A 54-year-old woman has postmenopausal vaginal bleeding. There is no associated pain or systemic symptoms, and speculum examination reveals an irregular appearance to the cervix, which bleeds easily when samples are taken for a Pap smear. The diagnosis is cervical cancer.
Although causation is not definite, a high proportion of cervical cancers reveal HPV-16 and HPV-18 on biopsy. HPV has also been isolated from vulvar, penile, and anal cancers.
A 58-year-old woman presents with RUQ abdominal discomfort. She has no history of gallstones, and on examination, there is a firm mass in the RUQ. Ultrasound of the liver reveals a 6-cm solitary lesion in the liver, and her alphafetoprotein level is elevated.
Cirrhosis, related to chronic HBV infection, is a leading cause of HCC.
The most common type of lung cancer in the United States.
Adenocarcinoma is now the most common form of lung cancer, accounting for 40% of the total cases.
Has the best prognosis of all malignant lung cancers.
Because of its tendency for early exfoliation and obstruction, squamous cell cancer is often detected at an earlier stage. Even correcting for this, there is some suggestion that its prognosis is still better, perhaps because of its slow growth rate.
Most likely to cause nonmetastatic hypercalcemia.
Nonmetastatic hypercalcemia occurs in up to 15% of all squamous cell cancers due to the production of parathyroid hormone relatedpeptide (PTH-rP). This is a paraneoplastic phenomenon.
Associated with syndrome of inappropriate antidiuretic hormone (SIADH).
SIADH occurs in up to 10% of all small cell cancers of the lung. SIADH, Cushing’s syndrome, and neurologic paraneoplastic syndromes usually occur with small cell lung cancer, not nonsmall cell lung cancer.
Associated with myasthenic syndrome (EatonLambert syndrome).
Eaton-Lambert syndrome is unusual, but small cell lung cancer causes the majority of cases that are paraneoplastic.
A 23-year-old man notices numbness in his hands and feet. On examination, there is distal loss of sensation to touch, and vibration in all four limbs. He recently finished chemotherapy for testicular cancer.
Cisplatin is used for the treatment of many different cancers including testicular cancer. Its major toxicities are renal, ototoxicity, myelosuppression, and peripheral neuropathy. The neuropathy is dose- and duration-dependent.
A 56-year-old woman is receiving chemotherapy for lymphoma for the past year. Her liver enzymes have been persistently elevated for the last 2 months. She has no prior history of chronic liver disease, and screening tests for viral hepatitis are negative. A liver biopsy indicates early hepatic fibrosis.
Liver toxicity is most common when methotrexate is used on a daily basis, such as for psoriasis. Myelosuppression and GI mucositis are the most common side effects in cancer therapy
A 64-year-old man is receiving chemotherapy for squamous cell cancer of the lung. He has now developed erythema, induration, thickening, and eventual peeling of the skin on the fingers, palms, and soles of his feet.
Although lung injury is the most serious complication of bleomycin, this unusual skin reaction is more frequent, occurring in almost 50% of patients.
A 54-year-old woman received adjuvant chemotherapy for breast cancer 1 year ago. She now presents with symptoms and signs of congestive heart failure. An echocardiogram confirms decreased left ventricular function.
Doxorubicin can cause a cumulative, dosedependent cardiomyopathy that can result in congestive heart failure. However, an acute, non-dose-related myocarditis-pericarditis can also occur. It can cause arrhythmias, heart failure, or pericardial effusions.
A 34-year-old man is undergoing preconditioning high-dose chemotherapy for a bone marrow transplant. On the third day of treatment, he develops hematuria.
Cyclophosphamide causes hemorrhagic cystitis in up to 10% of patients because active metabolites are excreted. Adequate hydration and frequent urination can decrease the frequency of this complication.
Has the best prognosis of all thyroid malignancies
Papillary cancer has the best prognosis of all thyroid cancers. Although it is seven times more common than follicular cancer, fewer people die from it. Even with follicular cancer, most patients will die of other diseases. In commonwith other thyroid cancers, age seems to be an independent risk factor for poor prognosis
Is proportionately more common in Blacks than Whites
Although well-differentiated thyroid cancer is twice as common in Whites than in Blacks, the proportion that is follicular is more than twice as high in Blacks.
Is associated with a specific marker
Serum calcitonin elevation is specific for medullary thyroid cancer and is the most specific tumor marker now available. When combined with provocative agents (e.g., calcium, pentagastrin), it is also very sensitive. In the familial syndrome, provocative tests have been superseded by genetic studies.
The only form of Hodgkin’s disease more common in women
Nodular sclerosing Hodgkin’s disease is more common in women, and is particularly common in younger age groups but can occur at any age.
Reed-Sternberg cells can be difficult to locate in this variant
In lymphocyte-predominant Hodgkin’s disease, multiple sections often have to be examined to find Reed-Sternberg cells. Some authorities question whether such cells are necessary for diagnosis of this form. Variants, often called lymphocytic and histiocytic (L&H) or popcorn cells, are often frequently found.
This variant has a particularly good outcome
Most patients with lymphocyte-predominant Hodgkin’s disease have clinically localized disease and are asymptomatic; the prognosis is usually favorable. However, it accounts for only 4–5% of cases
Can be accompanied by a nonnecrotizing epithelioid granulomatous reaction
This is a frequent accompaniment of Hodgkin’s disease and can be found in involved lymph nodes, and may be extensive enough to obscure the presence of Hodgkin’s disease. Rather than evidence of occult involvement, the presence of granulomas implies stage for stage, a better prognosis than those without this reaction.
A 52-year-old woman has metastatic breast cancer with boney metastases. She is taking hydromorphone for the pain but is still experiencing back pain. She is reluctant to take more of the hydromorphone since she become very drowsy with higher doses. This group of medications is particularly useful for pain from bony metastases.
Prostaglandins play a role in bone resorption in metastatic disease, perhaps explaining the effectiveness of NSAIDs for this type of pain. Aspirin has been shown to have an antitumor effect in an animal bone tumor model.
A 74-year-old man with metastatic prostate cancer develops shooting pains in his left legand constant back pain. Further evaluation reveals a pathologic compression fracture of the lumbar spine and involvement of the nerve roots in his lower spine causing the pain. He is started on a medication to help reduce the symptoms, but a limitation of the drug is leukopenia and thrombocytopenia.
Carbamazepine is an anticonvulsant used widely as an adjuvant analgesic for neuralgic pain caused by either tumor infiltration or surgical nerve injury. Because cancer patients commonly have compromised hematologic reserve, leukopenia and thrombocytopenia caused by carbamazepine may limit its use.
A 68-year-old woman was treated for melanoma 3 years ago. She now presents with constant headaches, nausea, vomiting, and leftsided weakness. A CT scan reveals two masses in the right parietal lobe consistent with metastatic melanoma. She is started on medication to help reduce her symptoms of headaches and nausea.
Steroids are useful for controlling pain in patients with leptomeningeal metastases or headache from increased intracranial pressure.
A 65-year-old man has metastatic lung cancer and severe bone and chest pain. He is started on morphine and ibuprofen to control the pain but is still not comfortable. Further gradual increases in the morphine dose achieve good pain control but he becomes drowsy on the appropriate dose and is unable to do much. He is started on a medication that can be useful in controlling opioid-induced sedation.
Usually, sedation can be controlled by altering opioid dosage, or switching to a drug with a shorter half-life, as well as stopping other sedating medications. If this fails, amphetamine, methylphenidate, and caffeine can be used to counteract the sedative effect.
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