Oncology

Question 1

Weakness (2)
A 62-year-old woman with metastatic breast cancer, including bone metastases,
presents to accident and emergency with sudden onset back pain and difficulty
walking. An urgent MRI of the spine confirms cord compression at the level of
L1–L2. What is the most appropriate initial management?
A. Surgical decompression of spinal cord
B. Dexamathasone
C. Radiotherapy
D. Chemotherapy
E. Physiotherapy

Question 1

Weakness (1)
A 62-year-old woman presents to accident and emergency with a 1-day history of
sudden onset back pain and difficulty walking. She has not opened her bowels or
passed urine for the previous day. She has a past medical history of breast cancer,
diagnosed two years earlier and staged as T2N1M0 disease with oestrogen receptor
positive status. She has been treated for her cancer with a wide local excision and
axillary node clearance, followed by radiotherapy, chemotherapy and tamoxifen.
On examination, there is reduced tone in the lower limbs. Power is diminished
throughout the lower limbs, but especially on hip flexion. There is reduced sensation
below the L1 dermatome. What is the most appropriate diagnostic investigation?
A. A full set of bloods, including bone profile
B. Computed tomography (CT) thorax, abdomen and pelvis
C. Magnetic resonance imaging (MRI) spine
D. Bone scan
E. Positron emission tomography (PET) CT

Question 2

Pyrexia
A 60-year-old man with metastatic adenocarcinoma of the lung, who has finished
two cycles of palliative cisplatin/pemetrexed chemotherapy, presents with a 2-day
history of fever and lethargy. On examination, he is pyrexial with a temperature of
38.8°C. What is the most appropriate next step?
A. Blood cultures
B. Urgent full blood count
C. Urgent chest x-ray
D. Start empirical broad spectrum antibiotics
E. Prescribe paracetamol

Question 3

Hypercalcaemia (1)
A 50-year-old woman with T2N2M1 squamous cell carcinoma of the tongue has
been electively admitted for her third cycle of palliative cisplatin/5-fluorouracil
chemotherapy. She has known metastasis to the T3 vertebrae and the ribs. Since her
last cycle of chemotherapy she has been very lethargic and constipated. Upon
checking her bloods you discover that her corrected calcium levels are 2.95 mmol/L.
The most appropriate treatment is:
A. Administering the chemotherapy
B. Intravenous rehydration and pamidronate
C. Calcitonin
D. Delaying the chemotherapy and advising the patient to minimize
calcium intake
E. Intravenous rehydration alone

Question 4

Hypercalcaemia (2)
A 50-year-old woman presents to accident and emergency complaining of excessive
lethargy. In addition, she mentions that she has been constipated. On examination,
there are clinical features of dehydration. Blood tests have revealed a corrected
calcium of 3.3 mol/L. Her chest x-ray shows bilateral streaky shadowing throughout
both lung fields. She is given 3 L of saline in 24 hours after admission. The following
day her blood tests are repeated and her corrected calcium level is now 3.0 mmol/L.
Results of parathyroid hormone levels and thyroid function tests are still awaited.
What is the most appropriate management?
A. Intravenous saline rehydration
B. Intravenous saline rehydration and pamidronate
C. Pamidronate
D. Calcitonin
E. Intravenous saline rehydration plus calcitonin

Question 5

Terminology
A 74-year-old man with T2N0M0 squamous cell carcinoma of the tongue is
currently undergoing hyper-fractionated radiotherapy with curative intent. He has
had no previous surgery. This type of therapy is best described by which of the
following terms:
A. Adjuvant
B. Neoadjuvant
C. Palliative
D. Radical
E. Brachytherapy

Question 6

Tumour markers
A 57-year-old woman with adenocarcinoma of the sigmoid colon with liver
metastasis is attending for cycle six of her palliative FOLFOX chemotherapy. Which
tumour marker can be measured in the blood test to indicate the effect of the
chemotherapy?
A. α-fetoprotein (αFP)
B. β-human chorionic gonadotrophin (β-hCG)
C. CA 19-9
D. CA 125
E. CEA

Question 7

Testicular cancer
A 22-year-old man with testicular cancer has undergone an inguinal orchidectomy.
Histology has confirmed teratoma. A preoperative CT staging scan has shown
involvement of the para-aortic lymph nodes. Which of the following treatments is
the best post-operative option?
A. Chemotherapy (bleomycin, etoposide, cisplatin)
B. Lymph node dissection
C. Radiotherapy to affected lymph nodes
D. Chemo-radiotherapy
E. Surveillance using tumour markers.

Question 8

Oesophageal carcinoma
A 60-year-old man has presented to the gastroenterology outpatient clinic with a
four-month history of progressive dysphagia. The patient reports a weight loss of
9 kg in the same time period. He has suffered from gastro-oesophageal reflux
disease for the past 10 years. At endoscopy, a 5 cm malignant stricture is seen at the
lower end of the oesophagus and biopsies are taken. Histological analysis is most
likely to reveal:
A. Squamous cell carcinoma
B. Small cell carcinoma
C. Adenocarcinoma
D. Leiomyoma
E. Gastrointestinal stromal tumours

Question 9

Skin cancer
A 70-year-old man presents to his GP having noticed a slowly enlarging ‘spot’ on
his left cheek. On examination, there is a well-circumscribed, skin-coloured nodular
lesion on the left cheek with some overlying small blood vessels visible. The most
likely diagnosis of this lesion is:
A. Basal cell carcinoma
B. Squamous cell carcinoma
C. Nodular malignant melanoma
D. Superficial spreading malignant melanoma
E. Basal cell papilloma

Question 10

Lung cancer (1)
A 62-year-old electrician has presented to accident and emergency with a sudden
decline in his exercise tolerance. He mentions that he can only walk 5 yards and
that he has had a persistent cough with some haemoptysis over the previous month.
A chest x-ray confirms a right-sided pleural effusion, which is then drained.
A repeat x-ray shows a round shadow in the right perihilar region. Subsequent
bronchoscopy and biopsy confirms small cell carcinoma. Which of the following
statements is most true about small cell carcinomas of the lung?
A. They are sensitive to chemotherapy
B. Two-year survival of disease confined to the lung is 50 per cent
C. They are more common than non-small cell lung carcinomas
D. They are not associated with cigarette smoking
E. They most commonly arise from the periphery of the lung

Question 11

Lung cancer (2)
A 68-year-old man presents to his GP complaining of increasing shortness of
breath. He has noticed deterioration in his exercise tolerance, particularly while
mowing the lawn. He has a past history of squamous cell carcinoma of the lung for
which he finished radiotherapy treatment a year ago. On examination, there are
fine inspiratory crackles in the right lung base. The most likely cause of his shortness
of breath is:
A. Recurrence of the cancer
B. Pneumonitis
C. Pulmonary oedema
D. Pulmonary fibrosis
E. Chronic obstructive pulmonary disease (COPD)

Question 12

Breast cancer
A 39-year-old woman has undergone a wide local excision for a 0.5 cm ductal
carcinoma of her right breast. Sentinal node biopsy, histology and staging scans
have confirmed the disease as T1N0M0. Histology has confirmed the cancer as
oestrogen and progesterone receptor positive. Which of the following statements is
most accurate regarding this female’s treatment options?
A. She should receive radiotherapy
B. She is not suitable for radiotherapy
C. She is not suitable for tamoxifen therapy
D. She requires no further treatment
E. She should be considered for cetuximab therapy

Question 13

Pain control (1)
A 51-year-old man with a recent diagnosis of pancreatic carcinoma with metastases
to the liver and omentum is about to commence gemcitabine chemotherapy. Prior
to his first cycle he mentions that he is getting increasing severe abdominal pains.
He is currently taking paracetemol for this, which eases the pain but is now
becoming less effective. The most appropriate analgesia for this patient is:
A. Fentanyl patch
B. Oral morphine sulphate solution as required
C. Morphine sulphate tablets
D. Codeine phosphate
E. Codeine phosphate plus paracetamol

Question 14

Pain control (2)
A 48-year-old woman with a recent diagnosis of metastatic cancer of unknown
primary, including metastasis to the sacral and thoracic spine, is currently being
treated for lower back pain with regular paracetamol, diclofenac and oral morphine
solution. She is receiving additional oral morphine solution rescue doses for her
breakthrough pain. On review of her drug chart, she has received 60 mg of oral
morphine solution over the past 24 hours. Which of the following is the most
appropriate escalation for this patient’s pain management?
A. 30 mg of morphine sulphate tablets, twice daily with 10 mg oral
morphine solution, as required
B. 5–10 mg of oral morphine solution, as required
C. 10 mg of oral morphine solution, six times a day
D. 30 mg of morphine sulphate tablets, twice daily
E. 18 mg of diamorphine via a continuous subcutaneous syringe driver

Question 15

Headache
A 58-year-old male with known small cell lung cancer presents to accident and
emergency with a 5-day history of severe headache and recurrent vomiting. He has
recently commenced chemotherapy for small cell carcinoma of the lung. On
examination of the visual fields, there is a left inferior homonymous quadrantinopia.
The most important diagnostic investigation is:
A. Urea and electrolyte blood tests
B. CT head
C. CT thorax, abdomen and pelvis
D. Lumbar puncture
E. Chest x-ray

Question 16

Anaemia
A 64-year-old man presents to accident and emergency following a collapse. He
describes a blackout, subsequently regaining consciousness when on the floor. He
presently feels well and describes no other symptoms. However, he mentions that
he has unintentionally lost some weight over the past few months. There is no past
medical history. Blood tests reveal a haemoglobin level of 9 g/dL with a mean cell
volume on 71 fL. The most appropriate next investigation of this patient is:
A. Flexible sigmoidoscopy
B. Endoscopy
C. Colonoscopy
D. Endoscopy and colonoscopy
E. Profile of tumour markers

Question 17

Skin reaction
A 57-year-old man with metastatic adenocarcinoma of the lung is attending for
cycle three of his palliative pemetrexed/cisplatin chemotherapy. During his cisplatin
infusion, he noticed his arm becoming painful, swollen and red at the cannula site.
The most likely cause of this is:
A. Cellulitis
B. Venous thrombosis
C. Extravasation of chemotherapy
D. Adverse drug reaction
E. Normal chemotherapy reaction

Question 18

Electrolyte imbalance (1)
A 55-year-old woman with metastatic pancreatic cancer attends the oncology
clinic prior to her second cycle of chemotherapy. She tolerated her first cycle well
but her husband mentions that there have been occasions where she has been
confused. Her urea and electrolyte blood tests reveal a serum sodium of
116 mmol/L. All other results were within the normal range. The chemotherapy is
delayed and a urine specimen is sent off. This reveals a urine osmolality of
620 mmol/kg. The most likely cause of the hyponatraemia is:
A. Water overload
B. Diabetes insipidus
C. Addison’s disease
D. Syndrome of inappropriate anti-diuretic hormone (ADH)
E. Renal impairment

Question 19

Electrolyte imbalance (2)
A 55-year-old woman with metastatic pancreatic cancer attends the oncology
clinic prior to her second cycle of chemotherapy. She tolerated her first cycle well,
but her husband mentions that there have been occasions where she has been
confused. Her urea and electrolytes on this occasion reveal a serum sodium of
116 mmol/L. All other results were within the normal range. The chemotherapy is
delayed and a urine specimen is sent off. This confirms a diagnosis of syndrome of
inappropriate ADH (SIADH). The most appropriate treatment is:
A. Intravenous infusion of 5 per cent dextrose
B. Intravenous infusion of normal saline
C. Intravenous infusion of hypertonic saline
D. Desmopressin
E. Fluid restriction to 1 L per day

Question 20

Electrolyte imbalance (3)
A 60-year-old man with metastatic adenocarcinoma of the lung, who has finished
two cycles of palliative cisplatin/pemetrexed chemotherapy, presents with a 2-day
history of nausea and vomiting. On examination, he is tachycardic with a blood
pressure of 105/60 mmHg. Blood tests show a urea of 15 mmol/L and a creatinine
of 180 μmol/L. Results from a week earlier showed a urea of 4.0 mmol/L and a
creatinine of 90 μmol/L. All other blood tests and arterial blood gas results are
within the normal range. What is the most appropriate initial management of this
patient?
A. Oral fluid rehydration
B. Intravenous fluid rehydration
C. Urgent renal ultrasound scan
D. Haemodialysis
E. CT scan of kidneys, ureter and bladder

Question 21

Electrolyte imbalance (4)
A 65-year-old woman who is currently receiving chemotherapy for acute myeloid
leukaemia is found on blood testing to have urea of 10.1 mmol/L, creatinine of
190 mol/L, potassium of 6.1 mmol/L, phosphate of 8.5 mg/dL and corrected calcium
of 2.00 mmol/L. The patient is asymptomatic. Her electrolyte levels were normal
prior to the start of treatment. What is the most likely cause of this electrolyte
disturbance?
A. Tumour lysis syndrome
B. Hypovolaemia
C. Haemolytic uraemic syndrome
D. Neutropenic sepsis
E. Disease progression

Question 22

Cutaneous manifestation of cancer
A 56-year-old man with gastric cancer presents to his GP complaining of a lump
in his belly button. On examination, there is a palpable nodule at his umbilicus.
This sign is referred to as:
A. Sister Mary Joseph nodule
B. Krukenberg tumour
C. Acanthosis nigricans
D. Peutz–Jeghers syndrome
E. Paget’s disease

Question 23

Facial flushing (1)
A 62-year-old man with known metastatic small cell carcinoma of the lung has
presented to accident and emergency with sudden onset shortness of breath and
arm and hand swelling. On examination, his face appears plethoric and Pemberton’s
sign is positive. What is the most likely diagnosis?
A. Pancoast’s tumour
B. Horner’s syndrome
C. Superior vena cava obstruction
D. Facial oedema
E. Malignant pleural effusion

Question 24

Facial flushing (2)
A 55-year-old man has presented to his GP complaining of several episodes of
spontaneous facial blushing. In addition, he mentions he has had several episodes
of watery diarrhoea. On examination of the cardiovascular system, giant v waves
are noted on observation of the jugular venous pressure. In addition, a pansystolic
murmur is heard in the lower sternal edge on inspiration. Examination of the
gastrointestinal system reveals an enlarged, irregular, non-tender liver edge. What
is the most likely diagnosis?
A. Superior vena cava obstruction
B. Carcinoid tumour
C. Carcinoid syndrome
D. Phaeochromocytoma
E. Conn’s syndrome