Oncology Flashcards
What are 2 factors that are most prognostic for breast cancer?
tumor size and axillary lymph node status
T/F: If mammogram is normal, you don’t need to biopsy a breast mass
False. You need to do a biopsy
1) How do you treat DCIS?
2) What if it is estrogen-positive DCIS?
1) wide excision (lumpectomy) with breast radiation
2) tamoxifen decreases risk of local recurrence but not survival
Which is better for invasive breast cancer treatment: mastectomy vs lumpectomy with both followed by radiation?
both are the same
For breast tumors that involve the skin, chest wall, or more than one quadrant of the breast, what is the recommended treatment?
mastectomy
For inflammatory breast cancer, what is the best treatment?
neoadjuvant chemo then mastectomy then radiation
What is a contraindication to breast radiation therapy?
previous irradiation
When would a bilateral mastectomy be recommended?
familial breast cancer syndromes
When is axillary lymph node dissection performed? (2)
stentinel lymphe node biopsy is positive or axillary lymph nodes are clinically involved
For patients with breast tumors >5cm, positive surgical margins, skin or chest wall involvement, inflammatory breast cancer, and positive axillary nodes…what is the recommended treatment?
mastectomy followed by chest wall radiation
What staging is adjuvant systemic therapy used in breast cancer?
stages I to III (not metastatic and is curable)
When do you use tamoxifen as adjuvant therapy?
premenopausal women x 10 years. If they become postmenopausal after taking 5 years of tamoxifen, then they benefit from taking aromatase inhibitor for 5 years
For patients on aromatase inhibitors (anastrozole, letrozole, exemestane), how often do you do DEXAs and bisphosphonate therapy?
q1-2 years and treat if T scores
What is indicated in hormone receptor-negative tumors, HER2-positie tuors, high grad tumors, extensive lymphovascular invasion and positive lymph nodes?
adjuvant chemotherapy
T/F: Patients with high risk recurrence scores will benefit when adjuvant chemotherapy is given followed by antiestrogen therapy
True
What can be given as adjuvant therapy with HER2-positive breast cancer? What prework up do you need to do?
trastuzumab; check LV function
If patients are hormone receptor negative or fail antiestrogen therapy, what can be used?
single agent chemotherapy
How do you treat lytic bone metastases in breast cancer?
bisphosphonate and denosumab
If a premenapausal woman cannot take tamoxifen, what do you need to do?
ovarian ablation or suppression
T/F: pregnancy after breast cancer does not increase the risk of recurrence
true
T/F: You need to biopsy new metastatic lesions
True–primary tumor and metastatic tumor estrogen receptor and HER2 status can differ
What are the side effects of 1) aromatase inhibitors? 2) tamoxifen 3) anthracyclines (doxorubicin, epirubicin) 4 trastuzumab 5) bisphosphonates 6) denosumab
1) arthralgia, bone pain, osteoporosis, hyperlipidemia
2) endometrial cancer, VTE disease
3) cardiomyopathy, acute leukemia
4) cardiomyopathy especialy with anthracycline
5) osteonecrosis of jaw especially with dental disease
6) hypocalcemia and osteonecrosis of jaw especially with dental disease
What are the criteria for annual low dose screening CT scan for lung cancer?
smoking for 20 pack years, quit within 15 years
ages: 50-80yo
Where is the best place to biopsy a lung mass?
peripheral lymph node of mediastinal node
What are 3 staging studies for a patient with SCLC?
Since it is viewed as metastatic disease, need CT C/A/P, whole body bone scintigraphy, MRI brain
Which type of lung cancer produces peptide hormones which can cause SIADH and hypercortisolism?
SCLC
What are the 2 staging studies for NSCLC?
identify metastatic disease (if find, then no surgery). get CT chest/upper abdomen and PET for lymphadenopathy
If a patient has both a lung mass and hypercalcemia, what kind of lung cancer do they have?
SCC
Treatment of SCLC:
1) limited stage
2) extensive stage
3) complete or partial response to therapy
4) symptomatic brain mets
1) chemo and radiation
2) chemo
3) add prophylactic brain irradiation
4) whole brain radiation therapy
Treatment of NSCLC:
1) stage I (solitary tumor 3-5 cm with no lymphadenopathy or metastases) or stage II (solitary tumor >5cm with regional lymphadenopathy or pleural chest wall involvement or tumor near carina
1) surgical resection with adjuvant chemo
Treatment of NSCLC:
2) stage III (mediastinum or contralateral mediastinal lymph nodes
3) stage IV (metastatic cancer with pleural or pericardial effusion)
4) solitary brain mets
2) chemoradiation
3) chemo only if good performance status
4) surgical excision and postoperative whole-brain radiation therapy
If have EGFR mutation in lung cancer, what can you use?
If you have ALK and ROS1 mutations, what can you use?
1) erlotinib
2) crizotinib
What is treatment for multiple brain mets in lung cancer?
glucocorticoids and radiation therapy
After curative treatment of NSCLC, what should follow up monitoring look like?
history, PE and CT chest
What is treatment for pulmonary airway obstruction, SVC syndrome and spinal cord mets in lung cancer?
thoracic irradiation (helps pain)
What is the form of lung cancer that is distinct from SCC but behaves and treated similarly to SCLC?
large cell neuroendocrine carcinoma
T/F: Treat SCLC with poor performance status with chemotherapy
T-it can significantly improve symptoms and increase survival (same is NOT true of NSCLC)
What is another name for: (can see in gastric cancers)
1) periumbilical nodule
2) left supraclavicular lymphadenopathy
3) enlarged ovary
4) mass in the cul de sac on rectal exam
5) explosive onset of seborrheic keratosis
1) Sister Mary Joseph node
2) Virchow node
3) Krunkenberg tumor
4) Blumer shelf
5) sign of Leser-Trelat
What is initial work up for gastric cancer?
upper endoscopy
What is therapy for localized gastric tumors?
neoadjuvant chemo followed by surgery
What chemo is used for metastatic gastric cancer?
cisplatin-based chemo; if overexpress HER2, then add trastuzumab; if MALT lymphoma and H pylori, then add antibiotics and PPI
Which patient is at highest risk for colorectal cancer? pancolitis or proctitis?
pancolitis
What is an autosomal dominant disorder that requires prophylactic colectomy?
familial adenomatous polyposis
What is the second leading cause of cancer death in familial adenomatous polyposis?
duodenal and periampullary cancers
What is a type of familial adenomatous polyposis with extraintestinal manifestations including osteomas, duodenal ampullary tumors, thyroid cancers, medulloblastomas?
Gardner syndrome
Lynch syndrome (hereditary nonpolyposis colon cancer) diagnostic criteria
> 3 relatives with CRC, 1 relative a first degree relative of the other two, >2 generations affected, cancer diagnosed before 50 yo
What are the mutations noted in Lynch syndrome? (2)
4 mismatch repair genes or epithelial cell adhesion molecule (EPCAM)
Which cancer is most common outside the GI system in Lynch syndrome?
endometrial cancer
How often do you screen:
1) first-degree relative diagnosed with adenomatous polyp or colon cancer <60 yo
2) 2 second-degree relatives with adenomatous polyp or colon cancer at any age
3) 2 first degree relatives with colon cancer
4) HNPCC risk (Lynch syndrome)
5) familial adenomatous polyposis risk
6) pancolitis
1) age 40 or 10 years prior to earliest diagnosis; check every 5 years
2) age 40 or 10 years prior to earliest diagnosis; check every 5 years
3) age 40 or 10 years prior to earliest diagnosis; check every 3-5 years
4) every 1-2 years starting at 20 or 25 years or 10 years earlier than the age of the youngest diagnosed with colon cancer
5) age 10-15 years with annual sigmoidoscopy
6) 8-10 years after initial diagnosis then every 1-2 years
Next colonoscopy?
1) 1-2 <10mm tubular adenomas
2) 3-10 adenomas, >10mm, villous histology, high grade dysplasia
3) >10 adenomas on a single exam
1) 5-10 years
2) 3 years
3) <3 years, genetic cause should be investigated
What is complete work up of colon cancer? (3)
colonoscopy, CT with contrast of C/A/P, serum CEA level
Colon cancer therapy
1) stage I (confined to colon) or stage II (local invasion)
2) stage III (metastatic to regional lymph nodes)
3) stage IV (distant mets)
4) stage II-III rectal cancer
1) resection for cure
2) resection and adjuvant chemo + FOLFOX or CAPOX
3) resection of primary lesion for palliation and chemo
4) radiation and chemo both before/after
What is treatment for colon cancer with single metatstatic lesion to a single organ?
surgical removal of priamry and met
What is treatment for metastatic colon cancer?
FOLFOX and FOLFIRI with bevacizumab (against VEGF) and cetuximab or panitumumab (anti-EGFR)
Don’t use anti-EGFR if have K ras or N ras patients
Don’t use both anti-VEGF and anti-EGFR agents together
Follow up for colon cancer after treatment (3)
- CEA measurement q3-6 months for first 2 years then every 6 months for 3 years
- colonoscopy 1 year after resection 3 years later, then every 5 years
- CT C/A/P annually for 3-5 years
What infection is anal cancer associated with?
HPV
What is needed for staging of anal cancer?
DRE, anoscopy, inguinal LN palpation with biopsy or FNA if enlarged, CT C/A/P
What is treatment of anal cancer?
radiation with mitomycin + 5-FU
What is the most important way to prevent HCC?
hep B vaccine
How often to HCC screening in cirrhosis and chronic hep B (African Americans and Asian Americans)
abdominal US q6m; if positive, then order CT or MRI with contrast
What is the characteristic findings of HCC on CT/MRI?
arterial phase enhancement
What is a hepatic tumor/cyst that is characterized by:
1) early peripheral nodular enhancement on contrast CT/MRI followed by delayed fill-in toward the center of the lesion? tx?
2) early arterial enhancement with rapid loss of enhancement and return to isointensity in surrounding liver. Have h/o of using what drug? Tx?
3) early arterial enhancement with rapid loss of enhancement in portal venous phase with return to isointesnity. Many larger focal nodular hyperplasias have central stellate scare. Tx?
4) single or multiple hypoechoic lesions on US that are hypovascular on Contrast CT scans. Tx?
1) cavernous hemangioma-no treatment needed
2) hepatic adenoma; using OCPs; tx: resection
3) focal nodular hyperplasia; no tx needed
4) metastatic tumors; tx: resection if isolated
What is treatment for HCC?
surgical resection or liver transplant; can use percutaneous ethanol injection or radiofrequency ablation for those who are not candidates for resection or transplant; can use chemo for advanced HCC who are not candidates for an other treatment
What can be used to improve overall survival in patients with advanced/metastatic HCC?
sorafenib
What is the most important risk factor for cholangiocarcinoma?
PSC
How do you diagnose cholangiocarcinoma? What is the treatment?
ERCP with MRCP or contrast enhanced CT; treatment is surgery; chemo is reserved for nonresectable; can also do liver transplant if nonresectable, perihilar cholangiocarcinoma without extra hepatic spread
T/F: if there is a percutaneous biopsy of perihilar cholangiocarcinoma, then that is an exclusion for transplant
True, worry about seeding
What is another name for vascular thromboses that can be seen in pancreatic cancer?
Trousseau syndrome
What is 2 advantages for doing endoscopic US for pancreatic cancers?
sensitive in detecting small cancers; tissue diagnosis by FNA
What can resemble pancreatic cancer (need to measure IgG4 which is elevated in this doppleganger)
autoimmune pancreatitis
What are 3 choices for treatment for a locally advanced, unresectable pancreatic disease (tumor went to SMA or celiac trunk)
1) radiation alone
2) 5-FU + radiation (most common)
3) single agent chemo (gemcitabine)
What is the treatment for stage I cervical cancer?
loop electrosurgical excision procedure or cervical conization to preserve childbearing; if finish with childbearing, then can go hysterectomy without lymph node dissection
What is the treatment for stage II-IV disease of cervical cancer?
radiation + cisplatin chemo
What is the treatment for recurrent disease or distant mets for cervical cancer?
radiation and chemo + bevacizumab
What should be offered to women at 35 yo or after childbearing who have BRCA1/2 genetic mutations or more than 2 first degree relatives with ovarian cancer?
oophorectomy
T/F: If have adnexal mass without ascites, removal of mass without biopsy has survival benefit
T
What is treatment for stage I and IB with grade 1 histology ovarian cancer?
remove ovaries
What is the treatment for stage IC to IV ovarian cancer?
adjuvant platinum-based chemo
What can be done in patients with ovarian cancer s/p surgery with small amounts of residual disease confined to the peritoneal cavity following surgery?
intraperitoneal chemo
What two things are needed in ovarian cancer follow up?
pelvic exam and CA 125 measurement if it was elevated previously
What is the treatment for endometrial cancer?
surgical resection of uterus, cervix and adnexa
can add radiation +/- chemo for higher risk disease
if high risk surgical patient, then radiation therapy alone
T/F: tamoxifen puts women at risk for endometrial cancer
T
T/F: Finasteride reduces incidence of prostate cancer but not cancer mortality rates and is not recommended for prevention
T
T/F: acute urinary retention increases PSA level regardless of obstruction cause
T
Prostate treatment:
1) very low risk cancer and life expectancy >10 years
2) high risk disease
3) metastatic disease
1) active surveillance
2) local therapy+ adjuvant ADT with GnRH agonist for 2-3 years
3) hormonal therapy = bilateral orchiectomy
What are 3 types of local therapy for prostate cancer?
external beam radiotherapy, brachytherapy, radical prostatectomy
What can be used in castration-sensitive disease in prostate cancer?
docetaxel
What can be used in castrate resistant prostate cancer?
bicalutamide, ketoconazole, megestrol, glucocorticoids, estrogens, abiraterone, enzalutamide
What is the first line treatment in hormone-refractory metastatic prostate cancer?
docetaxel + prednisone
What is a strong risk factor for testicular cancer?
cryptorchidism
What is the best way to obtain tissue to test for testicular cancer? inguinal orchiectomy or needle biopsy?
inguinal orchiectomy
Which hormone is NOT elevated in a pure seminoma? b-hCG, LDH or AFP?
AFP
T/F: hCG can be present in both seminomatous and nonseminomatous tumors
True
What is the treatment for seminoma testicular cancer in the following situations:
1) low risk/early stage
2) treatment recommended
3) intermediate disease (stage II A-B)
4) advanced disease (stage IIC or III)
5) nonpulmonary visceral mets
1) observation
2) carboplatin chemo
3) cisplatin-based chemo (preferred) or radiation
4) cisplatin based chemo
5) cisplatin based chemo
What is the treatment for nonseminoma testicular cancers in the following situations:
1) stage I
2) bulky retroperitoneal lymphadenopathy
3) advanced disease (IIC or III)
4) postop elevated serum tumor markers without radiographic evidence of disease
5) if tumor markers have normalized
1) active surveillance, cisplatin-based chemo or retroperitoneal lymph node dissection
2) cisplatin chemo
3) cisplatin chemo
4) chemo
5) surgical resection of residual mass (may be terotoma)
What cancer can a sudden varicocele be?
renal cell carcinoma
Which cancer can be associated with paraneoplastic syndromes (erythrocytosis, AA amyloidosis, polymyalgia rheumatic and hepatic dysfunction)
renal cell carcinoma
T/F: For suspected renal cell carcinoma, resect the large lesions without biopsy
T
What is the early-stage localized renal cancer treatment?
partial/radical nephrectomy
What is the treatment for metastatic renal cell carcinoma and good functional status?
debulking nephrectomy
What are PD1 antibody immunotherapy for renal cell carcinoma?
pembrolizumab or nivolumab
What are 3 targeted therapies that can be used for renal cell carcinoma?
VEGF inhibitors, mTOR inhibitors, immunotherapy with PD1 antibodies
What categories is the following therapies for renal cell carcinoma?
1) bevacizumab
2) sunitinib, sorafenib, pazopanib, axitinib
3) temsirolimus, everolimus
1) VEGF inhib
2) VEGF tyrosine kinase inhib
What can be given to decrease skeletal complications and delay bone lesions in renal cel carcinoma?
Zoledronate
What are the 4 types of thyroid cancer?
papillary, follicular, medullary, anaplastic
Medullary thyroid cancer (elevated calcitonin level) + pheochromocytoma + hyperparathyroidism (kidney stones, hypercalcemia)=what syndrome?
MEN2A
Medulllary thyroid cancer (elevated calcitonin level)+ pheochromocytoma+ hyperparathyroidism (kidney stones, hypercalcemia) + marfanoid habitus and ganglioneuromas = what syndrome?
MEN2B
What is the biopsy study for thyroid cancer? Which gene mutation should be looked for?
FNA
BRAF gene mutation
What is the BRAF gene mutation specific for? (2)
1) papillary carcinoma
2) more agressive thyroid cancer
Which gene is associated with inherited forms of medullary thyroid cancer?
RET proto-oncogene
What is the treatment for papillary and follicular thyroid cancer? Medullary thyroid cancer?
total thyroidectomy + radioiodine therapy
Medullary cancer=total thyroidectomy and neck dissection (cannot updake radioiodine)
T/F: chemo does not prolong or improve quality of life for metastatic thyroid cancer
T
What kind of biopsy is needed for diagnosis of lymphoma?
excisional biopsy (avoid FNA)
What are 2 other tests that you need after diagnosis of lymphoma is made?
total body CT scan with PET and bone marrow biopsy
What are 4 examples of indolent lymphomas?
follicular lymphoma, MALT, CLL, hairy cell leukemia
may not require therapy
What are 3 examples of aggressive lymphomas
diffuse large B-cell lymphoma, mantle cell lymphoma, Hodgkin lymphoma
Need immediate therapy
Which lymphoma has a cytogenetic analysis showing translocation of t14:18 with overexpression of bcl-2 oncogene?
follicular lymphoma
What is the treatment for the following stages of follicular lymphoma?
1) asymptomatic
2) localized symptoms
3) symptomatic, systemic disease
4) curative but significant morbidity and mortality
1) no treatment
2) radiation with rituximab
3) rituximab + multiagent chemo
4) stem cell transplant
Which lymphoma is associated with H pylori?
MALT lymphoma
Which lymphoma is associated with sludge cells, flow cytometry with CD5 and CD23?
CLL
What is the treatment for CLL?
1) asymptomatic=none
2) symptomatic=riximab + multiagent chemo (chlorambucil and irbrutinib)
What are 2 other autoimmune diseases are seen with CLL?
ITP and hemolytic anemia
T/F: There is an increased risk for transformation from CLL to large cell lymphoma
T
What can be given to prevent infection in CLL?
IVIG if IgG is low
Which lymphoma is characterized by pancytopenia and progressive splenomegaly without lymphadenopathy? There is an unsucessful bone marrow
Hairy cell leukemia
What is the treatment for hairy cell leukemia?
Cladribine
What are 2 of the most aggressive forms of large cell lymphoma? What is the treatment?
burkitt lymphoma and lymphoblastic lymphoma
treatment: ALL
What is treatment for mantle cell lymphoma?
Stem cell transplant
Which lymphoma presents with a palpable, firm lymphadenopathy or mediastinal mass?
Hodkin lymphoma
T/F: A bone marrow biopsy is needed to work up hodgkin lymphoma
F; just need PET scanning
What is the treatment for hodgkin lymphoma?
ABVD followeed by radiation; if recurrent disease, then HSCT
What disease should be monitored after treatment of hodgkin lymphoma?
viral infections and secondary cancers (breast, lung, skin) and MDS
Start annual mammography +/- MRI breast screening
T/F: Patients with Hodkin lymphoma w/ h/o mediastinal radiation who presents with chest pain should be evaluated for CAD
T; regardless of age!
What is the treatment for diffuse large B-cell lymphoma?
R-CHOP +/- radiation if have bulky disease
Which lymphoma causes mycosis funoides and if circulates in blood, Sezary syndrome?
Cutaneous T cell lymphoma (raised plaques, diffuse skin erythema and skin ulcers progressing to organ infiltration and immunodeficiency)
Which lymphoma has a cerebriform-appearing nuclei?
Cutaneous T cell lymphoma
What is the treatment for cutaneous T cell lymphoma?
1) early stage limited to skin
2) advance stage
3) young people
1) topical glucocorticoids
2) electron-beam radiation, photopheresis, monoclonal antibodies
3) HSCT
What is the work up and treatment for the following CUP:
1) axillary lymphadenopathy in women
2) isolated cervical lymphadenopathy
3) isolated inguinal lymphadenopathy
1) breast MRI–>tx according to stage or if neg, treat as stage II
2) upper endoscopy, bronch, laryngoscopy–>if negative, then chemo+radiation like in head and neck cancer
3) anorectal, genital, perineal exam–>if neg, then treat with lymph node resection or locoregional radiation
What is the work up and treatment for the following CUP:
1) peritoneal carcinomatosis and ascites
2) midline non-adenocarcinoma of mediastinum or retorperitoneum
1) treat as ovarian carcinoma with cytoreductive surgery and chemo
2) measure AFP and beta-hCG, perform testicular exam and US–>treat with platinum-containing germ cell tumor regimens
What are side effects of the following to cards:
1) doxorubicin
2) tamoxifen
3) trastuzumab
4) mediastinal radiation
1) dose related HF (irreversible)
2) VTE
3) non dose related HF (reversible)
4) myocardial, valvular, pericardial fibrosis, premature CAD
What are the side effects of the following to pulm:
1) bleomycin
2) radiation
1) pulmonary toxicity, usually pneumonitis
2) radiation-induced pneumonitis
What are the side effects of the following to reproductive system:
1) Chemo
2) tamoxifen
1) premature ovarian failure, male infertility
2) endometrial cancer
What are the side effects of the following:
1) radiation to head and neck
1) hypothyroidism
What are the side effects of the following to the MSK?
1) aromatase inhibitor
2) leuprolide, goserelin, castration
1) osteoporosis
2) osteoporosis
What are the side effects of the following–risk of secondary cancers
1) mantle radiation
2) chemo (breast cancer)
1) breast, lung, esophageal cancer
2) MDS and acute leukemia
What are the side effects of the following to the kidney and bladder?
1) cisplatin and ifosfamide
2) cyclophosphamide and ifosfamide
1) renal tubular damage and CKD
2) hemorrhage cystitis
What are the associated infections with the following cancers:
1) cervical and anal cancers
2) kaposi sarcoma
3) hodgkin lymphoma
1) HPV, HIV–risk proportional to number of partners
2) HHS8, HIV; don’t confuse with bacillary angiomatosis (bartonellosis)
3) EBV
What are the associated infections with the following cancers:
1) Burkitt lymphoma
2) MALT lymphoma
3) HCC
4) nonhodgkin lymphoma
1) EBV t(8; 14) positive, HIV, oral and nasopharyngeal cancer and posttransplantation lymphoma
2) H pylori
3) cirrhosis and hep C or B
4) HIV
What are the associated infections with the following cancers:
1) nasopharynx cancers
2) oropharynx cancers
1) EBV
2) HPV
What disease is seen with PTH-related protein in pattient with hypercalcemia of unknown cause?
What is treatment for this hypercalcemia?
tumor if this is elevated
tx: volume repletion with normal saline followed by forced diuresis with normal saline; can use bisphosphonates for long-term control; add glucocorticoids in steroid-sensitive malignancies (myeloma/lymphoma)
What is treatment for VTE with underlying cancer?
LMWH (if can’t use, then IVC filter)
what is treatment for metastatic brain tumor?
1) minimally sx dz
2) advanced dz
3) isolated brain met
4) multiple brain mets
1) oral glucocorticoids
2) osmotic diuresis and IV glucocorticoids
3) surgical excision + radiation
4) radiation (if solid tumor) or chemo (leukemia, lymphoma)
What is the treatment for spinal cord compression 2/2 mets?
glucocorticoids + decompressive surgery + radiation; can also use chemo if have lymphoma or breast cancer
What complication occurs with SOB, cough, facial edema, plethora, swollen arms, JVD, stridor, prominent collateral veins on the anterior chest wall? Dx and tx?
superior vena cava syndrome
dx: tissue biopsy and mediastinoscopy or percutaneous transthoracic CT guided needle biopsy
tx: glucocorticoids and diuretics
Management for the following neutropenic fevers:
1) high risk
2) low risk
1) cefepime or zosyn or carbapenam
2) cipro + augmentin
