Oncology/Skin Flashcards
What else can trastuzamab be used to treat besides breast?
Her-2 overexpressing stomach or esophagogastric adenocarcinoma
Dabrafenib can be used for what cancer?
Melanoma. Unresectable or metastatic melanoma BRAF V600
daBRAFenib
Cetuximab can be used for what cancer?
mechanism?
EGFR expressing metastatic colon cancer
If the tumor is KRAS (+) then no benefit for cetuximab
Also for squamous cell head and neck cancer
Erlotinib also EGFR. Used for non small cell lung CA, pancreatic
Erlotinib is used for what cancer?
tarceva
Metastatic non-small cell lung cancer with EGFR mutations
locally advanced or unresectable pancreatic cancer
What is the “halo” sign?
US Finding for papillary thyroid CA
What is the accordion sign?
Pseudomembranous colitis
Radiation. When giving 5000 cGy, which one is more potent? 500 for 10 days or 250 for 20 days?
Higher dose, shorter time is more potent
Median survival when peritoneal carcinomatosis is left untreated?
With chemo?
~7mo.
~12mo. With chemo
Describe the steps for HIPEC. what temperature? For how long? What agent?
Laparotomy
Debulk all tumors to < 2mm, strip the diaphragm
Mitomycin C heated to 42C, 90 minutes
Make anastomosis if needed then closeq
Usual chemo regimen for breast CA?
Adriamycin, cytoxan +/- taxotere
What is merkel cell tumor?
What is the treatment? Do you have to do sentinel node?
Neuroendocrine tumor of the skin
Wide excision with 1-2cm margin + sentinel node biopsy + adj RADIATION to the tumor bed (esp for tumor size > 10mm)
Sarcomas spread hematomgeously. Which types are exceptions to this and spread via nodes?
Synovial sarcoma
Epithelioid sarcoma
Angiosarcoma
For sarcomas when do you do incisional vs excisional biopsy?
<3cm: excisional bx
>3cm: core needle biopsy first then incisional bx if inconclusive
What is the most important prognostic factor for sarcoma?
Grade, even moreso than size
What’s the T staging for sarcoma?
There’s only 2 T staging for sarcomas.
T1: <5cm
T2: >5cm
Preferrable margin for sarcoma WLE
2cm
After resection of GIST, how long does the gleevec therapy last?
Prolonged 3yr therapy increases 5yr survival by ~10%, reduced recurrence by ~20%
Von hippel lindau
VHL gene
Renal cell Hemangioblastomas Retina Pheo CNS tumor
Li fraumeni
P53
Breast Sarcoma Brain Leukemia Pancreatic
CDH1
Diffuse gastric cancer
Which cell cycle phase is most susceptible to radiation?
M phase and G2
Cetuximab targets what? What kinds of cancer is it used for?
EGFR
colon, head & neck
Also EGFR expressing metastatic colon cancer
Other than PTLD, what other cancer does EBV cause?
What is kaposi sarcoma caused by?
A subset of gastric cancer is caused by EBV
kaposi is caused by human herpes virus 8 HHV8
Merkel cell tumor. Immunohistochemistry stain for CK20 is positive or negative?
What about TFF-1?
How is this different from small cell lung cancer?
CK20(+) cytokeratin
TFF-1(-) thyroid transcription factor
Small cell lung cancer: both positive
They give you a melanoma and asks how to biopsy but doesn’t give you punch as an option. What to do? Does it depend on the size?
Excisional biopsy with 1-2 mm margin
For lesions > 2cm may do partial incisional biopsy
Nec fasc. What is the most common organism? Overall?
What is the most common monomicrobial nec fasc?
Overall: polymicrobial
Most common monomicrobial: strep A
How do you classify nec fasc
First: clostridium vs non-clistridium nec fasc
Then non-clistridium nec fasc has 4 types
I: polymicrobial (mixed anaerobes and aerobes)
II: group A strep
III: vibrio (marine bacteria)
IV: fungal
Skin lesion pathology: “microscopic tentacles that extend laterally from the lesion “ or “spindle cells”
What is it? Treatment?
Dematofibrosarcoma
En Bloc excision with a wide 2cm margin
During a deep inguinal node dissection, where do you divide the inguinal ligament?
Where does the dissection start?
How do you close?
Over the femoral canal. Place the finger in the femoral canal to protect the femoral vessels
Starts at the common iliac vessels and extend caudally
Femoral canal is closed by suturing the inguinal ligament to the lacunar ligament. Then you can use a mesh or a sartorius flap to cover the defect to prevent hernias
Ehler danlos.
Which type collagen defect?
18yo comes into your office with this. What screening do you recommend?
Type III
CT angio for aortic root aneurysm
Flesh colored nodule on the back/arm. First step in diagnosis? Excisional biopsy?
Core needle first. If inconclusive then excisional bx
What is a natal cleft?
How is the disease here classified?
What’s a navicular area?
Buttcrack
Type I: asymptomatic Type II: acute disease Type III: limited to navicular area Type IV: extend beyond navicular area Type V: recurrent disease
Navicular area: areas you can’t see you when you push the buttcheeks together
What’s stage V pressure ulcer?
There is no stage V.
Stage IV: you see bone and muscle
Stage III: subQ fat
Stage II: partial skin breakdown
Stage I: erythema
Actinic keratosis is a risk factor for developing what kind of cancer?
Squamous cell
Lentigo maligna predominantly affects what area?
Head & neck
What is the most important reason for meshing up the skin graft?
Does it impact imbibition?
Surface area. Decreases the amt needed for harvest
Doesn’t really affect imbibition
CK20(+) TTF-1(-) treatment? It’s 15mm
It’s merkel cell carcinoma. Basically neuroendocrine tumor of the skin
CT neck, CAP
WLE with 2cm margin
Sentinel node
Adjuvant radiation (can be skipped if size < 10mm)
Why is sebaceous cyst a misnomer?
What is the pathogenesis of this? What gets blocked and what gets trapped in the cyst?
What is the most common location?
It’s epidermal cyst. It doesn’t contain sebum. It contains keratin
Hair follicle gets blocked. Epidermal cells gets implanted into the dermis. Keratin gets trapped, not sebum
Face, neck, scalp, back
Is Moh’s surgery okay for melanoma?
Yes but only for in situ disease. Start with 5mm margin
Full thickness skin graft. Keep the fat or get rid of it?
What is a usual donor site
Designed into what shape? Rectangular?
How to close donor site?
Make sure to remove fat to prevent fat necrosis
Retroauricular or superior eyebrow region
Other: subclailvicular, infraabdominal fold
Elliptical shape
Close donor site primarily. If unable split thickness skin graft can be used
Most common short term complication of inguinal node dissection?
Infection. 1-2%
Follow-up after melanoma
Stage IA
Everything else
When do you do CBC/LFT/LDH/PET?
Stage IA: history and physical every 3-12 months
Everything else: history and physical every 3-6 months for 3 years, then every 4-12 months for 2 years
Labs and imaging only if suspicion based on hnp
4 tumors that you can resect the liver met and can get a cure
Colon
Melanoma (primary from the eye. Typically only goes to liver)
Carcinoid/neuroendocrine
Ovarian
Which tumor metastasizes to the pancreas?
Renal cell
What genes are associated with lynch syndrome?
MLH1, MSH2, MSH6, PMS2
Microsatellite instability
What is the most common malignancy encountered during pregnancy?
Does pregnancy affect survival of this disease?
Melanoma
Pregnancy does not affect melanoma survival
Mechanism of action of ipilimumab?
anti-CTLA4
What drug can be used for BRAF(+) melanoma?
What % of melanoma are BRAF(+)?
Dabrafenib
About half
Treatment for subungal/digit melanoma?
Used to be amputation of the proximal joint but now digit sparing WLE. No survival benefit
Only if margin (+) amputate the joint
Dematofibrosarcoma protuberans
- cells stain for what antibody?
- treatment?
- sensitive to radiation ?
- what medical therapy?
- spindle cells stain for CD34
- WLE with 2cm margin. Sentinel node not needed because they don’t usually go through the nodes. Go to the lungs
- yes, sensitive to radiation
- imatinib (Gleevec bcr-abl tyrosine kinase inhibitor)
Does groin dissection for melanoma improve survival?
What is the rate of post-inguinal dissection lymphedema?
It improves disease free survival
But it does not improve melanoma specific survival.
Aka it decreases nodal relapse but overall survival is the same
MSLT-II. 24% lymphedema rate
Keloids and hypertrophic scars have excess type I or type III collagen?
Excess type I
What are the medical treatment options for hidradenitis suppurativa?
Zinc gluconate
Steroids
Crftriaxone, rifampin, moxifloxacin for weeks
If they fail, dapsone and or cyclosporine
Then adalinumab (humira. binds to TNF-a)
Diagnosis and treatment for:
Fluctuance under the nail bed
Erythema, pain, and edema of the fingertip pulo
Fluctuance under the nail bed:
Paronychia. Rx: remove the nail plate
Erythema, pain, and edema of the fingertip pulp:
Felon. Rx: incision and drainage
What is an early sign of nec fasc of LE?
Severe pain on passive motion
Think of the cancer for:
- BCR/abl
- erb-B2
- c-Kit
- K-ras
- B-raf
- BCR/abl: proto oncogene for CML
- erb-B2: breast proto onco. This is HER2
- c-Kit: proto onco for GIST
- K-ras: proto onco for CRS/pancreas
- B-raf: melanoma
For gastric cancer which pts get neoadj?
MAGIC trial: resectable T2 or greater lesions
T1: mucosa, submucosa
T2: muscularis propria
T3: serosa
T4: adjacent structures
actually the same as the esophagus. for esophagus, T4a: attaches to resectable things like pericardium, pleura, diaphragm, T4b: attaches to unresectable things like the vertebrae, aorta, trachea
Annular pancreas:
Duodenoduodenostomy vs DJ vs GJ. When to use what?
In neonates DD
Adults: DJ/GJ
Melanoma metastasis to where have better prognosis?
Skin and lung
What tumor is CK-20(+) TFF-1 (+)?
Small cell carcinoma of the lung
For cytoreductive debulking for ovarian cancer, residual tumor diameter of what size is considered “optimal debulking”?
<1cm
what drug is Anti CD-20 ?
Used to treat what?
Rituximab.
CML, rheumatoid, MS
PTLD in txp
Hereditary diffuse gastric cancer (DGC)
inheritance pattern?
Mutation in what gene?
What prophylactic surgery should be done at what age?
Anything else to do for women?
Autosomal dominant
CDH1 gene: codes for E-cadherin (found 30-50% of the time)
E-cadherin in breast is ADH. ALH = (-) e-cadherin
Prophylactic gastrectomy between 18-40
For women screen like BRCA1/2. Us and mri
What virus is related to kaposi sarcoma?
Human herpes virus 8. HHV-8
What cancer is EBV related to?
Burkitt, hodgkin, PTLD, gastric cancers, nasopharyngeal
Which cancer? Malignant degeneration if epithelial cells with differentiation toward keratin formation
SCC
Which cancer? Areas of tumor islands rising from the epidermis with peripheral palisading if nuclei and stromal retraction
Basal cell
What is the most common malignancy associated with DVT/PE?
lung cancer followed by pancreatic
Which poses a higher risk for DVT/PE?
prolonged hospitalization and immobility vs cancer?
Prolong hospitalization and immobility higher risk for DVT than cancer
PRSS1 is related to what?
Hereditary pancreatitis. It’s diagnostic for it
Renal cell carcinomas are associated with what paraneoplastic syndromes?
Most common site of metastasis for RCC?
Major risk factor?
PTH related protein
ACTH
renin
Erythrocytosis
most common met to lung
Smoking is the major risk factor
What is doxorubicin’s Moa?
Inhibition of DNA synthesis by inhibition if toooisomerase II
Cardiotoxicity
What genetic alteration is associated with improved prognosis for pancreatic neuroendocrine tumor?
Hypermethylation of hMLH1
This leads to microsatellite instability and is associated with improved prognosis
Sarcoma abuts but does not invade the artery. What to do?
Excision with adjacent vascular adventitia
Margin for marjolin’s ulcer?
5-20mm
Pembrolizumab
Target? Therapy for what?
PD-1
melanoma
STK11?
Peutz Jeghers
Autosomal dominant
What do the BRCA1 and BRCA2 proteins actually do?
BRCA1: complexes with RNA polymerase in the transcription process
BRCA2: binds directly to DNA to repair damage
What are the two biggest risk factors for cholangiocarcinoma?
Primary sclerosing cholangitis
Fibropolucystic liver disease
retroperitoneal liposarcoma:
true. recurrence is most likely to be local
false. debulking doesn’t improve survival. even the primary tumor. thus, subtotal resection should be limited to relieving intestinal obstruction when deemed appropriate
dermatofibrosarcoma vs. merkel cell:
- margin?
- sentinel node?
- radiation?
- medical therapy?
dermatofibrosarcoma protuberans:
- 2cm margin
- NO SLN
- YES RADIATE
- Imatinib can be used for locally advanced and metastatic disease.
Merkel cell:
- 1-2cm margin
- YES SLN
- YES RADIATE (esp for tumor size > 10mm)
Adjuvant therapy for resectable cholangiocarcinoma?
Capecitabine > gemcita + cisplatin.
