H/O Flashcards
(112 cards)
1
Q
Thrombotic thrombocytopenic purpura
A
a clinical diagnosis that requires the presence of thrombocytopenia and microangiopathic hemolytic anemia, which is confirmed by schistocytes on the peripheral blood smear. Patients may also have fever; kidney manifestations such as hematuria, elevated creatinine level, and proteinuria; and fluctuating neurologic manifestations, but the absence of these symptoms does not exclude the diagnosis. Assays for ADAMTS-13 activity and inhibitor titer are available but are best used for prognosis rather than to guide therapy, because TTP requires immediate treatment with plasma exchange that cannot be delayed until laboratory test results are available.
2
Q
Major bleeding associated with vitamin K antagonists
A
Should be treated by reversing anticoagulation with 4-factor prothrombin complex concentrate in addition to intravenous vitamin K.
3
Q
4-factor prothrombin complex concentrate
A
Contains all four vitamin K–dependent coagulation factors (factors II, VII, IX, and X) Unlike fresh frozen plasma (FFP), 4f-PCC is stored at room temperature, does not require ABO typing, and can be infused quickly because of its small volume, thus reducing the time to delivery of therapy. Compared with FFP, 4f-PCC has been shown to more rapidly achieve hemostasis in patients with visible or musculoskeletal bleeding with less risk of fluid overload and no difference in thromboembolic events. This agent has therefore been approved by the FDA for urgent reversal of coagulation factor deficiencies related to vitamin K antagonist therapy for adult patients with acute major bleeding, as well as for adult patients in need of urgent surgery or an invasive procedure.
4
Q
chronic thromboembolic pulmonary hypertension (CTEPH)
A
efined as a mean pulmonary artery pressure of greater than 25 mm Hg, with normal pulmonary capillary wedge pressure, left atrial pressure, and left ventricular end-diastolic pressure. It typically occurs within 2 years following a pulmonary embolism (PE), affecting 3.8% of patients, although only about 50% of these have a history of clinically detected PE If the V/Q scan suggests CTEPH, confirmatory right heart catheterization with pulmonary artery pressure measurements and pulmonary arteriography is indicated.
5
Q
paroxysmal nocturnal hemoglobinuria (PNH)
A
Hemolytic anemia, pancytopenia, or unprovoked atypical thrombosis. Hemolysis is caused by the absence of decay-accelerating factor (CD55) and the membrane inhibitor of reactive lysis (CD59), which are glycosylphosphatidylinositol-dependent complement regulatory proteins Mutations in the PIG-A gene lead to the reduction or absence of glycosylphosphatidylinositol, an important erythrocyte-anchoring protein
6
Q
Budd-Chiari syndrome associated with
A
Half of patients with idiopathic BCS had an acquired mutation in JAK2, without overt suggestion of a myeloproliferative neoplasm. Therefore, testing for JAK2 is part of the diagnostic testing protocol that includes consideration of paroxysmal nocturnal hemoglobinuria in the differential diagnosis of splanchnic vein thrombosis.
7
Q
Hemophilia
A
Hemophilia A results from factor VIII deficiency and hemophilia B from factor IX deficiency; both produce a prolongation of the activated partial thromboplastin time that fully corrects in a mixing study.
8
Q
hypereosinophilic syndrome (HES)
A
An elevated eosinophil count (>1500/µL [1.5 × 109/L]) without a secondary cause and evidence of organ involvement are diagnostic. Causes of eosinophilia are described in the CHINA: connective tissue diseases, helminthic infection, idiopathic [HES], neoplasia, allergy
9
Q
Urticaria pigmentosa
A
Pruritic yellow to red or brown macules, papules, plaques, and nodules. Systemic mastocytosis with eosinophilia is characterized by urticaria pigmentosa. The most common noncutaneous findings are gastrointestinal and include symptoms such as abdominal pain, diarrhea, nausea, and vomiting.
10
Q
identification of an inherited thrombophilia
A
Often does not change treatment decisions in a patient with VTE (does not reliably predict risk of recurrence or influence duration of recommended anticoagulation), evidence-based guidelines recommend against routine thrombophilia testing. In patients with an unprovoked proximal DVT, the recommendation for long-term anticoagulation would not be altered by the results of such testing, thus, it would not be helpful. Testing may be indicated, however, in patients with VTE at intermediate risk for recurrence by traditional predictors in whom finding a strong thrombophilic risk might alter therapeutic decisions.
11
Q
transfusing select patients who are immunocompromised to reduce the risk of transfusion-associated graft-versus-host disease and febrile nonhemolytic transfusion reaction.
A
Leukoreduced and irradiated erythrocytes should be used (those with severe, inherited T-cell immunodeficiency syndromes or Hodgkin lymphoma or recipients of allogeneic or autologous hematopoietic stem cell transplantation, purine analog–based chemotherapy [fludarabine, cladribine, deoxycoformycin], alemtuzumab, or rabbit antithymocyte globulin therapy) are at increased risk of developing transfusion-associated graft-versus-host disease (ta-GVHD)
12
Q
Washed erythrocytes
A
considered for patients with a history of severe allergic reactions to transfusions patients who are IgA deficient
13
Q
acute lymphoblastic leukemia (ALL) in older patients
A
Diagnosis: presence of 25% or more lymphoblasts on bone marrow examination. Cytochemical stains and flow cytometry can help distinguish ALL from acute myeloid leukemia (AML) and B-cell from T-cell ALL prognosis for an older patient with ALL has traditionally been poor, with Philadelphia chromosome [t(9;22)] positivity indicating worse outcomes The most significant advance in the treatment of older patients with Philadelphia chromosome–positive disease is TKI therapy. The results of dasatinib and dexamethasone therapy are better than those for traditional chemotherapy, with less toxicity. For older patients who have Philadelphia chromosome–negative ALL, no clear standard cytotoxic chemotherapy regimen exists. However, TKI therapy can provide disease control for greater than 1 year with much less toxicity. Combination regimens such as hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (Hyper-CVAD) can cure adults with ALL, but are too toxic for use in elderly populations. The paradox of ALL in older adults is that although less aggressive regimens are less toxic, they compromise the ability to control the leukemia.
14
Q
HLA-matched platelets.
A
Patients experiencing platelet transfusion refractoriness because of alloimmunization should receive
15
Q
β-thalassemia
A
Hemolytic anemia, microcytosis, and target cells are typical of β-thalassemia, which is associated with slightly increased hemoglobin A2 and some residual hemoglobin F.
16
Q
elevated erythropoietin level and hypoxemia
A
secondary erythrocytosis. Don’t need bone marrow biopsy.
17
Q
acquired hemophilia
A
associated with high titers of inhibitor. Recombinant activated factor VII is used to treat the bleeding episodes. Patients with low titers of inhibitor (measured in Bethesda units) may be treated with factor VIII concentrates. Patients with high inhibitor titers (>5 Bethesda units) require treatment with recombinant factor VIIa or prothrombin complex concentrates designed to activate factor X and secure hemostasis independent of factor VIII and the intrinsic pathway. Patients may require immunosuppression for inhibitor eradication.
18
Q
In some patients with fluctuating INRs while taking warfarin
A
daily supplementation with low-dose vitamin K (100-150 µg/d) can stabilize the INR.
19
Q
parvovirus and sickle cell disease
A
Parvovirus B19 infection can cause acquired pure red cell aplasia in an otherwise functionally asplenic patient with sickle cell disease.
20
Q
immune thrombocytopenic purpura treatment
A
without evidence of bleeding and platelet counts greater than 30,000 to 40,000/µL (30-40 × 109/L) have less than a 15% chance of developing more severe thrombocytopenia requiring treatment and can be managed with careful observation. Repeat the complete blood count at a designated interval, generally 1 to 2 weeks, u ITP is a diagnosis of exclusion, supportive clinical findings include an otherwise normal blood count and the absence of additional organ dysfunction. Platelets on the peripheral blood smear are large because they typically have been recently released from the marrow, and the enhanced hemostatic function of these young platelets may account for less severe bleeding symptoms than those associated with other diseases with a similar platelet count. therapy may be required for patients with platelet counts lower than 30,000 to 40,000/µL (30-40 × 109/L) or with bleeding. Initial therapy consists of glucocorticoids. Patients who do not respond to glucocorticoid therapy should be treated with an additional agent such as intravenous immune globulin or anti-D immune globulin or rituximab. Splenectomy leads to a sustained remission in 75% of patients.
21
Q
Isolated superficial venous thrombophlebitis
A
Duplex ultrasonography is indicated to assess for the possibility of an associated deep venous thrombosis (DVT) in patients with isolated superficial venous thrombophlebitis (SVT), because DVT or pulmonary embolism risk increases in patients with SVT of the great or small saphenous vein, with extremity swelling more pronounced than would be expected from the SVT alone, and with progressive symptoms. Nonextensive SVT, defined as less than 5 cm in length and not near the deep venous system, may be treated with only symptomatic therapy consisting of analgesics, anti-inflammatory medications, and warm or cold compresses for symptom relief, because the risk of progression into the deep venous system and of PE is low.
22
Q
folate deficiency
A
Those with generalized malnutrition or poor nutrition, can become folate deficient in weeks to months because of relatively limited stores of folate in the body. Measuring serum folate levels is typically unreliable in diagnosing folate deficiency, because folate levels increase rapidly after a single folate-containing meal. Plasma homocysteine levels increase in folate deficiency, whereas homocysteine and methylmalonic acid levels are increased in cobalamin deficiency.
23
Q
Treatment of essential thrombocythemia
A
Hydroxyurea plus low-dose aspirin is the best treatment option for essential thrombocythemia when treatment is required in patients older than 60 years, those with a platelet count greater than 1 million/µL (1000 × 109/L), or those with a history of thrombosis.
24
Q
Heyde’s syndrome
A
a syndrome of gastrointestinal bleeding from angiodysplasia in the presence of aortic stenosis Caused by the induction of Von Willebrand disease type IIA (vWD-2A) by a depletion of Von Willebrand factor (vWF) in blood flowing through the narrowed valvular stenosis. Can also get a MAHA from valvular replacement/disease.
25
Associated with ingestion of raw seafood, especially oysters, and the risk of sepsis and death is increased in persons with hereditary hemochromatosis.
Vibrio vulnificus
26
iron overload syndromes
excess iron appears to impair host defenses against certain infections, such as decreasing the chemotactic response and compromising the ability of phagocytic cells. The result is increased virulence among specific infectious organisms in patients with iron overload, including Vibrio species (vulnificus,cholerae), Escherichia coli, Yersinia enterocolitica, Listeria monocytogenes, cytomegalovirus, hepatitis B and C viruses, and HIV. Fungi include Aspergillus fumigatus and mucor.
27
factor V Leiden (FVL) mutation
Homozygous FVL carries an 18-fold increased risk of first-time venous thromboembolism (VTE), whereas FVL heterozygosity only carries a 2.7-fold increased risk. no evidence indicates testing for inherited thrombophilia is beneficial in an asymptomatic child, particularly with heterozygous FVL, which is not considered a strong thrombophilia. In patients in whom testing for FVL is indicated, the presence of FVL can be detected by an APC resistance assay that assesses the ability of protein C to inactivate factor Va. This is a very sensitive study that effectively excludes FVL if normal and is the preferred initial screening test, mainly because it is typically less expensive than the FVL genetic test.
28
acute promyelocytic leukemia
All-trans retinoic acid (ATRA) should be administered as soon as possible, followed by chemotherapy, for this patient with acute promyelocytic leukemia APL is a clinically and biologically distinct variant of acute myelocytic leukemia characterized by the presence of a (15;17) gene translocation, which gives rise to the promyelocytic leukemia–retinoic acid receptor-α fusion transcript and arrest of leukemic cells at the promyelocyte stage. ATRA to standard induction and consolidation chemotherapy releases the block in promyelocyte maturation and produces cure in up to 80% of patients.
29
hereditary spherocytosis
The osmotic fragility test with 24-hour incubation is a key step in diagnosing hereditary spherocytosis. Autosomal dominant
30
sickle cell disease, including pregnant patients, transfusion
not indicated for uncomplicated pregnancy, routine painful episodes, minor surgery not requiring anesthesia, or asymptomatic anemia. Erythrocyte exchange transfusion is indicated for acute ischemic stroke, ACS with significant hypoxia, and multiorgan failure/hepatopathy as well as in persons in whom simple transfusion would increase the hemoglobin level to greater than 10 g/dL (100 g/L). Chronic transfusion can lead to iron overload, alloimmunization, and an increased risk for a delayed hemolytic transfusion reaction. Erythrocytes used in transfusion should be leukoreduced, hemoglobin S negative, and phenotypically matched for the E, C, and K antigens as well as for any known alloantibodies. Hemoglobin targets should remain less than 10 g/dL (100 g/L) to avoid hyperviscosity.
31
In patients taking a vitamin K antagonist who have an INR greater than
9 and no evidence of bleeding, oral vitamin K and withholding warfarin are indicated to rapidly reduce the INR. For a supratherapeutic INR less than 5.0, withholding warfarin and restarting at a lower dose are usually adequate. For an INR of 5.0 to 9.0, a similar management strategy is appropriate, although administration of 1 to 2.5 mg of oral vitamin K is reasonable in patients at risk for bleeding. In patients with an INR greater than 9.0, such as this patient, administration of 2.5 to 5 mg of oral vitamin K is indicated to more rapidly reduce the INR to the desired range.
32
smoldering (asymptomatic) multiple myeloma
M protein level of 3 g/dL or more or clonal plasma cells representing 10% or more of the total marrow cellularity on bone marrow biopsy but the absence of disease-specific signs or symptoms median time to progression of 4.8 years. Therefore, surveillance in these patients is necessary
33
von Willebrand disease
easy bruising, postsurgical bleeding, and heavy menstrual bleeding in women in conjunction with normal prothrombin and normal to minimally prolonged activated partial thromboplastin times.
34
heparin-induced thrombocytopenia.
The 4T score is used to estimate the pretest probability of HIT based on clinical factors, including degree of thrombocytopenia, timing of the decrease in platelet count, presence of any potential sequelae of HIT (such as thrombosis), and whether another potential cause for thrombocytopenia exists. Possible point values range from 0 to 8; scores of 0 to 3 indicate low probability, 4 or 5 indicate intermediate probability, and 6 to 8 represent high pretest probability. Confirmatory testing for antiplatelet antibodies may be done by direct antibody testing or by functional assays that test the ability of serum from patients with HIT to activate test platelets. Direct antibody testing is typically performed by enzyme-linked immunosorbent assay (ELISA) that detects antibodies directed toward heparin-platelet factor 4 complexes. The two commonly used functional assays are the serotonin release assay (SRA) and the heparin-induced platelet aggregation (HIPA) assay.
35
polycythemia vera
Symptoms include generalized pruritus that often worsens after bathing, erythromelalgia (a burning sensation in the palms and soles), and hypermetabolic symptoms such as fever, weight loss, and sweating. On physical examination, patients may have plethora and hepatosplenomegaly. Twenty percent of patients experience arterial or venous thrombosis as their initial symptom. PV and the other MPNs predispose to the development of the Budd-Chiari syndrome (BCS), which is characterized by hepatic venous outflow tract obstruction (including the suprahepatic inferior vena cava) and other intra-abdominal thromboses, such as thrombosis of the portal, superior mesenteric, or splenic vein. Anticoagulant therapy is recommended for all patients with BCS regardless of whether an underlying prothrombotic disorder is discovered. Phlebotomy to normalize the hematocrit (goal \<45% in men, \<42% in women) is indicated, and adding the myelosuppressive agent hydroxyurea to phlebotomy decreases thrombotic events in patients with PV.
36
Diagnose cold agglutinin disease
A direct antiglobulin (Coombs) test is the most appropriate diagnostic step. Direct IgM binds more effectively at temperatures colder than 32.0 °C (89.6 °F), typically in the fingers, toes, and nose, causing cold agglutinin disease. IgM-coated erythrocytes agglutinate in the microvasculature, leading to cyanosis and ischemia in the cold extremities. The IgM antibodies fix complement and then detach from erythrocytes when they return to the warmer body core. An acquired hemolytic anemia associated with cold exposure and supported by his peripheral blood smear, showing agglutinated erythrocytes that disappear when warmed. Cold agglutinin disease may occur as a primary disorder or may be associated with a lymphoproliferative disorder or certain infections, such as Mycoplasma pneumoniae or Epstein-Barr virus. The primary treatment for cold agglutinin disease is avoidance of cold exposure.
37
clotting factor activity levels in liver failure, disseminated intravascular coagulation, or vitamin K deficiency/warfarin overdose
In liver failure, all clotting factor activity levels are low except for factor VIII, which is synthesized in all endothelial cells rather than only hepatic endothelial cells
Additionally, good hepatic function is required for factor VIII clearance, thus factor VIII levels increase in liver disease. Patients with severe liver failure (and on occasion those with acute liver failure) will have prolonged prothrombin and activated partial thromboplastin times because of decreased levels of coagulation factors. This is called the coagulopathy of liver disease. The elevated D-dimer level is also consistent with liver disease, because D-dimers are cleared by the liver; a high D-dimer level does not automatically indicate disseminated intravascular coagulation (DIC).
An elevated factor VIII level, as seen in this patient, rules out DIC.
Factor V levels can be used to distinguish between liver disease and vitamin K deficiency, because factor V is synthesized in the liver but is not a vitamin K–dependent factor. Thus, someone with vitamin K deficiency will have normal levels of factor V, whereas a patient with liver failure will have low factor V levels.
38
IGH/CD1
mantle cell lymphoma
39
PML-RAR
cute promyelocytic leukemia
40
chronic myeloid leukemia
insidious onset of fatigue; early satiety and progressive weight loss associated with splenomegaly; and a peripheral blood smear demonstrating myelocytes, metamyelocytes, and basophils. The peripheral blood smear of CML is commonly described as mimicking a bone marrow aspirate. Basophilia is a general clue to the presence of a myeloproliferative neoplasm (MPN).
41
transfusion-transmitted bacterial infection.
Clinical criteria for a possible septic transfusion reaction include any of the following within 5 hours of completion of a transfusion: temperature greater than 39.0 °C (102.2 °F) or temperature two degrees higher than pretransfusion, rigors, pulse rate greater than 120/min or more than 40/min higher than pretransfusion, or a decrease or increase in blood pressure of greater than 30 mm Hg.
Transfusion should be stopped immediately and intravenous fluids and antibiotics should be given to patients experiencing transfusion-transmitted bacterial infection.
42
Patients with sickle cell disease undergoing low- to moderate-risk surgery
should receive erythrocyte transfusion, which has been shown to be equivalent to exchange transfusion, targeting a hemoglobin level of 10 g/dL (100 g/L) before the procedure to avoid complications.
43
The “4T score”
degree of thrombocytopenia, timing of the decrease in platelet count, presence of potential sequelae of HIT (such as thrombosis), and whether another potential cause for thrombocytopenia exists
HIT develops 5 to 10 days after exposure to heparin, with a decrease in platelet counts of 50% or more and, in a subset of patients, paradoxical arterial or venous thrombotic events despite the presence of thrombocytopenia.
44
Treat a patient with venous thromboembolism who wishes to breastfeed.
Warfarin and low-molecular-weight heparin are considered safe for use by women requiring anticoagulant therapy who wish to breastfeed.
45
MM and bisphosphonates
Studies have shown that bisphosphonates inhibit osteoclast-mediated osteolysis, reduce the risk of skeletal-related events (pathologic fracture, need for radiation therapy or surgery to bone, spinal cord compression), decrease bone-related pain, and improve median overall survival. The risk of skeletal-related events was reduced in patients with or without evidence of lytic bone disease on plain radiographs. Bisphosphonates therefore represent a critical aspect of care for patients with myeloma requiring therapy, and guidelines call for the use of zoledronic acid or pamidronate in all patients with newly diagnosed multiple myeloma.
46
essential thrombocythemia
A patient with iron deficiency and isolated thrombocytosis that persists after correction of iron deficiency should undergo JAK2 V617F mutational analysis as part of the evaluation for essential thrombocythemia.
The JAK2 activating mutation is present in 50% of patients with ET, so a negative result would not exclude the diagnosis, but a positive result supports the diagnosis of a myeloproliferative neoplasm (polycythemia vera, ET, or primary myelofibrosis).
47
Iron malabsorption
celiac disease, achlorhydria secondary to atrophic gastritis or proton pump inhibitor therapy, or, occasionally, H. pylori infection
48
patient undergoing colonoscopy and taking a new oral anticoagulant.
interruption of anticoagulation is suggested in patients who are not at high risk for thromboembolic events, (which includes whose thrombotic event occurred more than 3 months ago).
For surgical procedures with standard risk for bleeding, the NOAC should be discontinued 2 to 3 half-lives beforehand, and in procedures with high bleeding risk, 4 to 5 half-lives beforehand.
49
alpha thalasemia
α-thalassemia shows a normal pattern and β-thalassemia typically has a slightly increased hemoglobin A2 band. α-Thalassemia trait (or α-thalassemia minor, double gene deletion -α/-α or –/αα) is associated with mild anemia, microcytosis, hypochromia, target cells on the peripheral blood smear, and, in adults, normal hemoglobin electrophoresis results. The (-α/-α) variant is often mistaken for iron deficiency.
The red cell distribution width (RDW) is also useful in distinguishing between thalassemia and iron deficiency, because the RDW is often elevated in iron deficiency but normal in thalassemia. No treatment or monitoring is necessary for α-thalassemia trait.
50
appropriate contraceptive choice for a woman at increased risk for venous thromboembolism.
Progestin-releasing intrauterine devices are the most appropriate contraceptive option for women at increased risk for venous thromboembolism (VTE) because they are not associated with increasing the VTE risk further, whereas progestin-only pills, implants, and injections may slightly increase the risk for thrombosis.
Women older than 35 years who smoke more than 15 cigarettes per day should not be prescribed estrogen-containing preparations because of an increased risk of stroke.
Contraindications to combination products include history or increased risk of thrombosis, liver disease, breast cancer, migraine with aura, and uncontrolled hypertension
51
PE management
A 2012 guideline from the American College of Chest Physicians (ACCP) recommends thrombolytic therapy for patients with PE and a systolic blood pressure less than 90 mm Hg and without contraindications (for example, high bleeding risk). Thrombolytic therapy does not appear to have therapeutic benefit in unselected patients with acute PE and is associated with an increased risk for major hemorrhage. No clear evidence indicates thrombolytic therapy should be used in patients with evidence of pulmonary hypertension or right ventricular dysfunction detected by echocardiography, positive cardiac enzymes, or both. This patient has no indications for thrombolytic therapy. If thrombolytic therapy were appropriate, the ACCP's guidelines recommend systemic administration rather than catheter-directed thrombolysis.
When treating acute pulmonary embolism (PE), it is essential to initiate anticoagulation immediately and achieve therapeutic levels of anticoagulation within 24 hours; failure to do so correlates with an increased risk of clinical progression and recurrence.
Outpatient management is safe for up to 50% of patients with PE, including some with mild right heart strain on cardiac echocardiography.
52
Patients with amyloidosis
hould undergo amyloid typing to classify his amyloidosis (for example, immunoglobulin light chain [AL], hereditary, or secondary [AA] amyloidosis)
Chemotherapy and autologous hematopoietic stem cell transplantation (HSCT) are appropriate therapies for a patient with an established diagnosis of AL amyloidosis but not hereditary amyloidosis.
53
transfusion nor exchange transfusion in sickle cell
neither transfusion nor exchange transfusion is indicated in asymptomatic patients without signs of end-organ damage. Neither has been shown to decrease maternal morbidity or mortality during pregnancy, but both would predispose the patient to iron overload and erythrocyte antibody production.
Transfusion would be appropriate to treat symptomatic anemia or signs of end-organ involvement (stroke symptoms, kidney failure, ACS, hepatic involvement).
54
Treat a patient with venous thromboembolism with an initial combination of a parenteral anticoagulant and warfarin.
Heparin should be given for no less than 5 days and only discontinued at that time if the INR is therapeutic for 24 hours. Warfarin may be initiated on the first or second day of heparin therapy. Because factor II and X levels require at least 5 days to decline sufficiently, parenteral anticoagulation should overlap with warfarin for at least 5 days and until an INR of 2 or more is achieved.
55
Diagnose cobalamin (vitamin B12) deficiency.
vegan diet for several years.
The methylmalonic acid level is elevated in 98% of patients with cobalamin deficiency, making it a sensitive and specific laboratory test to use in determining deficiency.
56
Waldenström macroglobulinemia
neoplastic infiltrate consisting of clonal lymphocytes, plasmacytoid lymphocytes, plasma cells, and immunoblasts comprising 10% or more of the bone marrow cellularity with disease-related manifestations, including night sweats, weight loss, anemia, lymphadenopathy, and splenomegaly
Management of this low-grade, mature B-cell, non-Hodgkin lymphoma consists of the anti-CD20 monoclonal antibody, rituximab, as single agent therapy or combined with chemotherapy
The chemotherapy regimen may consist of an alkylating agent base (such as cyclophosphamide) or purine analog base (such as fludarabine).
57
Glucose-6-phosphate dehydrogenase deficiency
pisodic hemolysis in response to oxidant stressors (for example, infections or drugs such as dapsone, trimethoprim-sulfamethoxazole, and nitrofurantoin)
x linked
uring an acute hemolytic episode, bite cells may be seen on the peripheral blood smear, as are apparent in this patient's peripheral blood smear.
58
warm autoimmune hemolytic anemia (WAIHA)
high reticulocyte count, elevated bilirubin and lactate dehydrogenase (LDH) levels, the positive direct antiglobulin (Coombs) test, and spherocytes seen on peripheral blood smear
WAIHA can manifest as a primary disorder or as a complication of another disorder, including autoimmune conditions (systemic lupus erythematosus) or lymphoproliferative disorders (chronic lymphocytic leukemia)
reatment is immunosuppression to halt the immune-mediated erythrocyte destruction and allow the patient's own bone marrow to regenerate the erythrocytes, if possible. The best initial treatment for this condition is a glucocorticoid such as prednisone.
Rituximab and splenectomy are typically reserved to treat patients in whom first-line therapy for WAIHA has failed; they are not used in the acute setting
Transfusion in patients with WAIHA is a topic of debate.
59
Manage myelodysplastic syndrome
asymptomatic pancytopenia. The mild macrocytosis is typical. The bone marrow biopsy is appropriate to confirm a suspected diagnosis of myelodysplasia in the setting of the normal vitamin B12 and folate levels and to provide important prognostic information.
5-Azacytidine is appropriate therapy for higher risk MDS for the purpose of improving blood counts, delaying AML progression, and extending survival. It would be indicated to lessen transfusion dependence or to improve prognosis for high-risk disease
Allogeneic hematopoietic stem cell transplantation in very high risk.
60
Distinguishing TACO from transfusion-related acute lung injury (TRALI)
Fever and hypotension occur in only one third of patients with TRALI. However, TRALI is not associated with signs of volume overload (increased jugular venous pressure, lower extremity edema, elevated CVP). BNP and N-terminal proBNP levels have not been studied in TRALI but are elevated with TACO.
61
Younger, fit patients with high-risk myelodysplastic syndrome should receive
allogeneic hematopoietic stem cell transplantation, which is the only curative therapy option.
62
Delayed hyperhemolytic transfusion reaction
Chronic transfusion in patients with sickle cell disease (SCD) can lead to iron overload, alloimmunization, and an increased risk for DHTR. DHTR is caused by an amnestic response of a preformed erythrocyte alloantibody after re-exposure to an erythrocyte antigen outside the ABO system. Additionally, an autoimmune component could be worsening the hemolysis. Following transfusion, a 1% to 1.6% chance exists of developing these antibodies. DHTR may then occur after re-exposure with subsequent transfusion. Clinical findings, which typically develop approximately 2 to 19 days after erythrocyte transfusion, include anemia, reticulocytosis, jaundice, a significant decrease in hemoglobin level, and increases in hemolytic markers such as lactate dehydrogenase and bilirubin levels, although many patients will be asymptomatic.
63
Felty syndrome
characterized by rheumatoid arthritis, splenomegaly, and neutropenia.
The unusual cell seen on the peripheral blood smear is a large granular lymphocyte (LGL). LGLs may be seen in up to 40% of patients with Felty syndrome; they may also be associated with other collagen vascular diseases and autoimmune neutropenia.
64
Manage a patient with suspected central nervous system lymphoma.
Patients who have increased intracranial pressure associated with suspected central nervous system lymphoma require immediate high-dose glucocorticoids to treat the mass effect and a brain biopsy to establish the tissue diagnosis.
a recommended dose of 8 to 10 mg every 6 hours. Higher-dose dexamethasone (100 mg/d) does not improve the response rate and is associated with more adverse effects.
Because lymphomas are extremely glucocorticoid sensitive, early administration may make obtaining a tissue sample difficult by distorting histologic findings; it is therefore preferable to obtain a biopsy in a stable patient with possible or likely CNS lymphoma prior to glucocorticoid therapy if there are minimal sequelae of increased ICP. However, in all patients with more advanced complications of increased ICP such as this patient, immediate glucocorticoid treatment is indicated.
65
Treat a patient with malignancy-associated hypercalcemia
Immediate hydration with large-volume normal saline infusion, forced diuresis with furosemide (controversial now), glucocorticoid therapy for glucocorticoid-responsive malignancies such as multiple myeloma, and a bisphosphonate is appropriate treatment of malignancy-related hypercalcemia.
Bisphosphonates are powerful inhibitors of osteoclast-mediated bone resorption with an onset of effect occurring several days after administration and a duration of up to several weeks depending on the specific agent used, which allows longer-term control of calcium levels.
Calcitonin can also be considered x 1-3 days.
Hypercalcemia is most common among patients with multiple myeloma and breast, renal, and lung cancer
Dialysis is an effective method for lowering serum calcium levels, although it is generally reserved for patients with severe, symptomatic hypercalcemia who have not responded to acute treatment with hydration and other measures or patients in whom aggressive hydration is contraindicated.
66
Treat stage III colon cancer
Chemotherapy with capecitabine and oxaliplatin (CAPOX) or leucovorin, 5-fluorouracil, and oxaliplatin (FOLFOX) is appropriate adjuvant therapy for patients with stage III colon cancer.
Because local recurrence of colon cancer rarely develops and because it can be difficult to isolate the small bowel from the radiation field, radiation therapy, either alone or in combination with chemotherapy, does not have a role in the routine management of patients with stage III colon cancer.
local recurrence is a greater problem in patients with rectal cancer and because it is far easier to isolate the small bowel from the radiation field when treating rectal cancer, the combination of radiation therapy and chemotherapy, preferably preoperatively, is routinely used for treating patients with stage II and III rectal cancer.
67
initial evaluation of all patients diagnosed with metastatic nonsquamous non–small cell lung cancer (NSCLC)
Testing to identify an epidermal growth factor receptor (EGFR) mutation is a key component in the initial evaluation of metastatic nonsquamous non–small cell lung cancer due to improved survival in patients with EGFR mutations who are treated with EGFR tyrosine kinase inhibitors (such as erlotinib, gefitinib, or afatinib).
Although K-ras testing can help determine the prognosis in patients with NSCLC, there are currently no approved drugs that target ras mutations. Furthermore, K-ras mutations are not negatively predictive for anti-EGFR therapies as in colon cancer.
PET scanning has a role in evaluating patients who are believed to have potentially resectable disease. However, obtaining a PET scan in a patient who clearly has metastatic disease based on CT imaging is unnecessary.
68
Ipilimumab toxicity
yervoy - CTLA-4
These include dermatologic (rash, mucositis), gastrointestinal (diarrhea, colitis), liver (autoimmune hepatitis), and endocrine (hypothalamic/pituitary, thyroid, and adrenal insufficiency). Other organ involvement (eye, kidney, hematologic, pulmonary, and neurologic) has also been reported. Because the toxicity results from triggering an exaggerated immune response, treatment of these toxicities involves removing the causative agent and providing immunosuppression, preferably with high-dose glucocorticoids due to their nonspecific immune-suppressing effects and rapid onset of action. Recognition of the autoimmune effect of the treatment is critical since the autoimmune-triggered toxicity from this class of medications can be fatal if immunosuppressive therapy is delayed.
69
posttreatment surveillance following therapy for head and neck cancer.
Following successful treatment of localized squamous cell carcinoma of the head and neck, patients remain at risk for developing both local cancer recurrence and second primary cancers, especially cancers due to tobacco and alcohol use.
Periodic oral examinations and direct laryngoscopy are usually warranted and if meets reqs for lung ca screening, then this should also be pursued.
70
appropriate timing of prophylactic bilateral salpingo-oophorectomies for a BRCA1 carrier
Patients with BRCA1/2 mutations are at increased risk for ovarian cancer. The lifetime risk is 35% to 46% in BRCA1 mutation carriers and 13% to 23% in BRCA2 carriers. National guidelines recommend risk-reducing BSO in women who carry deleterious BRCA1/2 mutations between ages 35 and 40 years, once childbearing is complete.
A recent registry data analysis of almost 6000 women with BRCA1 or BRCA2 mutations proposed that risk-reducing BSO be done by age 35 years in women with BRCA1 mutations due to a 4% risk of ovarian cancer between ages 35 and 40 years.
71
r-IPI score
most predictive of outcomes in patients with diffuse large B-cell lymphoma.
incorporates multiple clinical factors, including the patient's age, performance status, disease stage, degree of extranodal involvement, and serum lactate dehydrogenase level to generate a score that correlates with progression-free and overall survival after standard therapy
Ann Arbor Staging System criteria can be used for most other forms of lymphoma.
72
Treat advanced cervical cancer
Radiation therapy and concurrent cisplatin-based chemotherapy is the most appropriate treatment for bulky stage III cervical cancer (extending to the pelvic wall and/or involving the lower third of the vagina)
Early-stage cervical cancer without spread to the pelvic wall or to the lower third of the vagina can be treated successfully with surgery alone, but more locally advanced cancer requires radiation therapy instead of surgery.
Radiation therapy alone can be used for patients with stage I (confined to the cervix) or nonbulky stage II cervical cancer (invading beyond the uterus but not to the pelvic wall or lower third of the vagina) as an alternative to hysterectomy but should be combined with chemotherapy for patients with bulky stage II, stage III, and stage IVA cervical cancers (spread to adjacent organs but no distant metastases).
Radical hysterectomy is appropriate for patients with stage I or nonbulky stage IIA cervical cancer, which includes invasion beyond the uterus but not extending to the pelvic wall or to the lower third of the vagina.
73
Patients receiving long-term immunosuppressive therapy
greater risk for developing non-Hodgkin lymphoma.
74
Treat breast cancer with neoadjuvant chemotherapy
Neoadjuvant chemotherapy may be indicated for patients with HER2-amplified or triple-negative breast cancers and for patients with larger cancers who desire breast-conserving surgery
Disease-free survival and overall survival are equivalent in patients treated with neoadjuvant and adjuvant chemotherapy
n addition, the response to neoadjuvant chemotherapy is predictive of long-term disease-free and overall survival. Cancers with the highest response rate to neoadjuvant chemotherapy are those that are either HER2 positive or triple-negative tumors (tumors that are negative for estrogen receptor, progesterone receptor, and HER2 amplification). Patients with these types of cancer can be offered neoadjuvant chemotherapy even if decreasing the tumor size in order to perform breast-conserving surgery is not needed. After neoadjuvant chemotherapy, pathologic complete response, defined as the absence of any residual invasive cancer in the breast or lymph nodes, occurs in up to 60% of patients with HER2-positive cancers and up to 40% of those with triple-negative cancers and correlates with an excellent long-term disease-free survival.
Unless a patient has tumor progression or is on a clinical trial assessing the response of a new regimen, all of the chemotherapy is usually completed before surgery. A patient with a HER2-positive cancer would receive trastuzumab during the nonanthracycline part of adjuvant chemotherapy, receiving 1 year of trastuzumab in total. Trastuzumab-containing regimens without anthracyclines are an option, particularly for women with a higher risk of cardiomyopathy because of older age or pre-existing hypertension. Pertuzumab is a newly approved anti-HER2 monoclonal antibody that may be used with trastuzumab and chemotherapy for neoadjuvant treatment of HER2-amplified breast cancers that measure 2 cm or more and/or are sentinel lymph node positive. The NeoSphere study demonstrated improved pathologic complete response rates (46% vs 29%) when pertuzumab was added to trastuzumab and docetaxel for HER2-amplified breast cancers with these higher risk features.
75
Patients with estrogen receptor–positive breast cancer who develop metastases limited to bone
Patients with estrogen receptor–positive breast cancer who develop metastases limited to bone after a long disease-free interval should be treated initially with an aromatase inhibitor
76
Patients with newly diagnosed atypical ductal hyperplasia
should be offered breast cancer chemoprophylaxis; exemestane is associated with the greatest reduction in breast cancer risk.
Exemestane is an aromatase inhibitor that prevents conversion of androgens to estrogens and profoundly suppresses estrogen levels in postmenopausal women. At a median follow-up of 3 years, there was a 65% relative reduction in the annual incidence of invasive breast cancer in patients taking exemestane.
Alternate chemoprophylaxis options include tamoxifen and raloxifene. Tamoxifen decreases the risk of breast cancer by 49% though it has a 0.1% risk per year of endometrial cancer and a 1% risk of vascular events including venous thrombosis and strokes. Raloxifene does not increase the risk of endometrial cancer and has a 25% lower risk of vascular events. It is less effective than tamoxifen, retaining 76% of the benefit of tamoxifen, but is an option in patients who want to decrease toxicities. All three chemoprophylaxis agents (tamoxifen, raloxifene, and exemestane) can be used in postmenopausal women but only tamoxifen is an option in premenopausal or perimenopausal women.
77
Manage postoperative surveillance for a patient with stage III colon cancer.
Postoperative surveillance for patients with colorectal cancer includes physical examination and serum carcinoembryonic antigen measurement every 3 to 6 months, and CT scans of the chest and abdomen (and pelvis for patients with rectal cancer) annually for 3 to 5 years; colonoscopy, if done preoperatively, should be performed 1 year after resection and then repeated at 3- to 5-year intervals.
78
Recognize the risk of treatment-related complications following therapy for testicular cancer.
Treatment-related complications in men who had therapy for testicular cancer include cardiovascular disease (specifically metabolic syndrome), kidney disease, peripheral neuropathy, chronic pulmonary toxicity, secondary malignancy, and sexual dysfunction.
79
Standard therapy for all patients with diffuse large B-cell lymphoma
regardless of disease stage or prognosis, is rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP)
80
all patients with metastatic melanoma should have
their tumor tested for the presence of driver V600 BRAF mutation to determine whether treatment with a BRAF inhibitor is a therapeutic option. Vemurafenib and dabrafenib are the available BRAF inhibitors.
In patients with poor prognostic features and a BRAF V600 mutation, the more rapid response of a BRAF inhibitor is preferred.
81
oligometastatic colorectal cancer
The development of oligometastatic disease (usually to the liver or lung) in a patient who previously was treated for colorectal cancer is potentially curable by surgical resection.
82
Treat acute tumor lysis syndrome
In tumor lysis syndrome, rapid cell breakdown results in hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia, and disseminated intravascular coagulation (DIC). Hyperuricemia can lead to urate nephropathy and acute kidney injury.
Allopurinol is typically used in patients for prophylaxis for tumor lysis syndrome and in those without existing significant (\>8 mg/dL [0.47 mmol/L]) elevations of serum urate. The more expensive rasburicase is usually used in patients with significantly elevated serum urate levels or in those with baseline kidney failure or in those with evidence of kidney injury related to tumor lysis, in order to rapidly decrease the serum urate level.
83
Treat a premenopausal patient who has completed breast cancer therapy who is ER/PR positive
Tamoxifen has been the standard treatment in premenopausal women. As her breast cancer is estrogen receptor positive, adjuvant antiestrogen therapy will reduce her risk of distant recurrence by 40% to 50%. For premenopausal women with hormone receptor–positive early-stage breast cancer, tamoxifen should be used for at least 5 years—preferably 10 years based on the Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) and Adjuvant Tamoxifen Treatment Offers More (aTTom) trials.
exemestane (aromatase inhibitor that blocks peripheral conversion of androgens to estrogens) has recently been compared with tamoxifen in conjunction with ovarian suppression in premenopausal women. The Tamoxifen and Exemestane Trial (TEXT) and Suppression of Ovarian Function Trial (SOFT) trials have shown improved disease-free survival at 5 years for exemestane with ovarian suppression compared to tamoxifen with ovarian suppression, and this is now an option that can be discussed with premenopausal patients, particularly those at high risk of recurrence.
84
Treat a high-grade neuroendocrine tumor of unknown primary site
Neuroendocrine tumors of unknown primary site often respond rapidly to systemic platinum-based chemotherapy, such as the regimens used to treat small cell lung cancer.
85
Treat Burkitt lymphoma
hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (R-hyper-CVAD).
IPI score is based on the patient's age, serum lactate dehydrogenase level, number of extranodal sites, disease stage, and performance status. Patients with Burkitt lymphoma have high IPI scores and always warrant aggressive and immediate therapy. Careful monitoring is required when treating patients with Burkitt lymphoma because rapid cell turnover and cell death are exacerbated by initiation of chemotherapy. Aggressive intravenous hydration, urine alkalinization, and administration of allopurinol or rasburicase are indicated in addition to chemotherapy.
86
Treat metastatic pancreatic cancer
Multiagent systemic chemotherapy with 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) is appropriate
87
Treat locally advanced squamous cell carcinoma of the neck
Patients with early stage head and neck cancer should be treated with either surgery or primary radiotherapy; use of combined chemotherapy and radiation is not indicated.
An important exception to this general treatment approach for early stage head and neck squamous cell malignancies is nasopharyngeal cancer, which is treated with radiation alone for stage I disease and combined chemotherapy and radiation for stage II and higher disease because of a higher risk of distant disease occurrence with these tumors.
Cetuximab, a monoclonal antibody directed against the epidermal growth factor receptor, also has an established role in the treatment of locally advanced squamous cell carcinoma of the head and neck when given with radiation therapy. The addition of either cisplatin or cetuximab has been shown to improve survival when compared with radiation therapy alone in patients with locally advanced disease.
Because of their higher rate of locoregional recurrence, more locally advanced tumors (lymph node involvement) are usually treated with surgery (for accessible oral cavity tumors) or combined modality therapy (for other oropharyngeal anatomic sites) that includes radiation along with concurrent chemotherapy with a radiation sensitizer; cisplatin is the most commonly used agent for this purpose. Multiple studies have found that use of combined modality therapy results in significantly improved patient outcomes.
88
Treat a localized gastrointestinal stromal tumor
Location outside the stomach, larger size, and higher mitotic index constitute relative high-risk factors for recurrence after resection. Patients with small gastric GISTs with low mitotic indices may often be managed with surgery alone. Higher-risk tumors, such as in this patient, require further treatment. A 3-year course of the oral tyrosine kinase inhibitor imatinib has been shown to improve outcomes when used as adjuvant therapy after surgical resection of localized higher-risk GISTs. Imatinib has also been shown to be highly active in treating patients with metastatic GISTs, in whom lifelong therapy is recommended.
89
The MAGIC trial
demonstrated the superiority of preoperative and postoperative chemotherapy (epirubicin, cisplatin, and 5-fluorouracil) compared with surgery alone for treatment of gastric and esophageal/gastroesophageal junction adenocarcinomas
90
markedly elevated serum erythropoietin level
An elevated serum erythropoietin level indicates the presence of secondary erythrocytosis. Although the most common causes of secondary erythrocytosis are chronic hypoxia and elevated carboxyhemoglobin concentrations due to tobacco use, an important cause is an erythropoietin-producing tumor. Tumors commonly associated with secondary erythrocytosis include renal cell carcinoma, hepatocellular carcinoma and pheochromocytoma.
Polycythemia vera (PCV), a myeloproliferative neoplasm that results in excessive and unregulated erythrocyte production, is associated with very low serum erythropoietin levels.
91
Patients with a history of early breast cancer who develop suspicious findings
ndergo biopsy of one of the suspected metastatic sites to confirm the diagnosis and to assess hormone receptor and HER2 status, as these may differ from the original cancer.
92
Treat locally advanced anal cancer
standard treatment regimen for patients with stage I, II, or III anal squamous cell carcinoma is radiation therapy with concurrent chemotherapy consisting of mitomycin plus 5-fluorouracil.
93
Treat non–small cell lung cancer
Cisplatin-based adjuvant chemotherapy improves survival for selected patients who have undergone successful resection of stage II or stage III non–small cell lung cancer, regardless of histologic type.
94
Women who received chest wall radiation (such as mantle radiation therapy for Hodgkin lymphoma) between the ages of 10 and 30
are at high risk for developing breast cancer and should be screened with annual mammograms and breast MRIs.
95
Treat early-stage triple-negative breast cancer
Adjuvant chemotherapy, typically anthracycline-based chemotherapy, is recommended for patients with triple-negative breast cancers who have no medical contraindications to this regimen.
96
Manage a patient following radical inguinal orchiectomy for early-stage seminoma.
Active surveillance is appropriate for this patient with stage I seminoma following resection. Testicular germ cell tumors are divided into pure seminomas and nonseminomatous germ cell tumors (NSGCT). Recommended postsurgical treatments vary based on histologic findings and tumor stage. In general, pure seminoma is associated with a better prognosis than NSGCT. For men with stage I seminoma (disease confined to the testis), radical inguinal orchiectomy is curative in at least 80% of patients.
Active surveillance refers to a regimen of regular assessment with serum tumor marker measurement, CT scans of the abdomen and pelvis, and chest radiographic imaging.
Other management options after surgery include adjuvant therapy with either single-agent carboplatin or para-aortic lymph node irradiation, although neither approach has been shown to improve overall survival. In addition, neither of these alternatives appears superior to the other, but they might be reasonable to consider in patients who wish to decline active surveillance.
97
In patients with resected squamous cell carcinoma of the head and neck associated with either positive surgical margins or lymph node metastases with extracapsular extension.
Adjuvant combined-modality treatment with chemotherapy and radiation is most appropriate
98
Treat stage I rectal cancer
Surgical resection is the initial treatment for patients with stage I rectal cancer (defined as a tumor that invades into, but not fully through, the rectal wall, with no evidence of lymph node metastases).
If pathology findings indicate that the tumor is a higher T stage than expected (T3 or T4) or if any of the locoregional lymph nodes in the mesorectum are found to contain cancer (N1 or N2), postoperative chemoradiation and chemotherapy would be indicated.
99
Treat a patient with stage I mycosis fungoides
Patients with early-stage mycosis fungoides are treated initially with topical glucocorticoids; if glucocorticoids are ineffective, adding retinoids and psoralen and ultraviolet light therapy, sometimes combined with interferon alfa, may be effective.
100
Women with a personal and family history of ovarian, endometrial, and colon cancer should undergo testing for genetic mutations caused by
Lynch syndrome (also known as hereditary nonpolyposis colon cancer).
This is an autosomal dominant cancer susceptibility syndrome caused by a germline mutation in one of the DNA-mismatch repair genes (MLH1, MSH2, and MSH6 being the most common). Patients have an increased risk for several types of cancer, usually with early onset. The most common are a 70% risk for colon cancer, 27% to 71% risk for endometrial cancer, and 3% to 14% risk for ovarian cancer.
101
diffuse lymphadenopathy, B symptoms, extranodal involvement, and cyclin D1 overexpression
Mantle cell lymphoma. Overexpression of cyclin D1, a cell cycle gene regulator, is associated with a chromosomal translocation [t(11:14)] that is diagnostic of mantle cell lymphoma.
102
Newly diagnosed metastatic gastric cancer
Determination of HER2 tumor status is indicated for patients with newly diagnosed metastatic gastric cancer, as the anti-HER2 monoclonal antibody trastuzumab, when added to a systemic chemotherapy regimen, is beneficial in treating patients whose tumors overexpress HER2.
103
BRCA1/2 testing
Patients younger than 45 years with either newly diagnosed breast cancer or a family history of breast or ovarian cancer.
patients with breast cancer diagnosed at any age if one or more first-, second- or third-degree relatives have been diagnosed with ovarian cancer and is recommended for women with “triple negative breast cancer” (estrogen receptor–negative, progesterone receptor–negative, and negative for HER2 amplification) diagnosed before age 60 years.
104
Treat recurrent superficial bladder cancer
Cystectomy is indicated for patients who develop recurrence of superficial bladder cancer within 6 to12 months of undergoing initial transurethral resection of bladder tumor or after receiving one to two courses of intravesical bacillus Calmette-Guérin.
105
reat women with abdominal carcinomatosis of unknown primary site
Cytoreductive surgery followed by systemic chemotherapy is most appropriate in a patient with abdominal carcinomatosis due to cancer of unknown primary site (CUP). When evaluating a patient with CUP, it is important to identify whether the CUP is of a favorable or unfavorable prognostic subgroup to help guide management. Women with CUP presenting as abdominal carcinomatosis and ascites are classified as a favorable prognostic subgroup and should be assumed to have ovarian cancer until proved otherwise.
106
Treat a patient with a newly diagnosed intermediate-thickness melanoma.
Sentinel lymph node biopsy is recommended for patients with melanomas of 1- to 4-mm thickness to provide accurate staging. It is also recommended for lesions less than 1 mm with certain high-risk features, such as ulceration, more than 1 mitosis/mm2, or lymphovascular invasion. A 2-cm excision margin is appropriate for melanomas that are 1 mm thick or deeper.
107
Determine need for diagnostic imaging studies in a patient with low-risk prostate cancer.
Imaging studies are not indicated for men with newly diagnosed early-stage prostate cancer in the absence of symptoms or other high-risk features.
Currently accepted parameters for imaging studies include a serum PSA level of 20 ng/mL (20 µg/L) or higher, a PSA level of 10 ng/mL (10 µg/L) or higher associated with a T2 tumor, a Gleason score of 8 or higher, or a T3 or T4 tumor.
108
Manage metastatic colorectal cancer
utations in the K-ras or N-ras genes, present in approximately 50% of colorectal cancers, are associated with resistance to epidermal growth factor receptor–targeted agents (cetuximab, panitumumab).
109
n patients with aggressive breast cancer who develop severe arthralgia while on antiestrogen therapy due to an aromatase inhibitor
a second aromatase inhibitor should be tried; if the arthralgia fails to resolve, tamoxifen should be started.
110
Manage a patient with lung cancer and superior vena cava syndrome.
In patients with apparent malignant superior vena cava syndrome, a histologic diagnosis should be established, whenever possible, before treatment is begun.
not have stridor, laryngeal edema, or mental status decline. Immediate radiation therapy or stent placement is therefore not indicated.
111
squamous cell carcinoma of the head and neck, particularly those with oropharyngeal primary tumors.
p16 immunohistochemistry testing to detect human papillomavirus is now a widely accepted standard-of-care intervention to help determine prognosis
112
reat a patient with asymptomatic, nonbulky follicular lymphoma.
Early treatment does not improve survival in patients with grade 1 and 2 follicular lymphoma.
