Download Lowell E. Schnipper, M.D. Beth Israel Deaconess Medical Center

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Lowell E. Schnipper, M.D.
Beth Israel Deaconess Medical Center
Harvard Medical School
Oncology Review
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A 56 year man with metastatic carcinoma of the colon
has just completed a course of chemotherapy for
progressive hepatic metastatic disease. The tumor has
regressed, his appetite and energy are improved. The
patient asks to see you because he has right sided
pleuritic pain and cough. You find him to have swelling
of the RLE, and a palpable cord. A doppler reveals a
DVT in the right femoral vein and you order a
pulmonary angiogram.
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The appropriate management for this patient is:
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A. Insert an IVC filter and administer LMW heparin
B. LMW heparin
C. LMW heparin and transition to warfarin
D. Start warfarin as outpatient and gradually adjust dose to
INR of 2-5-3.5
E. Start a direct oral anti-coagulant
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Oncology Review
2. A 54 year old post-menopausal woman with osteolytic
metastases in ribs and vertebrae is receiving an aromatase
inhibitor as systemic anti-cancer treatment. In addition to the
endocrine therapy she should:
A. Start a course of radiation therapy to the sites of
metastatic disease
B. Start a regimen of calcium plus vitamin D
C. Start therapy with a bisphosphonate
D. Start therapy with a RANK ligand inhibitor
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Oncology Review
3. The oncologist caring for a 42 y.o. woman with a
T2N0M0, ER+/PR+/Her-2 non-amplified breast
cancer told her on the basis of his experience
she does not need chemotherapy, just endocrine
treatment. She asks for your opinion. Your best
advice is to:
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Obtain the opinion of another oncologist
Perform a gene expression assay
Consult adjuvantonline!
Assume all tumors greater than 2.0 cm in a premenopausal woman merit chemotherapy
a. ,
Kaplan-Meier plots for distant recurrence comparing treatment with tamoxifen
(Tam) alone versus treatment with tamoxifen plus chemotherapy (Tam + chemo)
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All Pts
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Int RS
Paik, S. et al. J Clin Oncol; 24:3726-3734 2006
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Low RS
High RS
Take Home Message for Internists
• Genomics can be used to predict responsiveness to
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hormonal therapy and the need for chemotherapy
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• The test is expensive, although many insurers cover it
since it can lead to the avoidance of chemotherapy
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• Lymphoma, colorectal cancer, NSCLC-analogous
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approaches
4.
On your initial visit with a 42 year old man, he
describes an extensive multi-generational family history for
cancer.
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Oncology Review
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4. Which of the following is most likely
to be mutated in this family:
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A. Retinoblastoma gene
B. p53 gene
C. BRCA2 gene
D. MLH 1 gene
E. Ataxia-telangiectasia gene
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Oncology Review
5. A 57-year-old man underwent surgery for an
acute obstruction of the ascending colon. He was
found to have a adenocarcinoma of the colon that
had perforated into the peritoneal cavity. All lymph
nodes in the resection specimen were negative for
metastatic cancer. His postoperative course was
unremarkable and he was discharged from the
hospital without evidence of symptoms.
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The appropriate management for this patient is for
this patient is:
Oncology Review 5
The most appropriate management for this patient
is:
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A. abdominal radiation to the area of the perforation
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B. systemic chemotherapy in conjunction with
radiation
C. intra-peritoneal chemotherapy
D. intra-peritoneal chemotherapy and external beam
radiation
E. systemic chemotherapy
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Oncology Review 6
6. Three years later the CEA was elevated
and CT scan revealed to lesions in the
right lobe of liver that were proven to be
metastatic colon carcinoma. The optimal
treatment is:
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A) Cryoablation of the metastases
B) Chemoembolization of right lobe of
liver
C) Chemotherapy and hepatic resection
D) Liver transplantation
Surveillance after Primary
Therapy
Indicated
• Colonoscopy perioperatively, 1 year,
every 3-5 years
• CEA screening: if
resection of met or
suture line recurrence
• CT scans at MD
discretion
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Not recommended
• Regular LFTs
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• Routine chest xrays
• PET scans
7. The patient’s father, father’s sister had colon
cancer, and the patient’s sister was recently found to
have endometrial cancer. This is the pedigree:
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Oncology Review
7. You should refer him to a genetics
clinic because of high suspicion for:
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A. Loss of p53
B. Loss of PTEN
C. Loss of MLH1
D. Loss of BRCA 2
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The Lynch Syndrome:
Hereditary Non-polyposis Colon Cancer
(HNPCC)
• Mutations in one of several
mismatch repair genes are the
basis of this cancer-prone
syndrome, e.g., MLH1, MSH 2, etc.
Path labs now routinely testing for
this
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• Women with the Lynch syndrome
are at high risk for endometrial
cancer, increased risk for ovarian
cancer as well as other cancers in
the GI tract
• Consider prophylactic TAHBSO
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Oncology Review
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8.* A 38 year old nulliparous woman has had 2 breast
biopsies in the past (all benign), and her mother had breast
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cancer at age 55. Although she is BRCA 1 and 2 negative,
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she proves to be at higher than standard risk for developing
breast cancer when employing the Gail model. She seeks your
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advice for the most clinically appropriate approach to
preventing breast cancer.
Gail Model for Br CA Risk
1. Does the woman have a medical history of any breast cancer or of ductal
carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS)?
2. What is the woman's age? The tool only calculates risk for women 35 years of age
or older.
3. What was the woman's age at the time of her first menstrual period?
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4. What was the woman's age at the time of her first live birth of a child?
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5. How many of the woman's first-degree relatives - mother, sisters, daughters - have
had breast cancer?
6. Has the woman ever had a breast biopsy?
6a. How many breast biopsies (positive or negative) has the woman had?
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6b. Has the woman had at least one breast biopsy with atypical
hyperplasia?
7. What is the woman's race/ethnicity?
8. Your advice to her is:
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a. perform bilateral mastectomies
b. Perform bilateral oopherectomy
c. Screen regularly with MRI and mammography
d. Start raloxifen 60 mg per day for 5 years
e. Start tamoxifen 20 mg per day for 5 years
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Effects of Tamoxifen vs Raloxifene on
the Risk of Developing Invasive Breast
Cancer and Other Disease Outcomes
TheNSABP Study of Tamoxifen and
Raloxifene (STAR) P-2 Trial
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Vogel, V. G. et al.
JAMA 2006;295:2727-2741
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Breast Cancer: Early Detection
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Mammography
Highly controversial
Ambiguous data <50 yrs
(RR 0.92; NNS 3,125/1
life saved
Improves survival in
those women 50-70 (RR
0.77) NNS 1 life/543
women screened
Tomosynthesis: more
sensitive
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MRI
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• Very sensitive
• Not very specific
although interpretation
is improving
• Clinical trials suggest
useful in those carrying
BrCa susceptibility
genes
Oncology Review
9. This patient was interested in risk reduction
therapy with Tamoxifen. After 3 months she
reports having hot flashes, and difficulty
sleeping at night. She awakens early and has
repetitive dreams about death. She cries
easily and complains of lassitude. You
interpret this as clinical depression and
recommend an anti-depressant.
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Oncology Review #9
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The most appropriate anti-depressant to
prescribe is:
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B.
C.
D.
E.
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Sertraline
Paroxetine
Amytryptylline
Venlafaxine
Nortryptylline
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10. Cancers evade the immune system by
invoking which one of the following mechanisms?
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a. Establishing a fibrin “cocoon” around the tumor
mass
b. Overwhelming the immune system by the
large tumor burden
c. Paralyzing B cells so no/or inadequate
antibody production is developed
d. Promoting apoptosis of cytotoxic T cells
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Oncology Review
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11. A 63 year old man was
diagnosed by multiple
myeloma three year earlier.
Because of intense skeletal
pain and a rising level of
serum IgA, he was placed
on chemotherapy. After a
two year period of
remission he presents with
dizziness, somnolence,
bruising, the peripheral
smear on the left and his
monoclonal IgA was
measured at 5.0 gm/dl.
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Oncology Review
11. Which diagnostic test is likely to be
most helpful?:
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A) Check the serum viscosity
B) MRI of the brain
C) Bone marrow aspiration and
biopsy
D) PET/CT scan
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Oncology Review #12*
•53 yo African American male
•Initial annual visit
•Father died of prostate cancer (states that “they
got it late”); paternal uncle has prostate cancer
•Married, sexually active; no significant comorbidities
•No urinary or urological symptoms
•PE: mild hypertension; negative DRE
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•WHAT ARE YOUR RECOMMENDATIONS REGARDING
PSA BASED TESTING?
Courtesy, M. Garnick
Oncology Review #12
A. Order a PSA test as part of the routine annual bloods,
along with lipid panel, glucose, and CBC (patient not
informed)
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B. Given the lack of symptoms and PE, do not bring PSA
issue up, but document your decision in the medical
record
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C. Briefly discuss controversies about PSA testing and
have patient make decision (and document)
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D. Briefly discuss controversies about PSA testing and
recommend the test (and document)
E. Briefly discuss controversies about PSA testing and do
NOT recommend the test (and document)
Oncology Review
13. A 40 year old woman is now 5 years from
completing adjuvant endocrine therapy for ER+,
Stage II adenocarcinoma of the right breast. Her
menses have returned and she asks you if it is
safe for her to become pregnant.
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Your assessment is that:
a. She should avoid pregnancy and continue to take
Tamoxifen
b. She should proceed with a pregnancy but anticipate
an enhanced risk of recurrence
c. She should avoid pregnancy due to enhanced risk of a
second breast cancer
d. She should proceed with pregnancy assuming no
increased risk of recurrence
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Oncology Review
14. A 55 year old Chinese woman has a 2 month
history of cough and blood streaked
sputum. She has a left upper lobe mass on
CT chest, biopsy of which demonstrates
adenocarcinoma. The genetic abnormality
that is most likely to be “driving” her cancer
is:
a. A mutation in the epidermal growth factor
receptor
b. A translocation involving EML4/ALK
c. A mutation of k-ras
d. A mutation of c-kit
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15. A 39 year old woman with a strong family history
and proven BRCA 1 mutation recent was recently
found to have stage IIB estrogen receptor negative
adenocarcinoma of the right breast and completed
treatment with partial mastectomy, 4 cycles of
adjuvant chemotherapy followed by radiation therapy
to the involved breast.
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Optimal follow up care for this patient includes:
a. Mammography alternating at 6 months with MR exams
b. Mammography alternating at 6 months with MR exams
plus semi-annual measurement of tumor markers and
CA27.29
c. Mammography alternating at 6 months with MR exams, semiannual measurement of tumor markers CA27.29 and yearly
CT scans
d. Mammography alternating at 6 months with MR exams, semiannual measurement of tumor markers CA27.29 and yearly
CT scans and bilateral mastectomy
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Best Site for Cancer Info for Docs and
Patients
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Cancernet --access via any search
engine
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or
Google nci---you ll get to the website
of the National Cancer Institute
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