Principle of surgical oncology Flashcards
A 62 year old male is found to have colorectal cancer. He has Dukes C disease. What is his 5 year prognosis?
100% 90% 80% 70% 50%
50%
A 55 year old man is found to have a carcinoma of the sigmoid colon on screening colonoscopy. How should this be staged?
MRI of the abdomen and CT of the chest
Liver MRI and Chest CT
CT scanning of the chest, abdomen and pelvis alone
MRI of the rectum and CT of the abdomen and chest
Endoluminal USS and CT scanning of the abdomen
CT scanning of the chest, abdomen and pelvis alone
Rectal cancer is staged with MRI rectum (and sometimes endolumenal USS for low T1 lesions) together with CT scanning of the chest, abdomen and pelvis. Historically, colonic cancer was staged with liver USS and CXR. However, modern imaging has made this practice obsolete.
A 43 year old lady is receiving chemotherapy for the treatment of metastatic breast cancer. You are called because it has become apparent that her doxorubicin infusion has extravasated. What is the most appropriate course of action?
Stop the infusion and administer dexamethasone through the infusion device
Stop the infusion and administer hyaluronidase through the infusion device
Stop the infusion and apply a cold compress to the site
Stop the infusion and apply a warm compress to the site
Stop the infusion and administer sodium bicarbonate through the infusion device
Stop the infusion and apply a cold compress to the site
The application of cold compresses is indicated in doxorubicin extravasation. Warm compresses increase the risk of doxorubicin ulceration. Hyaluronidase is indicated in the extravasation of contrast media, TPN and vinca alkaloids. However, if administered following doxorubicin extravasation it will dramatically worsen the situation and is contra indicated.
Up to 50% of those sustaining severe injuries will require delayed surgical reconstruction.
A 50 year old lady presents with pain in her proximal femur. Imaging demonstrates a bone metastasis from an unknown primary site. CT scanning with arterial phase contrast shows that the lesion is hypervascular. From which of the following primary sites is the lesion most likely to have originated?
Breast Renal Bronchus Thyroid Colon
Renal
Renal metastases have a tendency to be hypervascular. This is of considerable importance if surgical fixation is planned.
A 56 year old lady presents with a pathological fracture of the proximal femur. Which of the following primary sites is the most likely source of her disease?
Thyroid Breast Kidney Endometrium None of the above
Breast Primary site= BBRTP Breast Bronchus Renal Thyroid Prostate
The correct answer is breast, because the question asks for the most likely primary site. Breast cancer is the commonest cause of lytic bone metastasis in women of this age, especially from amongst those options given.
A 45 year old male is referred to clinic for consideration of resection of a lung malignancy. He reports shortness of breath and haemoptysis. Investigations reveal a corrected calcium of 2.84 mmol/l, an FEV 1 of 1.9L and histology of a squamous cell carcinoma. The patient is noted to have a hoarse voice. Which one of the following is a contraindication to surgical resection in lung cancer?
Haemoptysis FEV 1 of 1.9 litres Histology shows squamous cell cancer Vocal cord paralysis Calcium = 2.84 mmol/L
Vocal cord paralysis
Contraindications to lung cancer surgery include SVC obstruction, FEV < 1.5, MALIGNANT pleural effusion, and vocal cord paralysis
Paralysis of a vocal cord implies extracapsular spread to mediastinal nodes and is an indication of inoperability.
Chordoma may typically occur at the following sites, except?
Ribs Clivus Sacrum Lumbar vertebra Cervical vertebra
Ribs
Chordoma is a neoplasm originating from ectopic cellular remnants of the notochord and therefore arises from the midline of the axial skeleton. It accounts for 24% of all primary malignant bone tumours. Chordoma is the second commonest primary malignancy of the spine and accounts for over 50% of primary sacral tumours. The neoplasm has a predilection for the sacrococcygeal (50%) and clival (40%) regions, with other areas of the spine rarely involved. More than one vertebral body can be affected in half the cases. Chordomas most commonly present between 50 and 70 years of age. Sex incidence is equal below 40 years, but men are affected twice as often at older ages, particularly in the sacral region.
The most frequent radiographic appearance of chordoma is that of a destructive lesion of a vertebral body centered in the midline, with a large, associated soft-tissue mass.
A 45 year old woman with breast cancer is started on a chemotherapy regime containing epirubicin. What is the primary mode of action of this drug?
Intercalation of DNA Antimetabolite Monoclonal antibody to epidermal growth factor Inhibition of DNA gyrase Inhibition of topoisomerase 1
Intercalation of DNA
An 88 year old lady presents with a large mass in the upper inner quadrant of her right breast. Investigations confirm an oestrogen receptor positive, invasive ductal carcinoma. She has declined operative treatment. What is the best course of action?
Combined chemoradiotherapy Radical radiotherapy Administration of letrozole Best supportive care Chemotherapy alone
Administration of letrozole
Elderly patients may be managed using endocrine therapy alone. Eventually most will escape hormonal control. In post menopausal women oestrogens are produced by the peripheral aromatization of androgens and aromatase inhibitors are therefore the most popular agent in this age group.
A 55 year old lady has undergone a wide local excision and sentinel lymph node biopsy for breast cancer. The histology report shows a completely excised 1.3cm grade 1 invasive ductal carcinoma. The sentinel node contained no evidence of metastatic disease. The tumour is oestrogen receptor negative. What is the next course of action?
Monitor in clinic with annual review and mammography Arrange radiotherapy Arranged combined chemoradiotherapy Arrange chemotherapy Prescribe anti oestrogen
Arrange radiotherapy
Radiotherapy is routine following breast conserving surgery. Without irradiation the local recurrence rates are approximately 40%. These rates are potentially lower in older patients who receive endocrine therapy and who have small low grade tumours.
A 45 year old man has widespread metastatic adenocarcinoma of the colon. Which of these tumour markers is most likely to be elevated?
CA19-9 Carcinoembryonic antigen Alpha Feto Protein CA 125 Beta HCG
Carcinoembryonic antigen
Screening for colonic cancer using CEA is not justified
Carcinoembryonic antigen is elevated in colonic cancer, typically in relation to disease extent with highest serum levels noted in metastatic disease. It is falsely elevated in a number of non-malignant disease states such as cirrhosis and colitis and for this reason it has no role in monitoring colitics for colonic cancer
Which of the following group of patients are not screened for colorectal cancer?
Peutz Jeghers syndrome Asymptomatic patients aged 45 years Acromegaly Ureterosigmoidostomy Inflammatory bowel disease
Asymptomatic patients aged 45 years
Other disorders which are screened for colorectal malignancy include:
Familial adenomatous polyposis, Hereditary non polyposis colorectal cancer. The NHS screening programme starts at 60 in England (Sigmoidoscopy screening at 55 years). In Scotland it starts at 50.
A 23 year old lady presents with a nodule in the right lobe of the thyroid. Examination of the neck is otherwise unremarkable and clinically she is euthyroid. Imaging shows a solid nodule at the site. What is the correct course of action?
Image guided core biopsy Image guided fine needle aspiration for cytology Arrange a hemithyroidectomy Perform an incision biopsy Perform an excision biopsy
Image guided fine needle aspiration for cytology
FNAC is the first line investigation in this setting. Whereas FNAC has declined in popularity recently (in breast investigation), it remain a very popular option in the investigation of thyroid masses. It cannot reliably diagnose a follicular tumour.
A 67 year old lady is suspected of having Pagets disease of the nipple. Mammography and USS are normal. What is the most appropriate next step in her management?
Arrange a core biopsy Arrange FNAC of the area Arrange a punch biopsy Undertake a mastectomy Arrange for focused radiotherapy
Arrange a punch biopsy
This is a relatively clear indication for a punch biopsy. If cellular atypia is present on punch biopsy then any in situ malignancy should be considered. FNAC would be unsuitable.
A 73 year old man is recovering following an emergency Hartmans procedure performed for an obstructing sigmoid cancer. The pathology report shows a moderately differentiated adenocarcinoma that invades the muscularis propria, 3 of 15 lymph nodes are involved with metastatic disease. What is the correct stage for this?
T3, N1, M1 T4, N1, M1 T2, N0, M1 T3, N1, M0 T1, N2, M1
T3, N1, M0
Remember that the term metastasis simply refers to spread and can include the lymph nodes. In an examination setting marks can be lost by incorrectly selecting Dukes D (which would be consistent with liver metastasis) rather than nodal metastasis (Dukes C).
The involvement of lymph nodes up to 3 makes it N1 disease, note that only distant nodal involvement would equate to M1 disease and regional lymph node metastasis is not enough to make it M1 disease. We have moved away from the Dukes staging as it is not used these days, if you do encounter this scenario in the exam it would equate to a Dukes C.
What is the most common cause of osteolytic bone metastasis in children?
Osteosarcoma Neuroblastoma Leukaemia Rhabdomyosarcoma Medulloblastoma
Neuroblastoma
Neuroblastomas are a relatively common childhood tumour and have a strong tendency to developing widespread lytic metastasis. It is unusual for CNS tumours to spread to involve the skeleton.
A 38 year old lady has undergone a mastectomy and axillary node clearance for invasive ductal carcinoma. The histology report shows a completely excised 3.5cm lesion which is grade 3. Two of the axillary lymph nodes contain metastatic disease. The tumour is oestrogen receptor negative. What should be the next course of action?
Axillary radiotherapy Administration of cytotoxic chemotherapy Chest wall irradiation Administration of letrozole Surveillance alone
Administration of cytotoxic chemotherapy
The combination of a grade 3 tumour and axillary nodal metastasis in a young female would attract a recommendation for chemotherapy. Some may also add herceptin (if they are HER 2 positive).
A 45 year old patient undergoes a CT scan of the abdomen and is noted to have a 6cm mass in the right adrenal gland. Urinary catecholamines and other endocrine investigations are negative. CT of the chest and remainder of the abdomen is otherwise normal. What is the most appropriate course of action?
Image guided FNAC of the adrenal gland
Image guided core biopsy of the adrenal gland
List the patient for an adrenalectomy
Organise surveillance of the lesion with CT scanning
Organise surveillance of the lesion with USS
List the patient for an adrenalectomy
Most surgeons would excise a mass of this size rather than attempt biopsy. Further information relating to adrenal masses is covered under this topic.
A 56-year-old man with metastatic prostate cancer comes for review. He is known to have spinal metastases but until now has not had any significant problems with pain control. Unfortunately he is now getting regular back pain despite taking paracetamol 1g qds. Neurological examination is unremarkable. What is the most appropriate next step?
Switch to co-codamol 30/500 Refer for radiotherapy Add oral bisphosphonate Add non steroidal anti inflammatory drug Add dexamethasone
Add non steroidal anti inflammatory drug
Metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy
Bone pain often responds well to NSAIDs. Both radiotherapy and bisphosphonates have a role in managing bony pain but these are not first-line treatments.
In examining a biopsy of a primary tumour, the clearest evidence of malignancy is provided by:
Absence of a capsule Basophilia of the cytoplasm Invasion of surrounding structures Excess of mitoses Nuclear aberrations
Invasion of surrounding structures
Invasion is the hallmark of malignancy. The others may occur in insitu disease or dysplastic lesions.
A 63 year old lady with metastatic breast cancer presents with bone pain. Radiological tests show a metastatic lytic deposit to her femoral shaft. The lesion occupies 75% of the bone diameter. What is the most appropriate management?
Surgical fixation with a dynamic compression plate Hemi-arthroplasty Fixation with intramedullary nail Radical radiotherapy Chemotherapy
Fixation with intramedullary nail
Even with surgical fixation only 30% of pathological fractures unite. The type of fixation should be chosen accordingly.
A lesion of this nature is at high risk of spontaneous fracture. Whilst radiotherapy may palliate her symptoms of pain it will not reduce the risk of fracture. In fit patients, an intramedullary nail should be inserted. Very proximal lesions may be best managed by a total hip replacement
