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  • Question 1 - You evaluate a 68-year-old woman diagnosed with small-cell lung cancer.
    Which ONE paraneoplastic syndrome...

    Incorrect

    • You evaluate a 68-year-old woman diagnosed with small-cell lung cancer.
      Which ONE paraneoplastic syndrome is most frequently linked to this form of lung cancer?

      Your Answer: Hypertrophic pulmonary osteoarthropathy (HPOA)

      Correct Answer: Ectopic ACTH production

      Explanation:

      Ectopic production of ACTH is linked to small-cell lung cancer and can lead to Cushing’s syndrome. It can also be observed in cases of pancreatic cancer and thymoma.

      Hypertrophic pulmonary osteoarthropathy (HPOA) is characterized by the presence of periostitis, arthritis, and finger clubbing. On plain X-ray, subperiosteal new bone formation can be detected. This condition primarily affects the long bones and often causes pain. It is most commonly associated with squamous cell lung cancer and pulmonary adenocarcinoma.

      Gynaecomastia, which is the enlargement of breast tissue in males, can occur as a result of squamous cell lung cancer. In these cases, it tends to be accompanied by pain.

      Rarely, squamous cell lung cancer can cause ectopic production of TSH, leading to hyperthyroidism.

      Carcinoid syndrome is a condition that arises from carcinoid tumors, which secrete serotonin and kallikreins. This syndrome manifests as episodes of flushing, diarrhea, and bronchospasm. Additionally, 50% of patients develop a secondary restrictive cardiomyopathy. Carcinoid tumors can occur in various locations, with the small intestine being the most common site. Other locations include the lungs (bronchial adenoma), rectum, appendix, and stomach.

    • This question is part of the following fields:

      • Oncological Emergencies
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  • Question 2 - A 68-year-old woman, who has been smoking for her entire life, is diagnosed...

    Incorrect

    • A 68-year-old woman, who has been smoking for her entire life, is diagnosed with a small cell carcinoma of the lung. After further examination, it is revealed that she has developed the syndrome of inappropriate ADH secretion (SIADH) as a result of this.
      What kind of electrolyte disturbance would you anticipate in this case?

      Your Answer: High serum Na, low serum osmolarity, low urine osmolarity

      Correct Answer: Low serum Na, low serum osmolarity, high urine osmolarity

      Explanation:

      Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is characterized by the excessive and uncontrollable release of antidiuretic hormone (ADH). This can occur either from the posterior pituitary gland or from an abnormal non-pituitary source. There are various conditions that can disrupt the regulation of ADH secretion in the central nervous system and lead to SIADH. These include CNS damage such as meningitis or subarachnoid hemorrhage, paraneoplastic syndromes like small cell carcinoma of the lung, infections such as atypical pneumonia or cerebral abscess, and certain drugs like carbamazepine, TCAs, and SSRIs.

      The typical biochemical profile observed in SIADH is characterized by low levels of serum sodium (usually less than 135 mmol/l), low serum osmolality, and high urine osmolality.

    • This question is part of the following fields:

      • Oncological Emergencies
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  • Question 3 - A 45-year-old man presents with a history of feeling generally unwell and having...

    Incorrect

    • A 45-year-old man presents with a history of feeling generally unwell and having experienced fevers at home. He has a history of lung cancer for which he is currently undergoing radiation therapy. His observations are as follows: HR 92 bpm, BP 130/80, SaO2 98% on air, temperature 38.9°C. A diagnosis of neutropenic sepsis is suspected.
      Which of the following antibiotics are recommended by the current NICE guidelines for the initial empiric treatment of neutropenic sepsis?

      Your Answer: Ceftriaxone and gentamicin

      Correct Answer: Tazocin alone

      Explanation:

      Neutropenic sepsis is a serious condition that can occur when a person has low levels of neutrophils, which are a type of white blood cell. This condition can be life-threatening and is often caused by factors such as chemotherapy, immunosuppressive drugs, infections, bone marrow disorders, and nutritional deficiencies.

      To diagnose neutropenic sepsis, doctors look for a neutrophil count of 0.5 x 109 per litre or lower in patients undergoing cancer treatment. Additionally, patients must have a temperature higher than 38°C or show other signs and symptoms of significant sepsis.

      According to the current guidelines from the National Institute for Health and Care Excellence (NICE), the recommended initial antibiotic treatment for suspected neutropenic sepsis is monotherapy with piperacillin with tazobactam (Tazocin 4.5 g IV). It is important to note that aminoglycosides should not be used as monotherapy or in combination therapy unless there are specific patient-related or local microbiological reasons to do so.

    • This question is part of the following fields:

      • Oncological Emergencies
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  • Question 4 - A 45-year-old woman presents with increasing difficulty breathing, coughing up blood, and swelling...

    Correct

    • A 45-year-old woman presents with increasing difficulty breathing, coughing up blood, and swelling in her arms and hands. Upon examination, you observe that her face is also swollen and she has multiple enlarged veins and telangiectasia on her chest. She has a known history of lung cancer.

      What is the most probable diagnosis in this case?

      Your Answer: Superior vena cava syndrome

      Explanation:

      This patient has come in with worsening breathlessness and coughing, along with coughing up blood, all of which are occurring on top of their existing lung cancer. The diagnosis in this case is superior vena cava obstruction, which is being caused by the primary bronchial neoplasm.

      The typical clinical presentation of superior vena cava obstruction includes breathlessness and coughing, chest pain, swelling in the neck, face, and arms, dilated veins and telangiectasia on the arms, neck, and chest wall, facial flushing, stridor due to laryngeal edema, and cyanosis.

      Given the urgency of the situation, this man will require immediate treatment. Upon initial presentation, it is important to elevate his head and provide supplemental oxygen to alleviate symptoms. Additionally, corticosteroids and diuretics may be administered. Further investigation will be necessary through CT scanning, and radiotherapy may be recommended as a potential course of action.

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      • Oncological Emergencies
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  • Question 5 - You assess a patient who is currently undergoing systemic anticancer treatment. She has...

    Incorrect

    • You assess a patient who is currently undergoing systemic anticancer treatment. She has been experiencing chills and feeling unwell and is worried about the potential of having an infection. She informs you that she is currently prescribed a medication to prevent neutropenic sepsis.
      Which of the following medications is she most likely taking for this purpose?

      Your Answer: Prednisolone

      Correct Answer: Ciprofloxacin

      Explanation:

      According to the latest guidelines from NICE, it is recommended that adult patients who are undergoing treatment for acute leukaemia, stem cell transplants, or solid tumours and are expected to experience significant neutropenia as a result of chemotherapy, should be offered prophylaxis with a fluoroquinolone such as ciprofloxacin (500 mg taken orally twice daily) during the period when neutropenia is expected. This is to help prevent the occurrence of neutropenic sepsis, a serious infection that can occur in cancer patients with low levels of neutrophils.

      Reference:
      NICE guidance: ‘Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients’

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      • Oncological Emergencies
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  • Question 6 - You assess a patient who is currently undergoing systemic anticancer treatment. She has...

    Incorrect

    • You assess a patient who is currently undergoing systemic anticancer treatment. She has been experiencing chills and feeling unwell and is worried about the potential of having an infection. She informs you that she is currently prescribed an antibiotic as a preventive measure against neutropenic sepsis.
      Which of the subsequent antibiotic classes is utilized for this specific purpose?

      Your Answer: Macrolides

      Correct Answer: Fluoroquinolones

      Explanation:

      According to the latest guidelines from NICE, it is recommended that adult patients who are undergoing treatment for acute leukaemia, stem cell transplants, or solid tumours and are expected to experience significant neutropenia as a result of chemotherapy, should be offered prophylaxis with a fluoroquinolone such as ciprofloxacin (500 mg taken orally twice daily) during the period when neutropenia is expected. This is to help prevent the occurrence of neutropenic sepsis, a serious infection that can occur in cancer patients with low levels of neutrophils.

      Reference:
      NICE guidance: ‘Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients’

    • This question is part of the following fields:

      • Oncological Emergencies
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  • Question 7 - What is the threshold MASCC Risk Index Score for identifying patients as low...

    Incorrect

    • What is the threshold MASCC Risk Index Score for identifying patients as low risk for outpatient treatment with early antibiotics in cases of neutropenic sepsis?

      Your Answer:

      Correct Answer: 21

      Explanation:

      The MASCC Risk Index Score, developed by the Multinational Association of Supportive Care in Cancer, is a globally recognized scoring system that helps identify patients with neutropenic sepsis who have a low risk of complications and can potentially be treated as outpatients with early administration of antibiotics. This scoring system takes into account various characteristics to determine the risk level of the patient. These characteristics include the burden of febrile neutropenia with no or mild symptoms, absence of hypotension, no history of chronic obstructive pulmonary disease, presence of a solid tumor or hematological malignancy without previous fungal infection, absence of dehydration requiring parenteral fluids, burden of febrile neutropenia with moderate symptoms, being in an outpatient setting at the onset of fever, and age below 60 years. Each characteristic is assigned a certain number of points, and a total score of 21 or higher indicates a low risk, while a score below 21 indicates a high risk. The MASCC Risk Index Score has been validated internationally and has shown a positive predictive value of 91%, specificity of 68%, and sensitivity of 71%. For more detailed information, you can refer to the article titled Identifying Patients at Low Risk for FN Complications: Development and Validation of the MASCC Risk Index Score.

    • This question is part of the following fields:

      • Oncological Emergencies
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  • Question 8 - You assess a patient who has recently undergone a localized lung segmentectomy. A...

    Incorrect

    • You assess a patient who has recently undergone a localized lung segmentectomy. A few days after the procedure, he presents with feelings of illness, and today's blood results reveal the development of hyponatremia.
      What is the most probable cause of this biochemical abnormality?

      Your Answer:

      Correct Answer: Removal of hormonally active tumour

      Explanation:

      Small cell lung cancer (SCLC) that originates from neuroendocrine tissue has the potential to cause paraneoplastic endocrine syndromes, such as Cushing syndrome. This occurs due to the inappropriate secretion of ectopic adrenocorticotropic hormone (ACTH). In this particular case, it is highly likely that the patient underwent surgery to remove an ACTH-secreting neuroendocrine tumor within the lung.

      The tumors associated with the production of ectopic ACTH are as follows:
      – SCLC – 50%
      – Bronchial carcinoid tumors – 10%
      – Thymic carcinoma – 10%
      – Pancreatic islet cell tumors – 5%
      – Phaeochromocytoma – 5%
      – Medullary carcinoma – 5%

      When ectopic ACTH-secreting tumors are present, the typical signs and symptoms of Cushing syndrome may be minimal. The onset of symptoms can be sudden, especially in rapidly growing SCLCs. The typical biochemical profile observed in these cases includes elevated sodium levels, low potassium levels, and metabolic alkalosis.

      The body’s homeostatic mechanism will attempt to compensate for the elevated sodium levels by lowering them. However, after the tumor is removed, a paradoxical period of hyponatremia may occur during the postoperative period. This hyponatremia gradually normalizes until the sodium levels reach a normal range once again.

    • This question is part of the following fields:

      • Oncological Emergencies
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  • Question 9 - A 45-year-old man who is currently being treated for prostate cancer presents complaining...

    Incorrect

    • A 45-year-old man who is currently being treated for prostate cancer presents complaining of feeling constantly thirsty. His wife is accompanying him and states he has been very sleepy and disoriented over the past few days.

      Which of the following electrolyte imbalances is most likely to be present?

      Your Answer:

      Correct Answer: Hypercalcaemia

      Explanation:

      Thirst, drowsiness, and confusion are strong indicators of hypercalcemia. Considering the patient’s breast cancer history, it is probable that this condition is the underlying cause of the metabolic imbalance. Malignancy accounts for around 20-30% of hypercalcemia cases, and any type of solid organ malignancy can lead to hypercalcemia.

    • This question is part of the following fields:

      • Oncological Emergencies
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  • Question 10 - You assess a patient who is currently undergoing systemic anticancer treatment. She presents...

    Incorrect

    • You assess a patient who is currently undergoing systemic anticancer treatment. She presents with a high fever, and you have concerns about the potential occurrence of neutropenic sepsis.

      Which of the following statements is accurate regarding neutropenic sepsis?

      Your Answer:

      Correct Answer: Specialist management in an acute hospital setting involves implementing the standard UK Sepsis Trust 'Sepsis Six' bundle

      Explanation:

      Neutropenic sepsis is a serious complication that can occur in individuals with low neutrophil counts, known as neutropenia. There are several potential causes of neutropenia, including certain medications like chemotherapy and immunosuppressive drugs, stem cell transplantation, infections, bone marrow disorders, and nutritional deficiencies. In adults, mortality rates as high as 20% have been reported.

      To diagnose neutropenic sepsis, doctors look for a neutrophil count of 0.5 x 109 per litre or lower in patients undergoing cancer treatment. Additionally, patients must have either a temperature higher than 38°C or other signs and symptoms consistent with significant sepsis. Cancer treatments can suppress the bone marrow ability to respond to infections, making neutropenic sepsis more likely. This is most commonly seen with systemic chemotherapy but can also occur after radiotherapy.

      According to the current guidelines from the National Institute for Health and Care Excellence (NICE), adult patients with acute leukemia, stem cell transplants, or solid tumors who are expected to experience significant neutropenia due to chemotherapy should be offered prophylaxis with a fluoroquinolone antibiotic, such as ciprofloxacin. This should be taken during the expected period of neutropenia.

      When managing neutropenic sepsis, it is important to promptly implement the UK Sepsis Trust Sepsis Six bundle within the first hour of recognizing sepsis. This involves specialist assessment and management in an acute hospital setting.

      The NICE guidelines recommend using piperacillin with tazobactam (Tazocin) as the initial empiric antibiotic therapy for patients suspected of having neutropenic sepsis. It is advised not to use an aminoglycoside, either alone or in combination therapy, unless there are specific patient-related or local microbiological indications.

      Reference:
      NICE guidance: ‘Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients’

    • This question is part of the following fields:

      • Oncological Emergencies
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Oncological Emergencies (1/6) 17%
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