Oncology Flashcards
Colon CA
MCC gastrointestinal CA - 60K deaths/yr
Age>50
Diet rich in fat, red meat, sucrose, born in west
Pelvic irradiation
UC/Crohns >8yr (colonoscopy now then q 2yr)
1st deg relative with colon CA
h/o other CA (breast, ovarian, endometrial)
Familial polyposis (gardners, familiar adenomatous polyposis)
Hereditary non plyposis colono CA (HNPCC - lynch)
Adenomas - colon CA (hyperplastic polyp no malignant potential)
Decreased r/o colon CA
non-smoker NSAID ASA >20yr Celecoxib/sulindac Ca, folate, estrogens
Familial Adenomatous polyposis
Fhx adenomatous polyposis and CA
Mut of APC gene 5q
hundreds polyps before age 16
95% cancer
colectomy indicated before malignancy begins
Sigmoidoscopy age 12-16 then colonoscopy q yearly - if any polyps - colectomy
Gardner syndrome
Adenomatous polyps invovling colon
95% cancer
extraintestinal manifestation - osteomas mandible , skull, soft tissue, thyroid adrenal
Colectomy before malignancy begins
Sigmoidoscopy age 12-16 then colonoscopy q yearly - if any polyps - colectomy
HNPCC (lynch syndrome)
3 relatives with Cancer related to HNPCC one 1st deg 2 generations 1 extracolon CA FAP excluded
Adenoma Colonoscopy screening
Hyperplastic polyp - q10yr
Adenoma < 1cm x1 - q5-10yr
Adenoma <1cm 3 Q3yr
Villous adenoma - regardless of size q3yr
Colon CA screening
1st deg relative colon CA age 10
colonoscopy standard time (age 50 then q10yr
Two 1st deg relatives colon CA
colonscopy now then q5yr
Peutz-Jeghar’s syndrome
hemartomas of small intestine
Pigmented lesions on skin, lips, mouth
Juventile polypossi: hyperpalstic polyps in colons - p./w GI bleed or inussusception
Tx: colonoscopy
HNPCC (hereditary non-poyposis colon CA - Lynch syndrome
Automsomal dominant At least 3 relative with colon CA One 1st deg relative 2 generations with colon CA May have extracolonic CA At least one relative <50yo with colon CA
50yo F with HNPCC had colon CA done - adenomatous polyps - wtd?
TV US for uterine CA (extracolonic CA)
55yo M asx for routine checkup - fecal occult blood test neg (FIT) - signmoidoscopy => polyp
If bx= hyperplastic polyp wtd? FIT 1yr, sigmoidoscopy q3-5yr, or double contrast barium enema q5yr If bx=adenoma wtd>? Full Colonoscopy If bx=AdenoCA wtd? Full colonoscopy
55yo asx M routine checkup - sigmoidoscopy - neg - FIT +
Full colonoscopy
Male or postmenopausal femail with unexplained IDA - wtd?
Colonoscopy
Elderly pt with hematochezia, h/o hemorrohids wtd?
Colonoscopy
Pt on routine health maintenance exam FIT 1 out of 6 cards + occult blood - pt takes high doses of vit C
Colonoscopy
55yo F screening colonoscopy done - 2 polyps removed - both hyperplastic - when next colonoscopy
10 years
Pt with 2 adenomas <1cm removed when repeat colonscopy?
colonoscopy q5-10yrs
Pt with tubular adenoma 1cm - next colonoscopy?
3 years
Pt tubular adenoma 2.5 cm next colonoscopy?
3 years
Pt with 3-10 tubular aenoma <1cm next colonoscopy
3 years
Pt wit h1 villosu adenoma <1cm next colonscopy
3 years
Pt with obstructive colon CA with colonic resection wtd?
Full colonoscopy to r.o other concomitant lesions
Pre-op colonscopy with no other lesions
colonoscopy 1 yr then 3 years then q5yrs
measure CEA q3 to 6 mo for 2 years then q 1yr x 5 years
Best dx test r/o colon CA?
Colonoscopy with bx
When to stop colonoscopy screening?
75yo D/c mammo 75yo D/C pap smears - 65 Hep C screening 1945 to 1965 LDCT screen for smokers up to age 79
Familial Adenomatous Polyposis (FAP)
Sigmoidoscopy q1-2 yrs starting at age 12
HNPCC
start colonoscopy 25yr or 10 years younger than youngest affected relative with HNPCC - then q2yr up to age 40 then q1yr
If 2 first deg relatives or 1 first deg relative with colon CA before age 60 when to screen?
40 years or 10 yrs younger than youngest affected relative (whichever younger) then q5 yrs
If 1 first deg relative with colon CA after age 50 or 2 2nd deg relative - when to screen?
40 years FIT + sigmoid q3 to 5 years starting at 40yo or colonoscopy at least at age 40 then q10 years
General population colon CA screening
50 yo (AA 45yo) - FIT/signmoidoscopy q3-5 yr or colonoscopy at 50 then q10 yrs
Post colonic resection for Colon CA
Colonoscopy 1 yr after resection then 3 yrs then q5yrs
UC, Crohns’s dz
Colonoscopy 8yrs after dx then q1-2 yr
Colon CA 1st deg relative
Colonoscopy 10 years before age of dx of 1st deg relative then q5 yr
35yo asx - father with colon CA 45yo
Colonoscopy now then q5yrs
40yo asx father colon CA age 60, brother age 52
Colonoscopy now then q5yr
35yo asx father colon CA age 65
FIT+Sigmoidoscopy q 3-5yr or colonoscopy q10yr starting at age 40
25yo asx - family h/o HNPCC
Colonoscopy now then q2yr up to age 40 then q1yr
Pt with UC dx recently
Colonoscopy 8yrs after dx then q2yr
Pt with Colon Ca Duke B underwent resection of colon
Colonoscopy in 1 yr then 3 yrs then q5yr
50yo asx - neg fxhx colon CA
FIT + sigmoioscopy q3-5 yr, colonoscopy q10yr
Young pt with h/o familial adenomatous polyposis
Colonoscopy age 16yo
40yo asx father colon CA afte 55
Colonoscopy now then q5yr
37yo M father colon CA afe 65, brother colon CA age 50, aunt uterine CA age 48
HNPCC (microsatellite mismatch repair gene MSH
What does tamsulosin cause?
Floppy iris syndrome!
d/c tamsulosin
Acute afib chemical cardioversion
ibutelide
Colon Cancer Duke A
90% survival - thru submucosa but not past muscularis
tx - resection
Colon Cancer Duke B1
90% survival thru muscularis but not past serosa (no LN)
tx - resection
Colon Cancer Duke B2
60-80% survival - thru muscularis into serosa not into LN
tx resection +5FU+leuovorin + oxiplatin
Colon Cancer Duke C
60-80% survival - thru serosa and involving LN
tx : rsection +5FU+leucovorin+oxiplatin
Colon Cancer Duke D
7% survival - Widespread metastasis (liver)
Tx: resection palliative, 5FU leucovorin+I’tecam/B’zumab
When to rsect soitary liver metastasis
If have pursued curative intent in past
Pt with colon CA undergoes hemicolectomy - histopathology with infiltartion of musularis but not serosa wtd?
Observe
Pt with colon CA with hemicoloectomy infiltrating serosa wtd?
Chemotx (5FU + leucovorin + Ox
Pt with colon CA not infiltrating sera but 4/10 LN invovled - after hemicolectomy wtd?
Chemotx (5FU +leucovorin + ox)
Pt with stage B2 rectal CA - local resectio done - wtd?
Chemotx + RT
Anal Ca - cancer of anal margin how to treat?
Local resection
Cancer of anal canal muscosa wtd?
ext beam radiation tx + 5FU + mitomycin
Breast Mass suspicious mass w/u
Re-examine in 6 weeks mid cycle Mass dissappears - do nothing Mass persists - mammogram If young woman stright to US If older woman if + then excision bx/intraop bx If indeterminant/neg -> US If solid - FNA with bx - if neg then excisional bx If mixed echo FNA + bx if neg -> excisional bx If cystic then FNA bx
Risk factors for breast CA
Highest risk Female >50yo Personal hx breast CA strong Fhx pre-menopausal breast CA BRCA 1/2
High risk Any 1st deg relative with breast CA personal h/o ovarian or endometrial CA late preg nulliparous dense breasts
Moderate risk Early menarch Late menopause OCP>15 yrs etoh obesity
Breast CA screening
Women >50yr or <5-10 yrs prior to age of breast CA in 1st deg relative then q2yr
10% breast CA found on PE missed by mammo
BRCA1/2 5-10%
BRCA1 chrom 17 - breast, ovarian ca in woman, prostate CA in men high, high penetrance - make family members aware
BRCA 2 - Chrom 13
BRCA 1 testing recom with pt with strong fhx breast AND ovarian CA
Local breast diseas in situ (all w/in basement membrane)
tx - lumopectomy + RT or mastecotmy
tamoxifen (pre-menopause)/aromatoase inh (post-menopause if ER +
Lobular CA in situ
observation or if ER+ -> tamoxifen (pre)/aromatase (post menopause)
Infiltrating ductal CA LN neg
wide exceision of mass + RT
Adjuvant chemo for size >1cm
Tamoxifen/aromatase inh if ER +
Infiltrating ductal CA LN + pos
wide excisition + RT = modified radiacl mastectomy + adjuvant chemo + tamoxifen /aromatase inh if ER +
Locally invasive dz involving skin or chest wall
chemotx followed by mastectomy + tamoxifen/aromatose inh if ER+
Most important prognostic factor in breast CA?
LN invovlement>tumor size>receptor+>grade
Adjuvant therapy for LN+dz
Premenoapuse - ER+ -> chemo + tamoxfen
ER- chemotx
Post menopause - ER+ -> chemo + aromatase inhib
ER= - Chemotx
Adjuvant therapy for LN neg dz
premenopausal - ER+ tamoifen, ER- none
Post menopausal - ER+ aromatase inhib, ER- none
When to use chemo tx in breast CA
Tumor size>1cm, high grade
if <1cm NO CHEMOtx
Types of breast CA
Intraductal 80%
Lobular 10%
Other 10%
Excision of mass with free margin +RT =
Modifeid radiacla mastectomy + RT
If sentinel LN bx +
Further LN dissection
If sentinel LN bx neg
no further LN dissection
If LN + (rct)
Adjuvant tx - Chemo + tamoxifen (pre), aromatose inh (post)
tamoxifen/aromatase inhib used also?
LN neg ER+ (decreases rate of recurrence of breast CA)
37yo F fhx breast CA mother 65yo sister h/o breast CA 35yo - most important risk factor for pt to get breast CA?
Family hx breast CA
65yo F fhx breast CA mother 67yo - most important risk factor?
Her age
Highest risk fo rbreast CA
early menarch, late 1st preg, late menopause, strong fhx no deodorant
Pt with breast CA, 1st deg relative with breast and ovarian CA dx?
BRCA 1
Young female with BRCA 1 in screening
Mammo screening now (start 25-35)
50yo F regular checkup - best way to screen for breast CA?
clinical breast exam and mammo annually
How to screen for breast Ca in woman with breast implants
mammogram
Mammogram best in woman who is…
post menopausal
40yo F p/w new onset thickening of LU and outer breast in shower no fhx breast CA - menstruating - exam diffuse nodulatrity in both breasts - comes back mid cycle and persists - Mammo no CA or dominant mass wtd?
US and FNA
Pt US with mixed echo - FNAB no malign - wtd?
excisional bx
50yo Dx with breast CA - most important prognostic factor
LN status
35yo F 1.5cm mass
Excision bx with infiltrating dutcal CA margins free of CA - Axillary LN neg, ER+ does not want mastiectomy wtd?
RT with adjuv chemo and tamoxifen x 5yrs
63yo F lump in breast - lumpectomy done reveals infiltrating adenoCA with free margins - axillary LN+ ER+ adjuvant chemo administered
Radiotx + aromatase inhibitors
59yo F painful breast - RUO breast painful red thickened area 7cm no nipple d/c no LM warmth+ mammo no mass dx?
Inflammatory breast CA
Pt s/p breast LA tx RT, surgery chemo p/w lymphedema R arm best managmement?
lymphedema
Tamoxifen
decreases r/o new breast CA - effective for tx metastatic brast CA - works only if tumor ER/PR+ - both estrogenic and anti estrongic effects Anti-estrogenic - anti breast tumor Menopausal sx (tx with SSRI) Estrogenic effect - inc r/o endometrial CA 3x inc bone density inc thromboembolic risk/PE ALSO CAUSES HYEPR CA If erum Ca <14 - c/w tamoxifen
35yo Pt dx breast CA - pt asks how to dec r/o breast Ca in her?
Tamoifen
Post menopaual F with breast Ca after surgery RT and adjuvant chemotx ER+ wtd?
aromatoase inhib (letrozole, anastrozole, exemestane)
54yo F dx’d with infiltrating ductal CA LN 3/15+ pt with breast conserving sx +RT+chemo+tamoifen - likelyat risk for…?
Endometrial Ca
Pt with h/o breast s/p chemo and chemo/tamoifen 6 monthss ago - p/w polyurea, dry mucus membrane fatigue, lethargy - etio?
HyperCa
Pt with breast Ca and tx’ed as abv - wtd?
Ask for GYN sx every visit
Pt started o ntamoxifen 20mg po daily 3 years later with vaginal bloody d/ no other complaints excesept hot flashes - mammo and pap neg wtd?
Endometrial bx
Pregant women with breast Ca
treat like regular pt - surgery in 2nd to 3rd trimester - chemo tx 3rd trim
Male breast CA treated simlar to femail breast CA
Long term complication aromatase inhibitors?
osteoporosis
Best managment hot flashes from tamoxifen or aromatase inhibitors?
SSRI
Pt p/w nipple d/c - eczematous scaly lesion at nipple - preg test neg prolactin normal dx?
Pagets disease o fbreast
Tx - local wide srsn - if no mass
Treast as breast Ca if underlying
Pt h/o breast Ca s/p lumpectomy and chemotx 5 yrs ago p/w pain in hip xray hip 3cm lytic lesion - X ray LS normal wtd?
MRI LS spine
What is first sx of epidural compression fx?
Pain (NOT loss of sensation)
60yo F breast CA, s/p resected ER/PR+ chemo and aromatase inhib’s started - current meds ACEi, BB, lasix urinating more frequently - labs normal except Ca 11.2 - next best management?
Bone scan
THE LEADING solid tumor causing HyperCa+ is breast CA
65yo F dx with infiltrating ductal CA - lumpectomy with free margins, radiotx and adkuant chemo - 6 months after RT hre for f/u - exam neg for mass. LN, no compaints - mammo neg wtd?
Mammogram yearly
Pt s/p matectomy fo rbreast Ca with metastasis on increasing meperidine for pain control - is lethargic, dec’d responsiveness - pulis non-reactive diplopia, tongue dev to right absent gag - absent left ankel reflex - urinary retention + - CT brain no parencymal lesion dx?
Leptomeningeal spread
Pt with metastatic breast Ca ER neg HERR (Her2neu) rct + best med ?
Trastuzumab (herceptin)
34yo with breast lump excised -> fibroadenoma - GM with hx breast CA wtd?
repeat mammo at age 50
65yo M on spironolactone for ascites p/w one sided breast mass
bx
Endometrial Ca
Risk factors Obestity Early menarch late menopause Nulliparity Tamoxifen use P/w post menopausal bleeding
Obesity associated cancer
Endometrial Ca
Bariatric surgery comoplications
Opthalmoplegia - thiamind ef
Dark urine - no RBCs rhabdo
Tachycardia low grade fever - suture leak - gastrograffin study
Copper def - anemia, thrombocytopenia, leukopenia
Cervical CA
Pap Smear
Screening age 21-65 every 3 years
Only HPV screening after age 30 (before 80% chance clearing virus)
For women above 30 - pap smear with HPV DNA neg - pap q5yr
Don’t do HPV DNA in whom?
<30yo (unless Pap abnormal)
High risk patient pap smears
q1yr
Stop PAP at age?
65yo
Pt with warts -
30yo With primary PAP -
If ASC-US and HPV+ -> colposcopy
If ASCUS+ and HPV neg -> no colp, repeat pap 1 yr
If ASC neg and HPV + > no colp, re;eat pap and DNA in 6-12 months
24yo F vaginal d/c - Pap shows clue cells and some AS-CU - ?
bacterial vaginosis
tx: metronidazole
24yo F pap with AS CUS wtd?
HPV test - also give vaccine HPV
22yo F with AS-CUS HPV 16 still give vaccine?
Yes
What pt contraindicated for HPV vacc?
preg patient
50yo pt with h/o fibroids - 2yrs ago fibroid size 2cm - repeat size 3cm no menorrhagia - best managment?
Reassess in 1 year
If still there 3 yers later post menopause with bleeding - bx
Pt hysterectomy for sever fibroids - post hysterectomy do you need PAP?
If uterus/cerix removed for benign reason - NO
If uterus remove for malignant CA then yes bx
Pt with lesion in endocervical canal wtd?
bx
PT with pap high grade SIL - colposcopic bx confirms CIN III wtd?
cryotherapy, con bx if endocervical canal invovled or hysterectomy
Pt with invasive cervical CA wtd?
Hyperectomy or RT with chemo
Ovarian CA
leading cause of GYN CA - most p/w advanced stage
General screening NOT recommended (no pelvic US, CA 125, OCP dec risk of ovarina CA)
Pelvic US of pt with dermatomyostis or strong fhx ovarian + breast Ca
CA125 used in monitoring dz
Tx: surgical staging and debulking of tumor with salpingooophroectomy, hysterectomy omentectomy -> chemo (paclitaxel)
Pt with abdominal distension - US shows serous semi solid 6cm sep mass in R pelvic area CEA elevated - wtd?
CT scan to loclize tumor before laparoscopy