Oncology Flashcards
NEJM+ Questions
35 y/oF, mom diagnosed w/ colon CA at 48, when should she start getting screened?
Screening colonoscopy at age 38
-w/ first degree family member w/ colon CA start screening at 40 or 10 years before index case
Acral lantiginous melanoma
(a) Big difference from other types of melanoma
(b) Common location
(a) Most common type of melanoma in dark skinned ppl b/c it is the only subtype not associated w/ extreme sun exposure
(b) Palm, soles, nail beds (periungal pigmentation)
Age range for lung cancer screening
55-74 yoa w/ at least 30 pack years who quit within the past 15 years
39 y/oM w/ R sided colon CA, strong FHx of early endometrail cancer
Most likely syndrome?
Lynch syndrome (hereditary nonpolyposis colorectal cancer = HNPCC) = mismatch repair mutation
-MC cancer associated w/ Lynch syndrome that isn’t colon CA is endometrial CA
Distinguish Lynch syndrome and Li Fraumeni syndrome
Lynch = HNPCC = mismatch repair mutation
-colon CA and endometrail CA
Li Fraumeni = mutation in tp53 (tsg)
-breast cancer, sarcoma, brain, adrenal tumor, leukemia
During what kind of cancer treatment can EPO be used for chemo-induced anemia?
Only in palliative- b/c EPO has been associated w/ increased mortality in pts receiving chemo/radiation
Tx of malignant hypercalcemia (ex: cancer pt p/w nausea/vomiting found to have Ca 16.2)
(a) 2nd line for refractory
Hypercalcemia of malignancy treatment: IV fluids, lasix (loop diuresis), IV bisphosphonate, and calcitonin
IV bisphosphonates = zolendronate and pamidronate (while alendronate is only oral)
(a) Denosumab = monoclonal antibody against RANK-ligand to inhibit osteoclast breakdown of bone
Indication for cinacalcet
Cinacalcet (sensipar) used in secondary hyperparathyroidism- calcium receptor agonist to increase calcium receptors to serum Ca and therefore decrease PTH levels
ex: Pt on HD, has super high PTH due to low Ca levels from low active vitamin D
First line pharmacologic therapy for smoking cessation in 51 y/oF w/ h/o seizures
- varencicline (chantix)
- nicotine patch + lozenge
buproprion contraindicated given seizure history
Pt w/ metastatic GI stromal tumor with a KIT mutation
First line tx?
Imatinib (Gleevec) = tyrosine kinase inhibitor
Advanced inoperable (metastatic) GIST KIT = receptor tyrosine kinase
MC location of GIST tumor
Stomach
Driving mutation of most GIST tumros
GI stromal tumors (MC in stomach) are largely driven by KIT proto-oncogene = receptor tyrosine kinase
What to screen for in breast cancer pt starting tamoxifen vs. anastrozole
Tamoxifen (selective ER agonist/antagonist): annual GYN exam to monitor for any abnormal uterine bleeding given increased risk of endometrial CA
-actually strengthens bone
Anastrozole (aromatase inhibitor) requires baseline DEXA b/c can increase risk of osteopenia/porosis
Two dermatologic manifestations of gastric cancer
- Acanthosis nigricans- velvety hyperpigemnted patches in skin folds
- Leser-Trelat sign = diffuse seborrheic keratosis
MC location of colon cancer
Sigmoid colon like 23% (left colon)
What chronic autoimmune conditions increase risk of CRC?
Both UC and Crohn’s increase risk of CRC- and risk correlates w/ duration of symptomsdisease
How to distinguish colonic from rectal cancer?
(a) What percent of CRC are rectal?
Location- rectal CA like 12-15 inches from the anal verge
(a) Almost a quarter- like 22% of CRC are rectal, next 23% are sigmoid
For which hereditary polyposis syndrome is prophylactic colectomy indicated?
FAP = familial adenomatous polyposis = mutation in APC gene
Main risk factor for testicular cancer
Cryptorchidism = failure of one or both testes to descend from the abdomen into the scrotum
Carries 20-40x increase risk of testicular cancer
Main risk factor for testicular cancer
Cryptorchidism = failure of one or both testes to descend from the abdomen into the scrotum
Carries 20-40x increase risk of testicular cancer
Differentiate clinical presentation of R vs L sided colonic tumors
R sided colon CA presents w/ anemia from slow blood loss (normocytic)
L sided usually w/ change in bowel pattern- obstruction, constipation, diarrhea
Where do colon CAs typically develop in pts w/ Lynch syndrome?
Right sided colon CA at early age (30/40s)
Which stage of colon CA gets
(a) chemo
(b) radiation
Colon CA: stage II through muscularis propria
(a) Chemo- definitely for stage III (lymph nodes involved), sometimes used in advanced stage II
(b) Radiation- only stage IV, no benefit if no mets
Standard adjuvant chemo regimen for colon CA
Adjuvant chemo for colon CA (after resection):
5-Fluorouracil (pyrimidine analog) + Leucovorin (vitamin B12 than enhances effect of 5-FU) + Oxaliplatin (platinum based, crosslinks DNA)
2 differences in treatment for rectal vs. colonic cancer
Rectal CA- gets radiation even stage II b/c risk of local recurrence is so high
Chemo regimens:
Colon CA: 5-FU (pyrimidine analog), leucovorin, and oxaliplatin
Rectal CA: Just 5-FU
After diagnosis w/ CRC, when should repeat colonoscopy be performed?
1 year after- make sure they got it all (no micro-nearby disease)
Can repeat FOBT and CT C/A/P q6 months
BRCA 1 vs 2
(a) Mode of inheritance
(b) Which has higher risk of breast CA
(c) Which has higher risk of epithelial ovarian CA
BRCA 1 and 2
(a) Both autosomal dominant
(b, c) BRCA 1 has higher risk of breast (8-9 vs. 4-5%) and epithelial ovarian CA
Differentiate breast CA screening guidelines from American Cancer society (do more) vs. USPSTF
ACS- start at 40, get every year
USPSTF- start at 50, get q2 years
Most common type of breast cancer
Invasive ductal carcinoma
Which breast cancer is associated w/ increase risk of subsequent CA at same site vs. any site?
DCIS- increase risk on same breast
LCIS- increased risk either breast
Differentiate treatment for DCIS vs LCIS
Difference is that w/ DCIS excision’s goal is for negative margins, while for LCIS goal of excision is to r/o invasion and negative margins are not required
2 options for tx in invasive breast cancer
Equal survival for lumpectomy with radiation vs. total mastectomy
Distinguish stage I vs stage II breast cancer
Size and invasion
Stage I- under 2cm
Stage II- over 2 cm OR
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Distinguish stage I vs stage II breast cancer
Size and invasion
Stage I- under 2cm
Stage II- over 2 cm OR involved axillary lymph node
When to use hormonal vs. antibody therapy in adjuvant therapy for breast cancer
Depending on the receptor positivity-
ER/PR+ use hormonal therapy (tamoxifen if premenopausal, aromatase inhibitor in postmenopausal)
HER2+ benefit from trastuzumab (Herceptin)
How to decide which hormonal therapy to use in adjuvant therapy for breast cancer?
Pre or post-menopause
Pre-menopause- use tamoxifen (SERM)
-most estrogen still made in ovaries
Post-menopause- use aromatase inhibitor
Don’t use AI pre b/c prior to menopause the decrease in estrogen production stimulates the HPA axis to increase gonadotropin secretion, which then stimulates ovaries (still active) to release androgen => counteracts effect of the AI
-but technically more selective b/c inhibits estrogen production in adipose tissue local to the breast CA
3 mutations associated w/ increased risk of epithelial ovarian cancer
Epithelial ovarian cancer: BRCA 1, BRCA 2, and lynch syndrome (mistmatch repair mutation)
OCPs decrease risk of what specific type of cancer
OCPs reduce number of ovulations => reduces number of times the ovarian epithelium is disrupted => decreased risk of epithelial ovarian CA
Distinguish stage II and III epithelial ovarian cancer
Stage II- out of ovaries but within the pelvis (MC route of spread for ovarian cancer is intraperitoneally)
Stage III- extra-pelvic involvement
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Distinguish stage II and III epithelial ovarian cancer
Stage II- out of ovaries but within the pelvis (MC route of spread for ovarian CA is local shedding into peritoneum)
Stage III- extra-pelvic involvement (upper abdomen or reginal lymph nodes)
Treatment for epithelial ovarian cancer
Tx for epithelial ovarian cancer = surgical debulking
Then for anything stage II and above (outside the ovary)- chemo
Typical chemo regimen: platinum based (ex: carboplatin or cisplatin) cross-linking agent (cell-cycle nonspecific) and taxane (paclitaxel or docetaxal)
Tx in prostate cancer
(a) When to just observe
(b) Localized disease
Prostate cancer- 1 in 6 men! 2nd MC cancer death just b/c so common (after lung CA which is just so deadly)
(a) Observe if lifespan is under 10 years (b/c not likely to die from prostate CA anyway
(b) Localized disease (localized or confined w/in prostate capsule): equal survival rates for for radial prostatectomy and radiation
Two treatment options for advanced prostate cancer
Advanced prostate CA (meaning mets): surgical or medical castration (androgen deprivation)
Surgical- remove both testes (b/l orchiectomy)
Medical- GnRH agonists (leuprolide) to reduce LH/FSH, antiandrogens (flutamide)
Mainstay of chemo treatment for castration resistant prostate cancer
Defining castrate resistant prostate CA = rise in PSA or finding of new lesions despite medical or surgical orchiectomy
Use inhibitors of androgen-stimulated tumor growth and taxane therapy (docetaxel, paclitaxel) that inhibit microtubule formation
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3 treatments for bony mets in prostate cancer that are unresponsive to androgen deprivation
Castration-resistant bony mets in prostate cancer (blastic lesions meaning they build up bone)
- zolendronic acid- bisphosphonates to reduce fracture risk and bony pain (but doesn’t improve survival)
- Denosumab = antibody against RANK-ligand (osteoclast survival factor) to stop bone breakdown
- External beam radiation- reduce pain and fracture risk w/ isolated painful bony lesions
Name 2 risk factors for upper urinary tract malignancies
Recurrent UTI and kidney stones increase risk for ureter CA
Bladder cancer- when to do TURBT vs. cystectomy
Cystectomy (bladder removal) for anything stage II or above meaning it’s invaded into the muscularis propria
If hasn’t invaded muscularis propria can do TURBT
Name 2 paraneoplastic syndromes that can result from renal cell carcinoma
RCC paraneoplastic
Increased EPO production => high Hct
PTHrP => hypercalcemia
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Name 2 paraneoplastic syndromes that can result from renal cell carcinoma
RCC paraneoplastic
Increased EPO production => high Hct/polycythemia
PTHrP => hypercalcemia
Name a syndrome that causes hereditary renal cell carcinoma
(a) What else to look for
Von-Hippel Lindau
-Renal cell carcinoma
(a) CNS hemangioblastomas
Retinal angiomas
MC clinical presentation of testicular cancer
Painful testicular lesion
MC clinical presentation of testicular cancer
Testicular pain/swelling
Testicular cancer
(a) How to biopsy
(b) First line treatment
Testicular cancer
(a) Trick question- don’t biopsy!!! Just remove the testicle, biopsy carries increased risk of spread
(b) First line = orchiectomy
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Testicular cancer
(a) How to biopsy
(b) First line treatment
Testicular cancer
(a) Trick question- don’t biopsy!!! Just remove the testicle, biopsy (and scrotal orchiectomy) carries risk of local spread of tumor cells
(b) First line = inguinal orchiectomy of all solid (not cystic) intratesticular lesions
Differentiate lymphoma and leukemia
Lymphoma = overgrowth predominantly in lymph node and lymphatic tissue
Leukemia = abnormal growth predominantly in blood and bone marrow
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Differentiate lymphoma and leukemia
Lymphoma = overgrowth predominantly in lymph node and lymphatic tissue
Leukemia = abnormal growth predominantly in blood and bone marrow
Most likely diagnosis for mediastinal mass in young adult
Mediastinal mass in a young adult = Hodgkin’s lymphoma until proven otherwise
What are B-symptoms
B-symptoms = fever, night sweats, weight loss
Name 1st and 2nd MC types of Non-Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma = basically the other lymphomas that are not the one specific B-cell lymphoma known as Hodgkins
1st MC = DLBCL (aggressive)
2nd MC = follicular (indolent)
Name aggressive vs. indolent types of NHL
Non-Hodgkin’s lymphoma
Aggressive- DLBCL, Burkitt’s
Indolent- Follicular, Hairy cell
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Name 3 infectious risk factors for NHL
3 infections associated w/ higher risk of NHL
- HIV- esp DLBCL
- EBV- esp DLBCL
- H. pylori and MALT
Name aggressive vs. indolent types of NHL
Non-Hodgkin’s lymphoma
Aggressive- DLBCL, Burkitt’s, Mantle cell
Indolent- Follicular, Marginal zone
Why do we do LPs in lymphoma pts?
B/c lymphangitic spread is much more common then brain mets
Give intrathecal chemo if CSF is involved
When to add rituxan to typical chemo regimen for lymphoma pt?
Lymphoma typical chemo regimen = CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone), add rituximab when it is a B-lymphoma
Treatment for stage I, asymptomatic lymphoma
Nada, watch and wait
No proven benefit for localized (just one node) asymptomatic (no B-symptoms, no marrow involvement
When to add rituxan to typical chemo regimen for lymphoma pt?
Lymphoma typical chemo regimen = CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone), add rituximab when it is a B-lymphoma (which most are)
Why does the choice of adjuvant hormonal therapy for beast cancer differ by age?
Pre-menopausal- tamoxifen (SERM)
Main source of estrogen is ovaries
Post-menopausal- aromatase inhibitor
Main source of estrogen is exogenous tissue like fat
In pre-menopausal use of AI will cause reduction in estrogen that will feed back to HPA axis and increase signal to make more estrogen, counteracting the effect
Indications for treatment in CLL
Treat CLL if it becomes advanced (2 or more nodes, nodes on different sides of diaphragm) or if becomes symptomatic
- bone marrow involvement => anemia, thrombocytopenia
- B-symptoms
- high risk of Richter’s transformation to active lymphoma (ex: DLBCL): such as rapidly enlarging lymph node
- bulky lymphadenopathy
- weakness
- organomegaly
- autoimmune hemolytic anemia or autoimmune thrombocytopenia
Most likely dx: young M w/ sclerotic lesion of L humerus w/ onion-skin periosteal reaction
Ewing sacroma- infiltrative pattern of bone invasion that shows on imaging as onion skinning
-often presents w/ constitutional symptoms (while osteosarcoma w/ Codman’s triangle and spiculated appearance more typically asymptomatic
Distinguish radiologic features of Ewing sarcoma and osteosarcoma
Ewings = shaft of bone in an infiltrative pattern called onion skinning
tend to manifest w/ constitutional symptoms
Osteosarcoma- metaphysis of long bones, usually w/o symptoms
radiologically- spiculated appearance and Codman triangles (reactive bone edges of penetrating lesion by the periosteum)
Carcinoid tumor
(a) Typical clinical presentations
(b) Treatment for symptom/tumor control
Carcinoid
(a) Flushing, diarrhea, palpitations, wheezing, edema
(b) Octreotide (somatostatin analogue) can help w/ symptoms
Carcinoid tumor
(a) What hormone is elevated
(b) How to diagnose
(a) Excess serotonin
(b) 5-HIAA elevated in urine
Imaging findings of radiation-induced pneumonitis
- consolidation not conforming to an anatomic location or bronchopulmonary segments, but rather to the radiation port
- bronchiectasis (dilation of peripheral bronchi)
When to use tagged red-cell nuclear scan
Shows active bleed at a rate above 0.5 ml/minute
Initial test for pt w/ iron-deficiency anemia, weakly positive FOBT, and h/o radiation tx to prostate w/ now undetectable PSA
Colonoscopy to assess for lower GI source- more specifically radiation induced prostatitis
-radiation induced prostatitis can be acute (bleeding w/in 6 weeks) to decades later (6 yrs later BRBPR)
