2018 Medical Oncology 6% Flashcards
Colon CA
Risk factors
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
Decrease risk colon CA:
ASA >20yrs
Celecoxib & sulindac–> decrease load of polyps in colon
estrogens
colon cancer usually arises from adenomas
hyperplastic polyp has no malignant potential!
Familial Adenomatous polyposis
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????]
Gardner syndrome
- 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???]
HNPCC (lynch syndrome)???
3 relatives with Cancer related to HNPCC one 1st deg 2 generations 1 extracolon CA FAP excluded
Adenoma Colonoscopy screening????
Hyperplastic polyp - q10yr
Adenoma < 1cm x1 - q5-10yr
Adenoma <1cm 3 Q3yr
Villous adenoma - regardless of size q3yr
Colon CA screening ???
1st deg relative colon CA age 10
colonoscopy standard time (age 50 then q10yr
Two 1st deg relatives colon CA
colonscopy now then q5yr
Peutz-Jeghar’s syndrome
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????}
HNPCC (hereditary non-poyposis colon CA) or Lynch syndrome
-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
50yo F with HNPCC had colon CA done - adenomatous polyps - wtd?
TV US
??for uterine CA (extracolonic CA)???
55yo M asx for routine checkup - t neg (FIT) - signmoidoscopy => polyp
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
???55yo asx M routine checkup - sigmoidoscopy - neg - FIT +
Full colonoscopy
Elderly male or postmenopausal female with unexplained Iron deficiency anemia - wtd?
Colonoscopy
Elderly pt with hematochezia, h/o hemorrohids wtd?
Colonoscopy
Pt on routine health maintenance exam FIT 1 out of 6 cards + occult blood - pt takes high doses of vit C, wtd?
Colonoscopy
55yo F screening colonoscopy done - 2 polyps removed - both hyperplastic - when next colonoscopy
10 years
Pt with 2 adenomas <1cm removed when repeat colonscopy?
colonoscopy q5-10yrs
Pt with 1 tubular adenoma 1cm - next colonoscopy?
3 years
Pt 1 tubular adenoma 2.5 cm next colonoscopy?
3 years
Pt with 3-10 tubular aenoma <1cm next colonoscopy
3 years
Pt with 1 villous adenoma <1cm next colonscopy
3 years
Pt with obstructive colon CA with colonic resection wtd?
Full colonoscopy to r.o other concomitant lesions
Pre-op colonscopy with no other lesions
colonoscopy 1 yr then 3 years then q5yrs
measure CEA q3 to 6 mo for 2 years then q 1yr x 5 years
Best dx test r/o colon CA?
Colonoscopy with bx. Best risk reduction in left colon.
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???]
12y/o , Familial Adenomatous Polyposis (FAP)
Sigmoidoscopy q1-2 yrs starting at age 12
colonoscopy @ 16 y/o
HNPCC
start colonoscopy 25yr or 10 years younger than youngest affected relative with HNPCC - then q2yr up to age 40 then q1yr
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
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.
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
Post colonic resection for Colon CA
Colonoscopy 1 yr after resection then 3 yrs then q5yrs
UC, Crohns’s dz
Colonoscopy 8yrs after dx then q1-2 yr
35yo asx - father with colon CA @ age 45yo
Colonoscopy now then q5yrs
40yo asx father colon CA age 60, brother age 52
Colonoscopy now then q5yr
35yo asx, father colon CA age 65
FIT+Sigmoidoscopy q 10yr or colonoscopy q10yr starting at age 50
25yo asx - family h/o HNPCC
Colonoscopy now then q2yr up to age 40 then q1yr
Pt with UC dx recently
Colonoscopy 8yrs later and then q2yr
Pt with Colon Ca Duke B underwent resection of colon
Colonoscopy in 1 yr then in 3 yrs then q5yr
50yo asx - neg fxhx colon CA
FIT + sigmoidoscopy q10 yrs or colonoscopy q10yr starting at age 50
Young pt with h/o familial adenomatous polyposis
Colonoscopy age 16yo
40yo asx father colon CA after age 55
Colonoscopy now then q5yr
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)
What does tamsulosin cause?
Floppy iris syndrome!
d/c tamsulosin
Acute afib chemical cardioversion
ibutelide
Colon Cancer Duke A/ I
tx - resection
mucosa layer
[????90% survival - thru submucosa but not past muscularis????]
Colon Cancer Duke IIA
tx - resection
submucosa layer
????90% survival thru muscularis but not past serosa (no LN)????
Colon Cancer Duke B IIB
tx resection
muscularis layer
????60-80% survival - thru muscularis into serosa not into LN????
Colon Cancer Duke B IIC
tx : resection
serosa layer
???60-80% survival - thru serosa and involving LN???
Colon Cancer Duke C/ III
Tx: resection +5FU + leucovorin+oxaliplatin (folfox)
Lymph nodes
???7% survival - Widespread metastasis (liver)???
When to resect soitary liver metastasis
If have pursued curative intent in past**
Pt with colon CA undergoes hemicolectomy - histopathology with infiltartion of musularis , LN(-), wtd?
Observe
Pt with colon CA infiltrating serosa & pericolic structures (visceral peritoneum). After hemicoloectomy, wtd?
Chemotx (5FU + leucovorin + Oxaliplatin)
Pt with colon CA not infiltrating sera but 4/10 LN invovled - after hemicolectomy wtd?
Chemotx (5FU +leucovorin + oxaliplatin)
Pt with stage B2 rectal CA - local resectio done - wtd?
Chemotx + RT
Anal Ca - cancer of anal margin how to treat?
Local resection
Cancer of anal canal muscosa wtd?
external beam radiation tx + 5FU + leukovorin
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
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.
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.
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 +
Lobular CA in situ
observation or if ER+ -> tamoxifen (???pre)/aromatase (post menopause???)
Infiltrating ductal CA, LN neg
wide exceision of mass w/ free margins + RT
Adjuvant chemo for size >1cm
Tamoxifen/aromatase inh if ER receptor +
Infiltrating ductal CA, LN + pos
[wide excisition + RT = modified radical mastectomy] + adjuvant chemo + tamoxifen /aromatase inh if ER receptor +
Locally invasive dz involving skin or chest wall
chemotx followed by mastectomy + tamoxifen/aromatose inh if ER receptor+
Most important prognostic factor in breast CA?
LN invovlement>tumor size>receptor+>grade
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
Adjuvant therapy for LN neg dz >0.5 cms
premenopausal - ER+ tamoxifen + HERR-2 += trastuzumab
Post menopausal - ER+ aromatase inhib + HERR-2 + trastuzumab
???When to use chemo tx in breast CA
????Tumor size>1cm, high grade
if <1cm NO CHEMOtx
Types of breast CA
Intraductal 80%
Lobular 10%
Other 10%
Excision of mass with free margin +RT =
Modifeid radiacla mastectomy + RT
If sentinel LN bx +
Further LN dissection
If sentinel LN bx neg
no further LN dissection
If LN +
Adjuvant tx : Chemotherapy +/- tamoxifen (pre menopausal), aromatose inh (post menopausal)
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
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
65yo F fhx breast CA mother 67yo - most important risk factor for her to acquire breast cancer?
Her age
Highest risk fo rbreast CA
early menarch, late 1st preg, late menopause, strong fhx no deodorant
Pt with breast CA, 1st deg relative of breast and ovarian CA dx?
BRCA 1 mutation
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 **
50yo F regular checkup - best way to screen for breast CA?
clinical breast exam and mammogram every 2 yrs
How to screen for breast Ca in woman with breast implants
mammogram
Mammogram best in woman who is…
post menopausal
side note, for dense breast tissue use digital mammogram
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
Pt US with mixed ECHO - FNAB no malign - wtd?
excision bx ***
50yo Dx with breast CA - most important prognostic factor
LN (+)
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
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.
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
Pt s/p breast CA tx with surgery, RT and chemotherapy p/w lymphedema of R arm, what is best management?
progressive resistance training
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.
35yo Pt, sister dx w/ breast CA - pt asks how to dec r/o breast Ca in her?
Tamoxifen
???Post menopaual F with breast Ca after surgery RT and adjuvant chemotx ER+ wtd?
???aromatoase inhib (letrozole, anastrozole, exemestane)
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
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
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
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
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
Long term complication aromatase inhibitors?
osteoporosis
Best managment hot flashes from tamoxifen or aromatase inhibitors?
venlafaxine
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
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
What is first sx of epidural compression fracture?
Pain (NOT loss of sensation)
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
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
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
????Pt with metastatic breast Ca ER neg HERR (Her2neu) rct + best med ?
Trastuzumab (herceptin)
34yo with breast lump excised -> fibroadenoma - Grandmother with hx breast CA. How to follow up in this pt?
repeat mammo at age 50
65yo M on spironolactone for ascites p/w one sided breast mass. wtd?
bx
Endometrial Ca
Risk factors
*****Risk factors: Obestity Early menarchy late menopause Nulliparity Tamoxifen use
P/w post menopausal bleeding
Obesity associated cancer
Endometrial Ca
(Side note on other cancers:
- cervical cancer: HPV 16, 18,31
- ovarian ca- dermatomyositis
- adenocarcinoma stomach- L supraclavicular LN)
???Bariatric surgery comoplications
Opthalmoplegia - thiamind ef
Dark urine - no RBCs rhabdo
Tachycardia low grade fever - suture leak - gastrograffin study
Copper def - anemia, thrombocytopenia, leukopenia
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
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
???High risk patient pap smears
q1yr
Stop PAP at age?
65yo
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
24yo F vaginal d/c - Pap shows clue cells and some AS-CU - ?
bacterial vaginosis
tx: metronidazole
24yo F pap with AS CUS wtd?
HPV testing
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)
What pt contraindicated for HPV vacc?
preg patient
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????
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?????
Pt with lesion in endocervical canal wtd?
bx
PT with pap high grade SIL - colposcopic bx confirms CIN III wtd?
cryotherapy–> OR–> cone bx especially if endocervical canal involved –> OR hysterectomy
Pt with invasive cervical CA wtd?
hysterectomy or RT with chemotherapy
?????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)
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
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
Pt wants PSA wtd?
Discuss with patient
????Gleason score
determines prognosis
7 poor prognosis
????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
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
?????60yo P with PSA elevated rectal exam unremarkable wtd?
????TRUS - trans rectal US bx
????60yo pt with PSA normal but rectal exam with nodule
???TRUS bx
?????50yo Pt on routine exam with diffusely enlarged prostate elev PSA wtd?
???TRUS bx
82yo M prostate CA stage A2, wtd?
observe
????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
????Pt comes back after prostatecomy 3 years later with elev PSA and back pain - one met lesion on vertebral spine wtd?
Bone scan
????Bone scan localized mets to bone wtd?
ext beam radiation to lesion
????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
?????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
?????62yo with locally invasive prostate Ca stage C wtd?
RT + GnRH analog (hormonal)
S/E LHRH (leuprolide)
Short term - hot flashes
Long term - osteoporosis
Tx - Bisophosphonate - Zolendronate or alendronate
S/E Anti-androgens
impaired dark adaptation
Breast tenderness
Pt with met prostate CA started on leuprolide - mc problem
fracture - compression fx
???65yo pt with prostate CA B3
radical prostatectomy
?????65yo pt with prostate CA stage C (capsule)
RT+hormonal tx
?????65yo pt with prostate CA diffuse mets
Hormonal tx
?????84yo pt with prostate CA stage B2
Observe (elderly)
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.
????Pt fhx + prostate CA - wants to decrease risk wtd?
Finasteride
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)
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,
???Lung CA
MCC death men/women
85% dx die w/in 5 years
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
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
MC presentation of Lung CA
peristent or inc’ing cough, hemoptysis, post-obstructive pneumonitis
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
???Hemoptysis in young adult dx?
Bronchitis, PNA, bronnchiectasis
????Hemoptysis in immigrant from south asia or S america dx?
Myobacterium Tuberculosis
> 50yo pt successfully tx’d in hosptial for PNA with ceftriaxone and azithromycin - 3 months later cough persists - CXR with persistent density dx?
Malignancy
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)
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**
58yo chronic smoker >30pk yr p/w hemoptysis >1wk CXR neg wtd?
CT scan + bronchoscopy
???42yo p/w streaky hemoptysis x 3 weeks CXR clear wtd?
Bronchoscopy
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
60yo (55-70) pt with lung CA in family wants screening - 30 pack years, quit smoking 20 yrs ago, wtd?
no screening
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
????70yo chornic smoker with CT CT solitary ring enhancing lesion started on phenytoin - CT lung with hilar LAD - next test?
Bronchoscopy
Prevent emetogenic chemotx (cisplatin)
grani (setron s) +DMS+Aprepitant (Emed) +/- olzazpine
Piror to aministration of chemo pt is nauseous and receives granisetron or ondansetron - still nauseous prior to chemotherapyk wtd?
xanax (alprazolam)
MCC Paraneoplastic syndrome
Small Cell CA
Squamous cell CA
AdenoCA
Large cell CA
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
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??)
AdenoCA**
Paraneoplastic syndrome
Pulmonary osteoarthropathy - pain in hands or legs
Xray : periosteal thickening***
Marantic Endocardits w/ adenocarcinoma
Large cell CA**
Paraneoplastic syndrome
SVC syndrome
Gynecomastia
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
What is most important prognositic factor with advance non-small cell lung CA?
Poor performance status
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
Pt with pancoast tumore - whic is worst prognosis
Chest movement asymmetry (phrenic nerve involvement
Least likely paraneoplastic syndrome /w small cell CA
HyperCA
51 yo lung CA with gynecomastia inc HCG
Large cell CA
62yo chronic smoker pin in legs CXR with coin lesion in periphery of lungs
AdenoCA
55yo pt with lung CA and hyperCA
Squamous cell CA
55yo lung CA with wkness, gets better with repetitive movememnts - eaton lambert
Small cell lung CA
55yo Manual labororer heavy smoker p/w shoulder arm, medial forearm, ring, little finger pain wtd?
CXR
MC cancer in smoker and non-smoker
AdenoCA
MC cancer in non-smoker
AdenoCA
ACTH producting neoplastic syndrome
Small cell CA
Assume met at Dx
Small cell CA
<2% 5 year survival Lung Ca
Small cell Ca
Hyponatremia with lung CA
Small cell Ca
Squamous cell CA 2cm win in carina and ipsilar LN +
Surgical resection+ chemotherapy+ RT
AdenoCA >2cm from carina LN neg
Surgery + chemotherapy
Large cell Ca at carina nad contralat LN+
Chemo tx + RT lung
Small cell CA in one hemithorax
CHemotx, +RT lung+RT brain
Small cell Ca extensive
Chemo tx + RT brain (ppx)
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
Next step managment SVC syndrome?
elev of head (dec hydrostatic prssure and edema)
Tx definitive - radiation tx (superior to chemo)
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
Medicare guidlines when pt eligible for hospice care?
life expectancy less than 6 months
Testicular CA
-Seminomas -(???Better cure rate)
-Non-seminoma: embryona CA, teratoma, chorioCA,
yolksac tumor
Pt with testicular mass
- approach solid testicular growth as CA until otherwise proven
- 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 ????)
Hormone levels
Seminoma
B HCG inc/N (<100)
AFP normal
Non seminoma
B HCG elevated
AFP elevated
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)
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
BCG and afp elv
non-seminoma
AFP normal
seminoma
Inguinal approach for bx/orchiectomy
both: seminoma and non seminoma
???????Trans-scrotal bx?
????neither - never!
Respond to RT
seminoma
Don’t respond to RT
Non-seminoma
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
?????Young man with testicular mas and dragging sensation - nl AFP, nl HCG) wtd?
?????High inguinal orchiectomy
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%
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
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
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
38yo ho hodgkins txed with rad tx 10ya p./w chest pain while shoveling snow x 30 min
Accelerated CAD
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
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)
35yo with hodgkins 10ya s/p mantle radiation now with fatigue wtd?
Check TSH
Prone to Lung, breast, and thyroid CA
30yo undergoes chemo for hodgkins 10 ya ago - more likely complication?
increased incidence of AML
???r/o AML (topoisomerase inhib)???
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??????
Poor prognostic factors NHL
age >60 yrs serum LDH performance status <70 Ann arbor staging III or IV Hb<12
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
Post renal transplant lymphomas
EBV associated lymphoma
CNS lymphoma/burkitts/nasopharyngeal CA
EBV
MALT
h pylori
Kaposi’s sarcoma
HHV-8 -
?? danorubicin???
Ca Cervix/Anal Ca
HPV 16, 18,31
T cell leukemia
HTLV-1
65yo Pt w/ asx cervical LAD - LN bx reveals follicular small cell lymophoma, preserved architecture - Bone marrow findings are postive, wtd?
local RT
?????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
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???
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
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
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
What can you expect one month after two infusions of Rituximab? (s/e?)
lymphopenia
side note: hypogammaglobulinemia- CLL, CVID
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
PPX prior to bortezomib?
acyclovi (zovirax) for Herpes zoster ppx
MM (multiple myeloma)
protien >3.5
Lytice lesions
marrow plasmacytoma >10%
+ hyper Ca+
MGUS (monoclonal gammopthy of unknown significance)
protein <3.5
no lytic lesions
marrow plasmacytoma <10%
no hyper Ca+
????????Smoldering MM???????
??????no hyperCa+
>10% plasmacytoma
+lytic lesions???????????
T/F Hypercalemia with MM
T
T/F MM w/ inc’d protein?
T
T/F MM w/ renal dysfxn?
T
T/F MM w/ Plt dysfxn?
T
T/F MM w/ bone pain?
T
T/F MM- infections?
T
T/F MM -amyloidosis?
T
T/F MM -Dilation of retinal veins?
T
Hypervicosity caused by all of the following
Waldenstroms macroglobulinemia-> ??tx plasmphoresis??
PC Vera-> ??tx splenomegaly - phelebotomy/low dose ASA??
Leukemia - ??leukapheresis??
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
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
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
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
Tumor of pancreas
Pancreatic CA
Glucoagonoma
Gastrnoma
VIPoma
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
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
Pt with stage IV pancreatic CA and sever itching wtd?
Biliary stent
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
What is more commonly a/w pancreatic CA - tob or etoh?
smoking…
Diabetics ar prone to what kind of cancer - breast, colon or pancreatic?
pancreatic CA
Pt with familial adenomatous polyposis prone to what kind of cancer?
Ampulla of vater cancer
Pt with persistent hyperglycemia, wt loss anemia - exam with scaly necrotizing dermatitis - glucagon injection does not increase glucose level
glucagonoma - plasma glucagon >1000
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
Courvoisier’s sign
Pancreatic CA
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
Double duct sign
Pancreatic CA
Sentinel loop sign (small bowel ileus)
Acute pancreatitis
Pt with diarrhea h/o flushing sensation, exam with telangiectasia wtd next, and what is dx?
Check 5HIAA
dx? Carcinoid
Hepatocellular CA- best survelliance
liver US ever 6 months
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
What agent inc’s survival with hepatocellular CA
Sorafenib (Nexavar)
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????)
Follicular
Papillary CA
Cervical LN, pitted CAlcification (MC wit best prognosis), BRAF +
Follicular CA
mass and distant mts. RAS+
????Anaplastic CA?????
with mass - elderly with worst prognosis
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
Medullary CA recurrence
check Calcitonin level
CT scan neck and chest
Papillary CA recurrence
Check Thyroglobulin level
Follicular CA recurrence
Check Thyroglobulin level
Axillary LN
DIAGRAM on page 176!!!!
breast CA
Occipital LN
DIAGRAM on page 176!!!!
scalp infxn
Supraclavicular LN (R) DIAGRAM on page 176!!!!
esophaeal lung or mediastinal malignancy
L Supraclavicular LN
DIAGRAM on page 176!!!! please look at the diagram there are more nodes
Abdominal malignancy
Cancer of Unknown Origin
MC - adenoCA
then poorly diff
then Others
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
AdenoCA in females with axillary LN
pursue breast CA diagnosis
Do mammogram +- MRI, ER/PR receptors
Tx mastectomy +/- radiation +/- chemo
AdenoCA in females with bony invovlement
Pursue breast CA diagnosis**
AdenoCA in males with bony invovlement
Pursue prostate CA**
Ask for urinary sx, do PSA and rectal exam
Poorly diff CA in young males
Pursue germ cell tumor
DO alpha feto protein & B HCG
Platinum based chemo if +
Squamous cell CA
presentation with cervial LN +, -> pursue head/neck CA
present w/ lower Cervical LN +, -> pursue Lung CA
MCC CA of unknown origin
AdenoCA
MC place of presentation of CA unknown origin
Lymph node
Femaile with axillary LN+ most likely CA type
AdenoCA
Carcinoma of unknown origin in young male
Undiff cell CA
Head/neck CA
Squamous cell CA
50yo M smoker, single submandibular LN+ found to be undiff CA - Phy exam head/neck neg, CXR neg wtd?
Upper pan endoscopy
Which screenings DO NOT decrease mortality
PSA
Mmamo, pap, fecal occult, sigmoidoscopy DO decrease mortality
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
S/E Methotrexate (Trexall)
Reversible pneumonitis, hepatic fibrosis
S/E 5FU (efudex)
Myocardial ischemia, myelosuppression
S/E Vincristine (oncovin)
Neuropathy, SIADH
S/E Doxorubici (Doxil), Trastuzumab (herceptin)
Cardiomyopathy
S/E Bleomycin (Blenoxane)
also w/ Rituximab
interstitial fibrosi
S/e Mitomycin (Mutamycin)
HUS, blue green urine
S/e cyclophosphamide (Cytonxan)
hemorrhagic cystitis, bladder CA
S/e Bicalutamide (Casodex)
gynecomastia, pulm fibrosis, impaired dark adaptation
s/e paclitaxel (Abraxane)
Neuropathy, bradycardia
s/e gemcitabine (Gemzar)
anal pruritis, HUS, flu rash
s/e tamoxifen (Nolvadex)
hot flashes, thromboemboli, endometrial CA
LHRH agonists (Lupron, Zoladex) s/e
impotence, transient cancer flare, osteoporosis
s/e hyroxyurea (Hydrea)
dec’d wbc, myelosuppression
Cisplatin (platinol) s/e
double check this one on page 179!
nephrotoxic, ototoxic, neuropathy
s/e etoposide (etophophos)
double check this one on page 179!
myelosupp, hypotension, weakness, alopecia
S/e IL-2
capillary leak syndrome, erythema
S/E IFN alpha
Flu like sx, LFT inc, arthalgias, hypo/hyperthyroidism
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.
colonoscopy negative with improper bowel prep, wtd?
repeat w/ proper prep
Adjuvant therapy for Node (-) disease >1cms –>
chemotx plus endocrine therapy
HERR-2 (+) –>
pg 148
trastuzumab
tamoxifen, aromatase inh. =
Pg 148
endocrine therapy
Pt had hysterectomy for Ca cervix. Post hysterectomy do you need to do a pap smear?
yes
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
Pt post radical prostatectomy followed by decreased PSA levels. 3 yrs later, PSA <10. Pt is asymptomatic. wtd?
observe
Pt w/ metastatic prostate CA to bone refractory to LHRH agonists and anti androgens. Decrease mortality, decreased pain w/ ?
radium 223
65 y/o low dose CT scan lung is positive. What will you inform patient?
there are more false positives than true positives
How to diagnose hepatocellular carcinoma?
imaging studies
What is 1st line treatment for hepatocellular carcinoma?
resection or transplant
base of neck, by SCM lymph node
DIAGRAM on page 176!!!! there are moreeeeee
TB lymphoma
Lemier’s
IJV thrombosis
under sternocleidomastoid cord like
PD1, PDL 1, CTLA
S.E?
Rash, vitiligo, worsening of auto immune diseases
