SWOH Internal Medicine Update Review Course Rekha Chaudhary

SWOH Internal Medicine Update & Review Course: Rekha Chaudhary, MD Adjunct Associate Professor of Medicine Division of Hematology and Oncology

Oncology and Boards • Staging and Dx • Indications for Tx and Performance Status • Acute and Long Term Side Effects of Therapy

Question 1 Lucy is a 40 yo. F smoker cc weight loss and fatigue. CXR shows a new speculated RUQ mass. Bx is consistent with adenocarcinoma. What is the next best test? A. B. C. D. PET scan MRI brain Endoscopic evaluation of mediastinum CT scan abdomen and pelvis

Staging • TNM staging – T= tumor size and extent – N = nodal status – M = distant metastasis

Staging • Local Disease: (Stage I or II) – T 1 or T 2 surgery • Locally Advanced (Stage III) – Node positive or T 4 (ie invading chest wall) – Radiation and Chemotherapy • Metastatic Dz (Stage IV)

Question 2 Lucy was found to have widely metastatic lung cancer on PET scan with involvement of her bones and liver. She works full time as a trainer and exercises every day. What is her ECOG performance status? A. 0 B. 1 C. 2 D. 3

Performance Status

Karnofsky D, Burcnal J, The clinical evaluation of chemotherapeutic agents in cancer. In: Mac. Leod C, ed. Evaluation of Chemotherapeutic Agents. New York, NY: Columbia University Press; 1949: 191– 205.

Approach to a Cancer Pt • Cure or Not – Median survival versus percent chance of cure • Performance Status • Patient Wishes

Question 3 55 yo. F feels a lump in her breast and is dx’d with breast CA. US displays a 5 cm lesion and 5 axillary lymph nodes. Pt wants breast conservation if possible. Which of the following is the best therapy for this young pt? A. Mastectomy with lymph node dissection B. Neoadjuvant chemotherapy followed by lumpectomy and radiation C. Neoadjuvant chemotherapy followed by lumpectomy D. Mastectomy with radiation but no chemotherapy

Timing of Chemotherapy • Neoadjuvant • Adjuvant • Palliation

Neoadjuvant • Before surgery or radiation therapy • Given for organ preservation • Usually no overall survival benefit as compared to adjuvant • Bladder, rectal and laryngeal

Adjuvant • Latin “to help” • • • Patient has no visible dz but has a high chance of recurrence to dec chance of recurrence give chemotherapy adjuvant to surgery or radiation therapy Pt is clinically cured when offering adjuvant therapy

Question 4 40 yo. F receives CHOP chemotherapy for her T-cell non. Hodgkin’s lymphoma and you are discussing the side effects of chemotherapy with her. She asks you what is CHOP? A. B. C. D. Cyclophosphamide, hydrouracil, vinblastine and platinum Cyclophosphamide, hydrouracil, vincristine and platinum Cyclophosphamide, adriamycin, vinblastine and prednisone Cylcophosphamide, adriamycin, vincristine and prednisone

Bonus Question Becca from question 4 has heard of drug called rituximab. Why aren’t you using that? Monoclonal Ab against CD 20 found on B-cells; Hence the use in autoimmune disorders

Brave New World of Oncology • • Chemotherapy Targeted Therapy Immunotherapy Anti-Angiogenesis Therapy

Question 5 Becca from question 4 wants to know when she should be worried about fevers and low blood counts after her chemotherapy? a) 1 - 2 days b) 3 - 7 days c) 7 -14 days d) 14 - 21 days

Question 6 On the 7 th day after her 1 st cycle of CHOP, Becca develops a fever of 102*F at home with chills. She comes to the ER and the ER doctor tells you that her total white count is 800 with 50% neutrophils, 10% bands, 30% lymphocytes and 10% other. You ask him what her ANC is. He says: A. 400 B. 800 C. 50 D. 480

Question 7 • You admit Becca for neutropenic fever when she comes to the ER 10 days after her initial chemotherapy. You write the STAT order of which antibiotic? • a) Ceftin IV • b) Zithromax IV • c) cefepime IV • d) Unasyn IV • e) Levaquin IV

Question 8 What is the dose of cefepime for Becca? A. 1 gram q 8 B. 1 gram q 12 C. 2 grams q 8 D. 2 grams q 12

BONUS Question Is neupogen or neulasta indicated in this situation? A. Yes B. No

Question 9 Becca comes back to your office 3 months after completion of chemotherapy with SOB. Which one of the chemotherapy agents are you worried that may have caused these symptoms? A. Cyclophosphamide B. Doxorubicin C. Prednisone D. Vincristine

Question 10 60 yo. M recently dx’d with testicular cancer. His LDH, AFP and BHCG are all elevated. What time of cancer does he have? A. Non-seminomatous testicular CA B. Lymphoma of the testis C. Seminomatous Testicular CA D. None of the above

Question 11 Lance decides to get chemotherapy but is an avid cyclist. He is given the option of BEP versus EP. What is BEP? A. Bleomycin etoposide prednisone B. Bleomycin etoposide cisplatin C. Bleomycin epirubicin cisplatin D. Bleomycin epirubicin prednisone

Question 12 Lance decides not to get the Bleomycin and decides on 4 cycles of EP. Why? A. He is worried about the pulmonary toxicity. B. He is worried about the cardiac toxicity. C. He is worried about sterility D. He is worried about pituitary toxicity.

Question 13 55 yo. M recently dx’d with glioblastoma multiforme and unfortunately has failed initial tx. He now has to receive Bevacizumab. Which of the below is NOT a side effect that you discuss with him? A. B. C. D. GI bleeding Stroke HTN Renal Failure

Avastin (bevacizumab) S. K. Mukherji AJNR Am J Neuroradiol 2010; 31: 235 -236 © 2010 by American Society of Neuroradiology

Question 14 50 yo. F cc N/V/D x 3 days. She is severely dehydrated and her creatinine is 3. 5 mg/dl. She has been having 7 loose stools a day but no abdominal pain. She is on the drug ipilimumab for her Stage IV melanoma and received her third cycle last week. She has no sick contacts and has been on no Abx. What is the NEXT best tx? A. Test her for clostridium dificile. B. Start steroids IV C. Call a GI consult D. Treat her for CMV colitis

Question 15 Lori gets a colonoscopy with this picture. You think the diagnosis is? A. B. C. D. CMV colitis caused by her profound immunosuppresion Ischemic colitis Cdiff colitis Ipilimumab-induced colitis

Immunotherapy • Takes the brakes off the immune system a) Ipilimumab a) CTLA inhibitor b) PD 1 inhibitors a) Keytruda (pembrolizumab) b) Opdivo (nivolumab)

Side Effects of Immunotherapy • Hypophysitis – MRI – ACTH, TSH • • • Colitis Painful Neuropathy Hepatitis Nephritis Other immune phenomenona • TX: Steroids 1 mg/kg