Oncology Usmle Step 2 Lange Outline

Front 1

Wasting of Host (Tumor Cachexia)
Most common paraneoplastic syndrome. Possibly multifactorial. Tumor necrosis factor (cachexin)

Back 1

Treatment Steps
Treat the malignancy; hyperalimentation if surgery planned or if
hope of signicant remission or cure with therapy.

Front 2

Symptoms
Often subtle. Mild weakness, hypokalemia, psychosis, abnormal glucose tolerance curve.

Back 2

Ectopic Adrenocorticotropic Hormone (ACTH)
Description
Cushing’s syndrome: about 50% from the lung. Adrenal tumors pro-
duce cortisol, but not ACTH. Increased production by cancer cells
of pro-opiocortin (prohormone molecule of ACTH)

Hint 2

Diagnosis
Extremely high plasma ACTH that does not suppress with dexa-
methasone.
Treatment Steps
1. Treat the malignancy.
2. If unable to treat CA, then try aminoglutethimide or metyrapone.

Front 3

Symptoms
Polyuria, constipation, lethargy, personality change.

Back 3

2–2. Hypercalcemia
Description
Seen in solid tumors (lung, breast, kidney, ovary), and hematologi-
cal disease (multiple myeloma and adult T-cell lymphoma). Mecha-
nisms include release of osteoclast-activating factor, increased renal
calcium absorption.

Hint 3

Treatment Steps
Acutely: Saline, loop diuretics (furosemide), IV bisphonates, gluco-
corticoids, calcitonin.
Chronically: Treat malignancy, mobilize patient, bisphosphonates,
avoid dehydration

Front 4

Chorionic Gonadotropin
PARANEOPLASTIC SYNDROMES

Back 4

Cleared rapidly from serum; little clinical effect; rarely see gyneco-
mastia.

Front 5

Hypoglycemia
PARANEOPLASTIC SYNDROMES

Back 5

Most commonly in mesotheliomas, hepatic carcinomas, adrenal cortical carcinomas. Due to factors with insulin-like activity

Front 6

Growth Hormone and Growth
Hormone-Releasing Hormone (GHRH)
PARANEOPLASTIC SYNDROMES

Back 6

Acromegaly in bronchial carcinoid or pancreatic islet cell tumor.

Front 7

Calcitonin
PARANEOPLASTIC SYNDROMES

Back 7

Little or no biologic effect in normal adults, so no symptoms. Good
hormonal marker for medullary carcinoma of thyroid

Front 8

Vasopressin
PARANEOPLASTIC SYNDROMES

Back 8

Causes syndrome of inappropriate antidiuretic hormone (SIADH).
Seen in carcinoma of the lung

Front 9

Erythropoietin
PARANEOPLASTIC SYNDROMES

Back 9

enign and malignant renal conditions (hypernephroma, renal
cysts, hydronephrosis). Nonrenal conditions include hemangioblas-
tomas, uterine fibromas, adrenal cortical neoplasms, ovarian neoplasms, hepatomas, pheochromocytomas.

Front 10

Neurologic
PARANEOPLASTIC SYNDROMES

Back 10

ubacute cerebellar degeneration, subacute motor neuropathy, sen-
sory neuropathy, Eaton–Lambert syndrome, dermatomyositis.

Front 11

Symptoms: Back pain in at-risk patient, bowel or bladder incontinence, loss of sphincter tone.
ONCOLOGIC EMERGENCIES

Back 11

Spinal Cord Compressio

Hint 11

Treatment: Steroids, radiation, surgical decompression

Front 12

Symptoms: Mental status changes, polyuria, constipation.
ONCOLOGIC EMERGENCIES

Back 12

Hypercalcemia

Hint 12

Treatment: IV hydration (normal saline), loop diuretics (furosemide), IV bisphosphonates.

Front 13

Symptoms: Elevated uric acid, potassium, and phosphate cause hypocalcemia and renal failure
in rapidly growing tumors.

Back 13

Tumor Lysis Syndrome

Hint 13

Treatment: Allopurinol, hydration with alkalinizatin of the urine, close monitoring of electrolytes, dialysis.

Front 14

Symptoms: Change in mental status, papillary edema.

Back 14

Cerebral Herniation

Hint 14

Treatment: Steroids, radiation, decompression.

Front 15

Hematologic
PARANEOPLASTIC SYNDROMES

Back 15

Hematologic
4–1. Erythrocytosis
From erythropoietin secretion, renal or liver tumors (see Endocrine
section).
4–2. Leukemoid Reactions
From colony-stimulating factor (CSF) secretion. Also see granulocy-
tosis (lung, gastric, pancreatic, brain, melanomas, lymphomas) or
eosinophilia (lymphomas, Hodgkin’s, gastrointestinal [GI] carcino-
mas).
4–3. Anemia
See differential diagnosis in margin.
4–4. Microangiopathic Hemolytic Anemia
In stomach, breast, lung cancers.
4–5. Granulocytopenia
Usually from chemotherapy, radiation therapy, infection, marrow in-
volvement.
4–6. Idiopathic Thrombocytopenic Purpura (ITP)
In lymphomas.

Front 16

Description
Hypercoagulable state.
Paraneoplastic Syndromes

Back 16

Thromboembolic Paraneoplastic Syndromes

Front 17

Hypercoagulable state
w/ Usually GI neoplasm, but also lung, breast, ovarian, prostate.

Back 17

Migratory thrombophlebitis (Trousseau’s syndrome).

Hint 17

Treatment Steps
Difcult; may require long-term heparin or enoxaparin if warfarin
doesn’t work.

Front 18

Hypercoagulable state
May be common and subclinical.

Back 18

Disseminated intravascular coagulation (DIC).

Hint 18

Treatment Steps
Treat the tumor. May use heparin

Front 19

Hypercoagulable state
Usually mucin-secreting adenocarcinomas. May embolize.

Back 19

Nonbacterial thrombotic endocarditis (marantic endocarditis)

Hint 19

Treatment Steps
Treat the tumor.

Front 20

Renal
Paraneoplastic Syndromes

Back 20

a. SIADH.
b. Nephrotic syndrome. Hodgkin’s (lipoid nephrosis, minimal
change glomerulopathy). Non-Hodgkin’s lymphoma (im-
mune complex).
c. Myeloma and amyloid kidney.
d. Hypokalemia. Myelogenous leukemia (lysozyme related).

Front 21

Dermatologic
Paraneoplastic Syndromes

Back 21

Acanthosis nigricans (hyperkeratosis and pigmentation of axillae,
neck, and groin), dermatomyositis, flushing in carcinoid. Leser–Tre-
lat (sudden onset of seborrheic keratoses), porphyria cutanea tarda
(photosensitive skin lesions), pruritus.

Front 22

Gastrointestinal
Paraneoplastic Syndromes

Back 22

Protein-losing enteropathy, malignant hepatopathy

Front 23

Paraneoplastic Syndromes
Miscellaneous

Back 23

Miscellaneous
Fever (lymphomas, hypernephromas). Lactic acidosis (acute
leukemias, lymphomas). Hypokalemia and hypertension (lung, hyper-
nephroma, Wilms’). Hypertrophic pulmonary osteoarthropathy (lung,
mesothelioma, other metastases to lung). Amyloidosis (myeloma, lym-
phoma, carcinomas). Systemic lupus (lymphomas, leukemias, thymo-
mas, testicular, lung, ovarian).

Front 24

ANEMIA IN THE ONCOLOGY
PATIENT
differential diagnosis

Back 24

Anemia of Chronic Disease
• Normo- or microcytic
• Elevated ferritin, low total
iron-binding capacity
(TIBC)
Chemotherapy Related
• Cisplatin
• Hydroxyurea
• Cytarabine (Ara-C)
Hemolytic Anemia
• Immune mediated in
chronic leukemias and
low-grade lymphomas
• Microangiopathic
secondary to mitomycin
Renal Insufficiency
• Obstruction by tumor
• Chemotherapy toxicity
(i.e., cisplatinum)
• Tumor lysis
(hyperproliferative state)
Iron Deficiency
• Chronic GI or
genitourinary (GU) bleed

Front 25

CHANGE IN MENTAL STATUS
IN AN ONCOLOGY PATIENT
differential diagnosis

Back 25

1. Metabolic—
hypercalcemia,
hypoglycemia,
hyperkalemia
2. Neurologic—cerebral
metastases with edema,
cerebral thrombosis,
cerebral hemorrhage
3. Pulmonary—hypoxia
4. Drug-related—opioids
5. Infection
6. Dehydration

Front 26

Hormones—β subunit of human chorionic gonadotropin
(β-hCG)
TUMOR MARKERS

Back 26

testicular cancer, choriocarcinomas, hydatidiform mole.
The level assesses response to therapy. Others: Human placental lacto-
gen, ACTH, vasopressin, calcitonin, gastrin-releasing peptide.

Front 27

Oncofetal Proteins—α-Fetoprotein (AFP)
TUMOR MARKERS

Back 27

hepatoma and testicu-
lar CA. The level has predictive value in follow-up

Front 28

Carcinoembryonic Antigen (CEA)
TUMOR MARKERS

Back 28

GI tract, breast, lung, ovar-
ian tumors. Increased by smoking and inflammatory processes, so
should not be used for screening. Used to assess response and recur-
rence (colon)

Front 29

Immunoglobulins
TUMOR MARKERS

Back 29

myeloma and some other lymphoproliferative
disorders; good for following response to treatment. Heavy chains
and light chains in myeloma and Waldenström’s macroglobuline-
mia

Front 30

Prostatic acid phosphatase

Back 30

one-third of occult prostate
and 75% of more advanced prostate cancer

Front 31

Tumor Antigens—CA-125

Back 31

ovarian

Front 32

Tumor Antigens CA 19-9:

Back 32

biliary

Front 33

Tumor Antigens
β2 Microglobulin (a human leukocyte antigen [HLA] class I antigen

Back 33

assessing response in myeloma therapy.

Front 34

Prostate-specific antigen (PSA):

Back 34

prostate

Front 35

Tumor Antigens CA 27-29

Back 35

breast.

Front 36

Symptoms
Painless cervical or other adenopathy. Chest x-ray may show medi-
astinal mass, inltrates, effusions. Fever, sometimes cyclic (Pel–
Ebstein fever). Night sweats. Pruritis. Superior vena cava obstruc-
tion. Spinal cord compression. Hepatic and splenic enlargement. In-
fections (herpes zoster, cryptococcosis, Pneumocystis carinii pneumo-
nia, toxoplasmosis). Immunologic abnormalities common.
B Symptoms
Fever > 38.5; night sweats; 10% weight loss over 6 months. A—
absence of “B” symptoms. B—presence of 1 or more.

Back 36

Hodgkin’s Disease
Description
Lymph node malignancy of centroblast (proliferating germinal center cell); average age 32; male more than female
Pathology
Anemia of chronic disease, but occasionally due to hypersplenism,
marrow invasion, Coombs’-positive hemolytic anemia. Leukocytosis,
eosinophilia. Pathognomonic Reed–Sternberg cell (large, bilobed
cell with prominent eosinophilic nucleoli), is pathognomonic but
not necessary as variants exists.
Hodgkin’s
• Bimodal age distribution
• Contiguous spread
• Very high cure rate
• Linked to EBV
Four basic types—
nodular sclerosing
(60–75%), mixed
cellularity (20–35%),
lymphocyte predominant
(5–10%), lymphocyte
depleted (2–5%)

Hint 36

Diagnosis
Use computed tomography (CT) of chest and abdomen, lymphan-
giography. Bilateral bone marrow biopsy in all patients suspected of
diffuse or bone disease. Gallium scans can be useful. (See Fig. 6–1.)
Biospsy of an involved node, needle aspiration generally not ade-
quate. CT of chest, abdomen, and pelvis. Lymphangiography less
commonly used now. Bilateral bone marrow biopsy in patients sus-
pected of diffuse or bone disease. Positron-emission tomography
(PET) and gallium also helpful. (See Fig. 6–1.)
Staging:
I. Single lymph node or group.
II. More than one node or group; same side of diaphragm.
III. Spleen and nodes; both sides of diaphragm.
IV. Liver or marrow.
Treatment Steps
Biopsy rst. Staging before treatment. Staging laparotomy (with
splenectomy) is not used as frequently but still has a place in staging.
Treat with radiotherapy: 3,600 to 4,000 rads. Radiation alone initially
in stage I. Stages IIA and IIIA either radiation or chemotherapy.
Chemotherapy: in advanced (IIB, IIIB, and IV) disease. Standard is
changing and could be ABVD (adriamycin, bleomycin, vinblastine,
dacarbazine) or less commonly now MOPP (mechlorethamine, vin-
cristine [oncovin], procarbazine, prednisone), four to six cycles. Ra-
diation can be added to involved elds. Produces complete remis-
sion in 70–80%; disease free 10–20 years later in 50% of these.
Greatly improved prognosis due to staging, radiotherapy, and chemotherapy advances.

Front 37

Symptoms
Painless cervical or other adenopathy. Chest x-ray may show medi-
astinal mass, inltrates, effusions. Fever, sometimes cyclic (Pel–
Ebstein fever). Night sweats. Pruritis. Superior vena cava obstruc-
tion. Spinal cord compression. Hepatic and splenic enlargement. In-
fections (herpes zoster, cryptococcosis, Pneumocystis carinii pneumo-
nia, toxoplasmosis). Immunologic abnormalities common.
B Symptoms
Fever > 38.5; night sweats; 10% weight loss over 6 months. A—
absence of “B” symptoms. B—presence of 1 or more.

Back 37

Non-Hodgkin’s Lymphoma
Description
The largest group of immune system neoplasms, characterized by
monoclonal proliferation of B or T lymphocytes. An immune dys-
function may contribute (e.g., acquired immune deciency syndrome [AIDS]). Possible viral etiology in Burkitt’s, adult T-cell leukemia
Pathology
Classifying systems: Rappaport Classication, Lukes and Collins, The
NCI Working Formulation (1982), REAL classication.
Special Problems
Superior vena cava obstruction: chemotherapy or irradiate. Gastric
lymphoma: resect. Central nervous system (CNS) disease: irradiate.
Urate nephropathy: allopurinol to prevent, if severe may require dialysis support.
Non-Hodgkin’s
• Increasing frequency with
age
• Variable spread
• Variable cure rates—most
common types not
curable
• Over 30 different types
• NCI working formulation:
low grade, intermediate
grade, high grade

Hint 37

Diagnosis
Node pathology; B- and T-cell typing studies. Use CT of abdomen,
pelvis, and chest. Immunoglobulins, bone scan, upper GI studies
(UGI), bone marrow biopsies, PET scan, gallium scan
Treatment Steps
Depends on grade and stage. Modalities include multiagent
chemotherapy (CHOP—cytoxan, adriamycin, vincristine, pred-
nisone) or combined chemo/irradiation, and immunotherapy (rit-
uxamab).

Front 38

Symptoms
Pallor, fatigue, bleeding, fever, bone pain, adenopathy, arthralgias,
hepatosplenomegaly.
Pathology
Marrow inltrated or replaced with lymphoblasts.

Back 38

Acute Lymphoblastic Leukemia (ALL)
Description
Malignant proliferation of lymphoid precursors, with replacement
of normal cells; 75% of the 2,500 new acute leukemias.

Hint 38

Diagnosis
Marrow morphology, cytochemical staining, immunologic cell sur-
face markers, cytogenetics.
Treatment Steps
Cure rate 65–70%. Multiple-drug chemotherapy (prednisone, vin-
cristine, doxorubicin, methotrexate, asparaginase) + intrathecal
chemotherapy (methotrexate or cytarabine) or cranial irradiation.
Because of high cure rate, no marrow transplant usually with rst re-
mission unless patient has poor prognostic factors, but is recommended after second remission.

Front 39

Symptoms
Pallor, fatigue, bleeding, fever, bone pain, adenopathy, arthralgias,
hepatosplenomegaly.
Pathology
Marrow inltrated or replaced with myeloblast

Back 39

Acute Myeloblastic Leukemia (AML)
Description
Malignant proliferation of myelocytic precursors, with replacement
of normal cells; 15–20% of acute leukemias.

Hint 39

Diagnosis
Bone marrow biopsy.
Treatment Steps
Intensive chemotherapy with daunorubicin and cytarabine, some-
times combined with other agents. Intrathecal chemo or irradiation
in some cases. Produces 80% complete remission (CR) rate, 65% re-
main in continuous CR.

Front 40

Symptoms
Anemia, hemorrhage, infection, leukemic inltrates (bone pain,
meningitis, mediastinal mass, chloromas), lymphadenopathy,
splenomegaly.

Back 40

Acute Leukemia in Adults
Description
Malignant unregulated proliferation of immature myeloid or lym-
phoid precursors, with replacement of normal cells. Inciting agents
include ionizing radiation, oncogenic viruses, genetic and congenital factors, chemical agents.
Pathology
Bone marrow: morphologic, histochemical techniques, surface
markers (immunologic techniques), cytoplasmic markers (en-
zymes), chromosomal changes. Eighty percent are acute myeloge-
nous leukemia (AML).

Hint 40

Diagnosis
Anemia, thrombocytopenia, and abnormal bone marrow. Immuno-
histochemical stains and ow cytometry. Must distinguish from infections, other cancers, drug effects.
Treatment Steps
1. Correct complications.
2. Allopurinol.
3. Chemotherapy.
Acute Myelogenous (AML)—remission achieved in majority of pa-
tients older than 60 with one course of cytosine arabinoside (ara-
C) and daunomycin or doxorubicin. Bone marrow transplant for
relapse after rst remission or in rst remission if prognostic fac-
tors are unfavorable. Age limits vary from center to center and
with physiologic age. Cure rate 20% in AML.
Acute Promyelocytic Leukemia (APML)—induce remission with all-trans
retinoic acid (ATRA), then consolidate with standard
chemotherapy. Cure rates of 35–45% are clearly better than typi-
cal AML.
Acute Lymphoblastic (Acute Lymphocytic, ALL)—vincristine, prednisone,
and a third drug, such as L-asparaginase, doxorubicin, or
daunorubicin, gives 80% remission in adults. Need CNS prophy-
laxis (cranial irradiation or intrathecal methotrexate), then
maintenance or continuation therapy. For relapse, give systemic
chemo and local irradiation. Bone marrow transplant (30% survival rate in allogeneic transplant).

Front 41

Characterized by normal to increased marrow cellularity and ineffec-
tive erythropoiesis: refractory anemia (RA), refractory anemia with
ringed sideroblasts (RARS), refractory anemia with excess blasts
(RAEB), and RAEB-in transition (RAEB-IT).

Back 41

Myelodysplastic Syndromes

Front 42

Symptoms
Fatigue, anorexia, weight loss, sense of abdominal fullness.
Headaches, fever, sweats, bone pain. Hemorrhages, thromboses, fever.

Back 42

Chronic Myelogenous Leukemia (CML)
Description
Originates in primitive myeloid stem cell. Characteristic Philadelphia (Ph1) chromosome (see Fig. 6–3).
Pathology
Bone marrow aspiration reveals hypercellular marrow, increase in
eosinophils, basophils, megakaryocytes. Diagnosis conrmed by
Philadelphia chromosome.

Hint 42

Diagnosis
Splenomegaly. Leukocytosis with immature cells. Thrombocytosis.
Anemia with marked leukocytosis. Markedly decreased leukocyte al-
kaline phosphatase. Elevated uric acid, lactic dehydrogenase (LDH),
vitamin B12. Myelobrosis. Enters a blastic or accelerated phase
(myeloblastic or lymphoblastic) after 3 years in 80%.
Treatment Steps
1. Treat with imatinib mesylate (Gleevec), a tyrosine kinase in-
hibitor.
2. For relapsing disease, hydroxyurea, and α-interferon are the
main drugs, though cyclophosphamide and busulfan are also ef-
fective.
3. Acute leukostatic or thrombotic complications require leuka-
pheresis, or plateletpheresis. Good hydration and allopurinol.
4. Splenic radiation to reduce spleen size and white count.
5. Treatment of blastic phase very difcult.
6. In younger patients, consider bone marrow transplant in chronic
phase if donor available.

Front 43

Symptoms
Symptoms vary by extent of disease. Asymptomatic lymphocytosis.
Adenopathy, splenomegaly. Malaise, fatigue, weight loss, anorexia, fever, night sweats, bacterial infections; herpes zoster is common.
Diagnosis
Lymphocytosis, with > 50% of small lymphs with round nuclei in the
marrow. Peripheral blood ow cytometry for monoclonality of lymphocytes (CD5+) (see Fig. 6–4).

Back 43

Chronic Lymphocytic Leukemia (CLL)
Description
Twenty-ve percent of all leukemias. Monoclonal proliferation of
long-lived, usually B lymphocytes. Unknown etiology. May be asymp-
tomatic. High incidence of second malignancies.
Pathology
Lymphocytosis can be massive. Anemia, thrombocytopenia, neu-
tropenia. Coombs’-positive autoimmune hemolytic anemia is common.

Hint 43

Diagnosis
Lymphocytosis, with > 50% of small lymphs with round nuclei in the
marrow. Peripheral blood ow cytometry for monoclonality of lymphocytes (CD5+) (see Fig. 6–4).
Stage 0—lymphocytosis only
Stage 1—lymphocytosis with lymphadenopathy
Stage 2—lymphocytosis with splenomegaly
Stage 3—lymphocytosis with anemia
Stage 4—lymphocytosis with throbocytopenia
Treatment Steps
1. Should avoid vaccination with live vaccines.
2. Treat only if progressive and symptomatic. Chlorambucil or u-
darabine.
3. Corticosteroids for acute symptoms, hemolytic anemia, thrombo-
cytopenia.
4. Local radiotherapy to splenomegaly or massive adenopathy.

Front 44

Symptoms
Of marrow suppression and hypersplenism.
Pathology
Medium to large lymphocyte with hairy projections. Surface monoclonal immunoglobulin.
Diagnosis
Progressive splenic enlargement. Pancytopenia. Hairy cells in blood
and marrow are CD10+ and TRAP+ (tartrate-resistant acid phos-
phatase). May need marrow biopsy (see Fig. 6–5).

Back 44

Hairy Cell Leukemia (Leukemic
Reticuloendotheliosis)
Description
A chronic B-cell leukemia; 2% of all leukemias
Pathology
Medium to large lymphocyte with hairy projections. Surface mono-
clonal immunoglobulin.

Hint 44

Treatment Steps
1. May observe, as it is slowly progressive.
2. Cladribine drug of choice; 75% effective.
3. Also used after relapse are α-interferon, pentostatin, and splenec-
tomy.

Front 45

Symptoms
Skin eruption with appearance of eczema or psoriasis.
Pathology
Prolonged course, beginning with nonspecific lesions (premycotic
stage) that slowly evolve into cutaneous plaques and patches (my-
cotic stage), and then into ulcerative nodules and tumors (tumor
stage). May involve lymph nodes and internal organs later

Back 45

Mycosis Fungoides
Description
A cutaneous T-cell lymphoma. The Sézary syndrome is the leukemic
form of mycosis fungoides.

Hint 45

Diagnosis
Multiple biopsies necessary.
Treatment Steps
Local therapy:
1. Topical chemotherapy.
2. PUVA (psoralen plus irradiation).
3. Radiotherapy.
Systemic therapy:
1. Interferon.
2. Retinoids.
3. Cytotoxics—methotrexate, adriamycin, cladribine.

Front 46

Symptoms
Headache (morning), mental changes, generalized convulsions, pa-
pilledema (25%), vomiting, vasomotor/autonomic, hormonal
changes.

Back 46

Primary Neoplasms of the Brain
Description
Most common CA in children. “Benign” brain tumors can be lethal.
Cerebral edema is a major cause of morbidity
Pathology
Types:
1. Neuroectodermal are the most common. These include astro-
cytoma (more benign), glioblastoma multiforme (more malig-
nant).
2. Mesodermal meningioma (“benign,” though grow very large
and can cause death).
3. Pituitary adenoma and craniopharyngioma.
4. Pineal (produce endocrinopathies).
5. Metastatic.
6. Vascular arteriovenous malformations (AVMs), hemangioblas-
tomas.

Hint 46

Diagnosis
Magnetic resonance imaging (MRI) of head. Must distinguish from
benign intracranial hypertension (nonfocal), stroke (acute event),
subdural hematoma, Alzheimer’s.
Treatment Steps
1. Surgery for cure in meningioma, benign cerebellar tumors, or
acoustic schwannomas.
2. Radiation for malignant tumors or symptomatic unresectable “be-
nign” tumors.
3. Medical therapy: steroids relieve edema; anticonvulsants; chemo-
therapy, local and systemic.

Front 47

Symptoms
Neurologic symptoms, seizures, headaches, motor weakness.

Back 47

Metastases to the Brain
Description
Most CNS tumors are metastatic. Brain metastases are from lung
and breast; melanoma has high propensity to spread to brain.

Hint 47

Diagnosis
Use MRI with gadolinium or CT with contrast. Distinguish from seizure, meningeal carcinomatosis, paraneoplastic syndrome
Treatment Steps
Depends on the primary tumor and the extent of disease. Options
include
1. For solitary lesions, surgery and steroids.
2. For multiple metastases, irradiation chemotherapy (for small-cell lung and testicular CA).

Front 48

Symptoms
Headaches, altered mentation, cranial nerve defects, lumbosacral
radiculopathies, seizures.

Back 48

Leptomeningeal Metastases
Description
About 8% of CA patients develop meningeal spread

Hint 48

Diagnosis
Lumbar puncture (LP) (5–100 cells, increased protein, decreased
glucose). Positive cytology (repeat LPs may be needed) to confirm
diagnosis. MRI and CT are usually normal, but gadolinium contrast can be suggestive
reatment Steps
1. Cranial irradiation.
2. Intrathecal chemotherapy. Usually combined.

Front 49

Symptoms
Hearing loss, tinnitus, less often vertigo

Back 49

Acoustic Neuroma
Description
Schwannoma of eighth nerve.

Hint 49

Diagnosis
Brain stem auditory-evoked responses (BAERs); MRI or CT with contrast.
Treatment Steps
Microsurgery or radiosurgery yields 85–95% control rate

Front 50

The most common intraocular tumor of children

Back 50

Retinoblastoma
An autosomal dominant hereditary tumor of the retina

Front 51

Symptoms
Hemorrhagic nodules with violaceous, dark brown lesions. Before AIDS epidemic, primarily on lower extremities. With AIDS, see mucocutaneous and lymph node involvement.

Back 51

Circulatory System (Kaposi’s Sarcoma)
Description
Seen after immunosuppressive therapy and HIV infection (50% of homosexual men with AIDS). Originally described in elderly male of Mediterranean origin. Cause now felt felt to be human herpesvirus-8.

Hint 51

Diagnosis
Clinical picture; biopsy (see Fig. 6–6).
Treatment Steps
Local: Topical chemotherapy, intralesional injections, local radiation.
Widespread: α-Interferon, cytotoxics (e.g., vinblastine, vincristine, Adriamycin).

Front 52

Symptoms
Pharyngitis, lymphoid hypertrophy, voice change, conductive hear-
ing loss, dysphagia, odynophagia, halitosis, weight loss.

Back 52

Carcinoma of the Nasopharynx
Pathology
Most common is squamous cell. Also lymphoma, lymphoepithe-
liomas (Schmincke’s tumor), anaplastic carcinoma.

Hint 52

Diagnosis
Endoscopy, biopsy
Treatment Steps
1. Surgery.
2. Radiation.
3. Chemotherapy as radiation sensitizer or for recurrent disease.

Front 53

Symptoms
Hoarseness, pain, dysphagia, odynophagia, cough, hemoptysis, hali-
tosis.

Back 53

Tumors of the Larynx (Malignant)
Pathology
Squamous cell carcinoma, neuroendocrine, salivary gland.

Hint 53

Diagnosis
Direct laryngoscopy, pharyngoscopy, biopsy.
Treatment Steps
1. Radiation.
2. Laryngectomy.

Front 54

Symptoms/Diagnosis
Hoarseness, later dyspnea, dysphagia, pain. Diagnosed via en-
doscopy.

Back 54

Tumors of the Larynx (Benign)
Pathology
Papilloma (caused by papillomavirus), hemangioma, angiobroma.

Hint 54

Treatment Steps
Carbon dioxide laser (for papillomas)

Front 55

Symptoms
Cough, hemoptysis, weight loss, weakness, wheezing, fever, chest
pain.

Back 55

Carcinoma of the Lung
Description
Produces 180,000 new cases per year in United States; 150,000
deaths. Eighty to ninety percent associated with smoking and passive smoke inhalation. Occupational risks include uranium, halo-ethers,
arsenical fumes, asbestos. Asbestos and radon (heavily insulated
homes) may be cocarcinogens with cigarette smoke.
Pathology
Four types make up 95% (see Cram Facts).
LUNG CANCER
1. Adenocarcinoma:
• 40% and increasing
• Peripheral location
• Less frequent
association with
tobacco
• More likely spread to
brain and liver at
presentation (40–45%)
2. Squamous cell:
• 30%
• Central location
• Usually associated
with smoking
3. Small cell:
• 20%
• Neuroendocrine origin
• Systemic disease,
requires chemotherapy
4. Large cell:
• 10% and decreasing
• More often peripheral,
probably poorly
differentiated
adenocarcinoma
5. Screening chest x-rays
in smokers are of no
value in decreasing
mortality

Hint 55

Diagnosis
Chest x-ray (mass in lung). Need tissue via sputum cytology, bron-
choscopic biopsy or brushings, transbronchial biopsy or needle aspi-
ration, CT-guided transthoracic biopsy, thoracotomy.
Treatment Steps
Depends on stage and histology.
Non–small cell: TNM stages I and II: surgery.
Stage III: Surgery and irradiation. Surgery results: 10–35% 5-year
survival (squamous 37%, adeno 27%). Since very radiosensitive, give
radiation therapy (XRT) in I, II, and III who do not have surgery.
Unresectable (disseminated) non–small cell can be treated with con-
comitant XRT and chemotherapy; XRT also to palliate SVC syn-
drome, hemoptysis, cough, pain.
Chemotherapy: 30–40% response rate.
Small cell: Low survival, despite high initial response rate. Treat
with chemotherapy (very sensitive) and irradiation. Not a surgical
disease. Useful programs include a platinum plus a second agent
(paclitaxel, etoposide).

Front 56

Symptoms
Can be asymptomatic, dyspnea, chest pain, cough, cor pulmonale.
Can occur via lymphatic or hematogenous spread.

Back 56

Metastases to the Lung

Hint 56

Diagnosis
Sputum cytology, bronchoscopy, thoracotomy
Treatment Steps
1. Treat the primary.
2. Consider resection if solitary metastasis from colon, melanoma or
sarcoma.

Front 57

Symptoms
Cough, chest pain, dyspnea occur late.

Back 57

Mesothelioma
Description
Main primary pleural tumor. Benign or malignant. Malignant re-
lated to asbestos in 80–90%
Pathology
Benign associated with hypertrophic pulmonary osteoarthropathy
and clubbing (responds to surgical removal)

Hint 57

Diagnosis
Malignant cells in pleural fluid or pleural biopsy
Treatment Steps
No standard treatment. Prognosis very poor
Pemetrexed (Almta) is a
new agent approved for
mesothelioma and
advanced non–small cell
lung cance

Front 58

Symptoms/Diagnosis
Slow-growing mass leading to ulceration, invasion of nerves, numb-
ness or facial paralysis. Diagnose via biopsy

Back 58

Salivary Gland Neoplasms
Most common is pleomorphic adenoma (benign). Malignancies in-
clude mucoepidermoid carcinoma, adenoid cystic carcinoma, adenocarcinoma.

Hint 58

Treatment Steps
Surgery and/or radiation

Front 59

Symptoms
Painful indurated ulceration.

Back 59

Carcinoma of the Mouth
Description
Smoking and alcohol are risk factors. Tongue most common.
Pathology
Mostly squamous, with 20% chance of a second head and neck cancer.

Hint 59

Diagnosis
Biopsy
Treatment Steps
1. Radiation and surgery in combination can be curative.
2. Chemotherapy in more advanced cases (methotrexate,
bleomycin, cisplatin).
3. Rehabilitation and prostheses important; 50% survival rate

Front 60

Symptoms
Progressive dysphagia; steady, boring pain; halitosis; weight loss;
cough after drinking uid

Back 60

Carcinoma of the Esophagus
Description
Barrett’s esophagus, smoking, and alcohol are risk factors. Survival
has been increased to 40% by combined modality therapy
Pathology
Squamous (more common; associated with head and neck cancer,
lye strictures, inadequately treated achalasia). Adenocarcinoma
arises in columnar epithelium (Barrett’s esophagus––see Cram Facts)

Hint 60

Diagnosis
Esophagogram, endoscopy with biopsy and brushings, CT of chest, chest x-ray. (See Figure 6–7.
Treatment Steps
1. Surgery: much morbidity.
2. Combined radiation and a platinum and 5-FU regimen.

Front 61

Symptoms
Early are asymptomatic. Anorexia, weight loss, early satiety, bloating,
dysphagia, epigastric pain, vomiting.

Back 61

Carcinoma of the Stomach
Description
Majority are malignant; 5% are lymphomas.
Gastric cancer associated
with:
• Virchow’s node:
Enlarged supraclavicular
node
• Blumer’s shelf:
Metastatic tumor felt via
rectal exam
• Sister Mary Joseph’s
node: Enlarged
periumbilical node
• Acanthosis nigricans
Pathology
Usually adenocarcinoma. Spread to esophagus, liver, pancreas, trans-
verse colon, lung, brain, bone.

Hint 61

Diagnosis
Epigastric mass. Recurrent thrombophlebitis (Trousseau’s syn-
drome). Air-contrast UGI x-rays. Endoscopy with biopsy and brush cytology. Culture for H. pylori.
Treatment Steps
1. Surgery for cure or palliation.
2. Chemotherapy for unresectable disease.
3. Radiotherapy.
4. Antibiotics for H. pylori if culture positive in MALT

Front 62

Symptoms
Epigastric pain, weight loss, vomiting, hematemesis, melena, jaun-
dice, palpable mass, palpable gallbladder (Courvoisier’s sign),
thrombophlebitis, psychiatric disturbances, diabetes, anemia, blood
in stool.

Back 62

Carcinoma of the Pancreas
Description
Slowly progressive, highly malignant. Second most common GI tu-
mor after colon. Risk factors include smoking; high-fat, high-meat
diet; exposure to manufacturing of paper, oil rening, gasoline.
Usually not curable but can control symptoms
Pathology
Usually adenocarcinoma. Occasionally endocrine tumors (apudo-
mas and carcinoids).

Hint 62

Diagnosis
Ultrasound and/or CT, followed by needle aspiration. If negative,
endoscopic retrograde cholangiopancreatography (ERCP) (very
sensitive and tissue for cytology helpful). The UGI is poor in early detection. Occasional amylase elevation. Elevated CA 19-9.
Treatment Steps
1. Whipple’s resection (pancreaticoduodenectomy) for small focal
mass lesions. High operative mortality; 5% 5-year survival.
2. Chemotherapy with gemcitabine improves quality of life.
3. Radiation with 5-FU may improve survival by weeks.

Front 63

Symptoms
Obstructive jaundice, acute cholecystitis, palpable mass, right upper
quadrant pain, or disseminated carcinoma

Back 63

Carcinoma of the Biliary System
Description
Associated with tobacco use and cholelithiasis.
Pathology
Adenocarcinoma.

Hint 63

Diagnosis
Ultrasound. Must distinguish from cholesterol polyp or stone. Ele-
vated CA 19-9.
Treatment Steps
Surgery; 5% 5-year survival, even with optimal surgery.

Front 64

Symptoms
Abdominal pain, mass, weight loss, deterioration of patient with cir-
rhosis.

Back 64

Carcinoma of the Liver/Hepatocellular
Cancer
Description
Uncommon, but increasing in United States. Median survival 6 months
RISK FACTORS FOR
HEPATOCELLULAR CANCER
• Cirrhosis
• Hepatitis B and/or C
• Aatoxins (toxic
metabolites from
Aspergillus avus
[peanuts and grains])
• Very common in Asia

Hint 64

Diagnosis
Ultrasound, CT, or MRI. Elevated alkaline phosphatase, transami-
nase, CEA, and AFP. Needle biopsy, wedge biopsy at laparotomy.
Treatment Steps
1. Hepatic resection effective if early.
2. Chemotherapy with doxorubicin (Adriamycin), 5-FU, cisplatin
regimens yield 50% response rate, but minimal survival advan-
tage.
3. Chemoembolization.
4. Cryosurgery or radioablation (RITA).

Front 65

Symptoms
Silent; bleeding, obstruction, change in bowel habits, pain, symp-
toms of localized perforation. Right-side lesions rarely obstruct. Left-
side polypoid lesions cause diarrhea and signs of obstruction.

Back 65

Carcinoma of the Colon
See also Chapter 4, section V.
Pathology
About 60% occur from splenic flexure down, and almost all are adenocarcinomas
RISK FACTORS FOR
COLORECTAL CANCER
• Increased fat
• Animal protein
• Decreased fiber
• Increasing age
• Inflammatory bowel
disease
• Family history of female
genital or breast cancer
• History of colonic cancer
or adenoma (especially
villous adenomas)
• History of familial colon
cancer syndromes
(familial polyposis,
Gardner syndrome,
Peutz–Jeghers
syndrome, generalized
juvenile polyposis)
Screening
See American Cancer Society Recommendations for the Early Detection of
Cancer in Asymptomatic People. High-risk patients require annual sig-
moidoscopy beginning at puberty.

Hint 65

Diagnosis
In suspected case, digital rectal exam followed by colonoscopy.
Brushings and/or biopsy. Must distinguish from angiodysplasia, diverticulosis, benign tumors.
Treatment Steps
1. Surgery with curative intent.
2. Chemotherapy for metastatic disease (especially liver) with
irinotecan (Camptosar) and 5-FU. Evidence for effectiveness of
adjuvant chemo in Duke’s C colon carcinoma with 5-FU plus lev-
amisole or leucovorin. Follow with colonoscopy, CEA if elevated
preoperatively. Two new medications approved for metastatic col-
orectal cancer are cetuximab (Erbitux) and bevacizumab
(Avastin). Both are monoclonal antibodies.
3. Radiation for recurrent disease.

Front 66

Carcinoma of the Rectum

Back 66

If below the peritoneal reflection, it commonly recurs, and postop
radiation + 5-FU is recommended. Anal: chemotherapy + radiation
is better than surgery as primary treatment

Front 67

Symptoms
Cutaneous flushing (precipitated by alcohol, food, stress), facial
telangiectasias, tachycardia and decreased blood pressure, headache
after the flush, diarrhea, symptoms of peritoneal fibrosis, right-sided
endocardial fibrosis (with congestive heart failure). Bronchocon-
striction and wheezing less common

Back 67

Carcinoid Tumors
Description
Tumors that arise from enterochromafn cells (Kulchitsky) and pro-
duce biologically active amines and peptides (serotonin, bradykinin,
histamine, prostaglandins). Survival variable but if metastatic, < 5
years
Pathology
Often arise in ileum and metastasize to the liver. Excrete serotonin
and 5-HIAA. Carcinoids can arise in almost all organs, including ap-
pendix, rectum, stomach, and lung

Hint 67

Diagnosis
Clinical suspicion; markedly increased urinary 5-hydroxyindoleacetic
acid (5-HIAA) hepatomegaly. Of less help are CT, ultrasound, scans.
Treatment Steps
1. Surgery if resectable or symptomatic.
2. If not resectable, no treatment for mild symptoms. Symptomatic
treatment (antidiarrheal agents, bronchodilators, nutritional sup-
port).
3. Chemotherapy not very effective.

Front 68

Symptoms/Diagnosis
Asymptomatic, bleeding, pain, diarrhea. Seen on colonnoscopy;
biopsy needed to assess benign vs. malignant.

Back 68

Colon Polyps
Description
Importance: bleeding or malignant potential.
Pathology
Four main types:
1. Hyperplastic—(majority of rectal polyps; not considered neo-
plastic).
2. Tubular adenomas.
3. Villous adenomas—(neoplastic; villous have high malignant
transformation rate than tubular).
4. Mixed type—cancer rate much higher in larger polyps

Hint 68

Treatment Steps
1. Removal.
2. Follow with colonoscopy.

Front 69

Polyposis Syndromes
Autosomal dominant; will nearly all develop
carcinoma

Back 69

Familial polyposis

Hint 69

Treatment Steps
Subtotal colectomy. Also genetic counseling and intensive screening
of family members.

Front 70

Polyposis Syndromes
Dominantly transmitted; associated with
bone tumors (osteomas), and soft tissue tumors (lipomas, sebaceous cysts, fibromas, fibrosarcomas); high malignant potential.

Back 70

Gardner syndrome

Hint 70

Treatment Steps
Subtotal colectomy. Also genetic counseling and intensive screening
of family members.

Front 71

Polyposis Syndromes
Colon adenomas plus central nervous system
tumors; high malignant potential.

Back 71

Munro syndrome

Hint 71

Treatment Steps
Subtotal colectomy. Also genetic counseling and intensive screening
of family members.

Front 72

Polyposis Syndromes
Autosomal dominant; polyps plus mucocutaneous hyperpigmentation; low malignant potential.

Back 72

Peutz–Jeghers syndrome:

Hint 72

Treatment Steps
Subtotal colectomy. Also genetic counseling and intensive screening
of family members.

Front 73

Polyposis Syndromes
Autosomal dominant; hamar-
tomas; possible increased carcinoma incidence.

Back 73

Generalized juvenile polyposis

Hint 73

Treatment Steps
Subtotal colectomy. Also genetic counseling and intensive screening
of family members.

Front 74

Symptoms
Variable headaches, visual disturbances (blindness, optic atrophy),
temperature instability, hyperphagia, emotional disturbance, dis-
turbed sleep patterns, hypopituitarism, hypogonadism.

Back 74

Pituitary Adenoma
Description
Adenomas form 90% of all pituitary tumors; most are functioning;
benign, but may have aggressive local growth pattern.

Hint 74

Diagnosis
Enlarged sella by x-ray, mass on CT or MRI, visual elds, visual
evoked response.
Treatment Steps
1. Transsphenoidal pituitary surgery.
2. Optionally, can irradiate.
3. Will require endocrine replacement (see Chapter 3)

Front 75

Symptoms/Diagnosis
Asymptomatic. Large functioning adenomas produce hyperthyroidism. Diagnose via needle aspiration.

Back 75

Benign Nodules
• About 96% of thyroid
nodules are benign.
• A “functioning” or “hot”
nodule is also almost
always benign.

Hint 75

Treatment Steps
Follow warm (nonclinically thyrotoxic) nodules with annual thyroid
function tests. Hot (clinically toxic) nodules are treated with surgery
or radioactive iodine.

Front 76

Symptoms
Thyroid nodule; symptoms of local invasion.

Back 76

Thyroid Cancer
Description
Risk factors include childhood exposure to radiation and heredity;
11,000 cases per year; 1,000 deaths; 3–4% of solitary thyroid nodules
are cancer.
Pathology
May occur as part of familial thyroid carcinoma (multiple endocrine
neoplasia [MEN] types 2 and 3).
FACTORS THAT WORSEN
PROGNOSIS IN THYROID
CANCER
• Male gender
• Age > 40 years old
• Anaplastic histological
type
• Large primary tumor
> 1.5 cm in diameter
• Distant metastases
• Extrathyroidal invasion
1. Papillary—(the most benign and the most common; pathog-
nomonic is the psammoma body).
2. Follicular.
3. Medullary—(produces calcitonin). Can be associated with
MEN-2.
4. Poorly differentiated (anaplastic)—(the most highly malignant).
n anaplastic thyroid
cancer, the patient may
have hoarseness due to a
rapidly growing mass.

Hint 76

Diagnosis
Needle aspiration may reduce the need for surgery by 60%. Option-
ally, thyroid scanning and ultrasound. Thyroxine to suppress thyroid-stimulating hormone (TSH).
Treatment Steps
1. Needle aspiration.
2. Surgical resection (if hypo- or euthyroid)
3. Radiation therapy with 131I (if hyperfunctional).
4. Thyroxine suppression.
5. Irradiation and chemotherapy for thyroid lymphoma.

Front 77

Symptoms
Abdominal mass. Obesity, plethora, hirsutism, menstrual disorders,
hypertension, weakness (hypokalemia), back pain (from osteope-
nia), striae, acne, depression, bruising

Back 77

Cushing’s Disease
Description
A primary adrenal tumor secreting cortisol, causing signs and symp-
toms of glucocorticoid excess.
Pathology
Adenoma and carcinoma equally. Spread to liver and lung.

Hint 77

Diagnosis
Use 24-hour urine free cortisol; overnight 1 mg dexamethasone-suppression test; basal plasma ACTH levels. Tumor localization with CT & ultrasonography.
Treatment Steps
1. Adrenalectomy.
2. Mitotane for residual or nonresectable carcinoma.
3. Other cytotoxics—doxorubicin.
4. Control hypersecretion—aminoglutethimide, metyrapone.
5. Steroid replacement therapy.

Front 78

Female offspring of women given diethylstilbestrol during preg-
nancy may get adenosis of vagina and have increased risk of vaginal
cancer (adenocarcinoma, clear cell type).

Back 78

Neoplasms of the Vagina

Front 79

Symptoms
Painless lump. Hard, irregular mass, skin dimpling, or nipple retraction.

Back 79

Carcinoma of the Breast
Description
203,500 new cases in 2002; 12% of women will get it; 85% are older
than 40 years old. Risk factors: prior breast cancer, family history, early
menarche, late menopause, late or no pregnancy; moderate alcohol
intake; radiation exposure; western society diet. Oral contraceptives
do not increase the risk, nor does estrogen given for osteoporosis.
Pathology
Assume distant metastases. Size of tumor, and presence of axillary
nodes correlates with risk of recurrence. The presence of estrogen
receptors (ER) and progesterone receptors (PR) indicates better
prognosis. High Ki67 and the presence of the her-2 mutation a
poorer prognosis. About 80% are inltrating ductal; others are inl-
trating lobular, medullary, comedocarcinoma, colloid carcinoma
(see Fig. 6–8).

Hint 79

Diagnosis
• Screening. See American Cancer Society Recommendations for the Early
Detection of Cancer in Asymptomatic People.
• Mammograms (90% accuracy), ne-needle biopsy, excisional
biopsy.
Treatment Steps
Two steps: outpatient ne-needle biopsy or excisional biopsy under
local; discuss options, then do denitive treatment.
Stage I and II Disease—local resection (lumpectomy and axillary node dissection or modied radical) followed by irradiation. Adjuvant systemic therapy for poor prognosis stage I and all stage II.
Tamoxifen if postmenopausal and ER positive. Chemotherapy if
ER negative.
Lobular—higher risk of bilateral disease.
Resectable Stage III—do mastectomy followed by radiation and
chemotherapy. If patient strongly wishes breast conservation,
consider preoperative chemotherapy.
Unresectable Stage III or Inammatory Breast Carcinoma—give chemo-
therapy followed by irradiation (and possible resection).
Stage IV (Metastatic)—hormonal (bone, soft tissue, and mild pulmonary spread respond) or chemotherapy (liver, brain, and extensive lung).
–1. Premenopausal
Chemotherapy if adjuvant therapy indicated using such drugs as cy-
clophosphamide, 5-FU, methotrexate, and Adriamycin. Consider
adding a taxane if positive lymph nodes. Hormonal therapy of bene-
t if ER positive.
9–2. Postmenopausal
Tamoxifen if ER/PR positive (anastrazole also an option); chemo-
therapy if resistant to hormone.
Adjuvant chemotherapy. National Institutes of Health (NIH) Con-
sensus says adjuvant chemotherapy and hormonal therapy (tamox-
ifen) are effective in axillary node-positive patients (especially if ER
positive).
If CEA or CA 27-29 elevated preoperatively, can be used to monitor. No follow-up apart from mammogram proven to improve survival.

Front 80

Symptoms
Painless testicular mass. May have dyspnea, abdominal or back pain, gynecomastia, supraclavicular adenopathy, or ureteral obstruction.

Back 80

Nonseminomatous
Description
Germ cell tumors that include embryonal cell carcinomas, chorio-
carcinomas, and teratomas. Stages I and II, 99% cure rate. Stage III,
70%.

Hint 80

Diagnosis
Stage with chest x-ray, CT chest and abdomen, AFP, β-hCG. Do not perform percutaneous biopsy.
Treatment Steps
1. Inguinal orchiectomy and retroperitoneal lymph node dissection
for staging and initial treatment.
2. Cisplatin-based aggressive chemotherapy.

Front 81

Description
Rare; most are malignant, derived from germ cells, 20–35 years old.
Risk factor is cryptorchidism.

Back 81

Seminoma

Hint 81

Diagnosis
Evaluate with AFP, β-hCG, CT of abdomen and pelvis.
Treatment Steps
1. Inguinal orchiectomy and radiation produce 80–95% cure rates.
2. If increased AFP, treat like nonseminomatous germ cell tumor
(GCT).

Front 82

Symptoms
Gross or microscopic hematuria, ank pain, abdominal mass. Symp-
toms of paraneoplastic syndrome (fever, hypertension, anemia, he-
patic dysfunction [Stauffer syndrome]). Many unusual symptoms.
Erythrocytosis.

Back 82

Hypernephroma (Renal Cell Carcinoma,
Renal Adenocarcinoma)
Description
Risk factors include male gender and tobacco use
Pathology
Three histologic types: clear cell, granular cell, and sarcomatoid

Hint 82

Diagnosis
Intravenous pyelogram (IVP), ultrasound, CT, MRI. Rule out renal vein thrombus. (See Figs. 6–9 and 6–10.)
Treatment Steps
1. Stages I, II, and IIIA require radical nephrectomy and yield 50–
70% 5-year survival. No signicant benet to adjuvant therapy.
2. Stage IV—combination therapies of α-interferon, IL-2, and 5-FU are used.

Front 83

Symptoms
Asymptomatic palpable abdominal mass, hematuria, hypertension,
abdominal pain.

Back 83

Wilms’ Tumor (Nephroblastoma)
Description
Most patients are under 4 years old.
Pathology
About 80% are localized and resectable.

Hint 83

Diagnosis
IVP, ultrasound, or CT. Must distinguish from neuroblastoma (with
urinary vanillylmandelic acid [VMA]).
Treatment Steps
1. Limited disease: surgery + chemotherapy (doxorubicin, actino-
mycin D, vincristine) yields 85% disease-free survival.
2. Advanced disease: irradiation + chemotherapy.

Front 84

Symptoms
Hematuria, bladder irritability (frequency, dysuria).

Back 84

Carcinoma of the Bladder
Description
About 50,000 new cases per year; men predominate. Chemical car-
cinogens are implicated (including those in cigarette smoke)
Pathology
Transitional cell. Rarely squamous if Schistosoma haematobium infestation.

Hint 84

Diagnosis
Cystoscopy and transurethral bladder biopsy
Treatment Steps
Stage A:
1. Transurethral resection of bladder tumor (TURBT).
2. Cystoscopic surveillance for multiple recurrences.
3. Intravesical chemotherapy: bacillus Calmette–Guérin.
Stages B and C:
1. Pelvic lymphadenectomy and radical cystectomy. Metastatic dis-
ease.
2. Chemotherapy (e.g., methotrexate, vinblastine, platinums, doxorubicin, paclitaxel).

Front 85

Symptoms
Asymptomatic early, urinary retention symptoms, bone pain.

Back 85

Carcinoma of the Prostate
Description
Second leading cancer cause in males. No relationship to benign
prostatic hypertrophy (BPH); little relationship to smoking or alco-
hol. Of 30,000 deaths per year, 30–50% of men older than 50 have at
least a focus of adenocarcinoma of prostate. African Americans’ risk
two times that of Caucasians.
Pathology
About 50% of prostate nodules are malignant; 95% are adenocarci-
nomas. Bone metastases common (pelvis, lumbar spine, femurs, tho-
racic spine, ribs); lung and liver metastases the most common visceral spread.

Hint 85

Diagnosis
Digital rectal exam, transrectal prostatitic ultrasound (TRUS), con-
rmation with TRUS-guided needle biopsy. Do PSA before biopsy.
IVP, bone scan, if biopsy positive.
Treatment Steps
Will vary with physiologic age of patient, being more aggressive in
younger patients. Also considering importance of sexual function.
Suppression with leuprolide preoperatively.
• A1. Observation and rebiopsy.
• A2 and B1. Radical prostatectomy.
• B2 and C. Transurethral resection of prostate (TURP) followed
by radiation (40% post-XRT impotence; 2% incontinence).
• D (metastatic). Hormonal therapy (orchiectomy or luteinizing
hormone–releasing hormone [LHRH] analog), which should
be delayed until symptoms appear. Chemotherapy if hormone
independent not very effective.
Treating complications. Radiation for pain; erythropoietin or trans-
fusion for anemia, strontium for painful blastic lesions.
After treatment. Follow with periodic digital rectal exam (DRE) and PSA.

Front 86

Head and Neck Tumors

Back 86

Description
Risk factors: tobacco and alcohol. Premalignant lesions include
leukoplakia, erythroplakia.
Pathology
Usually squamous (epidermoid). Oral 44%; laryngeal 32%.

Hint 86

Treatment Steps
1. Surgery.
2. Irradiation.
3. Chemotherapy for palliation (e.g., cisplatin and 5-FU). High re-
sponse rates seen but not sustained.