ITE 2008 Oncology

Medical Oncology : 

Medical Oncology ITE-2008 High Yield Review

Screening Guidelines: Familial Colonic Syndromes : 

Screening Guidelines: Familial Colonic Syndromes FAP Full colonoscopy @ age 12, then sigmoidoscopy q 1-2 yr Test for APC gene in patient. HNPCC aka Lynch syndrome – [3:2:1] Rule Full colonoscopy @ age 25 (or 10 yrs younger than first affected relative) Then colonoscopy q 2y up to age 40, then q 1y Relatives 10 yrs before youngest affected relative, or age 40 if: 2 1st degree relatives or 1 1st degree before 60 - q 5 yrs 2 2nd degree relatives or 1 1st degree after 60 - q 10 yrs UC/Crohns- after 8 yrs, then q 1-2 yrs S/p resection for Colon Ca- Full colonoscopy within 3 years, then q 5 yrs.

Colon CancerWhat to do? : 

Colon CancerWhat to do? Sigmoidoscopy → Polyp → WTD ?? Hyperplastic: Repeat colonoscopy in 10 yrs. Adenoma or AdenoCa- Full colonoscopy Invasion of Tumor: Before Serosa- resection only (Duke A - B1) (Mucosa, Submucosa, and Muscularis) Serosa (B2), +LN (C) - Add chemo 5 FU and Leucovorin Solitary liver met: RESECTION !!

Breast Ca Screening : 

Breast Ca Screening Annual: Clinical Breast Exam + Mammogram Age > 40 < 5-10 yr prior to age in 1° relative with Breast ca HIGHEST RISKS: Age > 50 yr Personal hx of Breast CA Strong Fam Hx of pre-menopausal breast CA BRCA 1 or 2: strong family history of breast and ovarian ca HIGH RISK: 1° relative; Hx ovarian/uterine CA; Late preg; nulliparous

Breast Lump/Suspicious Mass Work-up : 

Breast Lump/Suspicious Mass Work-up First: Remember to reexamine in mid cycle or 6 weeks later. After this, if persistent get: Mammogram If positive: Do Excisional Biopsy If indeterminate/negative: Ultrasound Solid/Mixed ECHO  Excision Cystic  FNAC

Infiltrating Ductal Ca : 

Infiltrating Ductal Ca Surgeries: MRM Wide Excision + RT Always remember: Lymph node involvement guides Tx LN (+) • Add Chemo LN (-) • only add Chemo if tumor size > 1 cm ER (+) pre-meno: Add Tamoxifen post-meno: Add aromatase inhibitor Letrozole HERR receptor (+)  Traztuzumab (herceptin)

Early Breast CaGuidelines for F/u (s/p Tx) : 

Early Breast CaGuidelines for F/u (s/p Tx) Physical Exam: q 3-4 mos Self breast exam Mammogram - yearly

TamoxifenSERM : 

TamoxifenSERM Effective for the following: Treatment of Metastatic Disease (ER & PR +) Decreases risk of new breast Ca Prevents breast Ca in high risk women Increased bone mineral density Cataracts Adverse Effects Endometrial Ca (3X) Thromboembolic risk (not risk for CAD) Menopausal Sx (Use SSRI) What to monitor: Routine yearly pelvic exam for endometrial ca

Cervical Ca : 

Cervical Ca Start Screening: Age 21 Age of first intercourse Q 3y for low risk: Q 1y for high risk When to stop ?? 65 y/o or hysterectomy (not for CA reason) LGIS Low risk: rpt pap in 6 mos (50%  normal) High risk: Colposcopy Multiple Partners, poor follow-up, HIV, HPV DNA (+)

Breast Ca and Pregnancy : 

Breast Ca and Pregnancy Treat like regular patient Surgery in 2nd – 3rd trimester Chemotherapy in 3rd trimester Treat breast cancer in males similar to females

Other GYN Malignancies : 

Other GYN Malignancies Ovarian No screening recommended Transvaginal U/S with strong family history or dermatomyositis Endometrial Post-menopausal vaginal bleeding Tamoxifen and abnormal vaginal bleeding Strong association with Obesity, early menarche, late menopause, and nulliparity

Prostate AdenoCa : 

Prostate AdenoCa Screening Age 50 then annually: PSA + DRE African Americans X 2; Family History NOT shown to reduce mortality! After PSA  TRUS + Biopsy PSA > 4 or increased by > 0.75 in 1 year Hypertrophy or (+) nodule on rectal exam

Prostate AdenoCa : 

Prostate AdenoCa When to start Hormonal Tx: Anti-androgens Invades Capsule (stage C) and beyond Diffuse Bone Mets Back Pain  Get MRI  r/o cord compression Bone Mets  Treatment Radiation to lesion Anti-androgenic therapy Strontium 99

Testicular Cancer : 

Testicular Cancer Biopsy: always via a high inguinal incision Seminomas AFP and B-HCG: normal Radical orchiectomy  RT and Chemo if beyond retro LNs Non-Seminomas  No role for RT AFP and B-hCG: +++ Radical orchiectomy  Chemotherapy If biopsy (+) for testicular cancer  CT C/A/P

Lung Ca: Treatment/Paraneoplatic Syndromes : 

Lung Ca: Treatment/Paraneoplatic Syndromes Small Cell - NO Surgical Intervention Cushing’s, SIADH, Lambert Eaton, SVC syndrome Chemo RT Brain  for extensive disease RT Lung Mass  if limited to one hemithorax Non-small Cell  Surgical Intervention Chemotherapy + Radiation Squamous  Hypercalcemia, Pancoast, Horner’s AdenoCa: MOST COMMON Pulmonary Osteoarthropathy- periosteal thickening Marantic Endocarditis Large Cell  SVC syndrome; Gynecomastia

Chemotherapy: Adverse Effects : 

Chemotherapy: Adverse Effects Bleomycin – Interstitial Fibrosis Doxorubicin – Cardiomyopathy Cyclophosphamide – Hemorrhagic Cystitis Mitomycin; Gemcitabine – HUS Tamoxifen – Thromboemboli, Endometrial CA Cisplatin – ototoxicity/nephrotoxicity/neuropathy IFN alfa – DEPRESSION (SSRIs) 5 FU  Myelosuppression; myocardial ischemia

 Hemoglobin : 

 Hemoglobin  Erythropoeitin Normal PO2 Renal Cell Ca Nephrectomy  PO2 Hypoxic states, normal compensatory response COPD, Hi Altitude  Erythropoeitin P. Vera Normal PO2 Venous Clots Phlebotomy

Thrombocytosis : 

Thrombocytosis Plts < 800, 000 Reactive > 1 million Essential Thrombocytosis Vaso-occlusive Erythromelalgia Criteria to start Hydroxyurea Age > 60 Plts > 1.5 million Previous thrombosis

CML : 

CML Normal LAP Leukemoid reaction  LAP CML (+) Philadelphia Chromosome t(9,22) Tx: < 50: BMTx > 50: Gleevec

CLLWhen to start Tx : 

CLLWhen to start Tx Constitutional Sx Fever Night sweats Weight loss (> 10% over 6 mos) Bulky LAD HCT < 30 Platelets < 50 K Rapidly progressive leukocytosis Use monthly infusions of IV immune globulin to prevent recurrent infections

AML : 

AML A - Auer Rods M - Myeloperoxidase M3- DIC, Retinoic Acid Sweet Syndrome: Fever Leukocytosis Erythematous lesions Dense neutrophilic infiltrate

Hairy Cell Leukemia : 

Hairy Cell Leukemia Pancytopenia w/ Dry BM Tap Splenomegaly TRAP (+)

Splenomegaly : 

Splenomegaly Malignancy CML, CLL Myelofibrosis Infection Malaria Leischmania (visceral) EBV Genetic Gaucher’s B-Thalassemia Hereditary Spherocytosis Portal HTN Felty’s Syndrome

Multiple Myeloma : 

Multiple Myeloma Anemia Hypercalcemia Renal Failure Lytic Bone Lesions Rouleux Formation Marrow plasma cell-cytosis > 10% AL- Amyloidosis (Primary)

Bone Lesions : 

Bone Lesions Osteoblastic Prostate (normal ALP, no bone scan) Hodgkins Lymphoma Osteolytic Breast Lung MM

Hypergammaglobulinemia : 

Hypergammaglobulinemia Increased Globulins with no other abnormalities = MGUS 1st: SPEP/UPEP and HIV test IgG or IgA: can convert to MM Do skeletal survey to look for lytic bone lesions IgM: can convert to B-cell lymphoma or Waldenstrom’s Do CT C/A/P to look for LAD/splenomegaly

Waldenstrom’s : 

Waldenstrom’s Usually increased IgM Anemia Lymphadenopathy Hepatosplenomegaly Raynaud’s Palpable Purpura

Incidentalomas : 

Incidentalomas Kidney If parenchymal, solid & enhances with IV contrast Nephrectomy- RCC until proven otherwise Increased Hct Watch for IVC tumor thrombus Adrenal > 4 cm- remove < 4cm: Do functional studies

Solitary Pulm Nodule : 

Solitary Pulm Nodule Evaluate: Age > 35 Tobacco use ? Size > 2 cm (> 3cm = mass = malignancy) If none of these  f/u with CXR Q 3 mos X 2 yrs

Schistocytes : 

Schistocytes TTP HUS DIC Fatty liver disease of pregnancy Prosthetic valves

Spherocytes : 

Spherocytes Autoimmune hemolytic anemia Warm (IgG): PCN, CLL Hereditary spherocytosis

Statistics : 

Statistics ITE-2008 Please review on your own.

Statistics Favorite Questions : 

Statistics Favorite Questions Sensitivity- rules out- Screening Specificity- rules in – Confirmatory PPV- will increase if the prevalence of the disease increases. Sensitivity and Specificity NOT affected by prevalence

Stats Math : 

Stats Math Will tell you the prevalence, the Sensitivity, and specificity, and ask you the PPV Trick: how they state prevalence Actual Percentage- 1% Fraction- 1/1000 Make your box Answer the question

Math Example : 

Math Example Prevalence = 1/1000, Sens 90%, Spec- 95% PPV? 1 = TP + FN: so Sens = 90%= TP/1, so TP = .9, FN= .1 Spec = 95% = TN/999, so TN= 949, FP=50 PPV= .9/.9 + 50 =2% (goes with low prev)

Math Ex : 

Math Ex If prev = 10%, then use 100 as TP + FN and 900 as TN + FP

NNT : 

NNT Formula= 1/Absolute risk reduction Math Example: Drug X mortality is 6%, Drug Y Mortality is 3% How many patients will you prescribe drug Y to save 1 life?

Math Example : 

Math Example 6% - 3% = 3% (ARR) 1 / ARR = 1 / 0.03 = 33 1 life saved for every 33 people