Oncology

Question 1

Lambert-Eaton myasthenic syndrome

Answer 1

anti-P/Q-type voltage-gated calcium channel Ab, usually caused by small cell lung CA
Hx: progressive proximal muscle weakness, improvement with vigorous brief muscle activation, autonomic dysfunction, CN involvement, respiratory sxs
Dx: CT CAP, FND then MRI cranial and spinal, electrodiagnostic eval, test for Ab,
Txt: must treat underlying malignancy to treat neurological sxs, pyridostigmine, guanidine, if refractory>plasmapheresis

Question 2

Renal cell carcinoma

Answer 2

men>women (2:1 ratio), 60-70s, smoking, obesity, and hypertension
Hx: incidental finding on imaging or hematuria, flank pain, and an abdominal mass, paraneoplastic signs
Labs: erythrocytosis d/t inc EPO, inc Ca d/t PTHrp
Dx: bx (clear cell most common)
Txt:
small tumor- partial nephrectomy
>7 cm- radical nephrectomy
High-stage/high-grade tumors/Metastatic- interferon alfa alone (not preferred, causes fatigue), bevacizumab and interferon alfa, pazopanib (causes transaminitis), and sunitinib (causes fatigue, hand-foot syndrome, and thrombocytopenia)

Question 3

Testicular CA

Answer 3

Men 15-35 most common
Hx: history of cryptorchidism and prior orchiopexy
PE: painless mass, lower abdominal or scrotal aching, gynecomastia
Dx: scrotal US/ CT scan
Labs: seminoma-inc beta HcG, non-seminoma- inc alpha fetoprotein and beta HcG (inc LDH)

Question 4

Pancreatic adenocarcinoma

Answer 4

Hx: nausea, abdominal discomfort, and jaundice. weight loss, anorexia, and fatigue. migratory thrombophlebitis (Trousseaus syndrome)
PE: hepatomegaly, ascites, scleral icterus, peripheral adenopathy, and temporal wasting. palpable nontender gallbladder (Courvoisier sign), Virchows node, sister mary joseph node
Dx: CT AP or endoscopic US, CA 19-9
Txt: biliary obstruction: percutaneous drainage of fluid or by endoscopic stent placement in the bile duct.
Metastatic- palliation or by treatment with a gemcitabine-palliation or, treatment with a gemcitabine-based chemotherapy or folinic acid, irinotecan, oxaliplatin, and fluorouracil.

Question 5

Endometrial carcinoma

Answer 5

risk factors: Excess estrogen exposure, tamoxifen, chronic anovulation, obesity, early menarche, late menopause, advancing age, and family history
Hx: AUB, 55-65 yo
Dx: endometrial bx
Txt: total abdominal hysterectomy, bilateral salpingo-oophorectomy, and lymph node sampling is the standard initial treatment for women with newly diagnosed uterine cancer. Chemotherapy or radiation PRN

Question 6

Ovarian cancer

Answer 6

95% epithelial origin, delayed menopause, nulliparity increase risk, OCP dec risk, BRCA1/BRCA2 gene mutations highest risk followed by hereditary nonpolyposis colorectal cancer.
Sxs: vague gastrointestinal symptoms, early satiety, bloating, and dyspepsia
Labs: CA 125
Dx: abdominal CT/US: solid mass or a cyst with thick septations, ascitic fluid or pleural effusion cytology
First line: cisplatin or carboplatin in addition to a taxol-based chemotherapeutic such as paclitaxel

Question 7

Multiple Myeloma

Answer 7

plasma cell malignancy, anemia, bone pain/lytic bone lesions, hypercalcemia, and kidney disease with >30% plasma cells in the bone marrow or peripheral blood
Labs: peripheral blood smear: Rouleaux formations, Protein electrophoresis UA: Bence-Jones proteins
Dx: Serum or urine electrophoresis that reveals IgM spike, Bone marrow bx: > 30% plasma cells
Txt: induction therapies with bortezomib and dexamethasone, and lenalidomide with autologous stem cell transplantation, which confers a near-complete response rate of 57%, and the prior regimen followed by melphalan and reinfusion of autologous stem cells, which confers a near-complete response rate of 78%. Lenalidomide for maintenance

Question 8

Prostate CA

Answer 8

older man!, AA, family hx
Sxs: obstructive uropathy and lower back pain
Labs will show PSA > 10 ng/mL
Dx: needle core biopsy, Gleason score used to grade prognosis
Txt: if metastatic androgen deprivation therapy with a medication (leuprolide)

Question 9

Cardiac atrial myxoma

Answer 9

women, third and sixth decades of life, in the LA, thromboembolism, valvular obstruction, and dysrhythmias, thombus in LA appendage
Sxs: fever, weight loss, TIA
Echo: pedunculated mass with thrombus
Txt: resection

Question 10

Colon CA screening

Answer 10

first-degree relative diagnosed <60 then begin screening at 40 or 10 years earlier than the age of diagnosis of the youngest affected relative (whichever comes first) with colonoscopy q5 years
In general population: 50-colonoscopy q10 years, guaiac-based fecal occult blood test and fecal immunochemical test annually, or a flexible sig q5 years
IBD: colonoscopy 8 years after the onset of pancolitis or 12–15 years after the onset of left-sided colitis, q1-2 yers
Familial adenomatous polyposis: flexible sig between ages 10 and 12 and undergo colectomies for polyposis on an annual basis.

Question 11

chronic lymphocytic leukemia, CLL

Answer 11

Txt: frail patients with significant comorbidities, patients >65, and patients < 65 with significant comorbidities is ibrutinib or obinutuzumab and chlorambucil. First-line therapy for patients <65 who do not have significant comorbidities is fludarabine, cyclophosphamide, and rituximab. Ibrutinib may be continued for maintenance therapy after remission.
Sxs: B sxs
Labs: WBC>50,000, anemia, thombocytopenia, peripheral smear: isolated lymphocytosis, smudge cell
PE: splenomegaly, LAD
Txt: early stage-observation, purine analogs (fludarabine), Ab (rituximab, alemtuzumab), alkylating agents (chloroambucil), cyclophosphamide, IVIG for hypogammagloubulinemia and infxn

Question 12

Non-Hodgkin’s lymphoma

Answer 12

Higher risk with connective tissue disorders and immunocompromised, infxn with H.pylori, Borrelia burgdorferi, Chlamydia psittacosis, Coxiella burnetii, EBV
Sxs: painless LAD, fevers, night sweats, weight loss, pruritus, and fatigue
Dx: absence Reed-Sternberg cells on lymph node biopsy, noncontiguous spread, extra nodal involvement
Txt: Rituximab + chemotherapeutics

Question 13

Superior pulmonary sulcus tumor or Pancoast tumor

Answer 13

non-small cell lung cancer
Sxs: ipsilateral shoulder and arm pain, hand muscle weakness/pain and sensory abnormalities of the axilla and medial upper arm, Horner syndrome, supraclavicular LAD, weight loss, cough and hemoptysis may not be present until later in the disease course
Txt: chemoradiation, surgical resection

Question 14

acute myeloid leukemia (AML)

Answer 14

age >65
Sxs: bone marrow suppression (fatigue due to anemia, bleeding due to thrombocytopenia), fever, infections
Dx: Auer rods on pathology, cytogenetics translocation between chromosomes 8 and 21, mutations in the NPM1 gene and FLT3 gene, >20% blasts on peripheral smear or bone marrow biopsy
PE: petechiae and bleeding mucosa, gingival hypertrophy, typically no lymphadenopathy or hepatosplenomegaly
Txt: cytarabine and an anthracycline (daunorubicin) during induction and then undergo consolidation therapy with conventional chemotherapy or allogenic hematopoietic stem cell transplantation depending on genetic risk profile and various other patient factors
Non-APL: cytarabine and anthracycline induction
Acute Promyelocytic Leukemia (APL) - t(15;17) translocation, associated with DIC and significant bleeding>Tx: All-trans retinoic acid (ATRA) or arsenic trioxide

Question 15

Li-Fraumeni syndrome

Answer 15

Rare autosomal dominant disorder associated with increased risk of developing breast cancer, osteosarcoma, and soft tissue sarcomas like rhabdomyosarcoma . It is due to genetic mutations of tumor suppressor genes TP53 and/or the CHEK2 genes.
Can see brain tumors, leukemias, and adrenal cortical carcinoma. Screen with strong personal and/or family history of cancers associated with Li-Fraumeni syndrome
Dx: proband with sarcoma before 45, first degree relative with any cancer before 45, first/second degree relative with any cancer before 45 or sarcoma at any age
Txt: genetic counseling should be advised for consideration of confirmatory genetic testing.

Question 16

Esophageal CA

Answer 16

Mostly adenocarcinoma, in the lower esophagus and is primarily associated with GERD and Barrett’s esophagus then SCC, in the upper esophagus and is primarily associated with HPV infection and smoking
Sxs: dysphagia, weight loss, and regurgitation
Dx: endoscopic biopsies and then followed by a CT or PET scan of the chest and upper abdomen for staging
Txt: surgery, radiation, and chemotherapy.

Question 17

Basal cell carcinoma of skin

Answer 17

Sxs: nodular or cystic raised mass that is red, pearly, and translucent and has telangiectasias on the periphery on sun-exposed areas of the body
Risk factors for metastasis include neglect, perineural invasion, tumor size greater than 10 cm, and basosquamous or morphoeic subtypes.
Txt: surgical excision, radiotherapy, cryotherapy, photodynamic therapy, or treatment with imiquimod.

Question 18

Primary central nervous system lymphoma (PCL)

Answer 18

uncommon variant of extranodal non-Hodgkin lymphoma, primary risk factor is immunodeficiency, EBV
Sxs: confusion, lethargy, memory loss, hemiparesis, aphasia, and seizures, B sxs
Dx: CT scan or MRI showing one or multiple well-defined focal lesions in the corpus callosum, periventricular or periependymal areas, differentiate between PCL and toxoplasmosis, CSF cytology, Epstein-Barr virus DNA, toxoplasmosis serology, an empiric trial of antibiotics, and stereotactic brain biopsy
Txt: methotrexate-based chemotherapy regimens given in conjunction with radiation therapy, steroids and anti-retroviral therapy

Question 19

Inflammatory breast CA

Answer 19

Sxs: three to six months, pain, itching, erythema of at least one-third of the breast, edema, and warmth. There is classically a peau d’orange appearance of the breast, Nipples may appear flat, retracted, or crusted, and a palpable underlying mass may or may not be present, axillary LAD
rapidly progressive with frequent visceral metastasis and associated poor prognosis.
Dx: mammography, breast ultrasound, and biopsy
Txt: neoadjuvent chemo >masectomy with node dissection> post masectomy chest wall radiation if not metastatic

Question 20

Hodgkin’s lymphoma

Answer 20

four classical histologic subtypes: nodular sclerosis, mixed cellularity, lymphocyte-rich and lymphocyte-depleted, non-classical subtype: nodular lymphocyte-predominant
Sxs: painless LAD, mediastinal mass >dyspnea, cough, and obstruction of SVC, B sxs, hepatosplenomealy, pruritis
Dx: PET CT
Txt: no B symptoms>radiation alone or radiation combined with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD). Advanced disease or those with B sxs >ABVD.

Question 21

chronic myelogenous leukemia (CML)

Answer 21

translocation of the long arms of chromosome 9 and 22, creating BCR-ABL gene
Sxs: fatigue, night sweats, weight loss, LUQ pain or discomfort, and splenomegaly
Dx: Fluorescent in situ hybridization (FISH) may be used to detect the translocation, conventional cytogenetics not as good
chronic phase>accelerated phase>blast crisis phase
Chronic: <10% blasts
Accelerated phase: 10–19% myeloblasts in peripheral blood or in the bone marrow, >20% basophils in peripheral blood.
Blast crisis: > 20% myeloblasts in peripheral blood or bone marrow
Txt: tyrosine kinase inhibitor (dasatinib, imatinib, or nilotinib), can discontinue therapy when molecularly undetectable disease. Allogenic HSCT for young patients in chronic phase

Question 22

Cervical CA

Answer 22

HPV 16 and 18
Sxs: asx, vaginal bleeding and dyspareunia
Txt: Stage IA1: conization>Stage IA2: hysterectomy. Stage IB (cervix only): radical hysterectomy (preserve ovarian function) or by primary radiotherapy> Stage IIA and higher: chemotherapy and radiation therapy (Cisplatin and paclitaxel)

Question 23

Oral CA

Answer 23

SCC most common
Risk factors: tobacco (especially chewing tobacco or snuff) and alcohol use, HIV, sunlight exposure, and hyperplastic oral candidiasis, HPV 16
Sxs: originate from a premalignant disorder such as erythroplakia (older, smoke, drink), leukoplakia, or lichen planus, ulcerations with indurated borders or nonhealing masses
Dx: biopsy
Txt: surgical excision

Question 24

spermatocytic tumor

Answer 24

Types:
Germ cell tumors: seminomas (inc HCG) and nonseminomas (inc HCG and possibly AFB, younger age, types include embryonal carcinoma, yolk sac carcinoma, choriocarcinoma, teratoma, and teratoma with malignant transformation, and mixed tumor types)
Dx: radical inguinal orchiectomy
Txt:
stage I seminomas: radical inguinal orchiectomy then active surveillance
stage I non-seminoma: radical inguinal orchiectomy w/ close observation or retroperitoneal LN dissection with 1-2 cycles of bleomycin, etoposide, and cisplatin.
stage II: combination of radiotherapy to the para-aortic and iliac lymph nodes, retroperitoneal LN dissection, and bleomycin, etoposide, and cisplatin depending on the histology, stage, and patient and physician preference.
Stage III and metastatic: chemotherapy

Question 25

Carcinoid tumor

Answer 25

abnormal cluster of neuroendocrine cells secretes high levels of serotonin (5-HT) or other bioactive amines. In GI tract or lungs mostly.
Sxs: secretory diarrhea, cutaneous flushing, and asthmatic wheezing. right-sided valvular heart disease and pellagra (niacin deficiency), abdominal pain and sometimes bowel obstruction
Dx: 24-hour urinary excretion of 5-HIAA, CT scan, if RUQ pain suspect mets to liver> MRI, Imaging with radiolabeled somatostatin analogs to localize tumor
Txt: somatostatin analog such as octreotide. Surgical resection with metastatic disease or liver involvement

Question 26

glucagonoma

Answer 26

alpha cells secrete glucagon in pancreas tail
Sxs: necrolytic migratory erythema (erythematous vesicles and bullae > patches and plaques>ulcerate, crust, and form scale >hyperpigmentation on perioral area, trunk, groin, pelvis, and LE), weight loss, glucose intolerance, diarrhea, venous thrombosis, neuropsych changes, dilated CM
Dx: fasting glucagon level >500, CT/MRI/PET/somatostatin receptor scintigraphy to localize tumor
Txt: surgical resection, if metastasized >Chemotherapy Octreotide for necrolytic migratory erythema.

Question 27

myelodysplastic syndrome

Answer 27

dysplastic and ineffective blood cell production, risk of transformation to acute leukemia
Risk factors: chemotherapy (alkylating agents), environmental toxins, and radiation
Sxs: fatigue, weakness, angina, and dizziness, infxn
Labs: sideroblastic anemia, neutropenia
Dx: otherwise unexplained cytopenias, ≥ 10% of erythroid precursors, granulocytes, or megakaryocytes
AML: >20% Blast cells in bone marrow aspirate and peripheral blood, Granulocytes display reduced segmentation and appear with bilobed nuclei (pseudo-Pelger-Huet anomaly)
Txt: clinical trials

Question 28

Lung cancer

Answer 28

most are NSCLC
Risk factor: Smoking, previous radiation therapy, environmental toxins, and pulmonary fibrosis
Sxs: cough, hemoptysis, dyspnea, and chest pain, mets?>hip and back pain, Horner’s syndrome (ipsilateral ptosis, anhidrosis, and miosis), neurologic symptoms and hypotension with tachycardia that indicate a possible malignant pericarditis
Dx: CXR>CT>Bx (Small cell and squamous=central, adenocarcinoma aka NSLC and large cell=peripheral)
Txt: multidisciplinary approach and may include surgery, radiation, and chemotherapy.

Question 29

Gastric adenocarcinoma

Answer 29

H. pylori, EBV, poor prognosis, different from gastroesophageal cancer (cardia of stomach)
Sxs: weight loss, persistent abdominal pain, nausea, dysphagia, melena, early satiety, seborrheic keratosis, MAHA, acanthosis nigricans, Trousseau’s syndrome, membranous nephropathy
Dx: bx (adenocarcinoma most common)
PE: left supraclavicular node (Virchow’s node), left axillary node (Irish node), periumbilical node (Sister Mary Joseph’s node)
Txt: stage T1a in the lower 2/3 of the stomach> subtotal gastrectomy. If - margines no chemotherapy or postoperative radiation
Upper 1/3 somatch: total gastrectomy i
Locally advanced: total gastrectomy then adjuvant chemotherapy and postoperative radiotherapy. UnresectableLchemotherapy alone (fluoropyrimidine and a platinum with or without docetaxel)
Trastuzumab in advanced gastric cancers that harbor HER2 amplification

Question 30

Gallbladder CA

Answer 30

poor prognosis, women >men
Risk factors: cholelithiasis, calcification of the gallbladder wall, gallbladder polyps >10 mm in diameter, anomalous pancreaticobiliary duct junctions, and carcinogens such as methylcholanthrene, o-aminoazotoluene, and nitrosamine. Obesity, use of estrogens, PSC
Sxs: weight loss, anorexia, jaundice and RUQ pain
Dx: US, CT, MRI
Txt: surgical resection if possible, chemo: fluorouracil, doxorubicin, and mitomycin C

Question 31

Bladder CA

Answer 31

Risk factor: smoking
Transitional cell carcinoma (urothelial carcinoma) is the most common type
Sxs: hematuria
Dx: CT urography to visualize the upper urinary tract and cystoscopy to visualize the lower urinary tract
Txt: non-muscle-invasive: transurethral resection
low-risk disease: resection > intravesical chemotherapy, intermediate-risk: resection >one year of maintenance intravesical chemotherapy
high-risk: resection> Bacillus Calmette-Guerin immunotherapy
very high-risk non-muscle-invasive: cystectomy
muscle-invasive: radical cystectomy and pelvic lymphadenectomy (bladder-sparing txt complete transurethral resection> radiotherapy with concurrent chemotherapy-require lifelong surveillance, and salvage cystectomy). Chemotherapy for muscle-invasive includes dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (DDMVAC); gemcitabine and cisplatin; or cisplatin, methotrexate, and vinblastine

Question 32

graft-versus-host disease

Answer 32

attack of immunologically competent cells in the graft on target antigens in recipient tissues in a recipient who lacks an ability to mount an effective response to eliminate the donor immunologic cells
Acute>within 100d, involves predominantly the skin, gastrointestinal tract, and liver
Chronic> affect almost any organ system
Sxs: dyspigmentation of the skin, nail dystrophy, xerostomia, dry eyes, myositis, vaginal sclerosis, weight loss, transaminitis and jaundice, restrictive or obstructive lung disease, pericarditis, and bone marrow suppression
Txt: corticosteroids and immunosuppressive medications

Question 33

Osteosarcoma

Answer 33

in adolescents, young adults, > 50 yo
Sxs: pain and swelling of the long bones around the knee and upper arm, awakens at night, swelling
X-ray: sunburst periosteal reaction with radial deposition of calcium within the osteosarcoma. Codman’s triangle
Txt: surgery and chemotherapy.

Question 34

Monoclonal gammopathy of undetermined significance (MGUS)

Answer 34

premalignant clonal plasma cell or lymphoplasmacytic proliferative disorder that is asymptomatic
increases with patient age and men > women, Africans and African Americans
Findings: serum monoclonal protein (M-protein) <3, bone marrow < 10% monoclonal plasma cells, and the absence of end-organ damage due to the proliferative process
potential to progress to smoldering (asymptomatic) multiple myeloma with the possibility of developing symptomatic multiple myeloma
Txt: Monitor 6 months after diagnosis, then yearly with CBC, Creatinine, Calcium, M protein level via SPEP, serum free light chains, and immunofixation

Question 35

acute promyelocytic leukemia

Answer 35

increased peripheral promyelocytes, type of AML
Sxs: DIC
Dx: translocation between chromosome 15 and 17 on cytogenetics, and presence of the PML/RAR-alpha protein on polymerase chain reaction testing
Txt: all-trans retinoic acid and arsenic trioxide

Question 36

Glioblastoma

Answer 36

Sxs: HA, seizure, personality changes, focal weakness, nausea, vomiting, visual changes
Txt: surgical resection if not in sensitive area, oncurrent radiotherapy and temozolomide, which is then followed by a six-cycle course of temozolomide

Question 37

Multiple endocrine neoplasia type 2 (MEN 2)

Answer 37

autosomal dominant pattern
MEN 1: Parathyroid hyperplasia, pancreatic tumors, and pituitary adenoma
MEN2A: medullary thyroid cancer, pheochromocytoma, and parathyroid adenoma or hyperplasia
MEN2B: less common, aggressive medullary thyroid cancer, Pheochromocytoma, mucosal neuromas of the lips and tongue, intestinal ganglioneuromas, and developmental abnormalities (such as skeletal deformities, Marfanoid habitus, and joint laxity)

Question 38

diffuse large B cell lymphoma

Answer 38

most common non-Hodgkin lymphoma
Sxs: generalized LAD, B sxs
Txt: rituximab, cyclophosphamide, daunorubicin, vincristine, and prednisone (R-CHOP)