CCC Flashcards

Question

what is the principal investigation for detection of skeletal metastases?

Answer 1

bone scintography (bone scan)

Answer 2

positron emission tomography detects high-energy emitted by short-lived radioisotopes, which can be chemically tethered to molecules such as glucose or somatostatin to form a trace eg fluorine 18 deoxyglucose (SDG-18), a radioactive form of glucose

Answer 3

sensitivity of a marker describes its ability to detect those with a certain disease. If 100 people have the disease and the marker is elevated in only 95, sensitivity is 0.95 specificity describes its ability to accurately define those who are disease free. If in 100 disease-free people the marker is negative in only 90 (ie there are 10 false positives) the specificity of the test is 0.9

Answer 4

serum LDH, aFP, and BHCG (pregnancy test) to diagnose chemo sensitive and potentially curable germ cell tumours

Answer 5

HCG and aFP

Answer 6

in the setting of colorectal carcinoma also more common in people who smoke, or have IBD, hepatitis, pancreatitis or gastritis

Answer 7

mainly used as a tumour marker in ovarian carcinoma also elevated in pancreatic, lung, colorectal and breast cancer; usually where these are disseminated to the abdominal cavity

Answer 8

it is a glycoprotein produced by the normal foetal yolk sac, liver and intestines levels are moderately elevated in hepatitis, but high levels are also produced by hepatocellular carcinoma and cancers containing yolk sac elements eg teratoma it is undetectable in normal individuals after the first year of life

Answer 9

it is a glycoprotein consisting of two subunits HCG is elevated in patients with gestational trophoblastic disease (hydatiform mole, choriosarcoma) there is also a specific elevation of the B-subunit with non-seminomatous testicular cancers and some with seminoma It is also raised in pregnancy!

Answer 10

it is a protein produced by prostatic cells levels are raised in prostate cancers but also with benign hypertrophy of the prostate - a near ubiquitous phenomenon as men age may also be elevated by rectal exam, in prostatitis and UTI

Answer 11

can be a measure of the paraproteinaemias eg myeloma and Waldenstrom's macroglobulinaemia, and occasionally non-Hodgkin's lymphoma can be measured in the blood or their excretion can be measured as light chains in the urine (Bence-Jones protein), which occurs in 40-50% of all cases of myeloma

Answer 12

fine needle aspiration cytology tru-cut needle biopsy = a piece of the tumour is sampled under local anaesthetic incisional biopsy = a piece of the tumour is sampled at surgery excisional biopsy = the whole of a mass is removed

Answer 13

pre-operative treatment of an operable tumour before definitive surgical intervention aims are to make the tumour smaller, to allow less radical surgery, while at the same time treating occult micro metastases established for osteosarcoma, and is being tested in clinical trials for other malignancies such as breast cancer

Answer 14

initial chemotherapy for a tumour that is inoperable or of uncertain operability, where a reduction in the tumour bulk in a pre-defined manner may make surgery with curative intent feasible

Answer 15

it is the use of chemotherapy following a complete macroscopic clearance at surgery chemotherapy in this setting treats the occult microscopic metastases which we know usually lead to relapse after surgery for lymph node positive disease eg breast cancer and colorectal cancer.

Answer 16

used for in-situ breast cancer before invasive carcinoma is recognised (ie before overt malignancy appears)

Answer 17

haematopoietic stem cells and the lining of the GI tract, producing low blood counts (myelosuppression) and mucositis

Answer 18

treatment every 3-4 weeks, and maximally effective after a 6 month course

Answer 19

cyclophosphamide, etoposide, capecitabine and tamoxifen

Answer 20

given IV as bolus injection or short infusion

Answer 21

chemotherapy is routinely given this way in the management of superficial bladder cancer has the advantage of producing high doses at the site of the tumour, with negligible systemic absorption and hence minimal systemic toxicity

Answer 22

can be administered directly into the peritoneal cavity in the context of tumours that spread trans-coelomically (eg ovarian cancer)

Answer 23

any tumour that has a well-defined blood supply is potentially suitable eg hepatic artery infusion for liver metastases this allows higher doses to be delivered to the involved site and reduces systemic toxicity

Answer 24

according to the patient's body surface area - most commonly used formula is that of DuBois and DuBois

Answer 25

carboplatin - has its own dose calculated according to renal function

Answer 26

nausea arises from a combination of direct simulation of the vomiting centre, peripheral stimulation and anticipatory causes the use of 5-HT antagonist drugs like ondansetron can help with this

Answer 27

chemotherapy causes bone marrow suppression by killing haematopoietic progenitor cells this leads to a leucopenia and thrombocytopenia generally after 10-14 days from the beginning of each cycle the lowest point of this drop is known as the NADIR! a neutrophil cunt greater than 1x10^9/1 is rarely associated with a clinical infection. However, a risk of infection with a count less than 0.5 x 10^9/1 is significant haematopoietic recovery usually occurs after 3-4 weeks, enabling further cycles of chemotherapy to be given

Answer 28

may reflect more general damage to the whole GI epithelium, a rapidly dividing cell population susceptible to cytotoxic chemotherapy

Answer 29

due to colitis or small bowel mucosal inflammation

Answer 30

constipation is usually due to dehydration with reduced oral intake due to nausea, and to adverse effects of other meds being taken eg opiate analgesics or 5-HT antagonists

Answer 31

can be controlled by the use of a cold cap which reduces the blood flow to the scalp

Answer 32

these occur with the platinum drugs (particularly cisplatin), taxanes, and vinca alkaloids neuropathy, principally affecting sensory nerves, may recover partially over a period of months, but patients are usually left with a residual deficit

Answer 33

eg ifosfamide-induced encephalopathy and 5-FU induced cerebellar toxicity

Answer 34

cochlear damage rather than auditory nerve damage is believed to be responsible for the high tone hearing loss associated with cisplatin the effect is permanent pre-existing high-tone hearing damage precludes the use of cisplatin

Answer 35

this occurs with platinum agents, principally cisplatin, and with the alkylating agent ifosfamide renal excretion of many cytotoxics means that adequate renal function is required to reduce overall toxicity

Answer 36

cyclophosphamide and ifosfamide cause haemorrhagic cystitis in a dose-dependent manner antidotes exist such as Mesna

Answer 37

doxorubicin and paclitaxel are both associated with acute arrhythmias 5-FU (and related drugs such as capecitabine) may cause coronary artery spasm and therefore induce cardiac ischaemia

Answer 38

some cytotoxic drugs are highly vesicant and cause tissue damage on extravasation. they are administered through fast-running drips under direct observation, to dilute any vesicant action and to make nurses administering treatment aware immediately if extravasation occurs

Answer 39

ie palmar plantar erythema erythema of the palms of the hands and soles of the feet is frequently seen with 5-FU, capecitabine and some of the targeted agents eg sunitinib, erlotinib side effect usually responds to drug withdrawal and emollients but patients will need to be reviewed for other drug side effects eg bowel toxicity in the case of 5-FU

Answer 40

some drugs such as 5-FU cause photosensitivity patients should be advised regarding the use of high-factor sun blocks

Answer 41

bleomycin leads to skin and nail pigmentation it occurs in combination with pulmonary fibrosis and a common pathogenic process is thought to be responsible

Answer 42

with use of paclitaxel and are usually well controlled with non-steroidal analgesia

Answer 43

both paclitaxel and docetaxel cause allergic reactions

Answer 44

some cause sub-lethal DNA damage that may eventually lead to the genetic changes require to induce a second malignancy the most carcinogenic anti-cancer drugs are alkylating agents and procarbazine

Answer 45

most drugs are associated with a reduction in fertility some drugs, notably alkylating agents, render patients infertile at standard doses most patients who have high-dose treatments become infertile

Answer 46

may result from fibrosis induced by drugs such as bleomycin and busulphan high-dose or prolonged administration of most alkylating agents is associated with pulmonary fibrosis or pneumonitis

Answer 47

more common in haematological malignancies and certain solid cancers eg breast, lung and prostate cancer

Answer 48

often macrocytic but not megaloblastic

Answer 49

a transient nadir in blood counts following chemotherapy can be observed full evaluation (to check for bone marrow infiltration) includes a blood film, measurement of haematinics, bone marrow aspirate and trephine

Answer 50

heamoglobin less than 10 g/dl - may benefit from blood transfusion use of recombinant erythropoetin in preventing symptomatic anaemia can be benficial and reduce risks of transfusion reactions and viral transmission

Answer 51

petechial haemorrhage spontaneous nose bleeds corneal haemorrhage haematuria

Answer 52

platelet count less than 20 x 10^9/L

Answer 53

may quickly lead to multi-organ failure associated with septic shock - should seek immediate attention from the unit delivering their radiotherapy if they develop a fever

Answer 54

total white counts less than 1 x 10^9/L with an associated fever require immediate in-patient management with broad spectrum antibiotics

Answer 55

due to the risk of causing bacteraemia if the mucosa is breached

Answer 56

extensive cultures of blood, urine, sputum, throat etc and a chest X-ray

Answer 57

failure to respond to initial antibiotics within approximately 48 hours requires a change to second-line broad-spectrum antibiotics give patient additional antifungal or antiviral agents

Answer 58

should be considered in the presence of chronic obstructive airways disease and the use of co-trimoxazole in patients with lymphoma at risk of pneumocystis pneumonia

Answer 59

Cytotoxic T Lymphocyte Antigen 4 (CTLA4) expressed on T lymphocytes Programmed cell death protein 1 (PD1) more broadly expressed across a range of immune cells including B cells and antigen-presenting cells, and its ligand Programmed death Ligand 1 (PDL1) expressed on a broad range of both immune andcancer cells

Answer 60

they act via immune checkpoint blockage to release anti-tumour immunity some may also act against cancer cells through complement pathways and antibody-dependent cytotoxicity

Answer 61

all are delivered intravenously and dosing is either calculated by weight or flat dosing based on idealised body weight examples: ipilimumab, nivolumab, pembrolizumab and atezolizumab

Answer 62

most treatment is palliative, for patients with advanced disease

Answer 63

1. first side effects can occur any time from the start of first infusion until many months after the drug has been withdrawn 2. many side effects do not wax and wane with the cycle of treatment (in contrast to chemo) 3. peak incidence of new immune mediated side effects is 6-8 weeks after first treatment but the range is very wide

Answer 64

typically patients present with a maculopapular eczema type rash on the trunk. other patterns have been described including psoriatic plaques, angioedema and vitiligo > these will respond to topical emollients and steroid cream rare but serious include steven johnson syndrome > these patients require high dose IV steroids and specialist referral

Answer 65

can present with often dry cough, SOB, reduced exercise tolerance and fatigue symptoms may develop rapidly over a few days or more slowly over several weeks median time to onset after single agent nivolumab is 3-4 months and symptoms usually take 4-6 weeks to improve

Answer 66

initial: obs, FBC, CRP and CXR. full biochem screen can pick up other side effects and sputum, and screening for viral, opportunistic and bacterial chest infections is of benefit most patients will benefit form oral steroids though some eg with pyrexia, high neutrophil and CRP, will require treatment for infection first

Answer 67

can look like infection CXR shows consolidation and haziness

Answer 68

within the first 2 months

Answer 69

frequency >6 times a day associated abdo pain bloody diarrhoea nausea nocturnal diarrhoea

Answer 70

include obs, fluid balance, FBC, CRP, stool sample (for MCS & C.difficile toxin) and AXR. Flexible sigmoidoscopy is useful in guiding later treatment

Answer 71

should include a med review (consider recent statins and Abx), alcohol history, hepatitis blood screen (inc. viral hepatitis and iron studies) and imaging (usually USS) to investigate thrombosis and possible metastases

Answer 72

mild: withhold cancer immunotherapy treatment and frequent biochemical re-assessment serious: require immunosuppression with high dose steroids and specialist referral

Answer 73

less common occurring in 1-4% of patients consider if patients present with AKI nephritis can be asymptomatic at first or present with symptoms of uraemia: weakness, fatigue, anorexia, malaise, thirst and reduced urine output

Answer 74

include a careful history, focus on meds and infection and/or lower urinary tract symptoms next evaluate fluid balance and perform biochemistry, urine dipstick (send for MCS to microbiology if appropriate) and urine protein/creatinine ratio

Answer 75

dehydration , recent IV contrast, infection, meds, hypotension, obstructive uropathy

Answer 76

require immunosuppression with high dose steroids and specialist referral

Answer 77

acute tubulo-interstitial nephritis with lymphocytic infiltration

Answer 78

myalgia is muscle pain arthralgia is joint pain without swelling myalgia is more common than arthralgia

Answer 79

acute myositis, polymyalgia rheumatica and arthritis

Answer 80

rheumatological history, exam of skin and joints and use of plain x-rays to exclude bone metastases

Answer 81

mild cases: manage symptomatically eg paracetamol and or ibuprofen moderate or severe cases (ie patients with significant pain or swelling affecting function esp activities of daily living) benefit from specialist referral and oral or intra-articular steroids

Answer 82

often present with non-specific symptoms such as fatigue, mild headache, mood change, malaise, thirst, weight change or feeling generally unwell

Answer 83

should include regular assessment of thyroid function (T4, TSH) and cortisol (unless on systemic steroids) acute assessment of toxicity may require a wider panel of hormone bloods along with simple obs (BP critical) and biochemistry (look for low sodium in adrenal insufficiency)

Answer 84

thyroid disorders - in many cases acute thyroiditis cause hyperthyroidism (high T4 low TSH) followed after a delay of some weeks by hypothyroidism (low T4 high TSH)

Answer 85

always check and treat any abnormality of adrenal function

Answer 86

can cause headache, visual disturbance and a wide range of hormone abnormalities inc. adrenal insufficiency and secondary hypothyroidism (low T4 low TSH) blood cortisol levels vary across the day (9am sample is most useful) and formal assessment of adrenal function with a short Synacthen test is ideal patients with proven adrenal insufficiency or high clinical index of suspicion should start hydrocortisone replacement with adive about sick day rules (double dose), back up IM injection if vomiting and specialist referral

Answer 87

it is based on measurement of serum cortisol before and after an injection of synthetic ACTH - it assesses adrenal function

Answer 88

sleep disturbance, mood change, indigestion (+/- gastrointestinal bleeding), weight gain, high BP and increased risk of infection long term: diabetes, osteopenia/osteoporosis, and proximal myopathy

Answer 89

their rate of growth is influenced by levekls of hormones, and interfering with those hormones in one way or another may lead to growth arrest or tumour regression.

Answer 90

those arising within tissues under hormonal control of normal cellular proliferation or survival including: prostate, breast and endometrium (sex hormones), lymphocytic malignancies such as lymphoma, leukaemia, and myeloma (corticosteroids)

Answer 91

neo-adjuvant or instead of surgery (primary medical therapy) adjuvant therapy to shrink established metastases and improve quality and duration of life (palliative therapy)

Answer 92

the presence of cytoplasmic steroid receptors eg oestrogen receptor (ER) in breast cancer

Answer 93

long-acting LHRH analogues eg goserelin, leuprorelin by receptor down-regulation in the pituitary, block LH and FSH production and, in turn, gonadal hormone output unsuitable for postmenopausal women for whom sex hormone production is mainly extra-gonadal, in fat and adrenal glands

Answer 94

it is secreted by the adrenal and aromatized in other tissues including fat and liver. This step is the target for aromatase inhibitors

Answer 95

it was the first aromatase inhibitor and is non-specifc as it also blocks an earlier stage in steroid synthesis, corticosteroid supplementation is required

Answer 96

hormone inhibitor and acts as an anti-oestrogen

Answer 97

1. steroidal anti-androgens eg cyproterone acetate - have a dual action. in tumour cells they inhibit the androgen receptor, but in the hypothalamus they substitute for testosterone, so stimulate negative feedback inhibition with subsequent decrease in LHRH release 2. non-steroidal anti-androgens eg bicalutamide - inhibit testosterone in both tumour cells and hypothalamus, so feedback inhibition is lost and serum testosterone levels rise

Answer 98

describes the combination of a non-steroidal anti androgen with an LHRH analogue to prevent the effect of non-steroidals, where they increase the serum testosterone levels, and is used as a therapeutic strategy in prostate cancer

Answer 99

glucocorticoids in high concentration induce apoptosis in some malignant lymphoid cells and form an important component of treatments for lymphoid leukaemias, lymphomas, myeloma and Hodgkin's disease

Answer 100

to induce negative feedback loops eg oestrogen to down-regulate hypothalamic LHRH in prostate cancer, or tachyphylaxis (down-regulation) of receptors eg high-dose oestrogens in breast cancer

Answer 101

may give direct inhibition of tumour growth via acting as an agonist of the progesterone receptor, but also produce negative feedback on the pituitary/gonadal axis these drugs may also stimulate the appetite and are widely used in palliative medicine for that reason

Answer 102

using photons/x-rays electrons, radio-isotopes or protons external beam radiotherapy using photons/x-rays is the most common form in the UK

Answer 103

X-rays penetrate deep into body tissue whilst sparing the over-lying skin, where they produce secondary electrons and free radicals which cause DNA damage to both cancer cells and normal cells - this is the 'skin-sparing' effect

Answer 104

Normal cells can often repair the DNA damage and therefore survive. Conversely, cancer cells commonly have defective DNA repair pathways and are unable to repair radiotherapy induced DNA damage, with cancer cells subsequently undergoing cell death at the time of cell division (mitotic cell death) or apoptotic cell death

Answer 105

the dose of radiation delivered to body tissue is expressed in the unit Gray (Gy)

Answer 106

radiotherapy is commonly delivered as a series of small doses called fractions rather than as a single large dose

Answer 107

70Gy in 35 fractions over 7 weeks

Answer 108

8Gy in 1 fraction 20Gy in 5 fractions 30Gy in 10 fractions

Answer 109

seminoma and Hodgkin's disease are highly radiosensitive and respond well to low doses of radiation whereas cancers such as a glioblastoma multiforme are relatively radio-resistant to even high doses of radiotherapy

Answer 110

the balance between tumour control and the side effects of radiotherapy

Answer 111

chemotherapy given to patients during their radiotherapy treatment - it is thought to act as a radiosensitiser, increasing the sensitivity of the cells to radiation

Answer 112

3D-conformal radiotherapy

Answer 113

GTV: tumour is delineated on each CT slice it appears on CTV: margin is then added for microscopic disease spread, which may include adjacent nodal groups PTV: finally a further margin is added to allow for minor daily variations in patient and tumour position

Answer 114

MLC: part of the head of the radiotherapy machine and helps to shape the beam of radiation

Answer 115

radiotherapy treatment itself is painless and the patient neither sees nor fells anything as it is being delivered

Answer 116

1. acute: usually after first 5-10 fractions. side effects tend to increase during treatment and often hit a peak in the first few weeks following the end of treatment eg localised skin reaction, oral mucositis and diarrhoea 2. late: develop at least 3 months after radiotherapy and sometimes manifest years later. long-term toxicity occurs as some of the damage to normal cells cannot be repaired and partly due to the development of fibrosis and blood vessel damage within the irradiated tissue eg lung fibrosis, skin atrophy and infertility

Answer 117

yes - radiotherapy itself is a carcinogenic and there is a risk of a second malignancy developing as a result of treatment

Answer 118

radiotherapy is a teratogenic and therefore must be avoided in any woman who is pregnant

Answer 119

a form of radiation treatment where radiation sources are placed within or close to the tumour it allows the delivery of a localised high radiation dose to a small tumour volume, increasing the chance of tumour control whilst minimising the dose to surrounding normal tissue

Answer 120

prostate, gynaecological, oesophageal and head and neck cancers

Answer 121

intracavity: the radioactive material is placed inside a body cavity such as the uterus and cervix interstitial: where the material is put into the target such as the prostate

Answer 122

Radiation protection is of particular importance in brachytherapy. Whilst a radioactive source is in situ the patient will be radioactive. Before discharge a patient will be advised about their on-going radiation risk to others.

Answer 123

an unstable form of a chemical element which emits radiation when it decays and is another method of radiation delivery The most commonly used form is radioactive iodine, I-131, which is used in the management of the most common forms of thyroid cancer

Answer 124

the iodine is preferentially taken up by and concentrated in any remaining thyroid tissue, normal or malignant, where it emits radiation as it undergoes radioactive decay, ablating the thyroid cells few other tissues in the body take up iodine, and so it is selectively delivered radiation

Answer 125

The patient will need to remain in the lead lined room until the level of radiation they are emitting is low enough to be safe to others, which is usually around four days

Answer 126

when a tumour deposit is well defined and small eg brain metastases or lung primary, can deliver large dose of radiotherapy to target with a very small margin. Th biological dose (a concept that quantifies the chance of cell death within the target) can be increased by giving a small number of large fractions used to treat oligometastatic disease since they generally have minimal side effects and yet produce high levels of local control also possible in patients unfit for surgery

Answer 127

allow the treatment unit to deliver treatment continuously as it moves through an arc around the patient the MLC leaves can also be moved throughout this process advantages: treatment delivery can be very fast (so more patients treated per day on individual machine), dose can effectively be 'painted' onto the target volume with much greater accuracy and with sparing of surrounding tissue

Answer 128

refers to the moving of the MLC leaves during treatment delivery to build up dose in different parts of the treated volume - in Leeds volumetric modulated arc therapy is a type of intensity modulated radiotherapy used

Answer 129

aim is to determine toxicity (previously tested in vitro and in animals) and establish maximum tolerated dose (MTD) drugs with no clinical activity seen are NOT rejected at this phase dose escalation is performed, commencing at 10% of the dose /kg that is lethal in 10% of mice ('LD10'). in general, 3 patients are treated at each dose level until side effects are seen and then 6 patients per group until maximum tolerated dose is reached it is performed on patients with any tumour, in whom no conventional therapy is appropriate patients must remain generally fit and have near-normal renal and hepatic function trials are not randomized or comparative

Answer 130

once drug doses and scheduling have been defined from phase 1 trials, aim of phase 2 is to assess the particular anti-tumour activity of a new treatment in a range of different cancers the radiological tumour shrinkage ('response rate') is the primary outcome measure for most phase 2 trials it is not necessary to have a control arm and random allocation of treatment in all phase 2 trials, but can be useful

Answer 131

randomised trials comparing new with established treatments primary endpoints assessed are usually length of life whatever the cause of death (overall survival), or length of life until the cancer grows (progression-free survival) radiological shrinkage (response rate) and QOL are often secondary if benefit of a new treatment is thought to be small, a large sample size will be required to achieve statistical significance for this reason most of these trials are run in multiple centres and countries

Answer 132

RECIST (response evaluation criteria in solid tumours) definitions: complete response (disappearance of all target lesions) partial response (at least a 30% decrease in the sum of longest diameters of target lesions taking as reference the baseline LD sum) progression disease (at least a 20% increase in sum of LD of target lesions taking as reference the smallest sum LD recorded since treatment started or the appearance of one or more new lesions) stable disease (neither sufficient shrinkage to qualify for PR, nor sufficient increase to qualify for PD, taking as references the smallest sum LD since the treatment started

Answer 133

overall survival: the length of time between entry to the trial and death from whatever causes disease free survival: the time between entry into the trial and recurrence of the tumour or death from other causes progression free survival: time between entry into the trial and disease progression or recurrence

Answer 134

grade 1 = least toxic grade 4 = most toxic

Answer 135

“Basket trials” - where tumours harbouring a particular genetic mutation (of whatever primary site) are tested with a new drug that targets that mutation. “Umbrella trials” - where patients with a particular type of cancer (e.g. non-small cell lung cancer) are all tested to establish the genetics of their tumours and then offered different experimental treatments depending on the results. “Platform trials” - where multiple experimental arms are compared with a single control arm to reduce costs and increase the number of patients able to receive novel therapies.

Answer 136

oramorph PO

Answer 137

0 = normal 1 = symptomatic and ambulatory cares for self 2 = ambulatory >50% time 3 = ambulatory <50% time nursing care required 4 = bedridden

Answer 138

adjuvant chemotherapy

Answer 139

Palliative systemic hormone treatment Hormone therapy appropriate - chemo may be considered if liver involvement. Bisphosphonates may be added for prevention of skeletal related events

Answer 140

Paroxysmal AF Thyrotoxicosis and alcohol are RFs for AF. The episodic nature of her symptoms suggests paroxysmal AF depsite a normal HR on exam

Answer 141

Co-amoxiclav

Answer 142

erythromycin

Answer 143

Haloperidol The patient most likely has a chemical or ' toxic' cause for his vomiting (stimulation of the chemoreceptor trigger zone) probably hypercalcaemia and therefore the most suitable FIRST line antiemetic would be haloperidol Haloperidol is usually drug of choice in renal impairment (likely with this story)

Answer 144

Docusate capsules The patient is having difficulty passing hard stool but has no change in the frequency of opening her bowels. She therefore needs a laxative that will soften the stool. Docusate is the only laxative in the list with only softening action

Answer 145

MRI spine symptoms are highly suggestive of a neurological problem. Spinal cord compression is an oncological emergency and is best excluded or characterised if present by MRI, which can also determine whether surgery, radiotherapy or supportive care are best management. It is possible to have cord compression without back pain, Brain mets are very uncommon in prostate cancer

Answer 146

CXR, Echo and bloods for BNP The patients appears to have heart failure as a result of ischaemic heart disease and hypertension. Her ECG shows LVH and she may also have some valvular disease. NICE guidelines for Heart Failure 2010 suggest BNP and Echo in all patients suspected of having heart failure. A CXR would also be helpful.

Answer 147

Urgent direct access upper GI endoscopy NICE guidance offer urgent direct access upper GI endoscopy (to be performed within 2 weeks) to access for oesophageal cancer or stomach cancer in people: with dysphagia 55 and over with weight loss and upper abdominal pain or reflux or dyspepsia The HIV is a red herring - it should not change your investigation

Answer 148

Patient had an occupational-related illness therefore must be discussed with HM coroner who may give permission for death certificate to be issued (as per D)

Answer 149

Colon cancer Cancer Research Uk estimates obesity is one of the most important causes of colon cancer and accounts for 11-14% of cases

Answer 150

Calcium channel blocker and anticoagulant Beta blockers are contraindicated in patients with asthma NICE no longer recommend aspirin monotherapy for stroke prevention in AF Rhythm control not appropriate as you don't know how long she has had AF and there is no known underlying cause

Answer 151

Transient ischaemic attack sudden onset of symptoms. Amaurosis fugax and sensory change which lasts less than 24 hours

Answer 152

Obstructive uropathy In dehydration urea and sodium likely to be higher and clinical story to match hypercalcaemia unusual in prostate cancer (sclerotic not lytic mets) and creatinine usually rises to est 200 only medication only likely if on ACE/NSAIDs/diuretics Obstructive uropathy very common in prostate cancer: prostate and retroperitoneal LN obstruct ureters

Answer 153

Regular standard dose inhaled corticosteroid the patient is not controlled on step 1 of the BTS (british thoracic society) guidelines so must move up to step 2 which involves adding a regular steroid inhaler Long acting beta 2 agonists are step 3 and should only be started in patients already on regular inhaled steroid preventer therapy. What would you add next? NICE = leukotriene receptor antagonist LTRA eg montelukast (cheaper but less effective) SIGN/BTS = long acting B2 agonist inhaler LABA eg salmeterol

Answer 154

Bendroflumethiazide thiazide diuretics are a common cause of hyponatraemia in the elderly

Answer 155

FEV1 and FVC greater than 80% of predicted and FEV1/FVC greater than 70% indicate normal spirometry restrictive = FVC reduced, FEV1 reduced <80%, ratio normal Obstructive = FVC normal, FEV1 reduced <80%, ratio reduced

Answer 156

side effects: constipation, nausea and vomiting, drowsiness (usually subsides after 48-72 hours) toxicity: confusion, hallucinations, myoclonus, pupillary constriction, respiratory depression in overdose

Answer 157

subcutaneous morphine: divide by 2 oral oxycodone: divide by 2 oral codeine: x10 subcutaneous diamorphine: divide by 3

Answer 158

tumours should ideally: be curable when detected early in the majority of the patients be relatively common have a ling pre-invasive or non-metastatic stage be able to be detected by relatively simple tests be distinct from benign lesions

Answer 159

tests should ideally: be able to detect cancer at an early enough stage to implement effective treatment be sensitive (ie be able to distinguish tumours clearly and give a low false negative value) - not miss actual cases be specific (ie would not give false positive results) be well tolerated hence improving compliance be easy to administer or perform be inexpensive be well publicised in order to ensure high uptake amongst the target population

Answer 160

advantages: reduction of mortality by detecting early disease that is curable less radical treatment hence reducing morbidity saving on health service resources by increased cure rates reassurance given by a negative tes disadvantages: increased length of anxiety and morbidity if no effective intervention is possible the over-investigation of false positive cases with associated morbidity over-treatment of borderline cases that do not require treatment false reassurance from a false negative result possible harmful effects of the screening test cost of screening a large population

Answer 161

cervical cancer breast cancer colorectal cancer

Answer 162

cervical: all women aged between 25 and 64; women aged 25-49 invited for cervical smears every 3 years, after that invited every 5 years breast: regular mammography offered to all women between ages of 50 and 70 every 3 years colorectal: men and women offered bowel screening using faecal occult blood every 2 years from 60 to 69 - this is being extended to 74

Answer 163

a voluntary process of discussion and review to help an individual who has capacity to anticipate how their condition may affect them in the future and, if they wish, set on record choices about their care and treatment outcomes include: advance statement of wishes to inform subsequent best interest judgements advance decisions to refuse treatment which are legally binding if valid and applicable appointment of lasting powers of attorney for health and welfare and/or property and affairs

Answer 164

the disease itself eg bone invasion the treatment eg radiotherapy induced oesophagitis a concurrent disease eg osteoarthritis

Answer 165

features: either a dull ache over a large area or well localised tenderness over the bone. Often worse on weight bearing or with movement treatment: NSAIDs eg diclofenac 50mg tds, radiotherapy and bisphosphonates eg pamidronate infusion

Answer 166

features: dull, deep-seated, poorly localised pain. There may be tenderness over a particular organ eg liver. Some visceral pain is spasmodic such as bladder spasm or bowel colic. treatment: for constant dull visceral pains follow the analgesic ladder. Pain caused by visceral stretch such as liver capsule pain can be treated by NSAIDs or corticosteroids to reduce inflammation. Colic pain responds to anticholinergic drugs such as subcutaneous hyoscine butylbromide for bowel colic and oral oxybutynin for bladder spasm

Answer 167

features: dull, oppressive pain usually worse on waking, coughing, sneezing and may be associated with nausea and vomiting treatment: corticosteroids to reduce oedema eg 16mg po dexamethasone daily, reduce to lowest effective dose, NSAIDs and paracetamol

Answer 168

features: pain in an area of abnormal sensation. It may be localised to specific dermatomes or over a wider, less defined area. There may be altered sensation in the area such as numbness or hyperaesthesia and autonomic changes such as pallor or sweating. the patient may describe the pain as 'pins and needles' or burning treatment: antidepressants (amitriptyline 10-75mg nocte) and anticonvulsants (gabapentin 100-1200mg tds, pregabalin 25-300mg bd). Compression of a nerve may be helped by corticosteroids

Answer 169

step 1: paracetamol step 2: weak opioid eg codeine plus paracetamol eg co-codamol step 3: strong opioids eg morphine, diamorphine NSAIDs may be used at any step; other adjuvant drugs include antiepileptics, antidepressants, corticosteroids

Answer 170

co-codamol come as either 8mg codeine and 500mg paracetamol (weak), 15mg codeine and 500mg paracetamol, or 30mg codeine and 500mg paracetamol (strong) generally when progressing from step 1 the preparation with codeine 30mg should be prescribed

Answer 171

constipation - always prescribe a laxative eg co-danthramer N&V (usually settles within a few days) - prescribe a prn antiemetic eg haloperidol, and consider a regular antiemetic if patient is already nauseates or has had sickness in the past drowsiness when starting or changing dose (usually improves within 48 hours) confusion and visual hallucinations are rare if correct dose given - check dose and renal function and consider an alternative option if confusion persists respiratory depression is rare psychological dependence and addiction are common fears among patients but are rarely a problem in clinic practice

Answer 172

if patient has been on max strength of co-codamol then MST 20mg bd is usually appropriate

Answer 173

duration of action of 72 hours

Answer 174

mainly suitable for patients with severe chronic pain already stabilised on other opioids

Answer 175

treat with systemic antifungals - fluconazole 50mg od 7 days - or topical agents - nystatin 1ml qds 7 days

Answer 176

features: early satiety, epigastric fullness, hiccups, heartburn, often minimal nausea between vomits. May be caused by tumour, hepatomegaly, ascites ('squashed stomach') and dysmotility (drugs, autonomic failure) treatment: metoclopramide 10-20mg po/sc 30 mins before meals or 30-60mg sc over 24 hours. Stop any causative drugs if possible, consider PPI if gastric irritation

Answer 177

features: persistent or intermittent nausea, small vomits, 'possets', and retching. May be caused by drugs (opioids, digoxin, antiepileptics), hypercalcaemi, uraemia and infections (UTI, pneumonia) treatment: haloperidol 1.5-5mg po/sc nocte

Answer 178

features: early morning headache, vomiting, may be little nausea. Associated neurological symptoms/signs treatment: dexamethasone 8-16mg po od (reduced if possible) plus cyclizine 50mg tds po/sc or 150mg sc/24 hours

Answer 179

features: may have specific precipitants such as certain situations, overly anxious or depressed treatment: benzodiazepines, CBT, complementary therapies

Answer 180

levopromazine 6.25-12.5mg nocte po/sc

Answer 181

features: may be associated with movement, hearing loss, vertigo or tinnitus treatment: consider cyclizine, hyoscine or cinnarizine

Answer 182

bulk forming - fybogel (rarely appropriate in palliative care) stool softeners - lactulose and sodium docusate, movicol (predominantly a softener but may also stimulate bowel motions, eac sachet requires 125mls of liquid to be swallowed) stimulants - senna and dantron - avoid if patient has colic

Answer 183

may cause significant bloating and flatulence

Answer 184

co-danthrusate co-danthramer movicol

Answer 185

consider rectal exam and the use of suppositories and enemas

Answer 186

ovarian and bowel cancer

Answer 187

N&V colicky pain abdo distension dull aching pain diarrhoea and/or constipation

Answer 188

combination of antiemetics, analgesics, antisposmodics if colic is a feature, stimulant laxatives and prokinetic drugs (metoclopramide) should be stopped and antispasmodics prescribes (hyoscine butylbromide) dexamethasone and octreotide may also be used

Answer 189

1. asthma - bronchodilators 2. pulmonary oedema - diuretics, diamorphine 3. pulmonary embolism - anticoagulants eg tinzaparin

Answer 190

1. exacerbation of COPD - antibiotics, bronchodilators 2. pneumonia - antibiotics, physiotherapy 3. bronchial obstruction by tumour - dexamethasone, stents or laser 4. superior vena cava obstruction - dexamethasone, urgent stenting

Answer 191

1. congestive cardiac failure - diuretics, digoxin, ACE inhibitors 2. anaemia - tranfusion? 3. pleural effusion - pleural aspiration/pleurodesis 4. ascites - paracentesis if appropriate 5. lymphangitis carcinomatosis - trial dexamethasone

Answer 192

discussion of fears and explanation with patient, family and staff modification of lifestyle, breathing retraining and relaxation oxygen may help acute dyspnoea, but palliative patients will not benefit from ocygen therapy. A fan directed onto the face often helps

Answer 193

opioids: decrease resipratory effort and therefore breathlessness eg oramorph 2.5mg four hourly if opioid naive - gradually titrate up the dose benzodiazepines: lorazepam (0.5mg-1mg sub-lingual) may help anxiety associated breathlessness or give relief during panic attacks midazolam (2.5mg-5mg subcut) may benefit patients who cannot tolerate oral/sub-lingual route

Answer 194

if patient having difficulty expectorating, a trial of saline nebulisers may be helpful if cough is dry and irritating then simple linctus may help alternatively opioids are cough suppressants eg codeine linctus, normal release oral morphine

Answer 195

breast, bronchus and prostate

Answer 196

it is caused by tumour or metastass in the vertebral body or paraspinal region pressing on the spinal cord. 2/3 occur in the thoracic region and the remainder in the cervical or lumbar sppine

Answer 197

can even lead to paraparesis, paraplegia and incontinence

Answer 198

back pain or nerve root pain - either unilateral or bilateral, which may be aggravated by movement, coughing or lying flat. Pain may precede other symptoms or may be absent in some patients motor weakness - may be rapid or slow in onset, and can be subtle in the early stages; descriptions of perceived changes in strength are important subjective sensory disturbance - often precedes objective physical signs eg 'it feels like I am walking on cotton wool' bladder/bowel dysfunction - generally occurs late, urinary retention often develops insidiously

Answer 199

weakness/paraparesis/paraplegia changes in sensation occur below the level of compression; may be asymmetrical and may not necessarily be complete reflexes are usually increased below the level of the lesion clonus and painless bladder distension may be present

Answer 200

whole spine MRI!

Answer 201

corticosteroids (dexamethasone 16mg) should be commenced if there is a clinical suspicion of cord compression, pending definitive investigations. Subsequent treatment may involve surgery, radiotherapy or chemotherapy, either alone or in combination. Surgery is usually favoured in situations of mechanical collapse of a vertebral body (where radiotherapy will rarely reverse the situation) but is less likely to be used if there is extensive disease elsewhere. Management is usually coordinated by the on call oncology service, who will liaise with the neurosurgeons as required. Management is time critical. Outcomes correlate with the level of function at the time of treatment. Complete paralysis, that has been present for several days, is almost never reversible.

Answer 202

an extrinsic compression, thrombosis, or invasion of the wall of the superior vena cava

Answer 203

most commonly caused by extensive lymphadenopathy in the upper mediastinum (often in patients with lung cancer or lymphoma), but can occur with any solid tumour rarer causes include germ cell, breast or oesophageal cancer

Answer 204

essentially a clinical diagnosis should be regarded as an emergency since the patient's condition may deteriorate rapidly

Answer 205

* Headache or a “feeling of fullness” in the head * Facial swelling * Dyspnoea (often worse on lying flat) * Cough * Hoarse voice

Answer 206

* Facial / upper limb oedema * Prominent blood vessels on the neck, trunk and arms * Cyanosis

Answer 207

commence on corticosteroids (dexamethasone 16mg daily) which can sometimes produce short-term relief of symptoms urgent vascular stenting is the usual treatment of choice - often followed by radiotherapy or chemotherapy depending on the primary tumour type

Answer 208

biopsy is important if a germ cell tumour is possible then tumour markers may be useful eg AFP, BhCG, LDH

Answer 209

commonly seen in breast cancer, lung cancer, squamous cell carcinomas and myeloma

Answer 210

symptoms may develop insidiously and hypercalcaemia may be missed as a cause of some commonly occurring symptoms early: lethargy, malaise, anorexia, polyuria, thirst, nausea, vomiting, constipation late: confusion, drowsiness, fits, coma

Answer 211

serum calcium corrected for serum albumin

Answer 212

rehydration using normal saline followed by IV bisphosphonates such as pamidronate or zoledronic acid about 70% of patients respond maximum response is seen after 6-11 days with an average duration of response of 3-4 weeks

Answer 213

eg a head and neck cancer eroding into a major vessel

Answer 214

keep green towels close by to absorb and reduce the visual impact of blood loss if time allows, IM into the deltoid muscle or SC midazolam as a sedative and amnesic can be given

Answer 215

profound weakness confined to bed for most of the day drowsy for extended periods disorientated severely limited attention span losing interest in food and drink too weak to swallow medication

Answer 216

treat dry mouth with good regular mouth care assess immobility and pressure areas - special beds or mattresses may be needed consider catheter, convene, or pads for incontinence consider bowel care only if constipation is causing discomfort or agitation fast track/continuing care funding will enable patients. to die at home or in a care home

Answer 217

less vomiting and incontinence reduction in barriers between patient and family/carers prevention of painful venepuncture

Answer 218

vitamins/iron hormones anticoagulants corticosteroids antibiotics antidepressants cardiovascular drugs anticonvulsants used for pain

Answer 219

analgesic, antiemetic, anti-secretory and anxiolytic

Answer 220

this is rattling noise produced by the movement of secretions in the upper airways, generally in patients who are too weak to expectorate effectively patients are generally not distressed by the noise but relatives and carers may find this distressing treatment: reposition the patient, antisecretory drugs eg hyoscine butylbromide (buscopan) or hyoscine hydrobromide (which may cause paradoxical agitation) may be needed

Answer 221

the McKinley T34

Answer 222

* Inability to swallow drugs due to reduced conscious level, often in the last few days of life * Persistent nausea and vomiting * Intestinal obstruction * Malabsorption of drugs * Dysphagia

Answer 223

it is not an indication unless there is reason to believe oral analgesics are not being absorbed

Answer 224

may cause skin irritation

Answer 225

hyoscine butylbromide (buscopan) does NOT cross the blood brain barrier hyoscine hydrobromide may cause sedation or agitation

Answer 226

as they are too irritant: diazepam, chlorpromazine, prochlorperazine

Answer 227

breast, lung, prostate and colorectal

Answer 228

the most common cancer in women, accounting for 15% of all new cases of female cancer in UK: 55000 new cases diagnosed each year; approx 11000 women die from the disease in UK: 1 in 8 women and 1 in 870 men will develop breast cancer

Answer 229

increasing age increasing periods of oestrogen exposure: late childbearing, nulliparity, early menarche, late menopause, obesity COCP and some types of HRT obesity, alcohol ionising radiation FHx (first degree relative, particularly premenopausal) genetics: BRCA1 gene (breast and ovarian cancer), BRCA2 gene (linked to early onset breast cancer and male breast cancer, but not with ovarian cancer)

Answer 230

Infiltrating or invasive ductal carcinoma is the most common cell type, comprising 70-80% of all cases. Lobular carcinoma, comprising approximately 10% of cases, is characterized by a higher incidence of multicentric tumours within the same or opposite breast. Other less common histological types include medullary, colloid, comedo and papillary. Tumours are graded according to differentiation with grade 1 lesions being well differentiated and grade 3 lesions being poorly differentiated.

Answer 231

most patients present with a breast mass less common presentations include nipple discharge, regional lymphadenopathy (axillary or supraclavicular nodes) or symptoms of metastatic disease

Answer 232

referred to breast clinic either by GP (2ww) or through NHS breast screening programme triple assessment: 1. clinical assessment (exam and history) 2. bilateral mammography - to detect multicentric tumours or synchronous primaries in the opposite breast 3. targeted US and biopsy of symptomatic breast area or area of mammographic abnormality. patients will also have. anUS of axillae with/without biopsy of suspicious nodes cytological diagnosis should be confirmed by fine needle aspiration cytology (FNAC), needle biopsy, incisional or excisional biopsy

Answer 233

if there is discrepancy between clinical exam, mammogram and US findings, if breast density preludes accurate mammogram assessment and if the histology is lobular (as there is a higher frequency of multicentric disease)

Answer 234

T0 = no primary tumour Tis = in situ disease, non-invasive T1 = invasive tumour less than 2cm T2 = primary tumour between 2 and 5cm T3 = primary tumour greater than 5cm T4 = skin involvement

Answer 235

N0 = no lymph nodes N1 = mobile axillary nodes N2 = fixed axillary nodes N3 = internal mammary nodes M0 = no metastases M1 = distant metastases

Answer 236

1. stage 4 2. stage 0 3. stage 1 4. stage 5 5. stage 2

Answer 237

Each patient’s management plan should be discussed at a multidisciplinary meeting (MDT). The standard treatment would be surgery first. However for a certain subset of patients neoadjuvant chemotherapy is considered (chemotherapy before surgery) such as when * Initial surgery is not possible due to the size of the tumour * To allow for breast conservation * Her2 positive or triple negative breast cancer (ER, PR and Her 2 negative) as high response rates are possible

Answer 238

mastectomy or conservative surgery eg wide local excision, with postoperative radiotherapy

Answer 239

If the initial assessment shows evidence of metastatic involvement of the lymph nodes then patients will have an axillary clearance. If there is no evidence of metastatic involvement of the lymph nodes, patients will have a sentinel node biopsy (SNB). The sentinel nodes are the first few lymph nodes into which a tumour drains. Sentinel node biopsy involves injecting a tracer material that helps the surgeon locate the sentinel nodes during surgery. The sentinel nodes are removed and analyzed in a laboratory. If they are positive then patients will go on to have an axillary clearance or radiotherapy to the axillae.

Answer 240

* Hormone receptor status [oestrogen receptor (ER) status] * HER-2 receptor status * Menopausal status * Tumour size and grade * Nodal involvement * Performance status

Answer 241

Therapy with Trastuzamab (Herceptin®) is effective in metastatic and localised disease where the cancer over-expresses the target epithelial growth factor receptor (HER-2) eg breast cancer. In the adjuvant setting it is given for 12 months. It can affect cardiac function and therefore patients will need to have regular cardiac monitoring (normally with a MUGA scan).

Answer 242

tamoxifen - normally prescribed for premenopausal women who have tumours that are ER/PR positive (if no contraindications); 20mg/day reduces risk of recurrence and death in the adjuvant setting; increased thrombotic complications are reported and increased risk of endometrial cancer > normally given. for5 years Aromatase Inhibitors. e.g. anastrazole, letrozole are demonstrated to have superior efficacy to tamoxifen in post-menopausal women with breast cancer. They have a different side effect profile including fewer vascular and malignant events, but more problems with osteoporosis.

Answer 243

all patients require radiotherapy to the residual breast tissue to reduce chances of locoregional cancer recurrence standard treatment is daily, monday to friday, for 3 weeks

Answer 244

can be used in ER/PR positive disease in slowly progressive disease, especially where there is no visceral involvement and the patient has minimal symptoms median duration of response to a single endocrine therapy is 1-2 years

Answer 245

* The dominant site of disease (highest in women with disease in soft tissue, less in those with bone metastases and less again in those with visceral metastases). This may simply reflect ER status * An objective response to prior endocrine treatment. * Greater duration of previous disease free interval.

Answer 246

in premenopausal women, endogenous ovarian oestrogen production may be stopped by ovarian ablation (surgically or radiotherapy induced) or by the use of luteinizing hormone releasing hormone (LHRH) agonists

Answer 247

stage 1 = 95% stage 2 = 80% stage 3 = 60% stage 4 = 25%

Answer 248

* Lung cancer is the 3rd most common cancer in the UK. * 1 in every 13 men and 1 in every 15 women are diagnosed with lung cancer in their lifetime * Lung cancer accounts for 22% of cancer related deaths in the UK * Only 10% of patients who are diagnosed with lung cancer live for 5 years or more.

Answer 249

genetics smoking increasing age history of COPD industrial exposure to asbestos, chromium, arsenic and iron oxide exposure to radiation

Answer 250

Tumours usually arise from the epithelium of the large and medium sized bronchi (only rarely from the lung parenchyma itself).

Answer 251

15% These are highly aggressive tumours which grow rapidly. They have usually metastasised and become inoperable prior to diagnosis. They can be very responsive to chemotherapy initially, but often relapse quickly. Overall, prognosis is generally poor. They can also be associated with paraneoplastic syndromes - most commonly causing SIADH, Cushing’s syndrome or Lambert Eaton Myesthaenic syndrome (LEMS).

Answer 252

squamous cell carcinoma (42%): often found centrally close to the bronchi; can present with bronchial obstruction; closely linked to cigarette smoking; squamous cell cancers can also secrete PTH relate peptide (PTHrp) which can lead to malignancy-related hypercalcaemia adenocarcinoma (39%): often peripheral, more frequent in women, non-smokers and patients with previous asbestos exposure; more commonly associated with activating mutations. in EGFR and ALK large cell carcinomas (8%): less differentiated than other NSCLCs and tend to metastasise early other types = carcinoid, mesothelioma, sarcoma and lymphoma

Answer 253

majority present with non-specific symptoms of the primary tumour eg cough, dyspnoea, haemoptysis, chest pain, or recurrent chest infections lat presentation is frequent as most of these symptoms are common in smokers Occasionally, tumours are identified incidentally on x-rays or scans performed for some other reason.

Answer 254

apical tumours may invade the brachial plexus or sympathetic chain producing Horner's syndrome or pain in the distribution of the nerve routes involved (Pancoast's syndrome). Recurrent laryngeal nerve palsy and superior vena cava obstruction may be associated with mediastinal disease

Answer 255

clubbing is more frequent with squamous cell carcinoma. Sputum production may be excessive in bronchio-alveolar carcinoma

Answer 256

CXR CT chest and upper abdomen PET scan - used in patients who are thought to have operable disease to check for distant metastases which may not be picked up on CT. bronchoscopy Trans-thoracic biopsy under radiological guidance is sometimes required for the biopsy of peripheral lung tumours, or distant metastatic disease e.g. liver metastases. tumour markers - neuron specific enolase and lactate dehydrogenase (not routinely used) pulmonary function tests cardiopulmonary exercise testing - important for patients who are being considered for surgical resection to ensure they are fit enough to undergo an operation

Answer 257

SCLC is generally considered a systemic disease at presentation. As such, the vast majority of patients will receive palliative chemotherapy. If the disease appears “limited stage” at diagnosis (i.e. encompassable within a high dose radiotherapy field) then radical radiotherapy may be given (either alongside or following) the chemotherapy. If the disease is more extensive at presentation, then chemotherapy is the mainstay of treatment although consolidation thoracic radiotherapy may also be used in patients who have a good response to chemotherapy. Prophylactic cranial irradiation (see below) is also used in patients with limited disease and in those with extensive disease who respond to chemotherapy.

Answer 258

SCLC is one of the most chemo-sensitive solid tumours. Chemotherapy is therefore the mainstay of SCLC management with responses occurring within days. Complications such as superior vena cava obstruction or spinal cord compression can be treated with chemotherapy rather than radiotherapy. This is in contrast to NSCLC.

Answer 259

1. treatment of primary tumour 2. prophylactic cranial irradiation - brain mets frequent in SCLC; can have significant toxicities eg memory impairment, functional deficit and dementia 3. palliative

Answer 260

The early dissemination of SCLC means it should be considered a systemic disease at presentation. Surgical intervention is therefore inappropriate for the majority of cases.

Answer 261

without treatment: poor, median survival of 2-4 months treatment with systemic chemo: median survival 6-12 months prognostic factors: extent of disease at presentation, number of metastatic sites, performance status, degree of weight loss and biochemical abnormalities (elevated LDH or low sodium or albumin)

Answer 262

stage 1 and 2 - surgical resection has a good prognosis and possible cure mediastinal involvement is considered a contraindication to surgery

Answer 263

In patients with early stage disease, who are not suitable for surgery, radical radiotherapy has often been used and produces 20% 5-year survival for patients with stage 1 or 2 disease. Continuous, hyperfractionated accelerated radiotherapy (CHART) is radiotherapy which is given three times a day for 12 consecutive days, and compared with conventional radiotherapy (often 20 to 30 once daily treatments), results in improved survival. Giving radiotherapy at the same time as chemotherapy (concurrent chemo-radiotherapy) may also improve outcomes compared to giving chemotherapy first followed by radiotherapy (sequential chemo-radiotherapy). This is usually used in patients with Stage II-III dise early NSCLC located more peripherally in the lungs is treated by stereotactic ablative body radiotherapy (SABR). This delivers a small number (≤5) of very large doses of radiotherapy to a small, highly conformal volume around the lung tumour. Palliative radiotherapy is used frequently for symptomatic disease such as spinal cord compression, painful bone metastases or significant chest symptoms due to central disease (e.g. haemoptysis, cough).

Answer 264

combination regimens are used, either Carboplatin and Gemcitabine or Carboplatin/Cisplatin and Pemetrexed. Docetaxel can be used as a 2nd line option

Answer 265

beneficial in some patients with advanced non-small cell lung cancer. Patients with adenocarcinoma are tested for mutations in EGFR and ALK at the time of diagnosis. If these are positive, tyrosine kinase inhibitors (TKIs) can be used (e.g Afatinib/Erlotinib/Gefitinib for EGFR mutations and Crizotinib for ALK mutations). The proportion of patients suitable for these treatments is < 10% overall but is higher in some ethnic groups and non-smokers. Patients on these targeted therapies can be treated with second line targeted therapies (Osimertinib/Ceritinib) rather than the standard chemotherapy described above.

Answer 266

recently been approved for patients with advanced NSCLC in patients with high PDL1 expression (a molecule involved in controlling the normal immune response). This can be used either before or after chemotherapy and a small percentage of patients can have a prolonged benefit with this.

Answer 267

Without treatment, prognosis is likely to be short, and is usually measured between 3-6 months. Provided patients are fit enough to tolerate chemotherapy, this can extend average life expectancy by a number of months, possibly to just over a year. If patients are suitable for targeted treatment or immunotherapy, this can be substantially longer and prognosis may be around 2 years in some cases.

Answer 268

prostate cancer

Answer 269

Prostate cancer is the commonest cancer in males, with more than 47000 new cases diagnosed in the UK in 2015. It is predominantly a disease of older men, with more than 50% occurring over the age of 75.

Answer 270

increasing age higher in men from African and Afro-Caribbean backgrounds Fhx, and men whose mothers were diagnosed with breast cancer BRCA2 and pTEN gene mutations

Answer 271

over 95% are adenocarcinomas, developing in glandular tissue in posterior or peripheral parts of the prostate (benign prostatic hyperplasia more commonly arises in centre of gland) histology defined by Gleason system

Answer 272

may be asymptomatic and diagnosed with rectal exam or PSA blood test may present with lower urinary tract symptoms: poor stream, nocturia, dribbling and increased frequency, impotence is common 1 in 5 patients present with metastatic prostate cancer and may have bone complications such as anaemia, pain, pathological fracture, or spinal cord compression. Typical rectal examination findings would include an enlarged, hard, craggy gland (or nodule). Ultimately there is obliteration of the median sulcus.

Answer 273

initial: DRE and serum PSA if radical treatment appropriate then an MRI scan can visualise the prostate well and delineate any extra-capsular spread if metastatic disease concerns then isotope radionucleotide bone scan most patients will have US guided transrectal biopsy to confirm the diagnosis but where clinical suspicion is very high (e.g. PSA >100 with positive bone scan) this is not required

Answer 274

TX = primary tumour cannot be assessed T0 = no evidence of primary tumour T1 = clinically unapparent tumour not palpable nor visible by imaging T2 = tumour confined within prostate T3 = tumour extends through the prostate capsule T3a = extracapsular extension (unilateral or bilateral) T3b = tumour invades seminal vesicles T4 = Tumour is fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall

Answer 275

N0 = no regional lymph node involvement N1 = regional lymph node involvement M0 = no distant metastases M1 = distant metastases M1a = non-regional lymph nodes(s) M1b = bone(s) M1c = other or multiple site(s) with or without bone disease

Answer 276

Gleason system scores tumours from 2 to 10 on the basis of histological patterns in the 2 most dominant areas of the tumour eg Gleason 4 + 3 means main area is 4 with the second area 3

Answer 277

PSA, histological grade and stage can be used to stratify patients with local prostate cancer into risk groups and to counsel patients on management options. Treatment of locally advanced and metastatic patients is broadly palliative but can lead to durable symptomatic benefit and many patients live with their disease for years. . The most appropriate options are influenced by the patient’s age, fitness, existing medical issues and preferences

Answer 278

In patients with asymptomatic disease, confined to the prostate, observation rather than active treatment may be appropriate, particularly where other conditions limit the length of survival that is expected. Radical treatment is unlikely to benefit men with life expectancy of less than ten years, some of whom will not require on-going surveillance. The optimum management of patients with an elevated PSA but no clinical evidence of prostate cancer is unknown

Answer 279

Patients with localised disease (T2 disease or less) can be treated by radical prostatectomy with curative intent and this can be performed by perineal or retroperineal routes. Robotic laparoscopic surgery leads to reduced operating times, less blood loss and shorter hospital stays but, though mortality is low, prostatectomy can lead to temporary or lasting impotence and incontinence. Palliative surgical techniques such as trans-urethral resections may be used to relieve prostatic symptoms or urinary obstruction in some men.

Answer 280

Radical radiotherapy may be used as an alternative to surgery in T1 and T2 tumours, where PSA is low, suggesting no occult metastases. It is also more appropriate for the control of more advanced local disease. Adjuvant radiotherapy may also be given following radical surgery if there is concern for residual disease. Definitive radiotherapy should be delayed until at least six weeks following trans-urethral resection to prevent stricture formation. Radiotherapy may be performed by external beam irradiation, by the interstitial implantation of radioisotopes (brachytherapy) or by a combination of these. Side effects can include dysuria, rectal bleeding, diarrhoea, impotence and incontinence. Palliative radiotherapy is used to palliate the primary tumour and/or to treat metastatic complications e.g. recurrent haematuria due to bleeding from prostate bed, bone pain from metastatic disease.

Answer 281

eg leuprorelin, goserelin Luteinizing-hormone releasing hormone (LHRH) interferes with the normal release of gonadotropins from the pituitary. This reduces the level of circulating testosterone to those following castration. LHRH agonists are given by monthly or 3 monthly subcutaneous or intra-muscular depot injections. Side effects include impotence, loss of libido and tumour flare. Tumour flare occurs on initiation of treatment (prior to the down regulation of gonadotropin) and is avoided by short-term concomitant anti-androgen therapy. Long-term consequences of medical castration include increased cardiac risk and osteoporosis.

Answer 282

leads to castrate levels of testosterone in 96% of patients within 3 days (without risk of tumour flare). Given by monthly subcutaneous injection it is indicated when tumour flare may lead to significant symptoms e.g. a patient presenting with metastatic spinal cord compression.

Answer 283

Oestrogens inhibit LHRH production from the hypothalamus but are rarely the best option due to side effects: impotence, loss of libido, gynaecomastia, myocardial infarction, stroke and pulmonary emboli.

Answer 284

e.g. bicalutamide, enzalutamide) compete with androgens for sites on the androgen receptor. Enzalutamide shows progression and survival benefit when combined with LHRH therapy in advanced prostate cancer.

Answer 285

Cytotoxic treatment with docetaxel (in combination with prednisolone) and cabazitaxel has been shown to improve quality of life and overall survival in patients with castrate-refractory metastatic disease. Recent data supports use of early docetaxel chemotherapy (+/- prednisolone) around the time of diagnosis of metastatic prostate cancer: six cycles of chemotherapy in fit men prolongs survival (median 60 months, ie an extra 15 months, HR 0.76, p=0.005) and has led to a change in practice.

Answer 286

Survival is related to the extent of the disease. Prostate cancer survival of men with low risk localised prostate cancer is excellent (99%) at 10 years whether they choose active surveillance, radiotherapy or surgery. Prostate cancer 10 year survival (all UK patients) is around 84%. Patients with metastatic disease have a median survival of 3.5 years. Pattern of disease (bone metastases), aggressive pathology and younger age are associated with a poorer prognosis.

Answer 287

41000 new cases diagnosed every year in UK 4th most common malignancy after lung cancer - 10-15% of all malignancies, causes 16000 deaths each year cancer. ofcolon is 1.5 times more common than rectal carcinoma

Answer 288

diet - rich in animal fats and meat and poor in fibre; common in Western countries IBD - association with ulcerative colitis which is related to the extent of the bowel involvement and duration of inflammation familial association - hereditary non-polyposis colon cancer (HNPCC), familial adenomatous polyposis (FAP) and Gardner's syndrome; mutation sin APC gene (5q21-22 for FAP coli) and mutations in DNA mismatch repair genes (HNPCC)

Answer 289

APC mutations are associated with the development of benign adenomas whereas the progression to invasive carcinoma requires further mutations eg p53, DCC and RAS these mutations may be caused by carcinogens present in faeces in principle diets low in fibre prolong transit time and may prolong exposure to carcinogens bile salts may act as carcinogens both directly and when degraded by bacteria present in the faeces

Answer 290

40% of large bowel cancers occur in the rectum, 20% in the sigmoid colon, 6% in the caecum and the rest in the remaining colon the histological types of cancer that occur are: - epithelial: 90-95% adenocarcinoma (mucinous or signet ring). Rare others include squamous cell carcinoma and adenosquamous carcinoma. - carcinoid - gastrointestinal stromal tumour - primary malignant lymphoma colorectal cancer normally spreads by local invasion, lymphatic, venous and trans-coelomic spread within the peritoneal cavity

Answer 291

presentation can be with classical features of altered bowel habit, weight loss, rectal bleeding and vague abdominal pain, although clinical features vary according to the site of the primary tumour and degree of spread more occult tumours, typically of the right side of the colon and the caecum, can present with iron deficiency anaemia

Answer 292

RECTAL EXAM IS ESSENTIAL direct visualisation of the bowel with rigid sigmoidoscopy, flexible sigmooidoscopy and colonoscopy allows biopsy of suspicious lesions double contrast barium enema is less useful as no histology is provided CT provides staging and a useful evaluation of the bowel in some cases CT colonoscopy combines CT scanning with insufflation of the whole colon with gas - this can help identify synchronous polyps within the bowel where colonoscopy is not possible, however it does not facilitate biopsy other: tumour marker CEA (carcino-embryonic antigen) - although elevation of this protein is not diagnostic it can be useful to monitor

Answer 293

TX - primary tumour cannot be assessed T0 - no evidence of primary tumour T1 - tumour invades submucosa T2 - tumour invades muscularis propria T3 - tumour extends through muscularis propria into peri-colic tissues T4 - tumour invades visceral peritoneum or invades / adheres to adjacent organ or structure

Answer 294

N0 - no regional lymph node involvement N1 - involvement of 1-3 lymph nodes N2 - involvement of 4 or more lymph nodes MX - distant metastasis cannot be assessed (not evaluated by any modality) M0 - no distant metastasis M1 - distant metastasis M1a - confined to one organ or site eg liver or lung, but not peritoneum M1b - 2 or more sites (but not peritoneum) M1c - peritoneal spread

Answer 295

A invasion into but not through the bowel wall B invasion through the bowel wall but not into nodes C lymph node involvement D distant metastases

Answer 296

Radical resection is the standard treatment for primary colorectal carcinoma because of the risk of unsuspected nodal metastases. Patients with early stage colorectal carcinoma are usually cured by surgical resection alone. The long-term results with rectal carcinoma are related to the initial surgical resection. Surgery may also be indicated in patients with advanced disease. Resection of liver metastases in addition to the primary may be beneficial. Further resection of a local recurrence is associated with improved long-term survival. Surgery or colonic stenting may be used in the palliative setting to manage or prevent an obstructing lesion.

Answer 297

predominantly used in treatment of rectal carcinomas not commonly used in management of colon cancers due to the potential toxicity to adjacent organs and mobility of tumours pre-operative (or rarely adjuvant) radiotherapy is indicated in high risk rectal carcinomas before (or rarely following) total resection cases are selected on the basis of pelvic MRI staging scans local recurrences can be palliated with radiotherapy metastatic disease may also respond to palliative radiotherapy

Answer 298

adjuvant chemo for high-risk colorectal cancer eg Duke's C carcinoma 5-FU is the most active agent in colorectal carcinoma with a response rate of approximately 25% - newer drugs such as Oxaliplatin and Irinotecan are now also in standard use

Answer 299

5 year survival: A - 80% B - 50% C - 15-40% D - 5% age below 40 is an adverse prognostic factor reflecting a biologically more aggressive tumour

Answer 300

faecal occult blood testing of average-risk populations (with follow up colonoscopy for positive cases) given to people aged 60-74 every 2 years

Answer 301

CHADVASC is used for the stroke risk of AF patients ORBIT is used as a screening tool for the bleeding risk of AF patients and the need for anticoagulation

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