AKT – Oncology

Jessica Markovic, aged 52, presents with a 3-month history of fatigue, night sweats and unexplained weight loss. She reports a sensation of fullness in her abdomen and has recently noticed painless lumps in her neck.

She takes no regular medications and has no significant past medical history. She does not smoke and drinks alcohol occasionally. There is no family history of malignancy.

On examination, she has palpable non-tender cervical and axillary lymphadenopathy, and splenomegaly. Blood tests show normocytic anaemia and elevated LDH. Peripheral smear shows no blasts.

What is the most likely diagnosis?

David Nguyen, aged 68, presents with increasing lower back pain and fatigue. He reports nocturia and occasional constipation. He has also noted recent bruising and weight loss.

Medications include perindopril and atorvastatin. On examination, there is spinal tenderness over the lower thoracic vertebrae. No neurological deficits are noted.

Laboratory investigations reveal normocytic anaemia, elevated ESR, hypercalcaemia and renal impairment. SPEP shows a monoclonal spike.

What is the most appropriate next investigation?

Amanda Latu, aged 46, presents for routine screening. She has no symptoms and no past history of cancer. Her mother was diagnosed with breast cancer at age 61. Amanda has had regular mammograms every 2 years since turning 40.

Her most recent mammogram shows a 1.5 cm irregular spiculated mass in the upper outer quadrant of the left breast with associated microcalcifications. No axillary lymphadenopathy is noted.

What is the most appropriate next step in management?

Tom Beale, aged 72, presents with a 4-week history of worsening haematuria and urinary frequency. He has a 50-pack-year smoking history and worked in the rubber manufacturing industry. He denies dysuria or flank pain.

Urine dipstick confirms haematuria; MSU is negative for infection. Renal function is normal. Ultrasound shows a thickened bladder wall but no hydronephrosis.

What is the most appropriate next step?

Sandra Houghton, aged 38, presents with abdominal bloating, early satiety, and mild pelvic discomfort that has developed over the past two months. Her periods are regular. She has two children and no significant medical history.

On examination, she has a palpable mass in the left adnexal region. CA-125 is elevated. Transvaginal ultrasound shows a 9 cm complex ovarian mass with solid and cystic areas and papillary projections.

What is the most appropriate next step in management?

Michael Dunne, aged 65, presents with persistent hoarseness for six weeks. He is a former smoker and drinks alcohol socially. He has no sore throat or cough but reports a recent 3 kg weight loss and some difficulty swallowing solid foods.

Examination reveals no neck masses. Oral cavity and oropharynx appear normal. Flexible nasoendoscopy reveals a suspicious lesion on the left vocal cord.

What is the most appropriate next step?

Priya Rajan, aged 58, presents with persistent postmenopausal bleeding for three months. She reached menopause at age 51 and has no history of hormone replacement therapy. She has no pain or systemic symptoms.

On speculum examination, the cervix appears normal. Bimanual exam suggests a slightly enlarged uterus. A transvaginal ultrasound reveals an endometrial thickness of 9 mm.

What is the most appropriate next step in management?

Jason McCarthy, aged 70, presents for review of recent investigations. He has experienced increasing fatigue and shortness of breath on exertion. Full blood count shows a haemoglobin of 95 g/L with low MCV and low ferritin. Occult blood test is positive.

He has a history of osteoarthritis, managed with regular ibuprofen. No overt GI bleeding has been noted. He has not had recent endoscopy or colonoscopy.

What is the most appropriate next step in management?

Wendy Taylor, aged 49, presents for skin check. She has a 7 mm asymmetric pigmented lesion on her left upper arm with irregular borders and varying colours. She has a history of significant sun exposure and had a dysplastic naevus excised five years ago.

Dermatoscopy shows an atypical pigment network and blue-white veil. No lymphadenopathy is noted.

What is the most appropriate next step?

Robert Chao, aged 62, presents with mild right upper quadrant pain and weight loss. He has a history of hepatitis B. Examination reveals hepatomegaly without jaundice or ascites.

Liver function tests are mildly deranged and alpha-fetoprotein (AFP) is elevated. Abdominal ultrasound shows a 4 cm lesion in the right hepatic lobe.

What is the most appropriate next step in management?

Karen Elliott, aged 45, presents with a persistent dry cough for the past 3 months. She denies any wheeze or breathlessness. She is a non-smoker. Chest X-ray performed as part of initial work-up reveals a 2.8 cm solitary pulmonary nodule in the right upper lobe.

She has no systemic symptoms. No previous imaging is available for comparison.

What is the most appropriate next step in management?

Rosa Mendes, aged 37, presents with an abnormal cervical screening test. Her CST result shows high-grade squamous intraepithelial lesion (HSIL). She is asymptomatic and has regular periods. She is not pregnant and has no significant past medical history.

Her last CST was 5 years ago and was normal.

What is the most appropriate next step?

Alan Fisher, aged 73, presents with unintentional weight loss, anorexia and vague epigastric discomfort. He has a 30-pack-year smoking history and moderate alcohol intake. Examination reveals a palpable non-tender gallbladder and scleral icterus.

Bloods show elevated bilirubin, ALP and GGT with mildly elevated ALT and AST. CA 19-9 is elevated.

What is the most likely diagnosis?

Isabel Chen, aged 59, presents after finding a painless, firm, mobile lump in her right breast during self-examination. There is no family history of breast or ovarian cancer. Mammogram confirms a 2.2 cm irregular mass in the right breast. Core biopsy confirms invasive ductal carcinoma, ER/PR positive, HER2 negative.

What is the most appropriate initial treatment?

Gurpreet Singh, aged 64, presents with increasing fatigue, anorexia, and pruritus. He has a long-standing history of ulcerative colitis. On examination, he has jaundice and hepatomegaly.

Liver function tests show a cholestatic pattern. MRCP shows stricturing and beading of the intrahepatic bile ducts.

What malignancy is this patient at increased risk of developing?

Andrew Ghosh, aged 51, presents with abdominal discomfort and change in bowel habits over the past 3 months. He reports alternating constipation and diarrhoea, and a sensation of incomplete evacuation. His father was diagnosed with colon cancer at age 62.

On examination, he has mild left iliac fossa tenderness. Rectal exam is normal. FOBT is positive. FBC shows microcytic anaemia.

What is the most appropriate next step?

Leanne Brooks, aged 34, presents for genetic counselling following her mother’s recent diagnosis of breast cancer at age 48 and her aunt’s death from ovarian cancer at age 45. Leanne is well with no symptoms or findings on breast examination.

What is the most appropriate next step in management?

Thomas Yilmaz, aged 78, presents with a painless, enlarging mass in his left scrotum. He reports no trauma or fever. He has had no urinary symptoms. On examination, there is a firm, non-tender mass separate from the testis. Transillumination is negative.

Scrotal ultrasound shows a 4 cm hypoechoic intratesticular lesion with vascularity.

What is the most appropriate next step?

Naomi Fraser, aged 67, presents with progressive difficulty swallowing solids over the past 2 months, now involving liquids. She has lost 6 kg unintentionally. She is a former smoker. There is no history of reflux or odynophagia.

On examination, she appears cachectic. No cervical lymphadenopathy is noted. FBC is unremarkable.

What is the most appropriate next step?

Victor Hernandez, aged 58, presents with worsening back pain and new-onset urinary retention. He has a known diagnosis of prostate cancer managed with active surveillance. His PSA has recently risen significantly.

Examination reveals lower limb weakness and reduced anal tone. MRI spine shows metastatic lesion compressing the thoracic spinal cord.

What is the most appropriate immediate management?

Eliza Pang, aged 29, presents with a breast lump discovered 3 days ago. She is 34 weeks pregnant and has no personal or family history of breast cancer. The lump is 2 cm, mobile, and non-tender in the upper outer quadrant of her left breast.

On examination, there is no axillary lymphadenopathy. She is otherwise well.

What is the most appropriate next step in management?

Samuel Tran, aged 50, presents with multiple seborrhoeic keratoses that have rapidly increased in number over the last two months. He also reports fatigue and abdominal discomfort. Examination reveals widespread new seborrhoeic lesions on his back and chest.

What is the most appropriate next step in management?

Sophie Williams, aged 41, presents with ongoing fatigue and new bruising over her limbs. She reports no recent trauma. Examination reveals petechiae on her legs and gingival bleeding. FBC reveals Hb 95 g/L, WBC 3.2 x10^9/L, and platelets 21 x10^9/L.

Blood film shows blasts.

What is the most appropriate next step in management?

Liam O’Reilly, aged 66, presents with a non-healing ulcer on his lower lip that has slowly increased in size over the past three months. He is a farmer with significant sun exposure. On examination, there is a 1.2 cm ulcerated lesion with an indurated edge.

No lymphadenopathy is present. The lesion is crusted and bleeds easily on contact.

What is the most appropriate next step?

Nicholas Boyd, aged 47, presents with a 3-week history of painless jaundice and pruritus. He has dark urine and pale stools. Examination reveals scleral icterus but no hepatomegaly. LFTs show elevated bilirubin, ALP and GGT. CA 19-9 is elevated.

What is the most likely site of malignancy?

Harriet Long, aged 71, presents with persistent right-sided headaches and jaw claudication. She reports transient visual disturbances and scalp tenderness. ESR is 92 mm/hr. Examination reveals a tender, thickened right temporal artery.

She is otherwise well and has no neurological deficits.

What is the most appropriate initial management?

Rachel Greenwood, aged 61, presents with a 3-month history of a non-healing lesion on the anterior lower leg. The lesion is ulcerated with rolled edges and has increased in size. She has a history of sun exposure from gardening daily.

On examination, the lesion is 1.8 cm, pearly, with central ulceration and visible telangiectasia.

What is the most likely diagnosis?

Jonathon McCabe, aged 57, presents with progressive fatigue and early satiety. Examination reveals a palpable spleen 4 cm below the costal margin. FBC shows Hb 112 g/L, WBC 36 x10^9/L with neutrophilia, and platelets 510 x10^9/L.

Peripheral blood smear shows myelocytes and basophils.

What is the most likely diagnosis?

Grace Varga, aged 63, presents with vaginal bleeding 8 years after menopause. She is not on HRT and has no significant past gynaecological history. TVUS reveals an endometrial thickness of 11 mm.

What is the most appropriate next step?

Peter Rinaldi, aged 54, presents with back pain and recent onset of erectile dysfunction. PSA is 86 ng/mL. Digital rectal exam reveals a hard, irregular prostate. Bone scan shows multiple osteoblastic lesions in the lumbar spine and pelvis.

What is the most appropriate initial treatment?

Imogen Hart, aged 47, presents with persistent right upper quadrant pain and unintentional weight loss. She has a history of ulcerative colitis. Examination reveals mild hepatomegaly. LFTs show elevated ALP and GGT. CA 19-9 is elevated.

MRCP reveals multifocal strictures and dilatation of intrahepatic bile ducts.

What is the most likely diagnosis?

Damien Cowan, aged 58, presents with new-onset seizure. CT brain reveals a solitary ring-enhancing lesion in the frontal lobe. He has a 40-pack-year smoking history. Chest X-ray reveals a 3.5 cm lesion in the right upper lobe.

What is the most likely diagnosis?

Catherine Miles, aged 64, presents with weight loss and persistent fatigue. On examination, she has cervical lymphadenopathy and splenomegaly. FBC shows lymphocytosis and smear reveals smudge cells. Flow cytometry confirms CD5+ CD23+ B cells.

What is the most likely diagnosis?

Emily Zhao, aged 32, presents with a breast lump that has increased in size over the past two weeks. She is 5 weeks postpartum and breastfeeding. The lump is 3 cm, warm, tender and fluctuant.

What is the most appropriate next step in management?

Stephen West, aged 80, presents with increasing lethargy, low mood and confusion. Blood tests reveal corrected calcium of 3.2 mmol/L, normal renal function, and suppressed PTH. He has a known diagnosis of squamous cell carcinoma of the lung.

What is the most likely cause of his hypercalcaemia?

Melissa Pinder, aged 45, presents with left-sided breast pain and skin dimpling. She noticed the area becoming firm over the past two weeks. On examination, there is peau d’orange and nipple retraction.

No discrete lump is palpable. Axillary lymph nodes are enlarged and firm.

What is the most likely diagnosis?

James Abrahams, aged 76, presents with painless haematuria. He has a 60 pack-year smoking history and no recent infections or trauma. MSU is negative for infection. Renal function is normal. CT IVP shows a filling defect in the bladder.

What is the most appropriate next step in management?

Julie Wu, aged 66, presents with mild dysphagia to solids and weight loss. She also reports persistent heartburn despite PPI therapy. Endoscopy reveals a lower oesophageal stricture with an ulcerated lesion. Biopsy shows adenocarcinoma.

What is the most important risk factor in this case?

Sanjay Mehta, aged 62, presents with unexplained weight loss and abdominal pain. On exam he has a hard left supraclavicular lymph node. CT scan reveals a mass in the stomach and multiple liver lesions.

What is the most likely origin of the lymph node finding?

Aisha Noor, aged 52, presents with fatigue and an incidental finding of hyperpigmentation. She has a history of treated breast cancer. Blood tests show low sodium and high potassium. Her morning cortisol is low and ACTH is elevated.

What is the most likely diagnosis?

Lucinda Black, aged 36, presents with a 2-month history of left breast swelling and erythema. She is not breastfeeding. The area has become more indurated despite a course of antibiotics. Examination reveals warmth, peau d’orange, and axillary nodes.

What is the most appropriate next step?

Malcolm Trent, aged 67, presents with progressive shortness of breath and facial swelling. He has a known diagnosis of small cell lung cancer diagnosed 6 weeks ago and is awaiting staging PET scan.

On examination, he has dilated neck veins and periorbital oedema. CXR shows mediastinal widening.

What is the most appropriate immediate management?

Paula Nash, aged 55, presents with chronic abdominal pain and intermittent diarrhoea. She also reports flushing and episodes of wheezing. A 24-hour urinary 5-HIAA level is elevated.

What is the most likely diagnosis?

Anna Jeffries, aged 49, presents with new left breast pain and nipple inversion. She noticed bloody nipple discharge once last week. There is no palpable mass, but the nipple remains retracted.

What is the most appropriate next step in management?

Eric D’Souza, aged 60, presents with a new onset of hoarseness and difficulty swallowing. He has a history of heavy smoking and alcohol use. Laryngoscopy shows a lesion on the left vocal cord.

What is the most likely diagnosis?

Ismail Faheem, aged 68, presents with an enlarging, painless testicular mass. He has no history of trauma or infection. Ultrasound shows a 3.5 cm solid intratesticular mass. Tumour markers show elevated AFP and beta-hCG.

What is the most appropriate next step?

Beatrice Yeo, aged 72, presents with iron deficiency anaemia. She denies GI symptoms. FOBT is positive. She had a normal colonoscopy 5 years ago. Upper endoscopy reveals a 3 cm ulcerated lesion in the lesser curvature of the stomach.

What is the most likely diagnosis?

Olivia Tran, aged 40, presents with a persistent dry cough and recent onset of dyspnoea. She has no smoking history. Chest X-ray reveals a mediastinal mass. CT confirms a 6 cm anterior mediastinal mass compressing adjacent structures.

What is the most likely diagnosis?

Manoj Patel, aged 75, presents with persistent fatigue and low-grade fevers. He has mild hepatosplenomegaly. Blood smear shows rouleaux formation. Serum protein electrophoresis shows a monoclonal spike.

What is the most appropriate next investigation?

Fatima Khan, aged 58, presents with increasing abdominal girth, early satiety and dyspnoea. Examination reveals shifting dullness. CA-125 is elevated. Transvaginal ultrasound shows bilateral complex adnexal masses.

What is the most appropriate next step?