Hematology/Oncology

Question 1

What is normal hemoglobin for males and females?

Answer 1

14-18g/100nl (males) and 12-16g/100nl (females)

Question 2

TNM - Tumor Staging Review

Answer 2

T = Tumor Size in CM N=How many lymph nodes are involved M=Has it metastasized

Question 3

Normal HCT

Answer 3

Hct measures the % of a given volume of whole blood that is occupied by erythrocytes; the amount of plasma to total RBS mass (RBC concentration).

Normal - 40-54% (male) and 37-47 (female)

Question 4

Normal TIBC?

Answer 4

250-450 ug/dl

Question 5

Normal serum iron?

Answer 5

50-150ug/dl

Question 6

Normal MCV**

Answer 6

Mean Corpuscular Volume (average size) 80-100fl

Question 7

Microcytic Anemia

Answer 7

[MCV = <80fl] Iron deficiency anemia or thalassemia

Question 8

Macrocytic Anemias

Answer 8

[MCV = >100fl) B12 or folate deficiency (can be due to alcoholism, liver failure, drug effects, gastric sleeve etc.) // AKA Megaloblastic anemias

Question 9

Normocytic Anemias

Answer 9

MCV is 80-100fl // Anemia of chronic disease (i.e. sickle cell, renal failure, blood loss, hemolysis - etc. ).

Question 10

Iron deficiency anemia

Answer 10

// Most common type of anemia (except in the elderly). Iron loss exceeds intake due to a variety of reasons.

Symptoms: as the Hct falls <30% you will see dyspnea, fatigue, headache, postural hypotension, palpitations and weakness. Palpitations, tachycardia and fatigue.

MCV <80 + MCHC is less than 32% + low serum ferritin (<50ng/dl) + High TIBC (>250) and High RDW (normal is 12-15%)

Question 11

Iron deficiency anemia treatment

Answer 11

Oral Ferrous Sulfate 300-325mg 1-2 hours after meals. Eating decreased absorption 45-50%. Iron should never be taken with antacids. Taking oral iron with Vit. C increases absorption.

Foods that are high in iron: raisins, green leafy veggies, red meat, citrus, iron fortified breads and cereals

Question 12

(Beta) Thalassemia

Answer 12

Genetically inherited disorder resulting in abnormal Hgb production and MICROCYTIC HYPOCHROMIC anemia.

Asian with anemia? Think Thalassemia!

S/Sx are unremarkable unless the form of Thalassemia is severed.

Caused by a decreased production in normal adult Hgb - Hgb A

Question 13

Patho of Thalassemia

Answer 13

Hgb A (adult Hgb) has 2 polypeptide chains with 2 alpha and 2 beta chains. In a person with beta Thalassemia - the beta global chains are reduced or absent.

Thalassemia Minor = Heterozygous and will mimic iron deficiency anemia.

Thalassemia major is also known as Cooley’s anemia and is Homozygous - with a severe form and presentation just a few months after birth (because you still have fetal Hgb at birth!)

Question 14

Cooley’s Anemia

Answer 14

Thalassemia Major - homozygous and severe form of Thalassemia (a microcytic hypo chromic anemia.)

Early in life you will see (as Hgb A takes over) - FTT, feeding difficulties (due to lack of oxygen), fever, diarrhea, hepatosplenomegaly, jaundice, maxillary enlargement

Question 15

Thalassemia Management

Answer 15

No treatment for minor forms.

For Cooley’s anemia - RBC transfusion/splenectomy. Iron is CONTRAINDICATED due to risk of iron overload.

Question 16

Folic Acid Deficiency

Answer 16

Alcoholism!!!** - this is anemia of inadequate intake/malabsorption of folic acid.

S/Sx - The usual anemia symptoms + Glossitis (BEEFY red tongue is the case in both B12 and Folic acid - but NO NEUROLOGICAL signs are seen with Folic Acid Deficiency – this differentiates the two in clinical presentations)

MCV >80, MCHC 32-36% = MACROCYTIC and NORMOCHROMIC

Serum folate will be decreased and RBC folate will be <100ng/ml

Management - 1mg of folate every day. Dietary intake - bananas, peanut butter, fish, green leafy veggies, iron fortified breads and cereals

Question 17

Pernicious Anemia

Answer 17

Pernicious is Intrinsic and you need some B12!

MACROCYTIC (MCV >80) and NORMOCHROMIC (MCHC 32-36%) anemia due to deficiency of INTRINSIC FACTOR which results in a malabsorption of B12

Glossitis + a positive Romberg sign and Babinski sign

Serum B12 will be <200pg/ml and Anti-IF (intrinsic factor) and anti-parietal cell antibody test should be done

Management - 100mcg IM once weekly of Cyanocobalamin

Question 18

Romberg Sign

Answer 18

Swaying with eyes closed - think Pernicious anemia/B12 deficiency

Question 19

Babinski Sign

Answer 19

Extension of the tow with plantar stimulation —- Obviously has multiple etiologies - but Pernicious Anemia is one specific finding that is a possible board exam question

Question 20

Anemia of chronic disease

Answer 20

Is a NORMOCYTIC and NORMOCHROMIC anemia that is associated with chronic inflammation, infection, renal failure, and malignancy

TIBC will be LOW <250
but SERUM IRON will be high (>100ng)
MCV and MCHC will be normal

Treat the associated disease

Question 21

Sickle Cell Anemia

Answer 21

Chronic HEMOLYTIC anemia that is genetic. Sickling of the cells cause hyperviscocity and cellular hypoxia resulting in acidosis and tissue ischemia. Factors precipitate sickling include hypoxia, infections, high altitudes, etc. ..

Hgb will be decreased but you need to order a PERIPHERAL SMEAR to diagnose Sickle Cell.

Management includes fluids, analgesics, and oxygen

Question 22

Von Willebrand

Answer 22

Genetic. Reduced ability to clot caused by a mutation causing a deficiency in VW factor and clotting factor VIII.

Treatment is Demopressin/DDAVP and factor VIII concentrate. Patients can take this in a nasal spray - fyi.

Question 23

Leukemias

Answer 23

Lymphocytic leukemia refers to abnormal cell growth in the marrow cells that become lymphocytes, a type of white blood cell that plays a role in the immune system. In myelogenous leukemia, abnormal cell growth occurs in the marrow cells that mature into red blood cells, white blood cells, and platelets. There are four broad classifications of leukemia:

Acute lymphocytic leukemia (ALL)
Acute myelogenous leukemia (AML)
Chronic lymphocytic leukemia (CLL)
Chronic myelogenous leukemia (CML)

More frequently found in MALES

Ssx/ will see generalized lymphadenopathy, anorexia, fatigue, weight loss,.

Peripheral blood smears can usually distinguish acute vs chronic forms of leukemia but you must undergo a bone marrow biopsy to confirm the diagnosis.

Treatment: Chemotherapy. One important note for boards - ALLOPURINOL should be started to reduce the likelihood of tumor lysis syndrome.

Question 24

Acute Myelogenous Leukemia (AML)

Answer 24

80% of all ACUTE leukemias in adults (so AML is more common than ALL)

Remission rates are 50-85%

Question 25

Acute Lymphocytic Leukemia (ALL)

Answer 25

More difficult to cure than in children (90% remission in children)
Hallmark: Pancytopenia with circulation blasts

Question 26

Chronic Lymphocytic Leukemia (CLL)

Answer 26

Most common leukemia in adults
Increase in absolute lymphocyte count (usually >5000) = lymphocytosis is the hallmark of the disease

Question 27

Chronic Myelogenous Leukemia (CML)

Answer 27

PHILADELPHIA CHROMOSONE = CML

Question 28

Tumor lysis syndrome

Answer 28

Electrolytes!

Hyperuricemia (and subsequent renal failure)
Hyperphosphatemia
Hyperkalemia
HyPOcalcemia

Question 29

Lymphoma staging

Answer 29

Stage I - single lymph node involvement

Stage II - more than one lymph node but on ONE SIDE of the diaphragm

Stage III - Lymph nodes or spleen involved; but now on BOTH SIDES of the diaphragm

Stage IV - Liver or Bone Marrow Involved

Question 30

Non-Hodgkins Lymphoma

Answer 31

*May have viral etiology, we don’t know

Often presents with lymphadenopathy

Most common between 20-40 and at 57 years old (weird)

Less predictable and usually caught when the cancer is advanced.

Question 32

Hodgkins Disease

Answer 32

More common in males, average age 32
usually presents with cervical adenopathy and spreads in a predictable fashion
Characteristic - Reed Sternberg cells differentiate from non-Hodgkins disease

Question 33

Reed Sternberg Cells

Answer 33

This is only seen in HODGKINS DISEASE and is a hallmark

Question 34

Idiopathic Thrombocytopenia Purpura

Answer 34

More common in women. In adults, ITP is usually chronic causing mild to severe thrombocytopenia that may be asymptomatic.

It’s a diagnosis of exclusion. You need to order a bone marrow analysis. Low platelet counts with other causes of thrombocytopenia ruled out.

Gums and kidneys (urine) may be the first to bleed.

Management isn’t necessary until platelet counts are less than 20K

High dose corticosteroids will elevate the platelet count in 2-3 days, IV gamma globulin usually produces a response in 2-3 days (**Gamma globulin is preferred to steroids in HIV related ITP), platelet transfusions may occasionally have some benefit

Thrombocytopenia precautions - normal items (no flossing/shaving, hold pressure etc.) - but also avoid constipation.

Question 35

Platelets

Answer 35

Normal values are 150,000-400,000

Question 36

Heparin inducted thrombocytopenia purpura

Answer 36

50% drop in platelets 5-10 days after initiation.

Start Argatroban or Lepirudin

Question 37

How do you differentiate ITP from SLE?

Answer 37

Bone marrow biopsy

Question 38

Argatroban

Answer 38

A direct, highly-selective thrombin inhibitor. Reversibly binds to the active thrombin site of free and clot-associated thrombin. Inhibits fibrin formation; activation of coagulation factors V, VIII, and XIII; activation of protein C; and platelet aggregation.

Onset is immediate.

Question 39

Lepirudin