Oncology Flashcards
Carcinomas are cancers that start ?
Sarcomas are cancers that start ?
Leukemias are cancers that start ?
Skin/organ lining (breast/lung)
Bone Fat Cartilage Muscle Vessel CT/Support tissue (osteosarcoma)
Marrow causing abnormal cells to be released
What are the five prefixes of benign tumors?
What are the six prefixes of malignant tumors?
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
What are the three methods metastases spreads in the body and what type is usually found by each?
Seeding- ovarian
Lymph- typical for carcinoma
Hematgoenous- typical for sarcoma; usually to liver/lungs
Define Proto-Oncogenes
Define Oncogenes
Codes proteins that stimulate cell division
Cancer causing gene:
Mutation stimulates unregulated/early division
Define Tumor Suppressing Genes
What happens when these genes are mutated?
How do Proto become mutated to Oncogene?
Code proteins to suppress oncogenes (cell division)
No inhibition= cancerous growth
Carcinogens: Chemical UV radiation Virus
What are the hallmarks of Ca that are needed for it to develop and survive?
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
Basic Oncology focuses on ? three Dz parts and is instrumental in ?
What are the top three leading causes of death in the US?
Patterns, Cause, Effect
Screening, Prevention, Txs
Heart Dz
Cancer
Chronic lower respiratory dz
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
Esophageal Pancreatic Hepatocellular
Lung/bronchus
Colon/rectum
Melanomas of skin
Non-Hodgkin lymphoma
What are the top three RFs of cancer for men and women
What are the prevalence of Brca mutation and Ca
Smoking Obesity Alcohol
BRCA-1: 85% breast, 50% ovarian
BRCA-2: fe/male breast, ovarian, prostate Ca
What are the different types of MEN
What is the difference between Wermer and Werner
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
How does MEN 1 present
What is normal life expectancy
Hyperparathyroidism GEP-NETs Pituitary adenomas Insulinomas Gastrinomas
55yrs
How does MEN 2 present
Medullary thyroid carcinoma
Hyperparathyroidism
Pheochromocytomas
Hirschsprung Dz
Alcohol is linked to ? forms of Ca
Although associated w/ breast Ca, what is the catch w/ alcohol induced Ca?
Head Esophageal Liver Neck
Abstinence not linked w/ reduced risk
Radiations are linked to ? types of cancer
Radon is linked to ? type
Vinyl chloride is linked to ? type
Leukemia Breast Thyroid Lung
Lung
Hepatic angiosarcoma
Benzene exposure is linked to ? types of Ca
UV light is linked to ? types of Ca
AML Lymphoma
All types of skin cancer
USPSTF recommendations for breast Ca screening
Colon Ca screening for average risk PTs?
Mammography q2yrs 50-74y/o w/out S/CBE
Start at 50y/o, q10yrs w/ colonoscopy
Start AfAm/NAFLDz PTs at 45y/o
When are colon cancer screenings recommended for PTs w/ +FamHx
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
What are the US PSTF grading criteria for expected benefit?
A: substantial, offer
B: moderate, offer
C: small, selective PTs
D: harms out weigh/no benefit, discourage
I: insufficient evidence to assess harm/benefit
What are the 4 methods of direct visualization for GI oncology?
What are the 3 stool based oncology tests?
Colonoscopy- q10yrs
Flex sig w/ FIT- q10y, FIT q1yr
CT colonography- q5yrs
Flex sigmoid- q5yrs
gFOBT: q12mon
FIT: q12mon
FIT-DNA: q1 or 3yrs
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?
55-69: recommend, Grade C
+70: not recommended, Grade D
<21, >65, post-hysterectomy
How often are cervical cancer screenings conducted?
21-29: q3yrs w/ cytology
30-65: q3yrs w/ cytology or,
q5yrs w/ only hrHPV or,
q5yrs w/ hrHPV and cytology
When is lung cancer screening conducted?
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
Define Grading
Define Staging
Degree of differentiation based on pathology (1-4) w/ description
More predictive:
Severity and metastases; Estimates prognosis/guides Txs
What are the sub staging of T
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)
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
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
What biologicals/immunological Txs are used for Ca?
Monoclonal Ab therapy:
Rituximab/Rituxan- CD20+ lymphoma
Rastuzumab/Herceptin- HEGFR+ breast cancer
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
AFP indicates presence of ? two types of Ca?
CA-125 indicates presence of ? what type of Ca?
Hepatocellular
Testicular
Ovarian
CEA indicates presence of ? three types of Ca?
CA 19-9 indicates presence of ? type of cancer?
Colon
Pancreatic
Breast
Pancreatic
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)
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
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
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
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
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
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
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)
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)
What is the prognosis for PTs Dx w/ Myelofibrosis?
What usually kills these PTs
5yrs if untx
LF AML Bleeding
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
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
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
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
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
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
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
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
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
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
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
How does CML present?
55y/o
Inc WBC induced hyper metabolic state= F/Fatigue/NS
Satiety
Sternal tenderness
Define Sx Hyperleukocytosis
What clinical syndrome does this develop into?
Leukostasis:
WBC >100K, <500K in CML
Priapism
Blurred vision
Respiratory distress
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
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
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
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
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
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
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
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)
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
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
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
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
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
What is the hallmark lab finding for acute leukemia?
Define Aleukemic Leukemia
Pancytopenia w/ circulating blasts
No blast cells in peripheral smear
How do peripheral smear results differ between ALL/AML
What finding is pathognemonic for AML?
ALL- lymphoblasts
AML- myeloblasts
Auer rods
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
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
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
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
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
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
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
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
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
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
Define Lymphoma
This type of cancer involves ? cells
Heterogenous tumors in immune system, turn lymphocytes into malignant cells
T B NK
MC- B
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
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
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
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
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
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
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
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
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
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
How are indolent lymphomas Tx
Chemo/Rituximab combo
Acid blockage
Pylori ABX
Alternative: radiotherapy
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
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
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
What is the average survival time for indolent lymphomas?
Why is this time span limited?
10-15yrs
Becomes chemo refractory
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%
? 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
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
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
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
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
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
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%
What are the prognosis rates for HL
Where does Myeloma Cadevelop
1/2A: Excellent
3-4: half reach 10yrs
Plasma cells anywhere in marrow
How does marrow change w/ age?
What cell is the precursor to plasma cells?
Older= yellow replaces red
B-lymphocytes
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
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
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
How does Plasma Cell Myeloma present in clinic?
Fxs= cord compression
Anemia
Bone pain
Hyperviscosity
Infection: Spneumo/HInfluenza
Kidney Dz
Soft tissue masses
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
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
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
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
What is the mnemonic OLD CRAB mean
Plasma Cell myeloma presentation:
OLD Ca elevated RF
Anemia Bone lesions
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
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
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
What are two types of local oncology emergencies?
What are two types of systemic emergencies?
Obstruction
Pressure
Metabolic complication
Hormonal complication
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
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
How does HyperCa reflect on EKG?
When does HyperCa become deadly?
Short QTc
Corrected Ca >12 d/t
Arrhythmia/asystole
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
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
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
H Pyloris is associated w/ ? types of Ca
Schistosoma is associated w/ ? type
Gastric
MALT lymphoma
Bladder
HHV-8 is assicated w/ ? types of Ca
HIV is associated w/ ? types?
Kaposi sarcoma
Lymphoma (HL/NHL)
Sjogrens is associated to ? type of Ca due to inflammation
Dermatomyositis is associated w/ ? type of cancer MC
Lymphoma
Ovarian
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
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
Secondary myelofibrosis occurs as a result of ? disorders?
What are the 3 zones of a B-cell?
Any myeloproliferative d/o
Mantle Germinal Marginal
IgM:
Heavy Chain
% in serum
Fixed complement
Function
u (mu)
6%
Yes
Primary response
B-cell receptor
IgG:
Heavy Chain
% in serum
Fixed complement
Function
y (gamma)
80%
Yes
Main blood Ab
Neutralizes toxins
Opsonization
IgA:
Heavy Chain
% in serum
Fixed complement
Function
A (alpha)
13%
No
Sevreted into mucus, tears, salia
IgE:
Heavy Chain
% in serum
Fixed complement
Function
e (epsilon)
0.002%
No
Ab of allergy/parasitic
IgD:
Heavy Chain
% in serum
Fixed complement
Function
d (delta)
1%
No
B cell receptor
What are the heavy chained immunoglobulins
What are the light chained immunoglobulins?
GAMED
Kappa/Lambda
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
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
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
What is the MC neurological complication of Ca?
Why can Ca related cord compression result in permanent damage?
Brain metastasis
Myelin sheath damage
What PE Sx precedes neurological Sxs of cord compression d/t Ca?
What are two late findings?
Back pain
Bowel/bladder Sxs
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
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
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
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
What labs are ordered for febrile neutropneia?
What images are ordered?
CBC w/ Diff
CMP
Blood Urine Sputum cultures
CXR, CT
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
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
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
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
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+
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
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
How does superficial somatic pain present
How does deep somatic pain present?
How does nociceptive pain present?
Sharp/throb
Aching
Pressure Ache Cramp Squeeze
What are the 3 approaches to controlling Ca pain
What is the key to opioid use?
Block transmission
Alter perception
Modify source
Education
WHO pain ladder
Pain Non-opioid/adjuvants Opioid- mild/mod Opioid- mod/sev Pain management referral
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
Classifications
Rai- CLL (0-4, lymphocytosis + AOAT)
Ann Arbor- NHL (A/B FWNS)
1-4/ABEX
