Oncology Discussion

[curiousprepa]

I decided to make a discussion about ways to study oncology while in PA school. The infomation is overwhelming. What should I focus on?

[Timon]

Make mnemonics..

 

Here are some that I made for myself..

 

ALL

ALL Bundy sharted so loud it sounded like TDT exploded and STIANED his undies with GRANILOCYTES. First he had SCANT (sounds like scat) in his pants then he thought it was IRREGULAR and 3rd everything was FINE but he ended up being POOR.

 

CML

Deshawn Jackson was kicked off to the CML from the PHILADELPHIA eagles after he became IMMATURE and ran DOWN a LAP saying "I'm at INI B" (IMATINB). That's what happens when you're put on BLAST.

 

Hairy Cell

The HONEYcomb mascot is TWO HAIRY. I wouldn't eat that cereal DRY [TAP] until I set a TRAP to catch him. I guess only MATURE B-oys (B-Cells) should eat it.

 

Multiple Myeloma

While ESCAPing, BENCE JONES ran into the Mexican Mafia (MM aka 13th St la emme). The cholo said I'll PUNCH you out G (IgG), I'm no SHEETing you homes. I'll get some of my homies to ROLL YO (rouleux) in their family WAGON homes. He was in so much pain his BONES hurt.

 

 

Clearly these worked for me and everyone had their own ways to remember things so make it relevant to you.

[whoRyou]

Make mnemonics ..

 

Clearly these worked for me and everyone had their own ways to remember things so make it relevant to you.

 

That's the beauty of mnemonics, studying things that are relevant to you which ultimately helps you remember in your LTM. Try hooking information together in order to effectively recall it later.

[winterallsummer]

Are you guys studying oncology as a block?  Or for example lung CA is covered pulmonology, leukemias and lymphomas in heme, colon cancer in GI, etc?

 

General advice would be simplify things as much as possible and then yep key words.  

 

So first thing is - is it chronic vs acute?  If a kid is very sick, think ALL.  If it's found in an older adult, could be AML or CLL or CML.  Look at the white count.  Are there way too many WBCs?  Think chronic if pt is not that sick, or blast crisis of an acute onc if the patient is very sick.  Check the diff and see is it myelogenous or lymphocytic cell line? 

 

AML = with Aueur rods.  

CML = Philadelphia chromosome aka bcl22:9

ALL = "all kids get this cancer" young kid with heme cancer, think ALL

Hodg-Kins = Reed-Sternberg cells, also Hodg-Kins two syllables and presents with biphasic (two ages) range

 

If you have specific questions that may be more useful.

[curiousprepa]

@Timon: I'll try making stories to help me study. I've never done that before.

[curiousprepa]

@winterallsummer: To gather findings, how do you determine which is the most important one?

[winterallsummer]

Here is a quick and dirty approach to the heme cancers which include ALL, CLL, AML, CML, myelomas and (non)-hodgkin's.

 

First a patient may present sick.  

 

1. For any of these cancers besides multiple myeloma (MM), a palpable LN is a common presentation.  The LN may be firm, immobile, rubbery, large, present even though there is no reason for it (eg no viral symptoms), subclavicular (always concerning), or stick around for several weeks despite antibiotics, and no cat in the house (cat scratch fever).

 

2. Second a patient may have "B" symptoms which correspond classically with the hodgkin's or non hodgkin's lymphomas (HL and NHL) but also with the leukemias.  They include fever, night sweats, and significant weight loss.

 

3. Third a patient may have "bone pain" because blood grows in bone marrow, and in these cases cancerous blood overflows the bone marrows and causes an ache.

 

4. Fourth a MM patient classically presents with back pain secondary to lytic lesions, or they can present with pancytopenia

 

Or a patient may present totally asymptomatic but with an abnormal CBC on routine blood tests, or a CBC taken for some other reason.  There are three cell lines: (1) platelets, (2) RBCs, (3) WBCs.  If all three are low, this is pancytopenia - thin AML/ALL, MM, or something else fishy like aplastic anemia or bone marrow (BM) fibrosis.  If only platelets are high, thing TTP or ITP or essential thrombocytosis.  If only RBC or RBC are platelets are high, think polycythemia (ferritin also high).

 

In general, however, WBC will be high or low.  If low the patient is usually sick.  Let's start with high.  High can be blast crisis of an acute or, if the patient is not super sick, probably something chronic.  In real life, you need to go back and find old WBCs and see are they persistently high?  In a test, you just get one lab.  So let's say a WBC is 40 (normal 3.5-12) in a patient who is not sick and is not on steroids and has no reason to have a WBC of 40.

 

So let's say a patient comes in, healthy, WBC 40.

 

So next look at the differential.  There are many, many types of leukemias.  For our purpouse because this is what's on the tests let's focus on CML and CLL.  So the middle initial gives you what you need.  AML - chronic MYELOGENOUS leukemia.  CLL - chronic lymphoid leukemia.

 

CLL: The lymphoblasts are cancerous.  They may be to be mature yet canceous lymphocytes or be immature cancerous lymphoblasts, or fall somewhere in between.  But your differential will show an abnormally high lymphocyte count/percentage.

 

CML: The myeloblasts are cancerous.  They again may be immature or mature.  Myeloblasts grow up to be basophils, eoseonophils or neutrophils, or RBCs and platelets (PLTs).  But CML should have a normal lymphocyte count/percentage, but high neutrophils and/or basophil, esonophil and possible PLTs and RBCs.

 

So now our guy with WBC 40 we see his differential.  High lymphocyte count/percent?  Think CLL.  Regular lymphocyte count/percent (and high baso/eosono/neutrophil) - think CML.  Actually no matter what he now needs a bone marrow (BM) biopsy and hem/onc referral.

 

Similar approach looking at the differential for AML/ALL.  However these patients are usually sick, or present dramatically and symptomatically.  Also their WBC count is usually LOW, not HIGH, -UNLESS- they are in blast crises.  But generally the cancerous, blast-cells in AML or ALL crowd out the BMs and do not allow mature cells to properly grow and fill the veins, thus the WBC is low.  This is a very rough rule of thumb and take it with a grain of salt.  In general, ALL - think ALL kids get this cancer.

 

I can keep going... tell me if this is helpful or what you want??

[curiousprepa]

@winterallsummer: It is helpful. I have trouble putting information together to diagnose the patient. Any good resources to help with this?

[winterallsummer]

In the clinic or for tests?

[curiousprepa]

Both. I found some CMEs that explained the information too. It's kinda coming together. I just need to think about the material in a different way.

[winterallsummer]

Books as far as enhancing clinical understanding I recommend Clinical pathophysioligy made rediculously simple. And a great book but you may not have time to read it during didactic year is the medical book by Paul Cutler.

 

As far as tests you are given the differential (answer choices) so if you don't know the answer right away then rule out what you can and go with most common of whatever's left.

 

In clinic you have the CC before you go in. Say xx year old male with chest pain. If that's sixty year old you're thinking angina MI AS or PE etc. If on the other hand it's a fifteen year old you're thinking costochondritis or skeletal muscle or PTX etc. so try to get a short DDx based on age gender race and CC. Then go in the room and let the pt talk. Usually they'll tell you what's wrong. Do a short ROS including HA, CP, dyspnea, n/v/d, LE pain. Then work towards narrowing down what you suspected from your original DDx. Usually history and a quick directed exam gives it away. If its complicated or vague then you may need a fuller ROS and complete exam and order labs then put it all together. Always think most commons. An uncommon presentation of a common disease is more likely than a common presentation of a rare disease. But every now and then you'll see a few zebras. You'll get there with time and practice!