McNeil's notes - cardio, resp, gi, nephro, most cancer, radiation, chemo, transplant, pharmacology, infectious diseases Flashcards
Patient with acute right-sided M.I., what is the best course of action in managing this patient?
a. Volume resuscitation with N/S.
b. Inotropes are not indicated.
c. There is decreased right diastolic pressure once the pulmonary artery pressure is decreased.
d. EKG is often not diagnostic.
e. You should increase the right after load.
a. Volume resuscitation
The initial therapy for hypotension in patients with right ventricular infarction should almost always be volume expansion.
- Braunwald: Heart Disease: A Textbook of Cardiovascular Medicine, 6th ed., W. B. Saunders Company, p. 1181-1182.
a. Inotrops (yes if needed)
b. Reduce preload (opposite – want to increase preload)
c. IV fluid
d. Reduce afterload (yes, but most important is to give fluid to increase CO)
Post Operative MI, patients experiences cardiogenic shock. Which
is the best management?
a. Angioplasty
b. Intra-aortic balloon
c. Streptokinase
d. Decrease preload and afterload with an inotrope
a. Angioplasty
In the large randomized controlled SHOCK trial, investigators determined that patients with cardiogenic shock after acute myocardial infarction benefited if within 6 hours of the onset of shock they underwent an intervention that restored coronary blood flow, as opposed to medical stabilization and delayed intervention.[47] Two interventions used to restore coronary blood flow were immediate coronary artery bypass surgery and immediate percutaneous coronary interventions that included transluminal angioplasty and deployment of endoluminal stents to prevent reocclusion of the coronary artery.
- Townsend: Sabiston Textbook of Surgery, 18th ed.
Two days post major bowel surgery, a patient develops dyspnea, left-sided chest pain and ECG changes in lateral leads. Immediate treatment should include:
a) heparin
b) O2
- Most common time for post-op MI is day 2-3 due to reabsorption of 3rd space volume and therefore volume overload on the heart
- Diagnosis of acute MI is based on 2 of 3 of the following:
o history and physical
o ECG changes (ST segment elevation, T wave inversion, significant Q waves)
o cardiac enzyme elevation - management goal is to minimize the amount of infarcted myocardium and prevent complications
- immediate measures include:
o O2, sublingual NTG, morphine (pain relief, sedation), ASA, B-blocker (if not contraindicated), ACE I
o anticoagulation therapy - IV heparin to prevent extension of clot/thrombus
o thrombolytic therapy - this patient would not be a candidate since only POD #2, but criteria for review are:
CP for 30+ minutes
ECG changes:
• 1mm ST elevation in 2 limb leads OR
• 1mm ST elevation in 2 adjacent precordial leads OR
• new onset LBBB
presentation within 12h of symptom onset - Reference: MCCQE
Signs of cardiac tamponade include all of the following EXCEPT A. Narrow pulse pressure B. Pulsus alternans C. Wide pulse pressure D. Hypotension E. Distended neck veins
C. Wide pulse pressure
This is also asked with “Right atrial pressure greater than the Leftatrial pressure”
This question was often asked, and basically the answer is usually you do NOT see WIDE pulse pressure. Also Left atrial pressure is normally greater than the right, but in cardiac tamponade they can equalize as fluid accumulates.
One week after undergoing tooth extraction, a patient develops fever, increased white count and SOB. On exam, the patient has systolic murmur at left sternal border with hypotension and increased pulse pressure. The likely diagnosis is:
a. tricuspid endocarditis with tricuspid regurg
b. pulmonary valve endocarditis with regurg
c. mitral valve endocarditis with regurg
d. aortic valve endocarditis with regurg
- d. aortic valve endocarditis with regurg
The most common causes of an ejection systolic murmur are aortic stenosis and aortic sclerosis
The valves most commonly infected are left-sided valves, with approximately equal frequency between the mitral and aortic valves (see the following images). Vegetations on the mitral valve can extend onto the noncoronary and left cusps of the aortic valve, as they are contiguous, and double aortic and mitral valve replacements are not rare. Left-sided valve endocarditis is more frequent, even in drug addicts, than right-sided endocarditis,[3] although infections of the tricuspid and pulmonary valves are highly suspicious of intravenous drug abuse.
Tricuspid valve endocarditis may occur in community-acquired infection, usually in intravenous drug addicts, or hospital-acquired infections from implanted devices. Isolated pulmonary valve endocarditis is rare (except in patients with congenital heart disease) and may cause confusing clinical symptoms
Which drug of the following if given to cardiac patient in non cardiac surgery will improve survival:
b. Metoprolol
c. Digoxin
d. ASA
e. Atropine
b. beta blocker
Perioperative B-blocker therapy and mortality after major noncardiac surgery reduced risk of in-hospital death among high risk, but not low risk patients.
- NEJM July 28, 2005
- article does not differentiate between atenolol and metoprolol
- extended release metoprolol reduces cardiac mortality but increases overall mortality
In patients scheduled for noncardiac surgery, including those at high risk, we recommend not starting perioperative beta blockade (Grade 1B). (See ‘Patients not taking beta blockers’ above.)
●In patients treated with long-term beta blockers for recommended indications, we suggest continuing beta blockade perioperatively (Grade 2B). (See ‘Beta blockers’ above.)
what is the mechanism of epinephrine during a cardiac arrest?
Answer given: increase cardiac inotropy
Epinephrine Chronotropy 4+ Inotropy 4+ Vasoconstriction 4+ Vasodilatation 3+ - Piccini & Nilsson: The Osler Medical Handbook, 2nd ed.
Intraoperatively patient bradys down to 40 – drug to give
atropine
In hypertensive cardiomyopathy, which of the following is true regarding myocardial muscle cells?
a) there is an increase in the number of cells
b) the cells increase in size
c) the is an increase in both the size and number of cells
Histologically, individual muscle cells are hypertrophied, with a disorganized, characteristic whorled pattern.
- Marx: Rosen’s Emergency Medicine, 7th ed.
Worst prognosis with severe CHF
a. hypotension
b. hypoxia
a. hypotension
The largest analysis[152] found that BUN, systolic blood pressure, heart rate, and age were the main multivariate predictors, and using a different statistical approach with dichotomous variables, suggests that the best single predictor was an elevated admission blood urea nitrogen (BUN ≤ 43 mg/dl), followed by low blood pressure (systolic blood pressure
All of the following are benefits of smoking cessation 6 weeks prior to surgery except
a. improved ciliary function
b. decreased airway reactivity
c. decreased co2 retention
d. increased secretion clearance
e. none of the above
Answer given: c. decreased co2 retention
Intermittent quitters had less loss of lung function at comparable cumulative cigarette doses than continuing smokers. Interestingly, the shorter-term improvement after quitting or the decrement after relapsing was significantly related to methacholine reactivity, [145] implying that acute airway inflammation contributes to the observed FEV1 fluctuations.
- Sethi JM - Clin Chest Med - 01-Mar-2000; 21(1): 67-86, viii
Cigarette smoking increases perioperative mortality probably because of the effects of smoking on both the cardiovascular and the respiratory systems.[100] Smokers may have increased levels of carboxyhemoglobin as a function of their brand of cigarette, how deeply they inhale, the number of puffs they take, and the level of ventilation present while they are smoking.[101] The level of carboxyhemoglobin in smokers usually ranges from 3% to 15%, and the major effects are to reduce the amount of hemoglobin available to bind with oxygen, thereby decreasing arterial oxygen content, and to shift the oxygen-hemoglobin saturation curve to the left. Smokers have a decreased oxygen delivery and an increased tissue oxygen extraction, manifested by a reduced mixed venous oxygen content.[102] Patients at greater risk for elevated carboxyhemoglobin levels are those who smoke avidly late at night and then undergo an early morning operation. Therefore, it is recommended that smokers stop smoking 12 to 18 hours preoperatively to allow sufficient time (three half-lives) for carboxyhemoglobin clearance.
Decreased CO2 retention. There were lots of references made to improving ciliary function, increasing secretion clearance and decreasing airway reactivity but I couldn’t find anything about CO2 retention so I figured this is the answer.
You are called to see a patient after a blood gas that was ordered by the clinical clerk shows a PaO2 of 40mmHg. After 20 min of 100% O2 by face mask a CBC reveals a hematocrit of 0.65 and a repeat blood gas reveals values of 7.30/40/60/26 with a saturation of 88% on an FiO2 of 1.0. The likely diagnosis is:
a. polycythemia rubra vera
b. pulmonary fibrosis
c. COPD
d. Intrapulmonary shunt
e. Carbon monoxide poisoning
Answer given: b. pulmonary fibrosis
Carbon monoxide poisoning: “ arterial blood gases reveal metabolic acidosis, a normal PO2, decreased O2 saturation (by direct co-oximetry measurement rather than a calculated or pulse oximetry value) and a normal or slightly decreased PCO2”
- Harrison’s 13th ed
Polycythemia Vera: Normal arterial oxygen saturation (>92%)
- Ferri: Ferri’s Clinical Advisor 2010, 1st ed.
DDX Polycythemia
Absolute
a) autonomous erythroid proliferation (polycythemia rubra vera)
b) secondary erythroid proliferation
I – Autonomous or inappropriate increase in erythropoiten eg neoplasm, renal lesions, familial
2- Secondary increase in erythropoiten
i – hypoxia (decrease PO2) – eg high altitude, alveolar hypoventilation, pulmonary disease, cardiac left to right shunt
ii – abnormal hemoglobin function (normal PO2) – eg high affinity genetic variants, congenital methemoglbinemia, carboxyhemoglobin (smoker’s polycythemia)
c) Hormonal stimulus to erythropoesis eg cushing sydrome, androgen or corticosteroid administration
Relative (reduced plasma volume, normal cell mass) eg dehydration, stress erythrocytosis
- Harrisons pg 180
Any pulmonary disease which produces chronic hypoxia may lead to erythrocytosis
Woman in third trimester of pregnancy is jaundiced which test would show hepatocellular damage
a) increased alk phos
b) increased unconjugated bili
c) increased conjugated bili
d) increased GGT
e) decreased urobilinogen
D. we agreed GGT is the answer at review week
Also known as intrahepatic cholestasis of pregnancy. Usually occures in thrid trimester but may develop any time after the 7th week of gestation. Clinical features include: pruritis and jaundice. Clinical and laboratory abnormalities include: elevated alkaline phosphatase (but during pregnancy, this is usually due to placental source rather than hepatic), elevated bilirubin (conjugated > unconjugated) and elevated GGT.
a) increased alk phos (post-hepatic and other sources)
b) increased unconjugated bili (pre-hepatic)
c) increased conjugated bili (hepatic and post-hepatic)
d) increased GGT (cholestatic but also from liver)
e) decreased urobilinogen (no conjugated bilirubin)
GGT is another enzyme found in hepatocytes and released
from the bile duct epithelium. Elevation of GGT is an early
marker and also a sensitive test for hepatobiliary disease. Like
AP elevation, however, it is nonspecific and can be produced by
a variety of disorders in the absence of liver disease. Increased
levels of GGT can be induced by certain medications, alcohol
abuse, pancreatic disease, myocardial infarction, renal failure,
and obstructive pulmonary disease. For this reason, elevated
GGT levels are often interpreted in conjunction with other
enzyme abnormalities. For example, a raised GGT level with
increased AP level supports a liver source.
Schwartz
A 58 y.o. M with cirrhosis presents with an UGI bleed. Initial resuscitation measures are carried out. What is the MOST helpful adjunct to treatment? A. Synthetic vasopressin B. Somatostatin (Octreotide) C. Ranitidine D. NG tube
- Somatostatin infusion
if patient did not have a history of liver failure the diagnosis of duodenal or gastric ulcer is more likely , and treatment with PPI. PPI stablize the clot but does not speed clot resolution ***
Patients with evidence of liver disease (by history, physical examination, or laboratory data) who have active upper gastrointestinal bleeding should be started on pharmacologic therapy (e.g., intravenous octreotide) to lower portal venous pressure and stop the bleeding as soon as possible and then undergo urgent endoscopy.
- Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 8th ed.
Somatostatin and octreotide have been studied in patients with ulcer-related upper gastrointestinal bleeding. A meta-analysis revealed a reduction in the rate of rebleeding in 1829 patients treated with somatostatin or octreotide, but mortality was not improved.[114] It is this author’s opinion that these agents may be useful in some patients (e.g., those with severe bleeding who are awaiting endoscopy or surgery or those in whom other drug therapy is not possible) but are not indicated routinely.
- Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 8th ed.
Patient with bleeding esophageal varices is started on vasopressin. What side effect should you watch for?
a. Coronary vasoconstriction
b. Decreased small bowel motility
c. Bronchial dilatation
d. Peripheral vasodilation
Answer: a. Coronary vasoconstriction
Vasopressin is an alternative pharmacotherapeutic agent but is used less frequently because of significant complications (including myocardial ischemia and infarction, ventricular arrhythmias, cardiac arrest, mesenteric ischemia and infarction, and cutaneous ischemic necrosis). In patients with vascular disease or coronary artery disease, vasopressin should be used with caution in an ICU setting with cardiac monitoring. The infusion should be reduced or terminated if chest pain, abdominal pain, or arrhythmias develop. Concomitant infusion of nitroglycerin may reduce undesirable cardiovascular side effects of vasopressin therapy and may provide more effective control of bleeding. Nitroglycerin is administered only if the systolic BP is greater than 100 mm Hg, at a dose of 10 mu g/minute IV, increased by 10 mu g/minute q10-15min until the systolic BP falls to 100 mm Hg or a maximum dose of 400 mu g/minute is reached.
- Washington Manual
In addition, vasospastic side effects are seen in approximately 25% of patients receiving vasopressin, with the risk of myocardial infarction being of greatest concern.
- Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 6th ed., p.1299.
1 cause of massive upper GI bleed
The most common causes of UGIB include the following (in approximate descending order of frequency) [3-5,8,9]:
●Gastric and/or duodenal ulcers ●Esophagogastric varices ●Severe or erosive esophagitis ●Severe or erosive gastritis/duodenitis ●Portal hypertensive gastropathy ●Angiodysplasia (also known as vascular ectasia) ●Mass lesions (polyps/cancers) ●Mallory-Weiss syndrome ●No lesion identified (10 to 15 percent of patients)
2L of diarrhea will result in all except: a- decrease effective circulatory volume b- decrease urine Na c- increase thirst d- increase ADH e- decrease serum Cl
e. decreased serum Cl
Can easily answer this by process of elimination.
Remember: basically every fluid past the stomach is “high in bicarb”
Metabolic acidosis with normal anion gap results from a loss of fluid with a bicarbonate concentration greater than chloride concentration, the addition of acids with chloride as their associated anion, or the transient dilution of extracellular bicarbonate with nonbicarbonate solutions. To maintain electroneutrality, the decrease in serum bicarbonate is associated with a proportionate increase in the serum chloride level. For example, in diarrhea, bicarbonate loss is greater than chloride loss; thus, hyperchloremia develops.
- Shannon: Haddad and Winchester’s Clinical Management of Poisoning and Drug Overdose, 4th ed.
Most sensitve test for pancreatitis
a-serum lipase
b-serum amylase
c- urine amylase
a. lipase
Although serum lipase is derived from pancreatic acinar cells, it rises slightly earlier than amylase, 4-8 hours after the onset of acute pancreatitis, and peaks earlier, at 24 hours ( Steinberg, 1985 ). The serum lipase also lasts longer in the serum, 8-14 days. For these reasons, serum lipase is more sensitive and specific than the serum amylase.
- McPherson & Pincus: Henry’s Clinical Diagnosis and Management by Laboratory Methods, 21st ed.
Pancreatitis causes all of the following except:
a) makes the patient delusional
b) fat necrosis
c) pleural effusion
d) dyspnea
e) pain
a) makes the patient delusional
The typical symptoms of acute pancreatitis are abdominal pain, nausea, and vomiting.
Examination of the skin may reveal tender areas of induration and erythema resulting from subcutaneous fat necrosis
- Goldman: Cecil Medicine, 23rd ed.
Tachypnea and shallow respirations may be present if subdiaphragmatic inflammatory exudate causes painful breathing. Dyspnea may accompany pleural effusions, atelectasis, congestive heart failure, or ARDS.
- Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 8th ed.
Chronic pancreatitis indicates some degree of progressive and permanent damage to the pancreas, usually visualized as calcifications on radiographs and CT scans (Figs. 49-27 and 49-28 [27] [28]). This damage often leads to diabetes and pancreatic insufficiency, resulting in malabsorption with chronic diarrhea.
- Rakel: Textbook of Family Medicine, 7th ed.
Periostitis, nodular skin lesions, and synovial fat necrosis may develop as a result of lipases released during pancreatitis.
- Kliegman: Nelson Textbook of Pediatrics, 18th ed
Similarly asked question with choice diarrhea: answer is diarrhea (The question is likely ACUTE PANCREATITIS (which does not have diarrhea))
Hepatic dysfunction gives all except?
a. Decreased glucose
b. Increased bilirubin
c. Increased PT
d. Increased BUN
e. Altered circulating glucose profile
Glycogenesis, glycogen storage, glycogenolysis, and the conversion of
galactose into glucose all represent hepatic functions. Hypoglycemia is a rare accompaniment of extensive hepatic disease, but the amelioration of diabetes in patients with hemochromatosis is considered an indication of neoplastic change. The more common effect of hepatic disease is a deficiency of glycogenesis with resulting hyperglycemia. A hepatic enzyme system is responsible for the conversion of galactose into glucose, and abnormal galactose tolerance tests are seen in hepatitis and active cirrhosis.
Because urea is synthesized in the liver, hepatic dysfunction decreases urea production and, therefore, BUN concentration.
- Miller: Miller’s Anesthesia, 7th ed.
Saliva is ineffective in digestion because
a) amylase deactivated by stomach ph
b) too small amount
Answer given: a) amylase deactivated by stomach ph
The function of saliva is to begin chemical digestion, for lubrication of the food, and for protection. Saliva contains mostly water and electrolytes, as well as amylase, lipase, mucin, immunoglobins and lysosymes. Amylase begins breakdown of carbohydrates and lipase begins breakdown of fats (but this is not significant).
Lower esophageal sphincter is affected by all of the following except:
a) caffeine
b) smoking
c) alcohol
d) impaired peristalsis of the esophagus
Peristaltic contractions alone do not generate enough force to open up the LES
- Townsend: Sabiston Textbook of Surgery, 18th ed.
63 year old male heavy drinker & smoker present with 8 week history of difficulty in swallowing and weight loss. The most appropriate next step is:
a. Esophagoscopy and biopsy
b. 24h PH study
c. motility study
d. CT Scan
e. OR
Esophagoscopy and biopsy
All of the following are cause of ileus except :
a. Hyperkalemia
b. Hypokalemia
c. Early post op
d. Intra abdominal sepsis
e. All of the above
- Hyperkalemia
Drugs
Narcotics, phenothiazines, diltiazem, anticholinergic agents, clozapine
Electrolyte abnormalities
Hypokalemia, hyponatremia, hypomagnesemia, hypermagnesemia, hypocalcemia, hypercalcemia
Intestinal ischemia
Mesenteric arterial embolus or thrombosis, mesenteric venous thrombosis, chronic mesenteric ischemia
Intra-abdominal inflammation
Appendicitis, diverticulitis, perforated duodenal ulcer
Iatrogenic
Laparotomy, laparoscopy
Retroperitoneal inflammation or hemorrhage
Lumbar compression fracture, acute pancreatitis, pyelonephritis
Infection
Intra-abdominal or systemic sepsis
Thoracic diseases
Lower rib fractures, lower lobe pneumonia, myocardial infarction
- Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 8th ed.
With severe hypothyroidism (i.e., myxedema), paralytic ileus and intestinal pseudo-obstruction can occur.
- Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 8th ed.;
Causes of Ileus
o Postlaparotomy
o Metabolic and electrolyte derangements (e.g., hypokalemia, hyponatremia, hypomagnesemia, uremia, diabetic coma)
o Drugs (e.g., opiates, psychotropic agents, anticholinergic agents)
o Intra-abdominal inflammation
o Retroperitoneal hemorrhage or inflammation
o Intestinal ischemia
o Systemic sepsis
- Townsend: Sabiston Textbook of Surgery, 16th ed
What is the cause of hyponatremia in liver disease?
A variety of factors can contribute to the development of hyponatremia in patients with cirrhosis. The most important factor is systemic vasodilation, which leads to activation of endogenous vasoconstrictors including antidiuretic hormone (ADH); ADH promotes the water retention that is responsible for the fall in serum sodium.
(uptodate)
Which form of hypertension is associated with low renin? A. Renal artery stenosis B. Primary hyperaldosteronism C. CHF D. Cirrhosis
B. Primary hyperaldosteronism
My simplified way to see it is that the kidneys produce renin when they aren’t getting enough bloodflow in order to get more blood. So anything that would limit renal flow would cause increased renin. Primary hyperaldosteronism causes hypertension so kidneys are getting plenty of blood therefore don’t need to secrete renin.
As diagnostic tests for quantifying the components of the renin-angiotensin-aldosterone system have become available, the syndrome of primary hyperaldosteronism (PAL) is now identified by hypertension, suppressed plasma renin activity (PRA), and high urine and plasma aldosterone levels.
- Wein: Campbell-Walsh Urology, 9th ed.
Decreased renin levels are found in the following conditions:
a Primary aldosteronism (98% of cases)
b Unilateral renal artery stenosis
c Administration of salt-retaining steroids
d Congenital adrenal hyperplasia with 17-hydroxylase deficiency
e Liddle’s syndrome
Hyperaldosteronism > Increased sodium resorption at distal convoluted tubule > decreased renin release
Which of the factors below do not stimulate renin release by the kidney?
a) Epinephrine
b) Norepinephrine
c) Dopamine
d) Thromboxane A2
e) Leukotrienes
D and E
Renin is released in shock/hypoperfusion to the kidney.
- Stimulates: Catecholamines , also ACTH
- Does not stimulate: Thromboxane A2, Leukotrienes
Which of the following causes of polyuria is associated with a high urine specific gravity? A. Diabetes Mellitus B. SIADH C. Acute non-oliguric renal failure D. ATN
A. Diabetes Mellitus (increased, glucosuria and dehyrdation)
B. SIADH (increased retain H2O and concentrate urine)
C. Acute non-oliguric renal failure (decreased, lose both h20 and Na, osmols dilutes)
D. ATN (same as C)
Urine osmolality is determined by the number of particles in the urine (eg, urea, sodium, potassium), while the specific gravity is determined by both the number and size of the particles in the urine .
Notes: DI (high urine output – low specific gravity)
Which of the following drugs does not cause ARF?
a) NSAID.
b) ACE inhibitor.
c) Aminoglycosides.
d) Semi-synthetic penicillins.
e) Corticosteriods.
Answer: Corticosteroids.
Lab values in ATN, which is true:
a) Urine osmolality 600
b) Urine Na 80
c) FeNa
Answer: Urine Na of 80
Basically the kidney isn’t able to concentrate urine
a) Urine osmolality 600 (250-300 is plasma) - so able to concentrate
b) Urine Na 80 (the answer)
c) FeNa 3% in ATN)
d) WBC casts and pyuria (AIN)
Test Prerenal Parenchymal
Urine osmolarity (mOsm) >500 250–350
U/P osmolality >1.5 20 40
FENa 3%
- Greenfield
FeNa is the fractional excretion of Na+. It is the most reliable for distinguishing prerenal azotemia from ATN (a measure of the kidney’s concentrating ability)
Hyaline casts: Low urine flow, concentrated urine, or an acidic environment can contribute to the formation of hyaline casts, and, as such, they may be seen in normal individuals in dehydration or vigorous exercise
Which of the following statements regarding Lasix is true:
a. Acts on the distal tubules
b. Increase urine out put in patient with decrease GFR
c. Acts on collecting tubules
d. Act on the loop of Henley
e. None of the above
d. Act on the loop of Henley
The best way to monitor the diet of renal failure patient is:
a. Urea level
b. Creatinine level
c. Sodium level
d. BMI
e. All of the above
a. urea
Understanding of urea metabolism is critical for prescribing the diet for patients with CKD because a goal is to reduce the accumulation of potential uremic toxins. This will require reducing dietary protein to minimize net urea nitrogen production (i.e., urea appearance).
- Brenner: Brenner and Rector’s The Kidney, 8th ed.
Post-operatively, a patient develops acute renal failure. Which of the following conditions is MOST consistent with a renal cause for the failure?
a. Urine osmolality equivalent to serum osmolality
b. Diuresis following 80mg IV lasix
c. Urine urea concentration one hundred times that of serum
d. Recent gram negative rod sepsis
Answer: a. Urine osmolality equivalent to serum osmolality
Test Prerenal Parenchymal
Urine osmolarity (mOsm) >500 250–350
U/P osmolality >1.5 20 40
FENa 3%
- Greenfield
The normal value of erythrocytes on urinalysis (> or = 3)
What is the cut-off number of RBC/HPF that is considered normal on urinalysis?
- 0-2
- 2-4
- 5-10
- 20
- 50
0-2?
Hematuria is the presence of blood in the urine; greater than three red blood cells per high-power microscopic field (HPF) is significant.
- Wein: Campbell-Walsh Urology, 9th ed.
Normal urine should contain less than three red blood cells per HPF.
- Wein: Campbell-Walsh Urology, 9th ed.
Microscopic hematuria is a more commonly encountered entity. Various cutoff points defining microscopic hematuria exist in the literature. For adults, the American Urological Association Best Practice Policy has defined it as three or more red blood cells (RBCs)/hpf.
- Grossfeld et al, 2001a
A 35 year old female jogger has just is seen by her family doctor. A
urinalysis is done which reveals 8 rbc’s per hpf. She is sent to you. You should:
a) reassure and repeat urinalysis in 1 month
b) order a KUB roentogram
c) order an IVP
d) order a renal ultrasound
e) perform a cystoscopy
a) reassure and repeat urinalysis in 1 month
a) reassure and repeat urinalysis in 1 month
Exercise-induced hematuria is being observed with increasing frequency. It typically occurs in long-distance (>10km) runners, usually is noted at the conclusion of the run, and rapidly disappears upon rest. The hematuria may be of renal or bladder origin. An increased number of dysmorphic erythrocytes has been noted in some patients, which suggests a glomerular origin. Exercise-induced hematuria may be the first sign of underlying glomerular disease such as IgA nephropathy. Also, some patients with calculi in the renal pelvis may first develop hematuria when they run.
On the other hand, cystoscopy in patients with exercise-induced hematuria frequently reveals punctate hemorrhagic lesions in the bladder, which suggests that the hematuria is of bladder origin.
Vascular disease may also result in nonglomerular hematuria. Renal artery embolism and thrombosis, arteriovenous fistulas, and renal vein thrombosis all may result in hematuria. Physical examination may reveal severe hypertension, a flank or abdominal bruit, or atrial fibrillation.
In such patients, further evaluation for renal vascular disease
should be undertaken
Which is true regarding a patient with high output renal failure:
a. resolves spontaneously
b. responds to vasopressin
c. results in severe sodium depletion
d. secondary to contrast dye
e. treating with fluid restriction causes some resolution
b. responds to vasopressin: ? possible answer
Absolute indications for dialysis in patients with acute renal failure include all of the following except:
a. pH 500
d. Pericarditis
e. Encephalopathy
Answer: K100 mg/dl or a serum creatinine level of >10 mg/dl. However, we stress that in patients on a low-protein diet and/or possessing relatively little muscle mass, renal clearances of urea and creatinine are much lower for a given BUN or serum creatinine value.
- Walsh: Campbell’s Urology, 7th ed.
Indications for and Frequency of Renal Replacement Therapy
The decision as to when to institute dialysis depends on the patient’s signs and symptoms rather than an absolute level of blood urea nitrogen (BUN) or serum creatinine. The current opinion is that patients who begin dialysis at a relatively higher level of residual renal function have less morbidity and mortality. The benefits of early initiation include the avoidance of malnutrition, fluid overload, and the deleterious effects of prolonged exposure to the accumulation of phosphorus, β2-microglobulin, and other uremic toxins.
There is no question that hyperkalemia (unresponsive to diuretics, ion exchange resins, and dietary restriction) in the face of electrocardiographic changes is an absolute indication for dialysis to avoid life-threatening arrhythmias such as ventricular tachycardia, ventricular fibrillation, or asystole. Likewise, volume overload refractory to intravenous diuretics is an indication to start dialysis. Increasing lethargy, difficulty concentrating, nausea, and anorexia all may reflect advancing renal failure and may be manifestations of the uremic syndrome requiring dialytic therapy. Intervention should occur before the progression of uremic encephalopathy, seizures, and coma or the development of pericarditis or pericardial tamponade. Emergency hemodialysis is more costly, because the patients typically lack vascular access and are sicker, often requiring prolonged hospitalization.
- Goldman: Cecil Medicine, 23rd ed
1) What is the MOST likely electrolyte abnormality associated with adrenal insufficiency? A. Hyperkalemia B. Hypernatremia C. Hypokalemia D. Hypermagnesemia
Answers:
1) Hyperkalemia
Basically you have low aldosterone, so you have low Na retention/LESS K+ excretion, so you get hyperK+
Aldosterone is a steroid hormone (mineralocorticoid family) produced by the outer-section (zona glomerulosa) of the adrenal cortex in the adrenal gland, and acts on the distal tubules and collecting ducts of the kidney to cause the conservation of sodium, secretion of potassium, increased water retention, and increased blood pressure. The overall effect of aldosterone is to increase reabsorption of ions and water in the kidney.
Its activity is reduced in Addison’s disease and increased in Conn syndrome.
- http://en.wikipedia.org/wiki/Aldosterone
A 72 year old female with a longstanding history of rheumatoid arthritis and HTN presents to the ER. An X-ray shows a fracture of her left femoral head and profound osteopenia. She has had the flu for the past two days with nausea and vomiting and has not been taking her medication including ASA, prednisone, Imuran, and metoprolol. She is admitted and placed in Buck’s traction
Overnight she becomes hypotensive and unresponsive. Bloodwork on room air shows:
Na 129 mEq/L pH 7.1
K 7.1 mEq/L PO2 100 mmHg
Cl 91 mEq/L PCO2 55 mmHg
Glucose 0.3 mM HCO3 12 mEq/L
The likely diagnosis is:
a) myocardial infarction
b) fat embolus
c) addisonian crisis
d) sepsis
e) diabetic ketoacidosis
The immediate management of the above patient would include all EXCEPT:
a) Hydrocortisone 100mg IV q8h
b) Bicarbonate infusion
c) Fluid resuscitation and intubation
d) V/Q scan
e) Calcium gluconate 1g IV
Answers:
- addisonian crisis
Buzzwords: prednisone, not taking, + stressful situation = addisonian crisis
Adrenal Failure
I. Etiology. Adrenal failure may be due to disease of the adrenal glands (primary adrenal failure, Addison’s disease), with deficiency of cortisol and aldosterone and elevated plasma adrenocorticotropic hormone (ACTH), or to ACTH deficiency caused by disorders of the pituitary or hypothalamus (secondary adrenal failure), with deficiency of cortisol alone (N Engl J Med 335:1206, 1996 ).
A. Primary adrenal failure most often is due to autoimmune adrenalitis, which may be associated with other endocrine deficits (e.g., hypothyroidism).
B. Secondary adrenal failure is due most often to glucocorticoid therapy; ACTH suppression may persist for a year after therapy is stopped. Any disorder of the pituitary or hypothalamus can cause ACTH deficiency, but usually other evidence of these disorders can be seen.
II. Clinical findings. Findings in adrenal failure are nonspecific, and, without a high index of suspicion, the diagnosis of this potentially lethal but readily treatable disease is missed easily. Symptoms include anorexia, nausea, vomiting, weight loss, weakness, and fatigue. Orthostatic hypotension and hyponatremia are common. Usually, symptoms are chronic, but shock may suddenly develop that is fatal unless treated promptly. Often, this adrenal crisis is triggered by illness, injury, or surgery. All these symptoms are due to cortisol deficiency and occur in primary and in secondary adrenal failure. Hyperpigmentation (due to marked ACTH excess) and hyperkalemia and volume depletion (due to aldosterone deficiency) occur only in primary adrenal failure.
- Washington Manual of Medical Therapeutics, 30th ed., Copyright © 2001 Department of Medicine, Washington University School of Medicine
Management of Acute Adrenal Insufficiency
Draw blood for measurement of cortisol and ACTH.
Infuse sufficient normal saline with 5% dextrose to restore normotension.
Administer 2 mg dexamethasone IV immediately (which will not interfere with further testing)
Give 250 mug Cortrosyn (ACTH) IV and measure 30-minute cortisol level.
Begin IV hydrocortisone as a continuous infusion to total 200 mg in 24 hours; or doses can be given in bolus form, 50 mg every 6 hours.
Investigate underlying etiology of adrenal insufficiency with plain film of abdomen to rule out adrenal calcification, tuberculosis testing, and evaluation of thyroid and gonadal status.
Chronic oral replacement therapy can begin as soon as the patient is medically stable and able to take medication orally
- Noble: Textbook of Primary Care Medicine, 3rd ed., Copyright © 2001 Mosby, Inc.
All the following are effects of adrenal hyperplasia EXCEPT: A. Aseptic necrosis of bone B. Fat redistribution C. Delayed closure of growth plates D. Peptic ulcer disease
C. Delayed closure of growth plates
Cushing’s: aseptic necrosis, fat redistribution, peptic ulcers
CAH: premature closure of growth plate.
Congenital Adrenal Hyperplasia: Both males and females may exhibit rapid growth in childhood (due to early epiphyseal closure, which then results in short stature in adulthood).
- Ferri: Ferri’s Clinical Advisor 2010, 1st ed.
The most common cause of primary hyperaldosteronism:
a. Pituitary adenoma
b. Adrenal hyperplasia
c. Solitary adrenal adenoma
d. Bilateral adrenal adenomas
c. Solitary adrenal adenoma (Conn’s disease, 65% according to Sabiston)
Diagnose by renin and aldosterone levels
Will be hypernatremic due to sodium resorption and potassium and hydrogen excretion, will be volume overloaded.
Aldosterone secretion will increase volume thus decrease renin
Primary: look for lesion
Secondary: (cirrhosis, ren art stenosis) will have high renin and high aldosterone
Adrenal medulla produces a – aldosterone b – ACTH c – norepinephrine d – cortisol
Answer: norepinepherine
Adrenal cortex - zona glomerulosa: aldosterone
- zona fasciculata: cortisol
- zona reticularis: androgens (mainly DHEA)
Adrenal medulla - epi and noreip
Cortex: salt, sugar, sex
Medulla: pump-up juice
Which of the following tumors MOST commonly produces SIADH? A. Small cell lung cancer B. Pancreatic cancer C. Breast cancer D. Lymphoma E. Bronchogenic carcinoma
SCLC accounts for 15% to 20% of all lung cancers. This cell type has the strongest association with cigarette smoking, and is rarely observed in a never smoker. It is the cell type most commonly associated with paraneoplastic syndromes such as the syndrome of inappropriate (excessive) antidiuretic hormone secretion (SIADH), ectopic corticotropin secretion, Lambert-Eaton myasthenic syndrome (LEMS), and sensory neuropathy.
- Mason: Murray & Nadel’s Textbook of Respiratory Medicine, 4th ed.
2) All are seen in SIADH except:
a. Decrease urinary Na
b. Decrease urinary K
c. Hyponatremia
d. Increase urinary Osmolarity
e. Isovolemia
1) Hypernatremia
Potassium is actually normal (SIADH uses aquaporines, not Na/K pump)
3) SIADH; all true except?
a. Normal or low BUN
b. Decreased Na –where in the urine or serum?
c. Renal loss of Na
d. Urine osm > plasma osm
e. Renal loss of K
3) Renal loss of K
McNeil disagrees with this answer, but I think it’s true. Aquaporine, no Na/K pump
The cardinal features of SIADH are hypotonicity with hyponatremia and an inappropriately concentrated urine. It is often unnecessary to measure serum osmolality directly in a hyponatremic patient, since the effective serum osmolality– serum sodium (mmol/L) × 2 + glucose (mmol/L)–closely approximates direct measurements. [94] Any urinary osmolality greater than 50 to 60 mmol/L water is inappropriate in the setting of serum hypotonicity, which should inhibit the release of vasopressin and permit the excretion of a maximally dilute urine. The urinary osmolality in SIADH is often higher than the serum osmolality, but that is not a necessary feature of the syndrome.
SIADH has a number of other laboratory features that are helpful in diagnosis. The urinary sodium concentration is typically high, reflecting the natriuresis induced by expansion of extracellular fluid volume. However, the ability to conserve sodium in SIADH is usually unimpaired, [5] and the urinary sodium excretion can fall to low levels in the setting of reduced dietary sodium intakes. The blood urea nitrogen and serum uric acid levels are low, [95] again reflecting expanded extracellular fluid volumes and decreased tubular resorption of these solutes. Other electrolytes are diluted in proportion to the serum sodium, except for serum bicarbonate, which is normal.
- Wilson: Williams Textbook of Endocrinology, 9th ed
Hyponatremia caused by SIADH is characterized by a decrease in the plasma osmolality and inappropriately elevated urine osmolality. The urine osmolality is higher than 100 mOsmol/kg, and usually higher than 300 mOsmol/kg. The urine sodium is usually higher than 40 mEq/L, which is likely a consequence of increased levels of atrial natriuretic factor.
- Rakel: Textbook of Family Medicine, 7th ed
SIADH
Significant urinary losses of potassium, calcium, and magnesium may occur, so electrolyte levels should be monitored, with replacement accordingly.
- Rakel: Textbook of Family Medicine, 7th ed.
All are causes of hypernatremia except:
a. IV saline
b. Hyperaldosteronism
c. SIADH
d. DI
Answer: c. SIADH (inappropriate antidiuretic–>hyponatremic)
Decreased vasopressin release or decreased renal sensitivity to AVP leads to diabetes insipidus, a condition featuring hypernatremia (increased blood sodium concentration), polyuria (excess urine production), and polydipsia (thirst).
- http://en.wikipedia.org/wiki/Vasopressin
A 70kg male with peripheral edema, stable vital signs and a serum sodium of 120, is diagnosed with SIADH. Which of the following would be the MOST appropriate management?
A. Lasix, 40 mg IV
B. Restrict fluid to less than daily urine output
C. NS @ 150 cc/h
D. DDAVP
E. Desmocycline
What is the most appropriate treatment for SIADH?
a. Fluid restriction
b. DDAVP
c. IV D5
d. Lasix
Answer: a. Fluid restriction
Management (3):
1. For Na
What is the proper screen for familial medullary cancer?
a) CEA
b) Ret-oncogene
c) S-100
Answer: Ret-oncogene
For POS: MENII + Ret + Medullary cancer are friends
Because most familial cases have an identifiable RET mutation, as can occur in even apparently sporadic cases, screening should be vigorously pursued by routine testing of RET exons 10, 11, 13, 14, 15, and 16, with sequencing of the remaining 15 exons if indicated.
- Goldman: Cecil Medicine, 23rd ed.
MENII screening test for the siblings of affected adult is:
a. P53 protooncogene
b. RET oncogene
c. Ca levels
d. Parathyroid scan
e. CT scan
Answer: Ret-oncogene
Because most familial cases have an identifiable RET mutation, as can occur in even apparently sporadic cases, screening should be vigorously pursued by routine testing of RET exons 10, 11, 13, 14, 15, and 16, with sequencing of the remaining 15 exons if indicated.
- Goldman: Cecil Medicine, 23rd ed.
Which of the following is associated with an increased risk for developing thyroid cancer?
a. Smoking.
b. Dental radiography.
c. Medical treatment with I131
d. Child undergoing radiation therapy for a Wilms’ tumour.
e. None of the above.
I think the answer is D…
The association of irradiation and thyroid cancer has been known for years. The use of external beam irradiation in children and young adults in the 1950s and 1960s for acne and tonsillitis has been shown to result in an increased incidence of well-differentiated carcinoma (usually papillary) at any time, generally 5 years after exposure. Additionally, patients who have received external irradiation for soft tissue malignancy, such as Hodgkin’s lymphoma, have an increased incidence of thyroid nodules and cancer (as many as 30%-35% of those exposed). Areas near known nuclear fallout contamination, such as Chernobyl in the former Soviet Union and areas of the southwest United States, have increased incidence rates of well-differentiated thyroid carcinoma
-Sabiston’s
Squamous cell carcinoma of the central lip in a 85 year old man. Metastatic workup is negative (no nodes, no mets). The size measures 2.1cmx1cm. What is the best management?
a. excision only
b. excision and radiation
c. excision and chemotherapy
d. excision and bilateral neck dissection
e. excision and rad and chemo
A. excision
Early-stage lesions, surgery and rads equally effective
Recommended: surgery for stage I & II; post-op rads for III (T>4cm) & IV
Neck management
- Positive necks need treatment; SND I-III +/- rads
- Negative necks more controversial
- T1 has 3% risk of occult mets
- END if > 3 cm, thicker than 5 mm, recurrent or poorly differentiated
Like the rest of the oral cavity, staging of lip cancer is based on size at initial evaluation. Early-stage disease may be treated by surgery or radiation therapy with equal success. Local surgery (wide local excision) with negative margin control of at least 3 mm is the preferred treatment, with supraomohyoid neck dissection performed for tumors with clinically negative necks but deeper primary invasion or size greater than 3 cm. Neck dissection with postoperative radiation therapy for patients with clinically evident neck disease has an acceptable 91% regional control rate in the neck
- Townsend: Sabiston Textbook of Surgery, 18th ed.
60 year old male patient with bilateral painless parotid swelling:
a. Pleomorphic adenoma
b. Mixed tumor
c. Warthin tumor
d. Cystoadenosarcoma
Answer: Warthin tumor (10 % are bilateral)
Tip: It takes two sides to go to War (Warthin = bilateral)
Pleomorphic adenoma are benign, accounts for 80% of all parotid masses.
c. Warthin tumor = bilateral mass, male, 50-70 yo
a. Pleomorphic adenoma = painless isolated mass, female 30-60 yo, benign
what is the most common thyroid cancer:
a. papillary
b. follicular
c. medullary
d. anaplastic
Answer: papillary
Tip: Papillary is populary
180 cases of thyroid carcinoma dx 2006 (estim) 70-75% papillary, 10% follicular….. both are differtiated…..anaplastic (2-5%) undifferented/aggressive
What is the proper management of a 40 year old female with a previous history of head and neck irradiation for acne, who presents with a thyroid nodule?
a) Observation
b) Radioiodine
c) Thyroxine suppression
d) Excisional. Biopsy
e) Total thyroidectomy
The right answer is probably U/S guided FNA and CT with contrast. And she’ll get choice between diagnostic hemi or total thyroidectomy.
Neck irradiation for acne = stereotypical risk factor for thyroid cancer. Treat this person as if she had thyroid cancer.
Thyroid related history and PE are no different for exposed or nonexposed. FNA is the most informative method for charaterizing thyroid nodules. Accuracy of FNA appears to be similar for nodules in the general population and in patients exposed to radiation (Hatipoglu et al. FNA of thyroid nodule in radiation-exposed patients. Thyroid. 2000. Jan;10(1): 63-9)
However, hx of radiation is important b/c it affects treatment (as increased likelihood mass/nodule is cancer). If large nodules (>1.5cm) cannot be proven to be benign via FNA then indication for Sx. If nodule is cancer via FNA then would favor more extensive Sx (total lobectomy on side of dominant nodule and contralateral subtotal lobectomy) b/c high freq of multicentric cancer.
- Up to Date
- Total or near-total thyroidectomy is treatment of choice for most patients
- Lobectomy alone for papillary thyroid carcinomas
A 73 year old female is in the PACU following a total thyroidectomy. Her breathing is stridorous and she is complaining of dyspnea. Your initial management is:
a) observe and reassess
b) administer oxygen via a venturi mask
c) endotracheal intubation
d) aspirate the hematoma
e) open the wound and evacuate the clot
Post-op hematoma compromising airway – open wound and evacuate clot
Patient had SCC in the floor of the mouth which was resected and followed by radiotherapy. 1 year late, he came with painful ulcer in the floor of mouth with exposed mandible in the base of the ulcer. What is the diagnosis:
a. Recurrent SCC
b. Osteoradionecrosis
c. Osteosarcoma
d. Infection
Answer: Osteoradionecrosis
Guess it could be SCC too but.. I think they are trying to make us guess osteoradionecrosis. Depends on the stem I guess
Osteoradionecrosis is a possible complication following radiotherapy where an area of bone does not heal from irradiation. Irradiation of bones causes damage to osteocytes and impairs the blood supply. The affected hard tissues become hypovascular (reduced number of blood vessels), hypocellular (reduced number of cells) and hypoxic (low levels of oxygen). Osteoradionecrosis usually occurs in the mandible, and causes chronic pain and surface ulceration
Dr. Wikipedia
Patient with ulcerating lesion in the face (picture) with central keratin
crust and fleshy edges, what is the most appropriate management:
a. Excisional biopsy
b. Incisional biopsy
c. Excision with 1 cm margin
d. Excision with 2 cm margin
Hard to say what it is without seeing it.. but assuming it’s BCC:
Clinical recognition of basal cell carcinoma is not difficult. Typically, there is a raised, nodular lesion with a smooth, clear (pearly) border and telangiectasia ( Plate 1, D ). The lesion can ulcerate and form a crust.
Biopsy to confirm diagnosis
Variable with tumor size, location, and cell type:
• Excision surgery: preferred method for large tumors with well-defined borders on the legs, cheeks, forehead, and trunk.
• Mohs’ micrographic surgery: preferred for lesions in high-risk areas (e.g., nose, eyelid), very large primary tumors, recurrent basal cell carcinomas, and tumors with poorly defined clinical margins.
• Electrodesiccation and curettage: useful for small (
Patient had total thyroidectomy for papillary carcinoma, which marker will indicate recurrence:
a. TSH
b. T4
c. T3
d. Thyroglobulin
Answer: Thyroglobulin
Post-thyroidectomy Thyroglobulin levels are apparently associated with prognosis of papillary and follicular thyroid carcinomas and may predict tumor recurrence and metastastic potential. The detection of Thyroglobulin by biochemical and molecular means has important diagnostic significance due to its pleiotropic roles in identification of tissue of thyroid origin, differentiation, and post-operative follow-up.
- Lin JD (2007). “Thyroglobulin and human thyroid cancer”. Clin Chim Acta 388: 15
The most important investigation of a solitary thyroid nodule is:
a) CT scan
b) Ultrasound
c) FNA
Answer: FNA
Middle aged male with a nodule in the left lower pole. Cold nodule. FNA shows thyroiditis. What do you do now?
a. I131 therapy
b. Thyroidectomy
c. Repeat FNA
d. Observe
Cold means higher risk of cancer. Likely repeat after 6-12 months.
Emedicine
Thyroid scintigraphy
In most centers, the routine initial diagnostic evaluation of a solitary thyroid nodule no longer includes imaging studies. In the past, radionuclide scanning was an important imaging study performed routinely in the initial assessment of a thyroid nodule. Nuclear imaging can be used to describe a nodule as hot, warm, or cold on the basis of its relative uptake of radioactive isotope. Hot nodules indicate autonomously functioning nodules, warm nodules suggest normal thyroid function, and cold nodules indicate hypofunctional or nonfunctional thyroid tissue. (Examples of hot and cold nodules are seen in the image below.) Hot nodules are rarely malignant; however, 5-8% of warm or cold nodules are malignant.[2]
What is the most common presentation of a nasopharyngeal carcinoma?
a) Neck mass
b) Decreased hearing
c) Nasal obstruction
d) Sore throat
e) New onset of cough
A.??
A study conducted found that the most common presentations of NPC in patients are neck masses (commonly unilateral), followed by headache and epistaxis
Suzina SAH, Hamzah M. Clinical presentation of patients with NPC. Med J Malaysia. 2003;58(4):539–545
One study indicated the following symptoms:[4]
Nasal symptoms, including bleeding, obstruction, and discharge (78%)
Ear symptoms, including infection, deafness, and tinnitus (73%)
Headaches (61%)
Neck swelling (63%)
What is the most common gene responsible for nasopharyngeal cancer …
a) Epstein Barr virus
b) Retinoblastoma
c) P53
d) RB
Answer: Epstein Barr virus
The DNA of EBV has also been detected in pre-malignant lesions of the nasopharynx which further supports its role in the pathogenesis
ASIDE:
- other diseases associated with EBV infection include: - lymphoproliferative disease in patients with HIV, immunosuppression - chronic fatigue syndrome - malignancies - Burkitt lymphoma - Hodgkin s disease, T-cell lymphoma - tonsillar carcinoma, thymoma, gastric carcinoma - Reference: MD Anderson
The most common cause of Tongue cancer is?
a) Adenocarcinoma
b) Squamous cell ca
c) Lymphoma
d) Adenoid cystic ca
e) Mucoepidermoid ca
b. SCC
Most cancers of the base of tongue are squamous cell carcinomas, which are typically poorly differentiated
Radiation therapy or surgery are equivalent treatments for patients with early-stage disease. Because both sides of the neck are at risk for nodal involvement and surgical treatment sometimes involves total laryngectomy, radiation therapy is usually recommended for early-stage patients. More advanced tumors (T3 and T4) are managed by radiation therapy alone, or by surgery with postoperative radiation.
Advanced tumors of the base of tongue and elsewhere in the oropharynx often require a “composite resection” (or jaw-neck resection/dissection), since large tumors involving the tongue and tonsil typically abut the inner table of the mandibular body and ramus and have often spread to the neck.
- Abeloff: Clinical Oncology, 2nd ed.,
Which of the following is not associated with a patient who has a Pancoast tumor?
- Horner’s syndrome
- Adrenal hyperplasia
Answer: Adrenal hyperplasia
Pancoast’s syndrome is a constellation of symptoms and signs that include shoulder and arm pain along the distribution of the eighth cranial nerve trunk and first and second thoracic nerve trunks, Horner’s syndrome, and weakness and atrophy of the hand. This most commonly is related to a local extension of an apical lung tumor located in the superior pulmonary sulcus (Pancoast’s tumor). The most common cause of this symptom complex is NSCLC; however, SCLC and a number of other types of tumors and infections may rarely present in this manner.
- Mason: Murray & Nadel’s Textbook of Respiratory Medicine, 4th ed.
Infrequently, a patient with a Pancoast tumor may also have features of a paraneoplastic syndrome. Most of the metabolic manifestations are the result of the secretion of endocrine chemicals by the tumor. Manifestations encompass Cushing syndrome, excessive antidiuretic hormone secretion, hypercalcemia, myopathies, hematological problems, and hypertrophic osteoarthropathy.
- eMedicine
The MOST common cause of SVC syndrome is: A. Lymphoma B. Primary lung cancer C. Mediastinal fibrosis D. Tuberculosis
Answer: Primary lung cancer
The blockage of blood flow in the superior vena cava (SVC) results in SVC syndrome. Bronchogenic carcinoma accounts for the vast majority of these cases in older adults.[164][165] In teenagers and young adults, SVC syndrome is usually due to non-Hodgkin’s lymphoma.
- Mason: Murray & Nadel’s Textbook of Respiratory Medicine, 4th ed
Cancer is the most common cause of SVC syndrome. Lung cancer, lymphoma, and germ cell tumors of the chest are most commonly associated with SVC syndrome. Any cancer that has spread to the lymph nodes in the chest may cause compression of the superior vena cava. Some patients present with SVC syndrome as their first symptom of cancer. It can also be caused by some non-cancerous conditions including goiter, aortic aneurysm, and inflammation of the mediastinum. Rarely, central venous catheters can cause a blood clot to form and contribute to a SVC syndrome.
All are associated with mesothelioma Except:
a. Asbestos
b. Chest trauma
c. Hypoglycemia
d. Lethargy
e. Hypertrophic osteodystrophy
Chest trauma
Risk Factors: Asbestos (hydrated magnesium silicate fibrous minerals) exposure.10% lifetime risk of developing mesothelioma in asbestos workers! Also, will act syngeristically with cigarette smoking. Other Silicates (erionite).Viral (simian virus 40 – polyoma virus).
Radiation.
Symptoms: dyspnea, nonpleurtic chest pain, asymptomatic (pleural effusion on CXR) dysphagia, cough, horseness, wt loss, weakness, increase sputum, anorexia, nausea, abdo pain/mass, ascites cord compression, brachial plexopathy, Horner’s syndrome, SVC syndrome, Paraneoplastic syndromes (DIC, migratory thrombophlebitis, hypoglycemia, hypercalcemia (PTH-like peptide), thrombocytosis)
Note: found case report of mesothelioma diagnosised after chest trauma and persistent pulmonary symptoms (Machi et al. Malignant pleural mesothelioma diagnosed after chest trauma. Am Surg. 1997.)
13 year old boy presents with unilateral gynecomastia. What is the next appropriate step?
- anti-estrogen therapy
- unilateral mastectomy
- observe
Answer: observe
Hypertrophy of breast tissue in men is a common clinical entity for which there is frequently no identifiable cause. Pubertal hypertrophy occurs in boys between the ages of 13 and early adulthood, and senescent hypertrophy is diagnosed in men older than 50 years. Gynecomastia in teenage boys is common and may be either bilateral or unilateral. Unless it is unilateral or painful, it may pass unnoticed and regress with adulthood. Pubertal hypertrophy is generally treated by reassurance without surgery. Both pubertal and senescent gynecomastia may be left untreated and do not require biopsy.
- Townsend: Sabiston Textbook of Surgery, 18th ed.
A 58 year old Female presents with a chronic erythematous oozing eczematiod rash involving the right nipple and areola. There are not breast masses palpable, and her mammogram is normal. Which of the following recommendation is most appropriate?
a. Referral to a dermatologist
b. Oral Vitamin E and topical aloe and lanolin.
c. Biopsy.
d. Advise patient to wear nonallergenic brassiere.
e. Topical 5-FU.
Answer: Biopsy.
This is classic paget’s presentation
The disease [Paget’s of the breast] begins insidiously in one breast with a small area of erythema on the nipple that drains serous fluid and forms a crust (Figures 21-55 and 21-56). The inflammation is usually attributed to trauma, and partial healing comforts the patient. Patients equate lumps rather than inflammatory changes with cancer and, consequently, the disease continues. Malignant cells migrate through the epidermis, and the disease becomes initially apparent on the areola and, at a much later date (1 year or more), on the surrounding skin (see Figure 21-55). The process appears eczematous, but the plaque is indurated and has sharp margins, which remain relatively fixed for weeks. Ulceration is a late finding.
A crucial point to note is that Paget’s disease of the breast is a rare, unilateral disease, whereas eczematous inflammation of the nipples is common and almost invariably bilateral. Cytologic diagnosis can be made from nipple scrape smears. A biopsy may be studied with conventional stains and immunohistochemistry
- Habif: Clinical Dermatology, 5th ed.
A 33 year old asymptomatic woman is referred to you with an abnormal mammogram. No masses are palpable in either breast. The mammogram shows a tight cluster of microcalcifications at the 2 o’clock position of the left breast. Magnification compression views show at least 20 tiny, irregular calcification in a 2 cm area, varying in shape and density with no associated mass lesion. There are no other calcifications present in either breast. Which of the following is the most likely diagnosis?
a. Lobular carcinoma in situ.
b. Fibroadenoma.
c. Infiltrating ductal carcinoma.
d. Ductal carcinoma in situ (DCIS).
e. Fibrocystic changes.
Answer: Ductal carcinoma in situ (DCIS).
Isolated clusters of tiny calcifications are the most common and important diagnostic sign of an early carcinoma. Calcifications are often smaller than 0.5 mm in diameter and thus must be identified by a magnifying lens. The presence of five or more calcifications within a volume of 1 cm3 is termed a cluster. Subsequent breast biopsies will find 25% of clusters associated with cancer and 75% with benign disease.
- Adam: Grainger & Allison’s Diagnostic Radiology, 5th ed.
Between 20% and 25% of clustered microcalcifications are positive for cancer on biopsy. Benign calcifications usually are larger and coarser, and are often round, with smooth margins.
- Abeloff: Abeloff’s Clinical Oncology, 4th ed.
HIGHER PROBABILITY OF MALIGNANCY
Pleomorphic or heterogeneous (granular) - Usually more conspicuous than the amorphic forms. They are neither typically benign nor typically malignant irregular calcifications. They vary in size and shape and are usually
A 39 year old woman underwent a lumpectomy and axillary dissection for a 2 cm moderately differentiated, ER negative infiltrating ductal carcinoma. Margins around primary tumour were free, and 1 of 19 lymph nodes was positive for carcinoma. Which of the following treatment plans is most appropriate?
a. Radiation therapy alone.
b. Radiation therapy and single drug chemotherapy for 3-6 months.
c. Radiation therapy and single drug chemotherapy for 1 year.
d. Radiation therapy and multiple drug chemotherapy for 1 year.
e. Radiation therapy and multiple drug chemotherapy for 3-6 months.
Answer: Radiation therapy and multiple drug chemotherapy for 3-6 months.
The concept of dose density has been tested in recent clinical trials. The U.S. Intergroup tested dose-dense versus conventionally scheduled combination chemotherapy in women with positive axillary lymph nodes as an adjuvant to surgery. In this study, patients were randomly assigned to multiple schedules of three chemotherapy drugs (doxorubicin, cyclophosphamide, and paclitaxel). Although it was a complicated study, the women receiving compressed schedules of the three drugs at higher doses were better off during follow-up than their counterparts who received so-called less dense treatment (disease-free survival rate at 4 years of 82% for the dose-dense group versus 75% for the other groups). In practice, the duration of adjuvant treatment for breast cancer may be shortened to even less than the usual 4 to 6 months.
- Townsend: Sabiston Textbook of Surgery, 18th ed.
Chemotherapy indications:
ER negative plus node-positive or high-risk node-negative
ER positive and young age
Stage I disease at high risk of recurrence (high grade, lymphovascular invasion) palliation for metastatic disease
What is the most common benign breast lesion in women:
a. Fibroadenoma
b. Fibrocystic disease
c. Fat necrosis
d. Duct actasia
Answer: Fibrocystic disease
28 year old female presents with pain in Right upper outer quadrant of breast times months, on exam you find equal lumpiness to both upper outer quadrants, no distinct mass, and pain on exam only on right, what do you do
a) reassure and reexam in one month
b) bilateral mammogram
c) ultrasound
d) fine needle aspirate
e) bilateral mastectomy
Answer: reassure and reexam in one month
This is classic case of fibrocystic disease of the breast.
• breast pain, focal areas of nodularity or cysts often in the upper outer quadrant, frequently bilateral, mobile, varies with menstrual cycle, nipple discharge (straw-like, brown or green)
-mammography is not helpful in women under age 35 because the breast tissue is too dense for the mammographer to read clearly
-In a young woman with no physical findings indicating malignancy, it is reasonable to ask that the patient return 3 to 10 days after the next menstruation begins to determine if the lump regresses
-FNA can be performed if the lump remains easily palpable and feels cystic (round, smooth, and not hard) and the patient wants quick resolution of the issue.
-If fluid is obtained and is not bloody, the patient can be reassured and followed in 4 to 6 weeks to check for recurrence; a recurrence suggests the need for surgical referral.
-If bloody fluid is obtained it should be sent for cytology.
-If the lump does not feel cystic, the patient should be referred for ultrasound. If ultrasound shows a solid mass, the patient should undergo either FNAB, core needle biopsy, or excisional biopsy
-Ultrasonography can determine whether a breast mass is a simple or complex cyst or a solid tumor. It is most useful in the following circumstances:
• In women under age 35
• When a mass detected on screening mammography cannot be felt
• When the patient declines aspiration of a mass
• When the mass is too small or deep for aspiration
Adjuvant RT following mastectomy, which true
- Disease free survival improved
- Local recurrence reduced
Radiation indications:
decrease risk of local recurrence; almost always used after BCS, sometimes after mastectomy (is >4 nodes positive or tumour >5 cm)
inoperable locally advanced cancer
axillary nodal radiation may be added if nodal involvement
Colon cancer metastasizes by all of the following except:
a. Perinural invasion
b. Blood
c. Local invasion
d. Lymphatics
e. Trans peritoneal
Answer: Perinural invasion (???)
See TO notes
Spread: direct extension; lymphatic; hematogenous (liver most common, lung, rarely bone and brain); peritoneal seeding: ovary, Blumer’s shelf (pelvic cul-de-sac); intraluminal
Mass screening for colorectal carcinoma:
a) FOB is specific
b) CEA is as sensitive as FOB
c) Increased proportion of cases are detected earlier
d) Increased survival rates
??? I would say C?
TO notes
-carcinogenic embryonic antigen (CEA): to monitor for initial response to treatment, and to assess for recurrence q3 months (not a screening test)
Colonic adenomas are associated with malignancy. All of the following increase the risk of malignancy except:
a. sessile adenomas
b. multiple polyps
c. villous morphology
d. increased dysplasia
e. increasing size
Answer: sessile adenomas
The three principal features that correlate with malignant potential for an adenomatous polyp are size, histologic type, and degree of dysplasia. Although higher rates of malignant transformation are found when the source of the pathologic material is mainly from surgical polypectomies [7] rather than colonoscopic polypectomies, [8] the malignant potential is directly correlated with larger adenoma size, more villous histology, and higher degrees of dysplasia. To be sure, these three histopathologic criteria are usually interdependent so it is difficult to assign a primary premalignant role to any one of them. For example, although only 1.3% of all adenomas under 1 cm may harbor a cancer, if these small lesions have a predominant villous component or contain a focus of severe dysplasia, the cancer rate rises to 10% or 27%, respectively . Note, however, that a small (
Which of the following is TRUE with regards to multiple myeloma?
A. Commonly associated with hypocalcemia
B. Osteoblastic activity is increased
C. Associated with a monoclonal spike on protein electropheresis
D. Commonly presents with ↓ AlkP
Answer: Associated with a monoclonal spike on protein electropheresis
The lytic bone lesions, osteopenia, hypercalcemia, and pathologic fractures in patients with myeloma are a result of abnormal osteoclast activity induced by the neoplastic plasma cells and inhibition of osteoblast differentiation.
The serum alkaline phosphatase level may be increased.
With serum immunofixation, 93% of patients have detectable M protein.
- Goldman: Cecil Medicine, 23rd ed.
75 year old man presents with a pathologic fracture of left femur. Bloodwork shows hypercalcemia. X-rays show multiple lytic lesions. What is the likely diagnosis?
- osteosarcoma
- multiple myeloma
- osteoporosis
Answer: multiple myeloma
The lytic bone lesions, osteopenia, hypercalcemia, and pathologic fractures in patients with myeloma are a result of abnormal osteoclast activity induced by the neoplastic plasma cells and inhibition of osteoblast differentiation.
The serum alkaline phosphatase level may be increased.
With serum immunofixation, 93% of patients have detectable M protein.
- Goldman: Cecil Medicine, 23rd ed.
75 year old man presents with a pathologic fracture of left femur. Bloodwork shows hypercalcemia. X-rays show multiple lytic lesions. What is the likely diagnosis?
- osteosarcoma
- multiple myeloma
- osteoporosis
Answer: multiple myeloma
The lytic bone lesions, osteopenia, hypercalcemia, and pathologic fractures in patients with myeloma are a result of abnormal osteoclast activity induced by the neoplastic plasma cells and inhibition of osteoblast differentiation.
The serum alkaline phosphatase level may be increased.
With serum immunofixation, 93% of patients have detectable M protein.
- Goldman: Cecil Medicine, 23rd ed.
Which of the following entities is the most common childhood malignancy?
a. Lymphoma.
b. Leukemia.
c. Wilm’s Tumour
d. Neuroblastoma.
e. Rhabdomyosarcoma
Answer: Leukemia, ALL most common type of childhood tumours
Lymphohematopoietic cancers (i.e., acute lymphoblastic leukemia, lymphomas) account for approximately 40%, nervous system cancers for approximately 30%, and embryonal and sarcomas for approximately 10% each among the broad categories of childhood cancers. - Kliegman: Nelson Textbook of Pediatrics, 18th ed.
What is the most common solid tumor in children younger than 4 years:
a. Eewing’s sarcoma
b. Neuroblastoma
c. Wilm’s tumor
d. Astrocytoma
Answer: Neuroblastoma
Neuroblastoma comprised 28% of infant cancer cases and was the most common malignancy among these young children (65 per million infants).
- Gurney JG, Smith MA, Ross JA (1999). “Cancer among infants”. in Ries LAG, Smith MA, Gurney JG, Linet M, Tamra T, Young JL, Bunin GR (eds). Cancer Incidence and Survival among Children and Adolescents, United States SEER program 1975–1995. Bethesda, MD: National Cancer Institute, SEER Program. pp. 149–56.
Neuroblastoma>Wilms>Astrocytoma>retinoblastoma in this age group (leukemia is highest but this is not solid)
The most common pediatric tumor from sympathetic nerve origin is:
a. Neuroblastoma
b. Medulloblastoma.
c. Ganglioneuroma
d. Ganglioneuroblastoma
Sympathetic nervous system tumors accounted for 7.8% of all cancers among children younger than 15 years of age. Over 97% of sympathetic nervous system tumors are neuroblastomas, embryonal malignancies of the sympathetic nervous system that occur almost exclusively in infants and very young children.
Mediastinal tumors were more frequent in infants than in older children, while the opposite age pattern was observed for CNS tumors (Figure IV.1). The average age-adjusted annual incidence rate for all sympathetic nervous system cancers was 9.5 per million children. The occurrence of sympathetic nervous system malignancies was strongly
age-dependent (Figure IV.2). For neuroblastomas alone, the incidence rate for both sexes combined during the second year of life (29 per million) was less than half that of infancy (64 per million). Neuroblastomas were by far the most common cancer of infancy, with an incidence rate almost double that of leukemia, the next most common malignancy that occurred during the first year of life.
Which one is commonly associated with post chemo lymphoporliferative disease:
a. CMV
b. EBV
c. HCV
Infection with Epstein-Barr virus is associated with lymphoproliferative disorders, especially in immunocompromised hosts, and is associated with various tumors, including nasopharyngeal carcinoma and Burkitt lymphoma.
- http://emedicine.medscape.com/article/963894-overview
Majority >95% B-cell proliferation disorder associated with EBV
- Schwartz 2005
With respect to post-transplant lymphoproliferative disorders (PTLD), which is true …
a) B-cell lymphoma is the most common
b) Hodgkin s lymphoma is more common than non-Hodgkin s
c) T-cell lymphoma is more common than B-cell lymphoma
d) It is increased with OKT3
Answer: B-cell lymphoma is the most common
PTLD is a spectrum of B-cell abnormalities driven by EBV leading to the development of monoclonal B-cell lymphoma
- Schwartz
The majority of PTLDs are of B-cell origin and contain Epstein-Barr virus (EBV). However, PTLDs of T- or NK-cell origin have been described, and late-arising EBV-negative lymphoid tumors are becoming more frequently reported in this population.
- Transpl Infect Dis. 3(2):88-96, 2001 Jun.
Which does not lead to BCC a-dysplastic Nevus b-UV c-Nevus Sebacous d-xeroderma pigmentosum
Which one is not premalignant?
Answer: dysplastic Nevus
According to the National Cancer Institute, doctors believe that dysplastic nevi are more likely than ordinary moles to develop into a type of skin cancer called melanoma.
- http://en.wikipedia.org/wiki/Dysplastic_nevus
Multiple basal cell carcinomas (basaliomas) and other skin malignancies frequently occur at a young age in those with XP.
- http://en.wikipedia.org/wiki/Xeroderma_pigmentosum
The idea that a dysplastic nevus may transform itself into a malignant melanoma remains controversial.
- Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.
EPIDERMAL NEVUS SYNDROME
The syndrome name represents the predominant cell type of the nevus; for example, nevus verrucosus (keratinocytes), nevus comedonicus (hair follicles), and nevus sebaceous (sebaceous glands).
Tumors occur with moderate frequency in association with ENS. The nevus itself may undergo malignant transformation, often into a basal cell carcinoma.
- Bradley: Neurology in Clinical Practice, 5th ed
A biopsy of a lesion on the face reveals basal cell carcinoma. Repeat surgery is planned for complete excision. What is the acceptable margin of excision?
a) 2mm
b) 5mm
c) 1cm
d) 2cm
e) 5cm
Answer: 5mm
Although it is potentially dangerous to assign a “standard” margin, current surgical recommendations call for margins of 4 mm of healthy tissue in excision of nodular BCCs and more than 7 mm in aggressive BCCs.
- Townsend: Sabiston Textbook of Surgery, 16th ed., Copyright © 2001 W. B. Saunders Company
Most physicians recommend 0.5cm margins around basal cell carcinomas
- Schwartz
Cure rates for BCC and SCC treated with standard surgical excision approach 95%.[15] [21] Because BCCs and SCCs can extend unpredictably beyond the clinical border of the tumor, the recommended margin of normal skin to be included in the excision has ranged from 2 mm to over 10 mm.[23] The chances of incomplete excision and local recurrence rise as closer margins are obtained. [15] Ideally, margins should range from 4 to 6 mm with the understanding that micronodular, infiltrative, and morpheaform BCCs, basosquamous carcinomas, and poorly differentiated SCCs have a greater likelihood of tumor extension beyond the standard 4-mm margins.[8] [21] Tumors greater than 2 cm in size and recurrent tumors likely will have greater subclinical extension, and exact margins cannot be recommended.
- Cutaneous malignancies and their management. Padgett JK - Otolaryngol Clin North Am - 01-Jun-2001; 34(3): 523-53
62 year old man presents with a scaly, ulcerated lesion at the tip of left pinna. Biospy was done in suspicion of malignancy. Biospy results come back as a benign tumor. What is the likely diagnosis?
- Merkel’s tumor
- Keratoacanthoma
- fibrodermosarcoma
- squamous cell carcinoma
Answer: Keratoacanthoma (likely benign)
Merkel cell carcinoma is a particularly aggressive small cell tumor arising from the cutaneous nerve endings or Meissner’s corpuscles
- Goldman: Cecil Medicine, 23rd ed.
Keratoacanthoma (KA) is a relatively common low-grade malignancy that originates in the pilosebaceous glands and closely and pathologically resembles squamous cell carcinoma (SCC). In fact, strong arguments support classifying keratoacanthoma as a variant of invasive SCC.1 Keratoacanthoma is characterized by rapid growth over a few weeks to months, followed by spontaneous resolution over 4-6 months in most cases. Keratoacanthoma reportedly progresses, although rarely, to invasive or metastatic carcinoma; therefore, aggressive surgical treatment often is advocated. Whether these cases were SCC or keratoacanthoma, the reports highlight the difficulty of distinctly classifying individual cases.
- http://emedicine.medscape.com/article/1100471-overview
Melanoma: Known risk factors for children are giant hairy nevus (>20 cm), dysplastic nevus syndrome, and xeroderma pigmentosum.
- Kliegman: Nelson Textbook of Pediatrics, 18th ed.
An actinic keratosis may follow 1 of 3 paths; it may regress, it may persist unchanged, or it may progress to invasive squamous cell carcinoma. The actual percentage that progress to invasive squamous cell carcinoma remains unknown, and estimates have varied from as low as 0.1% to as high as 10%.1,7 Furthermore, predicting which course each individual lesion will follow is impossible.
Early data suggest that actinic keratoses may also progress to basal cell carcinoma, a paradigm originally not considered in the actinic keratosis risk profile; further research is necessary to confirm this potential relationship. Overall, actinic keratoses can be safely and effectively eradicated; therefore, therapy is warranted.
- http://emedicine.medscape.com/article/1099775-overview
Causes of BCC # UV radiation # Other radiation: X-ray and grenz-ray exposure # Arsenic exposure: # Immunosuppression is associated with a modest increase in the risk of BCC. # Xeroderma pigmentosum: # Nevoid BCC syndrome - http://emedicine.medscape.com/article/1100003-overview
Which of the following is the MOST sensitive indicator of malignancy in an incisional biopsy for an epithelial tumour?
A. Aneuploidy on flow cytometry
B. Positive stain for cytokeratin
C. Tumor cells breaking through the basement membrane layer
D. Multiple mitotic figures and prominent nucleoli
As compared with benign tumors and some well-differentiated malignant neoplasms, undifferentiated tumors usually possess large numbers of mitoses, reflecting the higher proliferative activity of the parenchymal cells. The presence of mitoses, however, does not necessarily indicate that a tumor is malignant or that the tissue is neoplastic. Many normal tissues exhibiting rapid turnover, such as bone marrow, have numerous mitoses, and non-neoplastic proliferations such as hyperplasias contain many cells in mitosis. More important as a morphologic feature of malignancy are atypical, bizarre mitotic figures, sometimes producing tripolar, quadripolar, or multipolar spindles
When dysplastic changes are marked and involve the entire thickness of the epithelium but the lesion remains confined by the basement membrane, it is considered a preinvasive neoplasm and is referred to as carcinoma in situ ( Fig. 7-10 ). Once the tumor cells breach the basement membrane, the tumor is said to be invasive.
In situ epithelial cancers display the cytologic features of malignancy without invasion of the basement membrane. They may be considered one step removed from invasive cancer; with time, most penetrate the basement membrane and invade the subepithelial stroma.
Lack of differentiation, or anaplasia, is often associated with […] abnormal nuclear morphology. Characteristically the nuclei contain abundant chromatin and are dark staining (hyperchromatic). The nuclei are disproportionately large for the cell, and the nuclear-to-cytoplasm ratio may approach 1 : 1 instead of the normal 1 : 4 or 1 : 6. The nuclear shape is variable and often irregular, and the chromatin is often coarsely clumped and distributed along the nuclear membrane. Large nucleoli are usually present in these nuclei.
- Kumar: Robbins and Cotran Pathologic Basis of Disease, Professional Edition , 8th ed.
If the mitotic figures are “atypical” and “bizarre”, I would say D, otherwise C.
NB: Cellular atypia is present in actinic keratosis as well. The distinguishing feature of SCC is that it invades the basement membrane.
With regards to the development of squamous cell skin cancer in the transplanted patients undergoing immunosuppressive therapy, which of the following is true?
a. Happens earlier
b. More aggressive
c. Sunlight protection decreases the chance of cancer
d. BCC is still more common in transplant recipients than SCC
D. SCC > BCC on immunosuppressives
Factors associated with SCC in OTRs (organ transplant recipients) include sun exposure, epidermodysplasia verruciformis-associated HPV types 5 and 8, fair skin, heart transplant, older age at transplant, male sex, and intense immunosuppression. Indeed, intensity and duration of immunosuppression have been associated with development of aggressive SCC. Studies suggest that antirejection therapies using tacrolimus, mycophenolate mofetil, or rapamycin versus cyclosporine, glucocorticoids, or azathioprine may decrease incidence of NMSC in OTRs.
- Abeloff: Abeloff’s Clinical Oncology, 4th ed.
Answer: Transplant patients have an overall 5% to 6% incidence of malignancy, which is 100 times greater than the general population.[1,65] As many as 40% to 53% of all malignancies among transplant patients are skin cancers.[38,66] The incidence of skin cancer varies with the amount of sun exposure. In regions with limited sun exposure, such as the Netherlands, the risk of a skin tumor is 10% at 10 years after transplantation and 40% at 20 years.[67] In regions with high sun exposure, such as Australia, the incidence is 45% at 11 years after transplantation and 70% at 20 years.[68]
Under normal circumstances, basal cell carcinomas (BCC) are much more common than SCC. However, the incidence of SCC in transplant recipients is 40 to 250 times that of the general population, whereas the incidence of BCC is 10 times greater in transplant patients.[55,69] This results in a reversal of the BCC/SCC ratio. SCCs in transplant patients are much more aggressive and deadly.[78,79] They tend to recur locally even after surgical excision
Bowen’s disease is :
a. Squamous cell ca in situ
b. Basal cell ca in situ
c. Benign disease of the bone
Answer: Squamous cell ca in situ
Which is least likely to increase risk of melanoma :
a. Nevus sebaceous
b. Actinic keratosis
c. Xeroderma pigmentosa
d. Lentigo maligna
Answer: Actinic keratosis
A is premalignant for basal cell. No mention of melanoma in literature
B is premalignant for SCC. No evidence of melanoma transformation
C is a risk for melanoma for sure,
D is premalignant for melanoma
Malignant melanoma stage IV the treatment include all of the following except:
a. Surgery
b. Chemotherapy (cisplastin, decarpamazine)
c. Radiotherapy
d. Levosmil local chemo
e. Topical chemotherapy
Answer: Levosmil local chemo
The treatment of a patient with metastatic melanoma emphasizes palliation. No evidence indicates that treatment of metastatic melanoma has any impact on survival, which ranges from 5 to 11 months, with a median of 8.5 months. Treatment options include surgery for resection of solitary metastases, single-agent chemotherapy such as dacarbazine, temozolomide (an oral version of dacarbazine), combination chemotherapy, immunotherapy (vaccines, interleukin-2, interferon), or combined immunotherapy. Melanoma can metastasize to virtually any organ, especially the lung, skin, liver, and brain. Ongoing clinical trials are evaluating a molecularly targeted inhibitor of the RAF kinases.
- Goldman: Cecil Medicine, 23rd ed.
Symptomatic skeletal metastases can be effectively palliated with radiation. Metastases resulting in fractures of weight-bearing bones require internal fixation before radiation therapy.
- Townsend: Sabiston Textbook of Surgery, 18th ed.
Can’t find anything in modern literature suggesting local or topical treatment of Stage IV melanoma.
stage I (T1, N0, M0 or T2, N0, M0); stage II (T3, N0, M0 or T4, N0, M0); stage III (any T, N1, M0 or any T, N2, M0); stage IV (any T, any N, M1); with distant metastases, surgical therapy is indicated for solitary lesions in brain/gut/skin if symptomatic; only adjuvant tx known to influence survival is INF alpha-2b (T4 or N1); radiation has been shown to be useful (symptomatic brain mets); hyperthermic regional limb perfusion with chemotx is used for patients with local recurrence or in-transit lesions (along lymphatics) on extremity or not amenable to excision; levamisole is an antihelmintic drug (used for colorectal CA; NO mention that it is used in melanoma)
8mm melanoma to be removed, what margins are appropriate
a-1 cm
b-2 cm
c-3 cm
According to the AAD’s 2001 guidelines, surgical management of primary cutaneous melanoma should focus on obtaining an excision margin based on histologic confirmation of tumor-free margins.
- Melanoma in situ: 0.5-cm margins
- Melanoma with Breslow’s thickness
A melanoma of 2.5mm thickness requires what margin? A. 2mm B. 5mm C. 2cm D. 5cm
According to the AAD’s 2001 guidelines, surgical management of primary cutaneous melanoma should focus on obtaining an excision margin based on histologic confirmation of tumor-free margins.
- Melanoma in situ: 0.5-cm margins
- Melanoma with Breslow’s thickness
Pigmented lesion beneath finger nail, most probably it will be:
a. Lentigo maligna
b. Superficial melanoma
c. Nodular melanoma
d. Acral melanoma
PICTURE: the picture is a toenail with a blue lesion underneath (African Canadian)
Acral lentiginous melanoma occurs on the palms, on the soles, or beneath the nail plate (subungual variant).
- http://emedicine.medscape.com/article/1100753-overview
Bob Marley
Melanoma in a black lady, which is true:
a. Nodular is the commonest
b. Commonest in hands and palms
c. F > M
d. Prognosis is not affected by grade
Answer: Commonest in hands and palms
Acral lentiginous melanoma characteristics are as follows:
* This is the least common subtype of melanoma (2-8% of melanoma cases in white persons). * It accounts for 29-72% of melanoma cases in dark-skinned individuals (ie, African American, Asian, and Hispanic persons) and, because of delays in diagnosis, may be associated with a worse prognosis.22,23 * Acral lentiginous melanoma occurs on the palms, on the soles, or beneath the nail plate (subungual variant). See the image below. * Subungual melanoma may manifest as diffuse nail discoloration or a longitudinal pigmented band within the nail plate. * It must be differentiated from a benign junctional melanocytic nevus of the nail bed, which has a similar appearance. * Pigment spread to the proximal or lateral nail folds is termed the Hutchinson sign, which is a hallmark for acral lentiginous melanoma. - http://emedicine.medscape.com/article/1100753-overview
Which is MOST specific for melanocytic lineage
a. polymerase
b. tyrosinase
c. hydrogen peroxidase
d. HMB-45 Ag
e. S-100 protein
… This seems like incredibly low yield.
HMB-45, Melan-A, and Mitf demonstrated specificities of 97%. S-100 protein and tyrosinase were less specific. Sensitivity and specificity for the combination Mitf+/Melan-A+ were 95% and 100%, respectively, whereas they were 80% and 100%, respectively, for S-100+/HMB-45+. Mitf Melan-A, and tyrosinase are sensitive markersfor epithelioid melanoma. Mitf and Melan-A seem more specific than S-100 and tyrosinase. An antibody panel consisting of Mitf and Melan-A is superior to a panel of S-100 and HMB-45 in the diagnosis of melanoma in cytologic specimens.
All of the following are true about Melanoma EXCEPT?
a) the incidence is increasing
b) prognosis is based mainly on depth of invasion
c) sun exposure is a risk factor
d) the incidence is equal among black and white people
Easy.
Black people get far fewer melanomas than white (commonly acral lentiginous melanoma
Which of the following is not a side effect of Vincristine?
a) paralytic ileus
b) thrompocytopenia
c) Hypofibroginemia
d) leucopenia
Hypofibroginemia
Memorization. This question seemed to pop up pretty often though on old exams
A patient on Vinblastine develops a duodenal ulcer. Post-operatively one would expect which complication as a result of the medication?
a. hirsuitism
b. paralytic ileus
Answer: paralytic ileus
Toxic Effects: Vincristine’s dose-limiting toxic effect is neurotoxicity, which appears to be related to its relative polarity. Peripheral neurotoxicity usually manifests as sensory impairment, decreased deep tendon reflexes, and paresthesias. Less commonly, severe painful dysesthesias, ataxia, foot drop, and cranial nerve palsy (eg, affecting the extraocular and laryngeal muscles) can occur. Autonomic neurotoxicities include constipation, abdominal cramps, and ileus, which may be prevented by use of mild laxatives. Alopecia occurs frequently, but myelosuppressive effects are minimal. Rare side effects include inappropriate secretion of antidiuretic hormone and ischemic cardiac toxicity. Vinblastine’s dose-limiting toxic effect is myelosuppression, with leukopenia more pronounced than thrombocytopenia. Anemia is uncommon. Neurotoxicity can also occur but is significantly less common than with vincristine. Vinblastine is also a vesicant.
- Hoffman: Hematology: Basic Principles and Practice, 5th ed.
Of the list of chemotherapeutic agents listed below, which is not an alkylating agent:
a) cyclophosphamide
b) vincristine
c) chlorambucil
d) melphalan
e) ifosfamide
Answer: vincristine (Plant alkyloid)
Alkylating agents Nitrogen mustards o Cyclophosphamide o Mechlorethamine or mustine (HN2) o Uramustine or uracil mustard o Melphalan o Chlorambucil o Ifosfamide Nitrosoureas o Carmustine o Lomustine o Streptozocin Alkyl sulfonates o Busulfan - http://en.wikipedia.org/wiki/Alkylating_antineoplastic_agent
PLANT ALKYLOIDS - Vincristine - Vinblastine - Paclitaxel - Etoposide Morell Notes
Vinblastine is a vinca alkaloid and a chemical analogue of vincristine.
- http://en.wikipedia.org/wiki/Vinblastine
Which of the following chemotherapeutics is an antimetabolite? A. Chlorambucil B. Gemcitabine C. Vinblastine D. Bleomycin
Gemcitabine
The “-abine” drugs are antimetabolites (cytarabine, fludarabine) plus 5-FU and methotrexate.
A. Chlorambucil (alkylating)
B. Gemcitabine
C. Vinblastine (anti-tublulin)
D. Bleomycin (anti-tumor antibody)
Which of the following is an antimetabolite:
a. Chlorambucil
b. vinblastin
c. cytarabin
c
The “-abine” drugs are antimetabolites (cytarabine, fludarabine) plus 5-FU and methotrexate.
What is the definition of neoadjuvant chemotherapy:
a. Chemotherapy pre op
b. Chemotherapy post op
c. Chemotherapy intra op
d. Chemo and radiotherapy
e. None of the above
Answer: Chemotherapy pre op
Which if the following is an antagonist to Methotrexate
a. Folic acid
b. Folinic acid
Answer: Folinic acid (leucovorin)
Folinic acid (INN) or leucovorin (USAN), generally administered as calcium or sodium folinate (or leucovorin calcium/sodium), is an adjuvant used in cancer chemotherapy involving the drug methotrexate. Folinic acid is administered at the appropriate time following methotrexate as part of a total chemotherapeutic plan, where it may "rescue" bone marrow and gastrointestinal mucosa cells from methotrexate. - http://en.wikipedia.org/wiki/Folinic_acid
Side effects: Myelosuppression Acute renal failure elevation transaminases and bilirubin pneumonitis cerebral dysfunction
What is the dose limiting toxicity of Bleomycin?
a. myelosuppression
b. pulmonary fibrosis
c. cardiomyopathy
d. GI upset
e. peripheral neuropathy
Answer: pulmonary fibrosis
The two cytotoxic agents that commonly cause pulmonary damage are bleomycin and busulfan. The pulmonary damage caused by bleomycin is dose-related; patients who receive a cumulative dose of greater than 450 units show a higher incidence of toxicity than those who receive a lower cumulative dose.
Side effects of cisplatin
Name them all
lol
Nephrotoxicity Ototoxicity Myelosuppression ,thrombocytopenia, leukopenia Hepatotoxicity Gastrointestinal Hyperuricemia Neurotoxicity Anaphylactic Optic neuritis, papilledema
* Nephrotoxicity (kidney damage) is a major concern when cisplatin is given. The dose is reduced when the patient's creatinine clearance (a measure of renal function) is reduced. Adequate hydration and diuresis is used to prevent renal damage. The nephrotoxicity of platinum-class drugs seems to be related to reactive oxygen species and in animal models can be ameliorated by free radical scavenging agents (e.g., amifostine). This is a dose-limiting toxicity. * Neurotoxicity (nerve damage) can be anticipated by performing nerve conduction studies before and after treatment. * Nausea and vomiting: cisplatin is one of the most emetogenic chemotherapy agents, but this is managed with prophylactic antiemetics (ondansetron, gra3nisetron, etc.) in combination with corticosteroids. Aprepitant combined with ondansetron and dexamethasone has been shown to be better for highly emetogenic chemotherapy than just ondansetron and dexamethasone. * Ototoxicity (hearing loss): unfortunately there is at present no effective treatment to prevent this side effect, which may be severe. Audiometric analysis may be necessary to assess the severity of ototoxicity. Other drugs (such as the aminoglycoside antibiotic class) may also cause ototoxicity, and the administration of this class of antibiotics in patients receiving cisplatin is generally avoided. The ototoxicity of both the aminoglycosides and cisplatin may be related to their ability to bind to melanin in the stria vascularis of the inner ear or the generation of reactive oxygen species. * Alopecia (hair loss): this does not generally affect patients treated with cisplatin. * Electrolyte disturbance: Cisplatin can cause hypomagnesaemia, hypokalaemia and hypocalcaemia. The hypocalcaemia seems to occur in those with low serum magnesium secondary to cisplatin, so it is not primarily due to the Cisplatin.
