hem/onc 2 Flashcards
Risk factors for thyroid cancer
- hx of radiation exposure
- Family hx of thyroid cancer
- subclinical hypothyroidism (elevated TSH)
- iodine deficiency
- *smoking and drinking have not been shown to increase risk for thyroid cancer and may actually be protective
- multiple nodules is not associated with increased risk
US findings of thyroid nodules that increases risk for malignancy
- size greater than 1 cm
- hypo echoic echotexture
- microcalcifications
- increased vascularity
- length greater than width
- infiltrative margins
physical exam features of malignant thyroid nodules
- rapid growth, firm, fixed
Clinical features of acute radiation pneumonitis + physical exam
- antibiotic-nonresponsive + appears like pneumonia (fever + cough + pleuritic heat pain + leukocytosis)
- exam = crackles and/or pleural rub
acute radiation pneumonitis radiographic features
- straight line effect (affected lung tissue is usually confined to the radiation treatment area and may form a distinct boundary with adjacent normal parenchyma)
treatment of acute radiation pneumonitis
prednisone for 2 weeks with a gradual taper
Cause of cancer-induced brachial plexopathy
- typically from direct invasion of breast or apical lung cancer or radiation injury
Presentation of cancer-induced brachial plexopathy
- severe pain at symptom onset
- weakness
+/- Horner syndrome
complex regional pain syndrome presentation
- throbbing pain + skin temperature changes + paresthesias
Physiologic cause of AKI in TLS
calcium-phosphate precipitation in renal tubules
Other sequela in TLS
- arrhythmias
- seizures
- sudden cardiac death
Criteria for diagnosis of TLS
2 or more of any of the following:
- uric acid 8 or higher
- K of 6.0 or higher
- phos of 4.5 or higher
- calcium of 7 or lower
- or 25% increase from baseline value
management of INR greater than 10 without bleeding
hold warfarin + administer 2.5-5 mg of oral vitamin K
management of INR 4.5-10
- hold warfarin + resume when INR is therapeutic
TRALI clinical features
within 6 hours of transfusion + acute onset dyspnea-hypoxemia + diffuse pulmonary infiltrates within 6 hours of a transfusion
TRALI pathophys
- not just transfusion of a patient with underlying heart failure
- it is likely due anti-leukocyte antibodies from donor’s plasma reacting with antigens on recipients leukocytes to intimate an inflammatory response within the pulmonary microvasculature
TRALI clinical course
Patients typically improve rapidly and most are extubated within 2 days
Management of TRALI
- supportive care
- no further plasma-containing blood products from the donor
Derm SE to know about with small molecule TKIs (imatinib, sorafenib, sunitinib)
- hand-foot skin reaction (HFSR): focal, tender lesions and hands and feet that appear as blisters in areas of friction or trauma
Management of hand-foot skin reaction (HFSR) from small molecule TKIs
- supportive care
- typically don’t need to discontinue treatment
Common association of Sweet’s syndrome
Heme malignancies
Is it possible to have myeloma without an M-spike or gamma gap?
YES – non-secretory myeloma
Next step of patient with CRAB symptoms with negative M spike and no gamma gap
urine immunofixation (need to rule out elevated protein in urine) to call it non-secretory and urine immunofixation further increases he sensitivity of identifying light or heavy chains
When DVT patients need to be admitted
- Significant RF’s for complications
- High bleeding risk
- Abnormal kidney function
- Hemodynamically unstable
- Unreliable social environment for administration of anticoagulation
- Large clot burden (iliofemoral DVT)
When is it safe to ambulate following DVT?
As soon as anticoagulant reaches therapeutic level (early ambulation has been shown to reduce complications)
Lab features of aplastic crisis
- 0% reticulocyte count
- profound anemia
What is hyper hemolytic crisis?
- sudden worsening of anemia with reticulocytosis that can present after acute sickling events (eg painful crisis, acute chest syndrome)
SE to know of with hydroxyurea
- myelosuppression (leukopenia or neutropenia)
VTE treatment of choice in pregnant patients + duration
- subcutaneous LMWH
- continue at least 6 weeks postpartum
- Xa inhibitors cross the placenta + there is inadequate information about their safety
- Unfractionated heparin can also be used for bridging during pregnancy
Etiology in stem of lymphadenopathy not resolving fully with abx
lymphoid lineage neoplasm
Initial step in evaluation of prolonged PT or PTT
mixing study
Urinary incontinence etiology + management following radical prostatectomy
- damaged urinary sphincter
- pelvic floor exercises with biofeedback
Patient subsets for which NOACs are not recommended
1) renal failure (CrClearance less than 30)
2) valvular heart disease
3) pregnant patients
First line treatment of VTE in patients with brain mets
LMWH
cancer types with brain mets that tend to bleed
melanoma, choriocarcinoma, thyroid carcinoma or RCC
Waldenstrom clinical features
- HSM + peripheral neuropathy + hyper viscosity syndrome (blurred vision, headache, vertigo)
- engorged retinal veins
Waldenstrom lab features
- elevated ESR
- Rouleaux formation
- elevated gamma gap
Labs in vWF
- typically prolonged PTT (but can be normal in some patients)
Screening tests for vWF
- plasma vWF antigen
- plasma vWF activity
- FVIII activity
what is a normal ferritin?
20-200
Clinical features of carcinoid syndrome
- episodic flushing
- diarrhea
- bronchospasm, dyspnea
- cardiac lesions (tricuspid regurgitation)
- cutaneous telangiectasis
Other trigger for TTP
- pregnancy (due to autoantibody formation or emergence of a previously undiagnosed hereditary case)
ADAMTS13 level in TTP
decreased
Features of anemia in TTP
- hemolytic (increased LDH, low haptoglobin)
- MAHA
General treatment of locally advanced rectal cancer + why
Neoadjuvant concurrent CRT (down-stage primary tumor + higher rates of sphincter preservation (which is important because it obviates the need for a permanent colostomy) + local control)
Enteropathy-associated T cell lymphoma clinical setting + behavior
- aggressive
- commonly seen in celiac patients with poor dietary compliance
Diagnosis of paraneoplastic cerebellar degeneration
paraneoplastic antibodies (anti-Yo, anti-Hu) (but low sensitivity)
initial step in fertility preservation prior to chemo
Referral to reproductive endocrinologist
NOACs and CKD
- Typically not used in GFR below 30 because of insufficient data in severe kidney disease
weighing risk and benefits of anticoagulating patients with AF and elevated bleeding risk
Studies show that there’s typically a positive net clinical benefit of chronic anticoagulation in patients with AF
Medical term for Pancoast tumor
Superior pulmonary sulcus tumor
Pancoast tumor presentation
- shoulder pain
- Horner syndrome
- paresthesias in 4th or 5th digits
(TUmor arises in apical groove next to subclavian vessels thus presents with shoulder pain due to brachial plexus invasion)
First step in workup of suspected pan coast tumor
CXR
Horner syndrome clinical features
- ipsilateral ptosis
- miosis
- enophthalmos
- anhidrosis
labs in vitamin K deficiency
- prolonged PT + PTT (with PT being more significantly prolonged)
- factor VII is initially low, and II, IX, and X may later become low
malignant cancer seen almost exclusively in young patients with sickle cell trait
- renal medullary carcinoma
Other lab feature commonly seen in IDA
Thrombocytosis
Patients who need bridging anticoagulation (generally speaking)
- high risk thromboembolic conditions + **high bleeding risk procedures
(low risk procedures like tooth extraction, cataract surgery, skin biopsy, you can just continue warfarin)
Most common cause of thrombocytopenia in pregnancy
Gestational thrombocytopenia
Management of gestational thrombocytopenia
- benign, no workup
Type 1 HIT mechanism
- non-immune
- heparin-induced platelet clumping
- not clinically significant
Type 1 HIT presentation
- mild thrombocytopenia within first 48 hours of starting heparin exposure
- platelet count usually greater than 100k
Type 2 HIT mechanism
- immune mediated
- antibodies directed against heparin-platelet factor 4 (PF4) complexes)
Types of HIT
- Type 1, Type 2, delayed-onset HIT
Type 2 HIT presentation
- mild or moderate thrombocytopenia with or without arterial, venous thrombus
- 5-10 days after heparin initiation OR within 1 day if prior heparin exposure within last 30 days
- platelet count greater than 20K
Delayed-onset HIT mechanism
- immune mediated due to high-titer antibodies against heparin-PF4 complexes in the absence of circulating heparin
Delayed-onset HIT presentation
- thrombocytopenia 5-19 days after heparin cessation
cardio toxicity features of anthracyclins
- dose dependent (related to cumulative dose)
- reversible
Chemo associated with increased risk of secondary malignancy in Hodgkins
alkylating agents
When secondary malignancies tend to occur after Hodgkin’s treatment
5-10 years
Other pulmonary toxicity of bleomycin
- organizing pneumonia
- hypersensitivity pneumonitis
(in addition to pulmonary fibrosis)
Medication approved to decrease severity of cardiomyopathy associated with anthracyclines in patients who have received a cumulative dose of 300 and who will continue to receive anthracyclines + caveat
- dexrazoxane (EDTA-like chelator)
- not recommended for use in patients who are initiating treatment because it lowers response to chemotherapy
primary toxicities of cisplatin
- nephrotoxic
- ototoxic
- peripheral neuropathy
primary toxicities of cyclophosphamide
- hemorrhagic cystitis
- bladder cancer
- gonadal toxicity
primary toxicity of 5-FU
- severe diarrhea
primary toxicity of EGFR inhibitors
- skin rash
Interpretation of scoring of 4 T’s score
3 points or less = low probability
4 = intermediate probability
Management of SCD patient with CVA (how to prevent recurrent stroke) + goal
- Scheduled simple transfusions every month
- maintain Hb S levels of less than 30%
Goal of exchange transfusion in acute SCD CVA management
- rapidly reduce Hb S levels
CLL presentation
- lymphadenopathy (most commonly – cervical, axillary, supraclavicular) (50-90%)
- splenomegaly (25-50%)
- hepatomegaly
Labs in CLL
- neutropenia, anemia, thrombocytopenia, *leukocytosis
Initial workup of CLL
- peripheral smear
- flow cytometry
- Imaging not done routinely (not used for staging)
Endometrial cancer presentation
- abnormal uterine bleeding
- underlying chronic unopposed estrogen exposure (anovulation, obesity, PCOS)
How to differentiate IDA from AICD based on bone marrow analysis and path
- increased iron staining in the macrophages (due to iron trapping) but decreased staining in the erythrocyte precursors
- IDA while show no iron staining in macrophages or red cell precursors
pernicious anemia lab features
- macrocytosis
- normal or low retic count
- normal-low WBC and platelet counts
Definition of polycythemia
- hematocrit greater than 48% in women and 49% in men
PV clinical features
- transient neurologic symptoms, including visual disturbance (signs of hyper viscosity syndrome)
- aquagenic pruritus
- erythromelalgia
- arterial or venous thrombosis
What is erythromelalgia
burning pain in the feet or hands associated with erythema, cyanosis, or pallor
labs in PV
- often significant thrombocytosis + leukocytosis (MPN)
physical exam in PV
- splenomegaly, facial plethora, skin excoriations
treatment of PV
phlebotomy
IF increased VTE risk ==> hydrea
Initial workup of suspected HUS
- peripheral smear (looking for schistocytes)
- e coli serology (more sensitive than stool culture)
Breast cancer surveillance in BRCA patients who don’t opt for prophylactic mastectomy
- breast self exam beginning at age 18 + annual mammogram and breast MRI starting at age 25
Features of lymphadenopathy concerning for malignancy
- non tender
- hard
- greater than 2 cm
- persistent for a month or more
- enlarging
- axillary or supraclavicular nodal involvement
- generalized
Management of pancreatic cancer patient presenting with biliary obstruction
- endoscopic stent placement
Initial workup of patient presenting with extrahepatic biliary obstruction + weight loss
CT abdomen (rule out pancreatic cancer first)
