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ABIM > Oncology > Flashcards

Oncology Flashcards

1
Q

Colon CA

A

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)

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2
Q

Decreased r/o colon CA

A 
non-smoker
NSAID
ASA >20yr
Celecoxib/sulindac
Ca, folate, estrogens
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3
Q

Familial Adenomatous polyposis

A

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

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4
Q

Gardner syndrome

A

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

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5
Q

HNPCC (lynch syndrome)

A 
3 relatives with Cancer related to HNPCC
one 1st deg
2 generations
1 extracolon CA
FAP excluded
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6
Q

Adenoma Colonoscopy screening

A

Hyperplastic polyp - q10yr
Adenoma < 1cm x1 - q5-10yr
Adenoma <1cm 3 Q3yr
Villous adenoma - regardless of size q3yr

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7
Q

Colon CA screening

A

1st deg relative colon CA age 10
colonoscopy standard time (age 50 then q10yr
Two 1st deg relatives colon CA
colonscopy now then q5yr

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8
Q

Peutz-Jeghar’s syndrome

A

hemartomas of small intestine
Pigmented lesions on skin, lips, mouth
Juventile polypossi: hyperpalstic polyps in colons - p./w GI bleed or inussusception
Tx: colonoscopy

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9
Q

HNPCC (hereditary non-poyposis colon CA - Lynch syndrome

A 
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
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10
Q

50yo F with HNPCC had colon CA done - adenomatous polyps - wtd?

A

TV US for uterine CA (extracolonic CA)

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11
Q

55yo M asx for routine checkup - fecal occult blood test neg (FIT) - signmoidoscopy => polyp

A 
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
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12
Q

55yo asx M routine checkup - sigmoidoscopy - neg - FIT +

A

Full colonoscopy

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13
Q

Male or postmenopausal femail with unexplained IDA - wtd?

A

Colonoscopy

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14
Q

Elderly pt with hematochezia, h/o hemorrohids wtd?

A

Colonoscopy

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15
Q

Pt on routine health maintenance exam FIT 1 out of 6 cards + occult blood - pt takes high doses of vit C

A

Colonoscopy

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16
Q

55yo F screening colonoscopy done - 2 polyps removed - both hyperplastic - when next colonoscopy

A

10 years

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17
Q

Pt with 2 adenomas <1cm removed when repeat colonscopy?

A

colonoscopy q5-10yrs

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18
Q

Pt with tubular adenoma 1cm - next colonoscopy?

A

3 years

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19
Q

Pt tubular adenoma 2.5 cm next colonoscopy?

A

3 years

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20
Q

Pt with 3-10 tubular aenoma <1cm next colonoscopy

A

3 years

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21
Q

Pt wit h1 villosu adenoma <1cm next colonscopy

A

3 years

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22
Q

Pt with obstructive colon CA with colonic resection wtd?

A

Full colonoscopy to r.o other concomitant lesions

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23
Q

Pre-op colonscopy with no other lesions

A

colonoscopy 1 yr then 3 years then q5yrs

measure CEA q3 to 6 mo for 2 years then q 1yr x 5 years

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24
Q

Best dx test r/o colon CA?

A

Colonoscopy with bx

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25
Q

When to stop colonoscopy screening?

A 
75yo
D/c mammo 75yo
D/C pap smears - 65
Hep C screening 1945 to 1965
LDCT screen for smokers up to age 79
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26
Q

Familial Adenomatous Polyposis (FAP)

A

Sigmoidoscopy q1-2 yrs starting at age 12

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27
Q

HNPCC

A

start colonoscopy 25yr or 10 years younger than youngest affected relative with HNPCC - then q2yr up to age 40 then q1yr

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28
Q

If 2 first deg relatives or 1 first deg relative with colon CA before age 60 when to screen?

A

40 years or 10 yrs younger than youngest affected relative (whichever younger) then q5 yrs

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29
Q

If 1 first deg relative with colon CA after age 50 or 2 2nd deg relative - when to screen?

A

40 years FIT + sigmoid q3 to 5 years starting at 40yo or colonoscopy at least at age 40 then q10 years

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30
Q

General population colon CA screening

A

50 yo (AA 45yo) - FIT/signmoidoscopy q3-5 yr or colonoscopy at 50 then q10 yrs

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31
Q

Post colonic resection for Colon CA

A

Colonoscopy 1 yr after resection then 3 yrs then q5yrs

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32
Q

UC, Crohns’s dz

A

Colonoscopy 8yrs after dx then q1-2 yr

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33
Q

Colon CA 1st deg relative

A

Colonoscopy 10 years before age of dx of 1st deg relative then q5 yr

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34
Q

35yo asx - father with colon CA 45yo

A

Colonoscopy now then q5yrs

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35
Q

40yo asx father colon CA age 60, brother age 52

A

Colonoscopy now then q5yr

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36
Q

35yo asx father colon CA age 65

A

FIT+Sigmoidoscopy q 3-5yr or colonoscopy q10yr starting at age 40

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37
Q

25yo asx - family h/o HNPCC

A

Colonoscopy now then q2yr up to age 40 then q1yr

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38
Q

Pt with UC dx recently

A

Colonoscopy 8yrs after dx then q2yr

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39
Q

Pt with Colon Ca Duke B underwent resection of colon

A

Colonoscopy in 1 yr then 3 yrs then q5yr

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40
Q

50yo asx - neg fxhx colon CA

A

FIT + sigmoioscopy q3-5 yr, colonoscopy q10yr

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41
Q

Young pt with h/o familial adenomatous polyposis

A

Colonoscopy age 16yo

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42
Q

40yo asx father colon CA afte 55

A

Colonoscopy now then q5yr

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43
Q

37yo M father colon CA afe 65, brother colon CA age 50, aunt uterine CA age 48

A

HNPCC (microsatellite mismatch repair gene MSH

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44
Q

What does tamsulosin cause?

A

Floppy iris syndrome!

d/c tamsulosin

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45
Q

Acute afib chemical cardioversion

A

ibutelide

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46
Q

Colon Cancer Duke A

A

90% survival - thru submucosa but not past muscularis

tx - resection

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47
Q

Colon Cancer Duke B1

A

90% survival thru muscularis but not past serosa (no LN)

tx - resection

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48
Q

Colon Cancer Duke B2

A

60-80% survival - thru muscularis into serosa not into LN

tx resection +5FU+leuovorin + oxiplatin

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49
Q

Colon Cancer Duke C

A

60-80% survival - thru serosa and involving LN

tx : rsection +5FU+leucovorin+oxiplatin

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50
Q

Colon Cancer Duke D

A

7% survival - Widespread metastasis (liver)

Tx: resection palliative, 5FU leucovorin+I’tecam/B’zumab

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51
Q

When to rsect soitary liver metastasis

A

If have pursued curative intent in past

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52
Q

Pt with colon CA undergoes hemicolectomy - histopathology with infiltartion of musularis but not serosa wtd?

A

Observe

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53
Q

Pt with colon CA with hemicoloectomy infiltrating serosa wtd?

A

Chemotx (5FU + leucovorin + Ox

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54
Q

Pt with colon CA not infiltrating sera but 4/10 LN invovled - after hemicolectomy wtd?

A

Chemotx (5FU +leucovorin + ox)

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55
Q

Pt with stage B2 rectal CA - local resectio done - wtd?

A

Chemotx + RT

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56
Q

Anal Ca - cancer of anal margin how to treat?

A

Local resection

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57
Q

Cancer of anal canal muscosa wtd?

A

ext beam radiation tx + 5FU + mitomycin

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58
Q

Breast Mass suspicious mass w/u

A 
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
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59
Q

Risk factors for breast CA

A 
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
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60
Q

Breast CA screening

A

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

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61
Q

Local breast diseas in situ (all w/in basement membrane)

A

tx - lumopectomy + RT or mastecotmy

tamoxifen (pre-menopause)/aromatoase inh (post-menopause if ER +

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62
Q

Lobular CA in situ

A

observation or if ER+ -> tamoxifen (pre)/aromatase (post menopause)

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63
Q

Infiltrating ductal CA LN neg

A

wide exceision of mass + RT
Adjuvant chemo for size >1cm
Tamoxifen/aromatase inh if ER +

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64
Q

Infiltrating ductal CA LN + pos

A

wide excisition + RT = modified radiacl mastectomy + adjuvant chemo + tamoxifen /aromatase inh if ER +

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65
Q

Locally invasive dz involving skin or chest wall

A

chemotx followed by mastectomy + tamoxifen/aromatose inh if ER+

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66
Q

Most important prognostic factor in breast CA?

A

LN invovlement>tumor size>receptor+>grade

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67
Q

Adjuvant therapy for LN+dz

A

Premenoapuse - ER+ -> chemo + tamoxfen
ER- chemotx
Post menopause - ER+ -> chemo + aromatase inhib
ER= - Chemotx

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68
Q

Adjuvant therapy for LN neg dz

A

premenopausal - ER+ tamoifen, ER- none

Post menopausal - ER+ aromatase inhib, ER- none

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69
Q

When to use chemo tx in breast CA

A

Tumor size>1cm, high grade

if <1cm NO CHEMOtx

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70
Q

Types of breast CA

A

Intraductal 80%
Lobular 10%
Other 10%

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71
Q

Excision of mass with free margin +RT =

A

Modifeid radiacla mastectomy + RT

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72
Q

If sentinel LN bx +

A

Further LN dissection

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73
Q

If sentinel LN bx neg

A

no further LN dissection

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74
Q

If LN + (rct)

A

Adjuvant tx - Chemo + tamoxifen (pre), aromatose inh (post)

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75
Q

tamoxifen/aromatase inhib used also?

A

LN neg ER+ (decreases rate of recurrence of breast CA)

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76
Q

37yo F fhx breast CA mother 65yo sister h/o breast CA 35yo - most important risk factor for pt to get breast CA?

A

Family hx breast CA

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77
Q

65yo F fhx breast CA mother 67yo - most important risk factor?

A

Her age

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78
Q

Highest risk fo rbreast CA

A

early menarch, late 1st preg, late menopause, strong fhx no deodorant

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79
Q

Pt with breast CA, 1st deg relative with breast and ovarian CA dx?

A

BRCA 1

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80
Q

Young female with BRCA 1 in screening

A

Mammo screening now (start 25-35)

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81
Q

50yo F regular checkup - best way to screen for breast CA?

A

clinical breast exam and mammo annually

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82
Q

How to screen for breast Ca in woman with breast implants

A

mammogram

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83
Q

Mammogram best in woman who is…

A

post menopausal

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84
Q

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?

A

US and FNA

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85
Q

Pt US with mixed echo - FNAB no malign - wtd?

A

excisional bx

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86
Q

50yo Dx with breast CA - most important prognostic factor

A

LN status

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87
Q

35yo F 1.5cm mass

Excision bx with infiltrating dutcal CA margins free of CA - Axillary LN neg, ER+ does not want mastiectomy wtd?

A

RT with adjuv chemo and tamoxifen x 5yrs

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88
Q

63yo F lump in breast - lumpectomy done reveals infiltrating adenoCA with free margins - axillary LN+ ER+ adjuvant chemo administered

A

Radiotx + aromatase inhibitors

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89
Q

59yo F painful breast - RUO breast painful red thickened area 7cm no nipple d/c no LM warmth+ mammo no mass dx?

A

Inflammatory breast CA

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90
Q

Pt s/p breast LA tx RT, surgery chemo p/w lymphedema R arm best managmement?

A

lymphedema

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91
Q

Tamoxifen

A 
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
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92
Q

35yo Pt dx breast CA - pt asks how to dec r/o breast Ca in her?

A

Tamoifen

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93
Q

Post menopaual F with breast Ca after surgery RT and adjuvant chemotx ER+ wtd?

A

aromatoase inhib (letrozole, anastrozole, exemestane)

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94
Q

54yo F dx’d with infiltrating ductal CA LN 3/15+ pt with breast conserving sx +RT+chemo+tamoifen - likelyat risk for…?

A

Endometrial Ca

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95
Q

Pt with h/o breast s/p chemo and chemo/tamoifen 6 monthss ago - p/w polyurea, dry mucus membrane fatigue, lethargy - etio?

A

HyperCa

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96
Q

Pt with breast Ca and tx’ed as abv - wtd?

A

Ask for GYN sx every visit

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97
Q

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?

A

Endometrial bx

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98
Q

Pregant women with breast Ca

A

treat like regular pt - surgery in 2nd to 3rd trimester - chemo tx 3rd trim
Male breast CA treated simlar to femail breast CA

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99
Q

Long term complication aromatase inhibitors?

A

osteoporosis

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100
Q

Best managment hot flashes from tamoxifen or aromatase inhibitors?

A

SSRI

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101
Q

Pt p/w nipple d/c - eczematous scaly lesion at nipple - preg test neg prolactin normal dx?

A

Pagets disease o fbreast
Tx - local wide srsn - if no mass
Treast as breast Ca if underlying

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102
Q

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?

A

MRI LS spine

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103
Q

What is first sx of epidural compression fx?

A

Pain (NOT loss of sensation)

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104
Q

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?

A

Bone scan

THE LEADING solid tumor causing HyperCa+ is breast CA

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105
Q

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?

A

Mammogram yearly

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106
Q

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?

A

Leptomeningeal spread

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107
Q

Pt with metastatic breast Ca ER neg HERR (Her2neu) rct + best med ?

A

Trastuzumab (herceptin)

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108
Q

34yo with breast lump excised -> fibroadenoma - GM with hx breast CA wtd?

A

repeat mammo at age 50

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109
Q

65yo M on spironolactone for ascites p/w one sided breast mass

A

bx

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110
Q

Endometrial Ca

A 
Risk factors
Obestity
Early menarch
late menopause
Nulliparity
Tamoxifen use
P/w post menopausal bleeding
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111
Q

Obesity associated cancer

A

Endometrial Ca

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112
Q

Bariatric surgery comoplications

A

Opthalmoplegia - thiamind ef
Dark urine - no RBCs rhabdo
Tachycardia low grade fever - suture leak - gastrograffin study
Copper def - anemia, thrombocytopenia, leukopenia

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113
Q

Cervical CA

A

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

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114
Q

Don’t do HPV DNA in whom?

A

<30yo (unless Pap abnormal)

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115
Q

High risk patient pap smears

A

q1yr

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116
Q

Stop PAP at age?

A

65yo

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117
Q

Pt with warts -

A

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

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118
Q

24yo F vaginal d/c - Pap shows clue cells and some AS-CU - ?

A

bacterial vaginosis

tx: metronidazole

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119
Q

24yo F pap with AS CUS wtd?

A

HPV test - also give vaccine HPV

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120
Q

22yo F with AS-CUS HPV 16 still give vaccine?

A

Yes

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121
Q

What pt contraindicated for HPV vacc?

A

preg patient

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122
Q

50yo pt with h/o fibroids - 2yrs ago fibroid size 2cm - repeat size 3cm no menorrhagia - best managment?

A

Reassess in 1 year

If still there 3 yers later post menopause with bleeding - bx

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123
Q

Pt hysterectomy for sever fibroids - post hysterectomy do you need PAP?

A

If uterus/cerix removed for benign reason - NO

If uterus remove for malignant CA then yes bx

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124
Q

Pt with lesion in endocervical canal wtd?

A

bx

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125
Q

PT with pap high grade SIL - colposcopic bx confirms CIN III wtd?

A

cryotherapy, con bx if endocervical canal invovled or hysterectomy

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126
Q

Pt with invasive cervical CA wtd?

A

Hyperectomy or RT with chemo

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127
Q

Ovarian CA

A

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)

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128
Q

Pt with abdominal distension - US shows serous semi solid 6cm sep mass in R pelvic area CEA elevated - wtd?

A

CT scan to loclize tumor before laparoscopy

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129
Q

Prostate CA

A

MCC cancer in males (190K/year)

Second leading cause of death from cancer

130
Q

Risk factors for prostate CA

A

Older age - median onset 72yo
African american x 2
FHx - father had it 3x, brother had it 4x
high fat diet
PSA screening NOT shown to reduce mortality
Discuss risks/benefits of PSA screening with patient

131
Q

Pt wants PSA wtd?

A

Discuss risks/benefits with patient

132
Q

Gleason score

A

determines prognosis

7 poor prognosis

133
Q

Staging of prostate CA

A 
A1 5% of resected tissue
B- found on needle bx after inc PSA
B1 < 1/2 one lobe
B2>1/2 on elobe
B3 both lobes invovled
Elderly - observe no sx
Yound Radiacla prostatectomy=Radiotx

C Capsule infiltrated - locally invasive
tx RT+hormonal (Lupron GnRH agonist)

D1 Pelvic node invovlement
Hormonal tx

D2 Distant mets, localized bone, diffuse bone
Beam RT, hormonal

134
Q

Anti androgens compete with androgens at receptor level in tests and adrenals

A

Flutamide, nilutamide, bicaltamide

Anti androgens block flare by LHRH agonists

135
Q

60yo P with PSA elevated rectal exam unremarkable wtd?

A

TRUS - trans rectal US bx

136
Q

60yo pt with PSA normal but rectal exam with nodule

137
Q

50yo Pt on routine exam with diffusely enlarged prostate elev PSA wtd?

138
Q

82yo M prostate CA stage A2

139
Q

60yo M elev PSA abnormal rectal exam - B1 on bx wtd?

A

radial prostatectomy OR ext beam RT
3yr later - PSA < 10 asx - wtd? - observe
If >10 then mets visible

140
Q

Pt comes back after prostatecomy 3 years later with elev PSA and back pain - one met lesion on vertebral spine wtd?

141
Q

Bone scan localized mets to bone wtd?

A

ext beam radiation to lesion

142
Q

One year later - after ext beam rad to spine back with bone pain bone scan diffuse mets wtd?

A

start GnRH agonist (Leuprolide, Goserelin - can combine with anti-androgens to block GnRH induced flares

143
Q

6 months later back pain again after tx wit GnRH/antiandrogens for met prostate CA - pt tx’d with mitoxantrong and fails - continues to have pain wtd?

A

IV strontium 89 for palliation of pain

144
Q

62yo with locally invasive prostate Ca stage C wtd?

A

RT + GnRH analog (hormonal)

145
Q

S/E LHRH (leuprolide

A

Short term - hot flashes
Long term - osteoporosis
Tx - Bisophosphonate - Zolendronate, alendronate

146
Q

S/E Anti-androgens

A

impaired dark adaptation

Breast tenderness -> tamoxifen

147
Q

Pt with met prostate CA started on leuprolide - mc problem

A

fracture - compression fx

148
Q

65yo pt with prostate CA B3

A

radical prostatectomy

149
Q

65yo pt with prostate CA stage C (capsule)

A

RT+hormonal tx

150
Q

65yo pt with prostate CA diffuse mets

A

Hormonal tx

151
Q

84yo pt with prostate CA stage B2

A

Observe (elderly)

152
Q

Pt afib on warfarin with hematuria INR 2.2, RBC in urine repeat UA with persistent hematuria - rectal exam enlarged proatste - CT scan, cystoscopy IVP neg - prostate bx with hyperplasia no CA wtd to tx hematuria

A

Add finasterid (enlarged prostate)

153
Q

Pt fhx + prostate CA - wants to decrease risk wtd?

A

Finasteride

154
Q

65yo chronic smoker - p.w painless heamturia with intermittent clots dx?

A

Bladder CA

155
Q

Lower abd pain fullness in suprapubic area - foley cath with relief of pain and drainage of urine PSA elevatged wtd next?

A

repeat PSA in 4-6wks - urinary retention from any etio can cuase inc PSA, so can foley insertion

156
Q

Lung CA

A

MCC death men/women

85% dx die w/in 5 years

157
Q

Small cell lung CA (20%)

A 
Assume mets at dx
NON-resectable
Squamous cell (MC)
Small cell
Large cell
158
Q

Non-small cell (80%)

A 
Squamous cell CA 
Large cell CA
AdenoCA
Eval for surgical resection at dx!!
AdenoCA with inc incidence in both smoker and non-smokers
159
Q

MC presentation of Lung CA

A

peristent or inc’ing cough, hemoptysis, post-obstructive pneumonitis

160
Q

Pt p/w hemoptysis

A

> 1wk, >40yr old - chronic tobacoo hx 40% chance of CA - evaluate pt further with these sx with CT & bronch

161
Q

Hemoptysis in young adult dx?

A

Bronchitis, PNA, bronnchiectasis

162
Q

Hemoptysis in immigrant from south asia or S america dx?

A

Myobacterium Tuberculosis

163
Q

> 50yo pt tx’d in hosptial for PNA with ceftx and azithro - 3 months later cough persists - CXR with persistent density dx?

A

Malignancy

164
Q

Non-small cell CA (can be resectable)

A

I: Tumor >2cm from carina, node neg
II: Tumor >2cm from carina node +
IIIa Tumore <2cm from carina or invading resectable structure or ipilateral hilar or mediastinal LN+
Tx: Surgery +chemo+radiotherapy

IIIb: Tumor invading unresectable structure contralateral mediastinal LN+
Tx: Chemo then radiotx

IV: Metastatic dz - Supraclavicular LN+ or pleural effusion with malignant cells+
Tx Erlotinib/Gefitinib

165
Q

Small Cell CA (non-resectable)

A

Limited to one hemithorax: chemo + RT lung+ RT Brain (ppx)
Extensive dz - Chemotx + RT brain (ppx)

Elderly Pt with SCC - shoudl be treated with chemotx

166
Q

58yo chronic smoker >30pk yr p/w hemoptysis >1wk CXR neg wtd?

A

CT chest then bronch

167
Q

42yo p/w streaky hemoptysis x 3 weeks CXR clear wtd?

A

Bronchoscopy

168
Q

70yo chronic smoker >50yo p/w seizure and lethargy - CT head shows single ring enhancing lesion with edema - startedon phenytoin wtd?

A

Start dexamethasone to dec cerebral edema

169
Q

60yo pt with lung CA wants screening - wtd?

A

no screening (unless is smoker)

170
Q

60yo pt with 30pk year smoking hx quit 5 yr ago here for routine check wtd?

A

low dose CT (55-79 quit < 15ya)

171
Q

70yo chornic smoker with CT CT solitary ring enhancing lesion started on phenytoin - CT lung with hilar LAD - next test?

A

Bronchoscopy

172
Q

Prevent emetogenic chemotx (cisplatin)

A

granisetron +DMS+neurokinin

173
Q

Piror to aministration of chemo pt is nauseous and receives granisetrong or ondansetrong - still naustious wtd?

174
Q

MCC Paraneoplastic syndrome

A

Small Cell CA
Squamous cell CA
AdenoCA
Large cell CA

175
Q

Small cell CA**.

Paraneoplastic syndrome

A 
hyponatremia 2/2 SIADH
Cushing's 2/2 inc ACTH
Carcinoid: flushing and diarrhea
Eaton lambert - power inc's with repetition
SVC syndrome
176
Q

Squamous cell CA**

Paraneoplastic syndrome

A

HyperCA 2/2 PTH like substace
PTH dec Ca inc, PO4 dec
Horner’s Ptosis, miosis anhydrosis
Pancoast tumor - compress 1st and 2nd throacic nerve - sholder pain pain in ulanr aspect of hand and little finger - CXR pancoast tumor

177
Q

AdenoCA**

Paraneoplastic syndrome

A

Pulmonary osteoarthropathy - pain in hands or legs
Xray periosteal thickening
Marantic Endocardits

178
Q

Large cell CA**

Paraneoplastic syndrome

A

SVC syndrome

Gynecomastia

179
Q

65yo Sq cell CA with pleural effusionhemorrhagic PT 160/100, hyper Ca, FEV1 2.4L Hg 9 what prevents from being surgical candidate

A

hemorrhage pleural effusion

180
Q

What is most important prognositic factor with advance non-small cell lung CA?

A

Poor performance status

181
Q

45yo post lung cancer s/p surgery and chemotx 5 years ago going fo relective surgery - echo EF 35% wtd?

A

ACE inhibitor

182
Q

Pt with pancoast tumore - whic is worst prognosis

A

Chest movement asymmetry (phrenic nerve involvement

183
Q

Least likely paraneoplastic syndrome /w small cell CA

184
Q

51 yo lung CA with gynecomastia inc HCG

A

Large cell CA

185
Q

62yo chronic smoker pin in legs CXR with coin lesion in periphery of lungs

186
Q

55yo pt with lung CA and hyperCA

A

Squamous cell CA

187
Q

55yo lung CA with wk gets better with repetitive movememnts - eaton lambert

A

Small cell lung CA

188
Q

55yo Manual labororer heavy smoker p/w shoulder arm, ring little finger pain wtd?

189
Q

MC cancer in smoker and non-smoker

190
Q

MC cancer in non-smoker

191
Q

ACTH producting neoplastic syndrome

A

Small cell CA

192
Q

Assume met at Dx

A

Small cell CA

193
Q

<2% 5 year survival Lung Ca

A

Small cell Ca

194
Q

Hyponatremia with lung CA

A

Small cell Ca

195
Q

Squamous cell CA 2cm win in carina and ipsilar LN +

A

Surgical resection

196
Q

AdenoCA >2cm from carina LN neg

A

Surgical resection

197
Q

Large cell Ca at carina nad contralat LN+

A

Chemo tx + RT lung

198
Q

Small cell CA in one hemithorax

A

CHemotx, +RT lung+RT brain (ppx)

199
Q

Small cell Ca extensive

A

Chemo tx + RT brain (ppx)

200
Q

SVC syndrome

A

Lung CA - NSCLC broncogenic CA most common
lymphoma
thymoma
catheter induced thrombosis
sx - dyspnea, facial swelling arm swelling, cyanosis, plethora, dysphagia

201
Q

Next step managment SVC syndrome?

A

elev of head (dec hydrostatic prssure and edema)

Tx definitive - radiation tx

202
Q

Pt with metastatic lung CA and skeletal mets and osteopenia wtd?

A

bisophosphonates - zolendronate or pamidronate

Pain not relieved? - strontium 89 IV

203
Q

Medicare guidlines when pt eligible for hospice care?

A

life expectancy less than 6 months

204
Q

Testicular CA

A 
Seminomas - Better cure rate
Non-seminoma
embryona CA,
teratoma
chorioCA
yolksac tumor
205
Q

Pt with testicular mass

A

solid testicular growth is CA until otherise proven
check B HCG and alpha feto protein
Bx via high inguinal incision (don’t spread CA)
if Bx + then CT chest abd pelvis to stage dz

206
Q

Hormone levels

A

Seminoma
BCG inc/N (<100)
AFP normal

Non seminoma
BCG elevated
AFP elevated

207
Q

Treatment testicular CA

A 
For all - radical orchiectomy via high inguinal incision then..
Stage 1 - confined to testes
Seminoma - RT
Non-seminoma - observe, remove LN
Stage II infradiaphragmeatic Node + <5cm
Seminoma - RT
Non-seminoma - Chemotx
Stage III beyond retroperitoneal LN
Seminoma - chemotx
Non-seminoma - Chemotx (no RT)
208
Q

24yo with no-seminoa tumor - BCG and AFP elevated CT pelvis with mass - radial orchiectomy done wtd?

A

chemotx

if with lung nodule - resect, c/w chemo

209
Q

BCG and afp elv

A

non-seminoma

210
Q

AFP normal

211
Q

Inguinal approach for bx/orchiectomy

212
Q

Trans-scrotal bx?

A

neither - never!

213
Q

Respond to RT

214
Q

Don’t respond to RT

A

Non-seminoma

215
Q

19yo inc’d breast enlargement for 2 years no other complaints - normal genitalia, +gynecomatia wtd?

A

check testosterone/estradio - testo 450 (n)
LH0.3, FSH 0.5 (l) and estradiol 304 (elev)
check US tests - if nromal CT adrenal (r/o germ cell tumor)

216
Q

Young man with testicular mas and dragging sensation - nl AFP, nl HCG) wtd?

A

High inguinal orchiectomy

217
Q

Lymphoma

A 
Hodgkin's lymphoma
B cells Reed sternberg +
Best prognosis
Lymphoyctic predominance
Nodular sclerosis
Mixed cellularity
Lymphocyte depletion (worse prognosis)

Non-hodgkin’s lymphoma B cells 90%, T cells 10%

218
Q

Lymphoma presentation

A

lymph node enlargement with contiguous spread +- paracrine effects
Fever,
peripheral granulocytosis
eosinophilia with pruritis (itching after shower)
Personality changes
+reed sternerg cells (owl eyes)

219
Q

Hodgkin’s dz tx

A

ABVD (doxorubicin, bleomycin, vinblastine dacarazine +-RT

Relapse/poor response - high dose chemo then autologous hematopoetic stem cell tx

220
Q

Complications after hodgkins’ tx

A 
Chemo
cardiomyopathy
AML
MDS
infertility, amenorrhea
Radiation tx
constrictive pericarditis (sqrt sign)
accelerated CAD despite age
solid tumores (breast, lung, thyroid)
Hypotheyorid
radiation pneumonitis
221
Q

38yo ho hodgkins txed with rad tx 10ya p./w chest pain while shoveling snow x 30 min

A

Accelerated CAD

222
Q

40yo egyptian man h/o hodgkins tx with mantel RT to chest 10 ya with palptiations wt loss JVD, ascites, pedal edema - echo with thickened pericardium

A

constrictive pericarditis

223
Q

42yo s/p hodgkin’s dz tx’d with chemo >7yr ago p/w easy bruising fatigue, how Gh low plts smear with anisocytosis, pelger huet - BM dysplasia of marrow precursor and hypercellularity

A

myelodysplasia (MDS)

224
Q

35yo with hodgkins 10ya s/p mantle radiationi now with fatigue wtd?

A

Check TSH

Prone to Lung/breast, thyroid CA

225
Q

30yo undergoes chemo for hodgkins 10 ya ago - complication?

A

r/o AML (topoisomerase inhib)

226
Q

Non-Hodgkin’s lymphoma

A

clonal proliferation of cell features of lymphoid cells
>60K/yr inc’ding indcidence
hematoglogic spread
90% B cells, 10% T cells
40% - diffuse large cell ymphoma (BCL 6)
30% follicular lymphoma (t 14:18)
Dx: excision of LN not aspiration (supraclavicular)
Stageing by ann arbor and CT/PET chest, abd pelvis
Tx base on staging and presence of poor prognositc factors
Tx: chemo with RCHOP or CVP
Relapse - aggressive chemo and stem cell tx

227
Q

Poor prognostic factors NHL

A

age >60
serum LDH
performance status <12, stroke, HTN, lymphoma

228
Q

NHL grading

A

Low grade lymophoma
Follicular small lymphocytes
Tx INdolent->observe
Aggressive transformation -> RCHOP/CVP
Intermediate grade lymphoma
follicular large or small cell, diffuse, mixed
tx CHOP (chylophos, doxorubinicine, vincristine, prednisone)
High grade lymophoma
large cell immunoblastic small non cleaved cell
Tx: CHOP+-rituximab
then stem cell tx

229
Q

Post tx lymphoma

A

EBV (HIV pts) associated lymphoma

230
Q

CNS lymphoma/burkitts/nasopharyngeal CA

231
Q

MALT

232
Q

Kaposi’s sarcoma

A

HHV-8 - danorubicin

233
Q

Ca Cervic/Anal Ca

234
Q

T cell leukemia

235
Q

65yo Pt asx cervical LAD - LN bx follicular small cell lymophoma preserved architecture - BM findings + tx?

236
Q

Pt with abdominal mass, wt loss, fever, bulky retroperitoneal LN - bx mass shows large cell lymophoma tx?

A

CHOP + rituximab
If failus chemo
Stem cell tx

237
Q

Pt post renal tx - 2 years later with ataxia - CTH ring enhancing lesion in cerebellum dx?

A

EBV = cause for lymphoma s/p tx

238
Q

Pt with well diff lymphoma p/w fatigue, wk, cbc hg 9.5, retic 5% smear with spherocytes, polychormasia best tes?

A

Cooms test r/o warm autoimmune hemoytic anema

Tx - steroids and underlying dz

239
Q

Pt with large hilar LAD dx with small cell ca p/w SOB - exam wit hmassive pleural eff wtd?

A

tap effusion

If recurs - talc pleuredysis

240
Q

Pt with lyphoma dx 2 ya not requ tx p/w sob, cxr with effsuion

A

Tap effusion

then chmotx

241
Q

Rituximab s/e

A

lymphopenia

242
Q

Multiple Myeloma

A

Lytic lesions, bone pain, hyperCa, serum/urine protein - m spike
Marrow cytosis >10%
Plastima cells
osteoclasts->punched out bone lesions->hyper Ca
Immuoglobulin(faulty IgG)->M spike in serum and urine->renal failure
->roleaux formation of RBCs
->inc’d ESR, plt dsyfxn, infections
Tx:
No end organ daamge (RF, lytic lesions, anemia)
-monitor
Evience of damage
->lenalidomide Melphalan/prednisone
Relapse - do not do induction with melphalan
tx with bortezomib/hemato stem cell tx

243
Q

PPX prior to bortezomib?

A

Herpes zoster

244
Q

MM

A

protien >3.5
Lytice lesions
marrow plasmacytome >10%
+ hyper Ca+

245
Q

MGUS

A

Protein<10% plasmacytoma

no hyper Ca+

246
Q

Smoldering MM

A

no hyperCa+
>10% plasmacytoma
+lytic lesions

247
Q

T/F Hypercalemia with MM

248
Q

T/F MM inc’d protein

249
Q

T/F MM renal dysfxn

250
Q

T/F MM Plt dysfxn

251
Q

T/F MM bone pain

252
Q

T/F MM infections

253
Q

T/F MM amyloidosis

254
Q

T/F MM Dilatino of retinal veins

255
Q

Hypervicosity caused by all of the following

A

Waldenstroms macroglobulinemia-> tx plasmphoresis
PC Vera-> tx splenomegaly - phelebotomy/low dose ASA
Leukemia - leukapheresis

256
Q

65yo Pt with protein 8gm glboulin 3.1 serum protein electrophor with inc’d IgG - best way to diff MM vs MGUS

A

skeletal survey

+lytic lesions in MM

257
Q

Pt dx with MGUS - wtd?

A

f/u 6 months r/o MM

258
Q

Pt with plasma cells >10% in BM, skeletal survey neg, Ca normal - no end organ damage - pt dx with smolerding MM - wtd?

A

f/u myeloma protein q2 months

259
Q

60yo M h/a blurred vision, LAD fatigue Gh 9, lethargic, dec’d power on one side, total protein 8gm globulin 3, Ca 9 - serum protein electroprhoesis IgM>2g, inc’d ESR dx?

A

Waldenstroms’s
caused by IgM (largest immunoglobulin) ->stays intravascular-> hyperviscosity syndrome
No lytic lesions
No hyperCa+
BM phlascytoid lymophocytes
Tx: plasmapheresis, fludarabine based chemo

260
Q

Tumor of pancreas

A

Pancreatic CA
Glucoagonoma
Gastrnoma
VIPoma

261
Q

Elderly man with h/o chronic smoking >40pk yr p/w wt loss, fagigue anorexia painelss jaundice+- diarrhea - painless palpable gall bladder (courvoisier’s sign) - best dx test?

A

CT Scan pancrease r/o pancreatic CA - mainly head of pancrease - double duct sign (bile and common duct enlarged)
Tx: Pancreatic Ca with no mets - surgery (whipple)
can invovle minimal invasion of protal or mesenteric vein

262
Q

If pt refuses surgery for pancreatic CA wtd?

A

Gemcitabine chemo tx

Pancreatic Ca with mets - palliative tx with stent and Gemcitabine

263
Q

Pt with stage IV pancreatic CA and sever itching wtd?

A

Biliary stent

264
Q

46yo F no h/o pancreatitis with 3.8cm mass head of pancreas seen on CT wtd?

A

Surgical excision - if mass not clearly defined or borderline resctable on CT wtd?
Endoscopic US first

265
Q

What is more commonly a/w pancreatic CA - tob or etoh

A

smoking…

266
Q

Diabetics ar prone to what kind of cancer - breast, colon or pancreatic?

A

pancreatic CA

267
Q

Pt with familial adenomatous polyposis prone to what kind of cancer?

A

Ampulla of vater cancer

268
Q

Pt with persistent hyperglycemia, wt loss anemia - exam with scaly necrotizing dermatitis - glucagon injection does not increase glucose level

A

glucagonoma - plasma glucogon >1000

269
Q

Pt with profuse watery diarrhea not responding to fasting, h/o wt loss serum K 3.3, hypochlorhydria - serum VIP level inc’d stool osmolar gap low

A

Dx: VIPoma
Tx: octreotide ?sulfonyurea OD

270
Q

Courvoisier’s sign

A

Pancreatic CA

271
Q

Trousseau’s syndrome

A

Pancreastic CA

272
Q

Double duct sign

A

Pancreatic CA

273
Q

Sentinel loop sign (small bowel ileus)

A

Acute pancreatitis

274
Q

Pt with diarrhea h/o flushing sensation, exam with telangiectasia wtd?

A

Check 5HIAA

dx? Carcinoid

275
Q

Hepatocellular CA

A

first line tx?

Resection or tx

276
Q

Dx of hepatocellular CA

A

Imaging studies - screen with US then CT contrast or MRI

277
Q

What agent inc’s survival with hepatocellular CA

278
Q

Thyroid CA

A 
Parafollicular
Medullary carcinoma
Calitonin increased, RET proto-oncogene
dense calcification in tumor
assoc with MEN II/III (check fhx)
Tx: total thyroidectomy (follow calcitonin levels after surgery)
279
Q

Papillary CA

A

Cervical LN, pitted CAlcification (MC wit best prognosis)

280
Q

Follicular CA

A

mass and distant mts

281
Q

Anaplastic CA

A

with mass - elderly with worst prognosis

282
Q

Best managment for papillary and follcular CA after surgery

A

Radioiodine ablation - will NOT work for medullary CA as radioiodine not take up by C cells

283
Q

Medullary CA recurrence

A

check Calcitonin level

284
Q

Papillary CA recurrence

A

Check Thyroglobulin level

285
Q

Follicular CA recurrence

A

Check Thyroglobulin level

286
Q

Axillary LN

287
Q

Occipital LN

A

scalp infxn

288
Q

Supraclavicular LN (R)

A

esophaeal lung or mediastinal malignancy

289
Q

L Supraclavicular LN

A

Abdominal malignancy (see chart pg 191)

290
Q

Cancer of Unknown Origin

A

MC - adenoCA
then poorly diff
then Others

291
Q

Presentation CA unknown origin

A

40% LN, Cervical supraclavicular>Mediastinal>axillary
30% Liver lung bone
20% pt primary CA will be identified
Expected mean survival time 6 months

292
Q

AdenoCA in females with axillary LN

A

r/o breast CA
Do mammogram +- MRI, ER/PR rct
Tx mastectomy +- radiation +- chemo

293
Q

AdenoCA in females with bony invovlement

A

Pursue breast CA diagnosis

294
Q

AdenoCA in males with bony invovlement

A

Pursue prostate CA

Ask for urinary sx, do PSA and rectal exam

295
Q

Poorly diff CA in young males

A

Pursue germ cell tumor
Do alpha feto protein & B HCG
Platinum based chemo if +

296
Q

Squamous cell CA

A

presentation with cervial LN + - persue head/neck CA

Cervical LN neg - pursue Lung CA

297
Q

MCC CA of unknown origin

298
Q

MC place of presentation of CA unknown origin

A

Lymph node

299
Q

Femaile with axillary LN+ most likely CA type

300
Q

Carcinoma of unknown origin in young male

A

Undiff cell CA

301
Q

Head/neck CA

A

Squamous cell CA

302
Q

50yo M smoker, single submandibular LN+ found to be undeiff CA - Phy exam head/neck neg, CXR neg wtd?

A

Upper pan endoscopy

303
Q

Which screenings DO NOT decrease mortality

A

PSA

Mmamo, pap, fecal occult, sigmoid DO decrease mortality

304
Q

Pt with metastatic CA with persisent pain - takes oxycodone wit tylenol prn and morphine sulfate twice a day wtd?

A

Extended release oxycodone or morphine q8-12hr continuously

305
Q

S/E Methotrexate

A

Reversible pneumonitis, hepatic fibrosis

306
Q

S/E 5FU

A

MI/myelosuppression

307
Q

S/E Vincristine

A

Neuropathy, SIADH

308
Q

S/E Doxorubicin

A

Cardiomyopathy

309
Q

S/E Bleomycin

A

interstitial fibrosis

310
Q

S/e Mitomycin

A

HUS, blue green urine

311
Q

S/e cyclophosphamide

A

hemorrhagic cystitis, bladder CA

312
Q

S/e Bicalutamide

A

gynecomastia, pulm fibrosis, impair dark adaptation

313
Q

s/e paclitaxel

A

Neuropathy, bradycardia

314
Q

s/e gemcitabine

A

anal pruritis HUS flu rash

315
Q

s/e tamoxifen

A

hot flashes, throboemboli, endometrial CA

316
Q

LHRH s/e

A

impotence, transient cancer flare, osteoporosis

317
Q

s/e hyroxyurea

A

dec’d wbc, myelosuppression

318
Q

Cisplatin s/e

A

myelosupp, hypotension, weakness, alopecia

319
Q

s/e etoposide

A

nephrotoxic, ototoxic, neuropathy

320
Q

S/e IL-2

A

capillary leak syndrome, erythema

321
Q

S/E IFN alpha

A

Flu like sx, LFT inc, arthalgias, hypo/hyperthyroidism

ABIM (14 decks)

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