Oncology

Question 1

Why is mammography performed even in women undergoing biopsy of a mass?

Answer 1

because it is helpful in detecting other lesions or bilateral disease which impacts disease management

Question 2

When are PET scans used in the management of breast cancer?

Answer 2

• it is helpful for identifying cancer in abnormal lymph nodes seen with CT that are not easily accessible for biopsy
• in other words, it is useful in excluding metastasis and the need for additional chemotherapy

Question 3

When is sentinel lymph node biopsy performed for breast cancer and what information does it provide?

Answer 3

• performed routinely in all patients at the time of lumpectomy or mastectomy
• a negative result eliminates the need for further axillary lymph node dissection

Question 4

How is breast cancer treated?

Answer 4

1. start with surgery
   - lumpectomy with radiation is equally effective compared to modified radical mastectomy
   - all patients routine have sentinel lymph node biopsy
2. add an aromatase inhibitor, like anastrozole, or tamoxifen for patients with ER or PR positive cancer
3. add trastuzumab a HER2/neu antagonist for patients with HER2/neu positive cancer
4. give adjuvant chemotherapy for lesions larger than 1 cm and patients with positive axillary lymph nodes

Question 5

Compare the benefit and adverse effects of aromatase inhibitors and tamoxifen for the treatment of breast cancer.

Answer 5

• all patients with an ER or PR positive cancer should receive hormonal therapy in one of these forms
• aromatase inhibitors (e.g. anastrozole, letrozole) are more effective but carry a greater risk for osteoporosis
• tamoxifen carries a risk for endometrial cancer and blood clots

Question 6

What is trastuzumab? What are it’s side effects?

Answer 6

• it is antibodies against HER2/neu receptors used in the treatment of HER2/neu positive breast cancers
• it is cardiotoxic

Question 7

What is adjuvant chemotherapy and when is it indicated for breast cancer patients?

Answer 7

• it is chemotherapy aimed at cleaning up presumed microscopic cancer cells
• it is indicated for lesions greater than 1 cm or that are associated with positive axillary lymph nodes

Question 8

What is the best initial test for prostate cancer?

Answer 8

biopsy is both the best initial and most accurate test

Question 9

What are the two most common complications of prostatectomy? How does prostatectomy compare to radiation in this regard?

Answer 9

• most common are erectile dysfunction and urinary incontinence
• radiation is less likely to cause ED but has more associated diarrhea

Question 10

What is Gleason grading and how is it used in the management of prostate cancer?

Answer 10

• it is a measure of the aggressiveness or malignant potential of prostate cancer
• a higher score suggests greater benefit from surgical removal

Question 11

How does the hormonal treatment of breast cancer compare to that used for prostate cancer apart from being different agents?

Answer 11

hormonal treatment for breast cancer prevents recurrence while that for prostate cancer will only shrink lesions that are already present

Question 12

How is an elevated PSA worked up?

Answer 12

• start with a DRE, if there is a palpable mass, perform a biopsy
• if there isn’t a palpable mass, perform a transurethral ultrasound
• if transurethral ultrasound detects a mass, biopsy it
• if transurethral ultrasound doesn’t detect a mass, perform multiple blind biopsies

Question 13

What role does ultrasound play in the management of prostate cancer?

Answer 13

it is only used to identify masses for biopsy if non can be detected with DRE

Question 14

What role is there for PSA in screening for prostate cancer?

Answer 14

it shouldn’t be routinely offered; however, if a patient is less than 75 and asks for it, then you should do the test

Question 15

What is abiraterone?

Answer 15

it is a 17-hydroxylase inhibitor use in the treatment of prostate cancer because it stops production of all androgens in the body, including adrenal production

Question 16

How is prostate cancer treated?

Answer 16

• the mainstay is radiation or prostatectomy, which prevent the spread of metastases, but radiation has a lower risk for erectile dysfunction
• hormonal therapy includes flutamide, GnRH agonists, ketoconazole, abiraterone, and orchiectomy to reduce testosterone levels and control the progression of disease
• unlike for breast cancer, these hormonal therapies do not prevent recurrence, they only reduce the size of lesions that are already present

Question 17

When can surgery not be performed for lung cancer?

Answer 17

if any of the following are present:

• bilateral disease or contralateral lymph node involvement
• malignant pleural effusion
• involvement of the carina, heart, aorta, or vena cava

Question 18

Why is small cell cancer so unlikely to be resectable?

Answer 18

because it is almost always discovered after it has metastasized outside of one lung, which is a contraindication for surgical resection

Question 19

What biomarker guides treatment of lung cancer?

Answer 19

• the programmed death biomarker
• cancers that are positive for this are likely to respond to pembrolizumab and nivolumab, which are better tolerated than platinum therapy

Question 20

What are pembrolizumab and nivolumab?

Answer 20

programmed death (PD) inhibitors that are the preferred agents for treating PD positive lung cancer

Question 21

What biomarker is used to follow the treatment of ovarian cancer?

Answer 21

CA-125

Question 22

Which cancer is unique in that there is benefit from removing large amounts of locally metastatic disease?

Answer 22

ovarian cancer, in which case it is beneficial to remove all visible tumor within the pelvis and abdomen and to remove the pelvic organs before starting chemotherapy

Question 23

What are the four common anterior mediastinal masses? what are the two common posterior mediastinal masses?

Answer 23

• anterior: thymoma, teratoma, thyroid, lymphoma

- posterior: neurofibroma, esophageal cancer

Question 24

With what cancers is asbestos associated?

Answer 24

• it is most often associated with lung cancer

- however, most cases of mesothelioma are associate with asbestos exposure

Question 25

What is pleurodesis?

Answer 25

a procedure in which minocycline, bleomycin, or talc is used to purposefully inflame the pleura and obliterate the pleural space in patients with recurrent, large pleural effusions

Question 26

How is testicular cancer diagnosed?

Answer 26

the answer is always inguinal orchiectomy because needle biopsy and cutting the scrotum risk seeding

Question 27

With what biomarkers are testicular cancers associated?

Answer 27

• B-hCG is associated with both seminomatous and non-seminomatous cancers
• AFP is only associated with non-seminomatous

Question 28

How do seminomatous and non-seminomtaous testicular cancers compare?

Answer 28

• seminomatous are sensitive to chemotherapy and radiation

- non-seminomatous are associated with elevated AFP but are only sensitive to chemotherapy

Question 29

How is testicular cancer managed?

Answer 29

1. start with inguinal orchiectomy for diagnosis
2. get a staging CT of the chest, abdomen, pelvis
3. add radiation for seminomatous disease
4. add chemotherapy for widespread disease of either seminomatous or non-seminomatous disease

Question 30

What is unique about the treatment of metastatic testicular cancer?

Answer 30

widespread disease can be cured with chemotherapy

Question 31

How is chemotherapy-induced nausea treated?

Answer 31

the only three classes that are useful are 5-HT inhibitors, glucocorticoids, and NK-1 receptor antagonists

• ondansetron is the best initial therapy unless patients have a prolonged QT
• glucocorticoids are used in combination with 5-HT inhibitors like ondansetron
• NK-1 antagonists like aprepitant are second-line