Oncology Flashcards

1
Q

Carcinomas are cancers that start ?

Sarcomas are cancers that start ?

Leukemias are cancers that start ?

A

Skin/organ lining (breast/lung)

Bone Fat Cartilage Muscle Vessel CT/Support tissue (osteosarcoma)

Marrow causing abnormal cells to be released

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2
Q

What are the five prefixes of benign tumors?

What are the six prefixes of malignant tumors?

A
Chondroma- cartilage
Andenoma- glandular
Papilloma- epithelial
Osteoma- bone
Fibroma- connective tissue
Hepatoma- liver
Melanoma- melanocyte skin
Sarcoma- tissue around joint
Leukemia- blood
Lymphoma- lymph tissue
Carcinoma- epithelial
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3
Q

What are the three methods metastases spreads in the body and what type is usually found by each?

A

Seeding- ovarian

Lymph- typical for carcinoma

Hematgoenous- typical for sarcoma; usually to liver/lungs

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4
Q

Define Proto-Oncogenes

Define Oncogenes

A

Codes proteins that stimulate cell division

Cancer causing gene:
Mutation stimulates unregulated/early division

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5
Q

Define Tumor Suppressing Genes

What happens when these genes are mutated?

How do Proto become mutated to Oncogene?

A

Code proteins to suppress oncogenes (cell division)

No inhibition= cancerous growth

Carcinogens: Chemical UV radiation Virus

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6
Q

What are the hallmarks of Ca that are needed for it to develop and survive?

A
A TRAGEDIES
Activating metastasis
Tumor promoting inflammation
Resisting death
Avoiding destruction
Genome instability/mutation
Evading growth suppressors
Deregulating energetics
Inducing angiogenesis
Enabling immortality
Sustained signaling
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7
Q

Basic Oncology focuses on ? three Dz parts and is instrumental in ?

What are the top three leading causes of death in the US?

A

Patterns, Cause, Effect
Screening, Prevention, Txs

Heart Dz
Cancer
Chronic lower respiratory dz

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8
Q

Only three forms of Ca that are not decreasing in prevalence or death rates?

What forms of Ca remain in the same location of developmental probability between M/F genders

A

Esophageal Pancreatic Hepatocellular

Lung/bronchus
Colon/rectum
Melanomas of skin
Non-Hodgkin lymphoma

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9
Q

What are the top three RFs of cancer for men and women

What are the prevalence of Brca mutation and Ca

A

Smoking Obesity Alcohol

BRCA-1: 85% breast, 50% ovarian

BRCA-2: fe/male breast, ovarian, prostate Ca

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10
Q

What are the different types of MEN

What is the difference between Wermer and Werner

A

MEN 1: Wermer Syndrome; MC, mutated menin gene

MEN 2: Sipple syndrome; mutated ret gene

MEN 3: mutated ret gene

MEN 4: mutated CDKIN1B gene

Wermer- MEN 1
Werner- premature aging

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11
Q

How does MEN 1 present

What is normal life expectancy

A
Hyperparathyroidism
GEP-NETs 
Pituitary adenomas
Insulinomas
Gastrinomas

55yrs

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12
Q

How does MEN 2 present

A

Medullary thyroid carcinoma
Hyperparathyroidism
Pheochromocytomas
Hirschsprung Dz

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13
Q

Alcohol is linked to ? forms of Ca

Although associated w/ breast Ca, what is the catch w/ alcohol induced Ca?

A

Head Esophageal Liver Neck

Abstinence not linked w/ reduced risk

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14
Q

Radiations are linked to ? types of cancer

Radon is linked to ? type

Vinyl chloride is linked to ? type

A

Leukemia Breast Thyroid Lung

Lung

Hepatic angiosarcoma

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15
Q

Benzene exposure is linked to ? types of Ca

UV light is linked to ? types of Ca

A

AML Lymphoma

All types of skin cancer

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16
Q

USPSTF recommendations for breast Ca screening

Colon Ca screening for average risk PTs?

A

Mammography q2yrs 50-74y/o w/out S/CBE

Start at 50y/o, q10yrs w/ colonoscopy
Start AfAm/NAFLDz PTs at 45y/o

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17
Q

When are colon cancer screenings recommended for PTs w/ +FamHx

A

One FDR or 2+ SDR Dx >60, start at 50

One FDR or 2+ FDR Dx <60, start at 40 or 10yrs prior to Dx, what ever if first

q5yrs there after

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18
Q

What are the US PSTF grading criteria for expected benefit?

A

A: substantial, offer
B: moderate, offer
C: small, selective PTs
D: harms out weigh/no benefit, discourage
I: insufficient evidence to assess harm/benefit

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19
Q

What are the 4 methods of direct visualization for GI oncology?

What are the 3 stool based oncology tests?

A

Colonoscopy- q10yrs
Flex sig w/ FIT- q10y, FIT q1yr
CT colonography- q5yrs
Flex sigmoid- q5yrs

gFOBT: q12mon
FIT: q12mon
FIT-DNA: q1 or 3yrs

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20
Q

What age groups are eligible for PSA screening and what age groups are not recommended for screening?

What groups are cervical cancer screenings not recommended?

A

55-69: recommend, Grade C
+70: not recommended, Grade D

<21, >65, post-hysterectomy

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21
Q

How often are cervical cancer screenings conducted?

A

21-29: q3yrs w/ cytology

30-65: q3yrs w/ cytology or,

q5yrs w/ only hrHPV or,

q5yrs w/ hrHPV and cytology

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22
Q

When is lung cancer screening conducted?

A

55-80y/o w/ 30+ p/year or quit <15yrs: Annual LDCT (Grade B)

Stop once PT has quit for >15yrs or develops health problem that limits life expectancy/ability for surgery

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23
Q

Define Grading

Define Staging

A

Degree of differentiation based on pathology (1-4) w/ description

More predictive:
Severity and metastases; Estimates prognosis/guides Txs

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24
Q

What are the sub staging of T

A
T= tumor size
TX= cannot be evaluated
T0= no primary evidence
Tis= carcinoma in situ; early, no spread
T1-4= primary tumor size
(small to large)
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25
What are the sub staging of N What are the sub staging categories of M?
``` N= number of nodes w/ Ca NX= can't be evaluated N0= no regional involvement N1-N3= extent of spread (mild mod severe) ``` ``` M= distant metastasis M0= no metastasis M1= metastasis ```
26
What are the 4 systemic effects of chemo? What are the 5 types of local toxicity induced by XRT Tx?
Neutropenia V/N GI/Skin toxicity ``` Pneumonitis Infertility Thyroid Ca, secondary Colitis Hypothyroidism ```
27
What biologicals/immunological Txs are used for Ca?
Monoclonal Ab therapy: Rituximab/Rituxan- CD20+ lymphoma Rastuzumab/Herceptin- HEGFR+ breast cancer
28
What are the four parts of supportive care? What lab result may be used for post-tx f/u and prognosis but not for dx/screening? These can not be used for Dx or screening except for ? exception?
Physical Emotion Psych Spirit Tumor markers PSA
29
AFP indicates presence of ? two types of Ca? CA-125 indicates presence of ? what type of Ca?
Hepatocellular Testicular Ovarian
30
CEA indicates presence of ? three types of Ca? CA 19-9 indicates presence of ? type of cancer?
Colon Pancreatic Breast Pancreatic
31
Define Paraneoplastic Syndrome
Set of S/Sxs from malignant tumors release of hormones/proteins Host Abs meant to kill tumor but damages healthy cells (AutoImm)
32
What type of cancer is most likely to be associated w/ multiple neoplastic syndromes? This form of Ca can develop ? 4 syndromes?
Small cell lung cancer Cushings SIADH HyperCa Lambert Eaton syndrome
33
# Define Myelo and Proliferative Myeloproliferative d/os are ? type of issue
Bone marrow, rapid reproduction of cells Mutated receptor kinase leads to excess activation and pathological cell division
34
Myeloproliferative d/os can progress into ? What are the 4 types of myeloproliferative d/os and what cells do they impact?
Acute Myeloid Leukemia Myelofibrosis- potential PCV- myeloid Essential/CML- progenator
35
What are the characteristics of myelofibrosis? What is the step by step process of myelofibrosis development?
Abnormal myeloid proliferation Atypical megakaryocytes Clonally expanded megakaryocytes release fibroblast GFs, Fibrosis of marrow occurs Extramedullary hematopoiesis leads to splenomegaly
36
How does myelofibrosis present? What two uncommon Sxs that don't show until late/advanced in Dz process?
>50y/o w/ insidious onset MC fatigue from anemia/satiety from spleno/hepatomegaly Thrombocytopenia- bleeding Satiety sensation
37
What presenting issue is a sign of poor prognosis for myelofibrosis? What are the clincial presenting issues of myelofibrosis?
Severe anemia Splenic infraction Cachectic upper leg pain Hematopoiesis- Transverse myelitits Ascites PHTN Esophageal varices
38
What Trifecta lab results indicates a Dx of myelofibrosis? What is a fourth finding seen too? 10% of Myelofibrosis PTs will be Triple Negative which means ?
Poikilocytosis Giant irregular shapes platelets Leukoerythroblastic Tear drop RBCs No JAK2 CALR MPL mutations (JAK2 mutated in +half of PTs)
39
How is Myelofibrosis Tx
Splenomegaly= hydroxyurea 1st line Tx Splenectomy if pain episodes, thrombocytopenia, transfusion requirements Anemia- tx w/ transfusion Control w/ Prednisone L-domide Androgens T-domide Allogenic transplant- potential curative Ineligible= JAK2 inhibitor (Ruxolitinib)
40
What is the prognosis for PTs Dx w/ Myelofibrosis? What usually kills these PTs
5yrs if untx LF AML Bleeding
41
What type of issue does Polycythemia Vera cause? Who and how does this usually present?
Myeloid cells over produce RBCs*, WBCs, Thrombocytes 60y/o hyperviscous male w/: HA Dizzy Blurred vision Erythromelalgia PUD/Epigastric pain
42
What will be seen on PE during Polycythemia Vera Why do PTs w/ Polycythemia Vera have paradoxical bleeding episodes?
Splenomegaly Engorged retinal veins Thrombosis- MC complication Acquired von Willenbrand Syndrome/PUD
43
What lab result is the hallmark for Polycythemia Vera and what other results will be seen? PTs w/ Polycythemia Vera can develop ? type of anemia? What ortho issue can PTs w/ PCV develop?
Hct: >49%M/>48%F** Inc B12 Platelets >1M Hypo Micro Possible IDA at presentation Hyperuricemia- gout
44
How is a PCV Dx confirmed? What lab results should cause the Dx to be re-considered? What are the DDx for Polycythemia Vera?
JAK2 mutation screening No Exon 14(MC)/12 mutation WBC > 30K= CML Abnormal RBC= Myelofibrosis Platelet inc- Essential Thromb
45
How are Polycythemia Vera PTs Tx?
Phlebotomy- 500ml/wk Hct <45% (induced IDA- avoid Fe) Hydroxyurea platelets <500K, neutrophil >2K for PTs w/: Problematic/high phlebotomy Intractable pruritis Thrombocytosis Hydroxyurea resistant- add Ruxolitinib ASA 75-81mg Allopurinol 300mg Antihistamines
46
What agents to Polycythemia Vera PTs need to avoid? What is the prognosis for PTs w/ Polycythemia Vera? What is the major cause of death?
Alkylating agents in chemo, risk for conversion to acute leukemia >15yrs Arterial thrombosis
47
Over time Polycythemia Vera can develop into ? Although etiology of Essential Thrombocytosis is unknown, it is known to cause ?
Secondary myelofibrosis AML refractory to therapy CML Megakarycyte proliferation Inc platelets
48
Essential needs to be a DDx anytime ? is found How does Essential Thrombocytosis present? Although usually ASx at presentation, this can present with ?
Thrombocytosis F>M 50-60y/o Mesenteric Portal Hepatic venous thrombosis
49
What can be clinical presenting issues of Essential Thrombocytosis? What will be seen on lab results?
``` HA Erythromelalgia Levido reticularis Mucosal bleeds Splenomegaly ``` Platelet >2M No Philadelphia mutation Inc megakaryocyte on biopsy
50
How is Essential Thrombocytosis Tx What management must be strictly followed in these PTs?
Hydroxyurea/Anagrelide- keep platelets <500K ASA after r/o VWS, helps erythromelalgia Control of co-existing CV risk factors
51
Although there is a normal prognosis, who are 'high risk' PTs for death from thrombosis and a Essential Thrombocytosis Dx? CML issues starts w/ ? cell and effects ? two cells?
>60y/o >11K leukocytes Thrombosis Hx Progenator, Myeloblast/Monoblasts
52
How does CML present?
55y/o Inc WBC induced hyper metabolic state= F/Fatigue/NS Satiety Sternal tenderness
53
# Define Sx Hyperleukocytosis What clinical syndrome does this develop into?
Leukostasis: WBC >100K, <500K in CML Priapism Blurred vision Respiratory distress
54
Accelerated CML is associated w/ ? What will be seen on peripheral smears? What lab test is required for Chronic Phase CML PTs?
Fever w/out infection Bone pain Splenomegaly L shift w/ Baso/Eosinophils Marrow biopsy for karyotype/morphological evaluation for phase of dz
55
What is the hallmark of CML? Define Accelerated/Blast phase of CML and S/Sxs
+bcr/abl gene (Philadelphia) chromosome Acc: blasts 10-20% (chronic) Blast: blasts >20% (acute) Anemia Thrombocytopenia
56
Early CML must be differentiated from ? What lab results prove there is no CML?
Reactive leukocytosis from infection WBCs <50K No splenomegaly No bcr/abl gene
57
How is leukostasis of CML Tx? How is the chronic phase Tx? How is accelerated/blast phase Tx?
Emergent pheresis Supression (Hydroxyurea) Tyrosine kinase inhibition: 1st: Imatinib 2nd: Nilo/Dasatinib TKI and/or chemo Consider stem cell transplant
58
How long does it take for CML chronic phase Sxs to improve after Tx starts? What are the 5 age categories for probability of developing invasive leukemia cancer? What is the relative survival rate?
Blood/splenomegaly- 3mon Cytogenic- 3-6mon Molecular- 12mon ``` Birth - 49 50-59 60-69 70+ Birth - Death ``` 5yrs
59
What are the different types of lymphocytes and the type of immunity/defense they offer?
Cell mediated- release of cytokines (ICLIT) Humoral- Bcells destroy bacteria, produce Abs T-cells: destroy Fungi Transplant Virus Cancer cells NKCs- destroy Infectious Malignant cells
60
Clinical manifestations of leukemia are due to ? What 3 events occur due to the manifestations?
Over proliferation of immature cells Marrow replacement Organ infiltration Activation of coagulation
61
What are the etiologies of CLL/ALL? What are the causes of AML?
Unknown ``` Prior chemo Radiation Drugs: Chlorophenicol/quine Benzene Marrow d/o: (myeloproliferative) ```
62
What type of leukemia has the highest estimated death rate? Fact comparison of AML and ALL
AML AML: peak 60y/o 80% of adult leukemia M>F ALL: peaks 3-7y/o 80% of childhood leukemia
63
What are the presenting Sxs of acute leukemia? What Sxs do they present w/ if they have impaired circulation? What is a less common presentation?
Bleeding Fever Anorexia Bone pain SoB HA Confusion DIC in APL- acute promyelocytic leukemia
64
What are common presenting infections of acute leukemia? What microbe causes these? What fungal infections can be seen?
Perirectal Cellulitis Pneumonia Klebsiella E Coli Pseudomonas Candidia Aspergillus
65
Acute leukemia infection risk increases when neutrophil levels fall below ? What bones may hurt upon PE? Why will a Hx potentially be difficult to get?
<500 Femur Tibia Sternum Stomatitis d/t mast cell reaction Gingival hypertrophy
66
What will be seen on lab results in the acute leukemia? How is it Tx? Why is Tx needed so promptly?
Hyperleukocytosis >100K HA Confusion Dyspnea Emergent Chemo w/ pheresis Death <48hrs w/out Tx
67
What is the hallmark lab finding for acute leukemia? Define Aleukemic Leukemia
Pancytopenia w/ circulating blasts No blast cells in peripheral smear
68
How do peripheral smear results differ between ALL/AML What finding is pathognemonic for AML?
ALL- lymphoblasts AML- myeloblasts Auer rods
69
If acute leukemia is present with DIC, what will lab results show? What work up must be done ASAP during acute leukemia work ups?
Dec fibrinogen Prolonged PT Pos D-dimer Marrow biopsy LP for ALL, commonly has CNS involvement
70
# Define Induction of acute leukemia Tx Post-remission therapy is given w/ ? intent and includes ? Txs What is the CNS prophylaxis for ALL?
Induction of remission; aggressive chemo to destroy visible leukemia cells Given w/ curative intent: Standard chemo w/ stem cell transplant Intrathecal chemo
71
Leukemia PTs up to ? age are Tx w/ objective of cure? What is the first step in Tx
60y/o Induction chemo to achieve complete remission
72
What is the remission criteria for acute leukemia? How to Tx Philadelphia pos ALL
Normal peripheral blood Dec/no marrow blasts Normal clinical status Combo chemotherapy Tyrosine kinase inhibitor CNS prophlyaxis
73
What type of Tx provides the best benefit for ALL in PTs <39y/o? PTs w/ ? 3 things tend to have low prognosis? What is the MC cause of leukemia in Western countries and affects ? gender?
Pediatric protocol of Chemo/transplant Older age Poor chemo response Adverse cytogenics CLL M>F +70y/o
74
How do PTs w/ CLL present CLL clinical manifestations are related to ? three events?
Fatigue Adenopathy- painless, mobile Hepato/Splenomegaly Marrow failure ImmSuppression Organ infiltration
75
Rai Classification System for CLL staging
0: lymphocytosis- low risk 1: lymphocytosis + adenopathy- low risk 2: lymphocytosis + organmegaly +/-adenopathy- intermediate risk 3: lymphocytosis + anemia- high risk 4: lymphocytosis and thrombocytopenia- high risk
76
What is the hallmark of CLL What is seen on lab smears? When/how is this Tx
Isolated lymphocytosis- >20K Small, mature lymphocytes Rai 0-1: Observe Rai 2-4 w/ FLAT Tx w/ Chemo: Fludarabine Cyclophasphamide Rituximab Chemo avoidance/refractory/recurrent: Ibrutinib Non-responsive to therapy- allogeneic transplant
77
What is the prognosis for CLL and which stage doesn't have a prognosis? Some PTs w/ CLL will progress into ?
0-1: 10-15yrs 3-4: 2yrs ``` Lymphoproliferative d/o- Richters transformation Prolymphocytic leukemia Hodgkin lymphoma Multiple myeloma ```
78
# Define Richter's Syndrome How does it present? What is the prognosis?
CLL progression w/ isolated node becoming diffuse large B cell Lymphoma Spleneomegaly Adenopathy LDH Anemia Thrombocytopenia 5-8mon
79
# Define Lymphoma This type of cancer involves ? cells
Heterogenous tumors in immune system, turn lymphocytes into malignant cells T B NK MC- B
80
What is the difference between HL and NHL What is the MC lymphoma
HL: Reed-Sternberg (large binucleated) cells Non-Hodgkin w/ B cell origin
81
What are the MC subtypes/presentations of NHL? What are the chronic inflammation etiologies of NHL? What are the chronic infection etiologies of NHL?
Follicular- indolent/low grade Aggresive: diffuse large B-cell Sjogrens RA Celiac Hep B EBV TLV Hep C HIV BETCH
82
H Pylori is a known etiology to what sub-type of NHL? EBV (Mono) is known to cause what type of lymphoma especially where in the world What chemicals can cause NHL?
Indolent B Cell MALT lymphoma Burkitt- aggressive B Cells, Africa; tonsil abdomen neck Pesticides Hair dyes
83
How do the slow indolent/follicular forms of NHL present? How do aggressive forms present?
Diffuse adenopathy Rarely w/ systemic Sxs + marrow involvement + hepatosplenomegaly Primary/Extranodal Rapid, painless progression w/ systemic Sxs
84
Aggressive NHLs can present as a ? Dz What is the MC initial finding seen on CBCs? After lab work, what is the definitive way to Dx?
Skin Extranodal- GI tract (MC) Testis Marrow Kidneys Anemia Excisional biopsy
85
What part of lab results correlates w/ the overall prognosis in NHL PTs? After NHL Dx, refer to IMC where they will do ? tests
LDH levels PET scan CT w/ contrast on neck, chest, abdomen and pelvis Marrow biopsy
86
What are the two types of cytogenetic translocations seen in NHL? How is NHL staged?
14: 18- MC, follicular 8: 14- Burkitts Ann Arbor- A: no B Sxs B: B Sxs w/in 6mon of staging
87
What are the 3 initial B Sxs seen in NHL What two bodily structures are of importance in the Ann Arbor staging system?
Fever > 100.4 Weight loss >10% of baseline Recurrent night sweats Diaphragm Lymphatic system
88
What are the 4 stages of Ann Arbor staging
1: single node region/ single extra lymphatic site 2: +2 regions on same side of diaphragm (2) or local extralymph extension/more nodal regions on same side of diaphragm (2E) 3: both sides of diaphragm (3), extralymph extension (3E) 4: one or more extralymphatic organs/sites
89
What are the 4 Ann Arbor classification annotations
A: no B Sxs B: One B Sx in past 6mon E: extension to extra lymph organ adjacent to known involved site X: bulky dz >10cm or mediastinal mass >1/3 transverse diameter
90
How are indolent lymphomas Tx
Chemo/Rituximab combo Acid blockage Pylori ABX Alternative: radiotherapy
91
How are aggressive lymphomas Tx
Diffuse large B: Innunochemotherapy Relapse of large B cell: autologous transplant Bulky/Extranodal Dz: nodal radiotherapy Mantle: rarest B cell Ca in older men; stem cell transplant
92
How is aggressive primary CNS lymphoma Tx How is aggressive high-grade lymphoma like Burkitt/Lymphoblastic Tx
IV Methotrexate + Rituximab Cyclic chemo Intrathecal chemo for CNS prophylaxis
93
Why is IV Methotrexate and Rituximab preferred for aggressive primary CNS lymphoma? Pts w/ aggressive peripheral T-cell lymphomas usually have what other underlying issues? Because of this, what Tx is added to their regime as first line?
Better results Less cognitive impairment Advanced nodal and extranodal dz Autologous stem cell transplant
94
What is the average survival time for indolent lymphomas? Why is this time span limited?
10-15yrs Becomes chemo refractory
95
What are the International Prognostic Index categories for poor prognosis of aggressive lymphomas? How do these categories correlate to cure rates?
``` >60y/o >1 extranodal site Poor performance status Inc LDH AA Stage 3-4 ``` Low risk: 0 factors, 80% High risk: +4 factors, 50%
96
? type of lympoma has bimodal age distribution? Although no clear etiology exists for this form, what is it linked w/?
HL- 20s and >55y/o Same sex siblings HIV Autoimmune EBV
97
How does HL present? What other presenting Sx may be noted?
Painless single lymph node, MC cervical/mediastinal/hilar Possible in supraclavicular and axilla w/ orderly spread B Sxs Nodal pain w/ alcohol ingestion
98
DDxs that can mimic HL presentation w/ a reactive lymph node How is HL Dx?
Cat scratch Other malignancy Mono Phenytoin reactions Excisional biopsy w/ Reed Sternberg cells
99
What are the four other sub-classical classifications of HL? All of the classical classification of HL will have ? commonality?
Lymphocyte rich/depleted Mixed cellularity Nodular sclerosis Reed sternberg cells
100
What is the non-classical classification of HL? How is HL Tx
No Reed-Sternberg cells Nodular lymphocyte predominant AA Stages 1-2: short chemo and nodal radiotherapy or, Full chemo course alone Mediastinal/Bulky 2, 3-4: ABVD course
101
What is the risk of PTs undergoing ABVD Tx regimens for HL? How is HL Tx if Pt is relapsing after chemo/radiation?
Pulmonary toxicity leading to fibrosis/death Autologous transplant
102
What are the 7 factors that confer poor prognosis for HL? How do these factors correlate into cure rates?
``` Gender M Age >45 Stage Hbg <10.5 Lymphocyte <600 Albumin <4 WBC <15k ``` 0-2 factors= 75% 3 or more= 55%
103
What are the prognosis rates for HL Where does Myeloma Cadevelop
1/2A: Excellent 3-4: half reach 10yrs Plasma cells anywhere in marrow
104
How does marrow change w/ age? What cell is the precursor to plasma cells?
Older= yellow replaces red B-lymphocytes
105
Plasma cell myeloma is characterized by ? three things What PT population does this usually present
Infiltration of marrow Bone destruction M-proteins (paraprotein) 65y/o AfAm male
106
How is Plasma Cell Myeloma Dx
Monoclonal plasma cell in marrow, Tumor (plasmacytoma) or Both w/ end organ damage Or Serum free kappa to lambda ratio >100 or <0.01 regardless of end organ damage
107
What type of end organ damage signifies Plasma Cell Myeloma Define Smoldering Myeloma
HyperCa Anemia Lytic bone lesions Kidney injury Plasma cell myeloma w/: 10-59% clonal plasma cells Serum paraprotein >3g Both w/out end organ damage
108
How does Plasma Cell Myeloma present in clinic?
Fxs= cord compression Anemia Bone pain Hyperviscosity Infection: Spneumo/HInfluenza Kidney Dz Soft tissue masses
109
What is seen on lab results of Plasma Cell Myeloma What two lab results are ordered on top of blood tests? What finding is the hallmark of PCM Dx
Anemia HyperCa AKI Serum/Urine electrophoresis Monoclonial spike w/ G*/B component
110
Electrophoresis separates proteins into what components? What will be seen on peripheral smear in Plasma Cell Myeloma
Gamma Albumin Beta-1/2 Alpha-1/2 Rouleaux- stacked RBCs w/ immunoglobulins as glue Not definitive Dx/exclusion
111
What images are ordered for Plasma cell myeloma? Why are radionucleotide bone scans not useful?
Whole body CT w/out contrast Whole body PET Whole body MRI No osteoblastic component
112
Plasma Cell Melanoma Dx requires what 3 components What are the 3 stages of PCM?
M-protein in serum/urine Marrow aspirate +10% plasma cells Plasma cell induced end organ damage 1: B2 <3.5, albumin >3.5 2: B2 3.5-5.5 3: B2 >5.5
113
What is the mnemonic OLD CRAB mean
Plasma Cell myeloma presentation: OLD Ca elevated RF Anemia Bone lesions
114
How is Plasma cell myeloma Tx What is the median survival rate?
Chemo +/- transplant Local radiation- bone pain HyperCa/Uric acid Tx Bisphosphonates for Fx Tx 7yrs
115
Why is a MGUS Dx significant? What are the criteria for Dx?
Precursor to PCM <10% marrow plasma cells M-protein <3g No end organ damage
116
What are the two most frequent M-proteins found in MGUS? What is done for MGUS managed
IgG, IgA ``` F/u q 3-6mon w/: Ca Hgb/Hct One marrow biopsy Renal panel Electrophoresis ```
117
What are two types of local oncology emergencies? What are two types of systemic emergencies?
Obstruction Pressure Metabolic complication Hormonal complication
118
What is the first and second MC cause of HyperCa? PTs experience Sxs when serum Ca levels exceed ?
1: hyper parathyroid 2: Ca- PCM, Breast, NSCLC (squamous) >15mg
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What are the S/Sxs of HyperCa If PTs are low on ? protein their total serum Ca will be underestimated? How is the corrected Ca calculated?
Stones Bones Moans Pyschic groans Albumin (Ca - albumin) + 4 or, Free ionized Ca
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How does HyperCa reflect on EKG? When does HyperCa become deadly?
Short QTc Corrected Ca >12 d/t Arrhythmia/asystole
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Cancer associated hyperCa will cause ? level of PTH and what f/u order is done? True hyperparathyroidism will have ? lab results
Low, order PTHrP Inc PTH and Ca
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How is HyperCa Tx What is used if Hyper Ca is refractory? What is used if kidney function is reduced?
``` NS 100-300mL/hr IV furosemide-hypervolemic IV bisphosphonates: Zoledronic 4mg 15min Ibandronate 2-4mg 2hrs Pamidronate 60-90mg 2-4hr ``` Calcitonin 4-8 IU/kg q12hrs Denosumab 120mg qWeeks x 4wks then monthly Denosumab
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When/why would CCS be added to HyperCa Tx? HPV is linked to ? types of Ca EBV is linked to ? types
PCM/Lymphoma Laryngeal Anal Cervical B-Cell Nasopharyngeal PO Hiary leukoplakia
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H Pyloris is associated w/ ? types of Ca Schistosoma is associated w/ ? type
Gastric MALT lymphoma Bladder
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HHV-8 is assicated w/ ? types of Ca HIV is associated w/ ? types?
Kaposi sarcoma Lymphoma (HL/NHL)
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Sjogrens is associated to ? type of Ca due to inflammation Dermatomyositis is associated w/ ? type of cancer MC
Lymphoma Ovarian
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Colorectal screenings are recommended for ? age groups w/ ? grade recommendation? This decision becomes strictly up to the PT past ? age and have ? grade recommendation?
50-75, Grade A 76-85y/o, Grade C
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Cervical cancer screenings fall into what grade of recommendation? What score does lung cancer screenings have?
21-65y/o: A >65 <21 post-hysterectomy: D 55-80y/o: B
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Secondary myelofibrosis occurs as a result of ? disorders? What are the 3 zones of a B-cell?
Any myeloproliferative d/o Mantle Germinal Marginal
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IgM: Heavy Chain % in serum Fixed complement Function
u (mu) 6% Yes Primary response B-cell receptor
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IgG: Heavy Chain % in serum Fixed complement Function
y (gamma) 80% Yes Main blood Ab Neutralizes toxins Opsonization
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IgA: Heavy Chain % in serum Fixed complement Function
A (alpha) 13% No Sevreted into mucus, tears, salia
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IgE: Heavy Chain % in serum Fixed complement Function
e (epsilon) 0.002% No Ab of allergy/parasitic
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IgD: Heavy Chain % in serum Fixed complement Function
d (delta) 1% No B cell receptor
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What are the heavy chained immunoglobulins What are the light chained immunoglobulins?
GAMED Kappa/Lambda
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What's the only Dx to order CMP for during work up? MGUS marrow, clinical picture and therapy
Plasme Cell Myeloma <10% plasma cells ASx, no organ damage Observation
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Smolder MM marrow, clinical picture and therapy MM marrow, clinical picture and therapy
10% or more plasma cells ASx, no organ damage Observe 10% or more plasma cells Sxs w/ organ damage Therapy req'd
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What two types of Ca can secrete PTHrP What is the 2nd MC complication of Ca? This 2nd MC is more likely to occur w/ ? types?
Breast Lung- squamous Cord compression Lung Breast Prostate Renal Lymphoma
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What is the MC neurological complication of Ca? Why can Ca related cord compression result in permanent damage?
Brain metastasis Myelin sheath damage
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What PE Sx precedes neurological Sxs of cord compression d/t Ca? What are two late findings?
Back pain Bowel/bladder Sxs
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What is the image modality of choice for Ca PTs w/ new onset back pain? What image is ordered if back pain Sxs are nonspecific?
Entire spine MRI Whole body PET scan w/ F-2-deoxyglucose
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How is spinal cord compression d/t Ca Tx
Known Ca Dx: 1st- Dexameth 10-100mg then 4-6mg q4-6hrs Solid tumor/single compression: Decompression then radiation therapy Multiple vertebral body involvement: Fractional radiation therapy No Ca Dx: No CCS, straight to emergent surgery
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# Define Febrile Neutropenia What is the equation for an absolute neutrophil count
Fever >100.4 >1hr or, Fever of 101 w/ neutrophil count <1500 ``` ANC= WBC x (N% + Segment band %) Norm= 1.5-8 ```
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What part of the PE must be avoided during febrile neutropenia? What are the MC cause of these infections?
DRE unless abscess/prostatitis suspicion, give ABX first Gram+ but, Gram- more serious/life threatening
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What labs are ordered for febrile neutropneia? What images are ordered?
CBC w/ Diff CMP Blood Urine Sputum cultures CXR, CT
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PTs w/ neutropenia and abdominal pain need to have ? DDx considered? How are febrile neutropenia PTs Tx
Neutropenic enterocolitis- thick bowels seen on CT Empiric ABX w/in 60min of presentation: Cefepime- injectable Carbapenem- beta lactam PiperTazo- PCN beta lactam
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How long are Febrile Neutropenia ABX given? What if no improvement is seen and fever persists on ABX? What phone call is made?
Neutrophils >1500 and Afebrile x 48hrs Antifungals: Caspfungin Itraconazole Amphotericin B Infectious Dz consult
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SVC syndrome is associated w/ ? two MC causes? What can be seen as provocative/pallative complaints on PE?
Lung cancer Lymphoma Bending/laying- worse Sitting quiet- better
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What procedure can and can NOT be done for PTs w/ SVC d/t lung cancer? What is the Tx procedure of choice for SVCS?
+ bronchoscopy - transcbronchial biopsy Balloon angioplasty w/ stent placement
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Tumor lysis sydrome occurs after Tx of ? hematologic malignancies? TLS develops due to the release of ? cellular contents?
ALL Burkitt Nucelic acid Protein PO4 K+
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Sequence of events leading to TLS
``` Release of DNA Purine catabolism Hyperuricemia Uric acid crytals AKI ``` Release of DNA Neucleotides develop hyperphosphatemia Ca/PO4 imbalance AKI Cell material released HyperK Neuromuscular irritability Arrhythmia
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How is TLS avoided What is the next step if urine output dec, SrCr/K inc or phyperphosphatemia persists?
Hydrate prior/after Chemo Allopurinol 800mg q8hrs Rasburicase- not in pregnant/lactating/G6PD Nephrology, dialysis
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How does superficial somatic pain present How does deep somatic pain present? How does nociceptive pain present?
Sharp/throb Aching Pressure Ache Cramp Squeeze
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What are the 3 approaches to controlling Ca pain What is the key to opioid use?
Block transmission Alter perception Modify source Education
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WHO pain ladder
``` Pain Non-opioid/adjuvants Opioid- mild/mod Opioid- mod/sev Pain management referral ```
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Hallmarks of Ca Hallmark of Myeloproliferative D/o Hallmark of CML Hallmark of acute leukemia Hallmark of CLL Hallmark of PCD
A TRAGEDIES Inc HCt 49/48% bcr/abl gene (philadelphia) Pancytopenia w/ circulating blasts Isolated lymphocytosis Monoclonial spike on electorphoresis
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Classifications
Rai- CLL (0-4, lymphocytosis + AOAT) Ann Arbor- NHL (A/B FWNS) 1-4/ABEX