ONCOLOGY Flashcards
(304 cards)
1
Q
Colon cancer risk factors
A
-age>45
long standing uc and chrohns >8 years
-primary relatives with colon cancer
-BRCA: breast and ovarian cancer
-FAP: famililal polyposis: gardeners syndrome
-HNPCC: hereditary non polyposis colon cancer aka lynch syndrome
-adenomas (5-10 yrs)
2
Q
Decreased risk
A
ASA>20 years
-celecoxib and sulindac: decrease polyp load
-estrogens
-less red meat, limited caloric intake and increased dietary fiber
3
Q
Colon cancer
A
-usually arises from adenomas; villous more than tubular; hyperplastic polyp haas no malignant potential
4
Q
Familial Adenomatous Polyposis
A
-family history of adenomatous polyposis and cancer
-mutation of the APC gene–>Chromosome 5
5
Q
Gardener’s syndrome
A
Subtype of FAP involving adenomatous polyps involving the colon
-Extraintestinal manifestations include: osteomas of mandible, skull and long bones, soft tissue tumors, epidermoid and sebaceous cysts
6
Q
Peutz Jegher Syndrome
A
-pigmented lesions on skin, lips and mouth
-do colonoscopy
-STK11 gene
7
Q
HNPCC (hereditary non polyposis colon cancer) lynch syndrome
A
-autosomal dominant
-need to have 3 relatives with colon cancer; two generations with colon cancer, one must be primary relative; may have extra colonic cancer as well
-at least one relative with colon cancer <50
8
Q
50 year old woman with HNPCC had a colonoscopy done, whicch revealed adenomatous polyps, what to do?
A
Endometrial biopsy
9
Q
Colorectal screening guidelines
-Flexible sigmoidoscopy with FIT
A
Every year FIT + every 10 year sigmoidoscopy OR
10
Q
FIT DNA
A
Every 1-3 years OR
11
Q
Colonoscopy
A
Every 10 years OR
12
Q
CT colonography
A
Every 5 years OR
13
Q
Flexible sigmoidoscopy
A
Every 5 years
14
Q
A 45 year old man, asymptomatic for routine check up, FIT negative, sigmoidoscopy –>polyp
A
A. If biopsy of polyp is hyperplastic polyp, what to do? FIT q1 year +sigmoidoscopy 10 years OR sigmoidoscopy alone q 5 years
B. If biopsy polyp is adenoma, what to do? full colonoscopy
C. If biopsy of polyp is adenocarcinoma, what to do? full colonoscopy prior to surgery
15
Q
Elderly male or post menopausal female with unexplained iron deficiency anemia, what to do?
A
Colonoscopy
16
Q
Elderly male with hematochezia, history of hemorrhoids, what to do?
A
Colonoscopy
17
Q
A 45 year old patient on routine health maintanece exam had FIT 1 out of 6 cards + for occult blood, what to do?
A
Colonoscopy
18
Q
A 55 year old woman had screening colonoscopy done, 2 polyps removed; biopsy showed they were hyperplastic, when to do next colonoscopy?
A
10 years
19
Q
Patient had 2 tubular adenomas (<1cm) removed; when to repeat colonoscopy?
A
5-10 years
20
Q
Patient had 1 tubular adenoma 1cm in size, next colonoscopy?
A
3 years
21
Q
Patient had 1 tubular adenoma 2.5 cm, next colonoscopy?
A
3 years
22
Q
Patient had 3-10 tubular adenomas <1cm; next colonoscopy?
A
3 years
23
Q
Patient had 1 villous adenoma <1 cm, next colonoscopy?
A
3 years
24
Q
Patient had 1 serrated polyp adenoma <1 cm, next colonoscopy?
A
5 years
25
Patient had 1 serrated polyp adenoma >1 cm, next colonoscopy?
3 years
26
Patient with obstructive colon cancer, underwent colonic resection, what to do next?
Full colonoscopy to rule out other concomitant lesions
27
Following curative resection of colon cancer, when is the next colonoscopy indicated?
Colonoscopy in 1 year, then 3 years, then every 5 years; measure CEA q 3-6months for 2 years, then every ear for 5 years
28
Best diagnostic test to rule out colon cancer?
Colonoscopy with biopsy; best risk reduction in left colon
29
When do you recommend against routine colon cancer screening?
75 years
30
Crohns disease or ulcerative colitis
having disease for 8 years give colonoscopy then every 1-2 years
31
Post colonic resection for colon cancer
Colonoscopy in 1 year, then in 3 years then every 5 years
32
General population or distant relative with colon cancer
45 years
33
40 year old patient with two primary relatives with colon ca even after age 60; one primary even after age 60
Colonoscopy now and every 10 years
-FIT every year and sigmoidoscopy every 10 years OR
-sigmoidoscopy every 5 years
34
40 years old; or 10 years younger than youngest affected relative: 2 first primary relatives or 1 first primary relative diagnosed before age 60 with colon cancer
Colonoscopy every 5 years
35
25 years old or 10 years younger than the youngest affected relative with HNPCC
Colonoscopy every 2 years up to age 40 then every year
36
12 years old with familial adenomatous polyposis
sigmoidoscopy 1-2 years
37
45 year old, asymptomatic, father had colon cancer age 45
Colonoscopy now then every 5 years
38
40 year old asymptomatic, father had colon cancer at age 60, brother had colon cancer at age 52
Colonoscopy now and every 5 years
39
35 year old asymptomatic, father had colon cancer at age 65
FIT or FIT DNA or colonoscopy, or CT colonography or flexible sigmoidoscopy or flexible sigmoidoscopy with FIT starting at age 40
40
A 25 year old asymptomatic, family history of HNPCC
Colonoscopy now and then every 2 years up to age 40 then every year
41
Patient with ulcerative colitis diagnosed recently
Colonoscopy 8 years later and then every 2 years
42
Patient with colon cancer Duke B and underwent resection of colon
Colonoscopy in 1 year, then 3 years then every 5 years
43
A 45 year old asymptomatic, family hx negative for colon cancer
FIT or FIT DNA or colonoscopy or CT colonography or flex sig or flex sig with FIT starting at age 45
44
Young patient with family history of familial adenomatous polyposis
Colonoscopy age 16 years old
45
40 year old asymptomatic, father had colon cancer at age 55
Colonoscopy now and every 5 years
46
A 37 year old man whose father had colon cancer at age 65, presents to the office; brother had colon cancer at age 50, aunt had uterine cancer at age 48, what is more likely?
HNPCC (microsatellite mismatch repair genees MSH)
47
Colonoscopy negative with improper bowel prep
Repeat with proper prep
48
Colon cancer stage 1, node negative
RESECTION
49
Colon cancer stage IIa, node negative
RESECTION
50
Colon cancer staage IIB, IIC, node negative
RESECTION
51
Colon cancer stage III node positive
RESECTION + 5FU + leucovorin + oxaliplatin (FOLFOX)
52
Colon cancer Mets positive
Resection palliative; 5FU + Leucovorin + irinotecan + bevacizumab (FOLFIRI) + Zif-Aflibercept
53
Patient with colon cancer underwent hemicolectomy; histopathology revealed infiltration of muscularis, LN-, what to do?
Observe
54
Patient with colon cancer, infiltrating serosa and pericolic structures like viscereal peritoneum
Adjuvant chemotherapy +RT
55
Patient with colon cancer not infiltrating the serosa, 4/10 lymph nodes +; after hemicolectomy what else do you do?
Chemotherapy (5FU, leucovorin, oxaliplatin)
56
Patient with stage B2 rectal cancer, local resection was done, what else will reduce relapse?
Adjuvant chemotherapy + RT
57
ANAL CANCER: cancer of anal margin, how to treat?
local excision
58
Cancer of anal canal mucosa
External beam radiation + 5FU + mitomycin
59
Breast cancer screening
Begin at 50, stop at 75 OR <5-10 years prior to age in primary relative with breast cancer then every 2 years
60
BRCA1
Chrom 17; breast, ovarian cancer in women, prostate cancer in men; high penetrance; other family members should be made aware; offfer prophylactic salpingo oopherectomy to patients
61
BRCA2
chromosome 13
62
Ductal carcinoma in situ
lumpectomy + RT + tamoxifen/aromatase inhibitor if ER receptor + OR mastectomy (no chemo or endocrine tx)
63
Lobular carcinoma in situ
Observation or in ER + -->tamoxifen
64
Infliltrating ductal cancer with LN -
Wide excision of mass with free margins + RT; adjuvant chemo for size >1 cm; tamoxifen/aromatase inhibitor if ER receptor +
65
Infiltrating ductal cancer with LN +
Wide excision + RT = modified radical mastectomy + adjuvant chemo + tamoxifen/aromatase inhibitor if ER receptor +
66
Locally invasive disease involving skin or chest wall
chemotherapy followed by mastectomy + tamoxifen/aromatase inhibitor if ER +
67
Most important prognostic factor
LN> tumor size > receptor > grade
68
Adjuvant therapy for node + disease in premenopause
ER + chemotherapy + tamoxifen, if ER - chemotherapy, HER-2 + trastuzumab
69
Adjuvant therapy for node + disease in post menopausal
ER + chemotherapy +aromatase inhibitor; ER - chemotherapy; HER2 + trastuzumab
70
Adjuvant therapy for node - disease >.5 cms; premenopausal
ER+ Tamoxifen + HER 2 + Trastuzumab
71
Adjuvant therapy for node - disease >.5 cm postmenopausal
ER+ aromatase inhibitors + HER2 + Trastuzumab
72
ER + HER 2 - -->Oncotype dx. RT PCR 21 Aka gene recurrence assay
<25 no chemotherapy
>25 chemotherapy
73
Adjuvant therapy for node - disease >1 cm
Chemotherapy + endocrine therapy
74
Adjuvant therapy for node + disease, ER -, PR -, HER2-, aka triple negative
Atezolizumab or pembrolizumab + paclitaxel
75
37 year oldwoman with family hx of breast carcinoma in mother at age 65 and sister age 35, the most important risk factor for the patient to get breast cancer is?
Her family history
76
A 65 year old woman with a family history of breast cancer in mother at age 67; most important risk facter for her to acquire breast cancer is?
Her age
77
Patient with breast cancer; primary relative with hx of breast cancer and ovarian cancer; you do genetic counseling for?
BRCA1 mutation
78
A 40 year old woman, genetic testing showed BRCA1 mutation, what to do next?
Annual mammogram and MRI screening starting now; also for BRCA2 and their first degree relatives, TP53, PTEN, CHEK2, RT to chest
79
50 year old woman presents for regular checkup; the best way to screen her for breast cancer is?
Mammogram every 2 years
80
How to screen for breast cancer in a woman with implants?
Mammogram
81
50 year old woman with dense breasts, what to do?
Digital mammography
82
40 year old presents with thickening of left upper outer breast; no family hx of breast cancer, you advise her to come mid cycle; after 3 weeks thickening persists; mammogram and ultrasound is doone which reveals no calcifications or dominant mass, you would?
Core needle aspiration biopsy
83
Above patient ultrasound reveals mass with mixed echo; fine needle core biopsy shows no malignancy, what to do?
Excision biopsy
84
50 year old diagnosed with breast cancer; most important prognostic factor is?
lymph node positivity
85
A 35 year old woman with a 1.5 cm mass; excision biopsy shows infiltrating ductal cancer and margins are free of cancer; axillary LN- ER +, what to do? she does not want mastectomy
RT + adjuvant chemotherapy + tamoxifen for 10 years
86
A 55 year old woman with a lump in the breast; lumpectomy was done which reveals infiltrating adenocarcinoma freee margins; Axillary LN +, ER+; adjuvant chemo + RT administered and tamoxifen given for 5 years; she is now menopausal, what to do?
Switch to aromatase inhibitor for 10 years
87
A 45 year old with heaviness, swelling and pain in breast for 4 weeks; on exam, erythema of right lower quadrant, thickened area, nipple retracted but no nipple discharge; +lymph nodes, no fever +/- mass
Inflammatory breast cancer
88
Patient s/p breast cancer treatment with surgery RT and chemotherapy; presents with lymphedema of right arm; what is best management?
Progressive resistance training
89
Decreases risk of new breast cancer; effective for treatment of metastatic breastcancer; works only if tumor is ER and PR +; effective in preventing cancer in high risk women; has both estrogenic and anti estrogenic effects
Tamoxifen
90
Anti estrogenic effect
Anti breast tumor effect, hence used in treatment; menopausal symptoms (citalopram and effexor only, works for depression too)
91
Estrogenic effect
Increased risk of endometrial cancer x 3; increased bone density; increased thromboembolic risk/PE, NOT osteoporosis
92
A 45 year old patients 40 year old sister was diagnosed with breast cancer; your patient asks how to decrease risk of contracting breast cancer
Tamoxifen
93
A 54 year old woman diagnosed with infiltrating ductal carcinoma with LN 3/15 +; patient has breast conserving surgery. + RT + chemottherapy + tamoxifen; she is most likely to be at risk for?
Endometrial cancer
94
Patient with a history of breast cancer ; she received chemotherapy and started tamoxifen; 6 months ago; she presents with polyuria, constipation, fatigue, lethargy and dry mucous membranes, most likely etiology?
Hypercalcemia
95
Above patient has a schedule of yearly mammogram and pap smear; what else would you recommend?
Ask for gyn symptoms every visit
96
Above pt continued taking tamoxifen 20mg po daily, 3 years later she presents for f/u and complains of a one time bloody discharge per vagina which resolved by itself about six months ago; no other complaints than hot flashes; no breast mass noted; mammogram and pap ssmear negative, what to do next?
Endometrial biopsy
97
Pregnant women with Breast cancer
Treat like regular pt; surgery in 2nd and 3rd trimester; chemo in 2nd trimester
98
What is long term complication of aromatase inhibitors?
Osteoporosis; do DEXA scan prior to starting AIs
99
Young nulliparous woman diagnosed with breast cancer, what will you do next?
Refer to fertility specialist
100
Patient presents with nipple discharge; exam reveals eczematous scaly lesion at nipple; pregnancy test negative; prolactin normal
PAGETS disease; local wide resection if there is no mass; treat as breast cancer if there is a mass
101
Patient with history of breast cancer s/p lumpectomy and chemotherapy 5 years ago presents with pain in the hip and lower back; x ray of the hip reveals 3 cm lytic lesion and xray of L5 spine is normal, what to do?
MRI of L5 spine
102
What is first sign of epidural compression fracture?
Pain
103
A 60 year old woman with hx of breast cancer s/p resected ER/PR + and had chemotherapy and aromatase inhibitors started; current meds include ace inhibitors, beta blockers and lasix; she is urinating more frequently; exam is normal labs are normal except ca is 11.2; what is best management?
Bone scan; the leading solid tumor causing hypercalcemia is breast cancer
104
A 65 year old woman is diagnosed with infiltrating ductal carcinoma; she undergoes lumpectomy with free margins, RT and adjuvant chemotherapy; 6 months later she presents for f/u; she has no complaints; negative mammogram; what else would you recommend?
Mammogram + MRI yearly
105
Patient s/p mastectomy for breast cancer with mets; on increasing opiates for pain control; she is lethargic with decreased responsiveness; pupils non reactive, diplopia, tongue deviated to right, absent gag reflex, absent left ankle reflex, +urinary retention, most likely diagnosis?
Leptomeningeal spread
106
A 34 year old with breast lump which was excised adn found to be fibroadenoma; grandmother with breast cancer at age 55; how to f/u this patient?
Mammogram at 50
107
65 year old man has been taking spironolactone for ascites presents with unilateral breast mass, what to do?
Biopsy
108
A 30 year old woman presents with breast pain one wek prior to the onset of menstruation and resolves with onset of menstruation, what to do?
Supportive bra and reassurance
109
Endometrial Cancer risk factors
-obesity
-early menarche
-late menopause
-nulliparity
-tamoxifen use
-HNPCC (lynch syndrome)
-PCOS
110
Which cancer is associated with obesity?
Endometrial cancer (due to excess endogenous estrogen from conversion in the adipose tissue)
111
Pap smear: screening between 21-29
Every 3 years
112
For women above 30, Pap smear with HPV DNA every
5 years
113
Dont do HPV DNA<30
Unless pap smear is abnormal
114
High risk (multiple sex partners, stds, HIV)
Pap smear yearly
115
Stop pap smear screening at 65 if
at least 3 consecutive past pap smears are negative in past 10 years, most recent test 3 years ago OR 2 consecutive HPV tests negative in past 10 years, most recent one within 5 years OR 2 consecutive co tests negative in past ten years, most recent 5 years ag
116
If ASCUS and HPV +
Colposcopy
117
IF ASCUS and HPV -
Repeat pap in 1 year
118
If ASCUS - and HPV +
Repeat pap and dNA in 6months to a year
119
24 year old woman with vaginal discharge; pap smear shows clue cells and some ASCUS, what to do next?
Treat with metronidazole
120
24 year old woman, pap smear shows ascus+, what to do next?
HPV testing
121
When is HPV vaccine contraindicated
pregnancy
122
22 year old with ASCUS, HPV 16 infection, can she get vaccine?
yes, it will help with 8 other serotypes
123
A 50 year old patient with hx of fibroids; 2 years ago fibroid size 2 cm; repeat exam now revels fibroid 3cm; no menorrhagia, what is best management?
Reassess in 1 year
124
Patient had hysterectomy for fibroids, do you need pap smears post hysterectomy?
No
125
Patient had hysterectomy for cervical cancer; do you need pap smears post hysterctomy?
Yes
126
Patient with lesion in endocervical canal, what to do?
Biopsy
127
Carcinoma in situ: confined to endocervical canal
Total hysterectomy or radical hysterectomy or conization
128
Carcinoma in situ: upper 2/3's of vagina
Radical hysterectomy and pelvic lymphadenectomy or RT with brachytherapy
129
Carcinoma in situ: Lower 3rd of vagina
Cysplatin based chemo with RT
130
Carcinoma in situ: disseminated
Cisplatin based chemo with RT palliative
131
Patient with cervical cancer treated with cisplatin and RT last year;now presents with abdominal pain; bun/cr 30/2.0; ultrasound reveals hydronephrosis; most likely etiology?
Retroperitoneal fibrosis; diagnose with CT; treat with steroids
132
Patient with abdominal distention; ultrasound shows a serous semi solid 6 cm septate mass in the right pelvic area; CEA elevated; what to do next?
CT scan to localize tumor before resection
133
Prostate cancer risk factors
-african american x2
-family history
-do BRCA1/2
*PSA screening has not shown reduction in mortality
134
66 year old man is diagnosed with prostate cancer with a gleason score of 8 (beyond the capsule); radiotherapy is done; what will you do next?
Androgen deprivation with GNRH agonist(leuprolide) and androgen blocker (bicalutamide) to prevent flare of GNRH agonist
135
Prior to starting androgen blocking therapy, what to do?
Do DEXA: osteoporosis, CAD and decreased libido are long term complications; best Tx: bisphosphonates (zoledronate or denosumab)
136
Patient with metastatic prostate cancer has been started on leuprolide; what do you most likely expect?
Vertebral compression fracture
137
Patient post radical prostatectomy followed by decreased PSA levels; 3 years later PSA<10; patient is asymptomatic, what to do?
Repeat h/p in six months
138
82 year old man found to have prostate cancer stage IIA, what to do?
Observe
139
Patient with a fib on warfarin has hematuria, INR 2.2; RBCs in urine 10-15 HPF; repeat UA with persistent hematuria; rectal exam with enlarged prostate; the CT scan, cystoscopy and IVP are negative; prostate biopsy reveals prostate hyperplasia, but no cancer, what to do to treat hematuria?
Add finasteride
140
65 year old chronic smoker presents with painless intermittent gross hematuria with clots; most likely diagnosis is:
Bladder cancer
141
A patient presented with lower abdominal pain, exam reveals fullness in the suprapubic area; foley cath was inserted with relief of pain and drainage of urine; a psa was done which was elevated; what to do next?
Repeat PSA in 4-6 weeks (urinary retention of any cause will increase PSA)
142
Patient with metastatic prostate cancer to bonek refractory to GNRH agonists and anti androgens with breakthrough pain on immediate relase morphine and NSAID, what to do?
Switch to sustained release morphine twice daily
143
Most common presentation of lung cancer
persistent cough or increasing cough, hemoptysis or post obstructive pneumonitis
144
Patient presents with hemoptysis >1 week; >40 years and chronic tobacco hx has a 40% chance of having cancer; so always evaluate patient further with above symptoms; what to do next?
chest x ray
145
A 50 year old patient presents with increasing cough for the past month, no fever, chills or hemoptysis with weight loss of 8 pounds; chest x ray shows effusion; CT of chest shows efffusion with 2cm lesion, 1.5 cm from periphery of pleura; thoracentesis is exudative, cytology is negative for malignant cells; what to do?
Repeat thoracentesis with cytology
146
LUNG CANCER TREATMENT
NON SMALL CELL LUNG CANCER
147
Stage I: tumor >2cm from carina, node negative
Surgery and chemotherapy
148
Stage II: tumor >2cm from carina, node positive
Surgery and chemotherapy
149
Stage IIIa: Tumor <2cm from carina, or invading resectable structure or ipsilateral hilar or mediastinal LN +
surgery + chemotherapy + RT
150
Stage IIIb: Tumor invading unresectable structure; contralateral mediastinal LN positive
Chemotherapy --> followed by radiotherapy
151
Stage IV: metastatic disease: supraclavicular LN positive or pleural effusion with malignant cells
Check for EGFR mutation, ALK translocation and PD L1
152
EGFR mutation
Erlotinib (tarceva)/ gefitinib (iressa)
153
Alk translocation
Crizotinib (Xalkori)
154
PD-L1
Pembrolizumab (keytruda) Nivolumab (opdivo)
155
SMALL CELL CANCER
156
Limited to one hemithorax
chemotherapy +RT lung +RT brain
157
Elderly patients with small cell carcinoma should
Be treated with cisplatin based chemotherapy before RT and prophylactic RT to brain
158
Patient >50 years old is successfully treated in hospital for a pneumonia with rocephin and azithromycin; 3 months later, cough persists; chest x ray reveals persistent density; most likely diagnosis?
Malignancy
159
50 year old patietn has lung cancer in family, wants screening, 20 pack years and quit 20 years ago
No screening recommended
160
50 year old patient with a smoking history of 20 pack years, quit smoking 15 years ago; presents for regular check up, what to do?
Low dose CT
161
65 year old patient, low dose ct scan lung is positive, what will you inform patient?
More false positives than true positives
162
To prevent highly emetogenic chemotherapy
Granisetron + DMS +Aprepitant (emend) + olanzapine
163
Patient prior to administration of next cycle of chemotherapy is nauseous despite receiving granisetron and zofran, what to do?
Alprazolam
164
Small cell carcinoma
-hyponatremia secondary to SIADH
-cushings syndrome secondary to ACTH
-Carcinoid: flushing and diarrhea
-Lambert eaton syndrome: power increases with repititon
-SVC syndrome
-Paraneoplastic cerebellar degeneration
165
Squamous cell carcinoma
-hypercalcemia secondary to PTH related protein
-Horners syndrome: ptosis, miosis, anhydrosis
-pancoast tumor: compress 1st and 2nd thoracic nerve causing shoulder pain and ulnar aspect of hand and little finger
166
Adenocarcinoma
Pulmonary osteoarthropathy: pain in hands or legs; x ray with periosteal thickening
-marantic endocarditis
167
Large cell carcinoma
Gynecomastia and SVC syndrome
168
65 year old patient with squamous cell carcinoma; hemorrhagic pleural effusion; bp 160/100; hypercalcemia +; FEV1 is 2.4 liters, hb 9; what prevents him from being a surgical candidate?
hemorhhagic pleural effusion
169
What is the most important prognostic factor in a patient with advanced non small cell lung cancer?
Poor performance status
170
A 45 year old s/p surgery and chemotherapy 5 years ago for lung cancer going for elective surgery; ECHO reveals EF 35%, what to do?
Ace inhibitor
171
In a patient with pancoast tumor, which of the following has a worse prognosis?
Chest movement assymetry
172
A 70 year old man presents with unsteady gait and history of falls; 3 days ago he had dizziness, nausea and vomiting; exam reveals he has diplopia, slurred speech and difficulty swallowing; chest x ray reveals a mass in the chest; ct/mri brain is negative; anitbody testing. reveals anti yo positive, ANA negative, Anti DNA ds negative; most likely diagnosis?
Paraneoplastic degenerative disease; cerebellar dysfunction
173
The least likely paraneoplastic syndrome with small cell lung cancer is
Hypercalcemia
174
Patient with history of lung cancer presents with chest pain; palpation with tenderness; x ray reveals multiple metastatic lesions on the rib, what to do?
Denosumab
175
A 51 year old with lung cancer, gynecomastia and increased hcg
Large cell carcinoma
176
a 62 year old chronic smoker with pain in his legs; chest x ray with coin lesion in the periphery of lung
Adenocarcinoma
177
A 55 year old patient with lung cancer and hypercalcemia
Squamous cell carcinoma
178
A 55 year old patient with lung cancer and weakness which gets better with movement
Small cell carcinoma
179
A 55 year old manual laborer and heavy smoker presents with shoulder, arm, medial forearm, ring and little finger pain, what to do next?
Chest x ray
180
Most common cancer in smokers and non smokers
adenocarcinoma
181
The most common cancer in non smokers
adenocarcinoma
182
ACTH producing neoplastic syndrome
Small cell carcinoma
183
Assume mets at diagnosis
Small cell carcinoma
184
Hyponatremia
Small cell carcinoma
185
Squamous cell lung cancer 2 cm within carina and ipsilateral lymph node positive
surgical resection + chemotherapy + Radiation therapy
186
Adenocarcinoma >2cm from carina, lymph node -
Surgery + chemotherapy
187
Large cell carcinoma at carina and contralateral LN +
chemotherapy + RT lung
188
Small cell carcinoma, extensive
chemotherapy + RT brain
189
SVC Syndrome: dyspnea, facial swelling, arm swelling, cyanosis, plethora and dysphagia
-lung cancer (NSCLC: bronchogenic most common 65%
-lymphomas
-thymomas
-catheter induced thrombosis
190
Management of SVC syndrome
Radiation therapy
191
Above patient pain not relieved by fentanyl patch and opoids, what to do?
Strontium 89
192
According to medicare guidelines, when is a hospital patient eligable for hospice?
<6 months to live
193
Seminoma
no hcg or alpha fetoprotein
194
Non seminoma
elevated hcg and alpha fetoprotien
195
Testicular cancer
Radical orchiectomy first via high inguinal incision, then according to stage treat as follows
196
Stage I: confined to testes
Seminoma: RT or carboplatin
Non seminoma: observe, reemove lymph nodes
197
Stage II: Infradiagmatic +<5cm
Seminoma: RT or carboplatin
Nonseminoma:cisplatin based chemo
198
Stage III: Beyond retroperitoneal nodes
Seminoma: chemotherapy
Non seminoma: Cisplatin based chemo, no RT
199
The above patient has a lung nodule as well, what to do?
Resect: same principle as for breast ca or colon ca as well
200
BHCH and alpha fetoprotein elevation
Non seminoma
201
Alpha fetoprotein normal
Seminoma
202
Inguinal approach for orichetomy
Both seminoma and non seminoma
203
Respond to RT
Seminomas
204
Don't respond to RT
Non seminoma
205
A 19 year old man with increasing breast enlargement for the past 2 years; no other complaints; firm sub areolar glandular tissue (gynecomastia) what to do?
Examine external genitalia;; check testosterone level (450) and estradiol level; LH .3 FSH .5, estradiol elevated at 304: next step: US of testes; if normal: Ct of adrenal
206
LYMPHOMA
207
Hodgkin lymphoma
Reed sternburg + cells,B cells, owl eyes, CD 15 and CD 30 positive
208
Hodgkin lymphoma
lymphocyte predominance > nodular sclerosis> mixed cellularity> lymphocyte depletion
209
Hodgkin lymphoma
Patients present with llymph node enlargement with contiguous sperad +/- paracrine effect: -fever -peripheral granulocytosis, - eosinophilia with pruruitis, - personality changes
210
Lymphoma
Non hodgkin lymphoma: b cells 90%, T cells 10 %
211
Treatment for Hodgkins Disease
ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) varying cycles of A +VD --> (brentuximab vedotin, doxorubicin, vinblastine and dacarbazine +/- RT)--> if patients relapse or poor response--> high dose chemotherapy followed by autologous hematopoietic stem cell transplant
212
Complications after therapy: CHemotherapy (alkylating agents, topoisomerase inhibitors, anthracyclie)
-cardiomyopathy
-AML
-Myelodysplastic syndrome
-infertility, amenorrhea (before RT or chemo --> refer to fertility specialist)
213
Radiation therapy
-constrictive pericarditis
-accellerated CAD
-solid tumors ( breast, lung, thyroid ca)
-Radiation pneumonitis: ssubacute 4-12 weeks, late 6-12 weeks
-hypothyroidism
214
A 38 year old with past history of hodgkins disease treated with RT 10 years ago presents with chest pain while shoveling snow for >30 min
Accellerated CAD
215
A 40 year old man with past history of hodgkins tx with mantle RT to chest 10 years ago presents with palpitations, weight lost, JVD +, ascites, pedal edema; echo reveals thickened pericardium
Constrictive pericarditis
216
A 42 s/p hodgkins lymphoma disease treated with chemotherapy >7 yearsago presents with easy bruising, hg 9, platelets 50,000; blood smear: anisocytosis; pelger huet anomaly; BM: dysplaasia of marro precursers and hypercellularity
Mylodysplasia
217
A 35 year old woman with Hodgkins 10 years ago s/p mantle radiation; now presents with fatigue; what to do?
TSH and mammogram annually
218
What are they prone to?
Breast, lung and thyroid cancer
219
A 30 year old underwent chemotherapy for hodgkins disease 10 years ago; what is a likely complication?
Increased incidence of AML
220
A 35 year old s/p R/T for hodgkins disease 6 weeks ago presents with SOB, low grade fever, cough, chest x ray normal
Acute radiation pneumonitis; treat with glucocorticoids
221
NON HODGKINS LYMPHOMA
-spreads hematogenously
-diagnosis by excision of lymph node, not aspiration or core biopsy
-site -->supraclavicular lymph node
-if relapse; repeat aggressive chemo and stem cell transplant
222
Above patient presents a year later with weakness and stiffness of joints , thickening of skin, dry eyes, ; most likely diagnosis?
GVHD
223
Poor prognostic factor for NHL
-age >60
-serum LDH
-performance status <70
-Ann arbor stage III and IV
-hg <12
224
NON HODGKIN LYMPHOMA
225
Low grade lymphoma: Follicular, small lymphocytes
Treatment: + L, no symptoms --> observe; Agressive transformation/bulky disease -->> Rituximab -->CHOP
226
Intermediate Grade lymphoma: Follicular with large or small cell; diffuse; mixed
R-CHOP (cyclophophasmide, doxorubicin, vincristine, prednisone)
227
High grade Lymphoma: large cell, immunoblastic; small. non cleaved cell
CHOP +/- rituximab + RT OR EPOCH + rituximab, NO RT (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin) --> stem cell transplant
228
Post renal transplant lymphomas
EBV associated lymphomas
229
CNS lymphoma/burkitts/nasopharyngeal carcinoma
EBV
230
MALT (gastric marginal zone lymphoma)
H pylori
231
Kaposi sarcoma
HSV8
232
Cervical cancer/anal cancer
HPV 16,18,31,33
233
T cell leukemia
HTLV-1
234
Patient post renal transplant 2 years ago presents with ataxia; ct of head shows ring enhancing lesion in the cerebellum; most likely diagnosis is?
EBV
235
Patient with well differentiated lymphoma presents with fatigue and weakness; cbc with hb 9.5, retic 5% (.5-2.5); peripheral smear reveals spherocytes, polychromasia; what is the best diagnostic test?
COOMBS test to rule out warm autoimmune hemolytic anemia
236
Best management for above patient?
steroids --> rituximab to treat underlying disease ( treats warm autoimmune hemolytic anemia)
237
Patient with large hilar adenopathy is diagnosed as small cell or lymphoma presents with shortness of breath; exam reveals massive pleural effusion, what to do next?
Tap the effusion
238
Pleural tap ph<7.3, lyphocytes, typically cancer induced pleural effusion; if pleural fluid not determining, then do CT chest before biopsy; what is best managment?
Chemotherapy
239
Above patient comes back a couple months later with recurrent effusion, what to do?
Thoracosopy with talc poudrage?
240
What can you expect one month after two infusions of rituximab?
lymphopennia
241
Multiple myeloma
-lytic lesions, bone pain, hypercalcemia, serum and urine protein M spike; marrow cytosis >10%; plasma cells -->osteoclasts, faulty IgG; punched out bone lesions-->hypercalcemia M spike in serum and urine--> renal failure; increased ESR; platelet dysfunction; infections; decreased anion gap
242
Multiple myeloma diagnosis:
Serum protein electrophoresis and free light chain analysis and or urine protein electrophoresis
243
CRAB criteria
-calcium, renal dysfunction, anemia, bone lesions
244
If CRAB is not present
Monitor for 3-6 months
245
If CRAB is present and not HCT eligible?
NO; CHF>III, confined to bed, >77 years, cirrhosis -->VRd induction: Bortezomib + lenalidomide + low dose DMS--> lenalidomide (can cause dvt) maintenance; with bortezomib shingles prophylaxis with acyclovir
246
If CRAB present and HCT eligible?
VRd induction. --> HCT--> lenalidomide maintenance
247
Multiple myeloma
protein >3 g/dl; lytic lesions in bone; >10 % marrow plasma cells, hypercalcemia
248
MGUS (monoclonal gammopathy of unknown significance
Protein <3 g/dL; no lytic bone lesions, <10 % marrow plasma cells, no hypercalcemia
249
Smoldering myeloma
Protein > 3 g/dL; no lytic bone lesions; >10 % marrow plasma cells, no hypercalcemia
250
Multiple myeloma
Hypercalcemia, increased proteins, renal dysfunction, platelet dysfunction, bone pain, infections, amylodosis, dilation of retinal veins
251
Hyperviscosity can be caused by:
-waldenstrom macroglobinemia
-polycythemia vera
-leukemia
252
A 65 year old patient found to have protein 8 gm; glovulins are 3.1 (2-3.5); serum protein electrophoresis shows increased IgG; the best way to differentiate between MM and MGUS is:
Low dose CT skeletal survey
253
Above patient with plasma cells <10% in bone marrow biopsy and radiological skeletal survey is normal; calcium is normal and patient is diagnosed with MGUS, what to do?
Follow up in six months
254
Patient with plasma cells >10% in bone marrow biopsy; radiological skeletal survey and calcium is normal, no end organ damage, cr and hb normal and no lytic lesions and the patient is diagnosed with smoldering multiple myeloma, what to do?
Follow up myeloma protein every 2 months
255
A 60 year old man presents with headache, blurred vision, lymphadenopathy and fatigue, hb 9, lethargic and decreased power on one side; total proteins 8, albumin 3.6, ca 9; serum protein electrophoresis shows increased igM >2, ESR increased; what is this?
Waldenstrom macroglobulinemia
256
Waldenstrom macroglobulinemia
-caused by IgM -->remains intravascular --> hyperviscosity
-no lytic bone lesions
- no hypercalcemia
-bone marrow shows pasmacytoid lymphocytes
257
Waldenstrom Macroglobulinemia Treatment
-plasmapheresis
-bendamustin with rituxan
-velcade/decadron/rituxan
-cytoxan/rituxan/decadron
258
Tumors of the pancreas
- pancreatic carcinoma
-glucagonoma
-gastrinoma
-VIPomas
259
Elderly man with >40 pack years smoking history presents with weight loss, fatigue, anorexia, painless jauncice, +/-diarrhea, painless palpable gallbladder (courvoisiers sign); best diagnostic test is?
CT scan of pancreas to rule out pancreatic cancer-->mainly in the head of pancreas -->double duct sign positive
260
Treatment of Pancreatic cancer with no metastasis
Surgery (pancreatoduodectomy) with chemo; can include minimal invasion of portal or mesenteric vein
261
Above patient refuses surgery and has good functional status, what to do?
Gemcitabine + nab-paclitaxel chemotherapy
262
Pancreatic cancer with mets
Palliative treatment with stent placement; gemcitabine (gemzar) + nab paclitaxel
263
Patient with stage IV pancreatic cancer with severe itching; what is the best management?
Biliary stent
264
A 46 year old woman with no previous history of pancreatitis has an incidental finding of 3.8 cm mass in the head of pancreas seen on multi detector dual phase contrast CT scan, what to do?
Surgical excision
265
If mass is not clearly defined or borderline resectable on ct scan then the best test is:
endoscopic ultasound
266
Diabetics are more prone to what kind of cancer?
Pancreatic cancer
267
What is more commonly associated with pancreatic cancer?
Smoking
268
Patient who had familial adenomatous polyposis are more prone to
Ampulla of vater cancer
269
Patient with persistent hyperglycemia, weight loss, chronic diarrhea and anemia; exam reveals scaly necrotizing dermatitis; ct reveals mass in pancreas; glucagon injection doesnt increase glucose level
Dx: glucagonoma
270
Patient with profuse watery diarrhea not responding to fasting; history of weight loss, serum k is 3.3 and hypochlorydhydria; serum vip is increased, stool osmolar gap low
VIPOMA; treatment: octreotride
271
Courvoisiers sign
pancreatic cancer
272
Trousseaus syndrome (migratory thrombophlebitis)
Pancreatic cancer
273
Double duct sign
Pancreatic cancer
274
Sentinal loop sign (small bowel ileus)
Acute pancreatitis
275
Patient presents with diarrhea, hx of flushing sensation, exam reveals some telangiectasia, what will you do next?
5HIAA; most likely diagnosis? carcinoid
276
Best surveillance for hepatocellular carcinoma?
Liver ultrasound
277
Patient has ultrasound done which shows .8 cm lesion, what to do?
Repeat ultrasound in 3 months
278
Above patient 6 months later the size is 1.2 cm, what to do?
Three phase CT scan (increased arterial phase enhancement, decreased venous and pearenchymal phase)
279
How to diagnose hepatocellular carcinoma?
Imaging studies
280
What is the first line treatment?
Resection OR radiofrequency ablation ethanol injection OR transplant
281
Which agent has shown survival benefit in hepatocellular carcinoma?
Sorafenib (nexavar) or Lenvatinib (lenvima)
282
THYROID CARCINOMA
283
Parafollicular:
Medullary carcinoma
-Calcitonin increased
-dense calcification in tumor
-Associated with MEN II A and II B(check family hx)
-TX: total thyroidectomy
284
Follicular
Papillary carcinoma --> cervical LN, pitted calcification, BRAF + (most common with best prognosis)
Follicular carcinoma --> mass and distant mets RAS+
285
Best management for papillary and follicular carcinoma after surgery is?
Radioiodine ablation (it will not work for medullary carcinoma as radioiodine is not taken up by C cells)
286
Medullary carcinoma recurrance (ct scan of neck)
Calcitonin level
287
Papillary carcinoma recurrance
Thyroglobulin level
288
Follicular carcinoma recurrence
Thyroglobulin level
289
Swollen parotid glalnds, dry eyes and mouth with cervical and supraclavicular LN +
Lymphoma
290
Swollen parotid glands, moist tongue sub mandibular LN+
bulimea
291
Carcinoma of unknown origin
mostly adenocarcinoma
292
Presentation
40% lymph nodes: cervical andsupraclavicular>mediastinal>axillary> 30% liver lung and bone; 20% will be identified; expected mean survival is six months
293
Adenocarcinoma in Females with Axillary LN
-pursue breast cancer diagnosis
-do mammogram +/- MRI, ER/PR receptors
-Mastectomy
294
Adenocarcinoma in female with bony involvement
Pursue breast cancer diagnosis
295
Adenocarcinoma in males with bony involvement
Pursue prostate cancer diagnosis; ask for urinary symptoms, do PSA and rectal examination
296
Poorly differentiated cancer in young males
Pursue germ cell tumor diagnosis; DO alpha fetoprotein and beta hcg; if + platinum based chemotherapy
297
Squamous cell cancer
Prseentation with cervical LN +-->pursue head and neck cancer diagnosis
-Present with lower cervical LN + -->pursue lung cancer diagnosis
298
Most common cause of carcinoma of unknown origin
Adenocarcinoma
299
Most common place of presentation of carcinoma of unknown origin
Lymph node
300
Female with axillary lymph node + most likely to have what type of cancer
Adenocarcinoma
301
Head and neck cancer
Squamous cell carcinoma
302
A 50 year old man, smoker with a single submandibular LN + which was found to be undifferentiated carcinoma; rest of physical exam is negative, chest x ray negative, what to do?
Upper panendoscopy
303
The following screenings have shown to decrease mortality EXCEPT:
PSA
304
Patient with metastatic cancer with persistent pain takes oxycodone with tylenol prn; he also takes morphine sulfate twice per day, what to do?
Use extended release oxycodone or morphone q 8-12 hours or fentanyl patch
