Cancer Emergencies — MCQs
Which finding is NOT associated with pulmonary embolism on CT angiography?
Which of the following is NOT a minimum clinical criterion in the CDC's diagnostic guidelines for pelvic inflammatory disease (PID)?
Which electrolyte abnormality is expected in tumor lysis syndrome?
A patient developed paraplegia. On routine examination and X-ray it was found that there are osteoblastic lesions in his spine. What is the MOST probable diagnosis?
What processing should be done of the blood before transfusion to reduce chances of febrile non-hemolytic transfusion reaction (FNHTR)?
What is the most common cause of hypercalcemic crisis?
In which of the following conditions is emergency radiotherapy indicated?
Metastases from follicular carcinoma should be treated by:
A 63-year-old man comes to the physician because of a 3-month history of fatigue and constipation. He reports having dull pain in the left portion of the midback for 2 weeks that has persisted despite taking ibuprofen. His father died of prostate cancer at 70 years of age. The patient has smoked one pack of cigarettes daily for 45 years. Vital signs are within normal limits. Physical examination shows a left-sided varicocele both in supine and in standing position. Rectal examination shows a symmetrically enlarged prostate with no masses. Laboratory studies show: Hemoglobin 11.2 g/dL Serum Creatinine 1.0 mg/dL Calcium 11.8 mg/dL Urine Protein 1+ Blood 2+ Which of the following is the most appropriate next step in management?
Prostatic cancer mostly seen in
Cancer Emergencies Indian Medical PG Practice Questions and MCQs
Question 1: Which finding is NOT associated with pulmonary embolism on CT angiography?
- A. Filling defects
- B. Hampton's hump (Correct Answer)
- C. Enlarged pulmonary artery
- D. Oligemia
Explanation: ***Hampton's hump*** - **Hampton's hump** is a **peripheral wedge-shaped opacity** representing **pulmonary infarction**, classically described as a **chest X-ray finding**, not a primary CT angiography (CTA) finding. - While the parenchymal opacity from infarction can be visualized on CT, it is **not what CTA is designed to detect**—CTA primarily visualizes the **pulmonary vasculature and intraluminal thrombi**. - Hampton's hump reflects a **consequence** of PE (tissue infarction) rather than the embolus itself, making it **NOT directly associated with PE on CTA**. *Filling defects* - **Filling defects** represent **intraluminal thrombus** within contrast-filled pulmonary arteries. - This is the **hallmark and primary diagnostic sign** of pulmonary embolism on CT angiography. - CTA is specifically performed to visualize these vascular abnormalities. *Enlarged pulmonary artery* - An **enlarged main pulmonary artery** (>29 mm) is a **secondary finding** on CTA that suggests **pulmonary hypertension**. - This can result from acute massive PE or chronic thromboembolic disease. - It is readily visualized and measured on CTA as part of PE assessment. *Oligemia* - **Oligemia (Westermark sign)** refers to **regional decreased vascularity** distal to a significant pulmonary artery obstruction. - While classically a **chest X-ray finding**, decreased vessel caliber and perfusion changes **can be appreciated on CTA**. - Unlike Hampton's hump (a parenchymal consequence), oligemia reflects the **vascular effect** of the obstruction and is thus more directly related to CTA findings.
Question 2: Which of the following is NOT a minimum clinical criterion in the CDC's diagnostic guidelines for pelvic inflammatory disease (PID)?
- A. Adnexal tenderness
- B. Uterine tenderness
- C. Cervical motion tenderness
- D. Elevated white blood cell count (Correct Answer)
Explanation: ***Elevated white blood cell count*** - While an elevated **white blood cell (WBC) count** can be seen in PID, it is a **supportive laboratory finding** (additional criterion), not one of the three minimum clinical criteria for diagnosis as per CDC guidelines. - The CDC's minimum clinical criteria are based on direct physical examination findings to broadly identify PID in a clinical setting. *Adnexal tenderness* - **Adnexal tenderness** (tenderness of the ovaries and fallopian tubes) is a **minimum clinical criterion** for diagnosing PID. - This tenderness indicates inflammation in the pelvic organs, which is a hallmark of PID. - Presence of adnexal tenderness alone (in a sexually active woman with pelvic pain and no other identifiable cause) is sufficient to initiate empiric treatment. *Uterine tenderness* - **Uterine tenderness** is a **minimum clinical criterion** for diagnosing PID. - This symptom reflects inflammation of the uterus and surrounding pelvic structures. - Presence of uterine tenderness alone (in appropriate clinical context) warrants empiric treatment. *Cervical motion tenderness* - **Cervical motion tenderness** (also known as "chandelier sign") is a **minimum clinical criterion** for diagnosing PID. - It indicates inflammation of the cervix and potentially the uterus and surrounding pelvic structures. - This finding alone is sufficient to meet diagnostic criteria for empiric treatment.
Question 3: Which electrolyte abnormality is expected in tumor lysis syndrome?
- A. Hypocalcemia
- B. Hyponatremia
- C. Hypernatremia
- D. Hyperkalemia (Correct Answer)
Explanation: ***Hyperkalemia*** - **Tumor lysis syndrome (TLS)** leads to the rapid breakdown of malignant cells, releasing their intracellular contents, including a large amount of **potassium**, into the bloodstream. [1] - This excessive release of intracellular potassium overwhelms renal excretion mechanisms, resulting in **hyperkalemia**, which can cause life-threatening cardiac arrhythmias. [1] *Hypocalcemia* - **Hypocalcemia** does occur in TLS but is not due to direct release from lysed cells. It results from the precipitation of **calcium** with the massive release of **phosphate** from the lysed cells. - The elevated phosphate levels bind to free calcium in the serum, forming **calcium phosphate crystals** that deposit in tissues, thereby lowering serum calcium levels. *Hyponatremia* - **Hyponatremia** is not a characteristic feature of tumor lysis syndrome. Sodium is primarily an extracellular ion, and its levels are not directly impacted by massive cell lysis in the same way as potassium or phosphate. - While fluid shifts or renal dysfunction in severe TLS could indirectly affect sodium, it's not a primary or expected electrolyte derangement of the syndrome itself. *Hypernatremia* - **Hypernatremia (elevated sodium)** is not expected in tumor lysis syndrome. The primary electrolyte disturbances involve intracellular components like potassium, phosphate, and uric acid, and secondary effects on calcium. - Hypernatremia would typically be associated with dehydration or impaired water balance, not the massive release of intracellular contents seen in TLS.
Question 4: A patient developed paraplegia. On routine examination and X-ray it was found that there are osteoblastic lesions in his spine. What is the MOST probable diagnosis?
- A. Breast Ca.
- B. Carcinoma thyroid
- C. Pancreatic Ca.
- D. Ca. Prostate (Correct Answer)
Explanation: ***Ca. Prostate*** - **Prostate cancer** has a strong predilection for metastasizing to bone and typically produces **osteoblastic lesions** (new bone formation) in the spine [2]. - The presence of **paraplegia** suggests spinal cord compression due to these metastatic lesions [1]. *Breast Ca.* - While **breast cancer** frequently metastasizes to bone (commonly spine, pelvis, ribs, skull), it typically causes **osteolytic lesions** (bone destruction), though mixed lesions can occur. - Paraplegia can result from breast cancer metastases but the primary lesion type is usually osteolytic. *Carcinoma thyroid* - **Thyroid cancer** metastases to bone are rare and generally lead to **osteolytic lesions**, not osteoblastic. - Although it can cause spinal cord compression, the characteristic osteoblastic appearance is not typical for thyroid cancer. *Pancreatic Ca.* - **Pancreatic cancer** rarely metastasizes to bone, and when it does, the lesions are almost exclusively **osteolytic**. - Therefore, it is highly unlikely to be the cause of osteoblastic spinal lesions and subsequent paraplegia.
Question 5: What processing should be done of the blood before transfusion to reduce chances of febrile non-hemolytic transfusion reaction (FNHTR)?
- A. Leucocyte reduction (Correct Answer)
- B. Washing
- C. Irradiation
- D. Glycerolization
Explanation: ***Leucocyte reduction*** - **Febrile non-hemolytic transfusion reactions (FNHTRs)** are primarily caused by cytokines released from donor leukocytes during storage or by recipient antibodies targeting donor leukocytes [1]. - **Leukocyte reduction** removes these donor white blood cells, thereby significantly decreasing the risk of FNHTRs. *Washing* - **Washing** removes plasma proteins and antibodies, which is useful for preventing allergic reactions or anaphylaxis in patients with IgA deficiency, but it is not the primary method for preventing FNHTRs. - While it can remove some cytokines, its main indication is different from preventing leukocyte-mediated reactions. *Irradiation* - **Irradiation** is performed to prevent **transfusion-associated graft-versus-host disease (TA-GVHD)** by inactivating donor lymphocytes, preserving their function but preventing their proliferation. - It does not primarily reduce the number of leukocytes or the associated cytokine release responsible for FNHTRs. *Glycerolization* - **Glycerolization** is a process used to cryopreserve **red blood cells** for long-term storage, often decades. - This process is essential for maintaining the viability of red blood cells in frozen storage but has no direct role in preventing FNHTRs.
Question 6: What is the most common cause of hypercalcemic crisis?
- A. Carcinoma of the breast
- B. Parathyroid adenoma (Correct Answer)
- C. Parathyroid hyperplasia
- D. Paget's disease
Explanation: ***Parathyroid adenoma*** - **Primary hyperparathyroidism**, most often caused by a solitary parathyroid adenoma, is the leading cause of hypercalcemic crisis, though this is rare [1][2]. - The adenoma autonomously overproduces **parathyroid hormone (PTH)**, leading to increased calcium reabsorption from bone and kidneys, and enhanced intestinal calcium absorption [1]. *Carcinoma of the breast* - While breast carcinoma can lead to **hypercalcemia** through bony metastases or parathyroid hormone-related peptide (PTHrP) production, it's not the most common cause of hypercalcemic crisis. - Metastatic bone disease is a common cause of hypercalcemia in malignancy, but the extent of hypercalcemia varies. *Parathyroid hyperplasia* - **Parathyroid hyperplasia** is a rarer cause of primary hyperparathyroidism compared to adenoma, and thus less frequently causes hypercalcemic crisis [2]. - All four parathyroid glands are typically enlarged and overactive, leading to excessive PTH secretion. *Paget's disease* - **Paget's disease of bone** primarily causes localized areas of increased bone turnover and can lead to elevated **alkaline phosphatase** levels. - It rarely causes significant hypercalcemia, and even more rarely a hypercalcemic crisis, unless there is prolonged immobilization or coexisting hyperparathyroidism.
Question 7: In which of the following conditions is emergency radiotherapy indicated?
- A. Neoplastic cardiac tamponade
- B. Acute epidural spinal cord compression
- C. Superior vena cava syndrome (Correct Answer)
- D. Tumor lysis syndrome
Explanation: ### Superior vena cava syndrome - **Emergency radiotherapy** is indicated in SVC syndrome, especially if caused by radiation-sensitive tumors, to rapidly reduce tumor burden and relieve **venous compression**. [3] - Rapid intervention is crucial due to the potential for **life-threatening compromise** of venous return from the head and upper extremities. [2] *Neoplastic cardiac tamponade* - The primary emergency treatment for **cardiac tamponade** is **pericardiocentesis** to urgently relieve fluid pressure around the heart. - Radiotherapy is not the immediate intervention for acute tamponade, though it may be used later to manage the underlying malignancy. *Acute epidural spinal cord compression* - **Acute spinal cord compression** requires immediate intervention, often with **high-dose corticosteroids** to reduce edema and emergent surgical decompression to prevent permanent neurological damage. [1] - Radiotherapy may be used as an adjunct or for less acute cases, but surgery is usually prioritized for acute compression. [1] *Tumor lysis syndrome* - **Tumor lysis syndrome** is a metabolic emergency managed with aggressive **hydration**, **allopurinol**, or **rasburicase** to prevent renal failure and electrolyte abnormalities. - Radiotherapy is not a treatment for the acute metabolic derangements of tumor lysis syndrome.
Question 8: Metastases from follicular carcinoma should be treated by:
- A. Radioiodine (Correct Answer)
- B. Surgery
- C. Thyroxine
- D. Observation
Explanation: ***Radioiodine*** - **Differentiated thyroid cancers**, including **follicular carcinoma**, retain the ability to uptake iodine, making **radioiodine (I-131) therapy** highly effective for treating metastases [1]. - This therapy targets and destroys thyroid cancer cells wherever they are located in the body, including distant metastatic sites. *Surgery* - While surgery (e.g., **thyroidectomy**) is the primary treatment for localized thyroid cancer and can be used to resect some metastases, it is **not always feasible** for all metastatic sites, especially widely disseminated disease. - Surgery for widespread metastases carries significant risks and may not be curative if all tumor burden cannot be removed. *Thyroxine* - **Thyroxine (T4)** replacement therapy is crucial after thyroidectomy to replace missing hormones and to **suppress TSH** production, which can stimulate residual cancer growth [1]. - However, thyroxine itself does **not directly destroy** existing metastases; it's a supportive and suppressive therapy, not a primary treatment for metastases. *Observation* - **Observation** is generally not appropriate for treating metastases from **follicular carcinoma**, as these metastases have the potential to grow and lead to significant morbidity and mortality if left untreated. - Active treatment is usually indicated to improve prognosis and quality of life.
Question 9: A 63-year-old man comes to the physician because of a 3-month history of fatigue and constipation. He reports having dull pain in the left portion of the midback for 2 weeks that has persisted despite taking ibuprofen. His father died of prostate cancer at 70 years of age. The patient has smoked one pack of cigarettes daily for 45 years. Vital signs are within normal limits. Physical examination shows a left-sided varicocele both in supine and in standing position. Rectal examination shows a symmetrically enlarged prostate with no masses. Laboratory studies show: Hemoglobin 11.2 g/dL Serum Creatinine 1.0 mg/dL Calcium 11.8 mg/dL Urine Protein 1+ Blood 2+ Which of the following is the most appropriate next step in management?
- A. Urine cytology
- B. CT scan of the abdomen (Correct Answer)
- C. Chest x-ray
- D. Serum protein electrophoresis
- E. Prostate biopsy
Explanation: ***CT scan of the abdomen*** - The patient's symptoms, including **fatigue**, **constipation**, **dull midback pain**, **anemia**, **hypercalcemia**, and **new-onset left-sided varicocele**, are highly concerning for a retroperitoneal malignancy, most likely **renal cell carcinoma** [1]. - A **CT scan of the abdomen** is the most appropriate next step to evaluate the kidneys and retroperitoneum for a mass, as it can characterize the varicocele etiology (tumor compressing the **left renal vein**) [1]. *Urine cytology* - **Urine cytology** is primarily used to detect malignant cells in the urine, typically for suspected bladder or upper urinary tract transitional cell carcinoma. - While there is hematuria, the overall clinical picture with **hypercalcemia**, **anemia**, and **varicocele** points to a broader retroperitoneal process rather than solely a urinary tract epithelial malignancy. *Chest x-ray* - A **chest x-ray** evaluates the lungs and mediastinum and would be useful for assessing for metastatic disease, particularly in the context of cancer. - However, given the strong localizing signs (left-sided varicocele, midback pain), the priority is to identify the primary tumor in the abdomen before scanning for distant metastases. *Serum protein electrophoresis* - **Serum protein electrophoresis** is used to detect and characterize monoclonal gammopathies, such as those seen in **multiple myeloma**. - While hypercalcemia can be associated with multiple myeloma, the presence of a **new-onset left-sided varicocele** is highly suggestive of a mass compressing the left renal vein, which is not typically seen in multiple myeloma. *Prostate biopsy* - A **prostate biopsy** would be indicated if there were suspicious findings on rectal exam (e.g., prostatic nodule) or an elevated PSA, suggesting prostate cancer. - The rectal exam showed a **symmetrically enlarged prostate with no masses**, and while the father had prostate cancer, hypercalcemia and a new varicocele are not typical primary manifestations of prostate cancer.
Question 10: Prostatic cancer mostly seen in
- A. Posterior (Correct Answer)
- B. Lateral
- C. Anterior
- D. Medial
Explanation: ***Posterior*** - The **peripheral zone** of the prostate, which is located posteriorly, is the most common site for the development of **prostatic adenocarcinoma**. - This anatomical location is why a **digital rectal exam (DRE)** is an important screening tool, as palpable nodules can be detected [1]. *Lateral* - While prostatic tissue extends laterally, this region is not the predominant site for cancer development. - Cancers originating here are less common than those in the posterior peripheral zone. *Anterior* - The **anterior fibromuscular stroma** and the anterior portion of the prostate are rarely the primary sites for prostate cancer. - Tumors found here are often extensions from more posteriorly located cancers. *Medial* - The **transition zone**, which is located medially and surrounds the urethra, is the most common site for **benign prostatic hyperplasia (BPH)**, not prostate cancer. - While cancer can occur in this zone, it is less frequent than in the peripheral zone.
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