Onc Prolog Flashcards
lynch, HNPCC syndrome
- gene association MLH1, MSH2
- AD
- endometrium, ovary, gastric tract, small bowel
- positive screening needs referal for genetic counseling
Li Fraumeni syndrome
- associated with soft tiddue sarcoma
- TP53 associated
- almost 100% get cancer
Cowden Disease
- PTEN association (genes)
- AD
- breast, thyroid, endometrial cancer
- benign mucocutaneous lesions
capacity to make decisison (suggested guideliens)
- communicate choice between treatment optoins
0- undrestand treatment optoins - understand info leading to the decision
- undersatnd consequences of treatment
women who have a 20-25%+ risk of breast and ovarian cancer due to familiar risk include;
- personal hx of BOTH cancer
- peronal hx breast or ovarian and close family member with it (especially males, young family, any family with ovarian, self Ashkenzi and dx 40 yo, or family BRCA+)
women who have 5-10% risk breast/ovarian cancer include those with:
- personal hx breast 40 years or younger
- personal hx ovarian cancer any age
- presonal hx bilateral breast cancer
- perosnal breast cancer 50yo and family breast 50 years old
- personal breast 50 yo, ashkinasy,
- breast cancer any age + two family members Br Cx any age
- unaffected women with family member who meets any above criteria
paraneoplastic syndromes from ovarian disease
- systemtic sx not due to direct efect on local cancer
- cerebellar degeneration, motor/cognitive decline
- anti-Yo preogressive cerebellar degeneration most commonly with ovarian and breast cancer
GTN WHO scoring
review the photo for a general idea
pharmacologic ppx anticoaguation preferneces in surgery
- LMWH better than unfractionated heparin for surgery
- LMWH better beacuse daily dosign (not BID), predictable pharmacodynamics, greaster anti-factor Xa activity, less thrombin activity, reduced risk of thrombocyotpenia
risk factors for PE well criteria and imaging to dx
- clincal s/sx PE
- PE more likely than alternative idea
- HR > 100
- immobilization greater than 3 days
- surgery in last four weeks
- previosuly had PE/DVT
- hemoptysis
- cancer
CT angio is how you diagnose for everyoene (not ddimer, VQ scan etc)
tamoxifen
- used for anjunctive breast cancer treatment or ppx for women at high risk breast cacner
- affects endometrium by increasing estrogen at that site
- asymptmatic women on tamoxifen do not need uterine surveillance (not helpfuL)
- symptomatic women REGARDLESS OF ENDO THICKENESS need yearly endometrial biopsies
- increas your risk for endometrial cancer 2-3x
women >30yo with breast mass need what work up
- diagnostic mammogrpahcy
- (MRI only helpful in women with breast implants, very dense breast tissue, lots of breast scaring from prior surgery)
gas embolism
- risk of LSC surgery
- sx include: dropped BP, end tidal carbon dioxide, SaO2
- sx also include: tachycardia, cardiac arrthymias, hyptension, icnreased central venous pressures, cyanosis, right heart strain
- Capnography is better than oximetry
- caues decareased cardiac output due to righr heart issues and vena cava issues, can cause cardiac collpase
- first you reduce all pneumo
- place in steeper trendeleburg
- turned to left side (all prevents gas embolis from getting into pulmonary system
- hyperventillate them
- mill wheel murmur classic for gas emolism
bowel obstruction with cancer
- SBO needs NG tube (often has vomiting)
- colonic obstruction look severely ill and needs treatment to avoid perforation (there forms a closed loop and gas cant’ go anywere)
- if palliative care underway, don’t want to have recovery time wasted after surgery, therefore endoscopic stenting is preferred to shit bag.
necrotizing fasciitis symptmos
- exquisitely tender (due to nerve death), erythematuous, edemtous (woody), watery dish water coming from incision after CS
- also with systmeic fever, tachycardia, relatively low BP
- risk factors include poor healing set up: diabetes
- fascial necrosis is a hallmark of the dieases
- dont need CT for this eval, take to OR for debridement (but CT findings would include gas). Large abdominal wound afterwards, can close by secondary intention wtih vaccum
- fatal in 25% of cases, need to act fast. Go until get to bloody good tissue.
- polymicrobial: clostridium, group A step, staph aureus,
non-cancer breast diagnosis
- non-profilferative: fibrocystic changes, fibrocystic disease, chronic cystic mastitis, mammary dysplasia and breast cysts. NTD
- proliferative breast lesions WITHOUT atypia: ductal hyperplasia w/o atypia, intraductal papillomas, sclerosing adenosis, radial scars, fibroadenomas. Slighty 1x risk icnrease in breast cancer. NTD.
- proliferative lesions: atypical ductal hyperplasia, atypical lobular hyperplasia. Can increase surveillence, but otherwise nothing to do.
gynecological hemorrhage
1000mL QBL or any QBL that requires transfusion
hcg levels in peri/postmenopausal women elevated <14
- can just be a weird thing that happens
- suppress with OCPs, shoudl go down, and then recheck hcg levels
ovarian cacner with bowel involvement: surgical extent
- go for complete resection with bowel resection. increases survival significantly and risk of mortailyt from surgery is acceptably low (5%)
AGC finding on pap requires what additional testing
- ECC, colpo if <35
- if >35 then ECC and Embx and colpo
when to pause chemo treatments based on lab values
Granulocysts
- day of therapy <1500
- cycle nadir <1000
Platelets
- day of therapy <7500
- cycle nadir <50,000
psuedomyxoma peritonei
- jelly belly
- associated with appendix tumor (not ovarian)
- occur because shit in the appendix accumulates and then bursts adn goes all over the bdomen
- these are mucous producing cells that repliate
- they spread to the ovary for some reason
anemia panel findings and meaning
- normal MCV: normal B12 and folate
- ferritin stores: iron related
*note that EPO and associated meds (darbopoein) are contraindicated beause of an association of cancer progressoin
some immunostaining markers to help tell cancers apart: CK7 KRT7 CA 125 PAX8 WT1 KRT 20 CK20 CEA CDX2 Vementin
SErous ovarian tumors CK7 KRT7 CA 125 PAX8 WT1
Gatsrointestintal tumors KRT 20 CK20 CEA CDX2
negative vinmentin: no endometiral or ovarian
palliative care and has bowel obstruction, what do you do?
- percutaneous endoscopic gastrotomy tube placement. This is done with minimal sedation and fixes n/v
- doesn’t need surgery too invasive
- TPN doens’t make a person not feel hungry and doesn’t stop the nausea from a blockage.
germ cell tumors
including immature teratomas
- germ cell respond very well with chemo (bleo,etopo, ciplatin)
- grade 1 immature teratomas only need removal though, and only need chemo if they are Stage 1A grade 2 or 3
SE of
- bleo
- etoposide
- cisplatin
- bleo: pulmonary
- etoposide: hemtoogic malignicnacies
- cisplatin: neuropathy and nephropathy
hyperkalemia
- risk with ACE - I increase
- risk with kidney issues
- EKG shows QT shortening
- treat with calcium to stabilize cardiac activity
- shoudl be hsopitalized, this needs to be managed aggressively
fibroids wtih undetermined malignant potential needs waht fu
- surveillance if had myomectomy. unliekly to actually be cacncerous
- no fu if had h ysterectomy
- cancerous fibroids have usually coagulative necrosis, 10+ mitoses per 10 high power fields, significant nuclear atypia
cisplatin antiemetic best
- zofran (5-HT3 antagonist) + dexa
sruveilleance after hyst for endo cancer
- PE, assessment of symptoms
prediction models for breast cancer include what
- age by a long shot is the most critical
- size of lesion
– note lymphaticvascular isn’t included. This is somehow different than nodes.
anal pap for women with what commorbidity
HIV (anal sex practices dont maek the cut)
types of endometrial cacner
Type 1: adeno
- younger
- estrongen related
- PTEN, DNA mismatch repair, B-caton, KRAS associatied
- lower stage at presentation, better prog
Type 2
- serous, poorly differentiated adeno, clear cell
- older
- unrelated to estrogen
- TP53 related
- later stage on presentatin, worse prognosis
tamoxifen vs aromaste inhibitors
TAMOXIFEN
- used for estrogen + breast cancer up to 10 years
- antiestrogen at breast, pro estrogen at bones and endometrium, also overall increase in estrogen therefore risk for VTE
- used wth PRE and POST meno pausal women with estrogen + breast cancer AND with women at high risk for breast cancer for prevention
- symptoms: POSTMENOPAUSAL SYMTPOMTS somehow…hot flushes,vaginal dryness, decreased libido, thin vaginal discharge
- going to be osteopenia protective
AROMATASE INHIBITORS
- only POST menopausal women
- block enzyme aromatase, so lowers overall levels of estrogen
- SE: POSTMENOPAUSLA SX
- also have joint and muscle pain (tamoxifen doesn’t)
- going ot have bone loss
colon cancer screening
- best optoin is colonoscopy
- ## can treat polyps and screen for malignancy at same time
ovarian chemo for
- all comers
- suboptimally reduced
- recurrent
- optimatlly reduced
- all comers: platinum based chemo
- supoptimally reduced: carboplatin/paclitaxel
- recurrent disease: caroplatin/doxyrubicin, carboplatin/gemcitabine
- optimally reduced can consider: IP (intraparitoneal) paclitaxel/cisplatin
**IV cisplatin/paciltaxel is old school and will likely not be a correct answer choice ever
risk factors for breast cancer
- AGE
- (genetic markers)
- then BMI later
ovarian cancer risk factors
Age Endometriosis family hx braest/ovarian cancer BRCA mutations early menarche late menopause mulligravidity infertility (but not infertility treatment) `
Bowel prep
not helpful
other name for internal iliac
hypogastric artery (ligate this if bleeding is out of control)
Cervical cancer staging and treatment
- Stage 1: cervix onl
- Stage 2: outside cervix but not extending to pelvic side walls or lower 1/3 of vagina
Treat Stage
1A1: Cone (microscopic)
1A2-1B: radical hyst vs rad trachylectomy vs radiation
vulvar lesion: slwoly growing, brown, raised,
1cm size, 1.5 from urethra
punch biopsy: basal cell carcinoma
- just basal cell carcinoma of skin, on vulva
- treatmetn: wide local excision, need negative margins 4-5mm
- no LN dissection
- (don’t want laser beacuse you dont’ get a path speciemn, margins, etc)
cergvical cancer screenign for LN invovlement
- no requried for staging, but useful for treatment where abliable
- cerfvical cnacer is clinical diagnosis including (history, PE, cystoscopy, proctoscopy, limited radioogy studies which could include IV urography, XCRAY lungs/bones)
- ## PET CT scan best for LN assessment
standard pap smear guide lines
<21: none
21-29: pap q3y with reflex HPV
30-65: cotesting q5y
65y: stop if no prior CIN 2/3
ovarian cancer looks like
- ascities
- pelvic pain/presure
- urinary frequency
endometriosis is assocaited wtih hat types of gyn cancer
- endometrioid ovarian cancer
- clear cell ovarian carcinoma
- overall increased for ovarian cancer as well (but survivial improved with hx endometriosis)
- related to downregulation of TDGF1
soemthing that reduces functional residual capacity
- lung parameter
- functional residual capaciy is what is left over after passive exhale (before froced exhal)
- with reduced, causes hypoxia
- plus trendelneburg does it
- BMI
_ lung conditions dont all do this, example:
COPD: increased functiona residual capacity because lungs can’t get small again
small cell tumor of the cervix
- neuroendocrine tumor of the cervix
(cervix MC cancer squamous, second is adenocarcinomas, then third is everything else) - TREAT with cisplatin-etoposide
- early stage: surgical (rad hyst, PLN out) + ajuvant chemo
- 1B tumors need systemic chemo
32 yo bmi 51, trying to lose weight grade 1 endometrial adenocarcinoma no mets seen on scans wants fertility --- what do you do next?
hormonal suppression taht wont increase wieght gain: IUD mirena
note surgical resection isn’t studied for this use
post exposure HIV treatment
- emtricitabline, tneofovir, raltegravir
- start now and continue for 28d
- need to prevent stpread to yoru partner if you actually got it, 6-12w condomes
- GTN contraceptions afterward for 6m is best doen by __. Also - what labs are part of the work up
- what is survillence pattern
- OCPs (beacuse you want to interpret the hcg levels)/ This is used cause this was studied, other methods weren’t studied
- CBC, T&S, Rh status, liver, renal, coagulation labs, CMPhcg, CXR, D&C wil likely be done to evacuate uterus
- after DC, weekly hcg, 3 weeks of normal range > mothly for 6 months
- woman with IIB squamous cell cancer cervix
- recurrent cancer, with symtpoms now again
- on chemo currently
- liver malfunctino assumed
- what do you do next? ____
palliatve care
- dont want to biopsy etc
mesh hernia repair
LSC vs LAP
LSC is fine if <10cm
salvage threapy after ovarian cancer recurrence
- is not curative
- regimen is carboplatin and doxorubicin
radiation cystitis
- raditation field includes bladder adn distal ureters
- short term problems are inflammation and edema : increased urgency, frequency, dysuria and nocturia (self limited)
- late radiation effects: 6 months afterwrads to years afterwards, extensive intersittial fibroisis, scloerosis of conenctive tissue, can lead to necrosis and fistual. visually will have vascular telangiectasia which can cuase hematuria
- most common long term effect is hemorrhagic cystitis
- can be so extensive that you can need transfusions
- intraperitoneal adjuvant chemo
- most sign risk factor for IP catheter is ___
- left colo-sigmoid (rectosigmoid) resection (because it’s palced at the time the shit is rolling around the abdomen)
- need interval placement if you want to avoid infection
- resection of other things didn’t create infection risks the same
surveilence of endometrial cancer
- History and PE
- most recurrenct cancer will have bleeding symtoms
when shoud you intube
- when they are unstable, when they are on pressers
- low spo2
- increased RR
- vomiting new onset
- less than 90 despite supplemental oxygen
- acute hypercarbia (pH is going to drop below 7.2
- increased work of breathing
- inspiratory msucle weakness
- acute decompensated heart failure (jugular venous distention, pulmonary edema, decreaed EF)
- inadequate lung expansion (RR 35 or more)
vulvar cancer palpible node means what regarding LN dissection
- i think it means you need all nodes removed beacuse sentinal node wont’ be hlpful cause the die can’t get passed that inflamed node
DCIS
- non-invasive cancer that doesn’t cross the basement membrane
- treatment mastectomy vs lumpectomy&radiation
- never do chemo because it’s local disease
- some want to consider lumpectomy alone without radiation to follow. Okay to consider for pt’s with large margin (>3mm), small lesion 2.5cm.
nerves damanged during surgery
- pudendal (S2-4) (vagina surgery during sacrospinous ligament suspension)
- femoral (L2-4) (compression from freestanding
- genitofemoral (L1-2) LN discetion (numb or pain over labia and medial thigh)
- linioinguilnal (L1-2) transverse incision, trochar insertion (will burn over suprapubic area)
- obturator (L2-4), LN dissection, placement of transobturaor tape
digital film mammography
- digital for dense breast tissue, young women
- mammo scrennign at 40yo
- MRI for epopel with personal hx of breast cancer or really big list
methadone
conitue pp or post surery and give them narcotics as well
CAM is good for what?
emesis
cervical cancer and pregnnacy
- CIN1 coplo (look) and leave alone until pp
- CIN2/3 colpo/pap, leave alone until pp (bring them back in 12w)
- if looks invasive, then biopsy
- diagnosiztic conizatino only for invasive cancer confirm, or you can postpone until pp
port site mets possible when
- when you do LSC, but it’s also associated jsut with advanced dieases, so go ahead and do the LSC
LMWH cancer pt with a midline incision… how long
4w
pelvic irradiation complications
- radiation enteritis secondary to adhesions, inflamation around the terminal ileum and proximal colon
- BRCA and HT after removing BSO risk prevention
- women with hx Breast cancer
- okay. 1st line. (need progestin if uterus in place)
- never give HT
ppx ovarian cancer
- BSO
- if this doesn’t want or needs fertility then do OCPs
greatest risk for lymphadenctomy is ____
- lymph node resection + radiation
GTN treatment
- low risk: signel agent chemo (no mets) – dactinomycin or methotrexate
- high risk: dual agent chemo
surgical prep better:
- chlorhexidine- alchol (better than idodine)
- hair clipping doens’t matter for infection
common nephrotoxins include
NSAIDS, ACE-I, ARBS, amnioglycosides, radioconstrast agents, diuretics
