IM13.1-19 | Common Malignancies and Oncology — Practice Quiz

Correct. A firm, non-tender left supraclavicular lymph node is Virchow's node (Troisier sign) — the clinical hallmark of disseminated upper abdominal or thoracic malignancy. The thoracic duct drains abdominal and left thoracic lymphatics and empties at the left subclavian-internal jugular junction. A palpable node here indicates retrograde lymphatic permeation by tumour cells, most commonly from gastric, oesophageal, lung, or pancreatic cancer. In this case with tobacco exposure, progressive dysphagia, and hoarseness, oesophageal squamous cell carcinoma with mediastinal/nodal spread is the likely primary.

Virchow's node (Troisier sign) = firm, non-tender left supraclavicular lymph node = hallmark of disseminated upper abdominal or thoracic malignancy. Always palpate the left supraclavicular fossa in any patient with unexplained weight loss, dysphagia, or upper GI symptoms.

Correct. The clinical picture — markedly elevated WBC with a full myeloid maturation spectrum (myelocytes and metamyelocytes prominent), basophilia, eosinophilia, thrombocytosis, and massive splenomegaly — is classic for chronic myeloid leukaemia (CML). The pathognomonic abnormality is the Philadelphia chromosome: translocation t(9;22), which juxtaposes the BCR gene on chromosome 22 with the ABL1 gene on chromosome 9, producing the BCR-ABL1 fusion oncogene. The resulting p210 BCR-ABL1 protein is a constitutively active tyrosine kinase driving myeloid proliferation. CML has three phases: chronic (as here), accelerated (blasts 10–19%), and blast crisis (blasts ≥20%). First-line treatment is imatinib or a second-generation TKI.

CML = t(9;22) Philadelphia chromosome → BCR-ABL1 fusion → constitutively active tyrosine kinase. Peripheral smear shows myelocyte peak. Basophilia and eosinophilia are characteristic clues. Blast crisis: blasts ≥20% = transformation to acute leukaemia.

Correct. The presentation of an elderly man with slowly progressive lymphocytosis (mature small lymphocytes), painless lymphadenopathy, smudge (basket) cells on smear, and absence of systemic symptoms is classic for chronic lymphocytic leukaemia (CLL). CLL is the most common adult leukaemia in Western countries and is increasingly diagnosed in India. Smudge cells represent fragile tumour lymphocytes disrupted during smear preparation. Rai staging (0–IV, based on lymphocytosis, lymphadenopathy, hepatosplenomegaly, anaemia, and thrombocytopenia) determines prognosis and timing of treatment. Many patients with early-stage CLL are managed with watch-and-wait.

CLL = mature small B-cell lymphocytosis + smudge cells on smear + painless lymphadenopathy in older adults. Distinguish from ALL (blasts, aggressive, younger patients). Rai staging (0–IV) guides management. CD5+/CD23+ B-cell immunophenotype confirms diagnosis.

Correct. The combination of painless cervical lymphadenopathy in a young patient, B symptoms (fever, night sweats, weight loss >10% in 6 months), and the pathognomonic Reed-Sternberg (RS) cells — large binucleate or bilobed cells with prominent eosinophilic 'owl-eye' nucleoli in a mixed inflammatory background — confirms Hodgkin lymphoma. The nodular sclerosis subtype (RS cells within lacunae in a collagen-banded background) is the most common subtype and typically involves mediastinal or cervical nodes in young adults. Staging uses the Ann Arbor system (I–IV, with A/B suffix for absence/presence of B symptoms and E/S modifiers for extranodal/splenic involvement).

Hodgkin lymphoma = Reed-Sternberg cells (owl-eye nucleoli) in mixed inflammatory background. B symptoms: unexplained fever >38°C, drenching night sweats, weight loss >10% in 6 months. Staged by Ann Arbor (I–IV, A/B). Curable in most stages with ABVD chemotherapy ± radiation.

Correct. The tetrad of hyperuricaemia, hyperkalaemia, hyperphosphataemia, and hypocalcaemia (due to calcium-phosphate precipitation) with acute kidney injury occurring after chemotherapy for a high-burden lymphoma is tumour lysis syndrome (TLS). TLS results from massive release of intracellular contents — uric acid (from purine catabolism), potassium, and phosphate — when tumour cells are rapidly destroyed. Prevention: aggressive IV hydration (to maintain urine output ≥100 mL/hr) + allopurinol (inhibits xanthine oxidase, reducing uric acid synthesis) started 24–48 hours before chemotherapy. Rasburicase (recombinant uricase) is reserved for high-risk patients (high tumour burden, elevated baseline uric acid) — it enzymatically degrades uric acid more rapidly than allopurinol.

TLS = hyperuricaemia + hyperkalaemia + hyperphosphataemia + hypocalcaemia + AKI after cytotoxic therapy. Most common in Burkitt lymphoma, ALL, and high-grade NHL. Prevention: IV hydration + allopurinol pre-chemo; rasburicase for high-risk. Monitor electrolytes, uric acid, and creatinine every 6–8 hours.

Correct. Malignant spinal cord compression (MSCC) is an oncological emergency. The degree of neurological recovery is directly proportional to the neurological function at the time treatment is initiated — patients still ambulatory at presentation have the best outcomes. Immediate management: high-dose dexamethasone (typically 16 mg IV loading, then 8 mg twice daily) to reduce perilesional oedema, followed by urgent multidisciplinary review for emergency radiotherapy (treatment of choice for most) or surgical decompression (for spinal instability, progressive neurology despite RT, or radioresistant tumour). Bladder dysfunction indicates cord compromise at sacral level; catheterisation may be needed.

MSCC = back pain + progressive limb weakness + sphincter disturbance in a cancer patient = emergency. Immediate dexamethasone; urgent MRI if not done; radiotherapy within 24 hours. Ambulatory status at treatment determines outcome. Never delay treatment awaiting biopsy in known malignancy.

Correct. Hypercalcaemia of malignancy is the most common life-threatening metabolic complication of cancer. The most frequent mechanism in solid tumours (squamous cell cancers, renal, breast, ovarian) is ectopic secretion of PTH-related peptide (PTHrP), which binds PTH receptors on osteoclasts and renal tubular cells, activating osteoclastic bone resorption and reducing renal calcium excretion. First-line treatment: aggressive IV 0.9% saline hydration (3–4 L/day) to restore intravascular volume and promote renal calcium excretion, followed by IV zoledronic acid (bisphosphonate) which inhibits osteoclast function and is the most potent and durable agent for hypercalcaemia of malignancy. Furosemide after hydration may be added if volume overloaded.

Hypercalcaemia of malignancy: most common mechanism = PTHrP (solid tumours); osteolytic metastases (breast, myeloma); 1,25-OH vitamin D excess (lymphoma). Symptoms: moans, groans, bones, psychic overtones. Treatment: IV saline hydration → IV bisphosphonate (zoledronic acid). Calcitonin for rapid acute effect (tachyphylaxis limits long-term use).

Correct. Febrile neutropenia (fever ≥38.3°C once or ≥38.0°C sustained for 1 hour + ANC <0.5 × 10^9/L, or <1.0 × 10^9/L falling to <0.5) is a medical emergency. Delay in antibiotic initiation of even 1–2 hours significantly increases mortality. Management: draw blood cultures (peripheral and from central line if present) and other appropriate cultures, then immediately start empirical broad-spectrum IV antibiotics covering gram-negative organisms (including Pseudomonas) within 1 hour — piperacillin-tazobactam or carbapenem are standard. Antifungal coverage is added only if fever persists >96 hours despite antibiotics, not empirically from the outset. G-CSF does not substitute for or precede antibiotics.

Febrile neutropenia = ANC <0.5 × 10^9/L + fever ≥38.3°C = oncological emergency. Give broad-spectrum IV antibiotics within 1 hour — NEVER wait for culture results. Add antifungal only after 96 hours of antibiotic failure. MASCC score stratifies low vs high risk for out-patient management.

Correct. The clinical triad of facial/neck oedema, plethora, and dilated anterior chest wall collateral veins (filling from below upward in the supine position) with orthopnoea in a patient with lung cancer is classic for superior vena cava (SVC) syndrome. This is caused by compression or invasion of the SVC, most commonly by right-sided lung cancer (especially small cell lung cancer or squamous cell carcinoma), mediastinal lymphoma, or central venous catheter thrombosis. Immediate management: sit the patient upright (reduces venous pressure in the head/neck), supplemental oxygen if needed, and CT chest with contrast to delineate the level of obstruction, degree of collateral flow, and primary tumour extent. Dexamethasone may provide temporary symptomatic relief. Definitive treatment depends on histology (chemotherapy for SCLC/lymphoma; SVC stenting for rapid relief; radiotherapy for radiosensitive tumours).

SVC syndrome = facial/neck oedema + plethora + dilated chest wall collateral veins in a cancer patient (especially lung/lymphoma). Sit upright immediately. CT chest with contrast to confirm. Dexamethasone for symptom relief; SVC stenting or chemo/radiotherapy per histology.

Correct. Constipation affects virtually all patients on regular opioids and, unlike nausea and sedation, does not improve with continued use (no tolerance develops). A stimulant laxative (senna, bisacodyl) ± a stool softener (docusate) should be prescribed prophylactically whenever an opioid is started — not added reactively after constipation develops. Bulk-forming agents are contraindicated in opioid-induced constipation because they require adequate fluid intake and gut motility (which opioids reduce) — they cause impaction. Reducing the morphine dose or stopping opioids is inappropriate if the patient's pain is not controlled by lower doses.

Opioid-induced constipation: never develops tolerance; always prescribe a stimulant laxative (senna/bisacodyl) prophylactically. Bulk-forming laxatives are CONTRAINDICATED with opioids. Nausea and sedation usually improve after 1–2 weeks (tolerance develops); constipation does not. WHO analgesic ladder: paracetamol → weak opioids (codeine/tramadol) → strong opioids (morphine/oxycodone).