11. Hematology & Oncology

Question 1

How can bone pain in patients with prostate cancer who have undergone orchiectomy be managed?

Answer 1

Radiation therapy (focal external beam therapy)

Question 2

How can you differentiate hereditary spherocytosis and autoimmune hemolytic anemia?

Answer 2

Both have spherocytes without central pallor
AIHA: neg family hx and positive Coombs test
HS: pos family hx and negative Coombs test

Question 3

What microcytic anemia shows target cells on peripheral smear and has normal RBC count?
Tx?

Answer 3

Thalassemia (B thal has elevated HbA2)
No tx for B-thal
Note: Fe def has low RBC count and is microcytic only when Hb <10g/dL

Question 4

What is the ddx of anterior mediastinal mass?

Eg. male with ant mediastinal mass and elevated AFP and BHCG

Answer 4

4Ts - teratoma (and other germ cell tumors), thymoma, thyroid neoplasm, terrible lymphoma
eg - nonseminomatous germ cell tumor like a mixed germ cell tumor

Question 5

What pathology can be found in the MIDDLE mediastinum?

Answer 5

Bronchogenic cysts - bengn.

Tracheal tumors, pericardial cysts, lymphoma, LN enlargement and aortic aneurysms of the arch can also be found

Question 6

How long is there risk of sepsis after splenectomy?

Answer 6

Up to 30 years
Recommend anti-pneumococcal, Haemophilus, and meningococcal vaccines several weeks bf operation. Daily oral penicillin prophy for 3-5 y after splenectomy

Question 7

Why is a Prussian blue stain done during hemolytic episodes?

Answer 7

positive stain indicates presence of hemoiderin

Question 8

What are the drugs of choice for stabilizing bony mets to prevent hypercalcemia of malignancy and pathological fractures?

Answer 8

bisphosphonates

Question 9

What is a common complication of hereditary spherocytosis?

Answer 9

Pigmented gallstones –> acute cholecystitis

Caused by hemolytic anemia

Question 10

What is the most likely cause of anemia in a patient with prolonged NSAID and aspirin use?

Answer 10

Iron def anemia - NSAIDs and aspirin can cause gastritis and/or gastric ulcers –> chronic GI blood loss and depletion of Fe stores
Confirm dx with upper and lower GI endoscopy

Question 11

What causes the presence of Howell Jolly bodies in a patient with sickle cell?

Answer 11

Chronic damage and autoinfarction of the spleen leads to functional asplenia by age 5 –> can remove normal nuclear remnants of RBCs.

Question 12

Patients with CF may develop what heme deficiency?

Answer 12

Vit K def (inc PT and INR, normal aPTT).
CF pts can absorb fats and fat-soluble vit (A,D,E, K) and require pancreatic enzyme replacement and fat-soluble vit supplementation.

Question 13

DVT in the setting of inc homocysteine should be treated with heparin and warfarin therapy as well as what?

Answer 13

Pyridoxine (B6) - lowers homocysteine levels (cofactor for cystathionine B-synthase) to metabolize homocysteine into cystathionine.
Elevated homocysteine can predispose to VTE

Question 14

Secondary malignancy is common in pts with Hodgkin lymphoma treated with chemo and radiation. What are a few of the MC secondary solid tumor malignancies?

Answer 14

Lung, breast, thyroid, bone and GI (colorectal, esophageal, gastric)

Question 15

What can be the earliest manifestation of vaso-occlusive disease in sickle cell disease and presents with the acute onset of bilateral hand and foot swelling and tenderness?

Answer 15

Dactylitis = microvascular occlusion/vaso-oclusive crisis

Question 16

patients with aggressive heme malignancies are at risk of tumor lysis syndrome when initiated on cytotoxic chemo. What happens to uric acid, phosphate, potassium, and calcium levels? How can you prevent? Consequences of TLS?

Answer 16

HYPER - uricemia, kalemia, phosphatemia
HYPO - calcemia.
Prevent by pretreatment with IV fluids and allopurinal to prevent AKI and cardiac arrhythmias.

Question 17

Differentiate initial management of suspected DVT vs PE

Answer 17

DVT: wells score and compression US for initial assessment. Confirm dx prior to anticoag
PE: start on anticoag if there are no contraindications while undergoing diagnostic eval.

Question 18

Fanconi anemia is an autosomal recessive disorder that is the MC congenital cause of what condition? Clinical manifestations of FA? Dx?

Answer 18

Aplastic anemia
Other manifestations: Short, microcephalic, abnormal thumbs, hypogonadism, hypo/hyperpigmented skin, cafe au lait spots, large freckles. Strabismus, low-set ears, middle-ear abnormalities.
Dx: chromosomal breaks o ngenetic analysis

Question 19

Why might patients with multiple myeloma develop constipation?

Answer 19

Osteolytic bone destruction –> hypercalcemia –> constipation, depression, fatigue.

Question 20

When on warfarin, the INR should be between 2-3. What does it mean if INR is <2?
What is as equally effective as warfarin in DVT or PE treatment, esp if difficulty in INR monitoring?

Answer 20

Inc risk of clot!

direct factor Xa inhibitors (eg rivaroxaban)

Question 21

When would whole blood transfusion be indicated rather than packed RBCs?

Answer 21

Whole blood = PRBCs + plasma. Use if pt has severe hemorrhage and needs massive blood transfusion to assist in vol expansion.
PRBCs used in acute GI bleeding for pt with hb <7.

Question 22

What type of anemia is the MCC of Vit B12 def in whites of norhtern European ancestry. Presents with megaloblatic anemia, atrophic glossitis (shiny tongue), vitiligo, thyroid disease, and neuro abnormalities)

Answer 22

Pernicious anemia (autoimmune condition in which the body’s immune system attacks the actual intrinsic factor protein or the cells in the lining of your stomach that make it.)

Question 23

All patients with presumed ITP should be tested for what two conditions as platelet counts can be affected by treating the underlying disease?

Answer 23

HIV and hep C.

Thrombocytopenia may be the initial presentation of HIV infection in up to 5-10% of patients.

Question 24

Differentiate graft vs host disease from graft rejection in a patient with BM transplant

Answer 24

GVHD: activation of donor T lymphocytes (maculopapular rash, diarrhea, abnormal LFTs)
Graft rejection: activation of host T lymphocytes (severe neutropenia and inc risk of infx)

Question 25

What is haptoglobin’s role? What are its levels in hemolytic anemia?

Answer 25

Haptoglobin is a serum protein that binds free Hb and promotes its excretion by teh RES.
Hemolysis: dec haptoglobin bc scavenges Hb

Question 26

Pancytopenia (dec RBC, WBC and platelets) is common in patients with SLE. What is the most likely cause of the thrombocytopenia?

Answer 26

Peripheral immune-mediated destruction

Question 27

Migratory superficial thrombophlebitis (Trousseau’s syndrome) is a hypercoag disorder that presents with unexplained superficial venous thrombosis at unusual sites. What can it be a sign of/associated with?

Answer 27

Cancer involved the pancreas (MC), lung, prostate, stomach, colon, and acute leukemias.

Question 28

Rapid onset (within seconds to min) of resp distress and hypotension that quickly progresses to resp failure and shock after blood products transfusion is due to what?

Answer 28

Anaphylactic reactions.
Note: indiv with IgA def area t risk due to presence of Anti-IGA abs.
Acute management: ei, circulatory and resp support