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STEP 2 > Heme/Onc & Preventive Med > Flashcards

Heme/Onc & Preventive Med Flashcards

1
Q

How do you test for estrogen /progesterone receptors or HER 2/neu to dx breast cancer?

A

must do a core needle bx OR open bx, which allows for frozen section to be done while patient is in the OR and immediate resection of the cancer followed by sentinel node bx; CANNOT DO RECEPTOR TESTING FROM FNA

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2
Q

Mammography guidelines

A

start at age 50, do every 2 years, stop at 75

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3
Q

When is breast U/S the right answer?

A

when dealing with an indeterminate mass lesions (need to determine whether it is cystic or solid), it is painful, and varies in size/pain with menstruation

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4
Q

When is breast PET scar the right answer?

A

when you need to determine the content of abnormal LN’s that are not easily accessible to bx

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5
Q

BRCA is asso with which cancers?

A

breast, ovarian, and pancreatic cancer

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6
Q

Has BRCA been shown to add mortality benefit to usual mgmt?

A

No

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7
Q

What is the sentinel node?

A

first node identified in the operative field of a definitively identified breast cancer; a negative sentinel node eliminates the need for axillary LN dissection

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8
Q

Main tx for breast cancer

A

lumpectomy and radiation

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9
Q

Role of radiation in breast cancer tx

A

prevents recurrences

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10
Q

Tamoxifen, who gets it, what it does, s/e’s

A

give to PREmenopausal women who are hormone positive, use when multiple 1st-degree relatives have breast cancer as it lower risk (prophylactically); risk of endometrial cancer and forming clots

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11
Q

Aromatase inhibitors, who gets it, what it does, s/e’s

A

give to POSTmenopausal women who are hormone positive, most likely to benefit the patient (vs SERMs), very useful in preventing metastasis in those with proven breast cancer; risk of osteoporosis

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12
Q

Trastuzumab, who gets it, what it does, s/e’s

A

give to women who test HER 2/neu positive, decreases risk of recurrent disease, increases survival

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13
Q

When to give adjuvant chemo in breast cancer?

A

if there is suspicion of microscopic cancer cells too small to be detected; give when lesion >1 cm and positive axillary LNs

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14
Q

Complications of prostatectomy and radiation

A

Prostatectomy - erectile dysfunction, urinary incontinence

Radiation - diarrhea

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15
Q

Hormonal manipulation in prostate cancer, agents

A

flutamide (androgen antagonist), GNRH agonists, ketoconazole, orchiectomy to help control size; do no prevent recurrences

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16
Q

Role of chemo in prostate cancer

A

only used when hormonal thx does not work

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17
Q

Get transrectal U/S to screen for prostate cancer only if

A

elevated PSA and no palpable mass; once mass identified - bx

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18
Q

> 50 yo F with increasing abdominal girth but is still losing wt

A

ovarian cancer

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19
Q

CA 125

A

ovarian cancer

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20
Q

Tx of ovarian cancer

A

remove all visible tumor and pelvic organs and give chemo

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21
Q

alpha-feto protein in pt with testicular mass or concerns for testicular cancer

A

non-seminoma

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22
Q

testicular cancer that is sensitive to chemo

A

non-seminoma

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23
Q

testicular cancer that is sensitive to chemo and radiation

A

seminoma

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24
Q

tx of testicular cancer after orchiectomy

A

local disease –> radiation

metastasis –> chemo

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25
Q

contraindication to 5HT inhibitors (e.g. nausea medication)

A

QT prolongation on ECG

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26
Q

what do you give a patient with chemo-induced nausea who has QT prolongation on ECG?

A

NK receptor antagonists (aprepitant)

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27
Q

colon cancer epidemiology

A

lifetime risk: 6-8%, number of deaths per year: 50,000, percentage of deaths that would’ve been preventable with screening: 95%

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28
Q

who gets pneumococcal vaccine?

A

everyone above 65, cochlear implant, CSF leak, alcoholic, tobacco smokers

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29
Q

Hep A postexposure ppx

A

between 12 mo and 40 years - vaccine (single dose)

<12 mo, >40 yrs - immune globulin

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30
Q

immunological response to different pneumococcal vaccines

A

23 valent - capsular polysaccharide - T-cell-independent B cell response
13 valent - conjugated capsular polysaccharide - T-cell dependent response

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31
Q

who diagnoses alcoholism?

A

the patient

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32
Q

patient with signs of pancytopenia (fatigue, infection, bleeding) with normal WBC and blood smear showing blasts

A

Acute leukemia

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33
Q

leukemia asso with DIC

A

Acute promyelocytic leukemia (M3)

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34
Q

leukemia with chromosome 15 to 17 translocation

A

Acute promyelocytic leukemia (M3)

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35
Q

Myeloperoxidase + Auer rods

A

Acute myelocytic leukemia / Auer rods are more common in acute promyelocytic leukemia (M3)

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36
Q

best indicator of prognosis in acute leukemia is…

A

cytogenetics - assessing specific chromosomal characteristics found in each patien
good cytogenetics –> chemo
poor cytogenetics –> greater chance of relapse –> BMT

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37
Q

tx of M3

A

ATRA (all trans retinoid acid)

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38
Q

what do you have to watch out for in ALL?

A

CNS relapse - add intrathecal methotrexate to thx

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39
Q

prevents tumor lysis related rise in uric acid

A

rasburicase

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40
Q

patient with persistently high WBC that is all neutrophils, may have aquagenic pruritus, splenomegaly (with early satiety, abdominal fullness, LUQ pain), hypermetabolic syndrome (fatigue, fever, night sweats)

A

Chronic myelogenous leukemia (must differentiate from a leukemoid reaction; leukemoid reaction is FAP positive)

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41
Q

Dx of CML

A

BCR-ABL = 9:22 translocation = Philadelphia chromosome

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42
Q

if CML is untreated, 20% of patients will develop what disorder?

A

blast crisis (acute leukemia)

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43
Q

tx of CML

A

imatinib; only BMT can cure CML but should never be 1st thx

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44
Q

priority in leukostasis reaction (extremely elevated WBC typically in patient with AML or CML presenting with sxs of decreased tissue perfusion)

A

leukaphersis - removal of excessive WBCs

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45
Q

myelodysplastic syndrome definition

A

preleukemic disorder presenting in older patients with a pancytopenia despite a hyper cellular bone marrow; most patient never develop AML because complication of infection and bleeding lead to death before leukemia occurs

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46
Q

myelodysplastic syndrome diagnosis and tx

A

asymptomatic pancytopenia on CBC, hypercellular BM, Pelget-Huet cells, 5q deletion
tx with transfusion, EPO, azacitidine (decreases transfusion presence and increases survival), lenalidomide (esp in those with 5q deletion), BMT in <50

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47
Q

pt (typically asx or may present with fatigue) with increased WBC which are mostly lymphocytes; dx with flow cytometry

A

chronic lymphocytic leukemia

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48
Q

CLL sxs

A

fatigue, LAD, hepatosplenomegaly, infection, hemolysis

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49
Q

diagnosis of CLL

A

increased WBC (usually >20,000), 80-90% lymphocytes, hypogammaglobulinemia, may present with anemia and thrombocytopenia (d/t BM infiltration or autoimmune warm IgG antibodies)

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50
Q

what is Richter phenomenon?

A

conversion of CLL to high-grade lymphoma, happens in 5% of patients

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51
Q

staging and tx of CLL

A

stage 0 (high WBC), stage 1 (LAD), and stage 2 (hepatosplenomegaly) - no treatment

stage 3 (anemia) and stage 4 (thrombocytopenia) - FLUDarabine, cyclophosphamide, RITUXimab (anti CD 20)

if FLUDarabine fails, use ALEMTUZUMAB (anti CD 52)

mild case + elderly –> CHLORambucil
autoimmune hemolysis or thrombocytopenia –> steroids

give PCP ppx

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52
Q

Hairy cell leukemia story

A

All the old (mature/Hairy) B cells left the BM (“dry tap”) and got TRAPped (TRAP positive) in the spleen (massive splenomegaly) - tx with CLADRIBINE or PENTOSTATIN

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53
Q

Non-Hodgkin Lymphoma definition and presentation

A

a proliferation of lymphocytes in the lymph nodes and spleen, can affect any organ that has lymphoid tissue, presents with painless LAD, may involve pelvic/retroperitoneal/mesenteric structures, B sxs, most patients present with widespread disease (stage III and IV)

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54
Q

B sxs

A

fever, weight loss, drenching night sweats

55
Q

Non-Hodgkin Lymphoma dx and staging

A

dx: excisional bx (take the whole LN out), LDH levels correlate with severity, staging determines intensity of thx, staging procedures involve CT scan of chest/abdomen/pelvis and BM bx

staging: 
stage 1 - LN group 
stage 2 - >/= 2 LN groups / same side of diaphragm 
stage 3 - both sides of diaphragm 
stage 4 - widespread disease
56
Q

Non-Hodgkin Lymphoma tx

A 
local disease (stage I and II) - local radiation and small dose/course of chemo
advanced disease (stage III and IV, B sxs) - chemo with CHOP and rituximab

C - cyclophosphamide
H - adriamycin (doxorubicin)
O - vincristine
P - prednisone

57
Q

CHOP

A

C - cyclophosphamide
H - adriamycin (doxorubicin)
O - vincristine
P - prednisone

tx of Non-Hodgkin Lymphoma

58
Q

MALT tx

A

Tx Helicobacter with clarithromycin and amoxicillin

59
Q

NHLs with worst prognosis

A

Burkitt and immunoblastic

60
Q

Hodgkin disease features

A

almost the same as NHL, but Reed-Sternberg cells on pathology, not usually disseminated but centered around cervical area, most patients stage I and II

61
Q

Tx of Hodgkin disease

A

stage III and IV, B sxs: ABVD

A - adriamycin (doxorubicin)
B - bleomycin
V - vinblastine
D - dacarbazine

62
Q

ABVD

A

A - adriamycin (doxorubicin)
B - bleomycin
V - vinblastine
D - dacarbazine

tx of Hodgkin disease

63
Q

Complications of radiation thx

A

solid tumors (breast, thyroid, lung), increased risk of premature CAD, risk of acute leukemia, MDS, and NHL

64
Q

Contraindication to adramycin (doxorubicin)

A

EF <50%

65
Q 
Adverse side effect of 
Doxorubicin - 
Vincristine - 
Bleomycin -
Cyclophosphamide - 
Cisplatin -
A 
Adverse side effect of 
Doxorubicin -cardiomyopathy  
Vincristine - neuropathy 
Bleomycin - lung fibrosis 
Cyclophosphamide - hemorrhagic cystitis 
Cisplatin - renal and ototoxicity
66
Q

abnormal proliferation of plasma cells

A

myeloma

67
Q

most common causes of death in myeloma

A

renal failure and infection

68
Q

serum protein electrophoresis shows IgG or IgA spike (monoclonal or “M” spike)

A

most likely monoclonal gammopathy of unknown signfiicance, but

69
Q

serum protein electrophoresis shows IgM spike (monoclonal or “M” spike)

A

Waldenstrom macroglobulinemia

70
Q

lab findings in multiple myeloma

A

IgA or IgG “M” spike
light chains or Bence-Jones protein on urine immunoelectrophoresis (not detected in urine dipstick)
hypercalcemia
smear with rouleaux
elevated BUN and creatinine
decreased anion gap
BM bx with > 10% plasma cells (nothing beside myeloma has this finding)

71
Q

tx of multiple myeloma

A

combo of steroids and lenalidomide, bortezomib, or both

72
Q

tx of Waldrenstrom macroglobulinemia

A

plasmapheresis; long term thx with rituximab, prednisone, cyclophosphamide

73
Q

types of bleeding
A) superficial, epistaxis, purpura, mucosal surfaces =
B) deep, joints, muscle =

A

A) platelet bleeding

B) factor bleeding

74
Q

megakaryocytes + thrombocytopenia + normal sized spleen =

A

immune thrombocytopenia purpura

75
Q 
tx of ITP 
A) no bleeding, count >30,000
B) mild bleeding, count <30,000
C) severe bleeding, count <10,000
D) recurrent episodes, steroid dependent 
E) refractory
A

tx of ITP
A) no bleeding, count >30,000 - observation (no tx)
B) mild bleeding, count <30,000 - steroids
C) severe bleeding, count <10,000 - IVIG, anti-Rho (anti D)
D) recurrent episodes, steroid dependent - splenectomy
E) refractory - romisplostim or eltrombopag, rituximab, steroid alt (azathioprine, cyclosporine, mycophenolate)

76
Q

vWD tx

A

DDAVP (desmopressin)

77
Q

reverses warfarin toxicity

A

prothrombin complex concentrate > FFP > vit K

78
Q

cryoprecipitate replaces

A

fibrinogen; never first line treatment

79
Q

tx of DIC

A

replace platelets and clotting factors (FFP), heparin?, replace fibrinogen (cryoprecipitate) if FFP does not control bleeding

80
Q

replaces clotting factors

A

FFP

81
Q

test for HIT

A

platelet factor 4 antibodies or serotonin release assay

82
Q

when do you give platelets?

A

bleeding patient with count <50,000; contraindicated in TTP

83
Q

FFP uses

A

replaces clotting factors in those with elevated PT, aPTT, or INR and bleeding. used as replacement with plasmapheresis. not a choice for those with hemophilia or vWD

84
Q

sxs of anemia

A

dyspnea and fatigue, lightheadedness, angina, syncope, chest pain

85
Q

less common causes of macrocytic anemia

A

liver disease, hypothyroidism, medications (zidovudine, phenytoin), myelodysplastic syndrome, cold agglutinins can falsely elevate MCV by clumping cells

86
Q

very low hematocrit in the elderly or those with heart disease

A

25-30

87
Q

things that will raise reticulocyte count

A

blood loss and hemolysis

88
Q

only microcytic anemia with elevated reticulocyte count

A

alpha thalassemia with 3 gene deleted

89
Q

stores iron; also acute phase reaction (elevated in acute infection)

A

ferritin

90
Q

regulates iron absorption; low in anemia of chronic disease

A

hepcidin

91
Q

alcohol causes what kind of anemia?

A

sideroblastic

92
Q

anemia of inability of iron to be incorporated into heme

A

sideroblastic

93
Q

initial test for microcytic anemia

A

iron study

94
Q

low ferritin + low serum iron + high TIBC

A

iron deficiency anemia

95
Q

high or normal ferritin + low serum iron + low TIBC

A

anemia of chronic disease

96
Q

the only microcytic anemia where serum iron is elevated

A

sideroblastic

97
Q

microcytic anemia with normal iron studies

A

thalassemia

98
Q

single most acute test to diagnose iron deficiency anemia, rarely done

A

BM bx for stainable iron

99
Q

staining for ringed sideroblasts

A

Prussian blue

100
Q

initial test for macrocytic anemia

A

blood smear looking for hypersegmented neutrophils; if positive, then get B12 and folate levels, both have high homocysteine levels but only B12 gives high methylmalonic acid levels; will also have increased LDH and indirect bilirubin levels (–> ineffective erythropoiesis)

101
Q

pancreatic insufficiency is asso with what type of anemia?

A

macrocytic anemia; pancreatic enzymes are need to remove B12 from R-protein so it can bind IF

102
Q

metformin is asso with what type of anemia?

A

B12 deficiency –> macrocytic anemia

103
Q

B12 may be normal in patients with B12 deficiency because

A

transcobalamine (the carrier protein) is an acute phase reactant

104
Q

what is a major complication of B12 or folate replacement?

A

hypokalemia; rapid production of RBCs depletes K+

105
Q

haptoglobin levels in hemolytic anemia

A

decreased

106
Q

what lowers mortality in sickle cell disease?

A

hydroxyurea (prevents sickle cell crises) and antibiotics with fever

107
Q

patient with sickle cell disease is admitted in acute pain crisis. hct drops from 34 –> 22% during stay. what’s the best initial test? what is the likely diagnosis? what is the best initial therapy?

A

patient with sickle cell disease is admitted in acute pain crisis. hct drops from 34 –> 22% during stay. what’s the best initial test? - reticulocyte count; if decreased –> aplastic crisis
what is the likely diagnosis? parvovirus B12 infection (confirm with PCR)
what is the best initial therapy? IVIG

108
Q

increased MCHC

A

hereditary spherocytosis

109
Q

alternative tx to diminish need for steroids

A

cyclophosphamide, cyclosporine, azathioprine, mycophenolate mofetil

110
Q

cold agglutinin disease asso w

A

EBV, Mycoplasma pneumoniae, and Waldenstrom macroglobulinemia

111
Q

tx of cold agglutinin disease

A

keep patient warm, rituximab, immunosuppressive agents

STEROIDS IS NEVER THE RIGHT ANSWER

112
Q

G6PD level after a hemolytic event

A

will be normal

113
Q

tx of HUS and TTP

A

plasmapheresis; if there is a delay to plasmapheresis –> infuse FFP; DO NOT TRANSFUSE PLATELETS

114
Q

most common cause of death in paroxysmal nocturnal hemoglobinuria

A

thrombosis (large vessel or mesenteric/hepatic veins)

115
Q

most accurate test to dx paroxysmal nocturnal hemoglobinuria

A

CD55 and CD59 levels

116
Q

eculizumab

A

complement ib, use in PNH, give meningococcal vaccine prior

117
Q

pancytopenia of unclear etiology

A

aplastic anemia

118
Q

tx of aplastic anemia

A

supportive: transfusions, antibiotic for infection, platelets for bleeding
<50 years old: BMT
> 5O: antithymocyte globulin and cyclosporine, also altentuzumab (anti CD 52, suppresses T cells) *

aplastic anemia is a autoimmune disorder in which the T cells attack the patient’s own marrow, treatment is based on medications like cyclosporine that inhibit T cells, this brings the marrow back to life

119
Q

labs in polycythemia vera

A

hct >60%, platelets and WBCs up as well, normal oxygen levels, low EPO, high vit B12 (unknown reason), low iron, low MCV, JAK2 mutation

120
Q

JAK inhibitor

A

RUXOLItinib

121
Q

meylofibrosis tx

A

teardrop shaped cells, tx with thalidomide and lenalidomide

122
Q

erythromelagia

A

burning cyanosis in hands and feet, seen in p vera, tx w ASA

123
Q

most common cause of iron deficiency anemia in a child

A

excessive consumption of cow’s milk (>24 oz or 700 ml/day)

124
Q

RDW

A

red cell distribution width, elevated (>20%) in iron deficiency anemia and other nutritional deficiencies

125
Q

duration of liver vit k supply

A

30 days, but in acutely ill person it can be depleted in 7-10 days

126
Q

factor v leiden causes a hypercoagulable state due to

A

activated protein C resistance

127
Q

most common bleeding disorders in children

A

hemophilias and vWD

hemophilia and other coagulation disorders commonly present with hemarthroses, soft tissue hematomas, and intramuscular hematomas; in constant platelet aggregation disorders such as vWD present predominantly with easy mucosal bleeding, ecchymoses, and petechiae

128
Q

anemia of prematurity

A

most common cause of anemia in preterm infants, d/t low EPO levels, short RBC life span, and blood loss; exacerbated by frequent blood draws / phlebotomy in the NICU

129
Q

autosomal recessive disorder of absent platelet glycoprotein Ib-IX-V, which acts as a receptor for vWF. patients usually have mild thrombocytopenia, circulating giant platelets, severe platelet dysfunction, and bleeding out of proportion to the degree of thrombocytopenia

A

Bernard-Soulier syndrome

130
Q

HIT causes thrombocytopenia (due to reticuloendothelial sequestration of antibody-coated platelets) plus

A

increased risk of arterial and venous thrombus formation (due to HIT antibody activation of platelets, results in platelet aggregation and release of procoagulant factors)

131
Q

effect of CYP450 inhibitors and inducers on warfarin

A

inhibitor - increase effect –> bleeding

inducers - decrease effect –> hypercoagulable

132
Q

CYP450 inhibitors

A 
acetaminophen, NSAID
antimicrobials 
amiodarone 
cimetidine 
cranberry juice, ginkgo, vit E 
omeprazole 
TH
SSRIs
133
Q

CYP450 inducers

A 
carbamazepine, phenytoin
ginseng, St John's wort 
OCPs 
phenobarbital 
rifampin
134
Q

difference btwn CML and leukemoid reaction

A

in CML, the leukocyte alkaline phosphatase score (a marker of neutrophil activity) is typically low

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