PRINCIPLES OF SURGICAL ONCOLOGY Flashcards
A 48 year old lady undergoes a laparotomy and a retroperitoneal tumour is identified. The surgeons suspect that the lesion is a liposarcoma. Which of the following is not typical of liposarcomas?
They are the most common variant of sarcoma in adults Core biopsies in low grade liposarcomas may be normal May have a pseudocapsule It is unlikely in a lesion measuring less than 5cm Pulmonary metastasis are more likely than regional nodal involvement
Malignant fibrous histiocytoma is the commonest variant of sarcoma and liposarcoma the second most common. The presence of a pseudocapsule should be borne in mind when performing surgery, as incomplete removal will result in local recurrence.
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
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
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
Class Example Mode of action
Antimetabolites 5 FU S Phase specific drug, mimics uracil and is incorporated into RNA
Anthracyclines Doxorubicin Inhibits DNA and RNA synthesis by intercalating base pairs
Topoisomerase inhibitors Etoposide Inhibits topoisomerase II, prevents efficient DNA coiling
Platinum Cisplatin Crosslinks DNA, this then distorts molecule and induces apoptosis (similar to alkylating agents)
Alkylating agent Cyclophosphamide Phosphoramide mustard forms DNA crosslinks and then cell death
Taxanes Docetaxal Disrupts microtubule formation
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 metastases have a tendency to be hypervascular. This is of considerable importance if surgical fixation is planned.
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
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 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
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.
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%
Dukes A Tumour confined to the bowel but not extending beyond it, without nodal metastasis (95%)
Dukes B Tumour invading bowel wall, but without nodal metastasis (75%)
Dukes C Lymph node metastases (50%)
Dukes D Distant metastases (6%)(25% if resectable)
Chordoma may typically occur at the following sites, except?
Ribs Clivus Sacrum Lumbar vertebra Cervical vertebra
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.
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 is the hallmark of malignancy. The others may occur in insitu disease or dysplastic lesions.
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
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.
A lung resection is least likely to be utilized in the management of which of the following?
Small cell lung cancer Adenocarcinoma of the lung Squamous cell carcinoma of the lung A solitary lung metastasis from colorectal cancer A solitary lung metastasis from a low grade sarcoma
Note, the question asked for least likely. That being the case, the correct answer is small cell lung cancer as they are nearly always disseminated at diagnosis.
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
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 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
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
