Justin Practice Questions 2022

Question 1

Which pathway is TGF-beta part of

Answer 1

SMAD or PI3K/AKT or RAS/RAF/MEK

Apoptosis

Question 2

Which is not in a proliferation pathway?

Answer 2

BAX (apoptosis gene)

Question 3

What are G coupled receptors

Answer 3

7 membrane spanning proteins that are activated with GTP then self hydrolyze to GDP and turn off

Transmembrane cell signalling proteins

Question 4

Proposed mechanism of synergy b/t chemo and angiogenesis inhibitors

Answer 4

Normalization theory - anti-angiogenic agent restores normal blood flow and reduces tumor interstitial fluid pressure favoring the penetration of cytotoxic agents

Question 5

Most common mechanism of oncogene activation

Answer 5

1) mutation (in promoter)
2) gene amplification (probably this one)
3) chromosome rearrangement

TL: Lit search suggests that gene amplification is the correct answer

Question 6

Mechanism by which tumor suppressor genes are deactivated

Answer 6

Methylation (think MLH1)

Question 7

Genes related to apoptosis

Answer 7

1. “bcl (b cell lymphoma) - anti-apoptosis
2. caspase - programmed cell death including apoptosis (fas pathway), pro apoptosis
3. BAX (bcel-2 like protein 4) encoded by BAX gene - pro apoptosis
4. TP53

Important: NOT VEGF

Question 8

Best way to amplify DNA

Answer 8

PCR

Question 9

Best way to quantitate protein

Answer 9

Mass Spec or ELISA

Question 10

What are static cells?

Answer 10

Well-differentiated that rarely undergo division as adults (ie neurons, oocytes, striated m, nephrons)

Question 11

What are expanding cells?

Answer 11

Normally quiescent but grow under stress/injury (ie hepatocytes, vascular endothelium

Question 12

What are renewing cells

Answer 12

Constantly replicating (ie BM, epidermis, GI

Question 13

Mechanism of apoptosis (3 phases)

Answer 13

initiation/induction:
—intrinsic pathway = response to internal pro-apoptotic stimuli such as DNA damage
–extrinsic pathway = activated by the binding of ligands
effector: caspase portion
degradation

Morphologically, apoptosis characterized by: condensation of chromatin, nuclear and cytoplasmic blebbing, and cellular shrinkage followed by phagocytic destruction

Question 14

Oncogene associated with EMCA/lynch syndrome

Answer 14

c-myc… we found kras (maybe wasn’t option?)

Think: M for MMR

diff to find/confirm but looks like similar question last year so trusting their answer (AW)

AS: could be KRAS?

Question 15

PTEN, MSH2, and TP53 are what type of gene

Answer 15

Tumor suppressor gene

Question 16

Molecular pathway responsible for epithelial to mesechymal transformation

Answer 16

Wnt/beta-catenin pathway

Question 17

What is the PD-1 effect on T cells?

Answer 17

PD-1 (expressed on T and B cells) is the negative regulator of T-cell activation.
On T cells, it promotes apopotosis of effector T cells and reduces apoptosis of Treg cells
T cells exhausted and unable to proliferate/secrete IL-2 or kill target cells

PD-1 expressed on: CD4 & CD8 T cells, B cells, monocytes, NK cells, and dendritic cells. Highly expressed on tumor-specific T cells

Question 18

IL-2 stimulates which cells?

Answer 18

T cells: helper T cells (CD4), cytotoxic T cells (CD8) and Tregs (CD4)
NK cells (in combo with IL-12)

Question 19

MHC and T cells - which go with which?

Answer 19

Tc/Cytotoxic = MHC1 = CD8 = apoptosis (From beginning to end = MHC1 & CD8)
Th/helper = MHC2 = CD4 (helpers are middle men = MHC2 and CD4)

Both add to 8:
1x8=8
2x4=8

Question 20

Where are B cells made?

Answer 20

Produced in bone marrow then migrate to lymphoid organs (spleen, LN follicles, GI tract) to mature

Question 21

What cells are included in innate immunity?

Answer 21

Present at birth. NK, macrophages, dendritic cells

Question 22

What cells are included in acquired immunity?

Answer 22

T cells and B cells

Question 23

What cells secrete histamine?

Answer 23

Basophils and Mast cells

Question 24

What cell / cell line do dendritic cells and macrophages originate from?

Answer 24

Monocytes (myeloid stem cell origin)

Question 25

Where is MHC I expressed?

Answer 25

MHC class I molecules are ubiquitously expressed on all nucleated mammalian cells including cells of epithelial origin. Platelets too (AW) (All cells except erythrocytes) ## Footnote they also had: trophoblast, germ cells ?, neurons? -expressed on neurons (AW) -not expressed on spermatogenic cells (AW) -expression on some types of trophoblasts (AW)...too much to know

Question 26

Where is MHC II expressed?

Answer 26

MHC class II molecules are selectively expressed on antigen-presenting cells (APC) including dendritic cells (DC), macrophages, and B cells.

Question 27

Which cells are MHC restricted?

Answer 27

Restrict = T cells MHC restriction= T cells will only recognize specific Ag on "self" MHC molecule subtype (HLA type) with the correct Ag in combination with it ## Footnote Prior card had: MHC restriction means that different T cells are restricted to either Class I or Class II MHC antigens. Cytotoxic T cells are restricted to Class I antigens present on nucleated body cells, thus play a role in protecting against virus-infected cells or cancerous cells.

Question 28

What immune cell secretes IL-1?

Answer 28

Macrophages (+ monocytes, dendritic cells) (AW)

Question 29

What does IL-1 do?

Answer 29

Mediates inflammation, fever Stimulates T cells (cell mediated response)- to make IL-2 Stimulates proliferation of B cells and increase Ab production (Ab mediated response/humoral immunity). ? stimulates Macrophages (inflammatory response) -*released by activated macrophage, not sure if it also then acts to further stimulat macrophage (AW)*

Question 30

What do dendritic cells do?

Answer 30

Professional Antigen presenting cells

Question 31

What do natural killer cells do?

Answer 31

Lymphocyte that destroy tumor cells and cells infected by viruses. Respond to cytokines and interferons. Do not require activation w/receptor (i.e., with MHC1)

Question 32

Which are the first immune cells to respond?

Answer 32

Polymorphonuclear neutrophils (PMNs) | PMNs=Neutrophils, eosinophils, and basophils

Question 33

What do CD4 cells do?

Answer 33

recognize MHC II; Th1 cells stimulate CTLs and macrophages (cellular immune responses) Th2 cells stimulate antibody responses Th17 cells mediate autoimmune diseases

Question 34

What do CD8 cells do

Answer 34

recognize MHC1; secrete cytokines and can defend against tumors by directly killing transformed cells (granuloeoxytosis) or induction of extrinsic apoptosis by activating Fas molecules

Question 35

What is the function of Immunoglobulins A, D, E, G, M

Answer 35

A = first response: defends mucosal surfaces D = B cell receptors prior to Ag exposure. Signals B cell activation and is initially coreleased with IgM. Activates basophils and mast cells to produce antimicrobial factors (respiratory immune defense) E = binds allergans/parasites. Trigger histamine release from mast cell and basophils. involved in hypersensitivity G = 2nd line Ab; opsonization and neutralization. Crosses placenta M = 1st line Ab; activates complement. B cell receptor. Used for non-protein Ag. Pentamer

Question 36

What is the MOA of ipilimumab? **TEST QUESTION**

Answer 36

mAb; CTLA4 blockade. CTLA4 is a receptor on T cells that receives inhibitory signal from dendritic cells/APC (CD80/86 aka B7 molecule). Ultimately results in Activation of CD4 and CD8 + effector T cells by removing an inhibitory checkpoint on proliferation and function, inhibits Treg activity Currently used in melanoma

Question 37

what makes a tumor antigen a good immune (antibody) target? (Duplicate)

Answer 37

expression on cell surface

Question 38

What are interleukins?

Answer 38

Interleukins (IL) are a type of cytokine first thought to be expressed by leukocytes alone but have later been found to be produced by many other body cells. They play essential roles in the activation and differentiation of immune cells, as well as proliferation, maturation, migration, and adhesion.

Question 39

How do you make monoclonal antibodies?

Answer 39

Fuse antibody secreting B cells (spleen cells from mouse immunized with antigen of interest) and myeloma cells —> hybridoma cells. Select immortal hybridoma that makes specific antibody for antigen of interest

Question 40

What is a significant limitation of using retroviruses for gene therapy?

Answer 40

Retroviruses (RNA viruses) only infect dividing cells and depend on reverse transcriptive (RNA to DNA) to allow the virus to integrate into the host genome and be continuously produced. Disadvantage: The ability of retroviruses to integrate into the host cell chromosome also raises the possibility of insertional mutagenesis and oncogene activation. this can lead to leukemia

Question 41

Which chemo drugs are vesicants? (Duplicate Q)

Answer 41

Doxorubicin/ Epirubicin/ idarubicin/ daunorubicin ActinomycinD Mitomycin C Nitrogen mustard Trabectinib Vinblastine, vincristine, vinorelbine (all vincas) DAMN TV

Question 42

Which chemos are S phase specific?

Answer 42

Antimetabolites, Topo 1 (topotecan, irinotecan) Doxorubicin most cytotoxic in S "HI 5 The Good Man"= **H**ydroxyurea,** I**rinotecan, **5**-FU, **T**opotecan, **G**em, **M**TX

Question 43

Which chemos are M phase specific?

Answer 43

**Vinca alkaloids & taxanes**: pure M phase - taxanes: promotes assembly of microtubules and stabilizes them, preventing depolymerization - vincas: interacts with tubulin w/resulting inhibition of microtubule assembly and cellular division (Mitotic spindle poisons) **Eribulin, ixabepilone**: arrest at G2/M -Eribulin: inhibitor of microtubule dynamics, binding a small number of high affinity sites at the plus ends of existing microtubules -Ixabepilone: semi-synthetic analog of epothilone B, like taxol=stabilizes microtubules

Question 44

Which chemos are G2 phase specific?

Answer 44

- Bleomycin: G2 phase - Etoposide: G2 (max kill) and S phase - Eribulin, ixabepilone: causes arrest at G2/M G2 BE2 or G2 BEE= bleo, etopo, eribulin/ixabepilone

Question 45

Which Chemos G1 phase specific?

Answer 45

No Chemos specifically act at G1; MTOR inhibitors, ActD, Tamoxifen - = agree, hormones cited as G1 frequently Act-D is cell cycle nonspecific with max kill in G1

Question 46

Which chemos are non-cell cycle specific?

Answer 46

Alkylating: Cyclophosph/ifosf, Altretamine/hexamethylmelamine, ecteinascidin Platinums Anti-tumor abx: Doxorubicin, Mitomycin-C, Actinomycin-D Nitrogen mustards/alk: Melphalan, Chlorambucil

Question 47

Which chemo leads to amenorrhea in young women? A. vincristine B. etoposide C. mtx D. cisplatin

Answer 47

Cisplatin NON CELL CYCLE SPECIFIC ARE MORE LIKELY TO BE GONADAL TOXIC Chemo induced amenorrhea risk: Highest risk: Alkylating agents (cyclophosphamide, ifos, busulphan, chlorambucil, melphalan, chlormerthin, procarbazine: Medium: platinum (cis, carbo); anthracyclines (doxorubicin), taxanes Low: vincas, bleo, antimetabolites (mtx, 5-FU) When short-term intensive chemotherapy is used, particularly with antimetabolites, vinca alkaloids, or antitumor antibiotics, injury to the reproductive system is less common. For example, men treated for testicular cancer, children with acute leukemia, and women cured of GTD or ovarian germ cell malignancies usually recover reproductive capacity after therapy

Question 48

Which chemo don't have to renally dose? A Cytoxan B topo C gem D methotrexate **TEST QUESTION **

Answer 48

Gemcitabine A BICCC THEMM (ones to renally dose) ActD bleo, ifos, cis/carbo, cytoxan, Capecitabine topotecan, hydroxyurea, etoposide, mtx/pemetrexed Melphalan

Question 49

Which chemos are pro-drugs?

Answer 49

Capecitabine, cyclophosphamide, ifosfamide, gemcitabine Also the following: - Oxaliplatin: extensive non-enzymati c conversion to its active metabolize - Irinotecan: converted to active metabolite SN-38 - MitomycinC - Cytarabine requires intracellular activation to its phosphorylated derivative - Temsirolimus

Question 50

Which of the following agents are cell cycle specific? A. mtx B. Taxol C. Cisplatin D. carboplatin E. cyclophosphamide

Answer 50

taxol: M only - anti-folates (i.e., mtx, pemetrexed): S and G1 Not cell cycle specific: Alkylating compounds (G1,G2,S): direct DNA damage, DNA adduct formation, free radical production; i.e., radiation, platinum, bleomycin; cyclophosphamide, carboplatin ## Footnote BAD QUESTION

Question 51

When is bev held?

Answer 51

Proteinuria >/= 2g in 24h urine (Nephrotic syndrome cutoff is 3.5 g/day) or hypertensive crisis > 180/120 or hypertensive encephalopathy. ## Footnote package insert says DC not just hold if HTN encephalopathy/PRES or nephrotic range proteinuria (AW)

Question 52

What toxicity does mtx not have? A. Cardiotoxicity B. hepatotoxicity C. nephrotoxocity D. hematologic toxicity

Answer 52

Cardiotoxicity

Question 53

What "rescue" med is available for methotrexate?

Answer 53

Leucovorin - derivative of folic acid (to overcome high dose mtx BM toxicity) Derivative of tetrahydrofolic acid (reduced by MTX) that is readily converted to other reduced folic acid derivatives which have vitamin activity equivalent to that of folic acid. "rescues" cells by replenishing intracellular reduced folate pools (give within 48 hours of mtx) FYI can also be used to potentiate anti-tumor activity of 5-FU

Question 54

What is the most common side effect of amifostine? (Duplicate)

Answer 54

Hypotension (62%); Used to protect the kidneys from cisplatin, reduce carbo thrombocytopenia and reduce renal/BM SE from cisplatin and cyclophosphamide protects salivary glands during radiation tx (decrease dryness in the mouth)

Question 55

What is the dose limiting toxicity of irinotecan?

Answer 55

Diarrhea > myelosupression Diarrhea Occuring during infusion- responsive to atropine (anti-cholinergic) Diarrhea Occuring subacute 2-3 weeks after is not responsive to that, so use anti-motility Diarrhea Can be life-threatening

Question 56

What drug characteristics are associated with better IP chemo administration?

Answer 56

ideal IP: - large molecular weight size - hydrophilic, ionized compounds. - high conc in peritoneum - no need for liver activation - high volume IP dialysate (low vol increases IP clearance rate rapidly, which is bad) ## Footnote drugs enter the tumor nodules by passive diffusion

Question 57

What drug is PPE associated with?

Answer 57

Capecitabine > 5-FU, Doxil, docetaxol (SGO chemo handbook) (old card had pemetrexed per Chi) Also Multitargeted tyrosine kinase inhibitors sorafenib, sunitinib | PPE=painful erythema, scaling, swelling, ulceration involving hands/feet ## Footnote prolonged oral etoposide, weekly and continuous-infusion 5-fluorouracil, capecitabine, PEG-liposomal doxorubicin, prolonged vinorelbine infusions (AW)

Question 58

What chemo most associated with constipation

Answer 58

Vincristine Due to autonomic neuropathy: Impaired intestinal motility constipation and upper colon fecal impaction, paralytic ileus

Question 59

What chemo is primarily renally cleared **TEST QUESTION ***

Answer 59

Bleomycin (bleo blows out those kidneys) Bleomycin is eliminated predominantly by the kidney, with 50% of the dose eliminated within 24 hours after administration. Pemetrexed: About 90% of the drug is excreted unchanged in the urine within 24 hours. Cisplatin, Carboplatin, oxaliplatin, and Mtx also renally cleared

Question 60

What chemo causes polymerization of tubulins

Answer 60

Taxol Unlike other tubulin targeting drugs such as colchicine that inhibits microtubule assembly, paclitaxel stabilizes the microtubule polymers and protects them from disassembly.

Question 61

What chemo cannot be given IP?

Answer 61

Cyclophosphamide and ifosfamide (are prodrugs that require activation in the liver!) Capecitabine (oral drug…), cyclophosphamide, ifosfamide gemcitabine CAN be used as IP chemo (and has been used in pancreatic cancer!) Some agents are excessively toxic given this route: doxorubicin, mitoxantrone

Question 62

What are the parameters for carbo calculator

Answer 62

Calvert formula: Dose (mg) = target AUC (mg/mL x min) x [GFR (mL/min) + 25 (mL/min)] GFR /CrCl calculated using: Age, creatinine, weight/height, gender - [(140-age)(wt)(0.85)]/(72xCr)

Question 63

Use of amifostine

Answer 63

Decrease nephrotox of cisplatin and cytoxan. Prodrug that acts as a free radical scavenger and tends to be selective to non-malignant tissues

Question 64

Taxol 24 vs. 3 hours

Answer 64

Less neurotoxicity for 24 hours but more BM toxicity AKA: 3hr= more neurotoxic, 24hr= more myelosuppressive (AW)

Question 65

Target for aprepitant **TEST QUESTION **

Answer 65

NK1 receptor (central NS); dominant ligand is substance P Aprepitant prevents acute and delayed vomiting by inhibiting the substance P/neurokinin 1 (NK1) receptor; augments the antiemetic activity of 5-HT3 receptor antagonists and corticosteroids to inhibit acute and delayed phases of chemotherapy-induced emesis. Aprepitant is a potent and selective NK-1 tachykinin receptor antagonist that blocks the effects of substance P (SP) in the central nervous system.

Question 66

Strategies to reduce nephrotoxicity of chemo

Answer 66

Dose reduce, hydration, eliminate other nephrotoxic drugs

Question 67

Side effect LEAST likely to be minimized when choosing aromatase inhibitor over tamoxifen **TEST QUESTION **

Answer 67

AI will not Reduce osteoporosis fractures, MSK pain. Tamox SE: endometrial cancer, vag bleeding, VTE/CVA, hot flashes - anti-est in breast, pro everywhere else (uterus, bone, liver, coagulation system), fatty liver, increased triglycerides, lower LDL, cataracts AI: hot flashes, osteopenia or osteoporosis, bone pain, diarrhea, heart disease, increase LDL/decrease HDL Both: hot flashes, sexual dysfunction

Question 68

Pt on BEP with pulm sx, what do you do first

Answer 68

Stop bleo

Question 69

Prodrugs: which is not (and list which are common prodrugs)? A gemzar B 5FU C taxotere D cyclophosphamide

Answer 69

taxotere is not. True Prodrugs: cyclophosphamide, ifosfamide, capecitabine Require activation: - irinotecan - reversible equilibrium with reactive intermediates (SN-38) - cisplatin, carbo: require activation through irreversible aquation - others: gemcitabine, 5-FU Others: Oxaliplatin: extensive non-enzymatic conversion to its active metabolize Cytarabine requires intracellular activation to its phosphorylated derivative

Question 70

Peak level IP vs. IV bioavailability for carbo A 1:5 B 1:20 C 1:200 D 1:500 (Duplicate)

Answer 70

1:20 Barakat - 18:1 IP vs IV concentration in peritoneal cavity 20:1 cisplatin 1000:1 paclitaxel Virtually all commonly used drugs administered IP in patients with ovarian cancer have peak or concentration x time product ratio of more than 20.

Question 71

Most unlikely side effect of bev A Hypotension B GI perf C bleeding D headache

Answer 71

Hypotension not complication Hypertension (24% to 42%) headache (22% to 49%) Hemorrhage (grades ≥3: ≤7%; including major hemorrhage) gastrointestinal perforation (≤3%)

Question 72

Most common sx of GCSF

Answer 72

bone pain Filgrastin: Neuromuscular & skeletal: Back pain (15%), ostealgia (3% to 30%) Pegfilgraststim: Neuromuscular & skeletal: Ostealgia (31%)

Question 73

Most emetogenic Chemos **TEST QUESTION **

Answer 73

Highly emetic (>90%, B&H) - Cisplatin - Anthracycline and cyclophosphamide - Cyclophosphamide >=1500 mg/m²

Question 74

Most common side effect of megace A breast tenderness B weight gain C hyperglycemia D hypercholesteremia

Answer 74

weight gain Hyperglycemia (6%) gynecomastia (1% to 3%), weight gain (not attributed to edema or fluid retention)

Question 75

Most common acute tox of IP chemo

Answer 75

Abdominal pain

Question 76

Mechanisms of platinum resistance

Answer 76

1) **Decreased uptake**: Downregulation of CTR1 (Copper transporter 1) 2) **Inactivation by glutathione**: Elevated levels of enzymes involved in GSH synthesis (gamma-glutamylcystein synthestase) and glutathione S transferase (binds to platinum inactivating it) 3) ** Nuclear excision repair (NER) pathway** : expression of ERCC1 leads to increased repair of platinum-DNA adducts (THIS most common) 4) **DNA MMR**: loss of function of MMR contributes to developing DNA damage tolerance 5) loss of pro apoptotic factors or over expression of anti-apoptotic factors

Question 77

Mechanisms of nausea and receptors drugs target/act on **TEST QUESTION **

Answer 77

Muscarinic - scopolamine H1 - benadryl, dramamine D2 - prochlorperazine (compazine, metoclopramie (reglan) 5HT3- zofran, palonsetron NK-1- aprepitant GABA - benzos

Question 78

Mechanism of cisplatin with radiation

Answer 78

Cell repair inhibited. Cisplatin binds with DNA causing INTRAstand cross-links and DNA adducts that are primarily repaired via NER. Radiation causes single and double strand breaks that are primarily repaired via NHEJ. When these DNA breaks are attempted to be repaired by DNA-protein kinase dependent NHEJ, presence of cisplatin-adducts prevents the repair and leads to cell death. Increased oxidative stress.

Question 79

Mechanism of action: topotecan **TEST QUESTION**

Answer 79

1. Inhibit TOPO-I (a nuclear enzyme that induces reversible SINGLE STAND DNA BREAKS during DNA replication) 2. forms topotecan-TOPO-I-DNA complex, preventing religation of ssDNA BREAKS 3. Interaction between complex and replication enzymes results in dsDNA breaks and cellular death S phase

Question 80

Mechanism of action: methotrexate

Answer 80

Mtx binds to DHF (dihydrofolate reductase) blocking DHF -->THF (tetrahydro-folic acid, active form of folic acid). As a result, thymidylate synthetase and other steps in de novo purine synthesis that require 1-carbon transfer rxn are halted. This arrests DNA, RNA and protein synthesis S phase specific

Question 81

Mechanism of action: gemcitabine **TEST QUESTION **

Answer 81

—> Prodrug metabolized inside **cells**!! Metabolized into triphosphate and diphosphate metabolites. Triphosphate metabolite incorporated into DNA as fradulent base pair, leading to addtl deoxynucleotide at end of DNA. Replication is terminated (called "MASKED CHAIN TERMINATION) which prevents exonucleases from excising fradulent base pair. Diphosphate metabolite inhibits ribonucleotide reductase, which depletes deoxynucleotide pools necessary for DNA synth/repair Primarily S-phase, but also blocks progression through G1 to S. Gems for short 💎. Gem can be found on a chain around the neck. So it does masked chain termination. Gems are found in pyramids, so gem-triphosphate is a **pyrimidine analog**

Question 82

Mechanism of action: etoposide

Answer 82

Inhibits TOPO-II enzymes (does NOT bind directly to DNA) rather stabilizes transition form of DNA-TOPII. by stabilizing this it "poisons" TOPOII enzymes which usually helps cells progress out of G2 Cell cycle: S/G2 checkpoint (think more G2) (JS) also decatenation

Question 83

Mechanism of action: doxorubicin

Answer 83

Anthracycline antibiotic from Streptomyces peucetius 1) DNA binding and intercalating, inhibiting DNA synthesis (S phase most potent, but not cell cycle specific) 2) Free radical formation - this may be related to the cardiotoxicity (iron chelation) 3) Inhibition of DNA topoisomerase II by inhibiting strand-passing activity of topo-II (acts in G2 phase) **topo II, free radicals (yes), intercalating (yes), DNA adducts**

Question 84

Doxorubicin Limit lifetime dose to what?

Answer 84

Limit dose to 550 mg/m2 cumulative life dose due to cardiac toxicity From PharmD: Risk for cardiomyopathy increases at cumulative dose 550 over age 18. Test answer on pharmacy exams is usually 550 but no one ever pushes that high since the recommendation to start dexrazoxane is at 300mg/m2 which is probably why you’re seeing that range! ## Footnote Cumulative incidence Cardiomyopathy: 450 mg/m2- 3% 550 mg/m2 - 7% 600 mg/m2 - 15% 700 mg/m2 - 40%

Question 85

Which of the following is the Most leukemogenic chemo? A etopsoside B platin C 5FU D melphalan

Answer 85

**melphalan - 10% risk** Etoposide- 1% Cisplatin- even less cyclophos- <1%

Question 86

Least protein bound chemo? A doxorubicin B topotecan C gem D carbo E ifos

Answer 86

Gem / but maybe actually **carbo** Chemos low protein bound gem negligible Carbo 0% Ifos negligible Highly protein bound ie to albumin: active metab of irinotecan SN-38: ~95% mtx: 50% doxorubicin 75% topotecan 35% Taxol, docetaxel 90s% Etoposide 97% Cis 90% BIG-CT (least protein bound) **B**leo **I**fos **G**em **C**arbo **T**opo

Question 87

Least leukemogenic chemo: A Cisplatin B melphalan C cytoxan D 5-FU

Answer 87

5-FU Most leukemogenic: melphalan, cyclophosphamide, etoposide, cisplatin

Question 88

What are advanced colon adenomas that increase colon cancer risk?

Answer 88

villous or tubulovillous histology (this is the answer), high-grade dysplasia, >/= 1 cm

Question 89

Changes in apoptosis (two questions)

Answer 89

"not cause inflammation, does cause chromatin condensation (this is the answer) 1) cell shrinkage and rounding due to caspase 2) cytoplasm dense and organelles tightly packed 3) chromatin undergoes condensation against the nuclear envelop (PYKNOSIS) 4) nuclear envelope becomes discontinuous and DNA is fragmented (KARYORRHEXIS) 5) cell membrane buds into blebs 6) cell breaks apart into multiple vesicles called apoptotic bodies - these are phagocytosed"

Question 90

Least emetogenic chemo? A Vinca B carbo C doxorubicin D dactinomycin **TEST QUESTION **

Answer 90

Vinca (vincas don't vom) Minimally emetic (<10%) - Bev - Bleo - Nivo, pembro, dostar, durva, ipi - Trastuzumab - Vinblastine, vincristine, vinorelbine

Question 91

Least bone marrow suprresive chemo

Answer 91

Bleomycin (main dose-limiting side effect is pulm tox, 10%; nephrotoxicity)

Question 92

IP chemo pharmacokinetics

Answer 92

Generally - IP chemo should be LARGER, HYDROPHILIC, IONIZED - b/c clear more slowly from peritoneal cavity and cancer, maintain concentration; penetrate tumor nodules through PASSIVE diffusion (up to 2-3 mm) but that's why we cytoreduce

Question 93

Cancer with elevated CA-125 (ovary not a choice)?

Answer 93

Pancreatic, breast, lung cancer), colon, gastric

Question 94

How does cisplatin augment radiation? (repeat)

Answer 94

Inhibit repair of sublethal damage Cisplatin sensitizes cancer cells to ionizing radiation via inhibition of non-homologous end joining Cisplatin pre-treatment increases the number of radiation-induced DNA double-strand breaks Cellular irradiation induces various forms of DNA damage, with DNA double-strand breaks forming the main cytotoxic lesions.

Question 95

Most common mutation in mucinous ovarian cancer (p53, KRAS, BRAF, Her2/neu)?

Answer 95

KRAS

Question 96

Doxil versus doxorubicin (Duplicate questions) ** TEST QUESTION **

Answer 96

Liposomal bound (aka pegylated) with MPEG methoxypolyethylene glycol to avoid detection by the mononuclear phagocyte system Results in: - longer plasma life - slower plasma clearance, - reduced volume of distribution - higher tumor-tissue drug concentrations - NOT a vesicant - associated with minimal cardiotox, alopecia, nausea/vomiting But increased rates of PPE (dose limiting in 25%) and stomatitis

Question 97

MOA P53 as tumor suppressor

Answer 97

can activate DNA repair, cause G1/S arrest to allow time for repair of DNA damage, maintains genomic stability, initiate apoptosis

Question 98

Mutation associated with mucinous epithelial ovarian cancer

Answer 98

KRAS, tp53

Question 99

Mucinous ovarian cancer most common tumor suppressor? Oncogene?

Answer 99

Tumor suppressor: TP53 Oncogene: KRAS

Question 100

Which pathway is responsible for the Epithelial to mesenchymal transition

Answer 100

WNT/Beta-catenin

Question 101

Telomerase

Answer 101

Telomeres are "caps" at ends of chromosomes and keep chromosomes from being degraded. Every time cell divides, a few base pairs lost and eventually these "caps" are gone. Telomerase is a protein/DNA complex that lengthens the 3' telomere end so the cell can divide forever (and thus be immortalized)

Question 102

Aromatase inhibitors most common side effect (Duplicate) **TEST QUESTION **

Answer 102

—> Arthralgia (15-36%) , ? asthenia actually more vasodilation (25% to 36%) Endocrine & metabolic: Hot flash (12% to 36%) Gastrointestinal: Gastrointestinal distress (29% to 34%)

Question 103

When p53 is activated - what stage of cell cycle does it arrest?

Answer 103

G1 (p53 is the first O.G.) - or apoptosis if defects are large

Question 104

Relative risk of raloxifene and thrombosis

Answer 104

RR 2.1 (grady 2004, RCT of 7700+ women) The risk of venous thromboembolic disease (deep venous thrombosis or pulmonary embolism) was 3.1 times higher (95% CI, 1.5-6.2) in women assigned to the raloxifene group than to the placebo group. (Cummings 1999, RCT of 7700+ women) JS- still lower risk for VTE on raloxifene than tamoxifen

Question 105

Are psammoma bodies in high grade serous ovary good or bad?

Answer 105

Good/favorable prognosis

Question 106

What cells make hCG?

Answer 106

Syncytiotrophoblast

Question 107

What makes up OVA1

Answer 107

CA-125, transthyretin (pre-albumin), Apo A-1, β2 microglobulin, transferrin (5 things)

Question 108

What stain is used for melanoma?

Answer 108

S100 ## Footnote additionally: SOX10, MelanA, HMB45

Question 109

What is function of gemzar prodrug

Answer 109

substitutes cytosine that stops replication by "masked chain termination" anticancer nucleoside is an analog of deoxycytidine. Gemcitabine inhibits thymidylate synthatase, leading to inhibition of DNA synthesis and cell death. Gemcitabine is a prodrug, and once transported into cell, must be phosphorylated by deoxycytidine kinase to an active form. Both gemcitabine diphosphate and gemcitabine triphosphate inhibit processes required for DNA synthesis. Incorporation of gemcitabine triphosphate into DNA is most likely the major mechanism by which gemcitabine causes cell death. After incorporation of gemcitabine nucleotide on the end of the elongating DNA strand, one more deoxynucleotide is added, and thereafter, the DNA polymerases are unable to proceed. This action “masked termination” apparently locks the drug into DNA as the proofreading enzymes are unable to remove gemcitabine from this position

Question 110

What is least leukomegenic chemo

Answer 110

bleo

Question 111

Topo vs etoposide (does etopo or topotecan bind topo I or II)

Answer 111

topo – topo I etop – topo II  (topo t one, etop second letter t two)

Question 112

Which chemos require adjustment for renal compromise (Duplicate) **TEST QUESTION**

Answer 112

A BICCC THEMM (ones to renally dose) ActD bleo, ifos, cis/carbo, cytoxan, Capecitabine topotecan, hydroxyurea, etoposide, mtx/pemetrexed Melphalan ## Footnote Alkylating Topoisomerase Act-D/Bleo Platinums Anti-metabolites (excluding 5-FU, gem)

Question 113

Which chemos requires adjustment for liver compromise? (Duplicate) **TEST QUESTION**

Answer 113

MTV ME 5 CD methotrexate Taxanes (docetaxel/ paclitaxel/nab-paclitaxel) vinkas (vincristine, vinblastine, vinorelbine) Mitoxantrone Epirubicin 5-FU cyclophosphamide doxorubicin/doxil

Question 114

Does 3 hr vs 24 hr administration of taxol lead to increase neurotoxicity or decrease in neurotoxicity?

Answer 114

3 hour more neurotoxic, 24 hour more neutropenia

Question 115

Most common serious side effect of tamoxifen? A thrombosis B ut cancer C vasomotor D colon cancer (Duplicate)

Answer 115

Endometrial cancer Notes say VTE, but… UTD: Serious, life-threatening, and fatal events include uterine malignancies, stroke, and pulmonary embolism. Incidence rates per 1,000 woman-years: Endometrial adenocarcinoma: 2.20 versus 0.71 for placebo Stroke: 1.43 for tamoxifen versus 1.00 for placebo. PE: 0.75 for tamoxifen versus 0.25 for placebo I confirmed with drug package insert from FDA - jv

Question 116

Most common overall side effect of tamoxifen? A thrombosis B ut cancer C vasomotor D colon cancer

Answer 116

Overall: vasomotor (>90%)

Question 117

What's the mechanism of action for Topotecan

Answer 117

Traps topoisomerase I on DNA causing unrepaired ssDNA break Stabilizes the cleavage complex Acts in G2 phase, but also has some activity in S phase

Question 118

Pertuzumab mechanism of action

Answer 118

Block HER2 heterodimerization Pertuzumab is a recombinant humanized monoclonal antibody which targets the extracellular human epidermal growth factor receptor 2 protein (HER2) dimerization domain. Inhibits HER2 dimerization and blocks HER downstream signaling halting cell growth and initiating apoptosis. Pertuzumab binds to a different HER2 epitope than trastuzumab so that when pertuzumab is combined with trastuzumab, a more complete inhibition of HER2 signaling occurs

Question 119

Which needs renal dosing more (etoposide vs. bleo) - since both are renally cleared **TEST QUESTION**

Answer 119

Bleo | Bleo BLOWS out the kidneys

Question 120

What is Calvert's formula?

Answer 120

Dose (mg) = target AUC (mg/mL × min) × [GFR (mL/min) + 25 (mL/min)] The Calvert formula is used to calculate the carboplatin dose accurately in order to obtain a target Area Under the Curve (AUC) by using only the GFR

Question 121

Crockroft-Gault

Answer 121

Equation used to estimate creatinine clearance Used in carboplatin dosing calculations CrCl = 0.85 for female * [(140-age)*(weight kg) / (72*Cr)] Unreliable in patients who are at the extremes of body weight or have an abnormally low serum creatinine

Question 122

Tamoxifen vs. raloxifene

Answer 122

Both anti-est in breast (tamox more effective in breast cancer prevention than raloxifene, but raloxifene less serious side effects [VTE, ut cancer, cataracts]) Both pro-est in the bone Tamox pro-est in endometrium, but raloxifene is not.

Question 123

Which is least emetogenic? A Carbo B vinca C doxorubicin D ifos **TEST QUESTION **

Answer 123

Vincas Highly emetic (>90%) - Cisplatin - Anthracycline and cyclophosphamide - Cyclophosphamide >=1500 mg/m² Minimally emetic (<10%) - Bev - Bleo - Nivo, pembro - Trastuzumab - Vinblastine, vincristine, vinorelbine

Question 124

Which chemo is activated within a tumor cell? ** TEST QUESTION **

Answer 124

Capecitabine | AS: and Gemcitabine

Question 125

Ideal ROC (receiver operating curve) - AUC

Answer 125

Higher AUC, the more accurate There are several scales for AUC value interpretation but, in general, ROC curves with an AUC ≤0.75 are not clinically useful and an AUC of 0.97 has a very high clinical value, correlating with likelihood ratios of approximately 10 and 0.1. AUC varies from 0 to 1. Closer to 1, the higher sensitivity and higher specificity.

Question 126

What are highly emetogentic chemos

Answer 126

Cisplatin, carbo AUC 4+, doxorubicin >60, Ifos >2 NCCN (>90%) AC combination defined as any chemotherapy regimen that contains an anthracycline and cyclophosphamide • Carboplatin AUC ≥4 • Carmustine >250 mg/m2 Cisplatin • Cyclophosphamide >1500 mg/m2 • Dacarbazine • Doxorubicin ≥60 mg/m2 • Epirubicin >90 mg/m2 • Fam-trastuzumab deruxtecan-nxki Ifosfamide ≥2 g/m2 per dose • Mechlorethamine • Melphalan ≥140 mg/m2 • Sacituzumab govitecan-hziy • Streptozocin

Question 127

What are moderately emetogenic chemos

Answer 127

Carbo AUC <4, doxorubicin <60, ifos, oxaliplatin NCCN (30-90%)

Question 128

Minimally emetogentic chemos **TEST QUESTION **

Answer 128

Vincristine, Nivolumab, Bev, Bleo, MTX <50, Pembro NCCN. <10%:

Question 129

mAb with emetogenic potential

Answer 129

Olaratumab (anti-platelet derived growth factor) Withdrawn from the market and used for sarcoma

Question 130

Anastrozole mechanism

Answer 130

reversible binding to aromatase, blocking extragonadal conversion of androgens to estrogens inhibiting aromatase thus, the conversion of androstenedione to estrone, and testosterone to estradiol, is prevented. Anastrozole causes an 85% decrease in estrone sulfate levels.

Question 131

Abraxane (nab-paclitaxel) compared to paclitaxel

Answer 131

Same terminal half life, larger clearance, larger Vd, less allergenic Paclitaxel is solvent-based and formulated in a mixture of polyoxyethylated castor oil and dehydrated alcohol, while nab-paclitaxel is an albumin-bound nanoparticle formulation of paclitaxel and is free of solvents

Question 132

Advantage of liposomal doxorubicin over standard

Answer 132

tumor-tissue drug concentration is 4x-16x higher in liposomal formulation Less cardiotox

Question 133

gemcitabine mechanism of actions (2)

Answer 133

1. Structurally similar to deoxycytidine, gets phosphorylated x3, then incorporated as fradulent base pair, then additional deoxynucleotide added--masked chain termination preventing excision of fradulent base pair--irreparable error that stops synthesis 2. Diphosphate version inhibits the enzyme ribonucleotide reductase (RNR), which is needed to create new nucleotides. The lack of nucleotides drives the cell to uptake more of the components it needs to make nucleotides from outside the cell, which increases uptake of gemcitabine as well

Question 134

Chemotx that need dose reduction for hepatic impairment (bili or transaminitis) **TEST QUESTION**

Answer 134

MTV ME CD Mtx Taxanes Vinkas Mitoxantrone Epirubicin cyclophosphamide Doxil/doxorubicin

Question 135

Doxorubicin MOA

Answer 135

Intercalates DNA inhibiting Topo-II, Chelates iron Forms free radicals, active during entire cell cycle, but most active in S

Question 136

Chemotx causing alopecia

Answer 136

Taxol, ifos, Act-D, etoposide, bleo alkylating agents (IV cyclophosphamide, ifosfamide, busulfan, thiotepa), antitumor antibiotics (dactinomycin, doxorubicin, epirubicin, idarubicin), antimicrotubule agents (paclitaxel, docetaxel, ixabepilone, eribulin), topoisomerase inhibitors (etoposide, irinotecan at higher doses) Alopecia is less common or incomplete with: bleomycin, low-dose epirubicin or doxorubicin (especially <30 mg/m2), oral cyclophosphamide, fluorouracil, capecitabine, gemcitabine, melphalan, methotrexate, mitomycin, mitoxantrone, platinum agents (oxaliplatin, cisplatin, and carboplatin), topotecan weekly low-dose irinotecan vinca alkaloids (vinorelbine, vincristine, vinblastine).

Question 137

Most Common side effect of anastrozole A asthenia B headache C increased bone density D decreased fractures E Arthralgia **TEST QUESTION **

Answer 137

Asthenia | AS: Package insert Asthenia 19%, arthralgia 15%, headache 14%, hot flash

Question 138

Chemo associated with ovarian failure (Duplicate)

Answer 138

Cyclophosphamide > melphalan, cisplatin, etoposide Biggest ones are alkylating agents and procarbazine Also cisplatin, doxorubicin

Question 139

Drug that will stay in the intraperitoneal cavity the longest?

Answer 139

paclitaxel (large molecule, water insoluble, high cavity to plasma AUC ratio[1000:1])

Question 140

Not renally cleared chemotherapy A topotecan B gemcitabine C Cyclophosphamide D methotrexate **TEST QUESTION**

Answer 140

Cyclophosphamide: hepatic inactivation appears to be the major mechanism of active drug elimination Carboplatin, oxaliplatin, Pemetrexed, Bleomycin, Topotecan, gemcitabine, and Mtx also renally cleared

Question 141

Mechanism of chemotherapy related nausea/vomiting? ** TEST QUESTION **

Answer 141

Acute: Related to 5-HT3 Delayed: substance P acute CINV, free radicals generated by toxic chemotherapeutic agents stimulate enterochromaffin cells in the gastrointestinal tract, causing the release of serotonin. Subsequently, serotonin binds to intestinal vagal afferent nerves via 5-HT3 receptors, which trigger the vomiting reflex via the nucleus of the solitary tract (NTS) and chemoreceptor trigger zone (CTZ) in the CNS. delayed CINV. Substance P is principal neurotransmitter. Chemotherapy drugs trigger the release of substance P from neurons in the central and peripheral nervous systems, which then binds to neurokinin-1 (NK1) receptors mainly in the NTS to induce vomiting.

Question 142

Amongst the agents known to cause secondary leukemia, which is the least likely? A Ifosfamide B cyclophosphamide C altretamine D carbo/cis E melphalan F etoposide

Answer 142

**Carbo/cis**? (I believe this is wrong, cisplatin has been associated with leukemia)... Notes said “Ifosfamide (THIS ONE we think)” But literature review suggests platinum agents are least likely in this list. * Leukemogenic agents: cyclophosphamide, cisplatin, etoposide, melphalan, cytoxan. Others: chlorambucil, CCNU (Lomustine), BCNU (carmustine), DTIC (dacarbazine), altretamine AS: B&H -alkylating agents, procarbazine and nutrosoureas are major offenders. Prolonged Etoposide as well A, B, C, E are alkylating agents + F etoposide

Question 143

Amongst the agents known to cause secondary leukemia, which is the least likely? A Ifosfamide B cyclophosphamide C altretamine D carbo/cis E melphalan F etoposide

Answer 143

Lowest risk likely platinum agents - Ifosfamide: listed in UTD - cyclophosphamide: bolded in UTD - altretamine discontinued; not listed as AE though is alkylating - carbo: not listed in UTD - cis: listed in UTD - melphalan: listed in UTD - etoposide: listed in UTD Most leukemogenic: melphalan > cyclophosphamide > etoposide, cisplatin, procarbazine, and the nitrosoureas two well defined groups 1) alkylating agents or 2) drugs binding to the enzyme DNA-topoisomerase II.

Question 144

Call Exner bodies

Answer 144

Granulosa cell tumors (Call your Granny)

Question 145

Schiller-Duval

Answer 145

Endodermal sinus tumor (ESS) its a papillary structure that grows into a cystic space. The papilla is covered by tumor cells and HAS A CENTRAL CAPILLARY region.

Question 146

Multinucleated giant cells

Answer 146

Dysgerminoma

Question 147

What cells make hCG?

Answer 147

Syncytiotrophoblast

Question 148

What makes up OVA1?

Answer 148

CA-125 (upregulated) transthyretin (pre-albumin) transferrin Apo A-1 Beta2 microglobulin (upregulated) 5 things! *OVA1 is also known as multivariate index assay. The score ranges from 0 to 10 and interpreted as follows: Premenopausal patients: *Low probability of malignancy: OVA1 <5 *High probability of malignancy: OVA1 ≥5 Postmenopausal patients: *Low probability of malignancy: OVA1 <4.4 *High probability of malignancy: OVA1 ≥4.4

Question 149

What tumor marker is elevated for PSTT

Answer 149

HPL * extravillous (intermediate) trophoblast cells, most PSTTs are female and diploid. * Surgery (hysterectomy with salpingectomy +/- pelvic lymph node biopsy if non metastatic with low risk findings vs. hysterectomy with salpingectomy and excision of mestastic disease + EMA-EP, EP/EMA or BEP for metastatic disease).

Question 150

Where is Breslow's depth measured from for melanoma?

Answer 150

From granular layer of surface epithelium to the deepest melanoma (Background: Breslow is a measure of how deeply a melanoma tumor has grown into the skin) *Layers of the skin from most superficial to deeper: stratum corneum, stratum lucidum, stratum granulosum, strutum spinosum, stratum basase > dermis.

Question 151

What are the levels of Breslow?

Answer 151

"Level 1 = in situ Level 2 = through BM Level 3 = through papillary dermis Level 4 = through reticular dermis (survival starts to drop off from 90% or higher to 67%) Level 5 = through subcutaneous fat (33%)" ## Footnote Measured from the granular layer of the epidermis to the deepest point of invasion

Question 151

Tamox least likely to be associated with what benign growth?

Answer 151

answer: ovarian cysts most likely to be associated with in order of highest association: benign endometrial polyps hyperplasia fibroids/adenomyosis *also sarcomas and carcinosarcomas

Question 152

What subunit of HCG is shared with other hormones

Answer 152

Alpha same as LH, FSH, TSH; beta is distinct * Thyroid work up should be obtained in patients with molar pregnancy or GTD with bHCG > 100,000. * If features of thyroid storm or impending storm begin immediate treatment with: Beta blocker – Propranolol preferred. Thionamide – Propylthiouracil (PTU) preferred. Iodine – Saturated solution of potassium iodide (SSKI) or Lugol's solution. Consider Hydrocortisone if confirmed clinic storm. Cholestyramine is an additional adjunctive therapy, especially if the patient is allergic to thionamides.

Question 153

Most common tumor in dysgenetic gonads

Answer 153

Gonadoblastoma (benign)

Question 154

Most common malignant tumor in dysgenetic gonads

Answer 154

Dysgerminoma

Question 155

Which growth factors bind to serine-threonine kinase receptor?

Answer 155

Peptide growth factors *Receptor serine/threonine kinases such as transforming growth factor beta (TGF-beta) receptors contain a single transmembrane domain. *Hypersignaling via the TGF-β pathway is associated with increased tumor dissemination (immune evasion, promotion of angiogenesis, increased epithelial to mesenchymal transformation) and has been well studied in ovarian cancer.

Question 156

Location of estrogen receptor and of action mechanism ** TEST QUESTION **

Answer 156

cytosol —> nucleus. MOA: transcription factor ERs are ligand-dependent transcription factors

Question 157

Cancer related to fusion protein

Answer 157

Endometrial stromal sarcomas (uptodate said: JAZF1-SUZ12 and EPC1/PHF1gene fusion) *JAZF1-SUZ12 is a carcinogenic fusion related to low-grade ESS. Its fusion frequency is reported to be 75% in endometrial stromal nodule, 50% in low grade ESS, and 15% in high grade ESS, and can be used to distinguish LG-ESS from HG-ESS. *EPC1-PHF1 is associated with the morphology and clinical features of low-grade ESS.

Question 158

FOXL2 and ovarian cancer subtypes

Answer 158

adult granulosa cell tumor

Question 159

EBRT vs brachytherapy: which symptom is shared?

Answer 159

FATIGUE (answer) -wrong answers: vaginal stenosis, 2 other

Question 160

Which is a direct (rather than indirect) effect of radiation?

Answer 160

LET (answer) wrong answers: photons, gamma rays, hypoxia, chemosens

Question 161

What radiation is used to treat superficial lesions (aka skin)?

Answer 161

Electrons (answer) wrong choices: gamma ray, orthovoltage

Question 162

What is the elemental source for brachytherapy/interstitial?

Answer 162

Iridium-192 (answer) wrong choice: cesium

Question 163

What is the depth of dose for 12 MeV in radiation?

Answer 163

4 cm (R90 where beyond <90% of dose is administered)

Question 164

What is the definition of linear energy transfer (LET)?

Answer 164

The rate of deposition of energy along the path of the radiation beam. Amount of energy transferred to local environment in form of ionizations and excitations. Average energy for a given path length traveled. Average path length for a given deposited energy. Unit = kEV/um

Question 165

What is high LET radiation?     OPTIONS:                   1. neutrons                                                       2. protons                                                         3. photons 4. Gamma rays     5. alpha particles (I added this option but not in justine's)                                        "

Answer 165

High LET: alpha particles, neutrons

Question 166

What is low LET radiation?

Answer 166

electrons, gamma rays, xrays (both electromagnetic radiation)

Question 167

What is % dose of XRT 1 cm vs 2 cm from source?

Answer 167

400% because dose is = 1/r squared *Repeated question

Question 168

How do you manage severe carboplatin sensitivity if patient is responding to the drug?

Answer 168

Desensitization protocol We do not recommend rechallenging patients with platinum agents, even with additional premedications. Instead, we advocate referral to an allergist for skin testing. If skin testing is positive, the patient should either avoid any future exposure to the drug or receive it only through a desensitization protocol.

Question 169

Chemotherapy agents associated with PPE?

Answer 169

Chi: Capecitabine > 5-FU, Doxil, Docetaxol Also Multitargeted tyrosine kinase inhibitors sorafenib, sunitinib

Question 170

Factors that increase the rate of PPE with doxil administration?

Answer 170

Higher dose infusion and prior neuropathy initial doses greater than 40 mg/m2 higher dose and more cycles increased the incidence of several toxicities, including PPE. The use of cooling mechanisms, higher number of PLD cycles, and occurrence of mucositis, neutropenia, and peripheral neuropathy are possible predictors of PPE.

Question 171

Dose limiting toxicity of Gemcitabine **TEST QUESTION **

Answer 171

Myelosuppression

Question 172

Chemo causing ovarian failure A. cyclophosphamide B. 5-FU C. MTX

Answer 172

Cyclophosphamide

Question 173

EXACTLY why we give taxol before cisplatin/ Carboplatin ( duplicate)

Answer 173

Carboplatinum, cisplatin, cyclophosphamide decrease its clearance and therefore increase myelosuppression so these drugs should be administered after paclitaxel (to decrease myelosuppression)

Question 174

Mechanism and dose limiting toxicity vinorelbine

Answer 174

Vinka alkaloid derived from vinblastine. It inhibits tubular polymerization, disrupting the formation of tubules during mitosis. Most of the drug is metabolized in the liver and excreted in the bile. Dose-limiting toxicity is myelosuppression.

Question 175

Loss of MSH2 & MSH6 in tumor MMR testing, what next step? A Tumor genetics B germline genetics C methylation testing **TEST QUESTION **

Answer 175

germline genetics methylation testing is for Loss of MLH1 and PMS2 —> MLH1 promoter methylation

Question 176

Which is more important for dosing methotraxate: biliary obstruction or poor renal function, both were choices

Answer 176

Poor renal function (table 13.11 and 13.9 in Principles and Practice Chi) ## Footnote confirmed (AW)

Question 177

Complication with giving carbo as 3rd line for ovary cancer

Answer 177

hypersensitivity

Question 178

Different side effect between SERM and aromatase inhibitors ** TEST QUESTION **

Answer 178

Tamox SE: endometrial cancer, VTE/CVA, hot flashes - anti-est in breast, pro everywhere else (uterus, bone, liver, coagulation system) , fatty liver, cataracts, decreased LDL Ralox: fewer serious side effects than tamoxifen. No increased UtCa risk AI: hot flashes, osteopenia or osteoporosis, bone pain, diarrhea, heart disease Both: hot flashes, sexual dysfunction

Question 179

Which is mTOR inhibitor? (Duplicate Qs)

Answer 179

the -olimuses not an option. metformin also inhibits mTOR Rapalogs: Rapamycin Temsirolimus Everolimus Deforolimus Zotarolimus Diet Derived: Curcumin Resveratrol epigallocatechin gallate (EGCG) 3,3-Diindolylmethane (DIM) Genistein Caffeine

Question 180

Bevacizumab MOA

Answer 180

binds to, and neutralizes, extracellular vascular endothelial growth factor (VEGF) A , preventing its association with endothelial receptors VEGFR1&2

Question 181

ERBB2 gene encodes

Answer 181

ERBB2 also known as HER2/neu is a gene that encodes for the receptor tyrosine-protein kinase erbB-2.

Question 182

How is mTOR related to pertuzumab?

Answer 182

Pertuzumab is a monoclonal antibody that binds to her2. mTOR is downstream from this receptor Her2 —> PI3K —> PIP3 —> PDK —> AKT —> mTOR

Question 183

VEGF roles

Answer 183

Causative factor in blood vessel permeability and development VEGFRs are predominantly found on endothelial cells and bone marrow derived cells

Question 184

PI3K/AKT/mTOR pathway

Answer 184

PI3K-AKT-mTOR pathway promotes cell growth/survival and inhibits apoptosis and autophagy 1. PI3K (phosphatidylinositol-3-kinase) is activated by Growth factor receptor or RAS 2. Activated PI3K generates PIP3 (phosphatidylinositol-3-4-5-triphosphate) 3. PIP3 activates PDK (phosphoinositide-dependent-kinase) 3.5. [PTEN inhibits PIP3]. 4. PDK phosphorylates AKT. 5. phosphorylated AKT: 6a. Activates mTOR —> synthesis of proteins, needed for cell growth and cell cycle progression 6b. Inhibits Foxo family of transcription factors, responsible for transcription of genes needed for apoptosis and apoptosis cell cycle arrest

Question 185

How does the HPV vaccine work

Answer 185

Recombinant L1 capsid protein (1 of 2 viral capsid proteins). Forms virus like particles (VLPs) which are combined with adjuvants. Adjuvants stimulate the immune system (aluminum based). VLPs induce humoral response with antbiotides and some cell-mediated immune response

Question 186

What are HAMAs (human anti-mouse antibodies)?

Answer 186

When patients react to mouse antibodies as if they were a foreign substance, and create a new set of antibodies against the mouse antibodies A single dose of mouse monoclonal antibodies has the potential to induce an immune response initiating the production on anti-mouse antibodies. However it has been shown that the concentration and IgG isotype of murine antibody used does not influence the production of HAMA [2]. Circulating HAMA has the capability to bind to mouse antibodies that are used in subsequent procedures or treatments. This diminishes the efficacy of the antibody based treatments. The presence of HAMA in patient samples can also be a cause of false positive or false negative immunoassay results, depending on the assay principles and the type of monoclonal antibodies used in the test

Question 187

Estrogen isoforms created by

Answer 187

Alternative splicing vs. Alternate promoter usage ## Footnote Pre-mRNA contains both coding regions (exons) that specify the protein sequence and introns that are removed during a process called splicing. Alternative splicing allows for different combinations of exons to be included in the final mature mRNA, leading to mRNA transcripts that exclude or include specific exons, resulting in isoforms with variations in their protein structure and function. genes may also have multiple promoters to create different isoforms

Question 188

Endometrial cancer mutation associated with good prognosis

Answer 188

POLE Excellent prognosis regardless of grade - high tumor mutation burden, tumor neoantigen production, and tumor infiltrating T cells

Question 189

Endometrioisis related marker

Answer 189

CA125 is the most common tumor marker associated with endometriosis ARID1A is the most frequently mutated in gene in endometriosis related ovarian cancer

Question 190

EGFR (epidermal growth factor receptor) (how it works)

Answer 190

Cell membrane receptors that bind peptide growth factors are composed of an extra cellular ligand-binding domain, a membrane spanning region, and a cytoplasmic tyrosine kinase domain Binding of a growth factor to the extracellular domain results in dimerization and confirmational shifts in the receptors and activation of the inner tyrosine kinase The kinase transfers a phosphate group from ATP to a specific tyrosine residue on the growth factor receptor itself (auto phosphorylation) and on molecular targets inside the cell

Question 191

Describe VEGF proteins and receptors

Answer 191

7 glycoproteins in the family: VEGF A-E and placental growth factor 1-2 - secreted by tumor cells, endothelial cells, stromal cells, leukocytes, platelets VEGF-A,B,E stimulate angiogenesis via VEGFR1 (A/B) and VEGFR2 (A/E) VEGFR-C,D activate VEGFR3 and stimulate lymphangiogenesis ABE12 and CD3 —> high VEGF-D expression is independent poor prognostic factor for epithelial ovarian cancer

Question 192

Describe HPV cancer pathway

Answer 192

E6/E7 are viral oncogene proteins: - E6 inactivates p53 leading to its proteosomal degradation, - E7 inactivates pRb by competing for binding and then frees transcription factor E2F —> expression of S phase genes, uncontrolled cell cycle progression

Question 193

Cancer vaccines general mechanism

Answer 193

designed to induce antitumor immune responses against specific tumor-associated antigens (TAA). TAAs may be (i) antigens that are overexpressed in cancers, (ex: Her2/Neu, or mesothelin) (ii) cancer/germline antigens that are only expressed in germline cells, but can be reexpressed in cancer cells, (ex: MAGE-A1 (melanoma associated antigen), NY-ESO-1, New York esophageal squamous cell carcinoma 1) (iii) cell lineage differentiation antigens, (ex: tyrosinase and gp100. Delivery classifications: i) peptide/protein-based, (ii) cell-based, (iii) DNA/RNA-based, or (iv) glycan-based. Sipuleucel-T (Provenge) is first therapeutic cancer vaccine for prostate (autologous APCs exposed to cancer antigen, then returned to pt

Question 194

Cancer risk with Peutz-Jeghers Also gene? (Duplicate)

Answer 194

* breast (32 to 54 percent) * Colorectal – 39 percent * Stomach – 29 percent * Small bowel – 13 percent * Pancreas – >15% * SCTAT - >10% **cervix (10 percent) adenoma malignum (minimal deviation adenocarcinoma) Stk11 (tumor suppressor), autosomal dominant multiple hamartomatous polyps in the gastrointestinal tract, mucocutaneous pigmentation

Question 195

Cancer risk with MEN2

Answer 195

Parathyroid hyperplasia (10-25%), medullary thyroid ca (almost all will get this, avg age 30s), pheo (~50% will get this), RET protooncogene

Question 196

Cancer risk with MEN1

Answer 196

M3 P's: pancreatic, parathyroid, pituitary. Pancreatic (~30%, Zollinger-Ellison syndrome, insulinoma), pituitary adenoma (15-20%), angiofibroma, parathyroid hyperplasia (almost 100%), lipoma, carcinoid tumors MEN1 gene

Question 197

Cancer risk with Li-Fraumeni Also gene

Answer 197

TP53 mut - CLASSICALLY: breast (>60%), sarcoma (bone & soft tissue), CNS, ACC (head and neck cancer) Osteosarcoma most common in kids Also melanoma, colorectal, gastric, prostate

Question 198

Cancer risk with Cowden also gene

Answer 198

PTEN mut breast (triple neg), endometrial, thyroid (3-38%), CRC, renal cell carcinoma. Also have mucocutaneous lesions, thyroid disease (50%), GI polyps

Question 199

Breast cancer screening for BRCA

Answer 199

annual MRI 25-29yo; 30-75yo annual mammo + breast MRI/ (NCCN 2/24) 

Question 200

MicroRNA when bind to 3’ UTR (untranslated region) of mRNA - targeted mechanism of action **TEST QUESTION **

Answer 200

miRNAs regulate gene expression by binding to the 3' untranslated region (3'UTR) of messenger RNA (mRNA), using mechanisms such as Translational repression (most common) and mRNA Cleavage (less common) to silence a gene by preventing translation (medium complementarity), faster degradation (low complementarity) or cleavage (perfect complementarity). Complementarity = matching

Question 201

Least recommended colon ca screening for lynch/HNPCC **TEST QUESTION **

Answer 201

Sigmoidoscopy aka flex sig (majority right sided tumors prior to splenic flexure)

Question 202

BRCA1 most common type of breast cancer & histologic characteristics (Duplicate) ** TEST QUESTION **

Answer 202

Triple negative, poorly differentiated invasive ductal carcinoma MC higher proportion of medullary carcinomas (13%) more frequently estrogen receptor- and progesterone receptor-negative, and p53-positive low frequency of HER2 expression. High grade, and had exceptionally high mean mitotic counts, a syncytial growth pattern, pushing margins, and confluent necrosis. Atypical medullary carcinoma was overrepresented in BRCA1 mutation carriers. Equal LVSI to wild type

Question 203

BRCA1 cancer risks

Answer 203

breast (>60% absolute risk), male breast cancer (0.2%–1.2%) ovary (39%–58%), pancreas (≤5%), prostate (7%–26%), Uterine serous

Question 204

BRCA2 cancer risks

Answer 204

breast (>60% absolute risk), male breast cancer (1.8%–7.1%), ovary (13%–29%), pancreas (5%–10%) prostate (19%–61%), uveal melanoma (BRCA2), melanoma ( BRCA2) stomach/biliary (maybe in BRCA2?), JD: Cannot confirm this....

Question 205

BRCA 2 - most common type of breast cancer A ductal ER+ B lobular ER+PR+ C phyllodes ER+

Answer 205

ductal ER+ 70% to 80% ER+ PR+ higher grade than sporadic age-matched controls. Usually her2 - Invasive ductal carcinoma is the most common histological type in BRCA2 breast tumors. There is no agreement about whether there is any special histological type with a higher frequency among BRCA2-mutation carriers. Poss higher incidence of tumors belonging to a “tubular lobular group” including invasive lobular, tubular, and cribriform carcinomas in BRCA2 patients. Pleomorphic lobular carcinomas and extensive intraduct carcinomas were more common in BRCA2 mutation carriers. ## Footnote JD: All I can find is that ductal is most common (searched B&H, UTD, Gemini, google search), lobular is increased, up to 10% but still not close to as common

Question 206

BRAF mutations common in what cancers?

Answer 206

Oncogene commonly mutated in Type 1 ovarian cancers (low grade serous cancers, endometrioid and clear cell cancers, and mucinous cancers). But rare in recurrent low grade serous. KRAS more common in borderline tumors, both activate MAP kinase pathway

Question 207

Best med for anticipatory chemo-induced nausea A 5HT3 antagonist B benzo C steroid D NK1R antagonist

Answer 207

benzo

Question 208

Best criteria to diagnose HNPCC A MSI B Amsterdam C MLH1 methylation D MMR gene alterations **TEST QUESTION **

Answer 208

MMR gene alterations

Question 209

at what age do you start HNPCC screening

Answer 209

20-25 for HNPCC genes MLH1, MSH2/EPCAM 30-35 for PMS2/MSH6 ....or 2-5yr prior to earliest familial CRC ## Footnote Age 10-15y for APC mutation (Famililal adenomatous polyposis) Age 18 for STK11 (PJS)

Question 210

Ascites and ovarian cancer - which VEGF/ VEGF-R?

Answer 210

VEGFR2 by VEGF-A has major permeability enhancing effect (Hint: VEGF-A "A for ascites" VEGF-R2 "2 much ascites"

Question 211

Ang-1, Ang-2 (Angiopoietin 1/2) targets A hypoxia-inducible factor 2-alpha B TIE 1 C FGF

Answer 211

Tie1. Angiopoietin ligands (ANG1–ANG4) and the TIE (TIE1 and TIE2) receptor tyrosine kinases form an endothelial signalling pathway that is necessary for embryonic cardiovascular and lymphatic development. In adults, this system regulates vascular homeostasis, and controls vessel permeability, inflammation and angiogenic responses. ## Footnote AW: I think this should be TIE2...Tie1 and Tie2 are highly homologous proteins both part of the angiopoietin/Tie signaling axis. Tie2 is the main signal-transducing receptor, while Tie1 modulates Tie2 signaling Tie2 can bind to all four known angiopoietins, while Tie1 cannot bind to any of them.

Question 212

AMG386 (Trebananib)- target A placental growth factor B hypoxia-inducible factor 2-alpha C VEGF, Tie1 D angiopoieten 1/2 ** TEST QUESTION **

Answer 212

AMG386 aka trebananib is angiopoietin (Ang) 1 and 2 neutralizing peptibody with anti-angiogenic activity Trebananib is a peptide-Fc fusion protein that targets the Ang1/Ang2/Tie2 pathway and inhibits angiogenesis by blocking the interaction between Ang1/Ang2 with the Tie2 receptor. ## Footnote JD: would add - "Anti-angiogenesis agent"

Question 213

3 ways that oncogenes are activated, which is not? A mutation in promoter region regulating inactivation B amplification C hypermethylation D chromosome rearrangement

Answer 213

hypermethylation

Question 214

BRCA1 chromosome location (Duplicate)

Answer 214

17q21 (Same chromosome as TP53)

Question 215

TP53 chromosome location

Answer 215

17p13 (Same chromosome as BRCA1)

Question 216

BRCA2 chromosome location (Duplicate)

Answer 216

13q12 (Same chromosome as RB)

Question 217

PTEN chromosome location

Answer 217

10q23

Question 218

Rb gene location

Answer 218

13q14 (Same chromosome as BRCA2)

Question 219

What are the three BRCA1/2 founders mutations?

Answer 219

BRCA1 185delAG BRCA1 5382insC BRCA2 6174delT

Question 220

What gene is encodes the CSF (colony stimulating factor) receptor?

Answer 220

The c-fms proto-oncogene (expressed on myeloid cells) encodes a receptor mononuclear phagocyte colony stimulating factor, CSF-1 (M-CSF)

Question 221

most common mutation location p53

Answer 221

Exons 5-8

Question 222

What are null cells?

Answer 222

a lymphocyte in the blood that does not have on its surface the receptors typical of either mature B cells or T cells NK cells are part of a group of lymphocytes originally called null cells (through this is an outdated term). Unlike other lymphocytes, such as T and B cells, they do not have to find their specific match to identify an invader. Similarly, they do not depend on memory of past pathogen infections to attack a cell.

Question 223

Difference between adenovirus and retrovirus as vector for gene therapy

Answer 223

Adenoviruses (DNA viruses) not incorporated into host DNA Not replicated when cell divides, so requires re-administration gamma retroviruses integrated into host genome. These resulted in a lower likelihood that adjacent genes will be activated, a better ability to transduce nondividing cells, and a shorter culture period… but oncogenic/leukemogenic

Question 224

Which PARP do PARPi’s inhibit?

Answer 224

PARP1 and 2; however Rucaparib inhibits PARP1-3 Olaparib, Rucaparib--PARP-1,2,3 | (JS) Niraparib, Veliparib--PARP-1,2 ## Footnote Reminder Rucaparb elevated Cr due to MATE1/2 inhibition

Question 225

purine bases

Answer 225

adenine & guanine (pure As Gold)

Question 226

pyrimidine bases

Answer 226

cytosine, thymine, uracil Cytosine is found in both DNA and RNA, thymine is present only in DNA, uracil is present only in RNA Pyramids CUT CUT the Py 🥧

Question 227

What inherited syndromes merit breast cancer screening with MRI

Answer 227

BRCA, Li-Fraumeni, Cowden/Bannayan–Riley–Ruvalcaba syndrome, PJS NCCN 6/23: Recommend: BRCA1/2, PALB2, STK11, TP53, PTEN Consider: ATM, BARD1, CDH1, CHEK2, NF1, RAD51C/D

Question 228

Which is most consistent with BRCA2: A 40yo with ovary cancer B 45yo with breast cancer C 65yo with ovary D woman with pancreatic cancer.

Answer 228

Think answer is pancreatic: https://www.nature.com/articles/gim201785 Notes said: “**45yo with breast cancer (later peak incidence with BRCA2)” = we think too** “The peak incidence of breast cancer was seen in women 41–50 years old for BRCA1 mutation carriers and those 51–60 years old for BRCA2 mutation carriers.”

Question 229

VUS in BARD1 gene found age 40 What to do? A Routine mammogram B MRI C tamoxifen D risk reduction surgery

Answer 229

Routine mammogram ## Footnote BRIP=normal breast screening, RRSO "RIP=ovary, like IP chemo" BARD=MRI/mammo, no ovary "BAD BREAST"

Question 230

Endo cancer with medullary thyroid and hamartomas, what is genetic mutation ** TEST QUESTION**

Answer 230

Cowden's syndrome; PTEN mutation

Question 231

Cardiac SE with taxol ** TEST QUESTION**

Answer 231

asymptomatic bradycardia

Question 232

trastuzumab MOA.

Answer 232

MAb binds to the extracellular domain of the human epidermal growth factor receptor 2 protein (HER-2); blocks downstream signaling ErbB2 (Her2Neu) part of EGRF family. HER2 does not directly bind ligand-activation results from heterodimerization with another ERBB member or by homodimerization when HER2 concentration are high it mediates antibody-dependent cellular cytotoxicity by inhibiting proliferation of cells (MAPK, PIK3 pathway inhibition) which overexpress HER-2 protein.

Question 233

most common G3-4 tox with olaparib (Duplicate)

Answer 233

anemia (21%) | next closest=neutropenia at 6%

Question 234

Growth factor associated with endometrial cancer ** TEST QUESTION **

Answer 234

Insulin Like Growth Factor -1 (IGF1)

Question 235

Describe the WNT/beta-catenin pathway

Answer 235

Beta-catenin (CTNNB1 gene) involved with cadherins in cell-cell adhesion junctions and plays a role in inhibiting excessive growth when cells contact one another (cytoplasmic function) Nuclear target genes promote cell proliferation such as c-myc, cyclin D1 (nuclear function) Beta-catenin regulated by the WNT pathway: WNT extracellular ligands bind frizzled cell surface receptor --> Frizzled activates intracellular dishevelled which breaks up destruction complex —> increased accumulation of beta -catenin. Saturates cytoplasmic sites first then translocates to the nucleus. Disheveled accomplishes this by inhibiting protein complex (axin, GSK-3 beta, **APC**) that normally proteolyticly degrades beta-catenin

Question 236

Describe epithelial to mesenchymal transition

Answer 236

A series of events that progress epithelial tumor cells along a mesenchymal like continuum and up regulates survival and invasion signals promoting single cell autonomy - down regulation of proteins that promotes homotypic cell attachment, such as E-cadherin. - Upregulation proteins that promote heterotypic cell adhesion, such as P and N cadherin An epithelial-mesenchymal transition (EMT) is a biologic process that allows a polarized epithelial cell, which normally interacts with basement membrane via its basal surface, to undergo multiple biochemical changes that enable it to assume a mesenchymal cell phenotype, which includes enhanced migratory capacity, invasiveness, elevated resistance to apoptosis, and greatly increased production of ECM components (1). The completion of an EMT is signaled by the degradation of underlying basement membrane and the formation of a mesenchymal cell that can migrate away from the epithelial layer in which it originated.

Question 237

Which of the following has the Least cumulative effect on bone marrow? A cisplatin B cytoxan C carbo D taxol

Answer 237

Taxol (AW) Chi: Radiation, alkylating agents (e.g., melphalan, carboplatin), and other DNA-damaging agents (e.g., nitrosoureas, mitomycin C), can have cumulative long-term effects on bone marrow reserve. Most other agents, including **taxanes and topotecan, show no evidence of cumulative toxicity** and can be administered for multiple cycles without dose modification, once a tolerable dose is established. cisplatin - dose limiting is renal, neurop, tinnitus; myelosupp is mild (occurs in 25-30%) cytoxan (myelosuppression is dose limiting, leukopenia), carbo - dose limiting is myelosuppression (thrombocytopenia) taxol (notes say we chose taxol) - dose limiting is neutropenia | Prior card: they thought cisplatin

Question 238

Most lethal impact of radiation

Answer 238

DOUBLE STRANDED BREAKS other options: single stranded break, 2 other choices

Question 239

Most common risk factor for radiation enteritis

Answer 239

**Chemorads** Answer choices: **chemorads (this one?) **= yes (AW) Prior abd surgery age (higher risk if older) cervical cancer higher obesity (no, higher risk in skinny people) Pubmed - Summary of RF for GI RT injury: *RT: tx volume, total dose, fractionation dose, schedule *Combined modality therapies: surgery, chemo (particularly concurrent) *Med co-morbidities: vascular disease, connective tissue disease, IBD, HIV *Genetic susceptibility: single nucleotide polymorphism, ataxia telangiectasia ## Footnote Predisposing risk factors: previous abdominal surgery, PID, thin body habitus, HTN, and DM

Question 240

Most common organ with toxicity in HDR (or any pelvic radiation)

Answer 240

Rectum HDR terminal ileum WPRT

Question 241

Main differences between HDR and LDR

Answer 241

LDR is 0.4-2.0 Gy per hour vs HDR is >12 Gy per hour. HDR: LESS TX TIME- technically more fractions and higher fraction dose for HDR (lower overall dose-60% with HDR vs LDR). Less time for tissue repair. higher fx size = More late toxicities. Lose out on "bioradiologic advantage" of LDR. LDR: Less fractions and dose - better tissue repair esp for "late responding tissues". Exposure of staff. less optimal positioning and higher risk of device moving. ## Footnote LDR where radioactive source (Cs) positioned inside for a few days vs HDR (Ir) temporary placement of radioactive source; more precise

Question 242

Just completed radiation, perforated sigmoid and feculent

Answer 242

choices: Loop ileostomy end ileostomy rectosigmoidectomy with end stoma (this one??)

Question 243

How to reduce small bowel complications with radiation?

Answer 243

Answer: tx with full bladder wrong choices: prone position decubitus position

Question 244

How had addition of chemosensitizers affect radiation outcomes

Answer 244

Mortality (THIS ONE) Wrong answers: enterocolitis noninfectious bladder cystitis fistula formation TL: In meta-analysis 2010 / HR death 0.69 or 10% absolute improvement, HR recurrence 0.66 (13% absolute improvement, OR 1.98 gr 3/4 esp GI tox) ## Footnote Increased OS and dx control with chemoRT. Also get more morbidity but worth it (AW)

Question 245

Dose of brachy after hyst for endometrial cancer is dosed to where

Answer 245

0.5cm deep and 0.5cm wide; 5mm! ## Footnote NCCN: 7 Gy x 3 fractions prescribed at a depth of 0.5 cm from the vaginal surface is a regimen used by many

Question 246

Direct and indirect radiation/xrt mechanisms

Answer 246

Direct = causes direct DNA break. Indirect = electron interacts with water and makes a free radical which produces oxidative stress and DNA damage

Question 247

Cervical cancer pt s/p RT presents with fever, diarrhea, imaging with collapsed bowel, thick walls, dilated bowel

Answer 247

Thumb printing (thickening of haustral folds) = cdiff due to edema ## Footnote UTD: findings consistent with toxic megacolon include small bowel dilatation, air-fluid levels (mimicking an intestinal obstruction or ischemia), and "thumb printing" (scalloping of the bowel wall) due to submucosal edema

Question 248

Advantage of HDR vs LDR?

Answer 248

Less treatment time (this one) *repeated question Wrong answers -Less treatment -Less toxicity -More effective Notes from Justine: HDR has higher acute tox, more treatments, lower dose overall (each fx larger, more fractions), may lose radiobiologic advantage of LDR, tx faster

Question 249

Advantage of HRD over LDR?

Answer 249

Answer: less exposure to staff to radiation for prolonged periods of time Other wrong answers: less treatments, less toxicity

Question 250

What effect does ionizing radiation have on DNA that results in largest impact (double strand break, single strand break, base alteration, one other choice)

Answer 250

DS Breaks | this is the lethal kill of ionizing radiation

Question 251

What's the half life of Cesium?

Answer 251

30 years ## Footnote seize the day in your 30s

Question 252

20 years after chemoRT, which risk factor led to lumbosacral radiculopathy?

Answer 252

answer: increased dose per fraction * lumbosacral radiculopathy is associated with intracavity and intraop radiation Wrong answers: cisplatin, 5-FU cream

Question 253

longest half life radio isotopes?

Answer 253

cesium (30 years) *This question has been repeated multiple times! Remember - Radium has the longest half life 1,600 years. Guessing Radium was not an answer choice in this question. -Iridium192: 74 days -Colbalt60: 5 years

Question 254

Superior border EBRT

Answer 254

answer: L4-5 interspace wrong: L4 vertebral body, L5 vertebral body ## Footnote Chi: superior border of the pelvic fields is S1–L5 interspace for early-stage disease (i.e., nonbulky IB or IIA) or at the L4–5 interspace for more advanced disease for lower PA nodes radiate up to L2, for full PA field radiate up to T12-L1.

Question 255

What phase of the cell cycle is most radio-resistant?

Answer 255

S (late) and early G1 reminder: S= synthesizing DNA that can be used as a template for repair; G1= long and quiescent

Question 256

Most radiosensitive phase(s) of cell cycle?

Answer 256

G2 and M reminder: G2 = short and cell is proliferating; M = chromosomes lined up in spindle and does not stop to repair

Question 257

At what energies do certain radiotherapy principles dominate?

Answer 257

1. Photo electric effect 10-25 kEV 2. Compton scattering 25kEV - 25mEV 3. Pair production (does not start until 1.02 MeV, dominant >30 mEV)

Question 258

What affects response/sensitivity to radiation? (4 R's)

Answer 258

1.Repair (if fractionated, time for recovery of sublethal injury) 2.Repopulation (growth of cells between fractors) 3.Redistribution (depending what part of the cell cycle)-give time to get into more sens G2/M 4.Reoxygenation (oxygenated cells are 3x more sensitive to radiation)"

Question 259

Advantage of high LET (alpha and neutrons)?

Answer 259

Does not depend on O2 so effective for hypoxic tumors (oxygen enhancement ratio = 1) Majority of effect is due to direct effect

Question 260

What organ is most sensitive to radiation?

Answer 260

Kidney (JS) Lowest RT tolerances: Kidney/Lung: 1500-2000 cGy Liver:2000-3000 cGy Ovary: 2000 cGy (as little as 500cGy in postmenopausal women)

Question 261

Dose to sterilize ovaries?

Answer 261

Age dependent, BUT: B&H: 20 Gy (as little as 5-10Gy in older premenopausal women) Chi says a single dose of 4-8 Gy or fractionated doses of 12-20 Gy Prior card says 2-6 (unfractionated), 6-10 (fractionated)

Question 262

How to calculate energy to get to certain depth

Answer 262

Depth in cm x 3 = amount of energy in MeV *internet:MeV means one mega electron volt, or one million electron volts ## Footnote 12mEV dose = 4 cm depth...4cmx3=12

Question 263

How to decrease acute effects of radiation

Answer 263

Decrease total dose and treatment time --> affects mucosal cells

Question 264

How to decrease chronic effects of radiation

Answer 264

Decrease DOSE PER FRACTION --> affects endothelial cells

Question 265

What does the shoulder of the cell survival curve represent?

Answer 265

Sublethal damage that is repaired

Question 266

What is the minimum amt of energy to cause ionization?

Answer 266

35 eV

Question 267

Max dose small bowel?

Answer 267

45 Gy (that's why dose for cervix is that.. And required to sterilize occult dz for adjv radiation)

Question 268

Max dose for bladder and rectum and lower 1/3 vagina?

Answer 268

75 Gy

Question 269

Name the mm/cm 1.Vaginal cancer - intracavitary alone 2.Add interstitial threshold 3.Add EBRT threshold

Answer 269

1. <5 mm 2. > 5mm 3. > 2 cm

Question 270

Radiation proctitis? Name treatment

Answer 270

All 4 are answers Steroid suppositories Low residue diet Anti-motility drugs Hydration

Question 271

Chronic radiation enteritis treatment?

Answer 271

can try cholestryamine (JS) UTD diet, hydration, antidiarrheals, bile acid sequestrants, abx for bacterial overgrowth)

Question 272

What radiation particle is decay of radioactive isotope

Answer 272

Gamma rays originate within the nucleus, emitted from radioisotope

Question 273

What type of radiation is caused by deceleration of high energy electrons?

Answer 273

X-rays originate outside of nucleus and produced by bombardment of target with high speed electrons

Question 274

Alpha particle

Answer 274

Two protons and two neutrons (i.e. He nucleus)

Question 275

Beta particle

Answer 275

high speed electrons | B- = electron B+ = positron

Question 276

What is Gompertzian tumor growth?

Answer 276

Doubling time increases as the tumor size increases y axis: tumor size log scale x axis: time

Question 277

What shifts the cell survival curve to the left?

Answer 277

Left = less radiation needed Oxygen and higher energy radiation ## Footnote (JS) Increased temp, decreased pH, increased 2,3-DPG (enzyme that helps release O2 to tissue) ^isn’t this for RBC’s? JD -yes it’s for both. Whatever shifts O2 curve right shifts cell survival curve left

Question 278

What shifts the cell survival curve to the left?

Answer 278

"Left = less radiation needed Oxygen and higher energy radiation"

Question 279

What is max fetal dose of radiation during pregnancy?

Answer 279

10 Gy

Question 280

What is dose of EBRT for breast cancer?

Answer 280

50Gy, if adjuvant only 10-15 Gy (JS)- I think this is old news. NCCN states hypofractionated WBRT (39–42.9 Gy in single fractions of 2.6–3.3 Gy) compared to standard 50 Gy in single fractions of 2 Gy were equivalent.

Question 281

First order cell kill kinetics?

Answer 281

Constant FRACTION of cells killed with each treatment

Question 282

When is LET best used?

Answer 282

necrotic tumor

Question 283

IMRT differs from 4-field radiation in all ways except:

Answer 283

Delivers same dose *repeated question

Question 284

Most common site affected in whole pelvic XRT?

Answer 284

answer: ileum wrong options: rectum, bladder, ureter

Question 285

Which has highest LET?

Answer 285

alpha particle Order of highest to lowest: alpha, neutron, proton MLH: Think it’s alpha then neutron (Hi! LET the APrN do the work! (alpha, proton, neutron))

Question 286

Cobalt decay produces what radiation?

Answer 286

This emits high intensity gamma rays

Question 287

Cobalt 60 half life?

Answer 287

5.26 year half life

Question 288

Iridium 192 half life?

Answer 288

74 days

Question 289

Cesium 137 half life

Answer 289

30 years! *This is asked multiple times

Question 290

How is WPRT targeted?

Answer 290

Targeted areas include primary tumor and areas of suspected microscopic disease (JS) Chi says: GTV: clinical/radiographically evident tumor CTV: where microscopic disease likely to spread aka lymph nodes

Question 291

How are LET and OER related?

Answer 291

INVERSELY; Higher LET (linear energy transfer) is associated with lower OER (oxygen enhancement ratio)

Question 292

Most important factor to determine the dose of HDR delivered?

Answer 292

Source dwell time HDR is performed using a single tiny (1mm x 3 mm) highly radioactive source of Iridium-192 that is laser welded to the end of a thin, flexible stainless steel cable. The source is housed in a device called an afterloader. The computer-guided afterloader directs the source into the treatment catheters placed in and around the prostate by the brachytherapy physician. The source travels through each catheter in 5 mm steps, called "dwell" positions. The distribution of radiation and dose is determined by the dwell positions the source stops at and the length of time it dwells there. This ability to vary the dwell times is like having an unlimited choice of source strengths. This level of dose control is possible only with HDR.

Question 293

What are the disadvantages of HDR?

Answer 293

answer: potential late tissue effects w HDR wrong answers: Lower therapeutic ratio, labor intense, need for sedation Chi: loss of the radiobiologic advantage of LDR, decreased time for normal tissue repair, potential increase in late tissue effects with large fraction sizes, an increase in number of implants (more labor-intensive), need for sedation

Question 294

What is the most important determinant of HDR dose?

Answer 294

Chi: source dwell time answer: Length of the source wrong choices: age of the source, shape of the source

Question 295

What clinical scenario is most likely to be a factor in oxygen enhancement ratio?

Answer 295

answer: 6 cm cervical mass bc necrotic so less oxygen so more radio resistant by 2 - 3 x more. other options: Tx of groins in vulvar ca, adjuvant tx to Pa nodes notes: Reoxygenation: hypoxic tumor cells get better oxygen during fractionated RT, this increase response of the tumor Oxygen is the MOST effective known radiation sensitizer. The sensitivity of fully oxygenated cells to low oxygen cells is 3X better Oxygen Enhancement Ratio (OER): ratio btw dose needed to achieve a given level of cell death under O2 vs hypoxic conditions

Question 296

How to protect vulva SKIN during radiation?

Answer 296

answer: frog leg all the way baby wrong choices: antifungal, estrogen cream, dilite H2O2, cold something

Question 297

Brachytherapy side effect that doesn't occur with EBRT?

Answer 297

vaginal atrophy

Question 298

Treatment of acute cystitis due to radiation?

Answer 298

answer: ditropan (oxybutynin) wrong answers: fulguration (tx for hemorrhagic cystitis) Fluid restruction Bladder irrigation (tx for hemorrhagic cystitis)

Question 299

LET relationship to OER

Answer 299

inverse! High LET: OER is diminished LET: linear energy transfer - rate of energy deposition along the path of a radiation beam OER: oxygen enhancement ratio - ratio btw dose needed to achieve a given level of cell death under O2 vs hypoxic conditions

Question 300

What has the highest linear energy transfer (LET)?

Answer 300

alpha particle

Question 301

What is the least likely complication associated with extensive terminal ileum resection? A. intrinsic factor deficiency B. Vit B12 def C. Vit K def D. fat malabsorption E. iron

Answer 301

answer: intrinsic factor deficiency (made in gastric cells, so plenty in system) notes: 1.B12 just not absorbed if resection >100 cm 2. bile acid deficiency b/c bile acid losses exceed compensatory increase in hepatic bile acid production this exacerbates absorption of fat and fat-soluble vitamins disruption of fluid absorption so cannot tolerate large bolus feedings or high osmolarity (i.e., simple carbs) 3. fat soluble vitamins (vitamin A,D,E,K)"

Question 302

Blind Loop Syndrome complication

Answer 302

small bowel bacterial overgrowth

Question 303

What is the cause of refractory hypokalemia in setting of K replacement?

Answer 303

answer: hypoMag wrong options: bicarb, phosphorus, calcium Notes: Patients with hypokalemia may also have hypomagnesemia due to concurrent loss with diarrhea or diuretic therapy or, in patients with hypomagnesemia as the primary abnormality, renal potassium wasting. Such patients can be refractory to potassium replacement alone

Question 304

What is the advantage of protons over electrons in radiation?

Answer 304

Dose stops at precise place due to Bragg peak (electrons are less precise; most of the dose is delivered 0.5-3 cm from patient's skin and then gradually loses energy until reaches its target; affecting the non-target tissues) The Bragg peak is a pronounced peak on the Bragg curve which plots the energy loss of ionizing radiation during its travel through matter.

Question 305

What cancer type has the least acute radiation effects?

Answer 305

answer: vagina wrong choices: ovary, bladder, small intestine

Question 306

Tx of HYPERmagnesemia

Answer 306

answer: Fluids and loop diuretic (i.e., lasix) wrong answer: calcium, other choices | (JS) UTD says IV calcium only if severe/symtpomatic

Question 307

Treatment of cystitis during xrt

Answer 307

Oxybutinin (anti-cholinergic, antagonizes M1, M2, M3 receptors of Ach receptor) Oxybutinin aka Ditropan

Question 308

What are Point A and Point B? hint: Manchester system

Answer 308

Point A = 2 cm lateral to central canal of uterus and 2 cm from external os/lateral fornix in axis of uterus (where ureter crosses uterine artery, avg point from which to assess dose in paracervical region) Point B = 5 cm from midline at level of point A aka 3 cm lateral to point A (correspond to obturator nodes)

Question 309

Most common TPN risk?

Answer 309

hyperGLYCEMIA

Question 310

Most common reason for hyperkalemia postop? **TEST QUESTION **

Answer 310

renal dysfunction

Question 311

Most calories from TPN come from…

Answer 311

answer: Glucose (40-80%) choices: fat (15-60%), protein

Question 312

Earliest lab value to measure in nutrition progress?

Answer 312

answer: pre albumin other options: albumin

Question 313

Which of the following is associated with steatosis aka fatty liver in TPN? CHOICES: 1. excess calories from glucose 2. excess calories from protein 3. excess calories from fat 4. excess calories from any source 5. insufficient fat soluble vitamins; 6. insufficient calories from fat"

Answer 313

answer: excess calories from glucose (dextrose) This is known as overfeeding syndrome.

Question 314

Which is not associated with blind loop syndrome? choices: 1.overgrowth of bacteria 2.fat malabsorption 3.Fe deficiency 4.diarrhea 5.vitamin b12 deficiency

Answer 314

answer: Fe deficiency *Blind loop syndrome arises when the bacterial colonies residing in the upper gastrointestinal tract grow out of control altering the physiological processes of the small intestine. Leads to: vitamin B12 deficiency, fat malabsorption and steatorrhea, nausea, flatulence, fat-soluble vitamin deficiencies (ADEK) and intestinal wall injury.

Question 315

How much ileum resection will result in B12 deficiency?

Answer 315

60 cm

Question 316

How much ileum resection will disrupt bile salt/fat malabsorption?

Answer 316

100 cm *Unabsorbed bile salts enter the colon and stimulate fat and water secretion, which results in diarrhea.

Question 317

What is refeeding syndrome?

Answer 317

Glu load leads to insulin productions with cells shifting P and K into cells > can lead to life threatening hypoP and hypoK *malnourished patients receiving artificial refeeding (whether enterally or parenterally) are high risk for refeeding syndrome

Question 318

Most common ELECTROLYTE abnormality with TPN?

Answer 318

Hypophosphatemia *add 15 to 30 mEq | UTD: 20-40mmol/d Angela's: 10-15 mEq to each 1L

Question 319

What is associated with zinc deficiency?

Answer 319

answer: alopecia and dry skin wrong choices (but all correct): growth retardation, decrease taste/smell, depression, impaired wound healing, arrhythmia ## Footnote Technically all are correct. Other source asked question of what def associated with alopecia and dry skin= zinc

Question 320

Where is zinc absorbed?

Answer 320

small intestine

Question 321

What is associated with selenium deficiency?

Answer 321

all of these: CHF, cardiomyopathy, muscle degeneration, white nail beds * critical in converting thyroid hormone thyroxine (T4) into its more active counterpart triiodothyronine, therefore can lead to hypothyroidism

Question 322

What vitamin is part of glutathione peroxidase?

Answer 322

Selenium (this is mineral) > (Selena has good gluts.) *Vitamin E ,C and B6 and B12 are all listed as possibly being inolved. *Glutathione peroxidase protect the organism from oxidative damage and inflammation, preventing ROS-mediated initiation of cancer (well studied in breast cancer).

Question 323

Where is copper absorbed?

Answer 323

Stomach and Small Intestines

Question 324

What percentage of copper is bound to ceruloplasmin?

Answer 324

90% *Ceruloplasmin is the major copper-carrying protein in the blood, and in addition plays a role in iron metabolism.

Question 325

What is associated with copper deficiency?

Answer 325

all of these: anemia, neutropenia, muscle weakness, ataxia, depigmentation, neurologic abnormalities NOT: bloody diarrhea

Question 326

Which is worse - micropapillary or microinvasion in borderline tumors?

Answer 326

micropapillary *Micropapillary is associated with higher recurrence rate, microinvasions and invasive implants.

Question 327

What is pathognomic for endodermal sinus tumors?

Answer 327

Schiller duval bodies

Question 328

Essential fatty acids?

Answer 328

Omega 6 (linoleic acid) and Omega 3 (alpha-linoleic acid)

Question 329

What is the half life of pre-albumin?

Answer 329

3 days

Question 330

What is the half life of albumin?

Answer 330

20 days or 3 weeks

Question 331

Calorie requirement based on weight for TPN?

Answer 331

30 kcal/kg/day

Question 332

What affects HDR?

Answer 332

applicator, distance and source (all 3) Source Dwell time May be most important

Question 333

How to reduce PPE sx

Answer 333

Cold packs, emoillents, B6, dose reduction, vitamin E

Question 334

What to do if recognized pancreatic injury during debulk A Repair injury B pancreatectomy   C splenectomy D place pelvic drain

Answer 334

pancreatectomy  (this one if option is distal?) place drain near site - not pelvic

Question 335

What preop abx is most assciated with cdiff

Answer 335

Options cefotetan (2nd gen, this one), ertapenem, two other choices From UTD: Fluoroquinolones Clindamycin Penicillins and combinations (broad spectrum) Cephalosporins (2nd/3rd/4th generation)* Carbapenems * Use of 1 to 2 doses of a first-generation cephalosporin (cefazolin) for surgical antibiotic prophylaxis does not confer significant risk for C. difficile infection.

Question 336

What is the LEAST appropriate palliative intervention in  a woman with a 12 cm cecum and malignant sigmoid lesion? A. pain management with tincture of opium b. loop colostomy c.  gastric tube d. tube through the cecum e. colorectal stent

Answer 336

Gastric tube (too proximal)

Question 337

What is better 6 month long term Laparoscopic vs. Laparotomy endom ca staging

Answer 337

Quality of life and body image Notes say: LSC - physical function, QOL, scar, pain Better QoL Lace trial: https://pubmed.ncbi.nlm.nih.gov/20638899/ Better body image GOG 2222: https://pubmed.ncbi.nlm.nih.gov/19805678/ Pain better @ 6 weeks, but same @ 6 months

Question 338

Temporary clamp on ureter, what to do

Answer 338

Stent

Question 339

Rectosigmoid - distal stenosis after radiation, mgmt A Progressive dilation B loop colostomy C LAR with Hartman's pouch

Answer 339

A Progressive dilation

Question 340

Pancreatic leak seen postoperatively, how to manage

Answer 340

Percutaneous drain

Question 341

Old lady died after unvaccinated and splenectomy done, likely cause?

Answer 341

Strep pneumo

Question 342

Most likely to have ureteral obst. Pt w hx of: A pelvic Radiation + extrafascial hyst B rad hyst + pelvic Radiation C pelvic Radiation D rad hyst

Answer 342

rad hyst + pelvic Radiation (this one)

Question 343

Most common cause not seeing SBO on x-ray? A NGT drainage B High/proximal obst C intestinal perforation

Answer 343

High/proximal obst (MLH can’t verify) perforation (would see free air) Lit Review: the accuracy of plain radiographs in the diagnosis of bowel obstruction ranges from only 50 to 80%. Plain radiographs are poor at identifying closed loop or strangulated obstructions in the setting of SBO

Question 344

Most common cause incorrect surgical count A multiple surgeries B Change RN staff C long operation D obesity

Answer 344

multiple surgeries Literature review: Items being dropped, not initially counted, large case, packing issue, change in procedure

Question 345

Most common complication of transverse loop colostomy? A Retraction B stricture C parastomal hernia D prolapse

Answer 345

Prolapse (this one most common) #1 is skin irritation if choice vs retraction for end colostomy

Question 346

Most common complication continent ileal conduit? A stone formation B leaking C Can't cath

Answer 346

Stones (5-35%) based on UTD notes say: Can't cath aka stomal stricture (2-14%, THIS ONE) leaking (short term 2-10%) stone formation (3% upper tract, 5-35% pouch calculi). infection 5%.

Question 347

Mgmt of ureteral injury at ureterovesical junction? A ureteroneocystotomy B Boari flap C ureteroureterostomy D transureterureterostomy E nephrostomy F nephrectomy

Answer 347

Ureteroneocystotomy Lower ureter 90% (ureteroneocystotomy), psoas hitch ureteral reimplantation helps if cannot do either of the prior w/o tension). Middle ureter 7% (Boari flap, transureterureterostomy). Upper ureter 2% (nephrostomy, nephrectomy, autotransplation, ileal or appendiceal interposition graft)

Question 348

Patient with history of Left hemicolectomy and needs diversion. What procedure to do?

Answer 348

Ileostomy on notes. MLH not verified

Question 349

Least thermal injury A pure coag B blend cut & coag C pure cut D spray

Answer 349

pure unblend cut

Question 350

Highest risk for VRAM flap complications? A Prior surgery B smoking C obesity

Answer 350

Obesity per lit review (AW-agree) preop RT, obesity increase risk of wound complications/ deep SSI. https://pubmed.ncbi.nlm.nih.gov/30113449/ says no risk in failure for pts w proper abdominal surgery Notes said: Prior surgery (this one - prior Maylard?), smoking, obesity

Question 351

For elective hyst pt with recent cardiac stent what should you do first?

Answer 351

Find out when/type of stent, If bare metal stent, wait minimum 4-6wk or 90d, if drug eluting wait 12 months "bare-metal stents should delay having elective surgery for at least 6 weeks after stent placement, and those who receive a drug-eluting stent should put off elective procedures for at least a year"

Question 352

Bowel injury during L/S no bowel prep, 1 cm, what do you do

Answer 352

Primary repair (answer if < = 1 cm)

Question 353

Biggest risk factor for LAR anastomosis leak A no bowel prep B only one dose of abx C Tension D hand sewn anastomosis E presence of ileostomy

Answer 353

Tension (this one), Distance of anastomosis from anal verge (if LAR <6cm from anal verge, highest risk i.e., 19% per Morrow) or this one if an option B&H: The most important variables in the anastomotic leak rate are the distance from the anus to the anastomosis, the vascularity of the cut ends, the tension on the anastomotic line, and the elimination of the pelvic cavity

Question 354

Associated with decreased SSI with rectosigmoid resection? A Chlorhexadine bath B normothermia C mechanical and antibiotic prep

Answer 354

mechanical and antibiotic prep (this one) Not Normothermia: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3398839/ Lit Review: Definitely antibiotic prep; just still out on added benefit of mechanical w/oral abx: https://www.sciencedirect.com/science/article/abs/pii/S0090825822019175

Question 355

Risk factors for anastomotic leak A Increasing ascites >4L B albumin <2 C smoking

Answer 355

if tension and <5-6 cm from small verge are not options… albumin <3.5 Cite: https://jamanetwork.com/journals/jamasurgery/fullarticle/600912 ## Footnote ? smoking: : Kwak et al. reported habitual smoking to be significantly associated with AL (OR 6.529, p = 0.007) (ASA) score of ≥ 3 (P < 0.001), **smoking (P = 0.001)**, diabetes (P = 0.035), a **preoperative serum albumin level of < 4 g/dl (P = 0.030),** https://onlinelibrary.wiley.com/doi/full/10.1111/codi.13476 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8700187/#B33-diagnostics-11-02382

Question 356

How do you diagnose Abdominal compartment syndrome

Answer 356

Measurement of bladder pressure (not imaging!) UTD: Intra-abdominal pressure can be measured indirectly using intragastric, intracolonic, intravesical (bladder), or inferior vena cava catheters [78]. The wall of the hollow viscus or vascular structure acts as a membrane to transduce pressure. ## Footnote Sustained intra-abdominal pressure >20 mmHg (with or without APP <60 mmHg) associated with new organ dysfunction

Question 357

How do you manage Abdominal compartment syndrome

Answer 357

Conservative mgmt: avoiding positive fluid balance after initial resuscitation, evac intraluminal contents, evac space-occupying lesions (i.e., ascites, hematoma), improve abdominal wall compliance, decrease tidal volume/paralyze. Surgical mgmt: abdominal decompression if pressure >25 mmHg (possibly 15-25 mmHg) and end organ damage; with temporary wall closure. ## Footnote proper positioning, improving abdominal wall compliance (eg, pain control, sedation, paralysis, mechanical ventilation), and reducing intra-abdominal volume

Question 358

Distal obstruction due to malignant disease with Cecum 12 cm. Best treatment option? A Transcutaneous gastrostomy B Percutaneous cecostomy C Transverse colostomy D stent

Answer 358

transverse colostomy

Question 359

Woman who is 12 months s/p rad hyst with unilateral leg swelling no erythema what is the best test to order to diagnose

Answer 359

LE DOPPLER

Question 360

What nerve injury is associated with numbness over the thigh after a pelvic LND?

Answer 360

genfem

Question 361

What are the phases of wound healing?

Answer 361

Wound healing is classically divided into 4 stages: (A) hemostasis / coagulation (mast cells, histamines, fibrin clot, vasoconstriction) (B) inflammation: release of PMNs, macrophages (C) proliferation / Fibroplasia (collagen deposition) (D) remodeling

Question 362

Tensile strength at 10% for PDS

Answer 362

56 days / 8w

Question 363

Tensile strength at 10% for polyglycolic acid (vicryl)

Answer 363

28 days / 4w

Question 364

Tensile strength at 10% for chromic catgut

Answer 364

14 days / 2w ## Footnote also seen 21-28 days listed (excel detroit sheet says 28d, Justin says 14d)

Question 365

Tensile strength at 10% for catgut

Answer 365

5 days / 1w

Question 366

What is max total local lido dose (mg) w/o epi? With epi?

Answer 366

300 mg WITHOUT epi 500 mg WITH epi

Question 367

What is max total local lido dose (mg/kg) w/o epi? With epi?

Answer 367

4.5 mg/kg WITHOUT epi 7 mg/kg WITH epi

Question 368

Tx for lidocaine tox Duplicate

Answer 368

Usually supportive - use benzos for seizures Dialysis is not useful

Question 369

EKG changes with HYPERmag

Answer 369

prolongation of the PR interval increase in QRS duration increase in QT interval. ## Footnote Complete heart block and cardiac arrest may occur at a plasma magnesium concentration above 15

Question 370

Which drug increases platelets A bactrim B vanco C GCSF D heparin E IL-11

Answer 370

IL-11 (THIS ONE)- tx and ppx against thrombocytopenia! bactrim, vanco, GCSF, heparin - the others all may lower

Question 371

What are acceptable options for colon cancer screening for those at average risk per ACOG?

Answer 371

Colorectal cancer screening for average-risk* women: -begin at age 45 years. -stopping routine screening at age 75 years. Screening test options: - Colonoscopy (gold standard) every 10 years - CT colonography (virtual colonoscopy) every 5 years - Flexible sigmoidoscopy every 5 years - Fecal immunochemical test (FIT) annually - Guaiac-based fecal occult blood test (gFOBT) annually - Multi-targeted stool DNA test (mt-sDNA or Cologuard) every 3 years

Question 372

What is associated with increasing opiate dose

Answer 372

Tolerance associated with increasing dose (THIS ONE) Other option included dependence, 2 other choices

Question 373

Sx of HYPERmag

Answer 373

(think of pre-e) 4-6: nausea, HA, drowsy/lethargy, diminished DTR, flushing 6-10: somnolence, hypocalcemia, absent DTR, bradycardia, hypotension; ECG changes (prolonged PR interval, increased QRS, increased QT interval) >10: flaccid quadriplegia, apnea, resp failure, cardiac arrest, complete heart blck (resp failure precedes cardiac collapse)

Question 374

Risk factors for lymphedema

Answer 374

UTD: - obesity, esp BMI >50 - lymphadenectomy + postoperative radiotherapy > lymphadenectomy alone - # LN removed - postoperative infections following lymph node dissection - Cellulitis - DVT Notes also say, but cannot verify: extent of surgery, postop DVT 20% in pt with hyst + LND; higher for inguinal LND 30%? ## Footnote Chi: Lymphedema starts to appear within weeks of surgery. Obesity, the number of lymph nodes removed, the extent of surgery, postoperative infection, radiation therapy, and postoperative DVT increase the risk of developing lymphedema.

Question 375

Pseudomonas UTI - which does NOT cover? A zosyn B Amox C cipro D meropenem E aztreonam

Answer 375

Amox (this one). Pseudomonas coverage: zosyn, ceftazidime or cefepime, aztreonam, cipro (not as much other fluroquinolones), levo, meropenem/doripenem (not as much imipenem), aminoglycosides AG but need dual therapy (except for tx of UTI). Oral: pick cipro (or levofloxacin but levo's additional spectrum of coverage is usually unnecessary)

Question 376

What antibiotics can be used to treat pseudomonas?

Answer 376

IV First Line Choices: ●Antipseudomonal penicillins + beta-lactamase inhibitor: *Piperacillin-tazobactam ●Cephalosporins with antipseudomonal activity include: *Ceftazidime *Cefepime ●Monobactam: Aztreonam ●Fluoroquinolones: *Ciprofloxacin (Levofloxacin has no advantage due to additional spectrum; potentially harmful. NOT moxifloxacin ●Carbapenems: Meropenem (preferred over imipenem due to resistance) Aminoglycosides (tobramycin favored over gentamicin; amikacin) are active against P. aeruginosa but are generally not used as single agents because of inadequate clinical efficacy at most sites. - can be single agent for treatment of lower urinary tract infections (cystitis). PO antibiotics — Fluoroquinolones are the only antibiotic class with oral formulation that is reliably active against P. aeruginosa. Ciprofloxacin > levofloxacin. Do not use moxifloxacin or fosfomycin

Question 377

How do you treat a pt with a PE postop with renal failure (CrCl 20)? A IVC filter B LMWH C heparin

Answer 377

**HEPARIN** UTD: "Renal failure — IV UFH is our preferred anticoagulant in those with severe renal failure (eg, CrCl <30 mL/minute) since renal adjustment is not required for therapeutic anticoagulation." enoxaparin would be ok w/ CrCl <30 @ 1mg/kg/day. Just not ok on dialysis Other anticoagulants acceptable at this CrCl: Apixaban Edoxaban Warfarin argatroban Not recommended: Dalteparin Dabigatran Rivaroxaban Notes Say: heparin (THIS ONE). LMWH (can dose 1 mg/kg daily rather than 1 mg/kg BID or 1.5 mg/kg daily but not if <30)

Question 378

PE on anticoagulation. Treatment?

Answer 378

Are they actually therapeutic? Switch to lovenox if on warfarin Increase lovenox dose. Consider IVC filter. Anti-Xa and direct thrombin inhibitors is unstudied in this population ## Footnote UTD: increase heparin dose if on UFH. If on LMW heparin, factor Xa or direct thrombin inhibitors in whom subtherapeutic anticoagulation suspected but unconfirmed, or those subtherapeutic on warfarin, switching to a rapid–acting anticoagulant that can be followed (eg, unfractionated heparin) may be prudent while investigations are ongoing. (AW)

Question 379

What is first line Outpatient treatment for neutropenic fever?

Answer 379

NCCN 1/24: Outpatient PO options: - Ciprofloxacin plus amoxicillin/clavulanate (category 1) - (use clinda if PCN allergy) - Levofloxacin - Moxifloxacin (category 1) Inpatient therapy: - Cefepime (category 1) - Imipenem/cilastatin (category 1) - Meropenem (category 1) - Piperacillin/tazobactam (category 1) - Ceftazidime (category 2B)

Question 380

Most sensitive/specific test for cdiff

Answer 380

Stool cell culture cytotoxicity assay- gold standard two-step approach: enzyme immunoassay (EIA) test first for glutamate dehydrogenase (GDH), followed by a toxin test and/or a nucleic acid test (NAAT)

Question 381

Most sensitive test finding to r/o CHF in woman with dyspnea postop? A BNP <100 B normal CXR C physical exam with no LE edema D low CVP

Answer 381

BNP <100 (this one) BNP levels below 100 pg/mL and those above 500 pg/mL have, respectively, a 90% negative predictive value (NPV) and positive predictive value (PPV) In patients with dyspnea at rest, the negative predictive value of a normal plasma NP level is high. NP levels are often (but not exclusively) elevated in patients with HFrEF, but may be normal in a substantial number of patients with HFpEF. CXR limitations - especially HFpEF, where the sensitivity of cardiomegaly is 24 percent and pleural effusion is only 9 percent. In contrast, the same study found that specificity for these findings is excellent (96 and 98 percent, respectively) specificity / sensitivity edema (72 and 53 percent) A decrease in cardiac output either due to decreased heart rate or stroke volume (e.g., in ventricular failure) results in blood backing up into the venous circulation (increased venous volume) as less blood is pumped into the arterial circulation. The resultant increase in thoracic blood volume increases CVP.

Question 382

Most predictive of pulmonary infection after surgery A Pulm edema B low vertical incision C EBL D nutrition

Answer 382

nutrition (low albumin associated with post-op PNA) Also: Increased age, chronic obstructive pulmonary disease, emergency surgery, postoperative reduced albumin, prolonged ventilation, and longer duration of bed rest were identified as significant https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9304902/

Question 383

What are risk factor for postop pulm complications?

Answer 383

UTD: Definite risk factors include [1,3,7]: ●Upper abdominal, thoracic (open), aortic, head and neck, neurosurgical, and abdominal aortic aneurysm surgery ●Emergency surgery ●Age >65 years ●Surgery lasting greater than three hours ●Poor general health status, ASA class >2 ●Heart failure ●Serum albumin <3 g/dL ●Chronic obstructive lung disease ●Cigarette use within the previous eight weeks ●Intraoperative long acting neuromuscular blockade ●Functional dependence ●Obstructive sleep apnea ●Recent lower respiratory tract infection ●Frailty Probable risk factors include: ●General anesthesia (compared with spinal, epidural anesthesia, or other regional anesthetic techniques) ●Arterial tension of carbon dioxide (PaCO2) >45 mmHg (5.99 kPa) ●Abnormal chest radiograph ●Current upper respiratory tract infection ●Postoperative nasogastric tube placement

Question 384

Most likely means to transmit cdiff

Answer 384

Not washing hands b/t patients

Question 385

Most likely complication from subclavian line placement

Answer 385

Arrhythmias Cardiac complications are one of the immediate complications which occur during subclavian line placement. Most common is the onset of arrhythmias (premature atrial and ventricular contractions) which occur when guidewire comes in contact with the right atrium. [9]These arrhythmias can be easily managed by slightly removing the guidewire. Notes say: NEJM 1994 misplacement (6%), arterial puncture (3.7%), PTX (1.5%), mediastinal hematoma (0.6%) (JS) can't find arrhythmias as the MOST common. UTD says below are the immediate complications of all central venuos access, but PTX more common in subclavian: Immediate complications: Bleeding Arterial puncture Arrhythmia Air embolism Thoracic duct injury (with left SC or left IJ approach) Catheter malposition Pneumothorax or hemothorax Delayed Complications Infection Venous thrombosis, pulmonary emboli Venous stenosis Catheter malfunction Catheter migration Catheter embolization Myocardial perforation Nerve injury H&H Pneumothorax and subclavian venous thrombosis are the most common catheter-related complications for temporary and permanent central venous catheters (CVCs) ## Footnote Detroit excel lists Pneumothorax (Gemini supports) (AW)

Question 386

Most common complication of HIT A Thrombosis B hypersplenism C ARF

Answer 386

Thrombosis (this one) UTD: Thrombocytopenia (platelet <150,000/microL) most common; 85 to 90% Thrombosis occurs in up to 50 percent bleeding was seen in approximately 6 percent —> Complications of thrombosis: death (most commonly due to pulmonary embolism), skin necrosis, limb gangrene (sometimes requiring amputation), and organ infarction

Question 387

Mechanism of action for bisphosphonates

Answer 387

Inhibit osteoclastic bone resorption (primary) -- also reduce decreased osteoclast progenitor development and recruitment by promoting osteoclast apoptosis

Question 388

Manifestations of hypoMg

Answer 388

Neuromuscular hyperexcitability (tremor, tetany, sz, weakness, apathy, delirium, up to coma), CV (widened QRS and peaked t-waves with moderate magnesium depletion, and widening of the PR interval, diminution of T waves, and atrial and ventricular arrhythmias with severe depletion. JS - similar sxs of hypocalcemia

Question 389

Which of the following is Inappropriate abx for neutropenic fever? A Meropenem B Piperacillin/tazobactam C Ciprofloxacin plus amoxicillin/clavulanate D Ceftriaxone E Levofloxacin

Answer 389

Ceftriaxone (3rd gen without pseudomonas coverage) Ceftazidine only 3rd generation with P. aeruginosa coverage 4th Generation - Adds Pseudomonas Coverage NCCN 6/24: Inpatient therapy: - Cefepime (category 1)  - Imipenem/cilastatin (category 1) - Meropenem (category 1) - Piperacillin/tazobactam (category 1) - Ceftazidime (category 2B) Outpatient PO options: - Ciprofloxacin plus amoxicillin/clavulanate (category 1)  - Levofloxacin - Moxifloxacin (category 1)

Question 390

How to tx DVT if renal failure (CrCl <10)

Answer 390

anticoagulants acceptable at this CrCl and for dialysis Apixaban Warfarin argatroban (makes sense bc used in HIT, which can have renal failure) Heparin ok as treatment, but only if no suitable alternative. *UTD says enoxaparin would be ok <30 @ 1mg/kg/day. This would not be ok on dialysis Not recommended: Dalteparin Dabigatran Rivaroxaban Edoxaban Notes say: Don't use lovenox --> can use coumadin or argatroban or heparin or apixiban (JS) UTD: recommends UFH followed by warfarin titration inpatient if dialysis dependent.

Question 391

Hyponatremia - most concerning sx

Answer 391

confusion Symptoms: ●Nausea and malaise, which are the earliest findings, may be seen when the serum sodium concentration falls below 125 to 130 mEq/L. ●Headache, lethargy, obtundation and eventually seizures, coma, and respiratory arrest can occur if the serum sodium concentration falls below 115 to 120 mEq/L. Noncardiogenic pulmonary edema has also been described.

Question 392

Euvolemic Hyponatremia with high urine sodium (>40)

Answer 392

High urine Na >40, high urine osmolality >300 = SIADH

Question 393

Euvolemic Hyponatremia with low urine sodium (<25)

Answer 393

Low urine Na <25, low urine osm <100 = primary polydipsia, malnutrition, potomania, or surreptitious diuretic use

Question 394

What’s the difference between HIT I and HIT II?

Answer 394

Type I HIT, also known as heparin-associated thrombocytopenia (HAT), is a non-immune mediated reaction. Type I HIT is much more common than type II and can occur as early as day 1 of therapy. This is a mild reaction, it is not associated with any complications, and platelet counts will spontaneously normalize even if heparin is continued. —> HIT 1 can happen on day 1 Type II HIT is an immune, antibody-mediated reaction. Because it takes time for the antibodies to form, this reaction usually occurs after 5 to 14 days of receiving heparin. However, if a patient has been exposed to heparin within the last 100 days, antibodies may remain in the system, causing this reaction to manifest as soon as day one of re-exposure to heparin. This is a very serious reaction that causes a hypercoagulable state and can lead to life-threatening complications. —> HIT II (looks like 11) happens on day 11 ish (classic HIT as we know it)

Question 395

Esophageal doppler vs. conventional monitoring intraop for fluid resuscitation A Lower mortality B less ICU stays C Faster return of bowel function D lower MAP E lower CO

Answer 395

**FASTER RETURN OF BOWEL FUNCTION** less ICU stays (THIS ONE) - disagree Lit review: shorter LOS Notes say: Less/shorter ICU stay would be my answer. Found association with higher CO. ## Footnote i found this: Intraoperative oesophageal Doppler guided fluid management associated w/a 1.5-day median reduction in postoperative hospital stay. Patients recovered gut function significantly faster and suffered significantly less gastrointestinal and overall morbidity (AW)

Question 396

EPO known risks

Answer 396

****BOXED WARNING: Erythropoiesis-stimulating agents (ESAs) ** increase the risk of death, MI, stroke, venous thromboembolism, thrombosis of vascular access. ESAs shortened overall survival and/or increased the risk of tumor progression or recurrence** - death risk (in CKD when used to target a hemoglobin level of greater than 11 g/dL.) This drug DOES reduce allogeneic RBC transfusion preop Can cause hypertension Epo DOES NOT improve quality of life, fatigue, or patient well-being.

Question 397

Define obesity hypoventilation syndrome

Answer 397

Obesity (body mass index ≥30-35 kg·m2) daytime/awake hypercapnia (arterial carbon dioxide tension ≥45 mmHg) and sleep disordered breathing. rule out other disorders that may cause alveolar hypoventilation

Question 398

COPD greatest preop eval risk

Answer 398

**HAVING COPD=FEV1/FVC <70** COPD is an independent predictor for postoperative pneumonia (OR 1.71, 95% CI 1.59-1.83), reintubation (OR 1.54, 95% CI 1.42-1.66), and failure to wean from the ventilator (OR 1.45, 95% CI 1.35-1.56), in addition to non-pulmonary adverse outcomes there appears to be no prohibitive level of pulmonary function below which surgery is absolutely contraindicated. ## Footnote preoperative spirometry was not predictive of complications following abdominal surgery. PFTs should not be performed routinely in patients undergoing nonresectional surgery. The degree of physiologic impairment (eg, FEV1 or FVC) does not correlate with the risk of postoperative pulmonary complications.

Question 399

Complication of cdiff

Answer 399

Toxic megacolon ●Megacolon should be suspected in patients with severe systemic toxicity together with radiographic evidence of large bowel dilatation (>6 cm diameter in the colon and/or >12 cm diameter in the cecum). Megacolon may be complicated by bowel perforation; manifestations include abdominal rigidity, involuntary guarding, diminished bowel sounds, rebound tenderness, and severe localized tenderness in the left or right lower quadrants; abdominal radiographs may demonstrate free abdominal air (JS) tx same as fulminant colitis -> supportive care until pushed to operate, then TOTAL colectomy (not partial)

Question 400

Colon cancer screening recs

Answer 400

for Average risk (no history of IBD, no family history) starting at age 45yo per NCCN, USPSTF, and ACS: 1) Colonoscopy q10 years (preferred) 2) Stool-based test (guaiac-based testing or Fecal immunochemical test (FIT) testing) q1yr --> if pos then scope 3) Multitargeted stool DNA (mt-sDNA)–based testing q3yr, aka cologuard 3) flex sig q5-10 years (+/- FIT) 4) CT colonosgraphy q5years Least helpful: MD digital rectal exam

Question 401

Best way to check for PE A V/Q B CT pulmonary angiography C Lower-extremity ultrasound with Doppler D Magnetic resonance pulmonary angiography E Catheter-based pulmonary angiography

Answer 401

CT pulmonary angiography FYI: normal chest radiograph is usually required prior to V/Q scanning Catheter-based pulmonary angiography: contrast is injected under fluoroscopy via a catheter introduced into the right heart, was the historical gold standard for the diagnosis of PE. less accurate than CTPA

Question 402

Best imaging to identify brain mets

Answer 402

MRI Contrast-enhanced MRI is the preferred imaging study for the diagnosis of brain metastases [36-39]. Contrast-enhanced MRI is more sensitive than either nonenhanced MRI or CT scanning in detecting lesions in patients suspected of having cerebral metastases and in differentiating metastases from other central nervous system (CNS) lesions

Question 403

Best abx for Klebsiella

Answer 403

Notes say: **Ceftazidime (this one), imipenem and clinda, vanc and gent** From emedicine: 3rd gen cephalosporins, carbapenemas (ie: imipenem), AG (gent), quinolones Lit review: - third or fourth-generation cephalosporin as monotherapy - respiratory quinolone as monotherapy - either 3/4 G cephalosporin or respiratory quinolone + aminoglycoside. - If penicillin-allergic: aztreonam or a respiratory quinolone - If nosocomial: carbapenem monotherapy

Question 404

Appearance of radiation enteritis on imaging

Answer 404

Diffuse bowel wall thickening The ileum is the most frequently injured segment of the small intestine because of its location in the pelvis. Submucosal edema and fibrosis are seen at barium examinations as thickening and straightening of small-bowel folds and separation of adjacent loops. CT can directly reveal bowel wall thickening related to submucosal edema (Fig. 4A,4B). Fluoroscopic evaluation may show single or multiple areas of stenosis and small-bowel obstruction. Altered peristalsis may also be encountered. Fibrotic changes in the mesentery may cause fixation of bowel loops; in this condition, the loops appear angulated and tethered at small-bowel follow-through examination. Increased density in the mesentery may be evident at CT [5].

Question 405

Least likely reason for afib A hypoxia B electrolyte imbalance, C Anemia D PE

Answer 405

Anemia (this one) Lit review: all can cause afib… but our discussion suggests anemia is likely correct

Question 406

What element is required in RBC production?

Answer 406

Copper

Question 407

What is a normal ventilator tidal volume setting based on weight?

Answer 407

6-8 cc/kg (more than 10cc/kg associated with lung injury)

Question 408

What is a normal A-a gradient?

Answer 408

5-10 mmHg

Question 409

What does PCWP approximate?

Answer 409

LA pressure

Question 410

Definition of acute renal failure

Answer 410

KDIGO guidelines define AKI as follows ●Increase in serum creatinine by ≥0.3 mg/dL (≥26.5 micromol/L) within 48 hours, or ●Increase in serum creatinine to ≥1.5 times baseline, which is known or presumed to have occurred within the prior seven days, or ●Urine volume <0.5 mL/kg/hour for six hours

Question 411

Which diuretics may lead to HYPERKALEMIA Duplicate

Answer 411

Potassium-sparing diuretics such as spironolactone, amiloride, and triamterene

Question 412

Which hyperK tx affect serum but not total K levels Duplicate

Answer 412

Things that push into cells - B2 agonist, glucose/insulin, bicarb FYI: IV calcium is administered for myocardium membrane stabilization and does not promote the intracellular shift or elimination of potassium

Question 413

Which hyperK tx affect both serum and total K levels Duplicate

Answer 413

K-binding agents: Kayexalate (sodium polystyrene sulfonate), Lokelma (sodium zirconium cyclosilicate). Dialysis, loop or thiazide diuretic

Question 414

When placing Swan ganz- where are you if you see dicrotic notch

Answer 414

Past the PULMONARY VALVE and into the pulmonary artery the location of the catheter can be determined by viewing the pressure measured from the tip of the catheter. - right atrium (RA), the pressure usually averages <5 mmHg and fluctuates a few mmHg. - right ventricle (RV), the systolic pressure increases to ~25 mmHg and the diastolic pressure remains similar to right atrial diastolic pressure. - pulmonary artery (PA), the systolic pressure normally is similar to the right ventricular systolic pressure, but the diastolic pressure increases to about 10 mmHg because of pulmonic valve closure at the beginning of diastole. - balloon Inflated occludes the PA branch. the pressure in the distal port rapidly falls, reaches a stable lower value that is similar to left atrial pressure (mean pressure normally 8-10 mmHg). The pressure recorded during balloon inflation approximates left atrial pressure because the occluded vessel and its distal branches that eventually form the pulmonary veins act as an extension of the catheter. See: https://cvphysiology.com/heart-failure/hf008

Question 415

Which blood product cannot transmit CMV?

Answer 415

FFP (b/c no leukocytes) Frozen components, including fresh frozen plasma (FFP) and cryoprecipitate, have not been shown to transmit CMV

Question 416

How long can you store RBC

Answer 416

42 days (6 weeks) due to current Anticoagulant-preservative (A-P) solutions

Question 417

Which coagulation factors are the following Fibrinogen Prothrombin Thrombin

Answer 417

Fibrinogen = factor I (think F1brinogen) Prothrombin = factor II (think proThrOmbin) Thrombin = factor IIA (pro means before so this must be 2A)

Question 418

Which component of the clotting cascade does PTT measure?

Answer 418

Intrinsic "PTT=play table tennis, Inside" ## Footnote Intrinsic

Question 419

Which component of the clotting cascade does PT measure?

Answer 419

Extrinsic \ "PT= play tennis, outside" JS- the only way out of the hospital is after PT eval (exit via PT)

Question 420

Most common organisms line infection

Answer 420

Coag neg staph, staph aureus, Enterococcus Most frequently isolated BSI organisms include coagulase-negative staphylococci (31%), Staphylococcus aureus — either methicillin sensitive or resistant (20%), enterococci (9%), Escherichia coli (6%), Klebsiella species (5%), and Candida species (9%). ## Footnote AS: UTD says Coag neg staph 16.4%, S. aureus 13.2%, Enterococcus 15.2%, Candida 13.3% as most common

Question 421

Tx of SVT

Answer 421

Adenosine

Question 422

What does labeling index do?

Answer 422

Measures proliferation and cells that have COMPLETED S phase ## Footnote Example: Ki-67 proliferative index

Question 423

What lab or vital sign abnormality is First and most sensitive to blood loss?

Answer 423

Pulse/tachycardia

Question 424

What to give if patient has low fibrinogen?

Answer 424

Cryoprecipitate

Question 425

What does FISH measure?

Answer 425

Fluorochrome-labelled DNA probe is hybridized to specific base pair sequence in metaphase chromosomes or interphase nuclei. Detects recurring numerical or structural chromosomal abnormalities

Question 426

What is ELISA?

Answer 426

Enzyme-linked immunosorent assay. Ab bound to plate to capture the antigen; also attached to enzyme that can convert some chemical into something that can be measured by color

Question 427

What is a southern blot?

Answer 427

Measures DNA ## Footnote "DNA is bigger/heavier, things are bigger in the south"

Question 428

What is a northern blot?

Answer 428

Measures RNA

Question 429

What is malignant hyperthermia?

Answer 429

Justines answer: reaction to anesthesia, tx with dantrolene, develop rhabdo. RYR1 mutation

Question 430

Which are vitamin K dependent coag factors?

Answer 430

II, VII, IX, X (2+7=9 and 10)

Question 431

What to do if suspect air embolism after Swan Ganz?

Answer 431

Answer: Left lateral and t-burg Wrong answer: try to aspirate

Question 432

Describe nec fasc

Answer 432

Gray margins, irregular borders, erythema, pain out of proportion, crepitus, fever ## Footnote AS: lymphangitis often = for erysipelas (group A strep)

Question 433

What is the risk of reinfarction <3 months and >6 months after MI?

Answer 433

Less than 3 months after MI: risk for reinfraction is 30% Greater than 6 months after MI - risk is 1-2%

Question 434

What abx for high risk endocarditis undergoing dental procedure?

Answer 434

Ampicillin

Question 435

Ideal time to stop smoking before surgery?

Answer 435

4 weeks | at least 4-6wk

Question 436

Which does not cause an increased A-a gradient?

Answer 436

hypoventilation wrong answers: shunting, V/Q mismatch

Question 437

Which is least likely to affect A-a gradient?

Answer 437

Hypoventilation wrong answers: ARDS, PNA, PE, pulmonary edema *Repeated question

Question 438

Best test for aneuploidy

Answer 438

answer: flow cytometry for propidium iodide background information: Flow cytometry (FCM) provides a fast and precise method for determination of DNA-aneuploidy index. *Aneuploidy was diagnosed previousy by counting the metaphase chromosomes under the microscope, with difficulties in precision/accuracy, long processin time and handling of strong acids (difficult for large scale use). *Flow cytometry surpasses the above barriers by quantifying the amount of DNA rather the counting the number of chromosomes, it has low level of variation coefficient of the DNA peaks, an equal proportion of cells in each peak, and a small difference in DNA of the sample and internal reference. It is now widely used to identify aneuploidy in cancers.

Question 439

OR is closer to RR if prevalence is high or low?

Answer 439

Low

Question 440

Which flap lowest failure?

Answer 440

Any RAM flap is flap of choice for gynecologic defects lower failure rate than gracillis Based on morrow Based on UTD for anterolateral thigh flaps: donor site morbidity, including skin separation and lymphocele, are recognized complications of flap harvest.

Question 441

What is the diff between assist control, intermittent mandatory ventilation, and pressure controlled ventilation?

Answer 441

assist control--Triggered with patient's resp effort but if not initiated will deliver a breath at pre-specified interval, patient can over-breathe the vent. intermittent mandatory ventilation--Initiates breath at prespecified intervals if patient doesn't (but not triggered by patient breath), can lead to increased work of breathing. Pressure-controlled ventilation: ventilate a patient with a maximal peak pressure. In contrast to volume-controlled ventilation, pressure-control involves the selection of an inspiratory pressure instead of a tidal volume target. The setting of an inspiratory pressure, as well as an associated positive end-expiratory pressure (PEEP), will allow a provider to control the peak pressure, thereby protecting from barotrauma.

Question 442

What is the pathophysiology of nausea and vomiting induced by uremia, hyperCa, and some medications? Duplicate

Answer 442

High plasma concentrations of emetogenic substances (opioids, selective serotonin reuptake inhibitors, urea, and calcium) trigger nausea and vomiting by stimulating dopamine D2 receptors located in the chemoreceptor trigger zone. The best treatment would be a dopamine antagonist, such as haloperidol, which is the most potent of dopamine receptor blockers, and metoclopramide. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2426995/

Question 443

What is the relationship between adjusted PCWP and ARDS vs CHF?

Answer 443

Adjusted PCWP < 44 mmHg below colloid oncotic pressure - likely ARDS (answer) Adjusted PCWP > 44 mmHg above colloid oncotic pressure - likely CHF (I'm not sure if this statement is correct - it was not highlighted in red) * I could not find these specific numbers. On UPTD, the following is mentioned: pulmonary edema occurs at pulmonary artery capillary pressures as low as 18 mmHg. By contrast, patients with chronic heart failure have an increased lymphatic capacity and do not develop pulmonary edema until much higher pulmonary capillary pressures (eg, >25 mmHg) are reached.

Question 444

What is the goal of phase I, II, III, IV trials?

Answer 444

I = defines max tolerated dose *Ia trials will provide a single dose of the drug to each participant to determine the MTD within one treatment arm. *Phase Ib trials run multiple arms simultaneously to test more than one dose of the drug. II = defined biologic activity > effectiveness in a certain type of cancer and side effects *Phase 2A studies are typically more preliminary and can address issues such as dosing and safety, while phase 2B studies are generally 'mini-phase 3' studies that provide data on efficacy. III = usually RCT > confirm efficacy compared to standard treatments *3a studies take place before FDA approval. *3b studies are conducted after. Post-approval studies may further research how the treatment impacts quality of life, for example. IV = large scale to see if can translate to larger population, post market studies.

Question 445

How would you approach the nutritional support for a patient following an uncomplicated debulking with moderately impaired nutritional status A partial parenteral nutrition (PPN) B TPN, C isotonic fluids with addition of D5 D enteral feeding

Answer 445

enteral feeding

Question 446

Best opioid for renal issues

Answer 446

Dilaudid (most likely because Fentanyl was not a choice. Fentanyl is preferred but it was most likely not listed on the exam) transdermal buprenorphine, transdermal fentanyl, and oral hydromorphone are the most tolerable opioids in these patients; hydrocodone, oxycodone, and methadone are useful but require careful monitoring tramadol, codeine, morphine, and meperidine should be avoided due to risk of accumulation and adverse events

Question 447

What is the relationship between standard deviation and variance?

Answer 447

Standard deviation = square root of variance ## Footnote SD = "how far datapoint is from measured mean". Variance = "how variable datapoints are from each other"

Question 448

What is smaller than the standard deviation? How do you calculate it?

Answer 448

Standard error of the mean standard error of the mean = SD / square root of n

Question 449

Doing multiple t-tests results in more of what type of error?

Answer 449

Type I (false positive aka erroneously rejecting null hypothesis)

Question 450

Is chi-square parametric or non-parametric?

Answer 450

Non parametric *used to examine whether two categorical variables are independent in influencing the test statistics. if ≤ 20% of expected cell counts are less than 5, then use the chi-square test; if > 20% of expected cell counts are less than 5, then use Fisher's exact test. Both methods assume that the observations are independent.

Question 451

Most likely EKG finding in post op MI

Answer 451

Characteristic ECG changes of periop MI include new T-wave inversion and ST-segment depression = NSTEMI most likely postop - Could not confirm this, based on UTD changes would be based on whether is a STEMI (ST segment elevation changes noted) vs. NSTEMI (above) with changes on EKG which may follow a sequence based on time of onset.

Question 452

Most likely EKG finding in post op MI

Answer 452

Characteristic ECG changes of periop MI include new T-wave inversion and ST-segment depression. * UTD changes would be based on whether is a STEMI (ST segment elevation changes noted) vs. NSTEMI (above).

Question 453

What is the heparin induced thrombocytopenia 4 T score?

Answer 453

Scoring system consisted of four criteria, each of which was worth 0, 1, or 2 points. Study used ≤3 points to define low probability group (≤5%) for HIT, 4-5 points for intermediate and 6-8 points for high. *The 4 Ts score should be used as a guide for clinicians and should not substitute for clinical judgment. *Based on UTD, HIT antibody testing or presumptive treatment for HIT is not pursued with scores ≤3 (eg, we do not discontinue heparin or start a non-heparin anticoagulant) because the risk of HIT is low and presumptive treatment carries risks (eg, bleeding). See pic

Question 454

ERAS style intraop fluid management most likely to cause what detrimental effect?

Answer 454

Cause AKI https://www.sciencedirect.com/science/article/abs/pii/S009082582100651X

Question 455

Insulin and endometrial cancer mechanism

Answer 455

Notes say: insulin is an anabolic hormone that stimulates cell proliferation via MAPK, PI3K, PTEN/atk pathways Lit review: estrogen + insulin promotes proliferation endometrial cancer cells compared with estrogen or insulin alone estrogen and IGF-1 can synergistically promote the development of tumors in mice by activating MAPK and AKT signaling pathways > *activate mTOR, p70S6 kinase, and GSK-3-beta, which are important for stimulation of protein synthesis and glucose transport. This pathway is also important for IGF-1 stimulation of cell motility, inhibition of apoptosis, and stimulation of cellular differentiation. estrogen may bind to IGF-1R and exert non-genetic transcriptional effects through the Ras/MAPK signaling pathway

Question 456

Most significant valve issue in elderly

Answer 456

aortic stenosis *According to a table on UTD mitral regurgitation prevalence is 9.3% versus 2.8% prevalence of aortic stenosis in elderly above the age of 75.

Question 457

Utility of FE Urea

Answer 457

- Results > 50 to 65 percent common in acute tubular necrosis (ATN) - Results < 35 percent in prerenal disease - FEUrea is more reliable on patients taking diuretics then FENa (which can be be falsely high in patients taking a diuretic). Similar to FeNa, a larger value is more indicative of ATN * Fractional Exceretion of Urea = Uur X Pcreat / Ucreat X Pur · 100% Uur = Urine urea Pcreat = Plasma creatinine Ucreat = Urine creatinine Pur = Plasma urea ## Footnote ICU- cystatin C (if neither option, uninfluenced)

Question 458

What lab testing exists for HIT

Answer 458

Solid-phase ELISA immunoassay that detects the presence of anti-platelet factor 4 (PF4)/heparin antibodies in patient serum - most widely used laboratory test for HIT. - fast but more false +. - sensitivity and specificity 97.5% and 83.4% - NPV of 99.6%, PPV 44.4% Functional assays (Serotonin release assay) - gold standard - disadvantages: high cost, use of radioactive material, technical demands of the assay, delay in obtaining results due to lack of routine availability at most institutions. - Ticagrelor: interfere with functional assays for HIT, leading to false negative tests.

Question 459

What is timing of HIT

Answer 459

Occurs 5-10 days after heparin exposure, or within 24hrs if antibodies already present

Question 460

How to monitor enoxaparin

Answer 460

factor Xa inhibition (anti-factor Xa activity): Target levels for BID enoxaparin are between 0.5 and 1 measured 4-6 hours after dose, starting after 3rd-4th dose Routine monitoring of anti-factor Xa activity is not required but has been utilized in patients with obesity, kidney insufficiency and pregnancy given changes in pharmacokinetic parameters and renal clearance. For patients >144 kg, if anti-factor Xa monitoring is available, adjusting dose based on anti-factor Xa activity is recommended

Question 461

Dose of lovenox for obese patients

Answer 461

treatment: BMI ≥30 kg/m2: usual dosing range: 0.7 to 1 mg/kg every 12 hours - actual body weight BMI ≥50 kg/m2: lower end of the usual dosing range Extreme BMI (~114 kg/m2), doses below usual may be indicated. anti-factor Xa monitoring is recommended Ppx BMI 30 to 39 kg/m2: standard dosing BMI ≥40 kg/m2: fixed or weight-based dosing - 40 mg twice daily or 0.5 mg/kg twice daily (based on actual body weight) BMI >50 kg/m2: 60 mg twice daily or 0.5 mg/kg twice daily (based on actual body weight). target anti-factor Xa level.

Question 462

Renal Dose reduction of lovenox

Answer 462

CrCl >=30: No dose adjustment necessary CrCl <30mL/min: 30mg daily prophylaxis, 1mg/kg once daily for therapeutic

Question 463

Standard dose of lovenox

Answer 463

Ppx: 40mg daily Treatment: 1 mg/kg every 12 hours (preferred) or 1.5 mg/kg once every 24 hours.

Question 464

How do hemodynamic parameters change with trendelenburg and pneumoperitoneum?

Answer 464

- increase CVP, MAP, SVR, PCWP and pulmonary arterial pressures - decrease cardiac output and stroke volume per UTD

Question 465

what opiate causes prolonged QT and torsades

Answer 465

methadone

Question 466

70 yo with DM, HTN, AFIB sp TLH/BSO what anti coag post op

Answer 466

lovenox

Question 467

was there a difference in QOL during or after IP chemotherapy for ovarian cancer?

Answer 467

worse during through 6 weeks after , but no different 1 year later (GOG172)

Question 468

Medicine class most associated with delirium in elderly post-operative patients?

Answer 468

Benzos Others: cimetidine, corticosteroids, diphenhydramine, belladonna, promethazine, warfarin, narcotics, benzodiazepines, and antiparkinsonian drugs

Question 469

Most common complication after splenectomy? A Transient bacteremia with encapsulated organisms B left atelectasis C abscess D pancreatic leak

Answer 469

left atelectasis (THIS ONE in Bristow text)

Question 470

During inguinal LND, use of fibrin sealants increases risk of? A lymphedema B Infection C drainage from site D wound separation

Answer 470

Infection https://www.gynecologiconcology-online.net/article/S0090-8258(08)00198-4/fulltext

Question 471

What is least likely complication of premenopausal BSO? A anxiety/depression B CV dz C Kidney stones D metabolic syndrome

Answer 471

Kidney stones (This one), Though does increase risk of - Chronic kidney disease - dementia - CV disease - all cause mortality - Parkinson’s - anxiety and depression - glaucoma - osteoporosis - sexual dysfunction

Question 472

Most common injury L/S

Answer 472

urinary tract of option and specific for gyn Otherwise Bowel slightly higher than vascular Bowel: 0.03 to 0.65% undergoing laparoscopic surgery Vascular: 0.01 to 0.64% of laparoscopies urinary tract 0.03 to 1.7% of laparoscopic gyn surgeries Up to one-half of complications occur at the time of abdominal access for camera or port placement

Question 473

ABG for PE

Answer 473

Respiratory alkalosis (tachypnic), decreased CO2 and PaO2; elevated A-a gradient

Question 474

What is Erythropoietin production stimulated by?

Answer 474

Decreased O2 in the renal artery Erythropoietin (EPO) is a glycoprotein hormone, naturally produced by the peritubular cells of the kidney, that stimulates red blood cell production. Renal cortex peritubular cells produce most EPO in the human body. PO2 directly regulates EPO production. The lower the pO2, the greater the production of EPO"

Question 475

If Swan-ganz will not wedge, what value most closely corresponds?

Answer 475

PA diastolic pressure pulmonary artery (PA) diastolic pressure is similar to the pulmonary artery wedge pressure and is similar to left atrial pressure (mean pressure normally 8-10 mmHg). - accurate as long as no pulmonary HTN exists See: https://cvphysiology.com/heart-failure/hf008

Question 476

What is contraindication to PA catheter placement

Answer 476

Notes say: LBBB Absolute contraindications: ●Infection at the insertion site ●The presence of a right ventricular assist device ●Insertion during cardiopulmonary bypass ●Lack of consent Relative contraindications: - coagulopathy (INR >1.5), thrombo (<50k) - risk hemorrhage - hypo- /hyper-K, -Mg, -Na, -Ca) - risk life-threat arrhythmias - pH <7.2 or >7.5 - risk life-threatening arrhythmias High risk - severe pulmonary HTN (risk pulmonary artery rupture) - Eisenmenger's syndrome (risk pulmonary artery rupture) - right or left bundle branch block (risk CHB) - defibrillator or pacemaker (risk of displacement) - prosthetic or stenotic tricuspid / pulm valve (diff cath adv) - latex allergy (most catheters have latex) - persistent L SVC (misplacement to the left atrium) - right atrial or ventricular masses (diff cath advancement).

Question 477

Best predictor of weaning off vent

Answer 477

Rapid shallow breathing index (RR/TV); Successful weaning predicted if RSBI <105 Weaning failure predicted if >=105

Question 478

What is nec fasc type I and type II?

Answer 478

Type I: (polymicrobial) immunocompromised pts (often DM, elderly). anaerobic/aerobic bacteria (eg., Staphylococcus aureus, Haemophilus, Vibrio, Escherichia coli, Bacteroides fragilis). Think DM Type1 are immune compromised Type II: (monomicrobial) immunocompetent patients w history of trauma (sometimes minor). S. pyogenes (GAS /other beta hemolytic strep) +/-Staphylococcus aureus

Question 479

What changes occur with short bowel syndrome to intestinal villi

Answer 479

- Epithelial hyperplasia - lengthening of remaining villi - remnant bowel will dilate and elongate, resulting in increased intestinal weight and protein content. - Villus lengthening - microvilli proliferation -Total enterocyte number is increased - Hypertrophy of the muscle layers —> increase in bowel wall thickness. - ileum demonstrates more adaptive capacity than the jejunum.

Question 480

Which is not a tx for short bowel syndrome? A anti motility agents B nutritional support C octreotide D B12 supplementation

Answer 480

Notes say: octreotide (this one - b/c stomach) <— unsure of stomach comment, but correct as it has a lot of negative effects Octreotide — The use of octreotide should be reserved for patients with intravenous fluid requirements that are greater than 3 L per day and only after the period of maximal intestinal adaptation Typical candidates include patients with SBS and a high-output end-jejunostomy. Octreotide increases small bowel transit time and reduces fluid losses, but tachyphylaxis often develops. Octreotide diminishes splanchnic protein synthesis, which can interfere with the process of adaptation predisposes patients to the development of gallstones for which patients with SBS are at high risk Also avoid growth hormone, cholestyramine, and glutamine — Fat soluble vitamins (A, D, E, and K), vitamin B12, folate, calcium, magnesium, zinc, iron, copper, and selenium are the main micronutrients at risk for deficiency ## Footnote JD: yeah, octreotide only for >3L and developes tachy. Bad. The rest are all neccessary.

Question 481

Calcium correction for albumin

Answer 481

Corrected Calcium mg/dL = (0.8 * (Normal Albumin - Pt's Albumin)) + Serum Ca | JD: Corrected Ca mg/dL = Measured Ca + (0.8* (4 - measured Alb))

Question 482

Indications for dialysis

Answer 482

These are "urgent indications". A (acidosis <7.1) E (electrolytes, hyperK >6.5) I (intoxication, methanol, ethanol, lithium, ASA) O (volume overload) U (uremia, encephalopathy/pericarditis)

Question 483

Most common lab abnormality in DIC

Answer 483

D-dimer elevation is most sensitive and specific and probably correct answer Also in the decreasing order of frequency are **thrombocytopenia**, elevated fibrin degradation products (FDPs), prolonged PT, aPTT and a low fibrinogen ## Footnote JD: I cannot confirm the above, and think likely thrombocytopenia https://emcrit.org/ibcc/dic/

Question 484

Is dialysis useful for lidocaine overdose

Answer 484

No Not dialyzable

Question 485

How often should splenectomy patients get vaccinated?

Answer 485

Every 5 years ## Footnote JD: MenB every 2-3 yrs (new as of 2019 ACIP reccomendation) PPSV23 and MenACWY every 5 years

Question 486

For transureteroureterostomy - where should it run in relation to IMA and great vessels

Answer 486

In front of great vessels can be in front of or behind IMA “This is achieved by tunneling the donor ureter through the sigmoid colon mesentery superior to the inferior mesenteric artery to avoid kinking.” BB: online textbook says inferior to IMA MLH: Also saw pics of this above IMA online Bottom line: IMA relationship probably depends on ureter length ## Footnote JD: " preferably cephalad to the IMA. If there is enough ureteral length that the ureter can be readily passed caudal to the IMA across to the contralateral side, then the patient is likely a candidate for ureteroneocystostomy." Hinmans atlas of urologic surgery

Question 487

Most common cause not seeing SBO on x-ray? A NGT drainage B perforation C High/proximal obst

Answer 487

High/proximal obst (this one), Unable to verify in lit review ## Footnote JD: unable to verify this as well

Question 488

Risk factors for unplanned retained foreign object in surgery:

Answer 488

The most common root cause of URFOs reportd to the Joint Commission are: - absence of policies/procedures, - failure to comply with policies/procedures, - problems with hierarchy and intimidation, - failure in communication with physicians, - failure of staff to communicate relevant patient information ## Footnote JD: In a retrospective study that used malpractice insurance files and identified 61 retained surgical items, a multivariate analysis identified three factors that were associated with a significantly increased risk: an emergency procedure (risk ratio [RR] 8.8, 95% CI 2.4-31.9), unplanned change in the procedure performed (RR 4.1, 95% CI 1.4-12.4), and increased body mass index (RR per one-unit increment 1.1, 95% CI 1.0-1.2) Ultimately mixed data depending on what study you look at..... but: Emergency surgical procedures, Unexpected change in the course of the surgical procedure, obesity, Involvement of two or more surgical teams, Procedures involving one or more open body cavities, Prolonged surgical procedures, use of an unusually large number of instruments, Absence of the attending surgeon at final closure were all associated. Trainees involved are LESS associated.

Question 489

What bowel diversion is best to do following a left hemicolectomy?

Answer 489

Ileostomy

Question 490

Estrogen receptor expression can help distingish: A LMS vs GIST B small cell cervix vs endometrial carcinoma C mucinous ovarian primary vs metastatic mucinous GI cancer D metastatic breast cancer and primary ovarian cancer

Answer 490

Answer: Small cell cervix (0%) vs endometrioid (80%), FYI: info from pathology outlines LMS (42%) vs GIST (0%): No mucinous ov (0%) vs metastatic mucinous GI cancer - colon 0% met breast (lobular 97%) and prim ov (HGSOC 97%) ## Footnote JD: Should be B. LMS is not 100%, (25-60% cited in PMID 25018868), Leito et al GynOnc 2012 with an LMS case series with 42%ER+.

Question 491

ECG Changes by electrolyte imbalance

Answer 491

HyperK and HyperMg - Increase PR and QTc - Prolonged QRS - Peaked T waves and flattened p waves - Bradycardia HypoMg - Prolonged PR - Prolonged QT HypoK - Prolonged PR - T wave flattening/inversion - U wave HyperCa - shortened QT - J waves HypoCa - prolonged ST segment (causing longer QT)