Pretest_5_Transplants, Immunology, and Oncology Flashcards
Which cells produce TNF?
Macrophages/monocytes
T/F: Portal venous thrombosis after liver transplant is only treated with exploratory lap and thrombectomy if it occurs early.
True! If it is a late complication, collaterals have formed
A paucity of bile ducts on biopsy following liver transplant suggests
“vanishing bile duct syndrome” = chronic rejection due to immune-mediated injury to the biliary epithelium
How is a cross-match performed?
Donor lymphocytes to recipient serum and complement
Tumor lysis syndrome is marked by which electrolyte abnormalities? Which cells mediate this?
hyperkalemia, hyperphosphatemia (both due to cell lysis); hypocalcemia (due to precipitation with phospahte)
mediated by cytotoxic T cells
How does cyclosporine work?
inhibits IL2 production (no clonal expansion of alloantigen-directed cytotoxic T cells and no stimulation of Ab production by B cells)
Patients requiring emergency dialysis should also have which standard conservative measures taken?
1) limitation of protein to <60 g/day
2) restriction of fluid intake
3) reduction of elevated serum potassium
Transplanted kidney becoming swollen and blue following revascularization indicates:
hyperacute rejection (extensive intravascular deposits of fibrin and paletelets and intraglomerular accumulation of PMNs, fibrin, platelets, RBCs)
T/F: Heart transplants are not matched by tissue typing.
True! It takes too long; hearts must be transplanted within hours. ABO compatibility must exist
What is the timeline for acute rejection?
1 week to 3 months
What are the most common posttransplantation viral infections?
DNA viruses of the herpesvirus family, including CMV, EBV, HSV, and VZV.
What are the variables in the MELD score? What is the MELD score used for?
total bili, INR, and creatinine
predicts greatest risk of mortality within 3 months
GVHD is seen most following which transplantation?
bone marrow (also liver sometimes)
Contraindications to liver transplant include:
ongoing/recent substance abuse, current extrahepatic malignancy (2y delay), sepsis, poor cardiac/pulm function, HCC with metastatic disease, vascular invasion, or significant tumor burden
OKT3 is a CD3 antigen antibody that is used to prevent and treat rejection. What is a possible complication?
pulmonary edema, nephrotoxicity, encephalopathy, aseptic meningitis
In patients with nonseminomatous testicular tumors, what are good markers to monitor for tumor recurrence?
B-hCG, AFP, LDH
Isolated enlarged cervical lymph nodes in adults are malignant ___% of the time
80 (usually metastatic squamous cell carcinomas)
Histologic grading, which reflects the degree of anaplasia of tumor cells, has prognostic value in which cancers?
soft tissue sarcoma, transitional cell cancers of the bladder, astrocytoma, chondrosarcoma
Mother palpates abdominal mass in son while giving him a bath; elevated BP; think:
Wilm’s tumor
What is MEN 1 syndrome?
pituitary, parathyroid, pancreatic tumors
What is MEN 2A?
medullary thyroid cancer, pheo, hyperparathyroidism
What is MEN 2B?
medullary thyroid cancer, pheo, neuromas/gangliomas/Marfanlike habitus
MEN syndromes occur due to germline mutations in which proto-oncogene?
RET
What are the symptoms of medullary thyroid cancer? What is the serum marker?
Calcitonin=elevated, causes flushing, diarrhea, pruritus
Risk for malignancy of a soft tissue tumor is increased for tumors greater than __ cm in diameter.
> 5cm
What is the most common site in the GI tract for non-Hodgkin lymphoma?
stomach
What operable complication is a common occurrence among patients receiving systemic chemo?
perirectal abscess
T/F; Seminoma is not radiosensitive.
FALSE. It is EXTREMELY radiosensitive!!
Pheochromocytomas are associated with mutations in which genes?
RET (MEN IIa and IIb), VHL (von hippel lindau), and NF1 (neurofibromatosis); also SDHB/SDHD…whatever that is
For colorectal cancer screening, colonoscopies should be performed every 10 years, or flexible sigmoidoscopy every __ years, or air contrast barium enema every __ years.
flexible sigmoidoscopy every 5 years; air contrast barium enema every 3 years
If an adenomatous polyp is detected on colonoscopy, then screening should happen every __ years henceforth. If five polyps are detected, then screening should occur every __ years.
every 3 years thenceforth.
5 polyps –> annually
For patients with HNPCC, when should colonoscopy/sigmoidoscopy/air contrast barium enema screening start?
20-25, or 10 years earlier than the youngest family member with colorectal cancer (whichever is earlier)
Which phase of the cell cycle is most susceptible to radiation?
M
T/F: Oxygen-depleted cells are resistant to radiation.
True
Ingestion of nitrates and nitrosamides in food and drinking water has led to an increased incidence of what kind of cancer?
gastric
Excess amounts of dietary fat and deficiency of fiber has been associated with _____ cancer
colon
Animal fats have been associated with which cancer?
exocrine pancreas, prostate, endometrium
Alcohol consumption, esp. when combined with cigarette smoking, increases the incidence of ____________ cancer
esophageal
T/F: The consumption of alcohol increases the incidence of pancreatic cancer.
False. But it does increase the incidence of pancreatitis
Mycophenolate mofetil is what kind of chemo?
antimitotic
Li-Fraumeni syndrome is associated with a mutation in which gene?
p53
Family adenomatous polyposis is associated with what gene?
APC
The PTEN suppressor gene is associated with which diseases?
Cowden disease = multiple hamartoma syndrome
Hereditary malignant melanoma is associated with what gene?
p16 tumor suppressor gene
T/F: BRCA1 is associated with an increased risk of colon cancer and prostate cancer in men
True
BRCA2 is more associated with gallbladder, bile duct, and pancreatic cancers.
BRCA (1/2) breast cancers are more likely to be estrogen-positive.
BRCA2 = estrogen positive BRCA1 = estrogen negative
What is an adverse outcome of vincristine use?
peripheral and central neuropathies
What is an adverse outcome of 5-FU?
mucositis, dermatitis, cerebellar dysfunction
What is an adverse outcome of cisplatin?
ototoxicity, neurotoxicity, nephrotoxicity
Post-transplant lymphoproliferative disorders are associated with
EBV
Hypercalcemia post-renal transplant should be treated with
total parathyroidectomy with autotransplantation of a portion of the gland into the forearm, or subtotal parathyroidectomyThis would be 3* hyperparathyroidism (autonomous parathyroid function)
A rising CEA following colon cancer surgery, in the absence of other conditions associated with an elevated CEA (UC, cirrhosis, pancreatitis, renal failure, pancreatic/stomach/breast/lung cancer), predicts what?
appearance of liver metastases within 1 year
Patients with lymph node involvement of colon cancer should receive
adjuvant chemo: 5-FU and leuvocorin
The most common site of bloodborne metastases from primary colorectal cancer is
the liver
Azathioprine has ________ as its major side effect, and needs monitoring of ______- in the post-transplant period
bone marrow toxicity; WBC and platelet counts need to be monitored
What is the principal cytokine mediator in gram-negative shock and sepsis-related organ damage?
TNF
Tumor lysis syndrome has which electrolyte abnormalities?
hyperkalemia, hyperphosphatemia, hyperuricemia, and HYPOcalcemia
CMV infections have a peak incidence __ weeks after transplant and manifest as
6 weeks
pneumonitis, ulceration and hemorrhage of stomach/duodenum/clon; hepatitis; esophagitis; retinitis; encephalitis; pancreatitis
Incisional biopsies oriented along the long axis of the extremity should be performed for suspected sarcomas unless
the mass is small such that complete excision would not jeopardize subsequent treatment
Which type of parotid tumor has worse prognosis: acinar or squamous?
squamous
Which type of testicular tumors are frequently associated with pulm metastases and are treated with chemo?
choriocarcinoma
Post-transplant lymphoproliferative disorders (PTLD) are associated with infection by
EBV
Name an immunosuppresive agent that can cause leukopenia:
azathioprine
In a patient with a renal transplant with elevated Cr at 3 month follow up with normal ultrasound, no fever, and no graft tenderness, suspect
cyclosporine-induced nephrotoxicity. Most appropriate step is reduction in cyclosporine dosage.
What is Li Fraumeni syndrome?
Li Fraumeni: breast cancer, brain tumors, acute leukemia, soft tissue sarcomas, bone sarcomas, and adrenal cortical carcinoma
A patient with diabetes mellitus about to undergo pancreatic transplant needs what checked before hte operation?
C-peptide (ensure the condition really is diabetes mellitus)
As soon as donor organs are harvested, what happens to cool them down?
they are rapidly flushed with 4*C saline as soon as removed from body
Which HLA genes are most helpful is assessing compatibility of tranplant?
A, B, DR
Which IL-2 receptor blockers are used in conjunction with a steroid and calcineurin inhibitor to decrease the frequency of episodes of acute rejection in kidney transplant recipients?
Basiliximab (once before surgery, and once after)
Daclizumab (once before surgery, again at 2 week intervals x 4 doses)
T/F: Antirejection drugs are known to cause birth defects, increase obstetric complications, and cause twinning.
False! Post transplant patients usually have no major complciations in pregnancy (though they often give birth prematurely, but for unknown reasons)
What are the most common indications for heart transplant?
CAD and cardiomyopathy (each make up 40% of cases for transplant)
remaining 20% = valvular disease, congenital heart disease
What is the best method to check for evidence of rejection of a heart transplant?
percutaneous (usually via the IJ into the right ventricle) endomyocardial biopsy
(standard measurements of cardiac function and routine clinical exam do not distinguish acute rejection from other cardiac pathologies)
Why are high dose steroids avoided in lung transplants?
steroids severely impair healing of bronchial anastamoses
Usually lung transplants are single, except when
there are bilateral infections because replacing only one allows the infection to easily spread to the new lung
T/F: Cardiopulmonary bypass is a feature of lung transplantation.
False. Except when patient has refractory hypoxemia or hemodynamic instability—bypass should always be on standby just in case.
What are the indications of chronic liver disease signifying end stage disease and warranting transplantation?
1) asictes refractory to treatment, with hydrothorax, with SBP
2) hepatic encephalopathy
3) recurrent esophageal varices
What is the most common indication for renal transplantation in the US?
glomerulonephritis
What is the probability that 2 siblings will be perfect HLA matches?
25%
The three HLA types that matter most (A, B, DR) are usually inherited together. Each parent has two haplotypes.
So 25% perfect match, 50% chance of sharing one, 25% chance of zero match
What is transplanted along with the pancreas in a standard pancreatic transplant?
segment of the duodenum (containing the ampulla of Vater) and part of the common iliac artery including the bifurcation and initial parts of the two segments
Pancreas usually goes into the right iliac fossa
