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?

A. They are the most common variant of sarcoma in adults

B. Core biopsies in low grade liposarcomas may be normal

C. May have a pseudocapsule

D. It is unlikely in a lesion measuring less than 5cm

E. Pulmonary metastasis are common

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.

Sarcomas

 Malignant tumours of mesenchymal origin

Types
May be either bone or soft tissue in origin.
Bone sarcoma include:

 Osteosarcoma
 Ewings sarcoma (although non bony sites recognised)
 Chrondrosarcoma - originate from Chondrocytes

Soft tissue sarcoma are a far more heterogeneous group and include:

 Liposarcoma-adipocytes
 Rhabdomyosarcoma-striated muscle
 Leiomyosarcoma-smooth muscle
 Synovial sarcomas- close to joints (cell of origin not known but not synovium)

Malignant fibrous histiocytoma is a sarcoma that may arise in both soft tissue and
bone.

Features
Certain features of a mass or swelling should raise suspicion for a sarcoma these
include:
  Large >5cm soft tissue mass
 Deep tissue location or intra muscular location
 Rapid growth
 Painful lump

Assessment
Imaging of suspicious masses should utilise a combination of MRI, CT and USS.
Blind biopsy should not be performed prior to imaging and where required should be
done in such a way that the biopsy tract can be subsequently included in any
resection.

Ewings sarcoma

 Commoner in males
 Incidence of 0.3 / 1, 000, 000
 Onset typically between 10 and 20 years of age
 Location by femoral diaphysis is commonest site
 Histologically it is a small round tumour
 Blood borne metastasis is common and chemotherapy is often combined with
surgery

Osteosarcoma

 Mesenchymal cells with osteoblastic differentiation

 20% of all primary bone tumours
 Incidence of 5 per 1,000,000
 Peak age 15-30, commoner in males
 Limb preserving surgery may be possible and many patients will receive
chemotherapy

Liposarcoma

 Malignancy of adipocytes
 Rare approximately 2.5 per 1,000,000. They are the second most common soft
tissue sarcoma
 Typically located in deep locations such as retroperitoneum
 Affect older age group usually >40 years of age
 May be well differentiated and thus slow growing although may undergo
dedifferentiation and disease progression
 Many tumours will have a pseudocapsule that can misleadingly allow
surgeons to feel that they can 'shell out' these lesions. In reality tumour may
invade at the edge of the pseudocapsule and result in local recurrence if this
strategy is adopted
 Usually resistant to radiotherapy although this is often used in a palliative
setting
Malignant Fibrous Histiocytoma

 Tumour with large number of histiocytes

 Most common sarcoma in adults
 Also described as undifferentiated pleomorphic sarcoma NOS (i.e. Cell of
origin is not known)
 Four major subtypes are recognised: storiform-pleomorphic (70% cases),
myxoid (less aggressive), giant cell and inflammatory
 Treatment is usually with surgical resection and adjuvant radiotherapy as this
reduces the likelihood of local recurrence

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?

A. They are the most common variant of sarcoma in adults

B. Core biopsies in low grade liposarcomas may be normal

C. May have a pseudocapsule

D. It is unlikely in a lesion measuring less than 5cm

E. Pulmonary metastasis are common

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.

Sarcomas

 Malignant tumours of mesenchymal origin

Types
May be either bone or soft tissue in origin.
Bone sarcoma include:

 Osteosarcoma
 Ewings sarcoma (although non bony sites recognised)
 Chrondrosarcoma - originate from Chondrocytes

Soft tissue sarcoma are a far more heterogeneous group and include:

 Liposarcoma-adipocytes
  Rhabdomyosarcoma-striated muscle
 Leiomyosarcoma-smooth muscle
 Synovial sarcomas- close to joints (cell of origin not known but not synovium)

Malignant fibrous histiocytoma is a sarcoma that may arise in both soft tissue and
bone.

Features
Certain features of a mass or swelling should raise suspicion for a sarcoma these
include:

 Large >5cm soft tissue mass

 Deep tissue location or intra muscular location
 Rapid growth
 Painful lump

Assessment
Imaging of suspicious masses should utilise a combination of MRI, CT and USS.
Blind biopsy should not be performed prior to imaging and where required should be
done in such a way that the biopsy tract can be subsequently included in any
resection.

Ewings sarcoma

 Commoner in males
 Incidence of 0.3 / 1, 000, 000
 Onset typically between 10 and 20 years of age
 Location by femoral diaphysis is commonest site
 Histologically it is a small round tumour
 Blood borne metastasis is common and chemotherapy is often combined with
surgery

Osteosarcoma

 Mesenchymal cells with osteoblastic differentiation

 20% of all primary bone tumours
 Incidence of 5 per 1,000,000
 Peak age 15-30, commoner in males
 Limb preserving surgery may be possible and many patients will receive
chemotherapy

Liposarcoma

 Malignancy of adipocytes
  Rare approximately 2.5 per 1,000,000. They are the second most common soft
tissue sarcoma
 Typically located in deep locations such as retroperitoneum
 Affect older age group usually >40 years of age
 May be well differentiated and thus slow growing although may undergo
dedifferentiation and disease progression
 Many tumours will have a pseudocapsule that can misleadingly allow
surgeons to feel that they can 'shell out' these lesions. In reality tumour may
invade at the edge of the pseudocapsule and result in local recurrence if this
strategy is adopted
 Usually resistant to radiotherapy although this is often used in a palliative
setting

Malignant Fibrous Histiocytoma

 Tumour with large number of histiocytes

 Most common sarcoma in adults
 Also described as undifferentiated pleomorphic sarcoma NOS (i.e. Cell of
origin is not known)
 Four major subtypes are recognised: storiform-pleomorphic (70% cases),
myxoid (less aggressive), giant cell and inflammatory
 Treatment is usually with surgical resection and adjuvant radiotherapy as this
reduces the likelihood of 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 approprate management?

A. Surgical fixation with a dynamic compression plate

B. Hemi-arthroplasty

C. Fixation with intramedullary nail

D. Radial radiotherapy

E. Chemotherapy
Even with surgical fixation only 30% of pathological fractures unite. The type of
fixation should be chosen accordingly.

A lesion of this nature is at high risk of spontaneous fracture. Whilst radiotherapy

may palliate her symptoms of pain it will not reduce the risk of fracture. In fit patients
an intramedullary nail should be inserted. Very proximal lesions may be best
managed by a total hip replacement

Secondary malignant tumours of bone

Metastatic lesions affecting bone are more common than primary bone tumours.

The typical tumours that spread to bone include:

 Breast
 Bronchus
 Renal
 Thyroid
 Prostate

75% cases will affect those over the age of 50

The commonest bone sites affected are:

 Vertebrae (usually thoracic)

 Proximal femur
 Ribs
 Sternum
 Pelvis
 Skull

Pathological fracture
Osteolytic lesions are the greatest risk for pathological fracture
The risk and load required to produce fracture varies according to bone site. Bones
with lesions that occupy 50% or less will be prone to fracture under loading
(Harrington). When 75% of the bone is affected the process of torsion about a bony
fulcrum may produce a fracture.

The Mirel scoring[1] system may be used to help determine the risk of fracture and is
more systematic than the Harrington system described above.

Mirel Scoring system

Score Site Radiographic Width of bone Pain

points appearance involved
1 Upper extremity Blastic Less than 1/3 Mild
2 Lower Mixed 1/3 to 2/3 Moderate
extremity
3 Peritrochanteric Lytic More than 2/3 Aggravated by
function

Depending upon the score the treatment should be as follows:

Score Risk of fracture Treatment

9 or greater Impending (33%) Prophylactic fixation
8 Borderline Consider fixation
7 or less Not impending (4%) Non operative management

Where the lesion is an isolated metastatic deposit consideration should be given to

excision and reconstruction as the outcome is better [2].

Non operative treatments

Hypercalcaemia- Treat with re hydration and bisphosphonates.
Pain- Opiate analgesics and radiotherapy.
Some tumours such as breast and prostate will benefit from chemotherapy and or
hormonal agents.

References
1. Mirels, H., Metastatic disease in long bones. A proposed scoring system for
diagnosing impending pathologic fractures. Clin Orthop Relat Res, 1989(249): p. 256-
64.
2. Mavrogenis, A.F., et al., Survival analysis of patients with femoral metastases. J
Surg Oncol, 2011.

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?

A. Breast

B. Renal

C. Bronchus

D. Thyroid

E. Colon

Renal metastases have a tendency to be hypervascular. This is of considerable

importance if surgical fixation is planned.

Secondary malignant tumours of bone

Metastatic lesions affecting bone are more common than primary bone tumours.

The typical tumours that spread to bone include:

 Breast
 Bronchus
 Renal
 Thyroid
 Prostate
75% cases will affect those over the age of 50

The commonest bone sites affected are:

 Vertebrae (usually thoracic)

 Proximal femur
 Ribs
 Sternum
 Pelvis
 Skull

Pathological fracture
Osteolytic lesions are the greatest risk for pathological fracture
The risk and load required to produce fracture varies according to bone site. Bones
with lesions that occupy 50% or less will be prone to fracture under loading
(Harrington). When 75% of the bone is affected the process of torsion about a bony
fulcrum may produce a fracture.

The Mirel scoring[1] system may be used to help determine the risk of fracture and is
more systematic than the Harrington system described above.

Mirel Scoring system

Score Site Radiographic Width of bone Pain

points appearance involved
1 Upper extremity Blastic Less than 1/3 Mild
2 Lower Mixed 1/3 to 2/3 Moderate
extremity
3 Peritrochanteric Lytic More than 2/3 Aggravated by
function

Depending upon the score the treatment should be as follows:

Score Risk of fracture Treatment

9 or greater Impending (33%) Prophylactic fixation
8 Borderline Consider fixation
7 or less Not impending (4%) Non operative management

Where the lesion is an isolated metastatic deposit consideration should be given to

excision and reconstruction as the outcome is better [2].

Non operative treatments

Hypercalcaemia- Treat with re hydration and bisphosphonates.
Pain- Opiate analgesics and radiotherapy.
Some tumours such as breast and prostate will benefit from chemotherapy and or
hormonal agents.
References
1. Mirels, H., Metastatic disease in long bones. A proposed scoring system for
diagnosing impending pathologic fractures. Clin Orthop Relat Res, 1989(249): p. 256-
64.
2. Mavrogenis, A.F., et al., Survival analysis of patients with femoral metastases. J
Surg Oncol, 2011.

Which of the following group of patients are not screened for colorectal cancer?

A. Peutz Jeghers syndrome

B. Asymptomatic patients aged 55 years

C. Acromegaly

D. Ureterosigmoidostomy

E. 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.

Colorectal cancer screening and diagnosis

Overview

 Most cancers develop from adenomatous polyps. Screening for colorectal

cancer has been shown to reduce mortality by 16%
 The NHS now has a national screening programme offering screening every 2
years to all men and women aged 60 to 69 years. Patients aged over 70 years
may request screening
 Eligible patients are sent faecal occult blood (FOB) tests through the post
 Patients with abnormal results are offered a colonoscopy

At colonoscopy, approximately:

 5 out of 10 patients will have a normal exam

 4 out of 10 patients will be found to have polyps which may be removed due
to their premalignant potential
 1 out of 10 patients will be found to have cancer

Diagnosis
Essentially the following patients need referral:

- Altered bowel habit for more than six weeks

- New onset of rectal bleeding
- Symptoms of tenesmus

Colonoscopy is the gold standard, provided it is complete and good mucosal

visualisation is achieved. Other options include double contrast barium enema and CT
colonography.

Staging

Once a malignant diagnosis is made patients with colonic cancer will be staged using
chest / abdomen and pelvic CT. Patients with rectal cancer will also undergo
evaluation of the mesorectum with pelvic MRI scanning.

For examination purposes the Dukes and TNM systems are preferred.

Tumour markers
Carcinoembryonic antigen (CEA) is the main tumour marker in colorectal cancer. Not
all tumours secrete this, and it may be raised in conditions such as IBD. However,
absolute levels do correlate (roughly) with disease burden and whilst this marker may
not be used extensively in follow up, it can be useful for investigation of patients with
cancer of unknown primary.
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?

A. Switch to co-codamol 30/500

B. Refer for radiotherapy

C. Add oral bisphosphonate

D. Add diclofenac

E. Add dexamethasone
Metastatic bone pain may respond to
NSAIDs, bisphosphonates or
radiotherapy

Bone pain often responds well to NSAIDs. Both radiotherapy and bisphosphonates
have a role in managing bony pain but these are not first-line treatments.

Palliative care prescribing: pain

SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected
points

 the breakthrough dose of morphine is one-sixth the daily dose of morphine

 all patients who receive opioids should be prescribed a laxative
 opioids should be used with caution in patients with chronic kidney disease.
Alfentanil, buprenorphine and fentanyl are preferred
 metastatic bone pain may respond to NSAIDs, bisphosphonates or
radiotherapy

When increasing the dose of opioids the next dose should be increased by 30-50%.

Conversion between opioids

From To

Oral codeine Oral morphine Divide by 10

Oral tramadol Oral morphine Divide by 5

From To

Oral morphine Oral oxycodone Divide by 2

The BNF states that oral morphine sulphate 80-90mg over 24 hours is approximately
equivalent to one '25 mcg/hour' fentanyl patch, therefore product literature should be
consulted.

From To

Oral morphine Subcutaneous diamorphine Divide by 3

Oral oxycodone Subcutaneous diamorphine Divide by 1.5
A 62 year old male is found to have colorectal cancer. He has Dukes B disease. What
is his 5 year prognosis?

A. 100%

B. 90%

C. 80%

D. 70%

E. 60%

Theme from September 2011 Exam

Dukes classification
Gives the extent of spread of colorectal cancer
Dukes A Tumour confined to the mucosa (90%)
Dukes B Tumour invading bowel wall (70%)
Dukes C Lymph node metastases (45%)
Dukes D Distant metastases (6%)(20% if resectable)
5 year survival in brackets
In examining a biopsy of a primary tumour, the clearest evidence of malignancy is
provided by:

A. Absence of a capsule

B. Basophilia of the cytoplasm

C. Invasion of surrounding structures

D. Excess of mitoses

E. Nuclear aberrations

Invasion is the hallmark of malignancy. The others may occur in insitu disease or
dysplastic lesions.

Tissue sampling

Tissue sampling is an important surgical process. Biopsy modalities vary according to

the site, experience and subsequent planned therapeutic outcome

The modalities comprise:

-Fine needle aspiration cytology
-Core biopsy
-Excision biopsy
-Tru cut biopsy
-Punch biopsy
-Cytological smears
-Endoscopic or laparoscopic biopsy

When the lesion is superficial the decision needs to be taken as to whether complete
excision is desirable or whether excision biopsy is acceptable. In malignant melanoma
for example the need for safe margins will mean that a more radical surgical approach
needs to be adopted after diagnostic confirmation from excision biopsy than would be
the case in basal cell carcinoma. Punch biopsies are useful in gaining histological
diagnosis of unclear skin lesions where excision biopsy is undesirable such as in
establishing whether a skin lesion is vasculitic or not.

Fine needle aspiration cytology (FNAC) is an operator dependent procedure that may
or may not be image guided and essentially involves passing a needle through a lesion
whilst suction is applied to a syringe. The material thus obtained is expressed onto a
slide and sent for cytological assessment. This test can be limited by operator
inexperience and also by the lack of histological architectural information (e.g.
Follicular carcinoma of the thyroid). Where a discharge is present a sample may be
sent for cytology although in some sites (e.g. Nipple discharge ) the information
gleaned may be meaningless.

Tissue samples may be obtained by both core and tru cut biopsy. A core biopsy is
obtained by use of a spring loaded gun with a needle passing quickly through the
lesion of interest. A tru cut biopsy achieves the same objective but the needle moved
by hand. When performing these techniques image guidance may be desirable (e.g. In
breast lesions). Consideration needs to be given to any planned surgical resection as it
may be necessary to resect the biopsy tract along with the specimen (e.g. In sarcoma
surgery).

Visceral lesions may be accessed percutaneously under image guidance such as

ultrasound guided biopsy of liver metastases. Or under direct vision such as a
colonoscopic biopsy.
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 1.9L 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?

A. Haemoptysis

B. FEV 1.9 litres

C. Histology shows squamous cell cancer

D. Vocal cord paralysis

E. 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.

Lung cancer: non-small cell management

Management

 Only 20% suitable for surgery

 Mediastinoscopy performed prior to surgery as CT does not always show
mediastinal lymph node involvement
 Curative or palliative radiotherapy
 Poor response to chemotherapy
Surgery contraindications

 Assess general health

 Stage IIIb or IV (i.e. metastases present)
 FEV1 < 1.5 litres is considered a general cut-off point*
 Malignant pleural effusion
 Tumour near hilum
 Vocal cord paralysis
 SVC obstruction

* However if FEV1 < 1.5 for lobectomy or < 2.0 for pneumonectomy then some
authorities advocate further lung function tests as operations may still go ahead based
on the results
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?

A. Stop the infusion and administer dexamethasone through the infusion

device

B. Stop the infusion and administer hyaluronidase through the infusion

device

C. Stop the infusion and apply a cold compress to the site

D. Stop the infusion and apply a warm compress to the site

E. 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 administed
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.

Extravasation injury

Chemotherapy may be complicated by extravasation reactions in up to 6% of cases.

The following chemotherapy agents are recognised causes of extravasation reactions;
doxorubicin, vincristine, vinblastine, adriamycin, cisplatin, mitomycin and
mithramycin.
Up to 30% of extravasation reactions may be complicated by the development of
ulceration.
When an extravasation reaction is suspected the infusion should be stopped and the
infusing device aspirated. The extremity should be elevated. As a general rule cold
compresses have been shown to reduce the incidence of subsequent ulceration with
doxorubicin. Warm compresses have been found to be beneficial in extravasation of
vinca alkaloids. Dimethylsulfoxide may be infused in some cases, ideally within 5
hours of the event occurring. No conclusive evidence exists to support the use of
corticosteroids or sodium bicarbonate for extravasation injuries.
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?

A. Thyroid

B. Breast

C. Kidney

D. Endometrium

E. None of the above

Theme from September 2011 exam

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.

Secondary malignant tumours of bone

Metastatic lesions affecting bone are more common than primary bone tumours.

The typical tumours that spread to bone include:

 Breast
 Bronchus
 Renal
 Thyroid
 Prostate

75% cases will affect those over the age of 50

The commonest bone sites affected are:

 Vertebrae (usually thoracic)

 Proximal femur
 Ribs
 Sternum
 Pelvis
 Skull
Pathological fracture
Osteolytic lesions are the greatest risk for pathological fracture
The risk and load required to produce fracture varies according to bone site. Bones
with lesions that occupy 50% or less will be prone to fracture under loading
(Harrington). When 75% of the bone is affected the process of torsion about a bony
fulcrum may produce a fracture.

The Mirel scoring[1] system may be used to help determine the risk of fracture and is
more systematic than the Harrington system described above.

Mirel Scoring system

Score Site Radiographic Width of bone Pain

points appearance involved
1 Upper extremity Blastic Less than 1/3 Mild
2 Lower Mixed 1/3 to 2/3 Moderate
extremity
3 Peritrochanteric Lytic More than 2/3 Aggravated by
function

Depending upon the score the treatment should be as follows:

Score Risk of fracture Treatment

9 or greater Impending (33%) Prophylactic fixation
8 Borderline Consider fixation
7 or less Not impending (4%) Non operative management

Where the lesion is an isolated metastatic deposit consideration should be given to

excision and reconstruction as the outcome is better [2].

Non operative treatments

Hypercalcaemia- Treat with re hydration and bisphosphonates.
Pain- Opiate analgesics and radiotherapy.
Some tumours such as breast and prostate will benefit from chemotherapy and or
hormonal agents.

References
1. Mirels, H., Metastatic disease in long bones. A proposed scoring system for
diagnosing impending pathologic fractures. Clin Orthop Relat Res, 1989(249): p. 256-
64.
2. Mavrogenis, A.F., et al., Survival analysis of patients with femoral metastases. J
Surg Oncol, 2011.
A 67-year-old man with colorectal cancer is currently taking MST 30mg bd for pain
relief. What dose of oral morphine solution should he be prescribed for breakthrough
pain?

A. 5 mg
 B. 10 mg

C. 15 mg

D. 20 mg

E. 30 mg
Breakthrough dose = 1/6th of
daily morphine dose

The total daily morphine dose is 30 * 2 = 60 mg, therefore the breakthrough dose
should be one-sixth of this, 10 mg.

Palliative care prescribing: pain

SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected
points

 the breakthrough dose of morphine is one-sixth the daily dose of morphine

 all patients who receive opioids should be prescribed a laxative
 opioids should be used with caution in patients with chronic kidney disease.
Alfentanil, buprenorphine and fentanyl are preferred
 metastatic bone pain may respond to NSAIDs, bisphosphonates or
radiotherapy

When increasing the dose of opioids the next dose should be increased by 30-50%.

Conversion between opioids

From To

Oral codeine Oral morphine Divide by 10

Oral tramadol Oral morphine Divide by 5

From To

Oral morphine Oral oxycodone Divide by 2

The BNF states that oral morphine sulphate 80-90mg over 24 hours is approximately
equivalent to one '25 mcg/hour' fentanyl patch, therefore product literature should be
consulted.

From To

Oral morphine Subcutaneous diamorphine Divide by 3

Oral oxycodone Subcutaneous diamorphine Divide by 1.5