the jury remains out on whether there is any mortality benefit
A 59 year old lady presents to her GP complaining of an itchy, red left nipple for the last 2 months. She denies any other symptoms and has no significant medical history. On examination, there is eczema of the nipple and a 1.5cm hard lump behind the nipple. What is the most likely diagnosis?
Fibroadenoma
Paget’s disease of the breast
Breast abscess
Fat necrosis
Duct ectasia
Paget’s disease of the breast
This is correct. Paget’s disease of the breast presents with nipple eczema (usually in the >50s) with an underlying lump (which is ductal carcinoma in situ)
A 42-year-old woman is referred to a breast clinic after finding a hard, irregular, 1 cm lump in her left breast. A triple assessment is carried out, and breast cancer cells are found in four axillary lymph nodes. There is no evidence of metastasis.
What is her TMN score?
T1 N1 M0
T1 N2 M1
T1 N2 M0
T1 N3 M0
T2 N2 M0
Small tumours under 2cm in size score T1.
If cancerous cells are found in 4-9 local lymph nodes (axillary or internal mammary), an N2 score is given. If fewer than 4 are affected, then the score is N1. If more than 9, or it has spread to supra- or infra-clavicular lymph nodes, the score will be N3.
If no metastasis is found, the score will be M0. If there is metastasis, the score will be M1.
A 24-year-old woman presents to the GP worried about new breast changes. She says every month, she has noticed that her breasts feel swollen and tender, and when she examines them, they feel more lumpy than normal. She has no history of breast cancer in her family and has no children. Her last menstrual period was two weeks ago. On examination, there is no pain or lumpiness in her breasts.
What is the most appropriate first-line management?
Surgical excision of the breast lumps
Advise a supportive bra and avoidance of caffeine
Needle aspiration of the breast lumps
Commence tamoxifen
Commence danazol
Advise a supportive bra and avoidance of caffeine
This woman is presenting with likely fibrocystic disease of the breast. The first-line management for this is supportive, and patients should be advised to wear a supportive bra, avoid caffeine, apply heat to the area, and take simple analgesia.
A 39-year-old woman presents to the GP with left-sided nipple discharge. On examination, there is no pain or palpable lumps, but a clear, blood-stained liquid can be expressed from the left nipple.
There are no overlying skin changes.
What is the most likely explanation for her symptoms?
Mastitis
Paget’s disease of the nipple
Mammary duct ectasia
Intraductal papilloma
Fat necrosis of the breast
Intraductal papilloma
An intraductal papilloma is a benign lesion that grows in the breast ducts. They most commonly occur in women aged 35–55 and present with blood-stained nipple discharge. They can also present with breast tenderness or palpable lumps.
Intraductal papillomas are treated with complete surgical excision.
A 31-year-old woman presents to the GP with a new breast lump. On examination, there is a hard, 2cm lump in the upper outer quadrant of her left breast. It is highly mobile and smooth to the touch. It is not painful, and there are no overlying skin changes.
Which is the most appropriate management?
Antibiotics
Needle aspiration
Urgent referral to the outpatient breast clinic
Routine referral to the outpatient breast clinic
Reassurance
Urgent referral to the outpatient breast clinic
The likely diagnosis for this patient is a benign fibroadenoma; however, as she is over 30 with a new breast lump, she should be urgently referred to the breast clinic for assessment for triple assessment.
A 65 year old woman who has a new diagnosis of metastatic breast cancer presents to the oncology clinic. She has a past medical history of heart failure and COPD.
She reports that she is able to mobilise for 2-3 hours a day but finds it difficult to carry out activities such as cooking or cleaning.
What is the WHO performance status of this patient?
0
3
4
1
2
3
