Hematology/Oncology

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What is not a likely clinical manifestation of leukemia?

Petechiae & Mucosal Bleeding

Bone Pain

Hyperleukocytosis

Decreased WBC Count

Answer:

None of the Above

Leukemia has a wide range of clinical manifestations including anorexia, bone and joint pain, CNS complications, and symptoms of pancytopenia (a decrease in all cell lines). The most dramatic presentation is of hyperleukocytosis when the WBC count is significantly elevated.

Question?

A 45 year old female comes into your office complaining of swollen lymph nodes, bone pain, and easy bruising and bleeding. Patient states that her symptoms started about 4 years ago but did not get worse until the past 3-6 months. Upon bloodwork, there is markedly increased blast count on peripheral blood smear. What is the least likely diagnosis?

Answer:

Acute Lymphocytic Leukemia

Acute Myelogenous Leukemia

Chronic Myelogenous Leukemia

Hodgkins Lymphoma

Answer:

C. Hodgkin’s Lymphoma.

The presence of blasts points towards a leukemia rather than a lymphoma and an acute processs is very likely. The Chronic myelogenous leukemia cannot be ruled out because they have a blast crisis especially end stage CML.

Question?

A 9 year old Caucasian boy complains of a sudden onset of easy bruising, frequent nose bleeds, loss of appetite, and flu like symptoms. Upon blood tests, you find circulating blasts and a negative myeloperoxidase stain. What is the most likely diagnosis? Chronic Lymphocytic Leukemia Acute Myelogenous Leukemia Acute Lymphocytic Leukemia Chronic Myelogenous Leukemia

Answer:

C. ALL. The symptoms and presence of blasts indicate it is an acute process and the negative myeloperoxidase stain points towards a lymphocytic origin. ALL would also have a positive CALLA

Question?

A 75 year old male comes in for an annual history and physical exam. During the physical exam, you find lymphadenopathy in the submandibular lymph nodes. Upon bloodwork, you find lymphocytosis with smudge cells. Patient is asymptomatic but you diagnosis him with leukemia. What would be the most appropriate treatment? Steroids Chemotherapy IV immunoglobulin No treatment

Answer:

D. No treatment because the clinical presentation points to Chronic Lymphocytic Leukemia and there has been no demonstrated benefit to treating the process early. Once the patient starts experiencing symptoms, the other choices are all possible treatment options.

Question?

A 30 year old female present with painless LAD in the axillary, inguinal, and femoral lymph nodes with fever, chills, fatigue and night sweats. You diagnose her with Hodgkin’s lymphoma. According to the Ann Arbor staging, what stage is the patient in? Stage IIIb Stage II Stage III Stage IIb

Answer:

A. Stage IIIb. Patient has 2 or more lymph nodes on both sides of the diaphragm. In addition she has “B-symtoms.” The B adds a worse prognosis to the disease.

Question?

A patient presents with splenomegaly and diffuse painless lymphadenopathy including the lymphoid tonsillar tissue and mesenteric nodes for the past 3 months. Patient is also experiencing fatigue, weight loss, and night sweats. What is the most likely diagnosis? Hodgkin’s Lymphoma Non- Hodgkin’s lymphoma Multiple Myeloma Hairy Cell Leukemia

Answer:

B. Non- Hodgkin’s Lymphoma. The presentation points toward a lymphoma over mutiple myeloma and hairy cell leukemia. The lymphoid tonisllar tissue aka Waldeyers ring and mesenteric lymph nodes are suggestive of Non- Hodgkins. Another common site of LAD is the epitrochlear nodes. Hodgkin’s and Non- Hodgkin’s have similar presentations but they are distinguishable on microscopic exam.

Question?

What is the most common electrolyte abnormality in Multiple Myeloma? Hypocalcemia Hypokalemia Hypercalcemia Hyperkalemia

Answer:

C. Hypercalcemia. This is from bone breakdown. Marrow infiltration processed often affect the bone, and causes bone pain, osteoporosis, lytic lesions and fractures. The hypercalcemia caused confusion, weakness, constipation, and polyuria.

Question?

What findings would support the diagnosis of Multiple Myeloma? Monoclonal Spike on serum protein electrophoresis Bence Jones Protein in the urine Reuleaux formation on CBC Multiple lytic lesions in skeleton on x-ray All of the above

Answer:

E. All of the above. These finding all correlate with multiple myeloma. The M spike is due to increased immunoglobulins in the blood. The Bence Jones protein form due to cleavage of antibodies. Reuleaux forms due to RBC stacking on eachother due to hyperviscosity.

Question?

True or False?

M- spike, Releaux formation, and Bence Jones proteins are findings specific to Mutiple Myeloma

Answer:

False

M-spike, Reuleaux formation, and Bence Jones proteins are found in other disease processes, specifically all three of those are in Waldenstrom’s macroglobulinemia, which is a big differential. However, in this disease, there is no bony lesions and therefore no hypercalcemia. Lytic lesions must be present to diagnose Multiple Myeloma.

Question?

A 32 yr old female has been complaining of bleeding from the gums for a while. She has a history of menorrhea for the last three months. Blood test revealed prolonged bleeding time and PTT and we do factor 8 levels. Normal platelet and normal PT. What is the most likely diagnosis? Von Willebrand disease Hemolytic uremic syndrome Acquired platelet dysfunction Drug-induced thrombocytopenia None of the above

Answer:

Von Willebrand disease diagnosis- prolonged bleeding time, decreased plasma vWf, characterisic abnormalities in platelet aggregation tests; factor 8 deficiency which leads to a prolonged PTT with normal platelet and normal PT.

Its not Hemolytic uremic syndrome b/c that contains a normal PT/PTT

Its not Acquired platelet dysfunction b/c both PT/PTT are prolonged

Its not Drug-induced thrombocytopenia b/c no hx of drugs usuage

Question?

When a patient is on Coumadin, what laboratory values should be closely monitored? PTT Immunoglobulins PT BUN/CR Both a and c

Answer:

C. PT

Coumadin works specifically on the extrinsic pathway and on PT while heparin works on the intrinsic pathway and on PTT

Question?

A 6yr old male complains of petechia and ecchymosis on the lower extremities and back following minimal traumas for two days. The child received an antibiotic a week ago because he had a URI. On the lab test, it revealed platelet autobodies. What is the first line treatment for this diagnosis? IV immunoglobulin G Oral steroids DDAVP Splenectomy Vitamin K supplements

Answer:

IV Immunoglobulin G

This is ITP and it occurs in a child which is most common in the acute self-limited form. The treatment would be IV immunoglobulin G as the first line and second line would be oral steroids. The IV immunoglobulin IgG will suppress the autoantibody production.

Question?

A 42 yr old female presents with altered mental status, hemolytic anemia, a fever of 101, low platelet count and increase BUN and Creatinin. PT and PTT are normal and decreased hemoglobin and hematocrit. What is the diagnosis? TTP HUS ITP DIC TPA

Answer:

TTP

It is TTP b/c it presents with the triad FARTN which can ultimately r/o all the other choices.

Question?

Pt presents with ecchymosis, purpura and bleeding from the GI tract, lab values show decrease platelets, prolonged PT/PTT and bleeding time, and decrease in fibrinogen. What is the test done for this diagnosis? D-Dimer Peripheral blood smear BUN/CR Immunoglobulin None of the above

Answer:

D-Dimer

The diagnosis is DIC. With DIC there would be a decrease in platelets, prolonged PT/PTT and bleeding time, a decrease in fibrinogen, an increase in D-Dimer which can conclude the diagnosis.

Question?

Which of the following would be affected by a deficiency in clotting factor 13 specifically? Convert prothrombin to thrombin Convert fibrin to fibrinogen Make cross-linked fibrin clots Activate factor 5 All of the above

Answer:

Make cross-linked fibrin clots

Factor 13 is associated with making clots. All the other choices are associated with deficiency in factor 10.

Matching!

Hemophilia A

Hemophilia B

Hemophilia C

Factor VIII Deficiency

Factor IX Deficiency

Factor XI Deficiency

Question?

A 31 y/o asian male is brought to ER after falling of the stairs, who is A&Ox2, lethargic and states “I feel dizzy.” Pt’s left knee has a large ecchymosis over the anterior lateral aspect of the joint. A head CT is done and that shows a small intracerebral bleed in the left parietal area. Which of the following disorders is it most likely that his pt may have? ITP TTP Hemophilia A DIC Sickle Cell trait

Answer:

Hemophilia A

It is common in Asians and this is a bleeding disorder that can occur spontaneously or following an injury. Its also most common found in men because it is Y-linked.

Question?

The most common histological subtype of lung cancer in smokers is?

Answer: Squamous cell lung carcinoma

Question?

The most common histological subtype of lung cancer overall is?

Answer: Adenocarcinoma (40%)

True or False?

Squamous cell carcinoma is strongly associated with cigarette smoking and has the worst prognosis among lung cancer?

Answer:

False!!!

Small cell carcinoma HAS the WORST prognosis

Question?

What type of lung cancer is associated withSIADH?

Answer: Small Cell Carcinoma

Question?

A major compressive complication of lung cancer, characterized by dyspnea, JVD, engorged neck and thoracic veins, and facial edema is:

Answer: Superior Vena Cava Syndrome

Question?

What is the MOST COMMON clinical manifestation of the previous syndrome?

Answer: DYSPNEA

True or False?

Clinicians use TNM system to assess the staging of lung cancers (SCLC and NSCLC)

Answer:

False!!!

SCLC’s staging is classified as Limited and Extended diseases

Question?

Which type of thyroid malignancy has a bimodal distribution and characterized as having psammoma bodies and orphan annie cells?

Answer:

Papillary

The most common type of thyroid cancer. It arises from thyroxine and thyrogobulin producing follicular cells. It also has the best prognosis

Question?

What are hot vs. cold nodules in diagnosing thyroid cancer and what is the one exception?

Answer: Hot nodules indicated that the cells are taking up

the nodules and functioning normally Cold Nodules mean the cells are not taking up radio

active iodine. This is indicative for a higher risk of malignancy.

What is the Exception?

Follicular malignancy is the exception. Iodine uptake and concentration is present

Question?

What will happen to Benign tumors with a TSH suppression test?

Answer:

Benign tumors use TSH to grow. Suppressing TSH will cause benign tumors to shrink

What are the two major hemoglobin subtypes in

the red blood cell?

HbA(adult hemoglobin) contains a pair of alpha chains and a pair of beta chains

HbF (fetal hemoglobin) the predominant hemoglobin within the fetus from the 3rd through 9th month of gestation, has a higher affinity for O2 than HbA. HbF is replaced by HbA within 6 months of birth. That’s why diseases like B-Thalassemia major (HbF-HbA) and sickle cell disease (HbF-HbS)are evident after an infant is over 6 months old

What is the storage form of iron in the body called?

Ferritin is the storage form of Fe within the body and it is measurable as an index of iron stores

What are the values for diagnosing anemia in males and females?

Male – Hg<13.5 g/dL, Hct <41%

Female – Hg<12g/dL, Hct <36 %

Question?

What is the preferred initial diagnostic test for Fe-deficiency anemia? What is the tx. of choice?

Answer:

Diagnostic test – serum ferritin (<30-35micrograms/L) (it will be lowered first in this anemia)

Ferrous sulfate, oral vs. parenteral Fe

Question?

Which anemia is common in Asians and African Americans? Which is common in Mediterranean (Italy and Greece) and African American Populations?

Answer:

Asians and African Americans – alpha thalassemia

Mediterranean and African American populations – beta thalassemia

What are some presentations of B-thalassemia major?

Facial abnormalities/bone distortion; tower skull, frontal bossing, maxillary hypertrophy (due to bone marrow expansion) – “chipmunk face”

Jaundice – due to hemolysis of RBCs

Iron overload due to numerous blood transfusions and the body’s inability to remove excessive Fe. Fe is consequently deposited in the myocardium, liver, endocrine organs ( pituitary, thyroid, adrenals and pancreas) leading to organ damage and resulting in death

Growth failure

Coagulation abnormalities

Question?

In sickle cell anemia, aplastic crisis (suppression of erythropoiesis by marrow due to infection) is most commonly caused by?

Answer:

Parvovirus B19 or folic acid deficiency

Question?

What is the most common cause of aplastic anemia?

Answer:

Idiopathic – autoimmune T cell-mediated

Question?

Decreased production of intrinsic factor is associated with what type of anemia?

Answer:

Pernicious anemia: autoimmune metaplastic atrophic gastritis – hypochlorhydria and decreased

production of intrinsic factor

Question?

What type of anemia is caused by an inadequate dietary intake of green, leafy vegetables or alcoholism?

Answer:

Folate Deficiency Anemia

Question?

Hypotension, increased jugular venous distention, muffled heart sounds are part of what triad?

Answer:

Beck’s Triad

Commonly seen in what oncologic emergency?

Pericardial Tamponade

Question?

What is the initial symptom of spinal cord compression?

Answer:

Pain that is not relieved with rest and increased at night

Which oncologic emergency has a “winking

owl” sign on X-ray?

Spinal Cord Compression

Question?

Hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, increased LDH (because RBC are being destroyed) are indicative of what syndrome?

Answer:

Tumor Lysis Syndrome