Different approaches to the delivery of the PT can impact significantly on student study patterns. The learning environment has an important impact on student perceptions of assessment and approach to learning. Careful decisions about PT deployment must be taken to ensure its optimal impact.

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Acinic cell carcinoma is a rare, typically indolent, neoplasm that arises in the salivary glands. Metastatic disease is uncommon, occurring in around 10% of cases. We report the case of a 46-year-old male in whom the first sign of disseminated disease was increased skin pigmentation due to paraneoplastic Cushing’s syndrome. He underwent 3 cycles of chemotherapy with carboplatin and paclitaxel with no symptomatic improvement and a mixed response on imaging. There is no evidence that systemic therapy prolongs survival in metastatic acinic cell carcinoma, and we lack a consensus as to which treatment options are most beneficial. A summary of published evidence regarding choice of palliative chemotherapy regimens and response is discussed in relation to the case.

A 72-year-old man with metastatic clear cell renal carcinoma, who had progressed after previous treatment with Sunitinib and Axitinib, was given one dose of immunotherapy. He was initially unwell after treatment with fever, shortness of breath, chest pain and raised inflammatory markers. Following this he elected not to have any further immunotherapy. Before the treatment he had multiple pulmonary metastases and hilar and mediastinal lymph nodes on chest X-ray and suffered with a persistent cough. Chest X-ray 10 months after treatment showed normal appearances and his cough had largely resolved. The patient initially declined repeat computed tomography imaging but agreed to it 2 years after the immunotherapy, the results showed a maintained response. Some patients with renal cell carcinoma show a durable response to immunotherapy but we are not aware of other published cases where a patient has shown such a dramatic and sustained response to one dose.

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