MKSAP Flashcards
(29 cards)
homme avec lymphoma large cellule B
quel test il faut demander parmi ces derniers
BMO
TRM cerebrale
BX d’une ADP RP
LDH
LDH: Nécessaire pour calculer échelle pronostique IPI:
Âge, LDH, Stade, et site extra nodaux ECOG
IRM = pas indiquée en l’absence de symptômes
Biopsie de moelle: plus requis à l’ère de la TEP, de toute façon déjà stade avancé (= 6-RCHOP)
biopsie = inutile
biopsie utile si LNH de bas grade et on soupçonne transfo haut grade
78 ans knee pain, préop
Leukocyte count of 62,000/μL (62 × 10 9/L) with 90% lymphocytes, hemoglobin level of 128 g/L , and platelet count 152,000/μL
Flow cytometry shows a predominance of CD5, CD19, and CD20 cells expressing only κ light chains consistent with chronic lymphocytic leukemia.
choix
1) BMO
2) Ibrutinib
3) Bendamustine-rituximab
4) Chirurgie comme prévu
1) Procéder à la chirurgie comme prévu
aucun tx n’est requis
* Si l’immunophénotype sanguin et la présentation clinique sont classiques, aucune biopsie de moelle ou ganglionnaire n’est requise.
Critères de traitement de la LLC
- Cytopénies non-immunes
- Splénomégalie massive (>6cm) non immune
*Adénopathies massives (>10cm) ou symptomatique
*Temps de doublement des lymphocytes courts et lymphos élevés - Cytopénies immunes réfractaires
- Atteinte EG/Sx B
- Envahissement d’organe avec dysfonction ou sx 2res
LLC admis pneumonie à répétition
There is diffuse adenopathy and splenomegaly.
Leukocyte count
IgG IgA IgM
46,000/μL (46 × 109/L) with 92% lymphocytes, 6% neutrophils, 1% bands, and 1% monocytes
320 mg/dL (3.2 g/L) 20 mg/dL (0.2 g/L) 34 mg/dL (0.34 g/L)
Choix
* Splénectomie
* Ibrutinib
* Immunoglobulines IV
* G-CSF
Immunoglobulines IV (données de MAUVAISE qualité, suggèrent diminution des épisodes infectieux, reste sujet contreversé, mais fait en clinique et recommandé)
A 56-year-old man is evaluated for an enlarging, painful inguinal lymph node he first noticed 1 month ago. He has a history of follicular lymphoma of 8 years’ duration. The patient was treated in the past with two courses of rituximab 8 and 3 years ago with durable partial responses. For the past 3 years, he had stable diffuse adenopathy managed with observation. He has no other symptoms.
* On physical examination, vital signs are normal. The patient has diffuse adenopathy in the neck, axillae, and right inguinal area and a new left inguinal conglomerate nodal mass measuring 5 × 7 cm.
* Complete blood count and metabolic profile are normal.
* PET/CT scan shows diffuse uptake in axillary, mediastinal, hilar, and mesenteric nodes with elevated standardized uptake values in the 4 to 12 range, but 28 in the left inguinal area.
choix :
Bendamustine-rituximab
* Rituximab
* Biopsie inguinale
* RT inguinale
BX INGUINALES
Justification: zone avec progression rapide, discordante et captation accrue au FDG: possibilité de transformation en lymphome de haut grade probable.
* Le résultat de LDH aurait été intéressant
* Si se confirme: R-CHOP = traitement approprié.
A 68-year-old man is evaluated for early satiety and right upper quadrant discomfort. He is otherwise well. He reports that he is still working full time and walks about a half mile to and from work each day.
* On physical examination, vital signs are normal. Examination is notable for hepatomegaly.
* Complete blood count is normal. On serum chemistry testing, alkaline phosphatase and aminotransferase levels are elevated; bilirubin and creatinine levels are normal.
* CT scan of the chest, abdomen, and pelvis shows hepatomegaly with multiple metastatic lesions and abdominal carcinomatosis with a small amount of ascites. No other abnormalities are noted. Liver biopsy reveals adenocarcinoma.
* The patient is diagnosed with metastatic cancer from an unknown primary.
- 1) Marqueurs tumoraux
- 2) Pannel génétique
- 3) TEP
- 4) Endoscopies
- 5) Commencer la chimiothérapie
Commencer la chimiothérapie
* Pas en désaccord complet avec cette réponse… mais: * Fine tuning du traitement
* Recherch de biomarqueurs
* Considérer aller un peu plus loin quand même…
A 54-year-old woman is evaluated for a several-month history of increasing abdominal girth. Medical history is otherwise unremarkable, and she takes no medications.
* On physical examination, vital signs are normal. Abdominal examination reveals ascites. Pelvic examination and the remainder of the physical examination are normal.
* Complete blood count and comprehensive metabolic profile are normal.
* Contrast-enhanced CT scan of the chest, abdomen, and pelvis reveals ascites with areas of peritoneal and omental thickening consistent with metastatic cancer. No abnormalities of the liver are noted, and the adnexa appear normal.
* Paracentesis is performed, and cytology reveals adenocarcinoma.
* Surgical debulking of the peritoneal tumor is planned.
- Régime de chimio pour tumeur GI
- Régime de chimio pour tumeur ovarienne
- Anti-PD1
- RT pan-abdominale
- Carcinomatose péritonéale isolée chez la femme = néo ovaire ad preuve du contraire * La cyto devrait quand même appuyer…
- Pas de place pour immuno ici sauf si perte des MMMR
- RT abdominale complète n’est pas un traitement adéquat en oncologie (JAMAIS)
A 55-year-old woman is admitted to the hospital for chemotherapy following a diagnosis of Burkitt lymphoma. She is considered to be at high risk for tumor lysis syndrome.
* On physical examination, blood pressure is 110/60 mm Hg and pulse rate is 110/min; the remainder of her vital signs are normal. The patient has large, palpable, bilateral cervical, supraclavicular, and axillary lymphadenopathy. Cardiopulmonary examination is normal.
* CT imaging of the chest, abdomen, and pelvis at the time of diagnosis revealed bulky mediastinal and periaortic lymphadenopathy.
* Intravenous isotonic saline is administered at 200 mL/hour.
choix:
* Acetazolamide * Allopurinol
* Furosemide
* Rasburicase
1) La rasburicase est clairement indiquée pour les situations à haut risque de lyse tumorale
* 2) La diurèse forcée (furosemide) ou l’alacalinisation des urines (acetazolamide) ne sont pas recommandés car comportent des risques:
* Contraction volémique (lasix)
* Accroissement dépots phospho-calciques (alcalinisation)
* 3) l’allopurinol n’est pas suffisant dans ce cas
A 66-year-old man is evaluated for increased confusion and lethargy over the past 2 days, as well as nausea and vomiting. He has also had diffuse bone pain that began 6 weeks ago and has worsened over the past month. His medical history is otherwise unremarkable, and he takes no medications.
* On physical examination, temperature is 36.4 °C (97.6 °F), blood pressure is 110/60 mm Hg, pulse rate is 110/min, and respiration rate is 16/min. He is somnolent but can be aroused. Mucous membranes are dry, and he has decreased skin turgor. Cardiopulmonary examination is normal.
* Results of laboratory studies show an albumin level of 3.8 g/dL (38
g/L), calcium level of 14.8 mg/dL (3.7 mmol/L), and creatinine level of 2.5 mg/dL (221 μmol/L).
- Denosumab
- NaCl 0,9 et calcitonine
- NaCl 0,9 et furosemide
- Acide zolendronique
Justification:
* 1re étape pour diminuer rapidement calcémie = hydratation
* Calcitonine peut aussi faire baisser rapidement la calcémie dans un cas aussi malade que celui-ci (mais tachyphylaxie rapide en 48h)
* Acide zolendronique est AUSSI indiqué pour faire diminuer calcémie (mais onset plus lent et pic d’action 3-7 jours) (vs heures pour soluté et calcitonine)
* X-geva = cas réfractaires aux bisphosphonates
* Furosemide = contre-indiqué re: risque de contraction volémique et de diminuer calciurie
A 68-year-old man is evaluated for shortness of breath, headache, and swelling of the neck. He first noticed symptoms 3 weeks ago, which have worsened over the past 2 days.
* Medical history is significant for a 25-pack-year history of smoking.
* On physical examination, temperature is 36.5 °C (97.8 °F), blood pressure is 110/65 mm Hg, pulse rate is 112/min, and respiration rate is 18/min. Oxygen saturation is 92% breathing ambient air. The patient is cachectic but appears comfortable. His face is plethoric, and there are distended cutaneous vessels over the anterior thorax. An enlarged right supraclavicular lymph node is palpable. Pulmonary examination is normal.
* CT scan of the chest reveals bulky mediastinal adenopathy compressing the superior vena cava, right supraclavicular adenopathy, and a small right-sided pleural effusion.
- Biospsie du gg sus-clav
- Stéroïdes
- Radiothérapie
- Résection chirurgicale du gg sus claviculaire
Un diagnostic histopathologique est de loin la priorité (mais on doit éviter si possible anesthésie générale, d’où CI à exérèse).
* Radiothérapie et stéroïdes peuvent négativer biopsie et nuire au plan oncologique à moyen terme (encore potentiellement curatif ici)
A 61-year-old man is evaluated in the emergency department for chronic low back pain, which has worsened rapidly over the past week and is now associated with new- onset weakness in his legs. Medical history includes metastatic non–small cell carcinoma of the lung. Previous to this event, the patient had good functional status.
* On physical examination, vital signs are normal. He has 4/5 muscle strength with flexion at the bilateral hips and knees.
* MRI of the entire spine reveals a 5-cm mass centered in the posterior elements of L1 and L2 with extension into the epidural space and spinal cord compression.
- Décadron
- Décadron, chirurgie, RT complémentaire * RT
- Chirurgie
Décadron, chirurgie, RT complémentaire
A 55-year-old woman is evaluated in the office following a recent diagnosis of metastatic adenocarcinoma of the lung. She has excellent performance status. Medical history is otherwise unremarkable, and she takes no medications.
* There are no molecular alterations (epidermal growth factor receptor, ALK, ROS1). Programmed death ligand-1 expression is negative.
- Chimiothérapie combo
- Chimiothérapie + pembro
- Pembro
- Monothérapie de chimiothérapie
Chimiothérapie + pembro
Pembrolizumab monothérapie supérieure à chimiothérapie si PDL1 >50%, pas
adéquat si PDL1 <50%
* Pembro + chimio > chimio seul pour tous les sous-groupes de PDl1 toutefois * Un doublet de platins > chimio mono-agent
A 77-year-old woman undergoes follow-up evaluation for recently diagnosed stage I adenocarcinoma of the lung. Medical history is notable for very severe COPD that limits her ability to dress unaided. Her medications are an inhaled corticosteroid, salmeterol, tiotropium, roflumilast, and an albuterol inhaler as needed.
* On physical examination, respiration rate is 25/min; other vital signs are normal. Oxygen saturation is 91% breathing 3 L/min of oxygen by nasal cannula. BMI is 20, and she is thin with significant muscle wasting. She has a prolonged expiratory phase of respiration and decreased breath sounds bilaterally.
* Surgical and pulmonary consults concur that the patient is too chronically disabled to safely undergo elective thoracic surgery
- Chimio
- Chimio-radio
- Immunothérapie * SBRT thoracique
SBRT
- Chimiothérapie n’est pas indiquée pour une maladie localisée et toxicité prohibitive ici
- Chimioradiothérapie conco en plus de ne pas être indiquée pour stade 1 = perte fonction
pulmonaire prohibitive - Pas de littérature à ce jour pour immunothérapie “curative“ en stade I – pas indiqué
- SBRT permet une RT locale très focale (peu-pas de perte de fonction) pour petites tumeurs (stade 1), résultats à long terme se comparent avantageusement à chx thorax.
A 55-year-old woman is evaluated in the office following treatment for limited-stage small cell lung cancer. She was treated with cisplatin/etoposide chemotherapy plus irradiation to the site of the primary tumor. Repeat imaging at the end of treatment showed complete response. She is currently asymptomatic.
- Chimio maintenance
- PET-CT dans 6 mois
- RT cérébrale prophylactique * Bronchoscopie.
RT cérébrale prophylactique
Par élimination:
* Chimio maintenance = non, pas de bénéfice à plus de 4-6 cycles
* PET-CT 6 mois = non… taco TAP 3 mois plus tôt
* Broncho de contrôle… mais pourquoi??
- PCI pour les stades limités = augmentation d’OS et diminution des métas cérébrales avec neurotoxicité acceptable
- Conseillé chez patients avec RC ou excellente réponse d’un stade limité
- Conseillé (mais plus controeversé) si stade extensif
A 64-year-old man is evaluated in the emergency department for 5 days of increasing bouts of diarrhea. He was diagnosed with metastatic melanoma 2 months ago and has received three doses of immunotherapy with ipilimumab and nivolumab. He was seen 3 days ago for diarrhea (two loose stools daily). Evaluation for infectious causes of diarrhea, including Clostridioides difficile, was initiated, and loperamide was begun. Today he reports increased diarrhea, with up to five loose stools per day. He takes no additional medications.
* On physical examination, temperature is 36.7 °C (98.0 °F), blood pressure is 95/70 mm Hg, and pulse rate is 100/min. Abdomen is slightly tender and distended without hepatosplenomegaly.
* Complete blood count, metabolic panel, and thyroid-stimulating hormone level are normal, and stool studies, including nucleic acid amplification testing for Clostridioides difficile toxin genes, are negative. Fecal calprotectin and fecal lactoferrin levels are elevated.
* Ipilimumab and nivolumab are discontinued. The patient is admitted to the hospital for intravenous fluids and additional treatment.
- Budenoside * Infliximab
- Mesalamine * Solumédrol
- La première ligne de traitement d’une colite à l’immunothérapie = corticostéroïdes systémiques.
- L’infliximab est le traitement de 2e ligne
- Le budenoside oral est parfois employé en “adjunct“ à ces traitements dans les
cas difficiles - En cas de bonne réponse, le sevrage aux stéroïdes doit être lent * 1 mois ou plus avant d’arriver à 10 mg par jour de pred ou équivalent.
- A 37-year-old woman is evaluated in the emergency department for fever 1 week after her second cycle of chemotherapy for breast cancer. She has no focal symptoms, is otherwise healthy, and takes no medications. The patient lives with her partner 20 minutes from the hospital.
- On physical examination, temperature is 38.3 °C (101 °F); other vital signs are normal. She appears well. There is a healed right mastectomy incision, and the left chest port is in place without erythema or tenderness.
- Laboratory studies show a leukocyte count of 1,600/μL (1.6 × 10 9/L) with an absolute neutrophil count of 600/μL (0.6 × 109/L), hemoglobin level of 11.1 g/dL (111 g/L), and platelet count 167,000/μL (167 × 10 9/L). Urinalysis and basic metabolic panel are normal. Blood cultures are obtained.
- Chest radiograph is normal.
- Admission cefipime
- Admission cefipime-genta
- Cipro-clavulin en externe
- Congé, pas d’antibiotique
- Admission cefipime
- Admission cefipime-genta
- Cipro-clavulin en externe
- Congé, pas d’antibiotique
- Pour les patients à faible risque
- Neutropénie non-sévère, anticipée courte
- Pas de comorbidité
- Fiable
- Habite proche de l’hôpital
- Ne vit pas seul
- Traitment externe de NF = adéquat
- Vu neutros absolus 600, admission probablement pas indiquée si BEG
- Congé sans antibios un peu audacieux d’autant plus qu’on ne sait pas si neutros vont baisser ou augmenter.
A 52-year-old woman is evaluated in the office for a left breast lump that developed 3 months ago. She is asymptomatic. Medical history is unremarkable, and she takes no medications.
* On physical examination, there is a 1.8-cm firm mass in the upper outer left breast. There is no axillary or supraclavicular adenopathy.
* Complete blood count and comprehensive metabolic profile, including alkaline phosphatase level, are normal.
* Mammogram and ultrasound confirm a 1.8-cm mass in the left upper outer breast.
* Core biopsy of the left breast reveals estrogen receptor–negative, progesterone receptor–negative, and human epidermal growth factor receptor 2–negative invasive ductal carcinoma.
- Rx pulm et scan osseus * Taco TAP
- Taco TAP et irm cérébral * Rien
- Pour les cancers RH+, her2- stade I ou II le taux de métastase est faible (<5%) et la spécificité des examens n’est pas 100%
- Si ALP normale, aucune douleur, aucun symptôme respiratoire: aucun bilan d’extention n’est recommandé.
A 63-year-old woman is evaluated for a mass in her right axilla. She first noticed the mass 2 months ago. She has also had a persistent cough. She was diagnosed 3 years ago with stage IIB right breast cancer for which she underwent lumpectomy, chemotherapy, and breast irradiation.
* On physical examination, vital signs are normal. There is a firm, fixed, 2-cm mass in the right axilla. Bilateral breast examination reveals no masses or nodules. The remainder of the examination is normal.
* Chest radiograph shows multiple bilateral pulmonary nodules. CT scan of the chest, abdomen, and pelvis shows new right axillary adenopathy and multiple peripheral pulmonary nodules measuring up to 1.5 cm in size. There is no hilar or mediastinal adenopathy.
- Biopsie nodule pulmonaire
- Biopsie axillaire
- Chimio
- Commencer traitement endocrinien
bx nodule pulmonaire
* Toujours mieux de biospsier la méta si risque acceptable > maladie locale (pas
toujours possible)
* Traiter sans biopsie ici = pas adéquat, * a) confirmer nature de la maladie
* B) si sein nécessaire de répéter Her2, RH.
- A 64-year-old woman is evaluated in the office following a diagnosis of metastatic breast cancer.
- Six years ago, she was diagnosed with breast cancer and treated with lumpectomy, irradiation, and a complete course of adjuvant hormonal therapy. Two weeks ago, a bone lytic lesion was found on a lumbar spine radiograph taken for low back pain after a fall while playing tennis. Subsequent CT scans revealed diffuse involvement of her axial skeleton with no associated fractures and no epidural extension. The patient is currently asymptomatic. Medical history is unremarkable, and she takes no medications.
- On physical examination, vital signs are within normal limits, and examination findings are unremarkable.
- Systemic therapy for metastatic breast cancer is planned.
- Cal-D
- RT colonne
- Teriparatide
- Acide zolendronique
Acide zolendronique = prouvée comme diminuant événement osseux * BesoindeRTpall
* Compressionmédullaire
* Hypercalcémie
* Fracture
* RT palliative seulement indiquée si symptômes * Cal-D indiquée mais insuffisant employé seul
* Teriparatide pas indiqué en oncologie
- A 62-year-old woman is evaluated for left lower pelvic pain for the last 3 months. Family history is significant for ovarian cancer in her mother at age 51 years and triple-negative breast cancer in her sister at age 42 years.
- On physical examination, vital signs are normal. Pelvic examination is notable for a left adnexal mass.
- Results of laboratory studies show a CA-125 level of 135 U/mL (normal, <20 U/mL). Complete blood count and liver chemistry test results are normal.
- CT scan of the chest, abdomen, and pelvis reveals an 8-cm left adnexal mass. There is no evidence of abdominal or pelvic adenopathy or distant metastases.
- Dépistage BRCA
- Biopsie de la masse
- Chimiothérapie néoadjuvante
- Résection
- Pour une masse ovarienne localisée et suspecte le geste diagnostic est quasi toujours une résection (surtout si post ménopause ou sans désir fertilité)
- BRCA indiqué, mais pas le premier geste
- Biopsie de la masse = échantillonnage imparfait (risque de faux négatif) et risque
essaimage - Chimio néoadjuvante: jamais sans histologie!
- A 45-year-old man is evaluated following a recent diagnosis of a gastrointestinal neuroendocrine tumor.
- The tumor was discovered after an abdominal CT scan for acute alcohol- related pancreatitis. The CT scan revealed more than 12 hypodense lesions in the liver ranging in size from 0.5 cm to 2.5 cm (replacing approximately 5% to 10% of the liver volume) and a 2-cm mesenteric mass.
- Following recovery from the pancreatitis, a core needle biopsy of one of the liver lesions was obtained and revealed a well-differentiated, low- grade neuroendocrine tumor. The patient reports feeling well since discharge from the hospital. He is enrolled in a 12-step facilitation program for alcohol use disorder.
- On physical examination, vital signs are normal. The remainder of the examination is normal.
- Observation
- Embolisation artère hépatique
- Analogue de la somatostatine
- Résection masse mésentérique
Tumeurs neuro-endocrines bien différenciées de bas grade, tumeurs souvent indolentes, peuvent ne requérir aucun traitement pour des années. Peuvent être observées si asympto (et pas de syndrome secrétoire)
* Si progression hépatique ou symptômes une embolisation hépatique = option ok * Si symptômes ou progression analogue somatostatine = bonne option
* Chx du primaire rarement indiquée si métastatique et asympto.
A 69-year-old woman undergoes follow-up evaluation for stage III colon cancer, which was resected 2 years ago. She is asymptomatic and takes no medications.
* On physical examination, vital signs and examination findings are unremarkable.
* Surveillance CT scan of the chest, abdomen, and pelvis reveals a new 3-cm lesion and a 2.5-cm lesion, both in the right lobe of the liver. No other abnormalities are noted.
- Embolisation artère hépatique * Biopsie
- Résection des deux lésions
- Chimiothérapie
- Résection des deux lésions
A 65-year-old man is evaluated for a single episode of painless gross hematuria that occurred 1 month ago. Medical history is notable only for atrial fibrillation managed with metoprolol and rivaroxaban.
* On physical examination, vital signs are normal. Cardiac examination reveals an irregularly irregular rhythm.
* Urinalysis is normal.
* Ultrasound of the kidneys and bladder is normal.
Cystoscopie
* Répéter l’analyse d’urine dans une semaine
* Modifier l’anticoagulation
* Cytologie urinaire
* Réassurance
A 65-year-old man is evaluated for a single episode of painless gross hematuria that occurred 1 month ago. Medical history is notable only for atrial fibrillation managed with metoprolol and rivaroxaban.
* On physical examination, vital signs are normal. Cardiac examination reveals an irregularly irregular rhythm.
* Urinalysis is normal.
* Ultrasound of the kidneys and bladder is normal.
A 60-year-old woman is evaluated for right-sided mid back pain of 2 months’ duration.
* Medical history is significant for hypertension treated with hydrochlorothiazide. She takes no other medications.
* On physical examination, vital signs are within normal limits. Oxygen saturation is 99% with the patient breathing ambient air. The remainder of the examination is normal.
hb haut
leach et pt n
Smu: 3+ sang
- Cancer pulmonaire
- SMD
- Polyglobulie vraie
- Érythrocytose relative
- Cancer rénal à cellules claires
Cancer rénal à cellules claires (un classique… dans les livres)
Néo pulmonaire ne secrète pas d’EPO
* SMD = cytopénies
* Polyglobulie = polyglobulie (généralement autres lignées élevées) et EPO supprimée * Érythrocytose relative… trop élevé
