Free UKMLA cancer questions with explanations

E. MRI of the whole spine

Back pain with neurological deficit in a patient with a bone-metastasising cancer is metastatic spinal cord compression until proven otherwise. MRI of the whole spine is the investigation of choice and should be done urgently, within 24 hours of neurological symptoms, because it shows the epidural soft tissue and the cord itself and around a third of patients have compression at more than one level, which changes radiotherapy or surgical planning. Dexamethasone 16 mg should be given at once, then 16 mg daily, when suspected compression causes neurological symptoms or signs, and the patient nursed flat with spinal precautions until stability is known. CT and plain films show bone but not the cord, and a bone scan shows metastases without indicating whether any are compressing the canal.

E. Superior vena cava obstruction

Swelling confined to the face, neck and arms, worse when lying flat or bending, with distended non-pulsatile neck veins and dilated collateral veins over the chest wall, is the picture of venous obstruction above the heart. In a smoker the usual cause is a bronchogenic carcinoma or its mediastinal nodes compressing the superior vena cava. Right heart failure raises pressure in both venae cavae and so causes ankle oedema and hepatomegaly as well, whereas here the lower body is spared. Urgent contrast CT of the chest confirms the level and cause of the obstruction.

D. Colonoscopy

Colonoscopy is the gold standard investigation for suspected colorectal cancer, as it permits direct visualisation of the entire colon and rectum, targeted biopsy of suspicious lesions, and therapeutic polypectomy. In primary care a faecal immunochemical test is now performed first for iron deficiency anaemia or change in bowel habit, with suspected cancer pathway referral (and colonoscopy) if faecal haemoglobin is 10 micrograms/g or more.

C. Caecum

Right-sided colonic tumours, particularly of the caecum, classically present with iron deficiency anaemia from chronic occult blood loss and a palpable right iliac fossa mass, because the wide caecal lumen allows tumours to grow large before causing obstruction or overt bleeding. Iron deficiency anaemia or an abdominal mass at any age should prompt a faecal immunochemical test, with urgent suspected cancer referral if FIT is 10 micrograms/g or more.

E. Oral squamous cell carcinoma

Oral lichen planus, particularly the erosive and atrophic forms, is a potentially malignant disorder with a small but real rate of transformation to squamous cell carcinoma, of the order of 1%, which is why patients need long-term follow-up and a low threshold for biopsy. A single ulcer that persists beyond 3 weeks, an indurated or rolled edge, fixation, and a firm regional lymph node are the features of carcinoma and override the background diagnosis; the lateral tongue is the commonest oral site. She needs an urgent suspected cancer referral for biopsy and staging. Any change in an oral lichen planus lesion that is asymmetrical, indurated or non-healing should be biopsied rather than attributed to a flare.

D. Urgent referral to ENT for endoscopy and biopsy

Simple inflammatory polyps are almost always bilateral. A unilateral nasal mass, particularly with blood-stained discharge, must be treated as a tumour until histology proves otherwise: inverted papilloma (which can harbour squamous carcinoma), sinonasal carcinoma, lymphoma, or in adolescents an angiofibroma. Such patients need urgent ENT referral for nasendoscopy, imaging and biopsy under specialist conditions, because some of these lesions bleed heavily if sampled blind. Treating a unilateral mass with topical or oral steroids delays the diagnosis of a neoplasm. Persistent unilateral blood-stained discharge or unilateral obstruction in an adult is a red flag even without a visible mass.

E. Urgent direct-access ultrasound of the lump

A soft-tissue lump that is enlarging, larger than 5 cm, deep to the fascia or painful is suspicious for sarcoma rather than a simple lipoma, and the correct first step in primary care is an urgent direct-access ultrasound; if the scan is suspicious or inconclusive, the patient goes on a suspected-cancer referral to a sarcoma service. Surgical excision or biopsy of a possible sarcoma outside a specialist centre contaminates tissue planes and compromises limb-sparing surgery, so any biopsy is planned by the sarcoma unit after imaging. A rapidly enlarging deep firm mass must not be watched.

A. Refer on the suspected cancer pathway to urology

A persistent, indurated, enlarging penile ulcer in an older uncircumcised smoker, with a hard inguinal node and infection excluded, is penile cancer until proven otherwise and meets the criterion for a suspected cancer pathway referral: a penile mass or ulcerated lesion where sexually transmitted infection has been excluded, or a lesion persisting after treatment for one. Penile squamous cell carcinoma spreads early to the inguinal nodes, and delay in diagnosis directly worsens both survival and the chance of penis-preserving surgery. Biopsy and staging belong to the specialist team, and treating empirically for candida or lichen sclerosus would delay diagnosis of a lesion whose features do not fit either.

D. Bronchoscopy

A lung abscess that fails to respond to an adequate course of antibiotics in an older smoker with no risk factor for aspiration should be assumed to hide an obstructing bronchial carcinoma or a cavitating tumour until proved otherwise, and bronchoscopy both visualises and biopsies an endobronchial lesion while allowing washings for culture including tuberculosis. Needle biopsy of an infected cavity risks bronchopleural fistula, empyema and pneumothorax, so it follows a non-diagnostic bronchoscopy rather than preceding it. Further watchful waiting delays a cancer diagnosis.

C. Burkitt lymphoma

A positive monospot confirms infectious mononucleosis caused by Epstein-Barr virus, a gamma-herpesvirus that establishes lifelong latency in B lymphocytes. EBV is found in almost all cases of endemic Burkitt lymphoma, which carries the defining c-MYC t(8;14) translocation and is the canonical EBV-associated B-cell tumour. EBV is also implicated in Hodgkin lymphoma, nasopharyngeal carcinoma and post-transplant lymphoproliferative disease.