Oncology Flashcards
Surveillance for Asian man above age 40 with HCC
6 monthly ultrasound
Sickle-cell-anemia: why do they not have splenomegaly?
Meta: rationale
Even mild disease: splenic infarcts from childhood
Sickle-cell disease: sickle trait:
Clinical phenotype
Asymptomatic
Sickle-cell: Stroke prophylaxis
Exchange transfusion
Hydroxyurea takes several weeks to reduce sickle hemoglobin concentrations. Mechanism of stroke in sickle: sickled cells.
90 to 95% of urothelial cancers
Transitional cell
A group of patients with NSCLC have tumors with inversion in chromosome 2 that juxtaposes the 5’ end of the echinoderm microtubule-associated protein-like 4 (EML4) gene with the 3’ end of the anaplastic lymphoma kinase (ALK) gene, resulting in the fusion oncogene EML4-ALK.
This fusion oncogene rearrangement is transforming both in vitro and in vivo.
Rx?
Crizotinib
ALK inhibitor
“ALK-positive” tumors are highly sensitive to tALK-targeted inhibitors.
alpha fetoprotein
- nonseminomatous GCTs
- HCC
AFP is not elevated in patients with pure seminomas.
Bladder cancer biopsy: Quality Criterion
should include bladder wall muscle
Bladder cancer: DxStagingEval
- Excretory urography/intravenous pyelogram followed by cystoscopy
- Retrograde pyelography ( upper tract lesions)
- Urine cytology; brush biopsies may increase the diagnostic yield
- Biopsies of any lesion must be of adequate size to include bladder wall muscle
- CT abdomen: Evaluate for local extension and nodal involvement
- bone scan if bony symptoms
- CXR staging evaluation
Bladder cancer: DxMethod
Excretory urography/intravenous pyelogram followed by cystoscopy
When cancer of the upper urinary tract is diagnosed, there is a _% to _% chance of cancer of the bladder.
When bladder cancer is diagnosed, there is a _% to _% chance of developing cancer of upper urinary tract.
When cancer of the upper urinary tract is diagnosed, there is a 30% to 50% chance of cancer of the bladder.
When bladder cancer is diagnosed, there is a 2% to 3% chance of developing cancer of upper urinary tract.
Exposure to aryl amines increases risk for _ cell cancer, while Schistosoma haematobium infection is associated with _ cell cancer of the bladder
Exposure to aryl amines increases risk for transitional bladder cancer, while Schistosoma haematobium infection usually associated with squamous cell carcinoma of the bladder
Bladder cancer: symptoms
- Hematuria: painless
- frequency, urgency, or dysuria
- Vesical irritation without hematuria: Common in carcinoma in situ of bladder
- Symptoms of advanced disease: Pain from metastatic sites, edema of lower extremities, cough or dyspnea from lung metastases
CA 125
Epithelial ovarian cancer
CA 19-9
Pancreatic cancer
Cancer associated with: membranous nephropathy, MAHA, PAN
Gastric cancer
OpenQuestion -what drives autoimmunity?
CEA
- GI tumors
- Some lung
- Some breast
- Some MCT
Chronic diarrhea after pancreatectomy
Rx
Oral pancreatic enzyme
When should first degree relatives of patients who have colon cancer before age 60 be screened?
40 or 10 years prior to dx whichever is first
Cryptorchidism: risk of testicular cancer is bilateral
True
Majority of testicular cancer in cryptorchid testicles
Pure seminoma
Diarrhea associated with carcinoid and VIP
octreotide
A familial nephropathy of unknown cause that results in progressive inflammation of the renal parenchyma, leading to renal failure and multifocal, superficial, low-grade cancers of the renal pelvis and ureters
Balkan nephropathy
Extracolonic cancer in Lynch syndrome
Endometrial
Febrile neutropenia: low risk vs high risk
Low risk neutropenia: MxL
- Expected duration of neutropenia of 7 days or less
- No evidence of sepsis
- No co-existing conditions (what does that mean?)
- No hepatic or renal dysfunction
Low risk neutropenia:
- No need to admit
- home on ciprofloxacin + Augmentin
ß-HCG: marker for
Germ cell tumor
gestational trophoblastic disease (GTD), testicular tumors, ovarian germ cell tumors, teratomas, and, rarely, other human chorionic gonadotropin (hCG)-secreting tumors
Irregular vaginal bleeding after sex
Cervical cancer
LCIS: ER status
Nearly always ER+
LCIS: Mx
- Surgical excision
- Annual mammogram
- Risk reduction counseling
- Tamoxifen
55 to 74 year old patient with 30 pack year history, currently smoke or have quit in 15 years
Yearly low dose CT
Lynch syndrome
- Autosomal dominant
- Error in DNA mismatch repair system
- AKA HNPCC
- Adenocarcinoma of the proximal colon, splenic flexure
- Amsterdam criteria: all have to be met
Lynch syndrome: lifetime risk of cancer
70%
Malignant tumor: most common men 25-35
Testicular
Morphine dosing rule in palliation
10% of daily total dose every hour (PO) or every 30 minutes IV
Morphine: time to peak effect
30 to 60 minutes
Nonsmoker with metastatic adenocarcinoma: OnDx
Test for EGFR, ALK
If EGFR +ve, erlotinib or geftinib
If ALK+ve: crizotinib
Palliation: morphine failure at high doses
Severe, continued pain in spite of high dose long acting, frequent high dose short acting
Switch to methadone
Post menopausal bleeding + Hx tamoxifen use: Mx
In-office endometrial biopsy
Postmenopausal bleeding: imaging
Pelvic USG, saline sonography
Endometrial thickness < 4 mm has NPV 99% for endometrial cancer
Prostate cancer: castration resistant, metastatic
docetaxel
Prostate cancer: life expectancy < 10 years
- No symptoms: Active surveillance
- Symptoms: Radiation (same efficacy as surgery)
Risk of lung cancer in smokers
(Model derived from CARET study)
- duration of smoking,
- number of cigarettes smoked per day,
- duration of abstinence
- age
http://nomograms.mskcc.org/Lung/Screening.aspx
10 year risk:
- 51-year-old woman who smoked one pack per day for 29 years but stopped smoking 9 years : 0.8%
- 68-year-old man who smoked two packs a day for the past 50 years and continued to smoke: 15%
Suspected ovarian cancer: first investigation?
Transvaginal ultrasound
Tamoxifen: can cause which cancer?
Uterine carcinoma and sarcoma
(Because it has both antiestrogenic and pro-estrogenic effects; can cause endometrial proliferation)
HIT: when does it occur?
Typically 5-14 days after exposure
HIT: Pre-test probability assessment
The score assesses the degree of Thrombocytopenia, the Timing relative to heparin exposure, the presence of Thrombosis, and oTher causes for thrombocytopenia. Points are assigned as follows:
Microcytosis: mild anemia
MCV 60s
Beta-Thal trait
Budd-Chiari: Commonest risk factor
MPN
Myeloproliferative neoplasm
Acute porphyria: FirstTest
Meta: FirstTest
Rapid urine screen for porphobilinogen
Sickle-cell: Acute chest syndrome: Severe:
Rx other than supportive
Exchange transfusion
β-thalassemia intermeda: why are they prone to venous thrombosis?
Abnormal erythrocytes which express prothrombotic phospholipids; activated clotting factors and activated platelets.
Meta: never seen a case
Several reports have described an increased risk of thromboembolic complications in thalassemia [68-70]. In a retrospective series of 584 individuals with beta thalassemia intermedia, thrombosis was observed in 82 (14 percent) [71]. (See “Clinical manifestations and diagnosis of the thalassemias”.)
The mechanisms are incompletely understood. It has been suggested that increased phosphatidylserine (PS) on the outer leaflet of the RBC membrane may promote thrombosis, similar to the role of PS in promoting coagulation on the surface of activated platelets [72]. (See “Overview of hemostasis”, section on ‘Multicomponent complexes’.)
Other hemostatic changes may include alterations in the levels of procoagulant or anticoagulant factors, and/or chronic activation of platelets, endothelial cells, or white blood cells [68]. Splenectomy may also increase the risk of thrombosis [73,74]. Similarity to the increased risk of thromboembolism in sickle cell disease has also been suggested. However, as high quality evidence for the increased risk of thrombophilia is lacking, we manage patients with thalassemia similar to the general population. Further study of this issue is warranted
β-thalassemia: classification-basis
Degree of beta-globin reduction
Beta thalassemia is further classified as:
- beta thalassemia major,
- beta thalassemia intermedia, or
- beta thalassemia minor (also called beta thalassemia trait) according to the degree of reduction in beta globin
β-thalassemia: causes of anemia
- Intramedullary hemolysis
- Reduced RBC survival
Beta thalassemia is caused by one or more mutations in the beta globin gene (figure 1) that result in an imbalanced ratio of alpha to beta globin. This imbalance in turn leads to impaired red blood cell (RBC) maturation and destruction of developing RBC precursors in the bone marrow, called ineffective erythropoiesis or intramedullary hemolysis; as well as hemolysis, with reduced RBC survival in the peripheral blood. The severity of beta thalassemia may also be affected by other mutations that affect the ratio of alpha globin to beta globin, including concomitant alpha thalassemia, hereditary persistence of fetal hemoglobin, concomitant sickle hemoglobin mutation, or concomitant hemoglobin E. (See ‘Imbalanced ratio of alpha to beta globin’ above.)
β-thalassemia: causes of organ damage
Meta: PathophysiologicMechanism
Organ damage in beta thalassemia (renal disease, cardiomyopathy, diabetes) is due to the combined effects of anemia, chronic hypoxia, iron overload, and possibly other disease features such as a chronic inflammatory state. (See ‘Organ damage’ above.)
CGD
recurrent, life-threatening bacterial and fungal infections and granuloma formation. Most diagnosed before age of five years.
Caused by defects in phagocyte enzyme complex which is responsible for the phagocyte respiratory burst.
lifelong antifungal plus antibacterial prophylaxis +/- immunomodulatory therapy
ITP: DxMethod
Meta: DxOfExclusion
Ruling out other causes of thrombocytopenia
The pathogenesis of immune thrombocytopenia (ITP) is related to a combination of increased platelet destruction and impaired platelet production caused by anti-platelet autoantibodies.
ITP: Rx
Meta: FirstLine, SecondLine
- FirstLine: prednisone/IVIG
- SecondLine: splenectomy, rituximab, thrombopoietin receptor agonists or immunosuppressive therapy
GM-CSF: evidence for use during sepsis + neutropenia
Not that great
Granulocyte colony stimulating factors (G-CSFs) have been widely evaluated to minimize the extent and duration of neutropenia associated with myelosuppressive cytotoxic chemotherapy or radiation therapy (RT) for conditions other than acute leukemia, myelodysplastic syndrome, and in the setting of hematopoietic cell transplantation (HCT). Despite their effects on neutropenia, prophylactic use of G-CSFs has not been shown to have an impact on survival in most clinical situations.
Aplastic anemia vs MDS: difference
In Myelodysplastic Syndrome (MDS), there is impaired production of myeloid class of blood cells by the bone marrow whereas aplastic anemia is a condition in which the bone marrow is damaged leading to decreased new blood cell production.
In MDS, the bone marrow produces new blood cells but they are abnormal and deformed whereas in aplastic anemia, the bone marrow stops producing new blood cells.
Read more: Difference Between Aplastic Anemia and Myelodysplastic Syndrome | Difference Between http://www.differencebetween.net/science/health/disease-health/difference-between-aplastic-anemia-and-myelodysplastic-syndrome/#ixzz4eqINRJn6
MDS vs myelofibrosis
- Myelofibrosis: leukoerythroblastic picture
- Myelofibrosis: splenomegaly
MPN: Common MPNs
- CML
- PV
- PMF
- ET
CML = chronic myeloid leukemia; PV = polycythemia vera; PMF = primary myelofibrosis; ET = essential thrombocythemia; IG = immature granulocytes; Megas = megakaryocytes; EPO = erythropoietin
See: http://surgpathcriteria.stanford.edu/mdsmps/primary-myelofibrosis/differential-diagnosis.html
Leukoerythroblastic
Neutrophilia and nucleated red blood cells may also be associated with teardrop shaped RBCs and early granulocytes in the blood, the so-called leukoerythroblastic blood picture (picture 7A-B). This combination suggests the presence of infiltrative marrow disease (eg, myelofibrosis, malignancy, granulomatous disease, inflammation or infection in the marrow itself).
5q minus syndrome
MDS subtype: severe anemia, normal platelet counts, and del(5q)
Approximately 5 percent of patients with MDS present with “5q minus syndrome” characterized by severe anemia, preserved platelet counts, and del(5q) as the sole cytogenetic abnormality. Patients with 5q minus syndrome with or without other cytogenetic abnormalities have demonstrated high response rates to treatment with low-dose lenalidomide.
MDS: Rx
- No standard Rx
- symptomatic anemia and an erythropoietin level >500 mU/mL who are not good candidates for immunosuppressive Rx, azacitidine, decitabine, or lenalidomide
- serum erythropoietin level >500 mU/mL, and a good probability of responding to immunosuppressive therapy, we suggest a trial of antithymocyte globulin (ATG) plus cyclosporin
