2018 Medical Oncology 6% Flashcards
1
Q
Colon CA
Risk factors
A
Age>50*
long standing UC&Crohns >8yr
1st deg relatives with colon CA
h/o other CA (breast, ovarian, endometrial)
Familial polyposis (gardners, familiar adenomatous polyposis highest risk (5Q- gene abnormality)
Hereditary non polyposis colono CA (HNPCC)
Adenomas –> next colonoscopy in 3 years if > or + 1 cm or 3 or more polyps
<60 1st degree relative–> 40 yrs + every 5 yrs
2 1st degree relatives –> 40 yrs + every 5 yrs
1 1st degree relative –> 40yrs + every 10 yrs
2
Q
Decrease risk colon CA:
A
ASA >20yrs
Celecoxib & sulindac–> decrease load of polyps in colon
estrogens
colon cancer usually arises from adenomas
hyperplastic polyp has no malignant potential!
3
Q
Familial Adenomatous polyposis
A
Fhx adenomatous polyposis and CA
Mut of APC gene–> Chr 5q-gene abnormality
[????hundreds polyps before age 16
95% cancer
colectomy indicated before malignancy begins
Sigmoidoscopy age 12-16 then colonoscopy q yearly - if any polyps - colectomy????]
4
Q
Gardner syndrome
A
- Subtype of FAP involving adenomatous polyps involving the colon
- extraintestinal manifestation - osteomas mandible , skull, and long bones, soft tissue tumors, thyroid and adrenal tumors, epidermoid and sebaceous cysts
[????Adenomatous polyps invovling colon
95% cancerColectomy before malignancy begins
Sigmoidoscopy age 12-16 then colonoscopy q yearly - if any polyps - colectomy???]
5
Q
HNPCC (lynch syndrome)???
A
3 relatives with Cancer related to HNPCC one 1st deg 2 generations 1 extracolon CA FAP excluded
6
Q
Adenoma Colonoscopy screening????
A
Hyperplastic polyp - q10yr
Adenoma < 1cm x1 - q5-10yr
Adenoma <1cm 3 Q3yr
Villous adenoma - regardless of size q3yr
7
Q
Colon CA screening ???
A
1st deg relative colon CA age 10
colonoscopy standard time (age 50 then q10yr
Two 1st deg relatives colon CA
colonscopy now then q5yr
8
Q
Peutz-Jeghar’s syndrome
A
STK 11
Pigmented lesions on skin, lips, mouth
Do colonoscopy
[???hemartomas of small intestine
Juventile polypossi: hyperpalstic polyps in colons - p./w GI bleed or inussusception
Tx: colonoscopy????}
9
Q
HNPCC (hereditary non-poyposis colon CA) or Lynch syndrome
A
-Autosomal dominant
-Need to have at least 3 relative with colon CA. One must be 1st deg relative of the other two,
2 generations with colon CA May have extracolonic cancer as well.
-At least one relative <50yo with colon CA
10
Q
50yo F with HNPCC had colon CA done - adenomatous polyps - wtd?
A
TV US
??for uterine CA (extracolonic CA)???
11
Q
55yo M asx for routine checkup - t neg (FIT) - signmoidoscopy => polyp
A
If bx of polyp= hyperplastic polyp wtd?
- ->FIT q 1yr, sigmoidoscopy 10 yr OR
- -> sigmoidoscopy alone q 5 yrs OR
- ->double contrast barium enema q 5 yrs.
If bx of polyp= adenoma wtd?
–>full colonoscopy
IF bx of polyp–> adenocarcinoa wtd?
–> full colonosopy prior to sx
12
Q
???55yo asx M routine checkup - sigmoidoscopy - neg - FIT +
A
Full colonoscopy
13
Q
Elderly male or postmenopausal female with unexplained Iron deficiency anemia - wtd?
A
Colonoscopy
14
Q
Elderly pt with hematochezia, h/o hemorrohids wtd?
A
Colonoscopy
15
Q
Pt on routine health maintenance exam FIT 1 out of 6 cards + occult blood - pt takes high doses of vit C, wtd?
A
Colonoscopy
16
Q
55yo F screening colonoscopy done - 2 polyps removed - both hyperplastic - when next colonoscopy
A
10 years
17
Q
Pt with 2 adenomas <1cm removed when repeat colonscopy?
A
colonoscopy q5-10yrs
18
Q
Pt with 1 tubular adenoma 1cm - next colonoscopy?
A
3 years
19
Q
Pt 1 tubular adenoma 2.5 cm next colonoscopy?
A
3 years
20
Q
Pt with 3-10 tubular aenoma <1cm next colonoscopy
A
3 years
21
Q
Pt with 1 villous adenoma <1cm next colonscopy
A
3 years
22
Q
Pt with obstructive colon CA with colonic resection wtd?
A
Full colonoscopy to r.o other concomitant lesions
23
Q
Pre-op colonscopy with no other lesions
A
colonoscopy 1 yr then 3 years then q5yrs
measure CEA q3 to 6 mo for 2 years then q 1yr x 5 years
24
Q
Best dx test r/o colon CA?
A
Colonoscopy with bx. Best risk reduction in left colon.
25
When do you recommend against routine colonoscopy screening?
75yo
(your book only lists this)
[???D/c mammo 75yo
D/C pap smears - 65
Hep C screening 1945 to 1965
LDCT screen for smokers up to age 79???]
26
12y/o , Familial Adenomatous Polyposis (FAP)
Sigmoidoscopy q1-2 yrs starting at age 12
| colonoscopy @ 16 y/o
27
HNPCC
start colonoscopy 25yr or 10 years younger than youngest affected relative with HNPCC - then q2yr up to age 40 then q1yr
28
If 2 first deg relatives or 1 first deg relative with colon CA before age 60 when to screen?
40 years or 10 yrs younger than youngest affected relative (whichever younger) then q5 yrs
29
If two second deg relative with colon CA after age 60 - when to screen?
40 years FIT q 1 yr + sigmoidoscopy q 10 yrs or colonoscopy now and q 10 yrs.
30
General population or distant family hx of colon CA screening
50 yo (??AA 45yo???) - FIT q 1 yr + signmoidoscopy q10 yr or colonoscopy at 50 then q10 yrs
31
Post colonic resection for Colon CA
Colonoscopy 1 yr after resection then 3 yrs then q5yrs
32
UC, Crohns's dz
Colonoscopy 8yrs after dx then q1-2 yr
33
35yo asx - father with colon CA @ age 45yo
Colonoscopy now then q5yrs
34
40yo asx father colon CA age 60, brother age 52
Colonoscopy now then q5yr
35
35yo asx, father colon CA age 65
FIT+Sigmoidoscopy q 10yr or colonoscopy q10yr starting at age 50
36
25yo asx - family h/o HNPCC
Colonoscopy now then q2yr up to age 40 then q1yr
37
Pt with UC dx recently
Colonoscopy 8yrs later and then q2yr
38
Pt with Colon Ca Duke B underwent resection of colon
Colonoscopy in 1 yr then in 3 yrs then q5yr
39
50yo asx - neg fxhx colon CA
FIT + sigmoidoscopy q10 yrs or colonoscopy q10yr starting at age 50
40
Young pt with h/o familial adenomatous polyposis
Colonoscopy age 16yo
41
40yo asx father colon CA after age 55
Colonoscopy now then q5yr
42
37yo M, father colon CA at age 65, brother colon CA age 50, aunt uterine CA age 48. what is more likely?
HNPCC (microsatellite mismatch repair gene MSH)
43
What does tamsulosin cause?
Floppy iris syndrome!
| d/c tamsulosin
44
Acute afib chemical cardioversion
ibutelide
45
Colon Cancer Duke A/ I
tx - resection
mucosa layer
[????90% survival - thru submucosa but not past muscularis????]
46
Colon Cancer Duke IIA
tx - resection
submucosa layer
????90% survival thru muscularis but not past serosa (no LN)????
47
Colon Cancer Duke B IIB
tx resection
muscularis layer
????60-80% survival - thru muscularis into serosa not into LN????
48
Colon Cancer Duke B IIC
tx : resection
serosa layer
???60-80% survival - thru serosa and involving LN???
49
Colon Cancer Duke C/ III
Tx: resection +5FU + leucovorin+oxaliplatin (folfox)
Lymph nodes
???7% survival - Widespread metastasis (liver)???
50
When to resect soitary liver metastasis
If have pursued curative intent in past****
51
Pt with colon CA undergoes hemicolectomy - histopathology with infiltartion of musularis , LN(-), wtd?
Observe
52
Pt with colon CA infiltrating serosa & pericolic structures (visceral peritoneum). After hemicoloectomy, wtd?
Chemotx (5FU + leucovorin + Oxaliplatin)
53
Pt with colon CA not infiltrating sera but 4/10 LN invovled - after hemicolectomy wtd?
Chemotx (5FU +leucovorin + oxaliplatin)
54
Pt with stage B2 rectal CA - local resectio done - wtd?
Chemotx + RT
55
Anal Ca - cancer of anal margin how to treat?
Local resection
56
Cancer of anal canal muscosa wtd?
external beam radiation tx + 5FU + leukovorin
57
Breast lump/ suspicious mass w/u
chart on page 147
Re-examine in 6 weeks mid cycle
Mass dissappears - do nothing
Mass persists - mammogram
If young woman straight to US
If older woman
if + mammogram then excision bx/intraop bx
If indeterminant/neg mammogram-> US
If solid on US - FNA with bx*** - if neg then excisional bx
If mixed echo US- FNA + bx if neg **-> excisional bx
If cystic on US then FNA bx
58
Risk factors for breast CA
```
Highest risk:
Female >50yo
Personal hx breast CA
strong Fhx pre-menopausal breast CA
Genetic BRCA 1+2
```
Other risk factors:
personal h/o ovarian CA or endometrial CA
dense breasts
OCPs>15yrs.
Screening:
- women >50yrs OR <5-10yrs prior to age in 1st deg relative w/ breast Ca and then q 2 yrs
- 10% of breast Ca found on PE is missed by mammogram
- BRCA 1: Chrom 17; breast, ovarian cancer in women and prostate cancer in men. High penetrance. Other family members should be aware. (MRI every year)
- BRCA 2: chrom 13
- TP53 mutation: breast cancer with other cancers in family at younger age; brain, leukemias, and sarcomas.
59
Breast CA screening
- women >50yrs OR <5-10yrs prior to age in 1st deg relative w/ breast Ca and then q 2 yrs
- 10% of breast Ca found on PE is missed by mammogram
- BRCA 1: Chrom 17; breast, ovarian cancer in women and prostate cancer in men. High penetrance. Other family members should be aware. (MRI every year)
- BRCA 2: chrom 13
- TP53 mutation: breast cancer with other cancers in family at younger age; brain, leukemias, and sarcomas.
60
Local breast diseas in situ (??all w/in basement membrane??)
tx - lumopectomy + RT or mastecotmy
| tamoxifen (pre-menopause)/aromatoase inh (post-menopausal). if ER receptor +
61
Lobular CA in situ
observation or if ER+ -> tamoxifen (???pre)/aromatase (post menopause???)
62
Infiltrating ductal CA, LN neg
wide exceision of mass w/ free margins + RT
Adjuvant chemo for size >1cm
Tamoxifen/aromatase inh if ER receptor +
63
Infiltrating ductal CA, LN + pos
[wide excisition + RT = modified radical mastectomy] + adjuvant chemo + tamoxifen /aromatase inh if ER receptor +
64
Locally invasive dz involving skin or chest wall
chemotx followed by mastectomy + tamoxifen/aromatose inh if ER receptor+
65
Most important prognostic factor in breast CA?
LN invovlement>tumor size>receptor+>grade
66
Adjuvant therapy for LN(+) dz
-Premenoapuse -
ER+ -> chemo + tamoxfen
ER- -> chemotx
HERR-2 (+)--> + trastuzumab
-Post menopause -
ER+ -> chemotx + aromatase inhibitors
ER - -> Chemotx
HERR-2 + --> trastuzumab
67
Adjuvant therapy for LN neg dz >0.5 cms
premenopausal - ER+ tamoxifen + HERR-2 += trastuzumab
| Post menopausal - ER+ aromatase inhib + HERR-2 + trastuzumab
68
???When to use chemo tx in breast CA
????Tumor size>1cm, high grade
| if <1cm NO CHEMOtx
69
Types of breast CA
Intraductal 80%
Lobular 10%
Other 10%
70
Excision of mass with free margin +RT =
Modifeid radiacla mastectomy + RT
71
If sentinel LN bx +
Further LN dissection
72
If sentinel LN bx neg
no further LN dissection
73
If LN +
Adjuvant tx : Chemotherapy +/- tamoxifen (pre menopausal), aromatose inh (post menopausal)
74
tamoxifen/aromatase inhib used also?
LN neg pts w/ ER+
- Anti HERR receptor trastuzumab can be used for ER/PR negative pts if HERR positive.
- it decreases rate of recurrence of breast CA
75
37yo F fhx breast CA mother 65yo, sister h/o breast CA 35yo - most important risk factor for pt to get breast CA?
Family hx breast CA
76
65yo F fhx breast CA mother 67yo - most important risk factor for her to acquire breast cancer?
Her age
77
Highest risk fo rbreast CA
early menarch, late 1st preg, late menopause, strong fhx no deodorant
78
Pt with breast CA, 1st deg relative of breast and ovarian CA dx?
BRCA 1 mutation
79
40 y/o female with BRCA 1 mutation, what to do next?
Mammogram and MRI scrrening now
Also for BRCA 2 and their 1st degree relative, TP 53, PTEN, CHEK 2, RT to chest **
80
50yo F regular checkup - best way to screen for breast CA?
clinical breast exam and mammogram every 2 yrs
81
How to screen for breast Ca in woman with breast implants
mammogram
82
Mammogram best in woman who is...
post menopausal
| side note, for dense breast tissue use digital mammogram
83
40yo F p/w new onset thickening of LU and outer breast in shower -no fhx breast CA - menstruating - exam diffuse nodulatrity in both breasts and vague thickening in LU and outer quadrant - comes back mid cycle, after 3 wks thickening persists - Mammo no CA or dominant mass wtd?
US and FNA bx
84
Pt US with mixed ECHO - FNAB no malign - wtd?
excision bx ***
85
50yo Dx with breast CA - most important prognostic factor
LN (+)
86
35yo F 1.5cm mass
| Excision bx with infiltrating dutcal CA adn margins free of CA - Axillary LN neg, ER+ does not want mastiectomy wtd?
RT with adjuv chemo and tamoxifen x 10yrs
87
55yo F lump in breast - lumpectomy done reveals infiltrating adenoCA with free margins - axillary LN+ ER+ adjuvant chemotherapy followed by RT administered Tamoxifen was given for 5 yrs. She is now menopausal, wtd?
switch to aromatase inhibitors for 5 yrs.
88
59yo F painful breast - R Upper Outer quadrant breast painful, red, thickened area 7cms. no nipple d/c, no LN, warmth+ mammo no mass dx?
Inflammatory breast CA
89
Pt s/p breast CA tx with surgery, RT and chemotherapy p/w lymphedema of R arm, what is best management?
progressive resistance training
90
Tamoxifen
- decreases risk of new breast CA
- effective for tx metastatic breast CA
- works only if tumor ER & PR+
- effective in preventing cancer in high risk women
- tamoxifen has both estrogenic and anti estrogenic effects
Anti-estrogenic Effect:
- anti breast tumor effect , hence used in tx
- Menopausal symptoms (tx with venlafaxine)
Estrogenic effect:
- inc risk of endometrial CA x 3x--> screen by asking if has gyn symptoms
- inc bone density
- inc thromboembolic risk/PE***
If there is contraindication to tamoxifen, then ovarian ablation or suppression an be done.
91
35yo Pt, sister dx w/ breast CA - pt asks how to dec r/o breast Ca in her?
Tamoxifen
92
???Post menopaual F with breast Ca after surgery RT and adjuvant chemotx ER+ wtd?
???aromatoase inhib (letrozole, anastrozole, exemestane)
93
54yo F dx'd with infiltrating ductal CA LN 3/15+ .pt with breast conserving sx +RT+chemo+tamoifen - likely at risk for...?
Endometrial Ca
94
Pt with h/o breast CA. s/p chemo and started on tamoxifen 6 months ago. p/w polyuria, constipation, fatigue, lethargy, and dry mucus membrane - etio?
HyperCa
95
Pt with breast Ca and tx'ed w/ chemo and started on tamoxifen 6 yrs ago. Pt has schedule of yearly mammogram & pap smear. What else would you recommend for this pt ?
Ask for GYN symptoms every visit
96
Pt started on tamoxifen 20mg po daily. 3 years later presents w/ follow up and c/o one time vaginal bloody d/c which resolved by itself about 6 months ago. no other complaints except occasional hot flashes. no other breast mass - mammo and pap neg wtd?
Endometrial bx
97
Pregant women with breast Ca
- treat like regular pt - surgery in 2nd to 3rd trimester - chemotherapy begin in 2nd trim ****
- Male breast CA treated similar to female breast CA
- Pt treated for breast cancer. Does getting preg increase risk of breast cancer? NO
98
Long term complication aromatase inhibitors?
osteoporosis
99
Best managment hot flashes from tamoxifen or aromatase inhibitors?
venlafaxine
100
Pt p/w nipple d/c - eczematous scaly lesion at nipple - preg test neg. prolactin normal dx and tx?
Pagets disease of breast
Tx - local wide resection if no mass
Treat as breast Ca if underlying mass
101
Pt h/o breast Ca s/p lumpectomy and chemotx 5 yrs ago p/w pain in hip and lower back. xray hip 3cm lytic lesion - X ray LS spine normal. wtd?
MRI LS spine
102
What is first sx of epidural compression fracture?
Pain (NOT loss of sensation)
103
60yo F breast CA, s/p resected ER/PR+ chemo and aromatase inhib's started - current meds ACEi, BB, lasix urinating more frequently - labs normal except Ca 11.2 - next best management?
Bone scan
| THE LEADING solid tumor causing HyperCa+ is breast CA
104
65yo F dx with infiltrating ductal CA - lumpectomy with free margins, radiotx and adjuvant chemo - 6 months after RT here for f/u - exam neg for new mass or LN, no complaints - mammo neg, what you recommend for this pt?
Mammogram yearly
105
Pt s/p matectomy fo rbreast Ca with metastasis on increasing opiates for pain control - is lethargic, dec'd responsiveness - pupils non-reactive, diplopia, tongue dev to right , absent gag relex - absent left ankle reflex - urinary retention + dx?
Leptomeningeal spread
106
????Pt with metastatic breast Ca ER neg HERR (Her2neu) rct + best med ?
Trastuzumab (herceptin)
107
34yo with breast lump excised -> fibroadenoma - Grandmother with hx breast CA. How to follow up in this pt?
repeat mammo at age 50
108
65yo M on spironolactone for ascites p/w one sided breast mass. wtd?
bx
109
Endometrial Ca
| Risk factors
```
*****Risk factors:
Obestity
Early menarchy
late menopause
Nulliparity
Tamoxifen use
```
P/w post menopausal bleeding
110
Obesity associated cancer
Endometrial Ca
(Side note on other cancers:
- cervical cancer: HPV 16, 18,31
- ovarian ca- dermatomyositis
- adenocarcinoma stomach- L supraclavicular LN)
111
???Bariatric surgery comoplications
Opthalmoplegia - thiamind ef
Dark urine - no RBCs rhabdo
Tachycardia low grade fever - suture leak - gastrograffin study
Copper def - anemia, thrombocytopenia, leukopenia
112
Cervical CA
| -paper smear screening
Pap Smear:
- Screening age 21-30 every 3 years
- For women above 30 - pap smear with HPV DNA neg - pap q5yr
- Don't do HPV DNA <30 yrs, UNLESS pap smear is abnormal
- High risk (multiple sex partners, STDs HIV)--> every year
- stop pap smear screening at 65 y/o
113
HPV DNA testing
| <30 and >30y/o?
<30 yrs:
NO testing for WARTS (low risk HPV usually transient and clears in 2 years in 70%)
--> repeat pap in 1 yr
NO testing unless ASCUS +
>30yrs:
with primary pap:
If ASC-US + and HPV+ -> colposcopy ***
If ASCUS+ and HPV neg -> no colp, repeat pap 1 yr ***
If ASCUS neg and HPV + -> no colp, repeat pap and DNA in 6-1 year***
114
???High risk patient pap smears
q1yr
115
Stop PAP at age?
65yo
116
Pt with warts -
30yo With primary PAP -
If ASC-US and HPV+ -> colposcopy
If ASCUS+ and HPV neg -> no colp, repeat pap 1 yr
If ASC neg and HPV + > no colp, re;eat pap and DNA in 6-12 months
117
24yo F vaginal d/c - Pap shows clue cells and some AS-CU - ?
bacterial vaginosis
| tx: metronidazole
118
24yo F pap with AS CUS wtd?
HPV testing
119
22yo F with AS-CUS. Infected w/ HPV 16, still give vaccine?
Yes
It will help other 3 serotypes prevention
(HVP vaccine: warty 6,11....oncogenic: 16,18)
120
What pt contraindicated for HPV vacc?
preg patient
121
50yo pt with h/o fibroids - 2yrs ago fibroid size 2cm - repeat size now 3cm. no menorrhagia - best managment?
Reassess in 1 year
?????If still there 3 yers later post menopause with bleeding - bx????
122
Pt hysterectomy for severe fibroids - post hysterectomy do you need PAP?
NO
?????If uterus/cerix removed for benign reason - NO
If uterus remove for malignant CA then yes bx?????
123
Pt with lesion in endocervical canal wtd?
bx
124
PT with pap high grade SIL - colposcopic bx confirms CIN III wtd?
cryotherapy--> OR--> cone bx especially if endocervical canal involved --> OR hysterectomy
125
Pt with invasive cervical CA wtd?
hysterectomy or RT with chemotherapy
126
?????Ovarian CA
???????leading cause of GYN CA - most p/w advanced stage
General screening NOT recommended (no pelvic US, CA 125, OCP dec risk of ovarina CA)
Pelvic US of pt with dermatomyostis or strong fhx ovarian + breast Ca
CA125 used in monitoring dz
Tx: surgical staging and debulking of tumor with salpingooophroectomy, hysterectomy omentectomy -> chemo (paclitaxel)
127
Pt with abdominal distension - US shows serous semi solid 6cm. septate mass in R pelvic area. CEA elevated - wtd?
CT scan to localize tumor before laparoscopy
128
Prostate CA
| Risk factors:
```
African american X2
family history (father had it x 3, brother had it x 4)
```
PSA screening has NOT shown reduction in mortality
129
Pt wants PSA wtd?
Discuss with patient
130
????Gleason score
determines prognosis
| 7 poor prognosis
131
????Staging of prostate CA
```
A1 5% of resected tissue
B- found on needle bx after inc PSA
B1 < 1/2 one lobe
B2>1/2 on elobe
B3 both lobes invovled
Elderly - observe no sx
Yound Radiacla prostatectomy=Radiotx
```
C Capsule infiltrated - locally invasive
tx RT+hormonal (Lupron GnRH agonist)
D1 Pelvic node invovlement
Hormonal tx
D2 Distant mets, localized bone, diffuse bone
Beam RT, hormonal
132
Anti androgens compete with androgens at receptor level in testes and adrenals
Flutamide (eulexin), nilutamide (nilandron), bicaltamide(casodex)
Anti androgens block flare by LHRH agonists
133
?????60yo P with PSA elevated rectal exam unremarkable wtd?
????TRUS - trans rectal US bx
134
????60yo pt with PSA normal but rectal exam with nodule
???TRUS bx
135
?????50yo Pt on routine exam with diffusely enlarged prostate elev PSA wtd?
???TRUS bx
136
82yo M prostate CA stage A2, wtd?
observe
137
????60yo M elev PSA abnormal rectal exam - B1 on bx wtd?
radial prostatectomy OR ext beam RT
3yr later - PSA < 10 asx - wtd? - observe
If >10 then mets visible
138
????Pt comes back after prostatecomy 3 years later with elev PSA and back pain - one met lesion on vertebral spine wtd?
Bone scan
139
????Bone scan localized mets to bone wtd?
ext beam radiation to lesion
140
????One year later - after ext beam rad to spine back with bone pain bone scan diffuse mets wtd?
start GnRH agonist (Leuprolide, Goserelin - can combine with anti-androgens to block GnRH induced flares
141
?????6 months later back pain again after tx wit GnRH/antiandrogens for met prostate CA - pt tx'd with mitoxantrong and fails - continues to have pain wtd?
IV strontium 89 for palliation of pain
142
?????62yo with locally invasive prostate Ca stage C wtd?
RT + GnRH analog (hormonal)
143
S/E LHRH (leuprolide)
Short term - hot flashes
Long term - osteoporosis
Tx - Bisophosphonate - Zolendronate or alendronate
144
S/E Anti-androgens
impaired dark adaptation
| Breast tenderness
145
Pt with met prostate CA started on leuprolide - mc problem
fracture - compression fx
146
???65yo pt with prostate CA B3
radical prostatectomy
147
?????65yo pt with prostate CA stage C (capsule)
RT+hormonal tx
148
?????65yo pt with prostate CA diffuse mets
Hormonal tx
149
?????84yo pt with prostate CA stage B2
Observe (elderly)
150
Pt afib on warfarin with hematuria INR 2.2, RBC in urine 10-15/hpf, repeat UA with persistent hematuria - rectal exam enlarged proatste - CT scan, cystoscopy IVP neg - prostate bx with prostate hyperplasia but no CA . wtd to tx hematuria?
Add finasteride (proscar)
Finasteride has shown to decrease the risk of prostate cancer, however if they do get prostate cancer, it will be high grade. It is not recommended for prevention of prostate cancer.
151
????Pt fhx + prostate CA - wants to decrease risk wtd?
Finasteride
152
65yo chronic smoker - p.w painless intermittent gross hematuria with clots. dx?
Bladder CA
(side note:
high volume: PSA >1.8; alpha block + finasteride
low volume: PSA <1.8; alpha block)
153
Lower abd pain, fullness in suprapubic area - foley cath with relief of pain and drainage of urine, PSA elevatged wtd next?
repeat PSA in 4-6wks
| urinary retention from any etio can cause inc PSA,
154
???Lung CA
MCC death men/women
| 85% dx die w/in 5 years
155
Small cell lung CA (20%)
pg 158
- oat cell carcinoma
- Assume mets at dx hence . NON-resectable
- adenocarcinoma w/ increasing incidence in both smokers and non smokers
156
Non-small cell (80%)
- Squamous cell CA
- Large cell CA
- AdenoCA
- Eval for surgical resection at dx!!
- AdenoCA with inc incidence in both smoker and non-smokers
157
MC presentation of Lung CA
peristent or inc'ing cough, hemoptysis, post-obstructive pneumonitis
158
Pt p/w hemoptysis
>1wk
>40yr old and chronic tobacoo hx has 40% chance of having CA
So always evaluate pt further with these sx with CT & bronchoscopy
CXR 1st
159
???Hemoptysis in young adult dx?
Bronchitis, PNA, bronnchiectasis
160
????Hemoptysis in immigrant from south asia or S america dx?
Myobacterium Tuberculosis
161
>50yo pt successfully tx'd in hosptial for PNA with ceftriaxone and azithromycin - 3 months later cough persists - CXR with persistent density dx?
Malignancy
162
Non-small cell CA (can be resectable)
pg 159
I: Tumor >2cm from carina, node neg
II: Tumor >2cm from carina node +
treatment: surgery + chemotherapy
IIIa Tumor <2cm from carina or invading resectable structure or ipilateral hilar or mediastinal LN+
Tx: Surgery +chemo+radiotherapy
IIIb: Tumor invading unresectable structure contralateral mediastinal LN+
Tx: Chemo then radiotx, no sx
IV: Metastatic dz - Supraclavicular LN+ or pleural effusion with malignant cells+
EGFR mutations- tx: Erlotinib(Tarceva)/Gefitinib(Iressa)
Alk transloc- tx: Crizotinib (Xalkori)
PDL 1 - tx: Pembrolizumab (Keytruda), Nivolumab (Opdivo)
(Autoimmune disorders dec)
163
Small Cell CA (non-resectable)
Limited to one hemithorax: chemo + RT lung+ ***RT Brain (ppx)
Extensive dz - Chemotx + RT brain
Elderly Pt with SCC - shoudl be treated with chemotx****
164
58yo chronic smoker >30pk yr p/w hemoptysis >1wk CXR neg wtd?
CT scan + bronchoscopy
165
???42yo p/w streaky hemoptysis x 3 weeks CXR clear wtd?
Bronchoscopy
166
70yo chronic smoker >50yo p/w seizure and lethargy - CT head shows single ring enhancing lesion with edema - started on phenytoin wtd?
Start dexamethasone to dec cerebral edema
167
60yo (55-70) pt with lung CA in family wants screening - 30 pack years, quit smoking 20 yrs ago, wtd?
no screening
168
60yo pt with 30pk year smoking hx quit 5 yr ago here for regular check wtd?
low dose CT
- 55-79y/o
- 30 PY smoking
- current smoke or quit in last 15yrs
169
????70yo chornic smoker with CT CT solitary ring enhancing lesion started on phenytoin - CT lung with hilar LAD - next test?
Bronchoscopy
170
Prevent emetogenic chemotx (cisplatin)
grani (setron s) +DMS+Aprepitant (Emed) +/- olzazpine
171
Piror to aministration of chemo pt is nauseous and receives granisetron or ondansetron - still nauseous prior to chemotherapyk wtd?
xanax (alprazolam)
172
MCC Paraneoplastic syndrome
Small Cell CA
Squamous cell CA
AdenoCA
Large cell CA
173
Small cell CA **
| Paraneoplastic syndrome
```
hyponatremia 2/2 SIADH
Cushing's 2/2 inc ACTH
Carcinoid: flushing and diarrhea
Eaton lambert - power inc's with repetition
SVC syndrome
```
174
Squamous cell CA**
| Paraneoplastic syndrome
-HyperCA 2/2 PTH like substace
PTH level dec Ca inc, PO4 dec
-Horner's: Ptosis, miosis (compression of sympathetic chain), anhydrosis
-Pancoast tumor - compress 1st and 2nd throacic nerve ------>sholder pain---> pain in ulanr aspect of hand and little finger
(??- CXR pancoast tumor??)
175
AdenoCA**
| Paraneoplastic syndrome
Pulmonary osteoarthropathy - pain in hands or legs
Xray : periosteal thickening***
Marantic Endocardits w/ adenocarcinoma
176
Large cell CA**
| Paraneoplastic syndrome
SVC syndrome
| Gynecomastia
177
65yo Sq cell CA with pleural effusion which is hemorrhagic. PT 160/100, hyper Ca, FEV1 2.4L Hg 9 what prevents from being surgical candidate
hemorrhagic pleural effusion
178
What is most important prognositic factor with advance non-small cell lung CA?
Poor performance status
179
45yo post lung cancer s/p surgery and chemotx 5 years ago going for elective surgery - echo EF 35% wtd?
ACE inhibitor
| the ejection fraction of 35% is chemo induced NICM
180
Pt with pancoast tumore - whic is worst prognosis
Chest movement asymmetry (phrenic nerve involvement
181
Least likely paraneoplastic syndrome /w small cell CA
HyperCA
182
51 yo lung CA with gynecomastia inc HCG
Large cell CA
183
62yo chronic smoker pin in legs CXR with coin lesion in periphery of lungs
AdenoCA
184
55yo pt with lung CA and hyperCA
Squamous cell CA
185
55yo lung CA with wkness, gets better with repetitive movememnts - eaton lambert
Small cell lung CA
186
55yo Manual labororer heavy smoker p/w shoulder arm, medial forearm, ring, little finger pain wtd?
CXR
187
MC cancer in smoker and non-smoker
AdenoCA
188
MC cancer in non-smoker
AdenoCA
189
ACTH producting neoplastic syndrome
Small cell CA
190
Assume met at Dx
Small cell CA
191
<2% 5 year survival Lung Ca
Small cell Ca
192
Hyponatremia with lung CA
Small cell Ca
193
Squamous cell CA 2cm win in carina and ipsilar LN +
Surgical resection+ chemotherapy+ RT
194
AdenoCA >2cm from carina LN neg
Surgery + chemotherapy
195
Large cell Ca at carina nad contralat LN+
Chemo tx + RT lung
196
Small cell CA in one hemithorax
CHemotx, +RT lung+RT brain
197
Small cell Ca extensive
Chemo tx + RT brain (ppx)
198
SVC syndrome
Lung CA - NSCLC broncogenic CA most common 65%
lymphoma
thymoma
catheter induced thrombosis
sx - dyspnea (in pt w/ cancer), facial swelling, arm swelling, cyanosis, plethora, dysphagia
199
Next step managment SVC syndrome?
elev of head (dec hydrostatic prssure and edema)
| Tx definitive - radiation tx (superior to chemo)
200
Pt with metastatic lung CA and skeletal mets and osteopenia wtd?
bisophosphonates - zolendronate or pamidronate
| Pain not relieved by fentanyl patch and opiods, wtd? - strontium 89
201
Medicare guidlines when pt eligible for hospice care?
life expectancy less than 6 months
202
Testicular CA
-Seminomas -(???Better cure rate)
-Non-seminoma: embryona CA, teratoma, chorioCA,
yolksac tumor
203
Pt with testicular mass
1. approach solid testicular growth as CA until otherwise proven
2. Do a B HCG and alpha feto protein level
Testicular Ca:
- Seminomas: B HCG: increase/ N <100, **alpha feto protein: N
- Non seminomas: B HCG: very inreased, alpha feto protein: very incrased
(????Bx via high inguinal incision (don't spread CA)
if Bx + then CT chest abd pelvis to stage dz ????)
204
Hormone levels
Seminoma
B HCG inc/N (<100)
AFP normal
Non seminoma
B HCG elevated
AFP elevated
205
Treatment testicular CA
For all - first DO radical orchiectomy via high inguinal** incision then...
Stage 1 - confined to testes
Seminoma - RT
Non-seminoma - observe, remove LN
Stage II infradiaphragmeatic Node + <5cm
Seminoma - RT
Non-seminoma - Chemotx
Stage III beyond retroperitoneal LN
Seminoma - chemotx
Non-seminoma - Chemotx (NO role for RT)
206
24yo with non-seminoa tumor - B HCG and AFP elevated CT pelvis with mass - radial orchiectomy via inguinal approach done, wtd?
chemotx
| if with lung nodule - resect it, same principle for Breast Ca or colon Ca as well
207
BCG and afp elv
non-seminoma
208
AFP normal
seminoma
209
Inguinal approach for bx/orchiectomy
both: seminoma and non seminoma
210
???????Trans-scrotal bx?
????neither - never!
211
Respond to RT
seminoma
212
Don't respond to RT
Non-seminoma
213
19yo inc'd breast enlargement for 2 years no other complaints - normal external genitalia, +gynecomatia wtd?
check testosterone/estradio
- testo 450 (n), LH 0.3, FSH 0.5 and estradiol 304 (elev)
next step:
US testes ...... if normal --> CT adrenal
214
?????Young man with testicular mas and dragging sensation - nl AFP, nl HCG) wtd?
?????High inguinal orchiectomy
215
Lymphoma
```
-Hodgkin's lymphoma:
B cells Reed sternberg +
...in order of Best prognosis to worst:
Lymphoyctic predominance
Nodular sclerosis
Mixed cellularity
Lymphocyte depletion (worse prognosis)
```
Non-hodgkin's lymphoma B cells 90%, T cells 10%
216
Lymphoma presentation
```
lymph node enlargement with contiguous spread +/- paracrine effects:
Fever,
peripheral granulocytosis
eosinophilia with pruritis
Personality changes
**** +reed sternerg cells (owl eyes)
```
Dx: hodgkin's disease
217
Hodgkin's dz tx
varying cyles of ABVD (doxorubicin, bleomycin, vinblastine dacarazine) +/-RT
If pts Relapse/poor response --> high dose chemo followd by autologous hematopoetic stem cell transplant
218
Complications after hodgkins' tx
```
Chemotherapy:
cardiomyopathy
AML
Myelodysplastic syndrome
infertility, amenorrhea
```
Radiation tx:
constrictive pericarditis (??sqrt sign??)
accelerated CAD despite age
solid tumores (breast, lung, thyroid)
Hypotheyorid
radiation pneumonitis
*MC cause of secondary malignancies
219
38yo ho hodgkins txed with rad tx 10ya p./w chest pain while shoveling snow x 30 min
Accelerated CAD
220
40yo egyptian man h/o hodgkins tx with mantel RT to chest 10 yrs ago with palptiations wt loss JVD+, ascites, pedal edema+ , echo with thickened pericardium
constrictive pericarditis
221
42yo s/p hodgkin's dz tx'd with chemo >7yr ago p/w easy bruising & fatigue, Hb 9, Platelets 50,000. Blood smear with anisocytosis, pelger huet anamoly (hyposegmented PMNs) .BM dysplasia of marrow precursor and hypercellularity
myelodysplasia (MDS)
222
35yo with hodgkins 10ya s/p mantle radiation now with fatigue wtd?
Check TSH
| Prone to Lung, breast, and thyroid CA
223
30yo undergoes chemo for hodgkins 10 ya ago - more likely complication?
increased incidence of AML
???r/o AML (topoisomerase inhib)???
224
Non-Hodgkin's lymphoma
- hematoglogic spread****
- Dx: excision of LN not aspiration****, Site : supraclavicular
- If relapse, repeat aggresive chemotx and Stem cell transplant**
??????clonal proliferation of cell features of lymphoid cells
>60K/yr inc'ding indcidence
90% B cells, 10% T cells
40% - diffuse large cell ymphoma (BCL 6)
30% follicular lymphoma (t 14:18)
Stageing by ann arbor and CT/PET chest, abd pelvis
Tx base on staging and presence of poor prognositc factors
Tx: chemo with RCHOP or CVP
Relapse - aggressive chemo and stem cell tx??????
225
Poor prognostic factors NHL
```
age >60 yrs
serum LDH
performance status <70
Ann arbor staging III or IV
Hb<12
```
226
NHL grading
1)Low grade lymophoma
-Follicular: small lymphocytes
-Tx INdolent->local Rt
aggressive transform--> R-CHOP/CVP
2) Intermediate grade lymphoma
- follicular w/ large or small cell, diffuse, mixed
- tx CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone)
3) High grade lymophoma
- large cell immunoblastic small non cleaved cell
- Tx: CHOP +/ -rituximab, NO RT--> stem cell tx
227
Post renal transplant lymphomas
EBV associated lymphoma
228
CNS lymphoma/burkitts/nasopharyngeal CA
EBV
229
MALT
h pylori
230
Kaposi's sarcoma
HHV-8 -
| ?? danorubicin???
231
Ca Cervix/Anal Ca
HPV 16, 18,31
232
T cell leukemia
HTLV-1
233
65yo Pt w/ asx cervical LAD - LN bx reveals follicular small cell lymophoma, preserved architecture - Bone marrow findings are postive, wtd?
local RT
234
?????Pt with abdominal mass, wt loss, fever, bulky retroperitoneal LN - bx mass shows large cell lymophoma tx??????
???????CHOP + rituximab
If failus chemo
Stem cell tx
235
Pt post renal tx - 2 years later with ataxia - CT head shows ring enhancing lesion in cerebellum dx?
EBV
??? = cause for lymphoma s/p tx???
236
Pt with well differentiated lymphoma (CLL) p/w fatigue, weakness, cbc hg 9.5, retic 5% smear with spherocytes, polychormasia best tes?
Coombs test r/o warm autoimmune hemoytic anema
| Tx --> steroids--> Rituximab --> Tx underlying dz
237
Pt with large hilar LAD dx as small cell Ca, p/w SOB - exam with massive pleural eff wtd?
tap effusion
If patient comes back couple of months later with recurrent effusion , wtd?
Thoracoscopy w/ talc poudrage
238
Pt with lymphoma dx 2 years ago, but not require tx at the time p/w sob, cxr with effsuion. wtd next and what is the best management?
Tap the pleural effusion
best management?
Same for NSCLC or breast cancer
239
What can you expect one month after two infusions of Rituximab? (s/e?)
lymphopenia
| side note: hypogammaglobulinemia- CLL, CVID
240
Multiple Myeloma
- Lytic lesions, bone pain, hyperCa, serum&urine protein 'M' spike
- Marrow cytosis >10%**
- Plastma cells
- ->osteoclasts->punched out bone lesions->hyper Ca
- ->Immuoglobulin(faulty IgG)->'M' spike in serum and urine->renal failure
- >roleaux formation of RBCs
- >inc'd ESR
- >platelet dsyfxn
- >infections
(anion gap low, Kappy> Lambda chains)
Tx:
No end organ daamge (RF, lytic lesion or anemia absent)
-monitor
Evience of damage
->lenalidomide/ Melphalan (Alkeran)/prednisone
Relapse - do not do induction with melphalan
tx with bortezomib (velcade)/hematopoietic stem cell transplant
Prior to bortezombi, what ppx? acyclovir (zovirax) for herpes zoster ppx
241
PPX prior to bortezomib?
acyclovi (zovirax) for Herpes zoster ppx
242
MM (multiple myeloma)
protien >3.5
Lytice lesions
marrow plasmacytoma >10%
+ hyper Ca+
243
MGUS (monoclonal gammopthy of unknown significance)
protein <3.5
no lytic lesions
marrow plasmacytoma <10%
no hyper Ca+
244
????????Smoldering MM???????
??????no hyperCa+
>10% plasmacytoma
+lytic lesions???????????
245
T/F Hypercalemia with MM
T
246
T/F MM w/ inc'd protein?
T
247
T/F MM w/ renal dysfxn?
T
248
T/F MM w/ Plt dysfxn?
T
249
T/F MM w/ bone pain?
T
250
T/F MM- infections?
T
251
T/F MM -amyloidosis?
T
252
T/F MM -Dilation of retinal veins?
T
253
Hypervicosity caused by all of the following
Waldenstroms macroglobulinemia-> ??tx plasmphoresis??
PC Vera-> ??tx splenomegaly - phelebotomy/low dose ASA??
Leukemia - ??leukapheresis??
254
65yo Pt with protein 8gm glboulin 3.1 serum protein electrophor with inc'd IgG - best way to diff MM vs MGUS
radiographic skeletal survey
| +lytic lesions in MM
255
Pt dx with MGUS (plasma cells <10% in bone marrow bx, radiological skeletal survey is normal, ca is normal) - wtd?
f/u 6 months r/o MM
256
Pt with plasma cells >10% in BM, skeletal survey normal, Ca normal - no end organ damage (Cr normal, Hb normal, no lytic lesions) - pt dx with smolerding (asymptomatic) MM - wtd?
f/u myeloma protein q2 months
257
60yo M h/a blurred vision, LAD fatigue Gh 9, lethargic, dec'd power on one side, total protein 8gm globulin 3, Ca 9 - serum protein electroprhoesis IgM>2g, inc'd ESR dx?
Waldenstroms's macroglobulinemia
-caused by IgM (largest immunoglobulin) ->remains intravascular-> hyperviscosity syndrome
-No lytic lesions
-No hyperCa+
-BM: 'phlascytoid lymophocytes'
Tx: plasmapheresis, fludarabine (Fludara) based chemotherapy
258
Tumor of pancreas
Pancreatic CA
Glucoagonoma
Gastrnoma
VIPoma
259
Elderly man with h/o chronic smoking >40pk yr p/w wt loss, fagigue anorexia painelss jaundice +/- diarrhea . painless palpable gall bladder (courvoisier's sign) - best dx test?
CT Scan pancreas r/o pancreatic CA
--> mainly head of pancreas -> double duct sign+ (??bile and common duct enlarged??)
Tx: Pancreatic Ca with no mets -> surgery (pancreaticduoenectomy)
can invovle minimal invasion (<50%)of protal or mesenteric vein
260
If pt refuses surgery for pancreatic CA wtd?
Gemcitabine + nab-paclitaxel chemotherapy
| Pancreatic Ca with mets -> palliative tx with stent placement and Gemcitabine (Gemzar) +nab-Pacitaxel
261
Pt with stage IV pancreatic CA and sever itching wtd?
Biliary stent
262
46yo F no h/o pancreatitis with 3.8cm mass head of pancreas seen on CT wtd?
Surgical excision
| - if mass not clearly defined or borderline resctable on CT then the best test is endoscopic US
263
What is more commonly a/w pancreatic CA - tob or etoh?
smoking...
264
Diabetics ar prone to what kind of cancer - breast, colon or pancreatic?
pancreatic CA
265
Pt with familial adenomatous polyposis prone to what kind of cancer?
Ampulla of vater cancer
266
Pt with persistent hyperglycemia, wt loss anemia - exam with scaly necrotizing dermatitis - glucagon injection does not increase glucose level
glucagonoma - plasma glucagon >1000
267
Pt with profuse watery diarrhea not responding to fasting, h/o wt loss, serum K 3.3, hypochlorhydria . serum VIP level inc'd. stool osmolar gap low
Dx: VIPoma
Tx: octreotide
268
Courvoisier's sign
Pancreatic CA
269
Trousseau's syndrome( migratory thrombophlebitis)
Pancreastic CA
Also seen in adenocarcinoma of stomach- L SC LN +
Renal cell CA- L bag of worms senssation in L testes
270
Double duct sign
Pancreatic CA
271
Sentinel loop sign (small bowel ileus)
Acute pancreatitis
272
Pt with diarrhea h/o flushing sensation, exam with telangiectasia wtd next, and what is dx?
Check 5HIAA
| dx? Carcinoid
273
Hepatocellular CA- best survelliance
liver US ever 6 months
274
Pt w/ cirrhosis has an US done which shows 0.8 cm lesion, wtd?
....pt 6 months later the size is 1.2 cm...wtd?
...0.8 cm lesion: Repeat US in 3 months
...6 months later when size is 1.2 cm: three phase CT scan
275
What agent inc's survival with hepatocellular CA
Sorafenib (Nexavar)
276
Thyroid CA
Parafollicular
Medullary carcinoma
-Calitonin increased, RET proto-oncogene (R/O pheo)
-dense calcification in tumor
-assoc with MEN II&III (check fhx)
-Tx: total thyroidectomy (???follow calcitonin levels after surgery????)
277
Follicular
| Papillary CA
Cervical LN, pitted CAlcification (MC wit best prognosis), BRAF +
278
Follicular CA
mass and distant mts. RAS+
279
????Anaplastic CA?????
with mass - elderly with worst prognosis
280
Best managment for papillary and follcular CA after surgery
Radioiodine ablation; f/u w/ thyroglobulin levels
| It will NOT work for medullary CA as radioiodine not take up by C cells
281
Medullary CA recurrence
check Calcitonin level
| CT scan neck and chest
282
Papillary CA recurrence
Check Thyroglobulin level
283
Follicular CA recurrence
Check Thyroglobulin level
284
Axillary LN
| DIAGRAM on page 176!!!!
breast CA
285
Occipital LN
| DIAGRAM on page 176!!!!
scalp infxn
286
```
Supraclavicular LN (R)
DIAGRAM on page 176!!!!
```
esophaeal lung or mediastinal malignancy
287
L Supraclavicular LN
| DIAGRAM on page 176!!!! please look at the diagram there are more nodes
Abdominal malignancy
288
Cancer of Unknown Origin
MC - adenoCA
then poorly diff
then Others
289
Presentation CA unknown origin
40% LN, Cervical supraclavicular>Mediastinal>axillary
30% Liver, lung, bone
20% of pts primary CA will be identified
Expected mean survival time 6 months
290
AdenoCA in females with axillary LN
pursue breast CA diagnosis
Do mammogram +- MRI, ER/PR receptors
Tx mastectomy +/- radiation +/- chemo
291
AdenoCA in females with bony invovlement
Pursue breast CA diagnosis**
292
AdenoCA in males with bony invovlement
Pursue prostate CA**
| Ask for urinary sx, do PSA and rectal exam
293
Poorly diff CA in young males
Pursue germ cell tumor
DO alpha feto protein & B HCG
Platinum based chemo if +
294
Squamous cell CA
presentation with cervial LN +, -> pursue head/neck CA
| present w/ lower Cervical LN +, -> pursue Lung CA
295
MCC CA of unknown origin
AdenoCA
296
MC place of presentation of CA unknown origin
Lymph node
297
Femaile with axillary LN+ most likely CA type
AdenoCA
298
Carcinoma of unknown origin in young male
Undiff cell CA
299
Head/neck CA
Squamous cell CA
300
50yo M smoker, single submandibular LN+ found to be undiff CA - Phy exam head/neck neg, CXR neg wtd?
Upper pan endoscopy
301
Which screenings DO NOT decrease mortality
PSA
| Mmamo, pap, fecal occult, sigmoidoscopy DO decrease mortality
302
Pt with metastatic CA with persisent pain - takes oxycodone with tylenol prn and morphine sulfate twice a day wtd?
Extended release oxycodone or morphine q8-12hr continuously
303
S/E Methotrexate (Trexall)
Reversible pneumonitis, hepatic fibrosis
304
S/E 5FU (efudex)
Myocardial ischemia, myelosuppression
305
S/E Vincristine (oncovin)
Neuropathy, SIADH
306
S/E Doxorubici (Doxil), Trastuzumab (herceptin)
Cardiomyopathy
307
S/E Bleomycin (Blenoxane)
| also w/ Rituximab
interstitial fibrosi
308
S/e Mitomycin (Mutamycin)
HUS, blue green urine
309
S/e cyclophosphamide (Cytonxan)
hemorrhagic cystitis, bladder CA
310
S/e Bicalutamide (Casodex)
gynecomastia, pulm fibrosis, impaired dark adaptation
311
s/e paclitaxel (Abraxane)
Neuropathy, bradycardia
312
s/e gemcitabine (Gemzar)
anal pruritis, HUS, flu rash
313
s/e tamoxifen (Nolvadex)
hot flashes, thromboemboli, endometrial CA
314
LHRH agonists (Lupron, Zoladex) s/e
impotence, transient cancer flare, osteoporosis
315
s/e hyroxyurea (Hydrea)
dec'd wbc, myelosuppression
316
Cisplatin (platinol) s/e
| double check this one on page 179!
nephrotoxic, ototoxic, neuropathy
317
s/e etoposide (etophophos)
| double check this one on page 179!
myelosupp, hypotension, weakness, alopecia
318
S/e IL-2
capillary leak syndrome, erythema
319
S/E IFN alpha
Flu like sx, LFT inc, arthalgias, hypo/hyperthyroidism
320
One 1st deg relative after age 60, when to screen for colon CA?
50 y/o, FIT q 1 yr + sigmoidoscopy q 10yrs or colonoscopy at 50y/o and q 10 yrs.
321
colonoscopy negative with improper bowel prep, wtd?
repeat w/ proper prep
322
Adjuvant therapy for Node (-) disease >1cms -->
chemotx plus endocrine therapy
323
HERR-2 (+) -->
| pg 148
trastuzumab
324
tamoxifen, aromatase inh. =
Pg 148
endocrine therapy
325
Pt had hysterectomy for Ca cervix. Post hysterectomy do you need to do a pap smear?
yes
326
Pt discusses about PSA test. You explain that if pt is diagnosed w/ prostate Ca and treated
small benefit and significant harm: urinary incontinence, erectile dysfunction and bowel dysfunction
327
Pt post radical prostatectomy followed by decreased PSA levels. 3 yrs later, PSA <10. Pt is asymptomatic. wtd?
observe
328
Pt w/ metastatic prostate CA to bone refractory to LHRH agonists and anti androgens. Decrease mortality, decreased pain w/ ?
radium 223
329
65 y/o low dose CT scan lung is positive. What will you inform patient?
there are more false positives than true positives
330
How to diagnose hepatocellular carcinoma?
imaging studies
331
What is 1st line treatment for hepatocellular carcinoma?
resection or transplant
332
base of neck, by SCM lymph node
| DIAGRAM on page 176!!!! there are moreeeeee
TB lymphoma
333
Lemier's
IJV thrombosis
| under sternocleidomastoid cord like
334
PD1, PDL 1, CTLA
| S.E?
Rash, vitiligo, worsening of auto immune diseases
