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)
2
Q
Decreased r/o colon CA
A
non-smoker NSAID ASA >20yr Celecoxib/sulindac Ca, folate, estrogens
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
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
5
Q
HNPCC (lynch syndrome)
A
3 relatives with Cancer related to HNPCC one 1st deg 2 generations 1 extracolon CA FAP excluded
6
Q
Adenoma Colonoscopy screening
A
Hyperplastic polyp - q10yr
Adenoma < 1cm x1 - q5-10yr
Adenoma <1cm 3 Q3yr
Villous adenoma - regardless of size q3yr
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
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
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
10
Q
50yo F with HNPCC had colon CA done - adenomatous polyps - wtd?
A
TV US for uterine CA (extracolonic CA)
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
12
Q
55yo asx M routine checkup - sigmoidoscopy - neg - FIT +
A
Full colonoscopy
13
Q
Male or postmenopausal femail with unexplained IDA - wtd?
A
Colonoscopy
14
Q
Elderly pt with hematochezia, h/o hemorrohids wtd?
A
Colonoscopy
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
16
Q
55yo F screening colonoscopy done - 2 polyps removed - both hyperplastic - when next colonoscopy
A
10 years
17
Q
Pt with 2 adenomas <1cm removed when repeat colonscopy?
A
colonoscopy q5-10yrs
18
Q
Pt with tubular adenoma 1cm - next colonoscopy?
A
3 years
19
Q
Pt tubular adenoma 2.5 cm next colonoscopy?
A
3 years
20
Q
Pt with 3-10 tubular aenoma <1cm next colonoscopy
A
3 years
21
Q
Pt wit h1 villosu adenoma <1cm next colonscopy
A
3 years
22
Q
Pt with obstructive colon CA with colonic resection wtd?
A
Full colonoscopy to r.o other concomitant lesions
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
24
Q
Best dx test r/o colon CA?
A
Colonoscopy with bx
25
When to stop colonoscopy screening?
```
75yo
D/c mammo 75yo
D/C pap smears - 65
Hep C screening 1945 to 1965
LDCT screen for smokers up to age 79
```
26
Familial Adenomatous Polyposis (FAP)
Sigmoidoscopy q1-2 yrs starting at age 12
27
HNPCC
start colonoscopy 25yr or 10 years younger than youngest affected relative with HNPCC - then q2yr up to age 40 then q1yr
28
If 2 first deg relatives or 1 first deg relative with colon CA before age 60 when to screen?
40 years or 10 yrs younger than youngest affected relative (whichever younger) then q5 yrs
29
If 1 first deg relative with colon CA after age 50 or 2 2nd deg relative - when to screen?
40 years FIT + sigmoid q3 to 5 years starting at 40yo or colonoscopy at least at age 40 then q10 years
30
General population colon CA screening
50 yo (AA 45yo) - FIT/signmoidoscopy q3-5 yr or colonoscopy at 50 then q10 yrs
31
Post colonic resection for Colon CA
Colonoscopy 1 yr after resection then 3 yrs then q5yrs
32
UC, Crohns's dz
Colonoscopy 8yrs after dx then q1-2 yr
33
Colon CA 1st deg relative
Colonoscopy 10 years before age of dx of 1st deg relative then q5 yr
34
35yo asx - father with colon CA 45yo
Colonoscopy now then q5yrs
35
40yo asx father colon CA age 60, brother age 52
Colonoscopy now then q5yr
36
35yo asx father colon CA age 65
FIT+Sigmoidoscopy q 3-5yr or colonoscopy q10yr starting at age 40
37
25yo asx - family h/o HNPCC
Colonoscopy now then q2yr up to age 40 then q1yr
38
Pt with UC dx recently
Colonoscopy 8yrs after dx then q2yr
39
Pt with Colon Ca Duke B underwent resection of colon
Colonoscopy in 1 yr then 3 yrs then q5yr
40
50yo asx - neg fxhx colon CA
FIT + sigmoioscopy q3-5 yr, colonoscopy q10yr
41
Young pt with h/o familial adenomatous polyposis
Colonoscopy age 16yo
42
40yo asx father colon CA afte 55
Colonoscopy now then q5yr
43
37yo M father colon CA afe 65, brother colon CA age 50, aunt uterine CA age 48
HNPCC (microsatellite mismatch repair gene MSH
44
What does tamsulosin cause?
Floppy iris syndrome!
| d/c tamsulosin
45
Acute afib chemical cardioversion
ibutelide
46
Colon Cancer Duke A
90% survival - thru submucosa but not past muscularis
| tx - resection
47
Colon Cancer Duke B1
90% survival thru muscularis but not past serosa (no LN)
| tx - resection
48
Colon Cancer Duke B2
60-80% survival - thru muscularis into serosa not into LN
| tx resection +5FU+leuovorin + oxiplatin
49
Colon Cancer Duke C
60-80% survival - thru serosa and involving LN
| tx : rsection +5FU+leucovorin+oxiplatin
50
Colon Cancer Duke D
7% survival - Widespread metastasis (liver)
| Tx: resection palliative, 5FU leucovorin+I'tecam/B'zumab
51
When to rsect soitary liver metastasis
If have pursued curative intent in past
52
Pt with colon CA undergoes hemicolectomy - histopathology with infiltartion of musularis but not serosa wtd?
Observe
53
Pt with colon CA with hemicoloectomy infiltrating serosa wtd?
Chemotx (5FU + leucovorin + Ox
54
Pt with colon CA not infiltrating sera but 4/10 LN invovled - after hemicolectomy wtd?
Chemotx (5FU +leucovorin + ox)
55
Pt with stage B2 rectal CA - local resectio done - wtd?
Chemotx + RT
56
Anal Ca - cancer of anal margin how to treat?
Local resection
57
Cancer of anal canal muscosa wtd?
ext beam radiation tx + 5FU + mitomycin
58
Breast Mass suspicious mass w/u
```
Re-examine in 6 weeks mid cycle
Mass dissappears - do nothing
Mass persists - mammogram
If young woman stright to US
If older woman
if + then excision bx/intraop bx
If indeterminant/neg -> US
If solid - FNA with bx - if neg then excisional bx
If mixed echo FNA + bx if neg -> excisional bx
If cystic then FNA bx
```
59
Risk factors for breast CA
```
Highest risk
Female >50yo
Personal hx breast CA
strong Fhx pre-menopausal breast CA
BRCA 1/2
```
```
High risk
Any 1st deg relative with breast CA
personal h/o ovarian or endometrial CA
late preg
nulliparous
dense breasts
```
```
Moderate risk
Early menarch
Late menopause
OCP>15 yrs
etoh
obesity
```
60
Breast CA screening
Women >50yr or <5-10 yrs prior to age of breast CA in 1st deg relative then q2yr
10% breast CA found on PE missed by mammo
BRCA1/2 5-10%
BRCA1 chrom 17 - breast, ovarian ca in woman, prostate CA in men high, high penetrance - make family members aware
BRCA 2 - Chrom 13
BRCA 1 testing recom with pt with strong fhx breast AND ovarian CA
61
Local breast diseas in situ (all w/in basement membrane)
tx - lumopectomy + RT or mastecotmy
| tamoxifen (pre-menopause)/aromatoase inh (post-menopause if ER +
62
Lobular CA in situ
observation or if ER+ -> tamoxifen (pre)/aromatase (post menopause)
63
Infiltrating ductal CA LN neg
wide exceision of mass + RT
Adjuvant chemo for size >1cm
Tamoxifen/aromatase inh if ER +
64
Infiltrating ductal CA LN + pos
wide excisition + RT = modified radiacl mastectomy + adjuvant chemo + tamoxifen /aromatase inh if ER +
65
Locally invasive dz involving skin or chest wall
chemotx followed by mastectomy + tamoxifen/aromatose inh if ER+
66
Most important prognostic factor in breast CA?
LN invovlement>tumor size>receptor+>grade
67
Adjuvant therapy for LN+dz
Premenoapuse - ER+ -> chemo + tamoxfen
ER- chemotx
Post menopause - ER+ -> chemo + aromatase inhib
ER= - Chemotx
68
Adjuvant therapy for LN neg dz
premenopausal - ER+ tamoifen, ER- none
| Post menopausal - ER+ aromatase inhib, ER- none
69
When to use chemo tx in breast CA
Tumor size>1cm, high grade
| if <1cm NO CHEMOtx
70
Types of breast CA
Intraductal 80%
Lobular 10%
Other 10%
71
Excision of mass with free margin +RT =
Modifeid radiacla mastectomy + RT
72
If sentinel LN bx +
Further LN dissection
73
If sentinel LN bx neg
no further LN dissection
74
If LN + (rct)
Adjuvant tx - Chemo + tamoxifen (pre), aromatose inh (post)
75
tamoxifen/aromatase inhib used also?
LN neg ER+ (decreases rate of recurrence of breast CA)
76
37yo F fhx breast CA mother 65yo sister h/o breast CA 35yo - most important risk factor for pt to get breast CA?
Family hx breast CA
77
65yo F fhx breast CA mother 67yo - most important risk factor?
Her age
78
Highest risk fo rbreast CA
early menarch, late 1st preg, late menopause, strong fhx no deodorant
79
Pt with breast CA, 1st deg relative with breast and ovarian CA dx?
BRCA 1
80
Young female with BRCA 1 in screening
Mammo screening now (start 25-35)
81
50yo F regular checkup - best way to screen for breast CA?
clinical breast exam and mammo annually
82
How to screen for breast Ca in woman with breast implants
mammogram
83
Mammogram best in woman who is...
post menopausal
84
40yo F p/w new onset thickening of LU and outer breast in shower no fhx breast CA - menstruating - exam diffuse nodulatrity in both breasts - comes back mid cycle and persists - Mammo no CA or dominant mass wtd?
US and FNA
85
Pt US with mixed echo - FNAB no malign - wtd?
excisional bx
86
50yo Dx with breast CA - most important prognostic factor
LN status
87
35yo F 1.5cm mass
| Excision bx with infiltrating dutcal CA margins free of CA - Axillary LN neg, ER+ does not want mastiectomy wtd?
RT with adjuv chemo and tamoxifen x 5yrs
88
63yo F lump in breast - lumpectomy done reveals infiltrating adenoCA with free margins - axillary LN+ ER+ adjuvant chemo administered
Radiotx + aromatase inhibitors
89
59yo F painful breast - RUO breast painful red thickened area 7cm no nipple d/c no LM warmth+ mammo no mass dx?
Inflammatory breast CA
90
Pt s/p breast LA tx RT, surgery chemo p/w lymphedema R arm best managmement?
lymphedema
91
Tamoxifen
```
decreases r/o new breast CA - effective for tx metastatic brast CA - works only if tumor ER/PR+ - both estrogenic and anti estrongic effects
Anti-estrogenic - anti breast tumor
Menopausal sx (tx with SSRI)
Estrogenic effect - inc r/o endometrial CA 3x
inc bone density
inc thromboembolic risk/PE
ALSO CAUSES HYEPR CA
If erum Ca <14 - c/w tamoxifen
```
92
35yo Pt dx breast CA - pt asks how to dec r/o breast Ca in her?
Tamoifen
93
Post menopaual F with breast Ca after surgery RT and adjuvant chemotx ER+ wtd?
aromatoase inhib (letrozole, anastrozole, exemestane)
94
54yo F dx'd with infiltrating ductal CA LN 3/15+ pt with breast conserving sx +RT+chemo+tamoifen - likelyat risk for...?
Endometrial Ca
95
Pt with h/o breast s/p chemo and chemo/tamoifen 6 monthss ago - p/w polyurea, dry mucus membrane fatigue, lethargy - etio?
HyperCa
96
Pt with breast Ca and tx'ed as abv - wtd?
Ask for GYN sx every visit
97
Pt started o ntamoxifen 20mg po daily 3 years later with vaginal bloody d/ no other complaints excesept hot flashes - mammo and pap neg wtd?
Endometrial bx
98
Pregant women with breast Ca
treat like regular pt - surgery in 2nd to 3rd trimester - chemo tx 3rd trim
Male breast CA treated simlar to femail breast CA
99
Long term complication aromatase inhibitors?
osteoporosis
100
Best managment hot flashes from tamoxifen or aromatase inhibitors?
SSRI
101
Pt p/w nipple d/c - eczematous scaly lesion at nipple - preg test neg prolactin normal dx?
Pagets disease o fbreast
Tx - local wide srsn - if no mass
Treast as breast Ca if underlying
102
Pt h/o breast Ca s/p lumpectomy and chemotx 5 yrs ago p/w pain in hip xray hip 3cm lytic lesion - X ray LS normal wtd?
MRI LS spine
103
What is first sx of epidural compression fx?
Pain (NOT loss of sensation)
104
60yo F breast CA, s/p resected ER/PR+ chemo and aromatase inhib's started - current meds ACEi, BB, lasix urinating more frequently - labs normal except Ca 11.2 - next best management?
Bone scan
| THE LEADING solid tumor causing HyperCa+ is breast CA
105
65yo F dx with infiltrating ductal CA - lumpectomy with free margins, radiotx and adkuant chemo - 6 months after RT hre for f/u - exam neg for mass. LN, no compaints - mammo neg wtd?
Mammogram yearly
106
Pt s/p matectomy fo rbreast Ca with metastasis on increasing meperidine for pain control - is lethargic, dec'd responsiveness - pulis non-reactive diplopia, tongue dev to right absent gag - absent left ankel reflex - urinary retention + - CT brain no parencymal lesion dx?
Leptomeningeal spread
107
Pt with metastatic breast Ca ER neg HERR (Her2neu) rct + best med ?
Trastuzumab (herceptin)
108
34yo with breast lump excised -> fibroadenoma - GM with hx breast CA wtd?
repeat mammo at age 50
109
65yo M on spironolactone for ascites p/w one sided breast mass
bx
110
Endometrial Ca
```
Risk factors
Obestity
Early menarch
late menopause
Nulliparity
Tamoxifen use
P/w post menopausal bleeding
```
111
Obesity associated cancer
Endometrial Ca
112
Bariatric surgery comoplications
Opthalmoplegia - thiamind ef
Dark urine - no RBCs rhabdo
Tachycardia low grade fever - suture leak - gastrograffin study
Copper def - anemia, thrombocytopenia, leukopenia
113
Cervical CA
Pap Smear
Screening age 21-65 every 3 years
Only HPV screening after age 30 (before 80% chance clearing virus)
For women above 30 - pap smear with HPV DNA neg - pap q5yr
114
Don't do HPV DNA in whom?
<30yo (unless Pap abnormal)
115
High risk patient pap smears
q1yr
116
Stop PAP at age?
65yo
117
Pt with warts -
30yo With primary PAP -
If ASC-US and HPV+ -> colposcopy
If ASCUS+ and HPV neg -> no colp, repeat pap 1 yr
If ASC neg and HPV + > no colp, re;eat pap and DNA in 6-12 months
118
24yo F vaginal d/c - Pap shows clue cells and some AS-CU - ?
bacterial vaginosis
| tx: metronidazole
119
24yo F pap with AS CUS wtd?
HPV test - also give vaccine HPV
120
22yo F with AS-CUS HPV 16 still give vaccine?
Yes
121
What pt contraindicated for HPV vacc?
preg patient
122
50yo pt with h/o fibroids - 2yrs ago fibroid size 2cm - repeat size 3cm no menorrhagia - best managment?
Reassess in 1 year
| If still there 3 yers later post menopause with bleeding - bx
123
Pt hysterectomy for sever fibroids - post hysterectomy do you need PAP?
If uterus/cerix removed for benign reason - NO
| If uterus remove for malignant CA then yes bx
124
Pt with lesion in endocervical canal wtd?
bx
125
PT with pap high grade SIL - colposcopic bx confirms CIN III wtd?
cryotherapy, con bx if endocervical canal invovled or hysterectomy
126
Pt with invasive cervical CA wtd?
Hyperectomy or RT with chemo
127
Ovarian CA
leading cause of GYN CA - most p/w advanced stage
General screening NOT recommended (no pelvic US, CA 125, OCP dec risk of ovarina CA)
Pelvic US of pt with dermatomyostis or strong fhx ovarian + breast Ca
CA125 used in monitoring dz
Tx: surgical staging and debulking of tumor with salpingooophroectomy, hysterectomy omentectomy -> chemo (paclitaxel)
128
Pt with abdominal distension - US shows serous semi solid 6cm sep mass in R pelvic area CEA elevated - wtd?
CT scan to loclize tumor before laparoscopy
129
Prostate CA
MCC cancer in males (190K/year)
| Second leading cause of death from cancer
130
Risk factors for prostate CA
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
Pt wants PSA wtd?
Discuss risks/benefits with patient
132
Gleason score
determines prognosis
| 7 poor prognosis
133
Staging of prostate CA
```
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
Anti androgens compete with androgens at receptor level in tests and adrenals
Flutamide, nilutamide, bicaltamide
| Anti androgens block flare by LHRH agonists
135
60yo P with PSA elevated rectal exam unremarkable wtd?
TRUS - trans rectal US bx
136
60yo pt with PSA normal but rectal exam with nodule
TRUS bx
137
50yo Pt on routine exam with diffusely enlarged prostate elev PSA wtd?
TRUS bx
138
82yo M prostate CA stage A2
observe
139
60yo M elev PSA abnormal rectal exam - B1 on bx wtd?
radial prostatectomy OR ext beam RT
3yr later - PSA < 10 asx - wtd? - observe
If >10 then mets visible
140
Pt comes back after prostatecomy 3 years later with elev PSA and back pain - one met lesion on vertebral spine wtd?
Bone scan
141
Bone scan localized mets to bone wtd?
ext beam radiation to lesion
142
One year later - after ext beam rad to spine back with bone pain bone scan diffuse mets wtd?
start GnRH agonist (Leuprolide, Goserelin - can combine with anti-androgens to block GnRH induced flares
143
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?
IV strontium 89 for palliation of pain
144
62yo with locally invasive prostate Ca stage C wtd?
RT + GnRH analog (hormonal)
145
S/E LHRH (leuprolide
Short term - hot flashes
Long term - osteoporosis
Tx - Bisophosphonate - Zolendronate, alendronate
146
S/E Anti-androgens
impaired dark adaptation
| Breast tenderness -> tamoxifen
147
Pt with met prostate CA started on leuprolide - mc problem
fracture - compression fx
148
65yo pt with prostate CA B3
radical prostatectomy
149
65yo pt with prostate CA stage C (capsule)
RT+hormonal tx
150
65yo pt with prostate CA diffuse mets
Hormonal tx
151
84yo pt with prostate CA stage B2
Observe (elderly)
152
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
Add finasterid (enlarged prostate)
153
Pt fhx + prostate CA - wants to decrease risk wtd?
Finasteride
154
65yo chronic smoker - p.w painless heamturia with intermittent clots dx?
Bladder CA
155
Lower abd pain fullness in suprapubic area - foley cath with relief of pain and drainage of urine PSA elevatged wtd next?
repeat PSA in 4-6wks - urinary retention from any etio can cuase inc PSA, so can foley insertion
156
Lung CA
MCC death men/women
| 85% dx die w/in 5 years
157
Small cell lung CA (20%)
```
Assume mets at dx
NON-resectable
Squamous cell (MC)
Small cell
Large cell
```
158
Non-small cell (80%)
```
Squamous cell CA
Large cell CA
AdenoCA
Eval for surgical resection at dx!!
AdenoCA with inc incidence in both smoker and non-smokers
```
159
MC presentation of Lung CA
peristent or inc'ing cough, hemoptysis, post-obstructive pneumonitis
160
Pt p/w hemoptysis
>1wk, >40yr old - chronic tobacoo hx 40% chance of CA - evaluate pt further with these sx with CT & bronch
161
Hemoptysis in young adult dx?
Bronchitis, PNA, bronnchiectasis
162
Hemoptysis in immigrant from south asia or S america dx?
Myobacterium Tuberculosis
163
>50yo pt tx'd in hosptial for PNA with ceftx and azithro - 3 months later cough persists - CXR with persistent density dx?
Malignancy
164
Non-small cell CA (can be resectable)
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
Small Cell CA (non-resectable)
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
58yo chronic smoker >30pk yr p/w hemoptysis >1wk CXR neg wtd?
CT chest then bronch
167
42yo p/w streaky hemoptysis x 3 weeks CXR clear wtd?
Bronchoscopy
168
70yo chronic smoker >50yo p/w seizure and lethargy - CT head shows single ring enhancing lesion with edema - startedon phenytoin wtd?
Start dexamethasone to dec cerebral edema
169
60yo pt with lung CA wants screening - wtd?
no screening (unless is smoker)
170
60yo pt with 30pk year smoking hx quit 5 yr ago here for routine check wtd?
low dose CT (55-79 quit < 15ya)
171
70yo chornic smoker with CT CT solitary ring enhancing lesion started on phenytoin - CT lung with hilar LAD - next test?
Bronchoscopy
172
Prevent emetogenic chemotx (cisplatin)
granisetron +DMS+neurokinin
173
Piror to aministration of chemo pt is nauseous and receives granisetrong or ondansetrong - still naustious wtd?
xanax
174
MCC Paraneoplastic syndrome
Small Cell CA
Squamous cell CA
AdenoCA
Large cell CA
175
Small cell CA**.
| Paraneoplastic syndrome
```
hyponatremia 2/2 SIADH
Cushing's 2/2 inc ACTH
Carcinoid: flushing and diarrhea
Eaton lambert - power inc's with repetition
SVC syndrome
```
176
Squamous cell CA**
| Paraneoplastic syndrome
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
AdenoCA**
| Paraneoplastic syndrome
Pulmonary osteoarthropathy - pain in hands or legs
Xray periosteal thickening
Marantic Endocardits
178
Large cell CA**
| Paraneoplastic syndrome
SVC syndrome
| Gynecomastia
179
65yo Sq cell CA with pleural effusionhemorrhagic PT 160/100, hyper Ca, FEV1 2.4L Hg 9 what prevents from being surgical candidate
hemorrhage pleural effusion
180
What is most important prognositic factor with advance non-small cell lung CA?
Poor performance status
181
45yo post lung cancer s/p surgery and chemotx 5 years ago going fo relective surgery - echo EF 35% wtd?
ACE inhibitor
182
Pt with pancoast tumore - whic is worst prognosis
Chest movement asymmetry (phrenic nerve involvement
183
Least likely paraneoplastic syndrome /w small cell CA
HyperCA
184
51 yo lung CA with gynecomastia inc HCG
Large cell CA
185
62yo chronic smoker pin in legs CXR with coin lesion in periphery of lungs
AdenoCA
186
55yo pt with lung CA and hyperCA
Squamous cell CA
187
55yo lung CA with wk gets better with repetitive movememnts - eaton lambert
Small cell lung CA
188
55yo Manual labororer heavy smoker p/w shoulder arm, ring little finger pain wtd?
CXR
189
MC cancer in smoker and non-smoker
AdenoCA
190
MC cancer in non-smoker
AdenoCA
191
ACTH producting neoplastic syndrome
Small cell CA
192
Assume met at Dx
Small cell CA
193
<2% 5 year survival Lung Ca
Small cell Ca
194
Hyponatremia with lung CA
Small cell Ca
195
Squamous cell CA 2cm win in carina and ipsilar LN +
Surgical resection
196
AdenoCA >2cm from carina LN neg
Surgical resection
197
Large cell Ca at carina nad contralat LN+
Chemo tx + RT lung
198
Small cell CA in one hemithorax
CHemotx, +RT lung+RT brain (ppx)
199
Small cell Ca extensive
Chemo tx + RT brain (ppx)
200
SVC syndrome
Lung CA - NSCLC broncogenic CA most common
lymphoma
thymoma
catheter induced thrombosis
sx - dyspnea, facial swelling arm swelling, cyanosis, plethora, dysphagia
201
Next step managment SVC syndrome?
elev of head (dec hydrostatic prssure and edema)
| Tx definitive - radiation tx
202
Pt with metastatic lung CA and skeletal mets and osteopenia wtd?
bisophosphonates - zolendronate or pamidronate
| Pain not relieved? - strontium 89 IV
203
Medicare guidlines when pt eligible for hospice care?
life expectancy less than 6 months
204
Testicular CA
```
Seminomas - Better cure rate
Non-seminoma
embryona CA,
teratoma
chorioCA
yolksac tumor
```
205
Pt with testicular mass
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
Hormone levels
Seminoma
BCG inc/N (<100)
AFP normal
Non seminoma
BCG elevated
AFP elevated
207
Treatment testicular CA
```
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
24yo with no-seminoa tumor - BCG and AFP elevated CT pelvis with mass - radial orchiectomy done wtd?
chemotx
| if with lung nodule - resect, c/w chemo
209
BCG and afp elv
non-seminoma
210
AFP normal
seminoma
211
Inguinal approach for bx/orchiectomy
both
212
Trans-scrotal bx?
neither - never!
213
Respond to RT
seminoma
214
Don't respond to RT
Non-seminoma
215
19yo inc'd breast enlargement for 2 years no other complaints - normal genitalia, +gynecomatia wtd?
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
Young man with testicular mas and dragging sensation - nl AFP, nl HCG) wtd?
High inguinal orchiectomy
217
Lymphoma
```
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
Lymphoma presentation
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
Hodgkin's dz tx
ABVD (doxorubicin, bleomycin, vinblastine dacarazine +-RT
| Relapse/poor response - high dose chemo then autologous hematopoetic stem cell tx
220
Complications after hodgkins' tx
```
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
38yo ho hodgkins txed with rad tx 10ya p./w chest pain while shoveling snow x 30 min
Accelerated CAD
222
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
constrictive pericarditis
223
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
myelodysplasia (MDS)
224
35yo with hodgkins 10ya s/p mantle radiationi now with fatigue wtd?
Check TSH
| Prone to Lung/breast, thyroid CA
225
30yo undergoes chemo for hodgkins 10 ya ago - complication?
r/o AML (topoisomerase inhib)
226
Non-Hodgkin's lymphoma
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
Poor prognostic factors NHL
age >60
serum LDH
performance status <12, stroke, HTN, lymphoma
228
NHL grading
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
Post tx lymphoma
EBV (HIV pts) associated lymphoma
230
CNS lymphoma/burkitts/nasopharyngeal CA
EBV
231
MALT
h pylori
232
Kaposi's sarcoma
HHV-8 - danorubicin
233
Ca Cervic/Anal Ca
HPV 16/18
234
T cell leukemia
HTLV-1
235
65yo Pt asx cervical LAD - LN bx follicular small cell lymophoma preserved architecture - BM findings + tx?
observe
236
Pt with abdominal mass, wt loss, fever, bulky retroperitoneal LN - bx mass shows large cell lymophoma tx?
CHOP + rituximab
If failus chemo
Stem cell tx
237
Pt post renal tx - 2 years later with ataxia - CTH ring enhancing lesion in cerebellum dx?
EBV = cause for lymphoma s/p tx
238
Pt with well diff lymphoma p/w fatigue, wk, cbc hg 9.5, retic 5% smear with spherocytes, polychormasia best tes?
Cooms test r/o warm autoimmune hemoytic anema
| Tx - steroids and underlying dz
239
Pt with large hilar LAD dx with small cell ca p/w SOB - exam wit hmassive pleural eff wtd?
tap effusion
| If recurs - talc pleuredysis
240
Pt with lyphoma dx 2 ya not requ tx p/w sob, cxr with effsuion
Tap effusion
| then chmotx
241
Rituximab s/e
lymphopenia
242
Multiple Myeloma
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
PPX prior to bortezomib?
Herpes zoster
244
MM
protien >3.5
Lytice lesions
marrow plasmacytome >10%
+ hyper Ca+
245
MGUS
Protein<10% plasmacytoma
| no hyper Ca+
246
Smoldering MM
no hyperCa+
>10% plasmacytoma
+lytic lesions
247
T/F Hypercalemia with MM
T
248
T/F MM inc'd protein
T
249
T/F MM renal dysfxn
T
250
T/F MM Plt dysfxn
T
251
T/F MM bone pain
T
252
T/F MM infections
T
253
T/F MM amyloidosis
T
254
T/F MM Dilatino of retinal veins
T
255
Hypervicosity caused by all of the following
Waldenstroms macroglobulinemia-> tx plasmphoresis
PC Vera-> tx splenomegaly - phelebotomy/low dose ASA
Leukemia - leukapheresis
256
65yo Pt with protein 8gm glboulin 3.1 serum protein electrophor with inc'd IgG - best way to diff MM vs MGUS
skeletal survey
| +lytic lesions in MM
257
Pt dx with MGUS - wtd?
f/u 6 months r/o MM
258
Pt with plasma cells >10% in BM, skeletal survey neg, Ca normal - no end organ damage - pt dx with smolerding MM - wtd?
f/u myeloma protein q2 months
259
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?
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
Tumor of pancreas
Pancreatic CA
Glucoagonoma
Gastrnoma
VIPoma
261
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?
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
If pt refuses surgery for pancreatic CA wtd?
Gemcitabine chemo tx
| Pancreatic Ca with mets - palliative tx with stent and Gemcitabine
263
Pt with stage IV pancreatic CA and sever itching wtd?
Biliary stent
264
46yo F no h/o pancreatitis with 3.8cm mass head of pancreas seen on CT wtd?
Surgical excision - if mass not clearly defined or borderline resctable on CT wtd?
Endoscopic US first
265
What is more commonly a/w pancreatic CA - tob or etoh
smoking...
266
Diabetics ar prone to what kind of cancer - breast, colon or pancreatic?
pancreatic CA
267
Pt with familial adenomatous polyposis prone to what kind of cancer?
Ampulla of vater cancer
268
Pt with persistent hyperglycemia, wt loss anemia - exam with scaly necrotizing dermatitis - glucagon injection does not increase glucose level
glucagonoma - plasma glucogon >1000
269
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
Dx: VIPoma
Tx: octreotide ?sulfonyurea OD
270
Courvoisier's sign
Pancreatic CA
271
Trousseau's syndrome
Pancreastic CA
272
Double duct sign
Pancreatic CA
273
Sentinel loop sign (small bowel ileus)
Acute pancreatitis
274
Pt with diarrhea h/o flushing sensation, exam with telangiectasia wtd?
Check 5HIAA
| dx? Carcinoid
275
Hepatocellular CA
first line tx?
| Resection or tx
276
Dx of hepatocellular CA
Imaging studies - screen with US then CT contrast or MRI
277
What agent inc's survival with hepatocellular CA
Sorafenib
278
Thyroid CA
```
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
Papillary CA
Cervical LN, pitted CAlcification (MC wit best prognosis)
280
Follicular CA
mass and distant mts
281
Anaplastic CA
with mass - elderly with worst prognosis
282
Best managment for papillary and follcular CA after surgery
Radioiodine ablation - will NOT work for medullary CA as radioiodine not take up by C cells
283
Medullary CA recurrence
check Calcitonin level
284
Papillary CA recurrence
Check Thyroglobulin level
285
Follicular CA recurrence
Check Thyroglobulin level
286
Axillary LN
breast CA
287
Occipital LN
scalp infxn
288
Supraclavicular LN (R)
esophaeal lung or mediastinal malignancy
289
L Supraclavicular LN
Abdominal malignancy (see chart pg 191)
290
Cancer of Unknown Origin
MC - adenoCA
then poorly diff
then Others
291
Presentation CA unknown origin
40% LN, Cervical supraclavicular>Mediastinal>axillary
30% Liver lung bone
20% pt primary CA will be identified
Expected mean survival time 6 months
292
AdenoCA in females with axillary LN
r/o breast CA
Do mammogram +- MRI, ER/PR rct
Tx mastectomy +- radiation +- chemo
293
AdenoCA in females with bony invovlement
Pursue breast CA diagnosis
294
AdenoCA in males with bony invovlement
Pursue prostate CA
| Ask for urinary sx, do PSA and rectal exam
295
Poorly diff CA in young males
Pursue germ cell tumor
Do alpha feto protein & B HCG
Platinum based chemo if +
296
Squamous cell CA
presentation with cervial LN + - persue head/neck CA
| Cervical LN neg - pursue Lung CA
297
MCC CA of unknown origin
AdenoCA
298
MC place of presentation of CA unknown origin
Lymph node
299
Femaile with axillary LN+ most likely CA type
AdenoCA
300
Carcinoma of unknown origin in young male
Undiff cell CA
301
Head/neck CA
Squamous cell CA
302
50yo M smoker, single submandibular LN+ found to be undeiff CA - Phy exam head/neck neg, CXR neg wtd?
Upper pan endoscopy
303
Which screenings DO NOT decrease mortality
PSA
| Mmamo, pap, fecal occult, sigmoid DO decrease mortality
304
Pt with metastatic CA with persisent pain - takes oxycodone wit tylenol prn and morphine sulfate twice a day wtd?
Extended release oxycodone or morphine q8-12hr continuously
305
S/E Methotrexate
Reversible pneumonitis, hepatic fibrosis
306
S/E 5FU
MI/myelosuppression
307
S/E Vincristine
Neuropathy, SIADH
308
S/E Doxorubicin
Cardiomyopathy
309
S/E Bleomycin
interstitial fibrosis
310
S/e Mitomycin
HUS, blue green urine
311
S/e cyclophosphamide
hemorrhagic cystitis, bladder CA
312
S/e Bicalutamide
gynecomastia, pulm fibrosis, impair dark adaptation
313
s/e paclitaxel
Neuropathy, bradycardia
314
s/e gemcitabine
anal pruritis HUS flu rash
315
s/e tamoxifen
hot flashes, throboemboli, endometrial CA
316
LHRH s/e
impotence, transient cancer flare, osteoporosis
317
s/e hyroxyurea
dec'd wbc, myelosuppression
318
Cisplatin s/e
myelosupp, hypotension, weakness, alopecia
319
s/e etoposide
nephrotoxic, ototoxic, neuropathy
320
S/e IL-2
capillary leak syndrome, erythema
321
S/E IFN alpha
Flu like sx, LFT inc, arthalgias, hypo/hyperthyroidism
