Hematology/Oncology

1. Hematology/Oncology Brought to You By: Group 7

2. What is not a likely clinical manifestation of leukemia? • Petechiae & Mucosal Bleeding • Bone Pain • Hyperleukocytosis • Decreased WBC Count

3. 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.

4. 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?

5. Answer: • Acute Lymphocytic Leukemia • Acute Myelogenous Leukemia • Chronic Myelogenous Leukemia • Hodgkins Lymphoma

6. 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.

7. 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

8. 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

9. 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

10. 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.

11. 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

12. 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.

13. 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

14. 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.

15. Question? • What is the most common electrolyte abnormality in Multiple Myeloma? • Hypocalcemia • Hypokalemia • Hypercalcemia • Hyperkalemia

16. 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.

17. 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

18. 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.

19. Question? • True or False? • M- spike, Releaux formation, and Bence Jones proteins are findings specific to Mutiple Myeloma

20. 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.

21. 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

22. 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

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

24. Answer: • C. PT • Coumadin works specifically on the extrinsic pathway and on PT while heparin works on the intrinsic pathway and on PTT

25. 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

26. 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.

27. 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

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

29. 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

30. 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.

31. 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

32. Answer: • Make cross-linked fibrin clots • Factor 13 is associated with making clots. All the other choices are associated with deficiency in factor 10.

33. Matching! • Hemophilia A  • Hemophilia B  • Hemophilia C  • Factor VIII Deficiency • Factor IX Deficiency • Factor XI Deficiency

34. 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

35. 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.

36. Question? • The most common histological subtype of lung cancer in smokers is? • Answer: • Squamous cell lung carcinoma

37. Question? • The most common histological subtype of lung cancer overall is? • Answer: • Adenocarcinoma (40%)

38. 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

39. Question? • What type of lung cancer is associated withSIADH? • Answer: • Small Cell Carcinoma

40. 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

41. Question? • What is the MOST COMMON clinical manifestation of the previous syndrome? • Answer: • DYSPNEA

42. 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

43. 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

44. 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.

45. What is the Exception? • Follicular malignancy is the exception. Iodine uptake and concentration is present

46. 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

47. 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

48. 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

49. 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 %

50. 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