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Internal Medicine Boards 2018 > Oncology > Flashcards

Oncology Flashcards

NEJM+ Questions

1
Q

35 y/oF, mom diagnosed w/ colon CA at 48, when should she start getting screened?

A

Screening colonoscopy at age 38

-w/ first degree family member w/ colon CA start screening at 40 or 10 years before index case

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2
Q

Acral lantiginous melanoma

(a) Big difference from other types of melanoma
(b) Common location

A

(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)

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3
Q

Age range for lung cancer screening

A

55-74 yoa w/ at least 30 pack years who quit within the past 15 years

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4
Q

39 y/oM w/ R sided colon CA, strong FHx of early endometrail cancer

Most likely syndrome?

A

Lynch syndrome (hereditary nonpolyposis colorectal cancer = HNPCC) = mismatch repair mutation

-MC cancer associated w/ Lynch syndrome that isn’t colon CA is endometrial CA

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5
Q

Distinguish Lynch syndrome and Li Fraumeni syndrome

A

Lynch = HNPCC = mismatch repair mutation
-colon CA and endometrail CA

Li Fraumeni = mutation in tp53 (tsg)
-breast cancer, sarcoma, brain, adrenal tumor, leukemia

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6
Q

During what kind of cancer treatment can EPO be used for chemo-induced anemia?

A

Only in palliative- b/c EPO has been associated w/ increased mortality in pts receiving chemo/radiation

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7
Q

Tx of malignant hypercalcemia (ex: cancer pt p/w nausea/vomiting found to have Ca 16.2)

(a) 2nd line for refractory

A

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

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8
Q

Indication for cinacalcet

A

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

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9
Q

First line pharmacologic therapy for smoking cessation in 51 y/oF w/ h/o seizures

A
  1. varencicline (chantix)
  2. nicotine patch + lozenge

buproprion contraindicated given seizure history

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10
Q

Pt w/ metastatic GI stromal tumor with a KIT mutation

First line tx?

A

Imatinib (Gleevec) = tyrosine kinase inhibitor

Advanced inoperable (metastatic) GIST
KIT = receptor tyrosine kinase
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11
Q

MC location of GIST tumor

A

Stomach

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12
Q

Driving mutation of most GIST tumros

A

GI stromal tumors (MC in stomach) are largely driven by KIT proto-oncogene = receptor tyrosine kinase

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13
Q

What to screen for in breast cancer pt starting tamoxifen vs. anastrozole

A

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

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14
Q

Two dermatologic manifestations of gastric cancer

A
  1. Acanthosis nigricans- velvety hyperpigemnted patches in skin folds
  2. Leser-Trelat sign = diffuse seborrheic keratosis
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15
Q

MC location of colon cancer

A

Sigmoid colon like 23% (left colon)

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16
Q

What chronic autoimmune conditions increase risk of CRC?

A

Both UC and Crohn’s increase risk of CRC- and risk correlates w/ duration of symptomsdisease

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17
Q

How to distinguish colonic from rectal cancer?

(a) What percent of CRC are rectal?

A

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

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18
Q

For which hereditary polyposis syndrome is prophylactic colectomy indicated?

A

FAP = familial adenomatous polyposis = mutation in APC gene

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19
Q

Main risk factor for testicular cancer

A

Cryptorchidism = failure of one or both testes to descend from the abdomen into the scrotum

Carries 20-40x increase risk of testicular cancer

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20
Q

Main risk factor for testicular cancer

A

Cryptorchidism = failure of one or both testes to descend from the abdomen into the scrotum

Carries 20-40x increase risk of testicular cancer

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21
Q

Differentiate clinical presentation of R vs L sided colonic tumors

A

R sided colon CA presents w/ anemia from slow blood loss (normocytic)

L sided usually w/ change in bowel pattern- obstruction, constipation, diarrhea

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22
Q

Where do colon CAs typically develop in pts w/ Lynch syndrome?

A

Right sided colon CA at early age (30/40s)

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23
Q

Which stage of colon CA gets

(a) chemo
(b) radiation

A

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

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24
Q

Standard adjuvant chemo regimen for colon CA

A

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)

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25
Q

2 differences in treatment for rectal vs. colonic cancer

A

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

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26
Q

After diagnosis w/ CRC, when should repeat colonoscopy be performed?

A

1 year after- make sure they got it all (no micro-nearby disease)

Can repeat FOBT and CT C/A/P q6 months

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27
Q

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

A

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

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28
Q

Differentiate breast CA screening guidelines from American Cancer society (do more) vs. USPSTF

A

ACS- start at 40, get every year

USPSTF- start at 50, get q2 years

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29
Q

Most common type of breast cancer

A

Invasive ductal carcinoma

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30
Q

Which breast cancer is associated w/ increase risk of subsequent CA at same site vs. any site?

A

DCIS- increase risk on same breast

LCIS- increased risk either breast

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31
Q

Differentiate treatment for DCIS vs LCIS

A

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

32
Q

2 options for tx in invasive breast cancer

A

Equal survival for lumpectomy with radiation vs. total mastectomy

33
Q

Distinguish stage I vs stage II breast cancer

A

Size and invasion

Stage I- under 2cm
Stage II- over 2 cm OR

**

34
Q

Distinguish stage I vs stage II breast cancer

A

Size and invasion

Stage I- under 2cm
Stage II- over 2 cm OR involved axillary lymph node

35
Q

When to use hormonal vs. antibody therapy in adjuvant therapy for breast cancer

A

Depending on the receptor positivity-

ER/PR+ use hormonal therapy (tamoxifen if premenopausal, aromatase inhibitor in postmenopausal)

HER2+ benefit from trastuzumab (Herceptin)

36
Q

How to decide which hormonal therapy to use in adjuvant therapy for breast cancer?

A

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

37
Q

3 mutations associated w/ increased risk of epithelial ovarian cancer

A

Epithelial ovarian cancer: BRCA 1, BRCA 2, and lynch syndrome (mistmatch repair mutation)

38
Q

OCPs decrease risk of what specific type of cancer

A

OCPs reduce number of ovulations => reduces number of times the ovarian epithelium is disrupted => decreased risk of epithelial ovarian CA

39
Q

Distinguish stage II and III epithelial ovarian cancer

A

Stage II- out of ovaries but within the pelvis (MC route of spread for ovarian cancer is intraperitoneally)

Stage III- extra-pelvic involvement

**

40
Q

Distinguish stage II and III epithelial ovarian cancer

A

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)

41
Q

Treatment for epithelial ovarian cancer

A

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)

42
Q

Tx in prostate cancer

(a) When to just observe
(b) Localized disease

A

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

43
Q

Two treatment options for advanced prostate cancer

A

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)

44
Q

Mainstay of chemo treatment for castration resistant prostate cancer

A

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

**

45
Q

3 treatments for bony mets in prostate cancer that are unresponsive to androgen deprivation

A

Castration-resistant bony mets in prostate cancer (blastic lesions meaning they build up bone)

  1. zolendronic acid- bisphosphonates to reduce fracture risk and bony pain (but doesn’t improve survival)
  2. Denosumab = antibody against RANK-ligand (osteoclast survival factor) to stop bone breakdown
  3. External beam radiation- reduce pain and fracture risk w/ isolated painful bony lesions
46
Q

Name 2 risk factors for upper urinary tract malignancies

A

Recurrent UTI and kidney stones increase risk for ureter CA

47
Q

Bladder cancer- when to do TURBT vs. cystectomy

A

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

48
Q

Name 2 paraneoplastic syndromes that can result from renal cell carcinoma

A

RCC paraneoplastic

Increased EPO production => high Hct

PTHrP => hypercalcemia

**

49
Q

Name 2 paraneoplastic syndromes that can result from renal cell carcinoma

A

RCC paraneoplastic

Increased EPO production => high Hct/polycythemia

PTHrP => hypercalcemia

50
Q

Name a syndrome that causes hereditary renal cell carcinoma

(a) What else to look for

A

Von-Hippel Lindau
-Renal cell carcinoma

(a) CNS hemangioblastomas
Retinal angiomas

51
Q

MC clinical presentation of testicular cancer

A

Painful testicular lesion

52
Q

MC clinical presentation of testicular cancer

A

Testicular pain/swelling

53
Q

Testicular cancer

(a) How to biopsy
(b) First line treatment

A

Testicular cancer

(a) Trick question- don’t biopsy!!! Just remove the testicle, biopsy carries increased risk of spread
(b) First line = orchiectomy

**

54
Q

Testicular cancer

(a) How to biopsy
(b) First line treatment

A

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

55
Q

Differentiate lymphoma and leukemia

A

Lymphoma = overgrowth predominantly in lymph node and lymphatic tissue

Leukemia = abnormal growth predominantly in blood and bone marrow

**

56
Q

Differentiate lymphoma and leukemia

A

Lymphoma = overgrowth predominantly in lymph node and lymphatic tissue

Leukemia = abnormal growth predominantly in blood and bone marrow

57
Q

Most likely diagnosis for mediastinal mass in young adult

A

Mediastinal mass in a young adult = Hodgkin’s lymphoma until proven otherwise

58
Q

What are B-symptoms

A

B-symptoms = fever, night sweats, weight loss

59
Q

Name 1st and 2nd MC types of Non-Hodgkin’s lymphoma

A

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)

60
Q

Name aggressive vs. indolent types of NHL

A

Non-Hodgkin’s lymphoma

Aggressive- DLBCL, Burkitt’s
Indolent- Follicular, Hairy cell

**

61
Q

Name 3 infectious risk factors for NHL

A

3 infections associated w/ higher risk of NHL

  1. HIV- esp DLBCL
  2. EBV- esp DLBCL
  3. H. pylori and MALT
62
Q

Name aggressive vs. indolent types of NHL

A

Non-Hodgkin’s lymphoma

Aggressive- DLBCL, Burkitt’s, Mantle cell
Indolent- Follicular, Marginal zone

63
Q

Why do we do LPs in lymphoma pts?

A

B/c lymphangitic spread is much more common then brain mets

Give intrathecal chemo if CSF is involved

64
Q

When to add rituxan to typical chemo regimen for lymphoma pt?

A

Lymphoma typical chemo regimen = CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone), add rituximab when it is a B-lymphoma

65
Q

Treatment for stage I, asymptomatic lymphoma

A

Nada, watch and wait

No proven benefit for localized (just one node) asymptomatic (no B-symptoms, no marrow involvement

66
Q

When to add rituxan to typical chemo regimen for lymphoma pt?

A

Lymphoma typical chemo regimen = CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone), add rituximab when it is a B-lymphoma (which most are)

67
Q

Why does the choice of adjuvant hormonal therapy for beast cancer differ by age?

A

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

68
Q

Indications for treatment in CLL

A

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
69
Q

Most likely dx: young M w/ sclerotic lesion of L humerus w/ onion-skin periosteal reaction

A

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

70
Q

Distinguish radiologic features of Ewing sarcoma and osteosarcoma

A

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)

71
Q

Carcinoid tumor

(a) Typical clinical presentations
(b) Treatment for symptom/tumor control

A

Carcinoid

(a) Flushing, diarrhea, palpitations, wheezing, edema
(b) Octreotide (somatostatin analogue) can help w/ symptoms

72
Q

Carcinoid tumor

(a) What hormone is elevated
(b) How to diagnose

A

(a) Excess serotonin

(b) 5-HIAA elevated in urine

73
Q

Imaging findings of radiation-induced pneumonitis

A
  1. consolidation not conforming to an anatomic location or bronchopulmonary segments, but rather to the radiation port
  2. bronchiectasis (dilation of peripheral bronchi)
74
Q

When to use tagged red-cell nuclear scan

A

Shows active bleed at a rate above 0.5 ml/minute

75
Q

Initial test for pt w/ iron-deficiency anemia, weakly positive FOBT, and h/o radiation tx to prostate w/ now undetectable PSA

A

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)

Internal Medicine Boards 2018 (13 decks)

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