next step with a BiRADs 2/3?
Breast USG - differentiates between cystic and solid masses
next step with a BiRADS 4/5?
fine needle aspiration or biopsy of nodule must be done
when should you test for BRCA1/2 mutations?
in women who appear to have genetic risk i.e. multiple relatives w/ breast or ovarian cancer, esp. early onset disease
young woman has a persisent, scaling, eczematous and ulcerated lesion over her nipple/areola; this lesion does not respond to medications - what should you consider?
Paget’s dz of the nipple
- do a biopsy
Biopsy finding in Paget’s dz of nipple?
malignant, intraepithelial adenocarcinoma cells w/in epidermis of nipple associated w/ underlying invasive ductal cancer
lichen simplex chronicus
localized disorder with intense pruritus, which leads to localized areas of thickened skin with increased and exagerated skin markings due to scratching
a women presents with a palpable breast mass but mammography comes back negative, what is the next best step?
fine-needle aspiration OR ultrasonagraphy
what do you recommend to a woman who just had cyst aspiration of her breast?
come back in 4-6 weeks to evaluate for recurrence or presence of residual lump
in whom should tumor estrogen/progesterone receptor assay be done?
patients with early stage breast cancer to determine optimal systemic therapy
breast conserving therapy
breast lumpectomy + radiation therapy
when do you perform axillary node dissection?
when sentinel LN shows metastatic involvement
screening for CRC in a person with a positive family history of CRC
start screening at age 40 or 10 years earlier than diagnosis of affected member; if normal colonscopy, repeat ever 3-5 years
when do you test for mutations of the APC gene?
in pts with polyposis
screening for CRC in normal-risk people
beginning age 50, then every 10 years if result is normal
screening recommendations for pts with IBD
annual colonoscopy beginning 8 years after diagnosis- take random biopsies in four-quadrants to evaluate for dysplastic changes
what test do you do in a pt presenting with signs of colon cancer?
colonscopy
findings that should prompt investigation for CRC
rectal or abdominal mass
hepatomegaly
abdominal tenderness
iron deficiency anemia
when can you choose flexible sigmoidoscopy over colonscopy?
pts < 40 yo with rectal bleeding
what is the appropriate follow-up for an asymptomatic patient with a positive FOBT sample?
colonscopy
what is capsule endoscopy used for?
visualization of the small bowel
how do you screen for lung cancer?
you dont
what is the appropriate follow-up in a pt who was found to have a 3 mm pulmonary nodule (incidental finding from abdominal CT)?
no further testing needed for pulm nodules < 4 mm bc risk of malignancy is extremely low in low risk patients; if the patient is at high risk for lung cancer, follow-up is with CT-scan at 12 months
first line management of someone with limited SCLC?
chemotherapy plus radiation therapy
- combo of carboplatin/cisplatin and etoposide/irinotecan
what is the next step in a man who comes in with a rising PSA (> 0.75 ng/ml/year)?
do a transrectal biopsy - even if pt is asymptomatic and DRE is non-specific
what is the appropriate screening method for prostate cancer?
inform patient about risks and benefits of screening; offer PSA testing to patients > 50 years old; no screening for men over 75
how do you tx. metastatic prostate cancer?
androgen deprivation therapy, w/ leuprolide or surgical castration (orchiectomy)
- leuprolide should be given with brief course of flutamide to prevent tumor flare
what is docetaxal+prednisone therapy used for?
patients with hormone-refractory prostate cancer
samarium 153 - what is this useful for?
radionuclide taken up by bone - useful in treating prostate cancer with painful bone mets that is unresponsive to other therapies
what is the next step in a female who has ASCUS on pap smear?
test for HPV
- if positive, do a colposcopy w/ biopsy
for whom in the HPV vaccine recommended for?
all girls and women between ages 9-26 regardless of sexual activity; high success rates for preventing infections with HPV strains 6,11,16 and 18
when should screening for cervical cancer begin?
within 3 years of onset of sexual activity but no later than at age 21
how often can you screen a low-risk woman for cervical cancer?
every 3 years - wait until age 30 to lengthen the screening interval
how should you screen women after total vaginal hysterectomy for cervical cancer?
you dont need to screen these women
uniformly dark blue or black (berry-like) lesions in an older patient
think nodular melanoma
solitary, well-defined pink, pearly translucent dome-shaped papule with telegiectasias on head or neck
superficial basal cell carcinoma
solitary round nodule that grows rapidly with formation of a central keratotic plug and eventually, the lesion becomes crater-like
keratoacanthoma
- rarely progresses to invasive dz; often involutes
precursor to squamous cell ca. of skin
actinic keratoses
actinic keratoses
erythematous lesions w/ overlying hyperkeratoses
for mild-moderate cancer associated pain, what is indicated tx. ?
short acting opioid (oxycodone, morphine, oxymorphone) when non-opioid drugs fail
how would you tx. moderate-severe cancer-related pain that is not adequately controlled with short-release formulas?
sustained-release morphine twice daily with breakthrough pain strategy as needed
what is an effective tx. of dyspnea in a terminally ill patient with either malignancy or cardiopulmonary disease?
opioids
