Cancers

Question 1

Squamous cell lung cancer

Answer 1

PTH-like hormone secretion
Hypertrophic pulmonary osteoarthropathy-long bone pain

Cavitation on CXR

Treatment: surgery and radiation (sugery does not work with metastases)

Question 2

Adenocarcinoma of the lung

Answer 2

Hypertrophic pulmonary osteoarthorpathy-long bone pain

Peripheral-pleural involvement

Associated with pulmonary scars/fibrosis

Question 3

Diagnosing Lung Cancer

Answer 3

Obtain: CXR, CT scan, tissue biopsy (determines histologic type)
Always perform a biopsy for intrathoracic lymphadenopathy (specificity is 60%)

CXR-not screening-most important
Stability of an abnormality over a 2 year period is benign

CT scan of chest-useful for staging
Local and distant metastases
nodules less than 1 cm or low probability of being malignant

Cytologic examination of sputum
Central tumors-may still need further tests

PET-distant metastases
nodules greater than 1 cm

Broncoscopy-central tumors
malignancy suspicion intermediate
Risk of surgery is high

Needle biopsy-can also do peripheraal lesions
Invasive-only selected patients
malignancy suspicion intermediate
Risk of surgery is high

resection-malignancy suspicion is high

mediastinoscopy-advanced disease

Question 4

Small Cell lung Cancer

Answer 4

SIADH
Ectopic ACTH
Eaton Lambert syndrome

Treatment: Chemo plus radiation
If extensive: just chemo with prophylactic radation

Question 5

Treatment of CRC

Answer 5

Surgery is only curative treatment

CEA level obtained before surgery-check every 3-6 months

Annual CT scan of abdomen/pelvis and CXR for up to 5 years
Colonscopy at year 1 and every 3 years after that

Question 6

Hepatocellular adenoma

Answer 6

History of contraceptie use, female sex, and anabolic steroid use

Can lead to hemoperinoteum and hemorrhage
Little malignant potential

Diagnosis: CT scan, ultrasound, or hepatic arteriography (most accurate but invasive)

Treatment: discontinue oral contraceptives
Surgically resect tumors >5 cm that do not regress after discontinuing oral contraceptives

Question 7

Cavernous hemagioma

Answer 7

Most common type of benign liver tumor

Symptoms: RUQ pain or mass

Complications: hemorrhage, obstructive jaundice, coagulopathy, CHF secondary to AV shunt, gastric outlet obstruction

Diagnose: ultrasound or CT scan with IV contrast
Biopsy contraindicated due to risk of rupture

Most do not require treatment

Question 8

Focal nodular hyperplasia

Answer 8

Tumor (no malignant potential) in women of reproductive age

No association with oral contraceptives

Hepatomegaly may be present

Treatment is not necessary

Question 9

Hepatocellular carcinoma

Answer 9

Two types:
Nonfibrolamellar-hep B/C and cirrhosis—poor prognosis
Fibrolamellar-adolescents

Risks: cirrhosis, aflatoxin, vinyl chlroide, thorotrast, AAT deficiency, hemochromo, wilsons, schisto, hepatic adenoma, cigarette, glycogen storage disease

Clinical: abdominal pain (hepatomegaly), portal HTN, ascites, jaundice, splenomegaly
Paraneoplastic: erythrocytosis, thrombocytosis, hypercalcemia, carcinoid, hypertrophic pulmonary osteodystrophy, hypoglycemia, high cholesterol

Diagnosis: liver biopsy-definitive diagnosis
Labs: hepatitis panel, LFTs, coagulation tests
Ultrasound, CT scan (abdomen chest and pelvis), MRI and MRA for surgery
AFP elevation-mointoring response to therapy

Treatment: liver resection
Liver transplantation

Question 10

Carcinoma of gallbladder

Answer 10

adenocarcinomas
Associated with gallstones

Surgery: cholecystectomy (can be with wedge resection of liver and lymph node dissection)

Low prognosis

Question 11

Cholangriocarcinoma

Answer 11

Tumor of intrahepatic or extrahepatic bile ducts
Most are adenocarcinomas

Poor prognosis

Risk: primary sclerosis cholangitis
Ulcerative colitis, choledochal cysts, and Clornochis sinensis

Diagnosis: Cholangioraphy (PTC or ERCP)
Stent can be placed to relieve biliary obstruction

Question 12

Choledochal cysts

Answer 12

Cystic dilatations of biliary tree

Complications: cholangiocarcinoma, hepaic absces, rucurrent cholangitis/pancreatitis, biliary obstruction, cirrhosis, portal HTN

Diagnosis: ultrasound, ERCP is definitive

Treatment: surgery

Question 13

Pancreatic cancer

Answer 13

Risks: cigarette smoking, chronic pancreatitis, diabetes, heavy alcohol use, benzidine, and b-napthylamine

Prognosis is poor

Migratory thrombophelbtis, courvoisiers sign (palpable gallbladder)

Diagnosis:
ERCP most sensitive
CT preferred
Markers: CA 19-9, CEA

Treatment: whipple procdure only hope for cure
ERCP or PTC with stent placement across the obstruction for palliation

Question 14

Esophageal Cancer

Answer 14

Squamous cell risks: alcohol and tobacco use, nitrosamines, betel nuts, hot food/tea, HPV, achalasia, Plummer Vinson, caustic ingestion, and nasopharyngeal carcinoma

Adenocarcinoma risks: GERD and Barrett’s esophagus

Prognosis is poor

Diagnosis: Barium swallow: evaluation of dysphagia
Upper endoscopy with biopsy and brush cytology is definitive diagnosis
Transesophageal ultrasound determines depth of tumor
Full metastatic workup: bone scan, CT scan, CXR

Treatment: palliation
Esophagectomy curative if not spread to local nodes
Chemotherapy plus radiation before surgery have been shown to prolong survival

Question 15

Gastric Cancer

Answer 15

Adenocarcinomas

Risks: atrophic gastritis, H. pylori, pernicious anemia, blood type A, high intake of perserved foods/smoked fish

diagnosis: endoscopy with multiple biopsies can complement with barium sereis
Abdominal CT scan for metastases
Fecal occult blood test

Treatment: surgical resection with wide (5cm) margins with extended lymph node dissection
Chemotherapy may be appropriate

Question 16

Thyroid solitary nodule

Answer 16

Detection on physical exam=>1 cm in diameter

Malignancy: nodule is fixed during swallowing, unusually firm, irregularity of nodule, solitary nodule, history of radiation therapy, history of rapid development, vocal cord paralysis, cervical adenopathy, elevated calcitonin, family history

Diagnosis: fine needle aspiration is initial evaluation (reliable except follicular)
FNA benign=observation and repeat FNA
FNA malignant: surgery

Thyroid scan: with indeterminate FNA or low TSH
Cold=decreased uptake of radionucletide iodine
warm=normal
Hot= increased uptake

Cold=surgery
Hot=close observation and periodic thyroid studies

US: differentiates solid from cystic (solid=malignant)
larger than 4 cm are not malignant

Question 17

Papillary thyroid cancer

Answer 17

Risk: history of radiation to head/neck in childhood

Cervical lymphadenopathy

Positive iodine uptake

Treatment: lobectomy with isthmusectomy
Total thyroidectomy if tumor is >3 cm, bilateral, advanced or distant metastases are present
TSH suppression therapy
Radioiodine therapy for larger tumors

Question 18

Follicular carcinoma of thyroid

Answer 18

Avidly absorbs iodine

Can have distant metastases

Associated with iodine defieciency

Tumor extension through the tumor capsule-diagnose via tissue sample

Hurthle cell carcinoma subset: abundant cytoplasm, tightly packed mitochondria, oval nuclei with prominent nucloli-radioiodine resistant

Treatment: total thyroidectomy with postoperative iodine ablation

Question 19

Medullary carcinoma of thyroid

Answer 19

Associated with MEN II (screen for pheochromocytoma)

Arises from parafollicular C cells-produces calcitonin

Treatment: total thyroidectomy,
Modified radical neck dissection when lymph node involvement

Question 20

Anaplastic carcinoma of thyroid

Answer 20

Elderly

Highly malignant

Arises from long standing follicular or papillary thyroid carcinoma

Grim prognosis due to invasion of adjacent organs

Treatment: chemotherapy and radiation
Pallliative care

Question 21

Craniopharyngioma

Answer 21

Tumors of suprasellar region arising from embryologic remnants of Rathke’s pouch

Pituitary adenoma is most common

Bitemporal hemianopsia may be present
Headaches, papilledema and changes in mentation
hyperprolactinemia,, diabetes insipidus, panhypopituitarism

Diagnosis: brain MRI

Treatment: surgical excision with our without radiation therapy

Question 22

Insulinomas

Answer 22

Associated with MEN I

Clinical: sympathetic activation: diaphoresis, palpitations, tremors, high BP, anxiety
Neuroglycopenic symptoms: HA, visual disturbances, confusion, seizures, coma

Diagnosis: 72 hour fast
patient becomes hypoglycemic (normal patients insulin will decrease) insulin levels will be too high
C peptide also elevated

Treatment: surgical resection

Question 23

Zollinger-Ellison syndrome

Answer 23

High gastrin secreting tumor in pancreatic islet cells

Associated with MEN I

Complications: GI hemorrhage, GI perforation, gastric outleet/obstruction/stricture, metastatic disease (liver)

Clinical: peptic ulcers, diarrhea, weight loss, abdominal pain

Diagnosis: secretin injection (normally inhibits gastrin) gastrin will increase after secretin
Gastrin >1000

Treatment: PPIs
expoloration for possible curative resection

Question 24

Glucagnoma

Answer 24

Clinical: necrotizing migatory erythema, glossitis, stomatitis, diabetes, and hyperglycemia
Low amino acid levels and high glucagon

Treatment: surgery

Question 25

Somatostatinoma

Answer 25

Poor progonosis

Clinical: gallstones diabetes and steatorrhea

Question 26

VIPoma

Answer 26

Clinical: watery diarrhea-dehydration, hypokalemia, acidosis
achlorhydria
Hyperglycemia and hypercalcemia

Treatment: surgery

Question 27

Treatment and risks of prostate cancer

Answer 27

Risks: age (most important), african american, high fat diet, positive family history, exposure to herbicides and pesticides

Prostectomy if life expectancy more than 10 years
locally invasive: radiation therapy plus androgen deprivation

Metastatic disease: reduce testosterone
Orchiectomy, antiandrogens, leuprolide, GnRH antagonists (Degarelix)

Question 28

Renal Cell carcinoma

Answer 28

Risks: cigarettes, phenacetin analgesics, ADKD, chronic dialysis, exposure to heavy met, hypertension

paraneoplastic syndromes: EPO, PTH like hormone, renin, cortisol, or gonadotropins

Diagnosis: renal ultrasound
Abdominal CT if ultrasound shows mass

Treatment: radical nephrectomy (kidney, adrenal, gertoas fascia and nodal tissue along renal hilum)

Question 29

Bladder Cancer

Answer 29

Risks: cigarette smoking (major), aniline dyes, azo dyes, long term cyclophosphamide

Diagnosis: urinalysis and urine culture to rule out infection
Urine cytology-to detect malignant cells
IVP
Cystoscopy and biopsy (definitive test)
Chest radiograph and CT for staging

Treatment: Stage 0: not invasion-intravesical chemo
Stage A: lamina propria invasion-transuretrhal resection of bladder tumor-recurs so frequent cystoscopy
stage B (muscle invasion) and C (perivescular fat invasion): radical cystecomy and removal of prostate/ureterus/ovaries/anterior vagina and urinary diversion
Stage D: metastasis-radical cystecomy and systemic chemo

Question 30

testicular cancer diagnosis and treatment

Answer 30

Diagnosis: testicular mass on physical exam
Testicular ultrasound initial test
B-HCG high in choriocarcinoma
AFP increased in embryonal tumors
CT scan and chest radiograph for staging

Treatment: remove surgically
Perform CT scan of chest, abdomen and pelvis for staging
perform HCG and AFP for comparison

Seminoma: also radiation
non seminoma: retroperitoneal lymph node dissection with or without chemo