Med Onco Flashcards
What is the effect of hormone replacement therapy on risk for
endometrial CA
colorectal CA
fractures
breast CA
Hormone replacement therapy (HRT) with conjugated equine estrogens plus progestins increases the risk of breast cancer. Epidemiologic studies have demonstrated a rapid decrease in elevated breast cancer incidence coincident with the discontinuation of HRT. it takes 6-7 years to double breast cancer risk.
HRT increases the risk of endometrial cancer, however, administration of conjugated estrogens with progesterone abrogates the increased risk of endometrial cancer compared to estrogen alone HRT
HRT decreases the risk of bone fractures and colorectal cancer.
Which subset of patient is MRI recommended for screening for breast cancer
● Women with dense breasts
● First cancer was not detected by mammography
● Axillary breast cancer presentation but no definable breast mass on PE or mammography
● History of radiation therapy to the chest between ages 10 and 30 years
● High genetic risk, such as BRCA1 or BRCA2 carriers or those with Li-Fraumeni, Cowden’s, or Bannayan-RileyRuvalcaba syndromes
35/F with a solitary breast mass left underwent MRM. Her histopathology report revealed invasive ductal carcinoma. Her breast panel IHCs findings revealed ER (+) PR (-) Her 2 (2+). What would be the BEST recommendation to this patient?
A. Request for repeat IHCs
B. Request for HER-2 FISH testing
C. Proceed with treatment with Hormonal therapy only
D. Proceed with treatment with Hormonal and Anti-Her2 Therapy
Answer: B. Request for HER-2 FISH testing
The two most important predictive factors in breast cancer are ER and HER2 expression, and they should be performed on all primary or metastatic cancer biopsy specimens. HER2 status is determined using either IHC staining for protein overexpression or fluorescent in situ hybridization (FISH) for gene amplification. IHC staining of 3+ (on a scale of 0–3+) is considered positive, whereas 0–1+ is considered negative. For cases with 2+ staining, reflex FISH analysis is recommended. FISH can either be used as the initial evaluation or for additional evaluation in IHC 2+ cases. HER2 is considered amplified if the ratio of HER2 to centromere signal on chromosome 17 is ≥2.0. FISH is unnecessary if IHC is 3+ or 0–1+, nor is there a reason for IHC testing if FISH is ≥2.0
How do you differentiate the luminal staging of Breast CA?
Example of TKI for breast CA that targets HER2
Lapatinib, neratinib, tucatinib
Example of TKI for breat CA that targets mTOR
Everolimus
Example of immunotherapy for breast CA that targets CDK4/6
Palbciclib, ribociclib, abemociclib
Example of immunotherapy for breast CA that targets PIK3CA
Alpelisib
Example of immunotherapy for breast CA that targets PDL-1/PD-1
Atezolizumab
Example of immunotherapy for breast CA that targets TROP 2
Sacizutumab govitecan
Example of SERMs
Tamoxifen, Raloxifene, Toremifene
Example of Aromatase inhibitors
Anastrozole, Letrozole, Exemestane
Example of LHRH agonists
goserelin, leuprolide
BRCA 1 gene mutation commonly fall to which molecular subtype of breast cancer
Basal
Indications for Post Mastectomy Radiation due to high risk of locoregional recurrence
● Tumors ≥5 cm
● Four or more positive axillary lymph nodes
● Postoperative positive margins
How is breast CA prognosis affected by pregnancy?
Breast cancer prognosis during pregnancy is similar, stage for stage, as that for age-matched women who are not pregnant.
How does fats affect the risk of prostate CA?
High consumption of dietary fats, such as α-linoleic acid or polycyclic aromatic hydrocarbons that form when red meats are cooked, is believed to increase the risk of prostate cancer
Medications that prevent prostate CA
Currently, no approved preventive agent for prostate cancer
Which is TRUE about PSA testing in prostate cancer screening, diagnosis, and treatment?
A. PSA test is prostate cancer-specific
B. Digital rectal exam (DRE) may increase PSA levels
C. PSA is a useful test for screening 50 years old men for prostate cancer
D. PSA level is strongly associated with the risk and outcome of prostate cancer
D. PSA level is strongly associated with the risk and outcome of prostate cancer
The level of PSA in the blood is strongly associated with the risk and outcome of prostate cancer. A single PSA measured at age 60 is associated (area under the curve [AUC] of 0.90) with a lifetime risk of death from prostate cancer. Most (90%) prostate cancer deaths occur among men with PSA levels in the top quartile (>2 ng/mL), although only a minority of men with PSA >2 ng/ mL will develop lethal prostate cancer.
Option A is incorrect. PSA is produced by both nonmalignant and malignant epithelial cells and, as such, is prostate-specific, not prostate cancer–specific.
Option B is incorrect. Serum levels of PSA may increase from prostatitis, BPH, or prostate cancer. Serum levels are not significantly affected by the DRE.
Option C is incorrect. Recommendations for screening with PSA are based on shared decision-making for men between the ages of 55 and 69. PSA-based screening is a target age group for whom benefits may outweigh the harm. Outside this age range, PSA-based screening as routine is not recommended.
Which diagnostic test is recommended for staging and treatment planning for prostate cancer?
MRI
This androgen deprivation therapy (ADT) used in managing metastatic non-castrate prostate cancer may initially cause a clinical flare of disease and is relatively contraindicated when given alone for patients with spinal cord compromise.
Leuprolide
GnRH agonists/antagonists, such as leuprolide acetate and goserelin acetate, initially produce a rise in LH and FSH followed by a downregulation of receptors in the pituitary gland, which effects a chemical castration. The initial rise in testosterone may result in a clinical flare of the disease, and as such, these agents are relatively contraindicated in men with significant obstructive symptoms, cancerrelated pain, or spinal cord compromise, events that do not occur with GnRH antagonists such as degarelix (Option D).
Most common anatomic site of the prostate where prostate cancer develops?
Peripheral
Most common malignancy that can cause Superior Vena Cava (SVC) syndrome among adult cancer patients?
Small Cell lung CA
Lung cancer, particularly of small-cell and squamous cell histology, accounts for ~85% of all cases of malignant origina
primary treatment for SVCS caused by non-small-cell lung cancer and other metastatic solid tumors
RT
Most common type of malignancy causing metastatic spinal cord compression
Lung CA
Most common site of spine involvement in metastatic spinal cord compression?
Thoracic
The thoracic spine is the most common site (70%), followed by the lumbosacral spine (20%) and the cervical spine (10%). Involvement of multiple sites is most frequent in patients with breast and prostate carcinoma
Next step when patient with CA presents with back pain and + Lhermitte sign
MRI of the spine
What is the initial management for suspicious or confirmed metastatic spinal cord compression?
High-dose steroids
The treatment of patients with spinal cord compression (SCC) is aimed at relief of pain and restoration/preservation of neurologic function. Management of Metastatic SCC requires a multidisciplinary approach. Radiation therapy plus glucocorticoids is generally the initial treatment of choice for most patients with SCC.
Electrolyte abnormalities associated with Tumor Lysis syndrome
Tumor lysis syndrome (TLS) is characterized by hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia and is caused by the destruction of a large number of rapidly proliferating neoplastic cells.
Tumors associated with TLS
TLS is most often associated with the treatment of Burkitt’s lymphoma, acute lymphoblastic leukemia, and other rapidly proliferating lymphomas, but it also may be seen with chronic leukemias and, rarely, with solid tumors
Preventive approaches for tumor lysis syndrome among high-risk cancer patients include the following; EXCEPT:
A. Aggressive hydration
B. Allopurinol
C. Febuxostat
D. Sodium bicarbonate
Urinary alkalinization with sodium bicarbonate is no longer recommended. It increases uric acid solubility, but a high pH decreases the solubility of xanthine, hypoxanthine, and calcium phosphate, potentially increasing the
likelihood of intratubular crystallization.
How do you prevent TLS?
Hydration 3000 mL/ m2 with PNSS or 0.45 NSS
Allopurinol 300 mg/ m2
Indications for HD if with TLS
What treatment modality has been shown to be successful in managing chemotherapy-induced Hemolytic - Uremic Syndrome (HUS)?
Rituximab
This condition may rarely occur after treatment with antineoplastic drugs. Mitomycin and gemcitabine are the most common offenders. Other antineoplastic drugs are gemcitabine, cisplatin, bleomycin, and proteasome inhibitors, and with VEGF inhibitors
What is the primary therapy or prevention for polyposis coli?
Total colectomy
This chemotherapeutic agent remains the backbone of systemic therapies in colorectal cancer
5-FU
Most common site of distant metastasis in colorectal cancer
Liver
Clinical criteria for the diagnosis of Lynch syndrome or also known as hereditary nonpolyposis colon cancer
Bethesda criteria for clinical diagnosis of Lynch Syndrome ( Remember 3-2-1)
3 - three or more relatives with histologically documented colorectal cancer, one of whom is a first-degree relative of the other two
2 - at least two generations with colorectal cancer involvement
1 - one or more cases of colorectal cancer diagnosed before age 50 in the family
What symptoms are more common in right sided compared to left sided colon CA?
This is the most common side effect of Irinotecan when used in colorectal cancer
diarrhea
Diarrhea is the major side effect of irinotecan. Irinotecan-induced diarrhea is enhanced by the intestinal bacterial production of beta-glucuronidases, causing the transformation of SN38-G to SN38 causing diarrhea.
Chemotherapeutic agents affect bone marrow function. In general, which bone marrow cell type is MOST susceptible to the effects of cytotoxic drugs?
PMNs
Which drug used in the prevention of chemo-induced nausea and vomiting (CINV) acts primarily by promoting gastric motility by inhibiting peripheral dopamine receptors and is used in high doses for highly emetogenic chemotherapy?
Metoclopramide
ideal time to administer primary G-CSF prophylaxis
The best time to give primary G-CSF administration is 24-72 hours after chemotherapy
Continue until ANC > 10,000 /uL
What are the preventive uses of G-CSF?
Dose of G-CSF
pathognomonic finding of anthracycline-induced cardiotoxicity
The pathognomonic finding of anthracycline-induced cardiotoxicity is myofibrillar dropout on
endomyocardial biopsy
Myocardial toxicity of anthracyclines is dose-dependent. Approximately 5% of patients receiving >450–550 mg/m2 total dose of doxorubicin will develop CHF, but it can also develop at substantially lower doses in some patients.
Chemotherapy or hormonal agents associated with CHF
Chemotherapy or hormonal agents associated with Pulmonary fibrosis
Chemotherapy or hormonal agents associated with pneumonitis
Chemotherapy or hormonal agents associated with secondary malignancies or myelodysplasia
Chemotherapy or hormonal agents associated with immune dysfunction and recurrent infections
Chemotherapy or hormonal agents associated with infertility
Chemotherapy or hormonal agents associated with hemorrhagic cystitis
Chemotherapy or hormonal agents associated with renal tubular dysfunction
Chemotherapy or hormonal agents associated with neuropathy
Chemotherapy or hormonal agents associated with ataxia
Chemotherapy or hormonal agents associated with vasomotor symptoms
Chemotherapy or hormonal agents associated with sexual dysfunction
most significant risk factor for cancer overall
age
ECOG status of a 70 year old female with metastatic breast cancer to the spine, capable of only limited self-case and confined to her bed more than 50% of waking hours
3
How do you differentiate complete vs partial response to tx based on RECIST criteria
Definition of progressive dse based on RECIST criteria
Conditions associated with elevated HCG
Conditions associated with elevated calcitonin
Conditions associated with elevated catecholamines
Conditions associated with elevated AFP
Conditions associated with elevated prostatic acid phosphatase
Conditions associated with elevated neuron specific enolase
Conditions associated with elevated LDH
Conditions associated with elevated PSA
Conditions associated with elevated monoclonal globulin
Conditions associated with elevated CA19-9
Conditions associated with elevated CD 30
Conditions associated with elevated CD 25
Which of the following statements describes the mechanism of action of cyclophosphamide accurately?
A. Forms covalent bonds with DNA bases, leading to cross-linkage of DNA strands
B. Interferes with purine synthesis, conveying the greatest toxicity to cells in the S-phase
C. Creates double stranded breaks through which another segment of DNA duplex passes before rejoining
D. Binds to DNA through the DNA minor groove eventually leading to the disruption of the FUS-CHOP transcription action
Option A is the mechanism of action of alkylating agents such as cyclophosphamide (cell cycle nonspecific).
Option B is the MOA of anti-metabolites (like 5FU or capecitabine).
Option C is the MOA of Top-2 inhibitors (like doxorubicin), and
option D is the specific MOA of trabectedin, another alkylating agent
The efficacy of which drug is enhanced by leucovorin by increasing the binding of a ternary complex with thymidylate synthase?
A. Methotrexate
B. 5-fluorouracil
C. Pemetrexed
D. 6-Thioguanine
The action of 5-fluorouracil is synergistic with leucovorin.
Option A is incorrect because leucovorin lessens the toxicity of methotrexate to normal tissues (folate rescue, otherwise cells die a thymine-less death) .
Options C and D are also incorrect because leucovorin has no role in enhancing their efficacy.
Additional information: Pemetrexed: give folate and VitB12 to reduce hematologic toxicity 6-thioguanine: Increased toxicity with thiopurine methyltransferase deficiency
Which mechanism explains early diarrhea, occurring less than 24 hours after irinotecan administration?
A. Acetylcholinesterase inhibition by the prodrug B. Acetylcholinesterase inhibition by the active metabolite, SN-38
C. Direct mucosal cytotoxicity from the prodrug D. Direct mucosal cytotoxicity by the active metabolite, SN-38
Early diarrhea is caused by acetylcholinesterase inhibition by the prodrug, Irinotecan. In order to prevent this, patients are premedicated with atropine. Late diarrhea occurs due to direct mucosal cytotoxicity by the active metabolite, SN-38. For late diarrhea, use loperamide 4mg after the first stool then 2mg Q2 hours until 12h without stool (max 16mg/24h)
This antibody drug conjugate (ADC) uses an antibody to NECTIN 4 to treat advanced urothelial neoplasms expressing this target. Internalization of the ADC-Nectin complex allows the release of auristatin, an antimicrotubule.
A. Belantamab mafodotin
B. Ziv-aflibercept
C. Ado-trastuzumab emtansine D. Enfortumab vedotin
This is the MOA of Enfortumab vedotin
Belantamab mafodotin targets B-cell maturation (BCMA) expressed myeloma, ziv-aflibercept targets VEGF and is used in colorectal cancer with 5fubased chemotherapy.
Ado-trastuzumab emtansine targets Her2/neu receptors as treatment in advanced breast cancer
Which agent may be given to patients with metastatic prostate cancer to inhibit androgen synthesis by blocking the action of CYP17A1? To counteract adverse events related to mineralocorticoid excess, this is often given together with corticosteroids.
A. Abiraterone
B. Leuprolide
C. Enzalutamide
D. Relugolix
Abiraterone inhibits the action of CYP17A1, thus preventing androgen biosynthesis
Leuprolide is an LHRH agonist, while Relugolix is a GNRH antagonist, preventing the release of LH and FSH, and consequently testosterone.
Enzalutamide is a second generation androgen receptor (AR) antagonist inhibiting androgen binding to AR, androgen receptor nuclear translocation, and subsequent interaction with chromosomal DNA for signaling
A third generation TKI and the only agent with T315I activity for CML
Ponatanib
A patient with metastatic non-small cell lung cancer starts taking a tyrosine kinase inhibitor that targets ALK but also has anti-ROS activity. After 2 months on the treatment, he reports having suicidal ideations, altered mood and sleep. Which among the following TKIs did the patient receive?
A. Ceritinib
B. Crizotinib
C. Lorlatinib
D. Larotrectinib
Answer: C. Lorlatinib
Explanation: Lorlatinib targets both ALK but also has anti-ROS activity. Apart from suicidal ideations, altered mood, sleep and cognitive disturbances, this is also known to cause dyslipidemia.
Ceritinib is an ALK-inhibitor, Crizotinib inhibits both ALK and ROS but both drugs are not known to affect mood or cognition.
Larotrectinib does not have ALK or ROS activity, but rather, targets NTRK fusion mutations
Only oral medication approved as maintenance treatment for germline BRCA mutated pancreatic adenocarcinoma after stable disease or response to first line platinum based chemotherapy
Olaparib
Which of the following cancer treatments warrants periodic monitoring for hyperglycemia? A. Abemaciclib
B. Adagrasib
C. Alpelisib
D. Axitinib
Answer: C. Alpelisib
Alpelisib is a PI3K inhibitor that can cause uncontrolled hyperglycemia. It is important to monitor glucose levels and hba1c.
MTOR inhibitors (everolimus, temsorolimus) and BRAF inhibitors (regorafenib, dabrafenib) can also cause hyperglycemia
Abemaciclib is a CDK4/6 inhibitor that can cause neutropenia, diarrhea and hepatotoxicity.
Adagrasib targets KRAS G12C mutated non-small cell lung cancer.
Axitinib is a multikinase inhibitors that causes hemorrhaging, clotting, diarrhea, hand foot syndrome, high blood pressure, proteinuria and even posterior reversible encephalopathy syndrome (like other multikinase inhibitors)
Necrotizing encephalopathy is the most severe form of radiation injury and almost always is associated with concurrent use of which chemotherapeutic drug?
A. 5-fluorouracil
B. Capecitabine
C. Gemcitabine
D. Methotrexate
Answer: D. Methotrexate
Which specific genetic alteration is usually seen in etoposide-related acute myeloid leukemia?
A. Chromosome 5 or 7 deletion
B. Chromosome 11q23 translocation
C. Chromosome T(14;18) translocation
D. Chromosome T(15;17) translocation
B. Chromosome 11q23 translocation
This mutation in AML patients is seen after exposure to top-inhibitors (with etoposide conferring the highest risk), rarely preceded by MDS.
Chromosome 5 or 7 mutations, may be seen in patients on previous alkylating agents especially when combined with radiation ad is often preceded by myelodysplasia.
Chromosome T(14;18) translocation is the defining molecular event in follicular lymphoma.
While chromosome T(15;17) translocation is the defining molecular event in acute promyelocytic leukemia, conferring sensitivity to retinoic acid
A 65 year old woman, nonsmoker, underwent a biopsy of an incidental lung mass. It yielded the following pathologic findings: well-differentiated, glandular carcinoma with a mix of acinar and solid features. Which combination of IHCs best represents the histology of his lung cancer?
A. TTF-1 positive, Napsin-A negative
B. TTF-1 negative, Napsin-A negative
C. TTF-1 negative, Napsin-A positive
D. TTF-1 positive, Napsin-A positive
Answer: D. TTF-1 positive, Napsin-A positive Explanation: The pathologic findings point to an adenocarcinoma histology, which confers the following positive IHC results: napsin A (>90% of the time) and TTF1 (>70% of the time).
- Which of the following statements is accurate regarding the use of sputum cytology in the diagnosis of lung cancer?
A. Although lower yield than other specimen types, the yield is highest for peripherally located tumors such as adenocarcinomas
B. The specificity is about <70%, while sensitivity is 100%
C. This specimen is usually adequate for PDL1 testing and molecular testing
D. At least three sputum specimens are recommended
Answer: D. At least three sputum specimens are recommended Explanation:
Option D is correct because it increases specificity
Option A is incorrect because the yield is highest for centrally located tumors (not peripheral) such as small cell or squamous tumors.
Option B is incorrect: it should be specificity of 100%, while sensitivity of <70%.
Option C is incorrect since specimen or tumor cells are usually scars, preventing PDL1 testing and other molecular testing.
Contraindications for curative resection for lung CA
necessitating chemoradiation or chemotherapy instead
Extrathoracic metastases, super vena cava syndrome , vocal cord paralysis, phrenic nerve paralysis, tumor within 2cm of the carina, metastases to the contralateral lung, metastases to the supraclavicular lymph nodes, metastases to contralateral mediastinal node, involvement of main pulmonary artery
For a patient who will undergo first-line palliative chemotherapy for his metastatic lung adenocarcinoma, which chemotherapy agent will you combine with Cisplatin for improved survival?
A. Gemcitabine
B. Pemetrexed
C. Paclitaxel
D. Ramucirumab
Answer: B. Pemetrexed
Pemetrexed in combination with platinum chemotherapy has high activity in adenocarcinomas.
Higher thymidylate synthase is seen in squamous cancer – hence, lower responsiveness to pemetrexed. Activity of gemcitabine is not impacted by levels of thymidylate synthase – thus cisplatin/gemcitabine combination or cisplatin/paclitaxel would be used for squamous histology.
Lastly, ramucirumab in combination with docetaxel is used in the second line setting for squamous or non-sqauamous histologies– not as first line.
Recommended 1st line tx for metastatic thymoma
CAP protocol
Cisplatin, Doxorubicin, Cyclophosphamide
Etiologic factors assoc with esophageal adeno CA
Chronic gastroesophageal reflux
Obesity
Barrett’s
Male sex
cigarette smoking - also risk factor for SCCA
Risk factors for SCCA of the esophagus
Which diagnostic modality is most appropriate to determine the clinical T-stage of esophageal carcinomas?
Esophageal UTZ
Which germline mutation increases one’s risk of developing gastric signet ring cell adenocarcinoma? Patients with this inherited mutation can be considered for prophylactic gastrectomy.
A. RHBDF2
B. CDH1
C. MMR
D. BRCA2
Answer: B. CDH1
Option B, CDH1, causes a specific subtype of gastric cancer: the diffuse or signet ring cell adenocarcinoma histology)
RHBDF2 is the germline mutation associated with tylosis palmaris et plantaris – a syndrome at high risk for esophageal SCCs.
MMR deficiency is seen in lynch syndrome (also increases one’s risk of gastric cancer).
BRCA 2 germline mutations also increases one’s risk for gastric cancer, pancreatic and prostate cancer, but more implicated in male and female breast cancers.
Which genomic result will influence your therapeutic choice when treating metastatic gastric adenocarcinomas?
A. Epstein Barr Virus DNA by PCR
B. MMR protein deficiency
C. CDH1 mutation
D. TP53 mutation
B. MMR protein deficiency
Explanation: For MSI-high or dMMRP gastric cancers, Pembrolizumab is used (currently approved in second line setting)
Determining the EBV, TP53 or CDH1 status of the gastric malignancy does not influence treatment (although, these can be prognostic).
Other genomic findings that can influence treatment include: MSIH and PDL1 result (using pembrolizumab or adding nivolumab to chemotherapy), and Her2 expression or amplification (adding trastuzumab or trastuzumab deruxtecan)
8A patient presents with stage II gastric MALT lymphoma. Upon further testing, the tumor tests positive for H.pylori on histopathology and t(11;18) by PCR. What is the most appropriate treatment for this patient?
A. Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (RCHOP)
B. RCHOP and radiation
C. Antibiotics for H.pylori
D. Antibiotics for H. pylori and Rituximab
Answer: D. Antibiotics for H. pylori and Rituximab
Option D is correct - adding radiation or rituximab is done due to lower response of t(11;18) translocation positive gastric MALT tumors to H. pylori eradication alone (making option C incorrect).
Options A and B (RCHOP+/- radiation) would be appropriate for diffuse large b cell lymphomas
A patient presents with a large, localized gastric mass. Resection was done and histopathology reveals a spindle cell subtype, with a high mitotic count. Further testing reveals positivity for cKIT 11 mutation. Which postoperative treatment option is appropriate?
A. Rituximab
B. Octreotide
C. Sorafenib
D. Imatinib
Explanation: For high-risk GISTs (larger size, higher mitotic index), adjuvant therapy with imatinib for 3 years improves relapse-free and overall survival.
Furthermore, patients with cKIT mutations (especially in exon 11) have good response and median survival with Imatinib
Other options are not indicated as adjuvant treatment for resected GIST
A patient has hepatocellular carcinoma, child-pugh B, ECOG 1, with portal invasion. Which is the most appropriate treatment option for his Barcelona stage?
A. Transplantation
B. Chemoembolization
C. Systemic therapy
D. Best supportive care
Child Pugh A-B, ECOG 1-2 with portal invasion, N1 or M1 = Barcelona C, which necessitates systemic therapy.
Transplantation is for Barcelona A, if a transplant candidate.
Chemoembolization or TACE is for Barcelona B.
Best supportive care is for Barcelona D
What is the most common molecular aberration in hepatocellular carcinoma?
TERT promoter
TERT promoter mutations are common in 56% of HCC tumors.
TP53 mutavons are the most frequent alteravons with a specific hotspot of mutavon (R249S) in pavents with aflatoxin B1 exposure.
While Alcohol abuse and HCV infecvon have been associated with CTNNB1 mutavons.
Which of the following is not a radiologic hallmark of hepatocellular carcinoma?
A. Presence of nodule of any size
B. Cirrhotic liver
C. Vascular uptake in the arterial phase
D. Washout in the portal venous or delayed phases
Answer: A. Presence of nodule of any size
Explanation: Option A should be >1cm; <1cm is unlikely to be HCC, repeat ultrasound at 4 months is recommended.
The other options are radiologic hallmarks of HCC.
Criteria for hepatocellular carcinoma that is eligible for liver transplant according to Milan criteria
1 nodule <5cm, 2-3 nodules <3cm, no microvascular invasion, no extrahepatic spread.
What is your preferred treatment option for a patient with HCC, with a 5cm single nodule, no vascular involvement but with significant comorbidities?
A. Transplantation
B. Resection
C. Ablation or TACE
D. Systemic therapy
Answer: C. TACE.
Size of single tumor precludes transplantation (1 nodule, <5cm in milan criteria).
Significant comorbidities precludes resection. Patient, however, is still eligible for TACE
A patient with HCC has already received two lines of systemic treatment. His latest scans show tumor progression and his latest serum AFP is still >400 (same as baseline). What is your next best treatment option?
A. Regorafenib
B. Cabozantinib
C. Durvalumab
D. Ramucirumab
Answer: D. Ramucirumab
This may be given as a third line treatment, for patients with baseline AFP value of >400, specifically. Other treatment options (A and B) may be given as third line options as well. Durvalumab can be given as first line treatment (not preferred, but noninferior to sorafenib based on the Himalaya trial – NCCN guidelines).
Which classification of cholangiocarcinomas often present with FGFR2 fusions or IDH1/2 mutations?
A. Perihilar
B. Intrahepatic
C. Distal
D. Mixed
Answer: B. Intrahepatic
Intrahepatic cholangiocarcinomas often present with FGFR2 fusions or IDH1/2 mutations. ERBB2/3 amplificavons and SMAD4 aberravons are characterisvc of extrahepavc CCA. Moreover, Perihilar subtypes are the most common type (50-60%)
Which adjuvant treatment for resected cholangiocarcinoma is reported improve overall survival?
A. Gemcitabine
B. Gemcitabine-oxaliplatin
C. Capecitabine
D. Capecitabine-oxaliplatin
Answer: C. Capecitabine
Explanation: Capecitabine, according to the BILCAP trial, can be given in the adjuvant se|ng for in all types of cholangiocarcinoma for improved overall survival
Other agents have no proven efficacy in the adjuvant setting
Which second line treatment for metastavc cholangiocarcinoma is your preferred opvon for pavents without any targetable driver mutavons?
A. Gemcitabine and cisplatin
B. Leucovorin, fluorouracil and oxaliplavn
C. Capecitabine and oxaliplatin
D. Pembrolizumab
Answer: B. Leucovorin, fluorouracil and oxaliplavn (mFOLFOX)
Explanatio: In the second-line se|ng, a phase 3 study randomized pavents who had progressed on cisplavn and gemcitabine (preferred first line for metastavc cholangiocarcinoma) to mFOLFOX (leucovorin, fluorouracil, and oxaliplavn) versus best supporvve care. The chemotherapy regimen showed an improvement in median OS.
Meanwhile, two molecular targeted therapies have been approved in the second-line se|ng in iCCA pavents with IDH1/2 mutavons (ivosidenib) or FGFR2 aberravons (pemigavnib).
Examples of highly emetogenic chemo drug
Dacarbazine
Cisplatin
Cylophosphamide> 1500 mg/m2
Steptozocin
Doxo-Cyclophosphamide
Prevention: Dexa, 5HT3 antagonist, neurokinin receptor antagonit
Baseline lab test to be requested to monitor pneumonitis before giving bleomycin
PFT with DLCO
Age to start screening for mammography
40-provide opportunity
How frequent should mammography be done for screening breast CA
yearly but biennial starting 50 (IJPSTF) or at least 55 (ACS)
How frequent should you screen patients for cervical CA using pap smear
When can you stop screening for cervical CA using pap smear
if more than 65 yrs and with negative prior screening
Age to start screening for colon CA
IJPSTF (50)
ACS: 45- qualified recommendation; at least 50- strong recommendation
How frequent should you screen for colon CA using the ff:
Sigmoidoscopy
FOBT
Colonoscopy
Fecal DNA testing
FIT
CT colonography
Sigmoidoscopy - 5 yrs (5igmoidoscopy)
FOBT- every yr
Colonoscopy - 10 yrs
Fecal DNA testing- 3 yrs
FIT - every yr
CT colonography- 5 yrs
When should you screen for lung CA and what modality should you use?
What screening should be used to screen for ovarian CA
Currently no reliable screening test for the early detection of ovarian CA
When should you start screening for prostate CA
Relationship of high BMI and prostate and pre-menopausal breast CA
inverse
Vinyl chloride is a suspected carcinogen in the devt of what CA
Angiosarcoma of the liver
Chromium is a carcinogen associated with what CA
Lung CA
Phenacetin is a carcinogen associated with what CA
Cancer of the renal pelvis and bladder
Diethylstilbestrol is a carcinogen associated with what CA
clear cell vaginal CA
Benzene is a carcinogen associated with what CA
AML
Aromatic amines is a carcinogen associated with what CA
bladder CA
Imaging modality with has a good sensitivity in visualizing LN and assessing local dse extent for surgery or RT planning for prostate CA
MRI
After radical prostatectomy, PSA should become undetectable in the blood within ___ weeks
6
If PSA remains or becomes detectable after, patient is considered to have persistent or recurrent dse
MOA of Abiraterone
Antiandrogen ; CYP17 inhibitor
Risk factors of breast CA
Risk of developing breast cancer is higher in women with early menarche (<12 years) and late first fullterm pregnancy (>35 years), and it is increased by exogenous hormone replacement therapy
Indications for testing for BRCA1/2 mutations
Any breast CA with triple negative breast CA
< 40 yrs old
Synchronous and metachronous contralateral breast CA
First degree relative with breast or ovarian CA
Personal hx of ovarian CA
Breast MRI should be done for px with high genetic risk and for those with hx of RT to the chest between ages _____
10-30
In premenopausal women, lesions that are nonsuspicious on PE should be reexamined in ____ weeks during the FOLLICULAR phase of menstrual cycle
2-4 weeks
Day 5-7 of cycle –> best time for breast PE
Diagnostic test recommended to evaluate cardiotoxicity of Trastuzumab
2d echo every 3 months but NOT after it is discontinued
When should you give endocrine therapy in an ER PR + patient who is also pregnant
Delayed after the delivery
Which has higher risk of becoming malignant? villous or tubular adenoma?
Villous = 3x as often as tubular
Lynch syndrome is associated with what germline mutation
hMSH2 or hMLH1
Gene implicated in Familial adenomatous polyposis
APC gene; there is deletion in the long arm of chromosome 5
Which has higher risk of developing colon CA? ulcerative colitis or chron’s?
Ulcerative colitis
Stage of colon CA invading muscularis propria but no LN metastasis
Stage II
if meron na lymph node mets, Stage III
Predictors of poorer outcomes following total surgical resection of Colon CA
Location of colon CA that may spread systemically to lungs or supraclavicular LN WITHOUT hepatic involvement
Distal rectum- tumor mays pread through paravertebral venous plexus –> lungs/ supraclavicular LN without hepatic involvement
What should be added to antibiotics for febrile neutropenia if there is no obv infectious site identified and patient remained febrile despite 4-7 days of abx?
Broad spectrum antifungal eg.amp b or newer azoles
Vaccines required priorto splenectomy
PCV 13, PPSV13 , meningococcal , Hib vaccines
Needed FEV 1 if for pneumonectomy for lung CA
> 2 L
if for lobectomy, adequate na and > 1.5L
Examples of ROS 1 inhibitors
Crizotinib, Lorlatinib , Entrecitinib
Si Criz and si Lor nagorder ng Entre-e sa ROStaurant
** Crizotinib and Lorlatinib also inhibit ALK
When is surgery followed by adjuvant chemo indicated in Lung adenoCA
Stage IB >4 cm and stage II and III
Tx of choice for N2 nodes in Lung CA
Combined chemoRT + Durvalumab
N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymph nodes
TX for choice for Lung SCCA or non SCCA with PDL 1>= 50%
Pembrolizumab OR
Atezolizumab
Most effective regimen for SCLCA confined to ipsilateral hemothorax
Concurrent chemoRT
