Heme
#Recurrent DVT
<2% of patients will experience new DVT on therapy. Assess drug adherence. Consider underlying cancer, APS, HIT. Consider LMWH for 4 weeks. Increase weight based LMWH to 120-125% for 4 weeks before resuming prior dose. Refer to hematology.
#Iron deficiency anemia
As defined by the AGA 2020 guidelines, ferritin <45, hemoglobin <13 in men and <12 in women. No vaginal bleeding.
-celiac and h pylori testing
-u/a per BSG guideline on IDA 2021
-refer to GI for upper and lower endoscopy per AGA 2020 guideline
-per BSG, iron replacement therapy should not be deferred pending further workup;
-however, appropriate to delay iron therapy if endoscopy will occur within 2 weeks
-one tablet ferrous sulfate 325mg immediate release every other day (recommend against enteric coated as decreases absorption and does not decrease side effects)
-counseled patient to take first thing in the morning, 60 minutes before a meal; no evidence that vitamin C co-administration is beneficial
-if using IV iron; Ganzoni equation:
-repeat CBC in 4 weeks
-continue treatment of iron replacement therapy for 3 months
-CBC q6 months for monitoring of recurrence of iron deficiency
AVERT trial (NEJM) for dvt ppx in cancer (Khodara score)
DOACs should be avoided entirely in a few subgroups, per the CHEST guideline update. A vitamin K antagonist should be prescribed instead in patients with antiphospholipid syndrome (APS), especially if they are positive for lupus anticoagulant, anti-cardiolipin, and anti-β2-glycoprotein-I antibodies (i.e., “triple-positive”), and in those with arterial thrombosis, it noted.
-Stevens SM, Woller SC, Baumann Kreuziger L, et al.Executive summary: antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel report. Chest. 2021;160:2247-2259. [PMID: 34352279]
#Evan's syndrome
Defines as autoimmune hemolytic anemia + ITP
Positive DAT, absence of other cause
Weakness/fatigue, pale, jaundice, SOB, lightheadedness, tachycardia, bruising, nose bleeds, petechiae, prone to infection, fever, mouth sores
Treatment: steroids, IVIG, mycophenolate mofetil, vincristine, danazol; rituximab; splenectomy
#Febrile neutropenia:
Localizing signs of infection: oropharynx, perineum, vascular catheter sites, skin, GI tract, lungs, sinuses
-FFWU: CBC, Bcx x2, u/a, ucx, cxr +/- fungal biomarkers
-cefepime 2g q8 (or renally dosed)
-add vanc for hemodynamic instability/severe sepsis, skin/soft tissue infection, pneumonia, gram-positive bacteremia, CLABSI, MRSA colonization
-add antifungal if febrile neutropenia for >5 days
If outpatient: oral cipro + augmentin (unless patient already on fluoroquinolone)
#malignancy associated severe hypercalcemia
Sx: n/v, constipation, polyuria/polydipsia, weakness, confusion
High volume normal saline; initial 200-300mL/hr, adjust to urine output goal of 100 to 150cc/hr
Monitor for volume overload and kidney failure
If kidney failure, use lasix
IV bisphosphonate; zoledronic acid
IM calcitonin
Denosumab if bisphosphonate resistant
Glucocorticoids for myeloma and lymphoma
#lymphedema:
Accumulation of interstitial protein rich filtered fluid caused by interruption of lymphatic drainage
Occurs in 17% of patients after breast cancer therapy
Risk factors: axillary lymph node dissection, radiation, high BMI
Treatment with compression therapy and physical therapy; skin and nail care to prevent infection; no BP measurements or IVs on affected side
#chemo induced nausea
Serotonin antagonists are very effective in preventing acute onset; no effect on delayed sx
NK1 antagonists, glucocorticoids, and olanzapine help with delayed (>24hrs)
Anticipatory (prior to chemo):
Tx: optimal primary prophylaxis, benzodiazepines, behavioral therapy
#Cord compression:
Steroids, surgical decompression --> radiation (if lymphoma, myeloma, germ cell tumors); radiation alone only if patient is not a candidate for surgery
Presents with localized spine or radicular pain, sensory loss, autonomic dysfunction (bladder outlet obstruction manifesting as overflow incontinence, constipation), muscle weakness
-gadolinium enhanced MRI of entire spine
#Lynch syndrome:
Amsterdam criteria (3-2-1-1-0); 3 family members with lynch related cancers, 2 generations, with one family member a first degree relative of the other 2, at least one member affected before age 50 years, and no familial polyposis
Autosomal dominant; referred for genetic testing/counseling
Increased risk of colorectal, endometrial, and ovarian cancer; also biliary, GU, sebaceous, and brain
CSP initiated by age 20 to 25, or 2 to 5 years before the age at diagnosis of the earliest cancer in the family, whichever is first
Gynecologic cancer screening (TVUS, endometrial aspirate cytology)
GU: urine cytology
#Familial adenomatous polyposis:
Recommend surgical total colectomy
Long term endoscopic surveillance of the duodenum
No indication for LFT screening due to risk of ampullary carcinoma as long as patient is undergoing surviellance endoscopy
Also at risk for gastric polyps, desmoid tumors, papillary thyroid cancer, hepatoblastoma, brain tumors
If patient has ileorectal anastomosis, still needs endoscopic surveillance because rectal polyps can develop in remaining rectum
#BRCA mutation:
also at risk for pancreas, prostate, fallopian tube, endometrial, peritoneal, uterine cancers
Pulmonology:
#Obstructive Sleep Apnea: Chronic. Patient on CPAP therapy at home. No acute issues at this time.
-Continue with CPAP therapy with sleep.
TUMOR LYSIS SYNDROME
Ppx with IVF
High risk: rasburicase
Moderate risk: allopurinol
Non Small cell lung cancer 2-3 can be treated with resection and cisplatin; no need for radiation
Solitary metastatic melanoma only to lung, if one nodule can be treated with resection, no need for BRAF
Women with breast cancer of childbearing age who wish to preserve fertility may undergo embryo banking before chemotherapy ; estrogen can cause infertility
In men with high risk prostate cancer (high Gleason, LNs, or distant Mets) should get BRCA testing, or a first degree relative with breast cancer before 50
Get mammogram for women 8 years s/p chest radiation, if treated between ages 10-30, needs MRI too
Lung MALToma
Treatment just rituximab
In patients with bone mets, zoledronic acid or denosumab are recommended for prevention of bone pain, cord compression, need for palliative irradiation, and hypercalcemia
Swelling and discomfort around left breast prosthesis
Ultrasound with moderate sized fluid collection, no evidence of rupture, aspiration shows serous non purulent fluid
Likely diagnosis Ana plastic T cell lymphoma
Early stage Hodgkin lymphoma:
Doxorubicin, bleomycin, vinblastine, dacarbazine + radiation
Burkitt lymphoma is high risk for TLS
#prostate cancer — active surveillance
PSA q6-12mo
Doubling in less than a year is grounds for prostate bx
Men with no metastatic disease and a very slow rising PSA do not always need treatment Bc developmental of clinical metastatic disease may take years; androgen receptor blockers have been shown to increase metastasis free survival in patients with nonmetastatic castrate resistant prostate cancer with rapidly rising PSA
#breast cancer
no imaging needed for asymptomatic patients with newly diagnosed stage 0 to stage II disease; basically all imaging is guided by sx/labs; breast cancer can undergo subtype switch between primary and metastatic disease and bx of metastatic site allows treatment to be tailored; the lesion that upstages the patient to the greatest degree should be biopsied
-if on aromatase inhibitor, should have DEXA q2 yr
-if wants to get pregnant, no increased recurrence of mortality; no increased congenital malformations post rads or chemo
-in pt receiving tamoxifen who depressed, avoid cyp2d6 inhibitors (bupropion and fluoxetine), duloxetine is okay
-inflammatory breast cancer is usually treated with neoadj chemo, followed by surgery, then radiation therapy
#Ovarian cancer
if advanced and BRCA positive who achieve some response to platinum based chemo, should receive subsequent maintenance iwht a poly ADP ribose polymerase inhibitor
#lung cancer
metastatic non small without a driver mutation with pembrolizumab plus chemotherapy
#follicular lymphoma
new nodes = concern for histological transformation needs confirmation with lymph node bx
#colon cancer: stage IIIb treatment is oxaliplatin, fluorouracil, and leucovorin (FOLFOX); can also use capacitabine (5-FU prodrug) + oxaloplatin; stage III is defined by metastases to local regional lymph nodes; recommend adjuvant therapy after surgery; if refractory to treatment and is metastatic mismatch repair deficient, indication for immune checkpoint inhibitors specifically programmed death receptor 1 inhibitors
#cancer of unknown primary with mets to liver; initiate combination chemotherapy
#newly diagnosed large b cell lymphoma: per international prognostic index score, get LDH for staging; do not need bone marrow biopsy; MRI not needed; if you already have a LN biopsy, no need for another
#unknown primary: in women with metastatic unknown primary, do breast exam, mammography, and gyn exam to eval for ovaria; women with adenocarcinoma with abdominal carcinomatosis and ascites should be presumptively treated for ovarian cancer
#cervical cancer: bulky or locally advanced stage III disease are treated with cisplatin based chemotherapy and radiation, not hysterectomy
#immunotherapy induced colitis: stop offending agent, most commonly with ipilimumab (CTLA-4 antibody) and nivolumab (anti PD1); can be life threatening; rule out infection, and start methylpred; can check lactoferrin and calprotectin to monitor bowel inflammation, can trend; proctoscopy/colonoscopy with bx can confirm dx
#CLL: treat hypogammaglobulinemia with IVIG; make sure vaccinated for flu and both 13 and 23 valent pna; goal IgG >600
#testicular mass: get an hcg and an afp; get an u/s, ctap; radical inguinal orchiectomy
#lung cancer
Primary symptoms: cough, dyspnea, chest pain, weight loss, hemoptysis
Advanced disease findings: consolidation, effusion, bone tenderness, neurologic findings
IR consulted for lymph node biopsy
#nodule on chest radiograph
Prior imaging? Stable >2 years, cancer unlikely
CBC, serum chemistries
CT scan of chest; bad = irregular or spiculated, upper lobe cavitation, thick walled cavitation, solid component within a ground-glass lesion, growth on followup imaging
#weakness in small cell lung cancer:
LEMS is most obvious; ie sx of dysautonomia (ED and dry mouth); proximal musc weak, better with use
Do an MME (CNS radiation can result in neuro toxicity)
Brain mets can cause aphasia, unilateral motor or sensory changes, headache
#firm lymph node
Upper LAD
Pan-endoscopy, followed by biopsy of any abnormal areas; if no lesions, can then perform fine needle aspiration of the palpable lymph node
#head and neck cancers:
Signs/sx: persistent/progressive LN enlargement, neck mass, unilateral tonsillar enlargement, unilateral hearing loss, tinnitus, ear pain, nasal obstruction, nonhealing oral ulcers, oral pain, dysphagia/odynophagia, hoarseness
#melanoma
Genetic markers: CDKN2A, CDK4
Poor prognostic factors: increased tumor thickness, ulceration, increased tumor mitotic rate, head/neck/trunk locations
For early melanoma, excision alone, with 1cm surgical margins is sufficient
Complete excision of thin (<1mm in depth), nonulcerated melanoms is associated with good outcomes with survival rates greater than 95%
Always get complete excisional biopsy
-early stage = wide excison only
-late stage = wide excision + LN dissection
-metastatic = immunotherapy
#lymphocytosis
Absolute lymphocyte count = ??
LAD? Splenomegaly?
Sx? Ie fever/night sweats/weight loss
Other cell counts?
Peripheral smear? Smudge cells?
Flow cytometry? CD5, 19, 20, 23
Only sx patients receive tx; bone marrow aspirate/biopsy not necessary
Complications: autoimmune hemolytic anemia, ITP, Richter transformation (relapse with B sx, aggressive large cell lymphoma, massive LAD/HSM
#SVC syndrome
Most commonly caused by lung cancer, but can also be caused by lymphoma and mediastinal germ cell tumors
Swelling of face, neck, upper extremities; cough; dyspnea/orthopnea; headache; JVD and dilated anterior chest veins
Must obtain tissue diagnosis; most accessible sites such as peripheral LAD, mediastinoscopy and biopsy are necessary and associated with low incidence of complications
#breast cancer
Asymptomatic patients with a family history of BRCA related cancers should receive genetic counseling for genetic risk assessment
BRCA1/2 testing for: women with triple negative breast cancer diagnosed before 60 years OR women with ovarian cancer at any age
Risk factors: BRCA1/2; chest irradiation between ages 10 and 30; atypical hyperplasia/lobular carcinoma in situ
Gail Model Risk Assessment tool; 5-year >1.67% = chemoprevention (antiestrogen)
PE: breast mass, nipple discharge, eczema, excoriation, retraction, inversion; localized breast pain; dimpling, thickening, discolored skin; axillary mass
Abnormal mammogram/ultrasound --> core needle biopsy (if palpable mass, perform even if imaging negative) with ER/PR/HER2 assays --> assess suspicious lymph nodes with FNA or core needle bx
Get chest CT, abd u/s, and/or bone scan if any of the following: positive axillary lymph nodes, tumor >5cm, suggestive signs of metastatic disease
-ductal carcinoma in situ: calcifications on mammogram
-lumpectomy + radiation
-mastectomy if extensive
-hormone therapy with tamoxifen if ER+
-invasive breast cancer:
-lumpectomy for tumors <5cm
-mastectomy if any of the following: >5cm, skin involved, inflammatory, high recurrence risk (BRCA)
-axillary LN dissection if ≥3 positive sentinel LNs
-post excision radiation
-systemic adjuvant therapy for non metastatic cancer
-ER/PR receptor positive breast cancer: adjuvant antiestrogen therapy
-premenopausal: 5 to 10 years tamoxifen (ADEs: endometrial cancer, VTE, CVA)
-postmenopausal: aromatase inhibitor (anastrozole, letrozole, exemestane) 5 to 10 years (ADEs: arthralgia, osteoporosis, CV events)
If on trastuzumab, always get TTE before and during treatment; avoid anthracycline therapy
If bone mets, add bisphosphonate or denosumab, surgical stabilization for impending fracture, radiation for pain
#cervical cancer screening:
HPV 16/18 + equals colposcopy referral now, regardless of prior or concurrent cytology
-if other genotypes, repeat 1 year surveillance with Pap +HPV
Sx: vaginal bleeding, postcoital bleeding, vaginal discharge, ulcer, induration, tumor mass
#prostate cancer:
Mainstay of treatment for metastatic disease is androgen deprivation by orchiectomy or chemical castration
Castrate resistant cancer = docetaxel, abiraerone +prednisone, enzalutamide
Needs ca +vitD while on androgen deprivation therapy; bisphosphonate/denosumab
Sx: usually asx, but can have lower uterine tract sx, bone or back pain indicative of metastasis
#colon cancer with mets to liver: surgical resection of a few isolated metastatic lesions may be curative; hepatic arterial embolization is used in the palliation of hepatocellular or neuroendocrine tumors, however not indicated in CRC
Radiation therapy not commonly used
Stage 1 = confined to colon, does not invade full bowel wall thickness, resection for cure
Stage 2 = full thickness of bowel, local invasion, resection for cure, adjuvant chemotherapy
Stage 3 = metastatic to regional lymph nodes, resection, adjuvant chemotherapy
Stage 4 = Distant metastases, resect primary lesion (palliative only), resect metastatic disease limited to liver/lung, adjuvant chemotherapy
Post treatment surveillance: 3 to 6 months x2 years, then q6mo for 5 years; CSP 1yr, 3yr, q5yr after; CT c/a/p annually x5 years for high risk patients
#Poorly differentiated carcinoma of unknown primary site that is predominantly presenting in a midline distribution should be treated presumptively for metastatic germ cell cancer with a cisplatin-based chemotherapy regimen.
#breast cancer
For patients with hormone receptor–positive, human epidermal growth factor 2–negative breast cancers with zero to three positive axillary nodes, the use of multigene assays informs the decision regarding the need for chemotherapy.