° Question 1 of 21 & B ° A5 year old lady has undergone a wide local excision and sentinel lymph node biopsy for breast cancer. The histology report shows a completely excised 1.3cm grade 1 invasive ductal carcinoma, The sentinel node contained no evidence of metastatic disease. The tumour is. estrogen receptor negative. What is the next course of action? Monitor in clinic with annual review and mammography Arranged combined chemoradiotherapy Arrange chemotherapy Prescribe anti oestrogen Radiotherapy is routine following breast conserving surgery. Without Irradiation the local recurrence rates are approximately 40%. These rates are potentially lower in older patients who receive endocrine therapy and who have small low grade tumours. wé | @ | Improve Breast cancer treatment * Treatment Indication Endocrine . therapy . Irradiation : Chemotherapy 7 Endocrine agents Oestrogen receptor positive tumours Downstaging primary lesions Definitive treatment in old, infirm patients Wide local excision Large lesion, high grade or marked vascular invasion following mastectomy Downstaging advanced lesions to facilitate breast conserving surgery Patients with grade 3 lesions or axillary nodal disease ‘Tamoxifen is used and works as a partial oestrogen receptor agonist. It will typically block activity at the breast. It does, however, stimulate the receptors at other sites and it is this thataccounts for its association with endometrial cancer. In post menopausal women the process of aromatisation accounts for most oestrogen production. Therefore in this group aromatase Inhibitors are the preferred agents. Women who are perimenopausal start on tamoxifen and switch at 3 years. More recent studies (aTTom and ATLAS) have demonstrated benefits for continuing the drug for 10 years. In pre-menopausal women, there is increasing preference for the use of Exemestane over tamoxifen. Chemotherapy The FEC regime Is most commonly used (Fluorouracil, epirubicin and cyclophosphamide). This was found to be superior to the older CMF regime. The Taxanes are commonly used in high risk patients and in this setting a regime of docetaxal, doxorubicin and cyclophosphamide may be used. The anthracycline class drugs have marked cardiotoxicity (a property that they share with trastuzumab) and this can limit their use. Bile @- #2. Tr & @ @ Search ‘Search textbook B {Q Google search on “Breast cancer treatment” + Suagest nk suggest media Dashboard weearaunrsona KA 45K ORKQuestion zorar + B ° ‘A 45 year old man has widespread metastatic adenocarcinoma of the colon. Which of these ‘tumour markers is most likely to be elevated? cA19-9 oe Alpha Feto Protein oe A125 oe oe Beta HCG. Screening for colonic cancer using CEA is not justified Carcinoembryonic antigen is elevated in colonic cancer, typically in relation to disease extent with highest serum levels noted in metastatic disease. It is falsely elevated in a number of non- malignant disease states such as cirthosis and colitis and for this reason it has no role in ‘monitoring colitics for colonic cancer{1}, Reference 1. Sturgeon, C.M., L.C. Lal, and M.J. Duffy. Serum tumour markers: how to order and interpret them. BMJ, 2009. 339: p. b3527. i % | Improve 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. This is being replaced by FIT testing * Patients with abnormal results are offered a colonoscopy - The NHS BOSS flexible sigmoidoscopy screening comprises a single flexible sigmoidoscopy to patients aged 55 years, At colonoscopy, approximately: + Sout 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 18D. However, absolute levels do correlate (roughly) with disease burden and it is once again being used routinely in follow up. Bigs &- Tr By @ @ Search Search textbook B Q Google search on “Colorectal cancer screening and diagnosis" ++ suggest tink + suggest media Dashboard » MSSeo Question 3 of 21 v 5 © A73 year old man is recovering following an emergency Hartmans procedure performed for an obstructing sigmoid cancer. The pathology report shows a moderately differentiated adenocarcinoma that invades the muscularis propria, 3 of 15 lymph nodes are involved with metastatic disease. What is the correct stage for this? Astler Coller Stage 82 Dukes stage A Dukes stage 8 Dukes stage D Remember that the term metastasis simply refers to spread and can include the lymph nodes. In an examination setting marks can be lost by incorrectly selecting Dukes D (which would be consistent with liver metastasis) rather than nodal metastasis (Dukes C). The involvement of lymph nodes makes this Dukes C. In the Astler Coller system the 8 and subsets are split to B1 and B2 and C1 and C2. Where C2 denotes involvement of the nodes in Conjunction with penetration of the muscularis propria | | improve | Dukes classification * Gives the extent of spread of colorectal cancer Dukes Tumour confined to the bowel but not extending beyond it, without nodal A metastasis (95%) Dukes Tumour invading bowel wall, but without nodal metastasis (75%) Dukes Lymph node metastases (50%) Dukes _ Distant metastases (6%)(25% if resectable) 5 year survival in brackets i° Question 4 of 21 v 5 © ‘A23 year old lady presents with a nodule in the right lobe of the thyroid. Examination of the neck is otherwise unremarkable and clinically she is euthyroid. Imaging shows a solid nodule at the site. What is the correct course of action? Image guided core biopsy Arrange a hemithyroidectomy Perform an incision biopsy Perform an excision biopsy FNAC is the first line investigation in this setting. Whereas FNAC has declined in popularity recently (in breast investigation), it remain a very popular option in the investigation of thyroid masses. It cannot reliably diagnose a follicular tumour. | | Improve 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 -£xcision blopsy 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. ‘Save my notes Search ‘Search textbook Q Google search on “Tissue sampling” ++ Suggest ink + Suggest mesa Dashboard weveaneone GARR LARSS<) Question Sof 21 v B °o What is the most common cause of osteolytic bone metastasis in children? Osteosarcoma | ° Leukaemia @ Rhabdomyosarcoma Medulloblastoma @ Neuroblastomas are a relatively common childhood tumour and have a strong tendency to developing widespread lytic metastasis. It is unusual for CNS tumours to spread to involve the skeleton. [4 | oe | improve 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 tisk 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 Radiographic Width of bone points site appearance involved Pain 1 Upper extremity —_Blastic Less than 1/3 Mild ‘- Lower extremity Mixed 1/3 to 2/3, Moderate 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 Torless 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- Oplate analgesics and radiotherapy. ‘Some tumours such as breast and prostate will benefit from chemotherapy and or hormonal agents. Re 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. et al. Survival analysis of patients with femoral metastases. J Surg Oncol, ences BES Pa Tr gy fl ©° ausston 6of 21 @ ‘A.62 year old male is found to have colorectal cancer. prognosis? 100% 90% 80% 70% Improve Dukes classification * Gives the extent of spread of colorectal cancer B ° He has Dukes C disease, What is his 5 year Dukes Tumour confined to the bowel but not extending beyond it, without nodal A metastasis (25%) Dukes Tumour invading bowel wall, but without nodal metastasis (75%) Dukes Lymph node metastases (50%) Dukes Distant metastases (6%)(25% if resectable) 5 year survival in brackets ‘Save my notes°o Question 7 of 21 ’ 5 © ‘A.45 year old patient undergoes a CT scan of the abdomen and is noted to have a 6cm mass in the right adrenal gland, Urinary catecholamines and other endocrine investigations are negative, CT of the chest and remainder of the abdomen Is otherwise normal. What Is the most appropriate course of action? Image guided FNAC of the adrenal gland @ Image guided core biopsy of the adrenal gland aa Organise surveillance of the lesion with CT scanning QP Organise surveillance of the lesion with USS eo Most surgeons would excise a mass of this size rather than attempt biopsy. Further information relating to adrenal masses is covered under this topic. | @ | Improve 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 vasculitc 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. Save my notes Search Search textbook B Q Google search on “Tissue sampling" 4 Suggest nk + Suggest media Dashboard eevounene (SRR K OSE°e Question 8 of 21 v n oO Which of the following group of patients are not screened for colorectal cancer? Peutz Jeghers syndrome ‘Acromegaly Ureterosigmoidostomy Inflammatory bowel disease Other disorders which are screened for colorectal malignancy include: Familial adenomatous polyposis, Hereditary non polyposis colorectal cancer. The NHS screening programme starts at 60 in England (Sigmoidoscopy screening at 55 years). In Scotland it starts at 50. | P| Improve 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. This is being replaced by FIT testing + Patients with abnormal results are offered a colonoscopy - The NHS BOSS flexible sigmoidoscopy screening comprises a single flexible sigmoidoscopy to patients aged 55 years ‘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 tenes mus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 Carcincembryonic 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 it is once again being used routinely in follow up. Tr By ml @ Save my notes d ‘Search ‘Search textbook. Q Google search on “Colorectal cancer screening and diagnosis” Suggest ink + suggest media Dashboard @vonrana eRBRADAT RS° Question 9 of 21 ¥ Pp © A63 year old lady with metastatic breast cancer presents with bone pain. Radiological tests show a metastatic lytic deposit to her femoral shaft. The lesion occupies 75% of the bone diameter. What is the most appropriate management? Surgical fixation with a dynamic compression plate eo Hemiarthroplasty oo Se ° Radical radiotherapy Chemotherapy e Even with surgical fixation only 30% of pathological fractures unite, The type of fixation should be chosen accordingly. Alesion 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 [|e | improve | 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 + Stemum + 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 Radiographic Width of bone points Site appearance involved Pain 1 Upper extremity Blastic Lessthan 1/3 Mild 2 Lower extremity Mixed 1/3 to 2/3 Moderate 3 Peritrochanteric Lytle 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 Torless 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, AF. etal. Survival analysis of patients with femoral metastases. J Surg Oncol,@ Question 10 of 21 v B © ‘An 88 year old lady presents with a large mass in the upper inner quadrant of her right breast Investigations confirm an oestrogen receptor positive, invasive ductal carcinoma. She has declined operative treatment. What is the best course of action? Combined chemoradiotherapy Radical radiotherapy Best supportive care Chemotherapy alone Elderly patients may be managed using endocrine therapy alone. Eventually most will escape hormonal control. In post menopausal women oestrogens are produced by the peripheral aromatization of androgens and aromatase inhibitors are therefore the most popular agent in this age group. [ @ | Improve (eS) Breast cancer treatment * Treatment Indication Endocrine * Oestrogen receptor positive tumours therapy * Downstaging primary lesions * Definitive treatment in old, infirm patients Irradiation * Wide local excision * Large lesion, high grade or marked vascular invasion following mastectomy Chemotherapy + Downstaging advanced lesions to facilitate breast conserving surgery * Patients with grade 3 lesions or axillary nodal disease Endocrine agents Tamoxifen is used and works as a partial oestrogen receptor agonist. it will typically block activity at the breast. it does, however, stimulate the receptors at other sites and itis this that accounts for its association with endometrial cancer. In post menopausal women the process ofaromatisation accounts for most oestrogen production. Therefore in this group aromatase inhibitors are the preferred agents. Women who are perimenopausal start on tamoxifen and switch at 3 years, More recent studies (aT Tom and ATLAS) have demonstrated benefits for continuing the drug for 10 years. In pre-menopausal women, there is increasing preference for the use of Exemestane over tamoxifen Chemotherapy ‘The FEC regime is most commonly used (Fluorouracil, epirubicin and cyclophosphamide). This was found to be superior to the older CMF regime. The Taxanes are commonly used in high risk patients and in this setting a regime of docetaxal, doxorubicin and cyclophosphamide may be used. The anthracycline class drugs have marked cardiotoxicity (a property that they share with trastuzumab) and this can limit their use. Next question > ‘Search ‘Search textbook. B Q Google search on “Breast cancer treatment” 4 Suggest link “Suggest media Dashboard wayrauneuna S644 642604@ Question 11 of 21 v Bp oO A 56-year-old man with metastatic prostate cancer comes for review. He is known to have spinal metastases but until now has not had any significant problems with pain control. Unfortunately he is now getting regular back pain despite taking paracetamol 1g qds. Neurological examination is unremarkable. What is the most appropriate next step? ‘Switch to co-codamol 30/500 Refer for radiotherapy ‘Add oral bisphosphonate Add 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. [oe [oe | improve 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 dally 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 meg/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 od Belem (seve notes Search Search textbook | co | Q Google search on “Palliative care prescribing: pain® + sugges link suggest media Dashboard Ti Rees<) Question 12 of 21 v p © ‘A555 year old man is found to have a carcinoma of the sigmoid colon on screening colonoscopy, How should this be staged? MRI of the abdomen and CT of the chest Liver MRI and Chest CT MRI of the rectum and CT of the abdomen and chest Endoluminal USS and CT scanning of the abdomen Colonic cancers are staged with CT scanning of the chest, abdomen and pelvis. Rectal cancer is staged with MRI rectum (and sometimes endolumenal USS for low T1 lesions) together with CT scanning of the chest, abdomen and pelvis. Historically, colonic cancer was staged with liver USS and CXR. However, modern imaging has made this practice obsolete. oo | 9 | improve 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. This is being replaced by FIT testing * Patients with abnormal results are offered a colonoscopy - The NHS BOSS flexible sigmoidoscopy screening comprises a single flexible sigmoidoscopy to patients aged 55 years At colonoscopy, approximately: * 5S 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 itis once again being used routinely in follow up. Nex Save my notes Search Search textbook. B ‘Q Google search on “Colorectal cancer screening and diagnosis" Suggest ink Suggest media Dashboard Rede oes ooe =t CSO 46EKr<) Question 13 of 21 v Pp °S 67 year old lady is suspected of having Pagets disease of the nipple. Mammography and USS are normal. What is the most appropriate next step in her management? Arrange a core biopsy ‘Arrange FNAC of the area Undertake a mastectomy Arrange for focused radiotherapy This is a relatively clear indication for a punch biopsy. If cellular atypia is present on punch biopsy ‘then any in situ malignancy should be considered. FNAC would be unsultable. a l® Improve | 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 (NAC) 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 (¢.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. [seve my cis | Search ‘Search textbook Q Google search on “Tissue sampling” + Suggest lnk Suggest media Dashboard RSE KKK EK EOKE a6° Question 14 of 21 v B °} ‘AS year old male is referred to clinic for consideration of resection of a lung malignancy. He reports shortness of breath and haemoptysis. Investigations reveal a corrected calcium of 2.84 ‘mmol/l, an FEV 1 of 1.9L and histology of a squamous cell carcinoma. The patient is noted to. have a hoarse voice. Which one of the following is a contraindication to surgical resection in lung cancer? Haemoptysis FEV 1 of 1,9 litres. Calcium = 2.84 mmol/L 2 @ Histology shows squamous cell cancer oe @ oe 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. oe Improve | 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 Illb or IV (Le. 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 Bie§®ree e- Save my notes Search Search textbook B ‘Q Google search on ‘Lung cancer: non-small cell management” Suggest ink + Suggest media Dashboard @Vousen " 12 13 4 15 16 7 18 19 RRABEREKRAREECAEARCRSEE EReo ‘Question 15 of 21 v p 6 ‘A590 year old lady presents with pain in her proximal femur. Imaging demonstrates a bone ‘metastasis from an unknown primary site. CT scanning with arterial phase contrast shows that the lesion is hypervascular. From which of the following primary sites is the lesion most likely to have originated? Breast a2 _ | ° Bronchus eo Thyroid Colon e Renal metastases have a tendency to be hypervascular. This is of considerable importance if surgical fixation is planned. | | Improve 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 Radiographic Width of bone points Site appearance involved Pain 1 Upper extremity Blastic Less than 1/3 Mild 2 Lower extremity Mixed 1/3 t0.2/3, Moderate 3 Peritrochanteric Lytle 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 Torless 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,3° Question 16 of 21 x n oO A.38 year old lady has undergone a mastectomy and axillary node clearance for invasive ductal carcinoma. The histology report shows a completely excised 3.5cm lesion which is grade 3. Two of the axillary lymph nodes contain metastatic disease, The tumour is oestrogen receptor negative. What should be the next course of action? Chest wall irradiation Administration of letrozole Surveillance alone The combination of a grade 3 tumour and axillary nodal metastasis In a young female would attract a recommendation for chemotherapy. Some may also add herceptin (If they are HER 2 positive) | | Improve Breast cancer treatment * Treatment Indication Endocrine * Oestrogen receptor positive tumours therapy + Downstaging primary lesions * Definitive treatment in old, infirm patients Irradiation * Wide local excision * Large lesion, high grade or marked vascular invasion following mastectomy Chemotherapy + Downstaging advanced lesions to facilitate breast conserving surgery + Patients with grade 3 lesions or axillary nodal disease Endocrine agents Tamoxifen is used and works as a partial oestrogen receptor agonist. It will typically block activity at the breast. It does, however, stimulate the receptors at other sites and it is this thataccounts for its association with endometrial cancer. in post menopausal women the process of ‘aromatisation accounts for most oestrogen production. Therefore in this group aromatase inhibitors are the preferred agents. Women who are perimenopausal start on tamoxifen and switch at 3 years. More recent studies (aT Tom and ATLAS) have demonstrated benefits for continuing the drug for 10 years. In pre-menopausal women, there is Increasing preference for the use of Exemestane over tamoxifen. Chemotherapy ‘The FEC regime Is most commonly used (Fluorouracil, epirubicin and cyclophosphamide). This was found to be superior to the older CMF regime. The Taxanes are commonly used in high risk patients and in this setting a regime of docetaxal, doxorubicin and cyclophosphamide may be used. The anthracycline class drugs have marked cardiotoxicity (a property that they share with trastuzumab) and this can limit their use. ‘Save my notes Search Search textbook B Q Google search on "Breast cancer treatment” + suggest nk + suggest mestia Dashboard weeyvenrena £46664 64%° Question 17 of 21 v B © Chordoma may typically occur at the following sites, except? Clivus Sacrum Lumbar vertebra Cervical vertebra ‘Chordoma is a neoplasm originating from ectopic cellular remnants of the notochord and therefore arises from the midline of the axial skeleton. it accounts for 24% of all primary malignant bone tumours. Chordoma is the second commonest primary malignancy of the spine and accounts for over 50% of primary sacral tumnours. The neoplasm has a predilection for the ‘sacrococcygeal (50%) and clival (40%) regions, with other areas of the spine rarely involved. More than one vertebral body can be affected in half the cases. Chordomas most commonly present between 50 and 70 years of age. Sex incidence is equal below 40 years, but men are affected twice as often at older ages, particularly in the sacral region. ‘The most frequent radiographic appearance of chordoma is that of a destructive lesion of a vertebral body centered in the midline, with a large, associated soft-tissue mass. * Improve Chordoma * ‘Chordoma is a rare slow-growing bone tumour. Their favored origin is remnants of the notochord. ‘Chordomas can arise anywhere from the skull base to the sacrum. The two most common locations are the skull base and sacrum. ‘There are three histological variants of chordoma: classical (or ‘conventional’, chondroid and de- differentiated. * The histological appearance of classical chordoma is of a lobulated tumor composed of groups of cells separated by fibrous septa. The cells have small round nuclei and abundant vacuolated cytoplasm. * Chondroid chordomas histologically show features of both chordoma and chondrosarcoma, ‘The 10-year tumor free survival rate for sacral chordoma was 46%. Chondrold chordomas appear to have a more indolent clinical course.In most cases, complete surgical resection followed by radiation therapy offers the best chance of long-term control. Unfortunately, the lesion has a close proximity to the spine Itself and this can compromise resection margins. Chordomas are relatively radioresistant, requiring high doses of radiation to be controlled. The proximity of chordomas to vital neurological structures such as the brain stem and nerves limits the dose of radiation that can safely be delivered. Therefore, highly focused radiation such as proton therapy and carbon ion therapy are more effective than conventional x-ray radiation. Save my notes, Search Search textbook Q Google search on "Chordoma" Suggest lnk Fuagest media Dashboard un 12 13 14 RAKRACEERCERELEE° — wm Pp ° ‘A 45 year old woman with breast cancer Is started on a chemotherapy regime containing epirubicin, What is the primary mode of action of this drug? aa o Antimetabolite @w Monoctonal antibody to epidermal growth factor o Inhibition of DNA gyrase Inhibition of topoisomerase 1 Class Example Antimetabolites 5 FU Anthracyclines” Doxorubicin Topoisomerase — Etoposide inhibitors Platinum Cisplatin Alkylating Cyclophosphamide agent Taxanes Docetaxal lain adverse effect cardiotoxicity Mode of action S Phase specific drug, mimics uracil and is Incorporated into RNA Inhibits DNA and RNA synthesis by intercalating base pairs Inhibits topolsomerase lI, prevents efficient DNA, coiling Crosslinks DNA, this then distorts molecule and Induces apoptosis (similar to alkylating agents) Phosphoramide mustard forms DNA crosslinks and then cell death Disrupts microtubule formation *+zIrinotecan is a similar drug which works by inhibition of topoisomerase | | | Improve Breast cancer treatment * Treatment Indication Endocrine * Oestrogen receptor positive tumours.3° Question 19 of 21 ’ Bp © A 56 year old lady presents with a pathological fracture of the proximal femur. Which of the following primary sites is the most likely source of her disease? Thyroid eo a - Kidney oe Endometrium None of the above Primary site= BBRTP + Breast + Bronchus + Renal = Thyroid + Prostate ‘The correct answer is breast, because the question asks for the most likely primary site, Breast cancer is the commonest cause of lytic bone metastasis in women of this age, especially from amongst those options given. & | | improve | 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 + Sterum * 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 Radiographic Width of bone points Site. ‘appearance involved Pain 1 Upper extremity Blastic Less than 1/3 Mild 2 Lower extremity Mixed 1/3 to 2/3 Moderate 3 Peritrochanteric Lytic More than 2/3 Aggravated by function Depending upon the score the treatment should be as follows: Scor Risk of fracture Treatment 9 or greater Impending (33%) Prophylactic fixation 8 Borderline Consider fixation 7 orless 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<) Question 20 of 21 v e ° ‘A.43 year old lady is receiving chemotherapy for the treatment of metastatic breast cancer. You are called because it has become apparent that her doxorubicin infusion has extravasated. What is the most appropriate course of action? ‘Stop the infusion and administer dexamethasone through the infusion device Stop the infusion and administer hyaluronidase through the infusion device ‘Stop the infusion and apply a warm compress to the site ‘Stop the infusion and administer sodium bicarbonate through the Infusion device ‘The application of cold compresses is indicated in doxorubicin extravasation. Warm compresses increase the risk of doxorubicin ulceration. Hyaluronidase Is indicated in the extravasation of contrast media, TPN and vinca alkaloids. However, if administered following doxorubicin extravasation it will dramatically worsen the situation and is contra indicated. Up to 50% of those sustaining severe injuries will require delayed surgical reconstruction, Improve 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, 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 vinea 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. Extravasation of total parenteral nutrition solutions is usually managed by the local administration of hyaluronidase to the infusion site. Hr Gl ©<) Question 21 of 21 v 5 © In examining a biopsy of a primary tumour, the clearest evidence of malignancy Is provided by: Absence of a capsule Basophilia of the cytoplasm Excess of mitoses 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. Bile W&- = Save my notes | Search ‘Search textbook B Q Google search on “Tissue sampling” Suggest ink #Suggest media Dashboard weeayveanronH BBR sa RKC EEE EEEEMRCS 2021 EDITED BY OMER KAMAL AHMED A SUDANESE MEDICAL OFFICER AT ALGAZIRA CENTER FOT ORTHOPEDIC AND TRAUMA coobLugKV\ER K AHMET Wit tery tl