hem/onc Flashcards
Surveillance for cervical cancer
- H&P q3 months for first 2 years, then q6 months for years 2-5
(most recurrences are symptomatic. There’s no indication that routine imaging with CT or US results in better outcomes than clinical monitoring)
Management of locally advanced anal cancer
Combined chemoradiotherapy (often curable, avoiding surgery)
Management of pt with DLBCL and residual mass that has responded well to chemo
- observation with serial CT scanning (probably represents scar tissue rather than viable tumor. Also – bulky lymphoma masses often don’t show complete resolution by CT)
Duration of increased risk for infection after HSCT
6-12 months after (compromised function of neutrophils and lymphocytes)
GVHD occurs in which transplant type
Allo NOT auto’s
Management of a rapidly enlarging lymph node in patient with history of follicular lymphoma
- biopsy (rule out transformation. Transformation to DLBCL occurs in 30% of patients with follicular lymphoma)
Indication for olaparib in ovarian cancer
- patients with germline BRCA-mutated advanced ovarian cancer previously treated with 3 or more lines of chemo
To watch out for with weight based lovenox dose
DON”T exceed max dose for obese patients
Warfarin reversal in patients experiencing severe bleeding or requiring urgent surgery
Four-factor PCC + vitamin K
Potential adverse effect of 4-factor PCC
VTE
What to think when sickle cell patient presents with isolated anemia
Parvovirus (preferentially affects erythrocyte precursors in the bone marrow, causing transient pure red cell aplasia)
When vitamin k deficient patients see improvement in coagulopathy following vitamin k administration
Within 1 day
Management of metastatic hormone receptor-positive, HER2-negative breast cancer
anti-estrogen therapy + palbociclib
Management of MDS requiring frequent transfusions
Lenalidomide
What are the goals of MDS treatment
- Relieve transfusion dependence
- Prevent transformation to AML
Caveats to know about using hypomethylaging agents for MDS
- both azacitidine and decitabine worsen blood counts initially
- may take up to 6 months to show an effect
When essential thrombocythemia needs to be treated
1) Patients older than 60
2) VTE
Treatment of essential thrombocythemia
Aspirin + hydroxyurea
Most significant complications of ET
1) Thrombosis (arterial more common than venous)
2) Hemorrhage
3) Progression to myelofibrosis
4) Transformation to acute leukemia
Drugs that are frequently the cause of drug-induced hemolytic anemia
Antibiotics (CTX commonly) (Thought that ceftriaxone may become affixed to the erythrocyte membrane, leading to an immune reaction resulting in erythrocyte hemolysis)
Positive direct antiglobulin test indicates
Autoimmune hemolysis
Spherocytes on peripheral blood smear indicate
- Hereditary spherocytosis
- *Autoimmune hemolysis
G6PD heme effect
Acute hemolysis
G6PD inheritance and clinical relevance
- x-linked recessive (thus it is uncommon in women)
What is cold agglutinin disease?
- autoimmune hemolytic anemia that is positive for C3
- read
Cold agglutinin disease triggers
- lymphoproliferative disorders
- Mycoplasma pneumonia
- EBV
When to NEVER perform hereditary thrombophilia evaluation
- Never in acute setting (during VTE diagnosis)
- Never while on anticoagulant therapy (delay at least 2 weeks after discontinuation of anticoagulant therapy)
- (except for testing for genetic mutations)
Indications for hereditary thrombophilia evaluation
- VTE in unusual sites
- recurrent idiopathic thrombosis
- patients younger than 45 with unprovoked VTE
- clear family history of VTE
- patients with warfarin-induced skin necrosis
Kidney sequelae of TLS
Uric acid nephropathy
Rasburicase efficacy
- rapid onset
- can rapidly lower urate levels
Pre-operative management of anemia
- Iron studies (anemia predicts perioperative blood transfusion requirements)
(should be treated with oral iron prior to surgery and source needs to be determined and corrected before surgery)
Term for DVT associated with acute limb ischemia
Massive DVT
Management of suspected pseudothrombocytopenia
Repeat platelet count in a heparinized blood specimen
Cause of psuedothrombocytopenia
Antibodies directed against the anticoagulant ethylenemdiaminetetraaacetic acid
Management of lobular carcinoma in situ
Chemoprophylaxis with antiestrogens (tamoxifen or raloxifen or AI)
Problem with severe autoimmune hemolytic anemia
- autoantibody typically reacts against all erythrocytes so a completely crossmatch-compatible unit may be impossible to find
Blood transfusion in autoimmune hemolytic anemia
Transfuse crossmatch-incompatible blood (The autoantibody typically reacts against all erythrocytes so a completely crossmatch-compatible unit may be impossible to find, even O negative)
Workup of patient presenting with mucocutaneous bleeding (epistaxis, gum bleeding) and normal CBC
Platelet Function Analyzer-100 to evaluate for acquired platelet dysfunction
Fibrinogen deficiency is typically seen in
1) DIC
2) Liver disease
Hemoglobin electrophoresis in SCD
- Pretty much all HbS (Greater than 90% HbS)
- no HbA
How to test for hereditary thrombophilia in someone on lifelong AC
- Temporarily stop AC and test 2 weeks later
* Never test in acute setting or while pt is on AC
Alpha-thalassemia trait on hemoglobin electrophoresis
- normal electrophoresis pattern (electrophoresis isn’t a measure of quantity, it’s of hemoglobin function – with trait there is inadequate production but hemoglobin A is otherwise normal and thus will migrate in a normal pattern)
Alpha-thalassemia trait lab features
- chronic microcytic anemia
- Hgb around 10
Management of thalassemia in general
- supplemental folate
- NO iron (they have increased ability to absorb iron, which can lead to iron overload)
Radiation in general for NSCLC
- adjuvant used after surgery with negative margins
- combined CRT is used as primary treatment for stage III with mediastinal involvement because these patients typically don’t fare well with surgery
Transferrin saturation threshold for HH screening
45%
RILI is
Radiation-induced lung injury
2 main types of RILI
Radiation pneumonitis + radiation fibrosis
Incidence of RILI depends
- area radiated
- technique (SBRT less likely, proton beam therapy)
- concurrent chemo (several chemo drugs are known sensitizers to radiotherapy)
Difference in presentation between acute radiation pneumonitis and fibrotic radiation pnumonities
- acute radiation pneumonitis = 4-12 weeks following irradiation
- symptoms of late or fibrotic radiation pneumonitis = 6-12 months after
Presentation of radiation pneumonitis
nonproductive cough + dyspnea + fever + chest pain
Physical exam for radiation pneumonitis
Can hear crackles + skin erythema
Next step after suspected radiation pneumonitis
- CT chest (compare to pretreatment CT images prior to radiation)
Treatment of RILI
- supportive care for fibrosis
- some experts recommend oral steroids for subacute
Indications for irradiated RBCs
1) BMT recipients
2) Acquired or congenital
cellular immunodeficiency
3) blood components donated by first or second degree relatives
Indications for leukoreduced blood products
- chronically transfused patients
- CMV seronegative at risk patients (AIDS, transplant recipients)
- potential transplant recipients
- previous febrile non hemolytic transfusion reaction
Indications for washed blood products
- IgA deficiency
- Complement-dependent autoimmune hemolytic anemia
Why you need to wash PRBC’s prior to giving to IgA deficient patient
When RBCs and plasma are separated from whole blood, small amounts of residual plasma remain in the RBC concentrate, which includes IgA. Washing removes as much plasma as possible.
Management of ED in patient with contraindication to PDE inhibitor
intraurethral alprostadil OR vacuum assist device
Major contraindication to PDE inhibitors (sildenafil) for ED
Nitrates
primary myelofibrosis clinical features
- MASSIVE hepatomegaly + splenomegaly (extra medullary hematopoiesis can also cause hepatomegaly)
- hallmark of PMF
CBC in primary myelofibrosis
- initial leukocytosis (greater than 30K) followed by leukopenia (due to marrow proliferation but then marrow becomes anemic/leukopenic as fibrosis replaces the marrow)
- initial thrombocytosis, followed by thrombocytopenia
primary myelofibrosis pathophys
- chronic myeloproliferative disorder characterized by an overproduction of megakaryocytes and bone marrow stroll cells, which release fibrosis-promoting cytokines into the marrow
Management of patient with high pretest for DVT but negative US
Repeat US within 24 hours (false negatives are rare but can happen)
Management of xerostomia (dry mouth) following radiation for head and neck cancer
- DC meds that can worsen xerostomia (anticholinergics and antidepressants)
- nonpharmacologic interventions (saline rinses, water-soluble mouth lubricants, regular dental care, frequent chewing of sugarless gum)
- cholinergic medications (pilocarpine, cevimeline) (stimulate salivary muscarinic receptors and increase saliva production
Presentation of severe xerostomia
oral pain, dental carries, oral infections, dysphagia, anorexia
How to monitor direct thrombin inhibitor
Thrombin time
Management of patient needing urgent surgery who’s on a direct thrombin inhibitor
Check thrombin time:
IF normal –> proceed directly to surgery
IF elevated –> idarucizimab if life-threatening bleeding or requiring urgent or emergency surgery
Initial step in workup of polycythemia
Differentiate primary (low epo) from secondary (normal or elevated epo) with Epo
Differential for secondary polycythemia
1) Hypoxemia (OSA, high altitude, cardiopulmonary disease)
2) EPO-producing tumors
3) congenital (high-affinity hemoglobin)
4) Following renal transplantation
5) androgen supplementation
Polycythemia definition
Hemoglobin greater than 16 in women and 16.5 in men
Presentation of sickle cell trait + potential complications
Just: usually asymptomatic but can have complications:
- hematuria (infarction of renal medullary blood vessels)
- splenic infarction from strenuous exercise or exposure to hypoxic conditions
- Renal medullary carcinoma
- Increased UTI
- VTE
- Priapism
splenic infarction presentation
- acute onset LUQ pain + nausea, vomiting
Management of prostate nodule + why
BIOPSY (REGARDLESS OF PSA)
*A significant number of men with prostate cancer have PSA values less than 4.0 and a small but significant percentage have values less than 2.0
indications for prostate biopsy
- nodule
- rising PSA level (usually over 4) OR rate of change
diagnosis of ABPA
- skin testing for aspergillus
strongest RF for critical illness myopathy
- use of IV steroids
critical illness myopathy presentation
- flaccid quadriparesis
- difficulty weaning from mechanical ventilation
- can have decreased reflexes
- can have myopathy with loss of myosin on muscle biopsy
critical illness myopathy treatment
- stop or reduce steroids ASAP
- PT
other common cause of weakness in ventilated patients in ICU
- prolonged neuromuscular blockade from prolonged paralytics
Management of acute chest syndrome
Mild (no significant desaturation) = simple transfusion
Moderate (desatting but not less than 85%) = simple transfusion
Severe (desatting below 85% or 2 lobes involved) = exchange transfusion
GVHD presentation
- maculopapular rash (that often becomes generalized)
- RUQ abdominal pain
- hepatomegaly
- LFT abnormalities
- profuse watery diarrhea
Other type of GVHD aside from HSCT-associated GVHD
ta-GVHD (transfusion-associated)
Difference in presentation from GVHD and ta-GVHD
- ta-GVHD causes bone marrow destruction leading to progressive pancytopenia
- treatment is typically ineffective and most cases are fatal
How to prevent ta-GVHD
- transfuse irradiated blood products to patients at risk (this inactivates donor lymphocytes prior to transfusion)
presentation of CMV from transfusion
- typically mono-like like syndrome (fever, maculopapular rash, LFT abnormalities, systemic symptoms)
Major long-term complications of PV
- myelofibrosis (“post-PV myelofibrosis”) and AML
Presentation of marginal-zone lymphoma
Splenomegaly + lymphocytosis + cytopenias
