Hematology & Oncology Flashcards
1
Q
Immune thrombocytopenic purpura can be idiopathic, triggered by medications, or associated with other disorders, such as systemic lupus erythematosus, chronic lymphocytic leukemia, lymphoma, hepatitis C, or Helicobacter pylori infection &?
A
HIV
2
Q
Patients who present with symptoms of mucocutaneous bleeding* and a *normal platelet count* should be evaluated for *acquired platelet dysfunction using?
A
Platelet Function Analyzer-100
Note: this test replaced the bleeding time test. Also, SSRIs & ginkgo biloba can increase platelet dysfunction
3
Q
Patients with a Pulmonary Embolism Severity Index score of less than 65 are at low risk of death and may be managed in the outpatient setting with a
A
a non–vitamin K antagonist oral anticoagulant, such as apixaban or rivaroxaban.
4
Q
Inflammatory anemia is usually mild to moderate in severity, characterized by low serum iron levels and total iron-binding capacity and elevated serum ferritin level, and usually requires?
A
No specific treatment
5
Q
In patients with myelodysplastic syndrome requiring frequent transfusions, supplemental treatments to help decrease transfusion requirements, such as?
A
Lenalidomide, should be used to improve quality of life and decrease transfusion-associated iron overload & alloimmunization. Second-line treatments: azacitidine and decitabine
Note: Treatment of MDS has two goals. The first goal is to relieve transfusion dependence; the second is to prevent transformation to acute myeloid leukemia (AML).
6
Q
Hypereosinophilic syndrome is characterized by moderate eosinophilia* and end-organ damage commonly involving the skin, lungs, gastrointestinal tract, and heart (e.g. *restrictive cardiomyopathy); what is the next step in management?
A
Secondary causes of eosinophilia should be excluded.
Note: causes of eosinophilia can be recalled using the mnemonic CHINA (Collagen vascular disease, Helminthic infection, Idiopathic, Neoplasia, Allergy/Atopy/Asthma).
7
Q
Acute viral infections may trigger a transient aplastic crisis in patients with hereditary spherocytosis & should be managed with?
A
Observation
HS- characterized by a mild lifelong anemia in assoc. w/ symptomatic cholelithiasis at an early age. The presence of spherocytes is supported by an elevated mean corpuscular hemoglobin concentration frequently seen in this disorder. HS is caused by mutations in several scaffolding proteins that make these cells less distensible & more susceptible to osmotic stress & hemolysis. Patients with this disorder may have mild anemia, an elevated reticulocyte response, & few or no symptoms. The development of pigmented gallstones resulting from excess bilirubin production may result in symptomatic cholelithiasis.
8
Q
Treat a patient with malignancy-associated pulmonary embolism with?
A
Low-molecular-weight heparin is the anticoagulant of choice for patients with active cancer and a venous thromboembolism.
Note: NOAC have been shown to be equally effective
9
Q
In the presence of normal Doppler studies of the lower extremities, diagnose pulmonary embolism in a pregnant patient?
A
Ventilation-perfusion lung scanning is the initial lung imaging study to evaluate for pulmonary embolism in pregnant patients; D-dimer testing has no diagnostic role.
10
Q
Patients scheduled for elective surgery who have anemia should be evaluated for?
A
Iron deficiency; preoperative management of iron deficiency anemia includes oral iron replacement and evaluation to determine the source of blood loss.
11
Q
Should be used to reverse the effects of warfarin anticoagulation in patients experiencing severe bleeding and those requiring urgent surgery?
A
Four-factor prothrombin complex concentrate
4f-PCC should be avoided in patients with a history of heparin-induced thrombocytopenia because it contains residual heparin.
Idarucizumab is a monoclonal antibody that binds dabigatran & causes a rapid reduction in available in the body for up to 24 hours.
12
Q
In approximately 10% of patients in whom an unprovoked venous thromboembolism is diagnosed, cancer will be found within 1 year, so ?
A
Age-appropriate screening test should be performed
13
Q
Pancytopenia*, *immature leukocytes* with morphologic features consistent with promyelocytes, and *DIC, all of which are consistent with?
A
Acute promyelocytic leukemia (APML)
A bone marrow aspirate & biopsy confirm the diagnosis. Treatment is with all-trans retinoic acid, which targets the underlying defect in cellular differentiation.
14
Q
In patients with IgG monoclonal gammopathy of undetermined significance (MGUS), an M spike of less than 1.5 g/dL*, and *normal findings on serum free light chain assay and urine protein electrophoresis, the risk of progression is low, so?
A
Extensive evaluation is not recommended, repeat labs in 6 months
15
Q
In patients with multiple myeloma, hypogammaglobulinemia, and recurrent infections, treatment should include?
A
Intravenous immune globulin (IVIG), should be given to provide passive immunity against causative organisms.
16
Q
A delayed hemolytic transfusion reaction, should be considered in a patient with low-grade fever and features of hemolytic anemia after recent transfusion (7-14 days). Diagnosis is confirmed using a?
Sxs: tea-colored urine, anemia, hyperbilirubinemia, scleral icterus
A
Direct antiglobulin (Coombs) test
Note: Flow cytometry use for the diagnosis of paroxysmal nocturnal hemoglobinuria (PNH), an acquired clonal stem cell disorder that should be considered in patients presenting with hemolytic anemia, pancytopenia, or unprovoked atypical thrombosis.
17
Q
What is the treatment of choice for patients with bleeding and hypofibrinogenemia secondary to disseminated intravascular coagulation
A
Cryoprecipitate
18
Q
This infection preferentially affects erythrocyte precursors in the bone marrow, causing transient pure red cell aplasia* in patients with *sickle cell anemia?
A
Parvovirus B19 infection
Note: Aplastic anemia (AA) is a condition characterized by pancytopenia with associated neutropenia, anemia, and thrombocytopenia and a severely hypocellular bone marrow.
Myelodysplastic syndrome (MDS) ranges in severity from an asymptomatic disease characterized by mild normocytic or macrocytic anemia to a transfusion-dependent anemia. MDS increases with age. Abnormal erythrocyte forms with basophilic stippling or Howell-Jolly bodies and dysplastic neutrophils with decreased nuclear segmentation and granulation may be present.
19
Q
Patients with essential thrombocythemia who are older than 60 years or who have had previous thromboembolic complications should be treated with:
A
Aspirin and hydroxyurea
20
Q
Typically appears as an isolated, mild neutropenia (1000-1500/µL [1-1.5 × 109/L]) found on routine testing in asymptomatic Black persons or certain other ethnic groups
A
Benign ethnic neutropenia
21
Q
Acute hemolytic anemia, indicated by an acute reduction in the hemoglobin and haptoglobin levels & reticulocytosis, & the bite cells seen on the peripheral blood smear also suggest G6PD deficiency. A drug reaction should always be suspected in such settings?
A
Discontinue Dapsone, which is one of the most commonly encountered drugs leading to G6PD-mediated hemolysis. G6PD deficiency is X linked, so it is much more common in men, especially in those of African descent.
22
Q
Normocytic anemia with a low reticulocyte count and normal erythrocyte morphology* in a patient with *underlying chronic kidney disease is usually caused by
A
Erythropoietin deficiency and will respond to therapy with an erythropoiesis-stimulating agent; however, normalization of the blood count is not advised.
Note: Inflammatory anemia, including a low TIBC & iron level & normal or elevated ferritin level. Myelodysplastic syndrome often have pancytopenia.
23
Q
The finding of an IgG λ monoclonal gammopathy can also be associated with amyloidosis. Diagnosis requires biopsy of the affected organ and demonstration of characteristic apple-green birefringence with Congo red staining;
A
Fat pad biopsy is sometimes performed because it is less invasive
24
Q
Treat iron deficiency due to malabsorption from inflammatory bowel disease with?
A
Parenteral iron is an appropriate alternative for restoring iron stores
25
Waldenström macroglobulinemia is an indolent B-cell lymphoma with clonal lymphoplasmacytic infiltration of the bone marrow that secretes IgM in the blood. How is the diagnosis confirmed?
Bone marrow biopsy
26
Atypical presentations of rheumatoid arthritis and osteoarthritis, particularly with *_hook-like osteophytes*_ of the second and third metacarpophalangeal joints, suggest the possibility of _*hemochromatosis_*; what should be evaluated next?
**_Transferrin saturation and serum ferritin_** level should be considered.
27
This should be considered as the initial therapy for patients with iliofemoral deep venous thrombosis with acute limb ischemia.
Thrombolysis with Alteplase
28
In patients with severe *_symptomatic autoimmune hemolytic anemia_*, the autoantibody typically reacts against all erythrocytes, and a completely crossmatch-compatible unit may be impossible to find; these patients should receive?
**_ABO and Rh-matched blood even if it is not crossmatch compatible_**
29
Immediately following hematopoietic stem cell transplantation, patients are at increased risk of?
Infection because of compromised function of lymphocytes and neutrophils
30
The International Myeloma Working Group recommends that all patients with smoldering multiple myeloma, should undergo?
Serum protein electrophoresis and immunofixation show an IgA spike of 3.5 g/dL. Skeletal survey findings are negative.
Whole body MRI to assess for lytic lesions
31
In patients with INR elevation and bleeding associated with warfarin administration, urgent reversal of anticoagulation should be accomplished using
Vitamin K and prothrombin complex concentrates
32
Secondary iron overload (as seen in a MDS patient with ferritin \> 1000) from chronic transfusions can be effectively treated with oral chelation agents, such as
Deferasirox
33
Patients with symptomatic anemia of chronic kidney disease may be treated with erythropoiesis-stimulating agents e.g. Darbepoetin to reduce transfusion requirements with a target hemoglobin level of?
11 to 12 g/dL (110-120 g/L) to avoid increased risk of adverse cardiovascular events.
34
Minor bleeding in patients taking a non–vitamin K antagonist oral anticoagulant (e.g Dabigatran) can be managed by:
Discontinuation of the anticoagulant alone without additional therapy
35
Manage preoperative transfusion in sickle cell anemia?
**_Simple transfusion to achieve a hemoglobin level of 10 g/dL_** (100 g/L) in patients having low- to moderate-risk surgery reduces surgical complications equivalent to exchange transfusion with less risk and cost.
36
Is associated with warfarin-associated skin necrosis?
Protein C or S deficiency
37
Patients identified as low risk and meeting the Pulmonary Embolism Rule-Out Criteria do not require?
D-dimer testing to eliminate the need for further diagnostic imaging. **_No further testing_**
38
Are effective for initial treatment of chronic myeloid leukemia in the chronic phase?
Tyrosine kinase inhibitors such as imatinib
39
*_Paroxysmal nocturnal hemoglobinuria (PNH)*_ presents with _*pancytopenia*_ with significant intravascular hemolysis & _*hemoglobinuria.*_ Patients with PNH commonly note _*fatigue & nonspecific abdominal pain_*, which worsens during times of increased hemolysis. What is the next step?
**_Flow cytometry_** results, which can detect _CD55 & CD59 deficiency_ on the surface of peripheral erythrocytes or leukocytes
40
Patients with coagulopathy of liver disease and low fibrinogen levels who are experiencing bleeding should receive immediate
Cryoprecipitate transfusion
41
In patients with cancer who are hospitalized, prophylactic anticoagulation with
Low-molecular-weight heparin should be provided to reduce the risk of venous thromboembolism
42
Patients with sickle cell disease and uncomplicated pregnancy should be
closely monitored and treatment withheld until symptoms appear or some measurable parameter changes
43
Presents with chronic microcytic anemia with hemoglobin levels of approximately 10 g/dL (100 g/L) and a *_normal hemoglobin electrophoresis pattern_*.
α-thalassemia trait
In β-thalassemia, the excess α chains link with δ and γ chains to produce increased amounts of hemoglobin A2 and hemoglobin F, respectively. Patients with thalassemia should receive supplemental folate but should not receive iron supplementation; they are not iron deficient & they have an increased ability to absorb iron, which can lead to iron overload. Genetic counseling may be indicated in reproductive planning.
44
Patients with asymptomatic INR elevation between 4.5 and 10 are managed
By simply withholding warfarin
45
Pre-eclampsia, HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, and thrombotic thrombocytopenic purpura–hemolytic uremic syndrome can all present with microangiopathic hemolytic anemia and thrombocytopenia during pregnancy; pre-eclampsia is defined by hypertension, edema, and proteinuria after the 20th week of gestation.
Manage pre-eclampsia in a pregnant woman with thrombocytopenia?
Emergent delivery
46
A history of mucosal or endometrial bleeding, normal prothrombin, activated partial thromboplastin times, prolonged Platelet Function Analyzer-100 result and normal platelet count with evidence of a qualitative platelet defect suggest the diagnosis of
von Willebrand disease
47
Typically have lifelong mild hemolytic anemia with microcytosis and *_detectable hemoglobin A on electrophoresis_*; the amount of hemoglobin A is inversely related to the severity of the symptoms and risk of complications
Hemoglobin S β-thalassemia
Note: Patients with hemoglobin SS disease (sickle cell anemia) have greater than 90% HbS and no HbA.
48
Manage acute upper gastrointestinal bleeding with a restrictive transfusion strategy.
A hemoglobin transfusion threshold of less than 7 g/dL (70 g/L) for hemodynamically stable patients is associated with less blood use and lower mortality compared with a more liberal hemoglobin transfusion threshold of 9 g/dL (90 g/L).
49
Prevent complications of sickle cell disease with?
Hydroxyurea therapy has been shown to decrease vaso-occlusive episodes and acute chest syndrome, to decrease transfusion requirements and hospitalizations, and to prolong overall survival
50
Diagnose polycythemia vera?
Presents with *_low erythropoietin level_* and splenomegaly
*JAK2 V617F* mutation is present in 97% of patients with polycythemia vera, so testing should be performed in patients in whom the disease is suspected.
51
In a patient with thrombocytopenia & hemolytic anemia establishes a presumptive diagnosis of thrombotic thrombocytopenic purpura, how is the diagnosis confirm?
A peripheral blood smear showing schistocytes, confirms the need to initiate early, life-saving therapy.
52
Survivors of acute lymphoblastic leukemia are at increased risk for the metabolic syndrome, including high BMI, truncal obesity, dyslipidemia, insulin resistance, and hypertension. Screen for hyperlipidemia and diabetes in adult survivors of pediatric leukemia using?
Lipid profile and fasting blood glucose
53
Include respiratory distress within 6 hours of transfusion, positive fluid balance, elevated central venous pressure, elevated B-type natriuretic peptide, and radiographic findings of pulmonary edema, what's the diagnosis?
Transfusion-associated circulatory overload
Note: Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related mortality. Characterized by the development of acute lung injury within 6 hours of transfusion of erythrocytes, platelets, or fresh frozen plasma. Signs and symptoms escalate quickly and include dyspnea, hypoxia, *_fever*_, chills, and _*hypotension*_. The chest radiograph shows _*diffuse bilateral pulmonary infiltrates_*.
54
Patients with sickle cell disease and acute chest syndrome (defined clinically by fever, respiratory findings that include tachypnea & hypoxia, & evolving infiltrates on CXR), with respiratory distress requiring mechanical ventilation should receive
Emergent exchange transfusion
Note: Mild episodes require no transfusion, moderate episodes are managed with simple or exchange transfusion, & severe episodes require exchange transfusion. The target hemoglobin level is 10 g/dL (100 g/L).
55
Patients taking Dabigatran and requiring urgent surgery should be given?
Idarucizumab, a monoclonal antibody fragment that binds free and thrombin-bound dabigatran and neutralizes its activity.
56
This deficiency should be suspected in patients with macrocytic anemia, malnutrition, and alcohol dependence.
Folate deficiency
Note: Unlike folate, cobalamin is effectively stored, & dietary inadequacy is not a common cause of deficiency. *_Alcohol dependence is not a risk factor for cobalamin deficiency_*.
57
Patients with hypercalcemia, renal failure, anemia, and bone disease should have further testing with?
Serum protein electrophoresis and serum free light chain assay to evaluate for multiple myeloma
58
Patients with pancytopenia, macrocytic erythrocytes, hypersegmented neutrophils, and findings consistent with intramedullary hemolysis should have?
Vitamin B12 & folate levels assessed to determine the cause of megaloblastic anemia
Methylmalonic acid and total homocysteine levels are helpful in differentiating cobalamin deficiency (both levels are elevated) from *_folate deficiency (elevated homocysteine level but normal methylmalonic acid level_*).
59
High sheer force seen in some patients with prosthetic heart valves, abnormal native valves, and *_left ventricular assist device placement_* may cause?
An acquired von Willebrand disease with clinical bleeding
60
Can help confirm the diagnosis of myelodysplastic syndrome in patients with macrocytic anemia and other cytopenias and a peripheral blood smear showing dysplastic, hypogranular neutrophils and nucleated erythrocytes?
Bone marrow biopsy
61
*_Pulmonary hypertension, a known complication in sickle cell disease_*, may worsen during pregnancy and should be initially evaluated by?
Echocardiography
62
Polycythemia is a common adverse effect of testosterone injections, and when this is noted, what is the next step in management?
Testosterone supplementation should be interrupted if the hematocrit level exceeds 54%
63
Patients with a high probability of heparin-induced thrombocytopenia should have heparin stopped, and therapy with an immediately effective anticoagulant, such as
Argatroban, should be initiated
64
Is a diarrhea-associated syndrome of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury caused by Shiga toxin–producing *Escherichia coli* and, less commonly, *Shigella dysenteriae?*
Hemolytic uremic syndrome (HUS)
65
Patients with artificial valves or those with left ventricular assist devices can develop anemia resulting from erythrocyte fragmentation known as
Macroangiopathic hemolysis or valve hemolysis
66
In provoked deep venous thrombosis with reversible risk factors, what duration of anticoagulation is advised?
3 to 6 months of anticoagulation is recommended
67
Evaluation of the peripheral blood smear to assess platelet clumping should be done in patients with isolated thrombocytopenia; if clumping is detected, the platelet count should be repeated in a heparinized blood specimen and what is the diagnosis?
Pseudothrombocytopenia
68
Has been shown to prevent new skeletal-related events and improve survival in patients with multiple myeloma requiring therapy?
Zoledronic acid
Myeloma therapy includes: bortezomib, lenalidomide, and dexamethasone.
69
These are effective treatments for *_cold agglutinin disease_*, which shows _direct antiglobulin (Coombs) test is positive for C3_ & a peripheral blood smear shows *_erythrocyte agglutination_*. glucocorticoids, splenectomy, and intravenous immune globulin are not helpful?
Cold avoidance and **_rituximab_**
Profound anemia & evidence of intravascular (decreased haptoglobin, hemoglobinuria, elevated lactate dehydrogenase) & extravascular (elevated indirect hyperbilirubinemia level) hemolysis.
Splenectomy is not effective at reducing this type of hemolysis compared with *_warm antibody-mediated hemolysis_*.
70
Is a cause of heparin resistance, in a patient on LMW heparin, who's aPTT remains normal despite increasing dose of heparin?
Antithrombin deficiency
71
A prolonged activated partial thromboplastin time that does not fully correct with a mixing study suggests the presence of a factor inhibitor and the diagnosis of *_acquired hemophilia A_*; treatment is with?
Activated factor VII, activated prothrombin complex concentrate, or recombinant porcine factor VIII.
72
Which can be recognized by a **normal activated partial thromboplastin time and an elevated prothrombin time**, should be expected in *_patients who have poor oral intake and are taking prolonged courses of antibiotics?_*
Vitamin K deficiency
73
With the exception of testing for genetic mutations, thrombophilia testing should not be performed in the acute setting or while receiving anticoagulant therapy and should be delayed at least
2 weeks after discontinuation of anticoagulant therapy to minimize diagnostic error
74
Patients with ***abdominal thrombosis, splenomegaly, and portal hypertension*** should be evaluated for the presence of a *_myeloproliferative neoplasm_*, specifically with the?
*JAK2 V617F* gene mutation, even in the absence of erythrocytosis or thrombocytosis
Note: Look for a triphasic CT scan of the abdomen showing occlusion of the hepatic veins, ascites, splenomegaly, and abdominal varices; no cirrhosis is seen.
PNH is also associated with abdominal vein thrombosis, but her _normal haptoglobin level_ & absence of *_indirect hyperbilirubinemia_* indicate no evidence of hemolysis. Performing flow cytometry to evaluate for loss of CD 55/59 would not be appropriate.
75
Many drugs are associated with drug-induced hemolytic anemia, and antibiotics are the most frequently encountered cause of this condition, with
Ceftriaxone being one of the most common causative agents
Although warm antibody hemolysis can cause a hemolytic anemia that is DAT positive for IgG, cold agglutinin disease is DAT positive for C3. The peripheral blood smear would show agglutinated cells, and spherocytes would not be present. Furthermore, cold agglutinin disease is not associated with Lyme disease. Cold agglutinin disease can be primary or associated with lymphoproliferative disorders and certain infections, typically *Mycoplasma pneumoniae* or Epstein-Barr virus.
76
Which of the following transfusion-transmitted diseases is the most likely diagnosis?
*Babesia microti* is a transfusion-transmissible pathogen that can be responsible for malaria-like symptoms, hemolytic anemia, thrombocytopenia, and abnormal liver chemistry study results.
77
*_Pregnant women with immune thrombocytopenia purpura_* can be safely?
**_Monitored_** during their pregnancy without intervention as long as they are asymptomatic and the platelet count remains greater than 30,000/µL (30 × 109/L).
78
For patients with small cell lung cancer who have large centrally located tumors that are not amenable to resection, standard management is
Combined chemotherapy & radiation, which can result in cure for about 20% to 30% of patients
79
Treat high-risk prostate cancer with?
Combination therapy with **_radiation and a gonadotropin-releasing hormone agonist_** for up to 2 to 3 years results in an improvement in 10-year disease-free and overall survival and is the standard care for patients with high-risk and very-high-risk prostate cancer.
High-risk prostate cancer is defined as a prostate-specific antigen (PSA) level greater than 20 ng/mL (20 µg/L), a Gleason score of 8 to 10, or evidence of extraprostatic extension of the cancer.
Brachytherapy is typically only recommended for men with low-risk and limited-volume cancer.
80
The standard treatment for locally advanced head and neck cancer is a combination of
Radiation with systemic therapy, most commonly cisplatin or **_cetuximab_**
Cisplatin is nephrotoxic and should be avoided or used cautiously in patients with preexisting kidney injury with a creatinine level greater than 1.5.
81
Manage early-stage 1A cervical cancer while maintaining fertility?
Conization, or excision of a cone-shaped portion of the cervix, is a fertility preservation surgery for patients who have stage IA cervical cancer, defined as microscopic disease without visible tumor.
82
In patients with low-risk, early-stage hormone receptor–positive breast cancer, use of tamoxifen for
10 years has been shown to decrease the risk for breast cancer recurrence and breast cancer mortality
83
All patients with classic Hodgkin lymphoma, regardless of stage, should be treated?
**_Chemotherapy, usually the doxorubicin, bleomycin, vinblastine, and dacarbazine regimen (ABVD_**), obviating the need for staging laparotomy and splenectomy
84
Treat advanced ovarian cancer with germline *BRCA1* and *BRCA2* mutations?
Oral poly (adenosine diphosphate [ADP]-ribose) polymerase (PARP) inhibitor. Olaparib is an oral PARP inhibitor.
Olaparib is FDA approved as monotherapy for patients with germline *BRCA*-mutated advanced ovarian cancer previously treated with three or more lines of chemotherapy.
85
For women who desire future childbearing who are medically stable, initiation of chemotherapy can be
delayed for a brief time to allow assessment by a fertility specialist
86
For all women with epithelial ovarian cancer, regardless of age of onset, family history, or ancestry?
Current guidelines recommend *BRCA1* and *BRCA2* genetic testing
87
Treat gastric MALT lymphoma associated with *Helicobacter pylori* infection?
The initial treatment for gastric mucosa-associated lymphoid tissue lymphoma associated with *Helicobacter pylori* infection is *_proton pump inhibitor and antibiotic therapy_*.
88
Provide chemoprevention in a patient at high risk for breast cancer, who has a history of thromboembolism?
Patients with lobular carcinoma in situ and atypical hyperplasia are candidates for chemoprophylaxis with antiestrogens such as Exemestane.
Tamoxifen in both premenopausal & postmenopausal women as well as raloxifene & aromatase inhibitors (such as exemestane or anastrozole) in postmenopausal women. Because this patient had a deep venous thrombosis while taking oral contraceptives in the past, both tamoxifen & raloxifene are contraindicated, & exemestane is the best option.
89
Staging of patients with colorectal cancer should include a
contrast-enhanced CT scan of the chest, abdomen, and pelvis to determine the extent of the cancer and to establish a baseline for surveillance
90
Treat ductal carcinoma in situ?
Anastrozole adjuvant therapy for ductal carcinoma in situ in postmenopausal patients younger than age 60 years decreases the risk of recurrent ipsilateral and contralateral breast cancer but does not decrease overall survival.
91
In newly diagnosed metastatic non-squamous non–small cell lung cancer, what's the most appropriate management?
Testing for molecular alterations in the epidermal growth factor receptor (EGFR), *ALK*, and *ROS1* genes informs treatment options; patients with *EGFR* mutations derive significant benefit from treatment with erlotinib, whereas those with *ALK* translocations and *ROS1* mutations derive similar benefit from crizotinib
92
Manage very-low-risk prostate cancer with?
Active surveillance is a reasonable option in men with low-risk or very-low-risk prostate cancer who have a life expectancy of at least 10 years; active surveillance consists of scheduled assessments that include DRE, prostate-specific antigen measurement, & prostate biopsy.
93
Many patients with head and neck cancer have significant smoking histories and should be offered
lung cancer screening if they meet high-risk criteria
94
Evaluate lymphadenopathy?
Diagnosis and classification of lymphoma are generally established based on lymph node biopsy.
95
Manage metastatic non–small cell lung cancer with?
In patients with metastatic non–small cell lung cancer, early institution of **_palliative care_** has been shown to improve both quality of life and survival; palliative care does not preclude aggressive cancer treatment
96
Treat mismatch repair–deficient colorectal cancer?
An immune checkpoint inhibitor, such as pembrolizumab, shows benefit in patients with metastatic mismatch repair−deficient colorectal cancer.
97
Prevent recurrent pneumonia in a patient with chronic lymphocytic leukemia?
Intravenous immunoglobulin G replacement therapy reduces the risk of infections in patients with chronic lymphocytic leukemia with documented hypogammaglobulinemia.
98
Evaluate recurrent colorectal cancer?
***_RAS_*** **_mutation status of primary tumor_**, should be tested in patients with metastatic disease to determine if they are candidates for treatment with an epidermal growth factor receptor inhibitor, such as cetuximab or panitumumab.
99
Treat non–small cell lung cancer that responds to first-line chemotherapy with?.
Maintenance chemotherapy e.g Pemetrexed, is an appropriate option for patients with metastatic non–small cell lung cancer who respond to first-line platinum-based chemotherapy.
Either the nonplatinum agent used for first-line treatment is continued as a single agent (“continuation maintenance”) or an alternative agent, most commonly docetaxel, is used (“switch maintenance”).
100
Treat early-stage laryngeal cancer WITH?
Radiation alone because it is highly effective in that area, has low morbidity, and is associated with superior voice quality compared with patients who are treated with surgery.
101
Rectal cancers without full thickness penetration of the bowel wall or involved lymph nodes are stage I and are treated with
surgical resection
102
is effective for prophylaxis and secondary prophylaxis of neutropenia in patients undergoing chemotherapy but has little benefit in patients who are currently neutropenic
Granulocyte colony-stimulating factor
NOTE: chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) for diffuse large B-cell lymphoma
103
High-risk gastrointestinal stromal tumors (GISTs) should be treated with surgery and 3 years of adjuvant
Imatinib
104
Manage superior vena cava syndrome?
Most patients with superior vena cava syndrome do not require emergency intervention, and a tissue biopsy (i.e Mediastinoscopy) should be obtained.
105
Treat locally advanced head and neck cancer?
Combined chemotherapy (e.g Cisplatin) and radiation improves survival in patients with locally advanced head and neck cancer after surgery when there are positive surgical margins or evidence of nodal metastases with extracapsular extension.
106
Treat stage II non–small cell lung cancer with?
Adjuvant chemotherapy after resection. Adjuvant cisplatin-based chemotherapy for stage II & stage III non–small cell lung cancer provides a survival advantage.
NOTE: Radiation as a single modality has no role in the adjuvant treatment of resected NSCLC in the absence of positive surgical margins. Also, combined chemoradiation for patients w/ stage III lung cancer w/ clinically evident mediastinal lymphadenopathy noted at the time of initial evaluation.
107
Manage cancer of unknown primary site in a patient with poor performance status?
Supportive management & hospice care.
Patients with several comorbidities & poor performance status are unlikely to benefit from aggressive chemotherapy, and such treatment is likely to cause serious or life-threatening toxicity.
108
How do you diagnose renal cell carcinoma in a patient with erythrocytosis & elevated EPO with?
CT Abdomen
Erythrocytosis is a common paraneoplastic syndrome associated with kidney cancer.
109
How do you treat oligometastatic liver metastases of colorectal cancer?
Resection of all lesions
Patients with recurrent colorectal cancer in a single organ in an oligometastatic pattern are candidates for surgery with curative intent.
110
Women with **isolated axillary lymph-node adenocarcinoma metastases** should be presumptively considered to have locoregional breast cancer and should be treated with?
Axillary dissection & management as primary breast cancer
111
Treatment to prevent tumor lysis syndrome in a patient with Burkitt lymphoma?
Rasburicase and intravenous hydration
## Footnote
Burkitt lymphoma often presents with early signs of tumor lysis, and it is important to institute tumor lysis syndrome prophylaxis before initiation of chemotherapy.
112
Is recommended to decrease breast cancer recurrence in women with high-risk, early-stage, hormone receptor–positive breast cancer who remain premenopausal after chemotherapy?
Ovarian suppression along with antiestrogen therapy e.g Leuprolide & exemestane (an Aromatase inhibitor)
Note: Not Tamoxifen, as this as not been shown to be as effective as the above treatment in these patients
113
In a patient with a residual mass after treatment of bulky diffuse large B-cell lymphoma with 6 cycles of chemotherapy with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP), what is the most appropriate management?
Observation with serial CT scanning
114
Treatment option for patients with advanced ovarian cancer after debunking surgery with residual mass not \>1cm?
Intravenous and intraperitoneal cisplatin and paclitaxel chemotherapy
115
Well-differentiated, low-grade, metastatic gastrointestinal neuroendocrine tumors are often indolent and asymptomatic and?
Do not require immediate treatment, so may repeat CT abdomen in 3 months
116
Are indicated for premenopausal patients with node-negative, hormone receptor–positive, *HER2*-negative breast cancer with low-risk recurrence scores?
Primary breast radiation and tamoxifen
117
For men with early-stage prostate cancer who have limited life expectancy or significant medical comorbidities,
Observation is the most appropriate management
## Footnote
Note: Androgen deprivation therapy is not a recommended treatment for early-stage prostate cancer & will expose this patient to unnecessary side effects, including decreased libido and erectile dysfunction, osteoporosis, fatigue, gynecomastia, & hot flushes.
118
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ are necessary for this patient with stage IIB invasive breast cancer. Patients with clinical stages I and II invasive breast cancers are at low risk for metastases at the time of diagnosis of their initial breast cancer.
No imaging studies
119
Initial therapy for hairy cell leukemia is
Cladribine or pentostatin, a purine nucleoside analogue
120
Transformation of follicular lymphoma to an aggressive non-Hodgkin lymphoma may be suggested by a change in the clinical pattern of disease, such as the development of new systemic symptoms or rapid progression of a localized area of disease. Therefore, diagnosis should be made by?
Biopsyng the largest & most accessible lymph node
121
Squamous cell carcinoma or poorly differentiated carcinoma presenting as isolated inguinal lymphadenopathy should prompt a careful examination of?
the vulva, vagina, and cervix in women, penis in men, and perineal skin and anus in both men and women by doing a **_Anoscopy_**.
122
Patients with stage II colon cancer without high-risk features should have?
Surgery, **_but they are unlikely to benefit from adjuvant treatment with chemotherapy._**
123
Treat melanoma with a solitary brain metastasis with?
Surgical resection of the brain lesion
Note: Stereotactic radio surgery for 3 or less lesion at 3cm or less. Whole brain radiation for multiple widespread lesion.
124
Treat locally advanced anal cancer with?
Anal cancer is often curable with combined chemotherapy and radiation, avoiding surgery. Mitomycin & 5-FU or capecitabine is the standard chemotherapy regimen.
Note: Rectal cancer is adenocarcinoma & anal cancer is squamous cancer
125
Treat early-stage breast cancer with extended aromatase-inhibitor therapy for ?
10 years, if no side effect
Extending aromatase-inhibitor therapy beyond 5 years to 10 years in postmenopausal women with hormone receptor–positive early breast cancer is associated with an increase in the 5-year disease-free survival rate but not overall survival.
126
Management of metastatic lung cancer in a patient with poor performance status?
Patients with non–small cell lung cancer and poor performance status do not benefit from systemic treatment of their cancer; in such patients, the most appropriate intervention is **_palliative care consultation_**.
127
Treatment for neoplastic epidural spinal cord compression?
Initial administration of dexamethasone followed by **_decompressive surgery_** for epidural spinal cord compression is recommended in patients who are acceptable surgical candidates and who have an expected survival of at least 3 months.
128
Manage a *BRCA2* mutation carrier who desire further childbearing?
B/L salpingo-oophorectomy by age **_40 to 45 years_**.
Note: _For_ *_BRCA1_* _mutation carriers, the risk for ovarian cancer increases substantially after age 35 years, and thus prophylactic BSO is recommended between the ages of 35 and 40 years and after completion of childbearing._
129
Diagnose chronic lymphocytic leukemia?
**_Flow cytometry on peripheral blood_** is the most appropriate test to make an initial diagnosis of chronic lymphocytic leukemia.
130
Treatment for metastatic renal cell carcinoma with a single pulmonary nodule?
Debulking nephrectomy improves survival in patients diagnosed with metastatic kidney cancer, particularly in those with limited metastatic disease. Following nephrectomy it would be appropriate to consider metastasectomy for removal of the isolated pulmonary lesion.
131
Management for patients with nonbulky follicular lymphoma who are asymptomatic?
Survive many years without the need for therapy
Note: Follicular lymphoma associated with symptomatic systemic disease requires multiagent therapy that traditionally includes rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP)
132
Screen for breast cancer in a patient with previous chest wall radiation.
The International Late Effects of Childhood Cancer Guideline Harmonization Group recommends that for women who received chest wall radiation before the age of 30 years, **_breast screening should begin at age 25 years or 8 years after completion of radiation therapy, whichever is last._**
133
Manage fertility in a patient with early-stage breast cancer?
Fertility specialist consultation is recommended for all patients before chemotherapy during their reproductive years.
134
Treatment for localized gastroesophageal cancer?
Neoadjuvant chemotherapy before surgery plus radiation
135
Treatment for superficial high-grade bladder cancer?
Initial treatment for high-grade or recurrent low-grade bladder cancer is transurethral resection of the bladder tumor followed by **_intravesical chemotherapy with bacillus Calmette-Guerin and periodic cystoscopy_**.
Note: Cisplatin-based chemotherapy is used most often as a neoadjuvant treatment before surgery in patients with muscle-invasive cancer.
136
Results of clinical trials in patients with cancer, usually encompassing medically fit patients with good performance status, cannot be extrapolated to patients with poor health and performance status. And these patient's would likely see?
Decrease efficacy & increased toxicity
137
Patients with widely metastatic hormone receptor–positive, *HER2*-negative breast cancer that has reoccurred after previously completing aromatase therapy can benefit from combination?
Letrozole plus palbociclib
138
Treat stage III colon cancer with positive lymph nodes?
The FOLFOX regimen of 5-fluorouracil, leucovorin, and oxaliplatin or oxaliplatin with oral capecitabine (CAPOX) is the most appropriate adjuvant therapy for stage III colon cancer.
139
Evaluate anemia in a patient with chronic lymphocytic leukemia by ordering a?
Coombs test
## Footnote
Autoimmune hemolytic anemia is common in patients with chronic lymphocytic leukemia; a direct antiglobulin (Coombs) test can confirm the diagnosis and guide treatment.
140
It has now become standard practice to test all patients newly diagnosed with metastatic non−small cell lung cancer for?
Programmed cell death ligand 1 expression.
141
Young men with poorly differentiated carcinoma that is characterized by centrally located bulky retroperitoneal or mediastinal lymphadenopathy of unknown primary and are best treated with?
A germ cell chemotherapy regimen
142
Define an inclusionary predictive tumor marker?
Inclusionary predictive tumor markers identify which therapies are more likely to be effective e.g BRAF V600E
143
Asymptomatic patients with a family history of *BRCA*-related cancers should receive
Genetic counseling for genetic risk assessment
144
Evaluate suspected testicular cancer?
Before histologic confirmation of testicular cancer with radical inguinal orchiectomy, **_α-fetoprotein and β-human chorionic gonadotropin levels should be measured_** to most accurately determine stage and prognosis.
145
Patients with symptomatic brain metastases should be initially treated with?
Glucocorticoids
146
Posttreatment surveillance of patients with cervical cancer is limited to a?
thorough **_history and examination every 3 to 6_** months for the first 2 years, then every 6 to 12 months for years 2 through 5; frequency of visits can be tailored to the patient's risk.
147
Patients with Stage III non–small cell lung cancer who have extensive primary tumors or bulky, multistation lymphadenopathy in the mediastinum are not candidates for surgery and instead should be treated with?
Combined chemotherapy and radiation
148
Evaluate metastatic gastroesophageal junction adenocarcinoma for?
**_Human epidermal growth factor receptor 2 (_*****_HER2_*****_)_** amplification to guide chemotherapy.
149
In men with clinical metastatic prostate cancer that is castrate sensitive, treatment should include?
**_Docetaxel along with continuation of androgen deprivation therapy (i.e. Leuprolide_**) has been shown to improve survival and is accepted as standard care.
Note: Other prostate cancer treatment, which works by blocking the androgen receptor with an antiandrogen agent (such as flutamide or bicalutamide)
