Hem/Onc Exam 2

A patient receiving paclitaxel is scheduled for her first infusion. Which counseling and monitoring points are appropriate?

monitor for peripheral neuropathy; pre-medicate with corticosteroid, antihistamine, and H2 blocker; assess liver function

T/F: a patient with stage I colon cancer undergoes complete surgical resection with adequate lymph node evaluation. Adjuvant chemotherapy should routinely be recommended to decrease recurrence risk.

False

You are rounding in the infusion center. A patient is starting FOLFOXIRI. During the infusion, the patient experiences abdominal cramping and diaphoresis. He also experiences an episode of diarrhea.

What is the most appropriate intervention to alleviate the patient’s symptoms?

give atropine and consider pre-medication with atropine for future cycles

MJ is a 41 year old female who was just diagnosed with breast cancer after an abnormal mammogram. She reports that she had her first period when she was 13 yrs and she reports that she still has periods. She has 2 children. She gave birth to her first child when she was 33 yrs old.

Based on this information, what factor increased her risk of breast cancer?

late age of first birth

MJ is tarted on the TC regimen. What does the TC regimen include?

docetaxel + cyclophosphamide

A patient is receiving cetuximab with FOLFIRI for metastatic left-sided RAS wild-type colon cancer. Which counseling points are appropriate regarding EGFR inhibitor-associated rash?

presence of rash may correlate with treatment response; use sunscreen regularly; consider prophylactic doxycycline

A patient has a breast biopsy showing HR+/HER2- invasive breast cancer with no lymph node involvement. Oncotype Dx testing reveals a recurrence score of 12. Which treatment recommendation is most appropriate?

endocrine therapy w/o adjuvant chemotherapy is reasonable

A premenopausal woman with HR+ breast cancer is receiving tamoxifen. Her primary care provider plans to start paroxetine for vasomotor symptoms. What is the best recommendation?

avoid paroxetine and recommend Veozah

A 48 year old premenopausal woman with stage I HR+/HER2- breast cancer following lumpectomy and radiation =

tamoxifen

A 65 yr old postmenopausal woman with metastatic HR+/HER2- breast cancer who has not received prior systemic therapy for metastatic disease =

letrozole + ribociclib

A 52 year old woman with stage III HER2+ breast cancer receiving neoadjuvant treatment to reduce tumor size before surgery =

trastuzumab + pertuzumab + docetaxel + carboplatin

A patient with HER2+ breast cancer has residual invasive disease after neoadjuvant TCH followed by surgery =

ado-trastuzumab emtansine

A patient with metastatic triple negative breast cancer whose tumor demonstrates PD-L1 expression >10

paclitaxel + pembrolizumab

A patient with HR+/HER2- metastatic breast cancer and a confirmed germline BRCA mutation

olaparib

Which chemotherapy is matched correctly with an associated black box warning?

doxorubicin : secondary maligancy

You are rounding in the infusion center. A patient is starting FOLFOXIRI. During the infusion, the patient experiences abdominal cramping and diaphoresis. He also experiences an episode of diarrhea.

Which agent is the most likely cause of these symptoms?

irinotecan

MJ’s doctor just got results back to help determine staging and treatment. Pertinent findings are T2N2M0, grade 1, HER-/HR+. Based on this information, what anatomical stage of disease does MJ have?

stage III

PA is a 73 yr old male who presented to the ER with left flank pain. CT of abdomen/pelvis reveled a tumor in the descending as well as multiple large hepatic lesions. Biopsy of the liver lesion found adenocarcinoma consistent with colorectal cancer. Negative for KRAS and BRAF mutation. pMMR/MSS. His PMH is significant for HTN (controlled) and Crohn’s disease. ECOG score of 1.

What is the most appropriate initial treatment for PA’s metastatic colorectal cancer?

FOLFOX + panitumumab

A 48 yr old patient with average risk for colorectal cancer asks about screening options. She completed a FIT test last year and prefers to avoid invasive procedures whenever possible. Which screening strategy is most appropriate according to current screening recommendations?

mt-sDNA every 3 years

GW is a patient with stage IV colorectal cancer, currently treated with FOLFOX. She returns today for cycle 8. Oxaliplatin was previously dose reduced on cycle 5 for grade 2 paresthesias. Today she report that the tingling and numbness has worsened and now she has pain in her hands to the point she has difficulty buttoning her shirt. Which of the following is the most appropriate modification to GW’s treatment plan?

Omit the oxaliplatin from further treatments

A 56 yr old patient is diagnosed with stage II colon cancer after surgical resection. Pathology reveals poorly differentiated histology, bowel obstruction at diagnosis, and only 8 lymph nodes examined.

Which factors place this patient in the high risk stage II category and support consideration of adjuvant chemotherapy?

poorly differentiated histology; eight lymph nodes examined; bowel obstruction

A 28 yr old woman presents for a preventive care visit. Her mother was diagnosed with breast cancer at age 45, and her calculated lifetime breast cancer risk is 23%. Which screening recommendation is most appropriate?

annual mammography beginning now

What is the definition of right side of the colon?

cecum to hepatic flexure (ascending colon)

What is the definition of the left side of the colon?

splenic flexure to rectum (descending colon)

How often are fecal occult blood tests (FOBT) recommended for screening of colon cancer?

annually

Which FOBT is more specific for lower GI bleeding?

fecal immunochemical tests (FITs)

What is the best non-invasive screening option for colon cancer?

multi-target stool DNA (mt-sDNA) or Cologuard

How often is Cologuard recommend for screening of colon cancer?

every 3 years

What is the GOLD standard in screening for colon cancer?

colonoscopy

Which structural/visual screening test for colon cancer ONLY examines the lower intestine therefore ONLY looks at left side?

Flexible Sigmoidoscopy (FSIG)

How often is colonoscopy recommended for screening of colon cancer?

every 10 years

When is it recommended to get a colonoscopy for screening of colon cancer?

45-75 yrs w/ life expectancy of more than 10 years

How often is FSIG recommended for screening of colon cancer?

every 5 years

How often is Computed Tomography Colonography (CT) recommended for screening of colon cancer?

every 5 years

What is the 1st place colon cancer will metastasize to?

liver

92% of colon cancers are ______

adenocarcinomas

Histology grading of colon cancer: highly differentiated, some normal function, BEST prognosis =

low grade

Histology grading of colon cancer: moderately differentiated =

intermediate grade

Histology grading of colon cancer: poorly differentiated, loss of function, POOR prognosis =

high grade

All patients with colon cancer will get which genetic testing no matter their stage?

micro-satellite instability (MSI) and mismatch repair gene (MMR)

What is the autosomal dominant trait caused by mutations in MMR genes that has up to 80% lifetime risk of colon cancer?

Lynch Syndrome

What is the somatic alteration we test for in stage II-III of colon cancer patients?

P13K mutation

What are some somatic alteration mutations we test for in stage IV colon cancer patients?

BRAF, RAS, HER2

What is the commonly expressed on carcinomas originating from GI tract?

carcinoembryonic antigen (CEA)

Elevated levels of what could indicate residual of metastatic disease in colon cancer patients?

carcinoembryonic antigen (CEA)

What type of imaging is done in colon cancer patients to evaluate pulmonary, hepatic, and retroperitoneal involvement?

CT chest/abdominal/pelvis (CT CAP)

CM is a 12 year old girl who was just diagnosed with ALL. At the time of diagnosis, her WBC was 35,000 cells/mm³ .What would be an appropriate induction regimen for CM?

Vincristine + corticosteroids + pegasparagase + daunorubicin + IT methotrexate + IT cytarabine

A 60 year old male with extensive-stage SCLC is starting first-line therapy. ECOG score of 1. Which regimen is preferred?

carboplatin + eptoposide + durvalumab

CL is a 67 yo F patient who presents to the oncology clinic with a history of lymphadenopathy in her cervical and inguinal lymph nodes. She complains of drenching night sweats. A lymph node biopsy revealed diffuse large B-cell lymphoma. Bone marrow biopsy was positive for malignant lymphoma cells. CT scan of pelvis showed 2 lymph nodes measuring 6.8 and 5.4 cm respectively. CT scans of chest was positive for lymphadenopathy in cervical lymph nodes. All labs are within normal limits.

Based on this information, what stage would CL be classified as?

stage IV

A 60-yr old Asian female non-smoker is diagnosed with Stage IV NSCLC. Molecular testing reveals an EGFR exon 19 deletion. Which treatment is most appropriate?

Tagrisso

CL is a 67 yo F patient who presents to the oncology clinic with a history of lymphadenopathy in her cervical and inguinal lymph nodes. She complains of drenching night sweats. A lymph node biopsy revealed diffuse large B-cell lymphoma. Bone marrow biopsy was positive for malignant lymphoma cells. CT scan of pelvis showed 2 lymph nodes measuring 6.8 and 5.4 cm respectively. CT scans of chest was positive for lymphadenopathy in cervical lymph nodes. All labs are within normal limits.

What is the goal of therapy for CL?

disease cure

Which one of the following medications has a BBW for QTc prolongation?

• Gleevec

• Sprycel

• Bosulif

• Tasigna

Tasigna

Which of the following patients meet the criteria for annual low-dose CT scan screening for lung cancer?

• 55 yr old female who smoked 1.5 packs per day for 15 years but quit smoking 12 years ago

• A 70 yr old male with a 40 pack-year smoking history who currently smokes

• 52 yr old male with 25 pack-year smoking history who quit smoking 3 years ago

Subcutaneous administration of Velcade results in which of the following when compared with IV administration?

decrease risk of peripheral neuropathy

You are monitoring a patient who is scheduled to start Rituxan as part of R-CHOP for follicular lymphoma. You notice the following lab results. All other labs within normal limits.

HBsAG +

HBCAb -

Which of the following is the most appropriate recommendation for this patient?

start entecavir

WR is a 67 yo M patient with stage II squamous cell carcinoma of the lung. The oncologist is recommending starting systemic therapy. You review his labs. ANC 6500, CrCL 38 mL/min. All other labs WNL. Which of the following would be the most appropriate chemotherapy regimen to recommend?

carboplatin + gemcitabine

A 7+3 regimen is the most common induction regimen in adults with

AML

Which of the following medications is indicated for FLT+AML?

midostaurin

a 66 yr old female with Stage III NSCLC is being started on carboplatin-based chemotherapy. Her target AUC is 5. Calculate the appropriate carboplatin dose using the Calvert equation

Weight = 65 kg

SCr = 1.1

What is the appropriate carboplatin dose?

383

FOLFOX =

5-FU, leucovorin, oxaliplatin

CapeOX =

capecitabine and oxaliplatin

FOLFIRI =

5-FU, leucovorin, irinotecan

FOLFOXIRI =

5-FU, Leucovorin, oxaliplatin, irinotecan

Surgery in colon cancer is DOC in which pts?

stage I-III

What is the treatment for stage I colon cancer?

surgery of tumor and regional lymph nodes; NO chemo

What is the treatment for stage 2 colon cancer?

surgery and if high risk give adjuvant chemo

what are the high risk characteristics that would make a stage 2 colon cancer pt eligible for adjuvant chemo after surgery?

<12 lymph nodes removed, poorly differentiated, lymphatic invasion, bowel obstruction, localized perforation, positive margins, high tumor burden

What are the adjuvant chemo options for high risk stage II colon cancer patients? Monotherapy =

capecitabine or 5FU/leucovorin

What are the adjuvant chemo options for high risk stage II colon cancer patients? combo therapy

FOLFOX or CAPOX

What is the treatment for stage 3 colon cancer?

surgery with adjuvant chemo

Adjuvant chemo options are the same for stage 3 colon cancer as stage 2 (CapeOX and FOLFOX), just combo therapy; but what is added if the pt is dMMR/MSI-H?

atezolizumab (Tecentriq)

What is the brand name for atezolizumab?

Tecentriq

What is given for stage 2 and 3 colon cancer patients w/ a P13K alteration?

162 mg aspirin for 3 years

What is the goal of therapy for stage 4 colon cancer?

control growth, reduce symptoms, improve QOL, extend survival

What is the first step in determining treatment options for patients with stage 4 colon cancer?

test for targeted genetic mutations

For Stage 4 colon cancer patients with wildtype KRAS/NRAS/BRAF and left-sided what is their treatment regimen?

FOLFOX/CAPOX/FOLFIRI + EGFR inhibitor (panitumumab or cetuximab)

Forr Stage 4 colon cancer patients with dMMR/MSI-H what is their treatment regimen?

immunotherapy w/ pebrolizumab, dostarlimab-gxly, nivolumab±ipilimumab

Forr Stage 4 colon cancer patients with pMMR/MSS, right-sided and have mutations what is their treatment regimen?

FOLFOX/CAPOX/FOLFIRI/FOLFOXIRI ± bevacizumab

If oxaliplatin is in chemo regimen, when should it be given?

should be given prior to 5-FU

What is the most important side effect with oxaliplatin?

peripheral neuropathy

What are the two types of peripheral neuropathy with oxaliplatin?

acute and persistent

What is the treatment or management of peripheral neuropathy with oxaliplatin?

decrease rate of infusion if acute; dose reduction or stop therapy after 6 cycles; can use gabapentin or duloxetine

What is the genomic issue with irinotecan?

UGT1A1 converts to inactive metabolite and some patients may have UGT1A1*28 poor metabolizer phenotype leading to dose reduction

What is the BW associated with irinotecan?

diarrhea

What is the treatment for acute diarrhea w/ irinotecan?

atropine

What is the treatment for delayed diarrhea w/ irinotecan?

loperamide

What is the brand name for bevacizumab?

Avastin

What is the BW associated with bevacizumab?

GI perforation, wound dehiscense, hemorrhage

What is the brand name of penitumumab?

Vectibix

What is the brand name of cetuximab?

Erbitux

What is the drug class of panitumumab?

EGFR inhibitor

What is the drug class of cetuximab?

EGFR inhibitor

What do you need to premedicate with before EGFR inhibitor infusion?

APAP, H1 and H2 antagonist, steroid

What is the BW associated with EGFR inhibitors?

skin reactions

How to manage EGFR inhibitor skin rash?

prevention with hydrocortisone, sunscreen, and doxycycline; treat with topical steroids, antihistamines, antibiotics

What is the brand name of nivolumab?

Opdivo

What is the brand name of pembrolizumab?

Keytruda

What is the brand name for dostarlimab-gxly?

Jemperli

What are the endocrine related risk factors for breast cancer?

early menarche, late menopause, late age of 1st birth, nulliparity, HRT w/ estrogen & progestin

What is considered early menarche?

period at <11 yrs