Oncology

Question 1

35 y/oF, mom diagnosed w/ colon CA at 48, when should she start getting screened?

Answer 1

Screening colonoscopy at age 38

-w/ first degree family member w/ colon CA start screening at 40 or 10 years before index case

Question 2

Acral lantiginous melanoma

(a) Big difference from other types of melanoma
(b) Common location

Answer 2

(a) Most common type of melanoma in dark skinned ppl b/c it is the only subtype not associated w/ extreme sun exposure
(b) Palm, soles, nail beds (periungal pigmentation)

Question 3

Age range for lung cancer screening

Answer 3

55-74 yoa w/ at least 30 pack years who quit within the past 15 years

Question 4

39 y/oM w/ R sided colon CA, strong FHx of early endometrail cancer

Most likely syndrome?

Answer 4

Lynch syndrome (hereditary nonpolyposis colorectal cancer = HNPCC) = mismatch repair mutation

-MC cancer associated w/ Lynch syndrome that isn’t colon CA is endometrial CA

Question 5

Distinguish Lynch syndrome and Li Fraumeni syndrome

Answer 5

Lynch = HNPCC = mismatch repair mutation
-colon CA and endometrail CA

Li Fraumeni = mutation in tp53 (tsg)
-breast cancer, sarcoma, brain, adrenal tumor, leukemia

Question 6

During what kind of cancer treatment can EPO be used for chemo-induced anemia?

Answer 6

Only in palliative- b/c EPO has been associated w/ increased mortality in pts receiving chemo/radiation

Question 7

Tx of malignant hypercalcemia (ex: cancer pt p/w nausea/vomiting found to have Ca 16.2)

(a) 2nd line for refractory

Answer 7

Hypercalcemia of malignancy treatment: IV fluids, lasix (loop diuresis), IV bisphosphonate, and calcitonin

IV bisphosphonates = zolendronate and pamidronate (while alendronate is only oral)

(a) Denosumab = monoclonal antibody against RANK-ligand to inhibit osteoclast breakdown of bone

Question 8

Indication for cinacalcet

Answer 8

Cinacalcet (sensipar) used in secondary hyperparathyroidism- calcium receptor agonist to increase calcium receptors to serum Ca and therefore decrease PTH levels

ex: Pt on HD, has super high PTH due to low Ca levels from low active vitamin D

Question 9

First line pharmacologic therapy for smoking cessation in 51 y/oF w/ h/o seizures

Answer 9

1. varencicline (chantix)
2. nicotine patch + lozenge

buproprion contraindicated given seizure history

Question 10

Pt w/ metastatic GI stromal tumor with a KIT mutation

First line tx?

Answer 10

Imatinib (Gleevec) = tyrosine kinase inhibitor

Advanced inoperable (metastatic) GIST
KIT = receptor tyrosine kinase

Question 11

MC location of GIST tumor

Answer 11

Stomach

Question 12

Driving mutation of most GIST tumros

Answer 12

GI stromal tumors (MC in stomach) are largely driven by KIT proto-oncogene = receptor tyrosine kinase

Question 13

What to screen for in breast cancer pt starting tamoxifen vs. anastrozole

Answer 13

Tamoxifen (selective ER agonist/antagonist): annual GYN exam to monitor for any abnormal uterine bleeding given increased risk of endometrial CA
-actually strengthens bone

Anastrozole (aromatase inhibitor) requires baseline DEXA b/c can increase risk of osteopenia/porosis

Question 14

Two dermatologic manifestations of gastric cancer

Answer 14

1. Acanthosis nigricans- velvety hyperpigemnted patches in skin folds
2. Leser-Trelat sign = diffuse seborrheic keratosis

Question 15

MC location of colon cancer

Answer 15

Sigmoid colon like 23% (left colon)

Question 16

What chronic autoimmune conditions increase risk of CRC?

Answer 16

Both UC and Crohn’s increase risk of CRC- and risk correlates w/ duration of symptomsdisease

Question 17

How to distinguish colonic from rectal cancer?

(a) What percent of CRC are rectal?

Answer 17

Location- rectal CA like 12-15 inches from the anal verge

(a) Almost a quarter- like 22% of CRC are rectal, next 23% are sigmoid

Question 18

For which hereditary polyposis syndrome is prophylactic colectomy indicated?

Answer 18

FAP = familial adenomatous polyposis = mutation in APC gene

Question 19

Main risk factor for testicular cancer

Answer 19

Cryptorchidism = failure of one or both testes to descend from the abdomen into the scrotum

Carries 20-40x increase risk of testicular cancer

Question 20

Main risk factor for testicular cancer

Answer 20

Cryptorchidism = failure of one or both testes to descend from the abdomen into the scrotum

Carries 20-40x increase risk of testicular cancer

Question 21

Differentiate clinical presentation of R vs L sided colonic tumors

Answer 21

R sided colon CA presents w/ anemia from slow blood loss (normocytic)

L sided usually w/ change in bowel pattern- obstruction, constipation, diarrhea

Question 22

Where do colon CAs typically develop in pts w/ Lynch syndrome?

Answer 22

Right sided colon CA at early age (30/40s)

Question 23

Which stage of colon CA gets

(a) chemo
(b) radiation

Answer 23

Colon CA: stage II through muscularis propria

(a) Chemo- definitely for stage III (lymph nodes involved), sometimes used in advanced stage II
(b) Radiation- only stage IV, no benefit if no mets

Question 24

Standard adjuvant chemo regimen for colon CA

Answer 24

Adjuvant chemo for colon CA (after resection):

5-Fluorouracil (pyrimidine analog) + Leucovorin (vitamin B12 than enhances effect of 5-FU) + Oxaliplatin (platinum based, crosslinks DNA)

Question 25

2 differences in treatment for rectal vs. colonic cancer

Answer 25

Rectal CA- gets radiation even stage II b/c risk of local recurrence is so high Chemo regimens: Colon CA: 5-FU (pyrimidine analog), leucovorin, and oxaliplatin Rectal CA: Just 5-FU

Question 26

After diagnosis w/ CRC, when should repeat colonoscopy be performed?

Answer 26

1 year after- make sure they got it all (no micro-nearby disease) Can repeat FOBT and CT C/A/P q6 months

Question 27

BRCA 1 vs 2 (a) Mode of inheritance (b) Which has higher risk of breast CA (c) Which has higher risk of epithelial ovarian CA

Answer 27

BRCA 1 and 2 (a) Both autosomal dominant (b, c) BRCA 1 has higher risk of breast (8-9 vs. 4-5%) and epithelial ovarian CA

Question 28

Differentiate breast CA screening guidelines from American Cancer society (do more) vs. USPSTF

Answer 28

ACS- start at 40, get every year USPSTF- start at 50, get q2 years

Question 29

Most common type of breast cancer

Answer 29

Invasive ductal carcinoma

Question 30

Which breast cancer is associated w/ increase risk of subsequent CA at same site vs. any site?

Answer 30

DCIS- increase risk on same breast LCIS- increased risk either breast

Question 31

Differentiate treatment for DCIS vs LCIS

Answer 31

Difference is that w/ DCIS excision's goal is for negative margins, while for LCIS goal of excision is to r/o invasion and negative margins are not required

Question 32

2 options for tx in invasive breast cancer

Answer 32

Equal survival for lumpectomy with radiation vs. total mastectomy

Question 33

Distinguish stage I vs stage II breast cancer

Answer 33

Size and invasion Stage I- under 2cm Stage II- over 2 cm OR **

Question 34

Distinguish stage I vs stage II breast cancer

Answer 34

Size and invasion Stage I- under 2cm Stage II- over 2 cm OR involved axillary lymph node

Question 35

When to use hormonal vs. antibody therapy in adjuvant therapy for breast cancer

Answer 35

Depending on the receptor positivity- ER/PR+ use hormonal therapy (tamoxifen if premenopausal, aromatase inhibitor in postmenopausal) HER2+ benefit from trastuzumab (Herceptin)

Question 36

How to decide which hormonal therapy to use in adjuvant therapy for breast cancer?

Answer 36

Pre or post-menopause Pre-menopause- use tamoxifen (SERM) -most estrogen still made in ovaries Post-menopause- use aromatase inhibitor Don't use AI pre b/c prior to menopause the decrease in estrogen production stimulates the HPA axis to increase gonadotropin secretion, which then stimulates ovaries (still active) to release androgen => counteracts effect of the AI -but technically more selective b/c inhibits estrogen production in adipose tissue local to the breast CA

Question 37

3 mutations associated w/ increased risk of epithelial ovarian cancer

Answer 37

Epithelial ovarian cancer: BRCA 1, BRCA 2, and lynch syndrome (mistmatch repair mutation)

Question 38

OCPs decrease risk of what specific type of cancer

Answer 38

OCPs reduce number of ovulations => reduces number of times the ovarian epithelium is disrupted => decreased risk of epithelial ovarian CA

Question 39

Distinguish stage II and III epithelial ovarian cancer

Answer 39

Stage II- out of ovaries but within the pelvis (MC route of spread for ovarian cancer is intraperitoneally) Stage III- extra-pelvic involvement **

Question 40

Distinguish stage II and III epithelial ovarian cancer

Answer 40

Stage II- out of ovaries but within the pelvis (MC route of spread for ovarian CA is local shedding into peritoneum) Stage III- extra-pelvic involvement (upper abdomen or reginal lymph nodes)

Question 41

Treatment for epithelial ovarian cancer

Answer 41

Tx for epithelial ovarian cancer = surgical debulking Then for anything stage II and above (outside the ovary)- chemo Typical chemo regimen: platinum based (ex: carboplatin or cisplatin) cross-linking agent (cell-cycle nonspecific) and taxane (paclitaxel or docetaxal)

Question 42

Tx in prostate cancer (a) When to just observe (b) Localized disease

Answer 42

Prostate cancer- 1 in 6 men! 2nd MC cancer death just b/c so common (after lung CA which is just so deadly) (a) Observe if lifespan is under 10 years (b/c not likely to die from prostate CA anyway (b) Localized disease (localized or confined w/in prostate capsule): equal survival rates for for radial prostatectomy and radiation

Question 43

Two treatment options for advanced prostate cancer

Answer 43

Advanced prostate CA (meaning mets): surgical or medical castration (androgen deprivation) Surgical- remove both testes (b/l orchiectomy) Medical- GnRH agonists (leuprolide) to reduce LH/FSH, antiandrogens (flutamide)

Question 44

Mainstay of chemo treatment for castration resistant prostate cancer

Answer 44

Defining castrate resistant prostate CA = rise in PSA or finding of new lesions despite medical or surgical orchiectomy Use inhibitors of androgen-stimulated tumor growth and taxane therapy (docetaxel, paclitaxel) that inhibit microtubule formation **

Question 45

3 treatments for bony mets in prostate cancer that are unresponsive to androgen deprivation

Answer 45

Castration-resistant bony mets in prostate cancer (blastic lesions meaning they build up bone) 1. zolendronic acid- bisphosphonates to reduce fracture risk and bony pain (but doesn't improve survival) 2. Denosumab = antibody against RANK-ligand (osteoclast survival factor) to stop bone breakdown 3. External beam radiation- reduce pain and fracture risk w/ isolated painful bony lesions

Question 46

Name 2 risk factors for upper urinary tract malignancies

Answer 46

Recurrent UTI and kidney stones increase risk for ureter CA

Question 47

Bladder cancer- when to do TURBT vs. cystectomy

Answer 47

Cystectomy (bladder removal) for anything stage II or above meaning it's invaded into the muscularis propria If hasn't invaded muscularis propria can do TURBT

Question 48

Name 2 paraneoplastic syndromes that can result from renal cell carcinoma

Answer 48

RCC paraneoplastic Increased EPO production => high Hct PTHrP => hypercalcemia **

Question 49

Name 2 paraneoplastic syndromes that can result from renal cell carcinoma

Answer 49

RCC paraneoplastic Increased EPO production => high Hct/polycythemia PTHrP => hypercalcemia

Question 50

Name a syndrome that causes hereditary renal cell carcinoma (a) What else to look for

Answer 50

Von-Hippel Lindau -Renal cell carcinoma (a) CNS hemangioblastomas Retinal angiomas

Question 51

MC clinical presentation of testicular cancer

Answer 51

Painful testicular lesion

Question 52

MC clinical presentation of testicular cancer

Answer 52

Testicular pain/swelling

Question 53

Testicular cancer (a) How to biopsy (b) First line treatment

Answer 53

Testicular cancer (a) Trick question- don't biopsy!!! Just remove the testicle, biopsy carries increased risk of spread (b) First line = orchiectomy **

Question 54

Testicular cancer (a) How to biopsy (b) First line treatment

Answer 54

Testicular cancer (a) Trick question- don't biopsy!!! Just remove the testicle, biopsy (and scrotal orchiectomy) carries risk of local spread of tumor cells (b) First line = inguinal orchiectomy of all solid (not cystic) intratesticular lesions

Question 55

Differentiate lymphoma and leukemia

Answer 55

Lymphoma = overgrowth predominantly in lymph node and lymphatic tissue Leukemia = abnormal growth predominantly in blood and bone marrow **

Question 56

Differentiate lymphoma and leukemia

Answer 56

Lymphoma = overgrowth predominantly in lymph node and lymphatic tissue Leukemia = abnormal growth predominantly in blood and bone marrow

Question 57

Most likely diagnosis for mediastinal mass in young adult

Answer 57

Mediastinal mass in a young adult = Hodgkin's lymphoma until proven otherwise

Question 58

What are B-symptoms

Answer 58

B-symptoms = fever, night sweats, weight loss

Question 59

Name 1st and 2nd MC types of Non-Hodgkin's lymphoma

Answer 59

Non-Hodgkin's lymphoma = basically the other lymphomas that are not the one specific B-cell lymphoma known as Hodgkins 1st MC = DLBCL (aggressive) 2nd MC = follicular (indolent)

Question 60

Name aggressive vs. indolent types of NHL

Answer 60

Non-Hodgkin's lymphoma Aggressive- DLBCL, Burkitt's Indolent- Follicular, Hairy cell **

Question 61

Name 3 infectious risk factors for NHL

Answer 61

3 infections associated w/ higher risk of NHL 1. HIV- esp DLBCL 2. EBV- esp DLBCL 3. H. pylori and MALT

Question 62

Name aggressive vs. indolent types of NHL

Answer 62

Non-Hodgkin's lymphoma Aggressive- DLBCL, Burkitt's, Mantle cell Indolent- Follicular, Marginal zone

Question 63

Why do we do LPs in lymphoma pts?

Answer 63

B/c lymphangitic spread is much more common then brain mets Give intrathecal chemo if CSF is involved

Question 64

When to add rituxan to typical chemo regimen for lymphoma pt?

Answer 64

Lymphoma typical chemo regimen = CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone), add rituximab when it is a B-lymphoma

Question 65

Treatment for stage I, asymptomatic lymphoma

Answer 65

Nada, watch and wait No proven benefit for localized (just one node) asymptomatic (no B-symptoms, no marrow involvement

Question 66

When to add rituxan to typical chemo regimen for lymphoma pt?

Answer 66

Lymphoma typical chemo regimen = CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone), add rituximab when it is a B-lymphoma (which most are)

Question 67

Why does the choice of adjuvant hormonal therapy for beast cancer differ by age?

Answer 67

Pre-menopausal- tamoxifen (SERM) Main source of estrogen is ovaries Post-menopausal- aromatase inhibitor Main source of estrogen is exogenous tissue like fat In pre-menopausal use of AI will cause reduction in estrogen that will feed back to HPA axis and increase signal to make more estrogen, counteracting the effect

Question 68

Indications for treatment in CLL

Answer 68

Treat CLL if it becomes advanced (2 or more nodes, nodes on different sides of diaphragm) or if becomes symptomatic - bone marrow involvement => anemia, thrombocytopenia - B-symptoms - high risk of Richter's transformation to active lymphoma (ex: DLBCL): such as rapidly enlarging lymph node - bulky lymphadenopathy - weakness - organomegaly - autoimmune hemolytic anemia or autoimmune thrombocytopenia

Question 69

Most likely dx: young M w/ sclerotic lesion of L humerus w/ onion-skin periosteal reaction

Answer 69

Ewing sacroma- infiltrative pattern of bone invasion that shows on imaging as onion skinning -often presents w/ constitutional symptoms (while osteosarcoma w/ Codman's triangle and spiculated appearance more typically asymptomatic

Question 70

Distinguish radiologic features of Ewing sarcoma and osteosarcoma

Answer 70

Ewings = shaft of bone in an infiltrative pattern called onion skinning tend to manifest w/ constitutional symptoms Osteosarcoma- metaphysis of long bones, usually w/o symptoms radiologically- spiculated appearance and Codman triangles (reactive bone edges of penetrating lesion by the periosteum)

Question 71

Carcinoid tumor (a) Typical clinical presentations (b) Treatment for symptom/tumor control

Answer 71

Carcinoid (a) Flushing, diarrhea, palpitations, wheezing, edema (b) Octreotide (somatostatin analogue) can help w/ symptoms

Question 72

Carcinoid tumor (a) What hormone is elevated (b) How to diagnose

Answer 72

(a) Excess serotonin | (b) 5-HIAA elevated in urine

Question 73

Imaging findings of radiation-induced pneumonitis

Answer 73

1. consolidation not conforming to an anatomic location or bronchopulmonary segments, but rather to the radiation port 2. bronchiectasis (dilation of peripheral bronchi)

Question 74

When to use tagged red-cell nuclear scan

Answer 74

Shows active bleed at a rate above 0.5 ml/minute

Question 75

Initial test for pt w/ iron-deficiency anemia, weakly positive FOBT, and h/o radiation tx to prostate w/ now undetectable PSA

Answer 75

Colonoscopy to assess for lower GI source- more specifically radiation induced prostatitis -radiation induced prostatitis can be acute (bleeding w/in 6 weeks) to decades later (6 yrs later BRBPR)