IM-Hematology

Charlie A. Clarion, MD, FPCP, DPCCP

Fellow, Philippine College of Physicians
Diplomate, Philippine College of Chest Physicians
Fellow, MSc in Epidemiology (Clinical Epidemiology)
• Q. According to WHO, what level of hemoglobin defines anemia?

• A. F <110; M <120
• B. F <115; M <130
• C. F <120; M <130
• D. F <120; M <135
• Ans. C. F <120; M <130

• Acute blood loss:

– 10-15%: vascular instability
– >30%: postural hypotension and tachycardia
– >40%: hypovolemic shock

• Hgb <80-100 à pallor

• Hgb <80 à palmar crease lighter in color

• Reticulocyte count à key in the initial classification of anemia

• Ferrireductase: enzyme in the brush border that converts ferric iron to ferrous
iron
• Hephaestin: oxidized iron to ferric form

• Acid pH: facilitates iron absorption (Ascorbic acid facilitates iron absorption)
• Ferroportin: transports iron from epithelial cell basolateral surface to circulation
• Hepcidin: principal iron regulator; inhibits ferroportin

• Transferrin: iron transport protein

• Ferritin: storage form of iron bound to protein; readily available
– Normal: M 100ug/L, F 30ug/L
– <15 ug/L: diagnostic of absent iron stores
• Hemosiderin: aggregates of iron within RES; less readily available
• Q. What is the most common type of anemia?

• A. Anemia of chronic disease

• B. Iron deficiency anemia
• C. Anemia of chronic blood loss
• D. Anemia of inflammation
• Answer: B. Iron deficiency anemia

• Hypoproliferative anemia: most common anemia

– 1. IDA
– 2. Anemia of inflammation

• Important substrates for effective erythropoiesis

– Iron, FA, B12
• Q. This finding in the peripheral blood smear signifies absence of
functioning spleen?

• A. Target cells
• B. Howell Jolly bodies
• C. Teardrop cells
• D. Schistocytes
• Ans. B. Howell Jolly bodies

• Target cells: thalassemia, liver disease

• Teardrop cells: myelofibrosis, marrow

infiltration

• Schistocytes: RBC fragments such as in

DIC, AIHA
• Burr cells: uremia

• Spur cells: acanthocytes

• AniSocytosis: variations in RBC

size
• Poikilocytosis: variations in RBC
shape
• Q. Which of the following does NOT cause microcytic hypochromic
anemia?

• A. Aplastic anemia
• B. Iron deficiency anemia
• C. Sideroblastic anemia
• D. Thalassemia
• Ans. A. Aplastic anemia

• Microcytic, hypochromic anemia

– IDA
– Thalassemia
– Sideroblastic anemia
– Lead poisoning

– Chronic disease: initially normocytic normochronic, later on microcytic

hypochromic
• Q. What are the components of the major adult hemoglobin?

• A. 2 alpha, 2 beta
• B. 2 alpha, 2 delta
• C. 2 alpha, 2 epsilon
• D. 2 alpha, 2 zeta
• Answer: A. 2 alpha, 2 beta

• Major adult: 2 alpha, 2 beta

• Minor adult: 2 alpha, 2 delta
• Fetal hemoglobin: 2 alpha, 2 gamma

• Embryonic Hemoglobin:
– Gower I: 2 zeta, 2 epsilon
– Gower II: 2 alpha, 2 epsilon
– Portland I: 2 zeta, 2 gamma
– Portland II: 2 zeta, 2 beta
• Q. How many alpha globin chains are present in Bart’s hydrops
fetalis?

• A. 0
• B. 1
• C. 2
• D. 3
• Answer: A. 0
• Q. Which is NOT a cause of megaloblastic anemia?

• A. Cobalamin deficiency
• B. Folate deficiency
• C. Methotrexate treatment
• D. Paclitaxel treatment
• Answer: D. Paclitaxel treatment
• Q. A 15-year old male patient had severe pallor after he was
prescribed with cotrimoxazole for his urinary tract infection. What
is the diagnosis?

• A. Autoimmune hemolytic anemia

• B. Glucose-6-phosphate dehydrogenase deficiency
• C. Pyruvate kinase deficiency
• D. Hemolytic uremic syndrome
• Answer: B. Glucose-6-phosphate dehydrogenase deficiency

• HUS
– Triad: microangiopathic HA, thrombocytopenia, acute renal failure
– Treatment: supportive

• TTP
– Pentad: microangiopathic HA, thrombocytopenia, acute renal failure,
fever, neurologic symptoms
– Treatment: Plasma exchange
• Q. What is the treatment of a non-life threatening autoimmune
hemolytic anemia?

• A. Blood transfusion
• B. Splenectomy
• C. IVIg
• D. Steroid
• Answer: D. Steroid

• AIHA
– Non-life threatening:
• First line: prednisone 1mg/kg/day + rituximab (anti-CD20)

– Splenectomy: does not cure but may be beneficial by removing major site
of hemolysis

– Life threatening: blood transfusion

• Q. Which is NOT a characteristic of paroxysmal nocturnal
hemoglobinuria?

• A. Intravascular hemolysis
• B. Pancytopenia
• C. Arterial thrombosis
• D. None of the choices
• Answer: C. Arterial thrombosis

• PNH
– Chronic acquired hemolytic anemia
– Triad: intravascular hemolysis, pancytopenia, venous thrombosis
– CD55 and CD59 deficiency, PIG-A gene mutation
• Q. A 54/M non-smoker has facial plethora, mild splenomegaly, Hgb
196, WBC 19, and plt 842. He also complains of aquagenic pruritus.
What is your diagnosis?

• A. Erythrocytosis
• B. Polycythemia vera
• C. Spurious polycythemia
• D. Secondary polycytosis
• Ans. B. Polycythemia vera

• Increased RBC à hyperviscosity and thrombosis

– Thrombosis: most significant complication
– Phlebotomy: may reduce hyperviscosity

• Elevated platelet à bleeding risk (platelets are dysfunctional)

• JAK-2 Mutation
– 95% of polycythemia vera
– 50% of essential thrombocytosis and primary myelofibrosis
• Q. What is the trigger of erythropoietin production?

• A. Low hemoglobin
• B. High carboxyhemoglobin
• C. Low oxygen
• D. High carbon dioxide
• Ans. C. Low oxygen

• EPO: produced by kidneys, trigger erythropoiesis

• Q. Which of the following conditions causes left shifting in oxygen
dissociation curve?

• A. Increased fetal hemoglobin

• B. Increased 2,3 BPG
• C. Increased pCO2
• D. Increased hydrogen
• E. Increased temperature
• Ans. A. Increased fetal hemoglobin

• Sigmoidal Shape: due to cooperative binding

• Q. Hemoglobin that causes bluish-brown muddy color blood
resembling cyanosis, with high affinity to oxygen.

• A. Carboxyhemoglobin
• B. Sulfhemoglobin
• C. Methemoglobin
• D. Deoxyhemoglobin
• Ans. Methemoglobin

• Methemoglobin: iron is ferric state

– Acquired form: taking nitrate and nitrite-containing food

• Sulfhemoglobin: green blood (H2S), sulfa drugs (NO TREATMENT)

• Carboxyhemoglobin: cherry red blood (CO), chronic smokers

• Oxyhemoglobin: Hb bound to O2; bright red

• Deoxyhemoglobin: Hb without O2
• Q. Patient underwent gastrectomy, what is the expected anemia
type?

• A. Microcytic anemia
• B. Macrocytic anemia
• C. Normocytic anemia
• D. Spherocytic anemia
• Ans. B. Macrocytic anemia

• Megaloblastic anemia
– B12 deficiency
• Nutritional: vegans,
• Malabsorption: pernicious anemia
• Gastric: gastrectomy
• Intestinal: D latum infection, ileal resection, tropical sprue, Chrohn’s disease
– Folate deficiency
• Antifolate drug, methotrexate, pyrimethamine, trimethoprim à give folinic acid
• Beer (folate antagonist)
• Liver disease
• Q. A 19/M used naphthalene balls for his clothing. After few days,
he developed anemia. What is your diagnosis?

• A. Pyruvate kinase deficiency

• B. Thalassemia
• C. G6PD deficiency
• D. Sideroblastic anemia
• Ans. C. G6PD deficiency

• PBS
– Bizarre poikilocytes
– Hemighosts: RBC with unevenly distrubuted hemoglobin
– Bite cells/Blister cells: RBC with parts that are bitten away
– Heinz bodies: ppt of denatured Hgb and hemichromes
• Q. What is the most important predictor of bleeding risk?

• A. Intake of aspirin
• B. low platelet count
• C. prolonged PT, aPTT
• D. history of bleeding
• Ans. D. history of bleeding

• Mucosal bleeding à platelet disorder

• Spontaneous hemarthroses à Factor VIII or Factor IX deficiency

• Aspirin effect persists for 7 days

• Q. Which among the following causes isolated prolangation of
aPTT?

• A. DIC
• B. Factor VII deficiency
• C. Hemophilia A
• D. Warfarin anticoagulation
• Ans. C. Hemophilia A

• Mixing Studies
– Used to assess prolonged aPTT, less commonly PT

– Factor deficiency: PT/PTT corrects with mixing and stay corrected with
incubation

– Lupus anticoagulant: mixing and incubation will show no correction

• Q. Major risk factor for arterial thrombosis?

• A. Atherosclerosis
• B. Obesity
• C. Malignancy
• D. Immobility
• Ans. A. Atherosclerosis

• Major Risk Factors

– Arterial thrombosis: atherosclerosis

– Venous thrombosis: immobility, surgery, malignancy, OCP, obesity,

genetic predisposition

• Virchow’s Triad
– Venous stasis
– Endothelial injury
– Hypercoagulable state
• Q. What is your primary consideration if a male patient has iron
deficiency anemia?

• A. Inflammatory disorder
• B. Gastrointestinal blood loss
• C. Poor intake
• D. Malabsorption
• Ans. B. Gastrointestinal blood loss

• Cheilosis and koilonychia à advanced IDA

• Prussian blue à stains iron stores in bone marrow
• Hepcidin à primary iron regulatory hormone
• Carry oxygen à major role of iron
• Proximal intestine à major site of iron absorption
• Q. What is the most prominent side effect of oral iron therapy?

• A. Gastrointestinal distress
• B. Diarrhea
• C. Insomia
• D. Tooth discoloration
• Ans. A. Gastrointestinal distress

• Iron dextran à causes anaphylaxis

• EPO à given to patients with anemia due to CKD

– Give iron, folic acid as well

• Type O, Rh negative à emergency blood transfusion and ABO

and Rh typing cannot be obtained
• 1u PRBC à increase Hgb by 10g/L, Hct by 3%

• 1u of random donor platelet à increase plt 7-10

• Q. Which of the following is NOT present in cryoprecipitate?

• A. Factor VIII
• B. von Willebrand factor
• C. Fibrinogen
• D. Prothrombin
• Ans. D. Prothrombin

• Contents of cryoprecipitate:
– Fibrinogen
– Factor VIII
– vWF
– Factor XIII
– Fibronectin
• Q. Which of the following causes megaloblastic anemia?

• A. Severe pancreatitis
• B. Use of proton pump inhibitors
• C. Total or partial gastrectomy
• D. Bariatric surgery
• Ans. C. Total or partial gastrectomy

• Megaloblastic anemia
– MCV >100 fL; hypersegmented neutrophils

• Other causes of Megaloblastic anemia

– Vegans, Pernicious anemia, ileal resection, fish tapeworm, crohn’s disease

• Ileum: cobalamin absorption

• Upper small intestine: folate absorption
• A. Which of the following is NOT a typical PBS feature of G6PD
Deficiency?

• A. Hemighosts
• B. Bite/blister cells
• C. Howell-Jolly bodies
• D. Heinz bodies
• Ans. C. Howell-Jolly bodies

• Bizarre poikilocytes of G6PD Deficiency

– Hemighosts: RBCs with unevenly distributed hemoglobin
– Bite/Blister cells: RBCs that have parts bitten away
– Heinz bodies: precipitates of denatured hemoglobin and hemichromes
• Q. Which of the following is NOT part of the classic triad of
autoimmune hemolytic anemia?

• A. Anemia
• B. Jaundice
• C. Splenomegaly
• D. Pallor
• Ans. D. Pallor

• Steroids: first line treatment for AIHA

• Q. What chemical is notoriously associated with aplastic anemia?

• A. Formalin
• B. Benzene
• C. Phytates
• D. Kerosene
• Ans. B. Benzene

• Aplastic anemia à pancytopenia with bone marrow

hypocellularity
– Etiology: radiation, drugs, chemicals, virus

• Benzene à aplastic anemia, acute myeloid leukemia

• Q. This drug can be given to patients with acute promyelocytic
leukemia?

• A. all-trans retinoic acid

• B. Cytarabine
• C. Decitabine
• D. Doxorubicin
• Ans. A. all-trans retinoic acid

• ATRA à causes differentiation of leukemic cells

• Auer Rods à acute promyelocytic leukemia
– High risk for DIC
• Q. Most common physical finding of Chronic Myelogenous
Leukemia?

• A. Anemia
• B. Bruising
• C. Splenomegaly
• D. Bleeding
• Ans. C. Splenomegaly

• T (9;22): CML
– Philadelphia chromosome
• Q. What is the most common cause of thrombocytopenia?

• A. Viral-induced
• B. Idiopathic
• C. Drug-induced
• D. Consumptive
• Ans. C. Drug-induced

• Thrombopoietin: primary regulator of platelet production

• Heparin-induced thrombocytopenia
– Tx: discontinue heparin and use alternative anticoagulant
• Q. What condition presents as a pentad of microangiopathic
hemolytic anemia, thrombocytopenia, renal failure, neurologic
findings, and fever?

• A. Immune thrombocytopenic purpura

• B. Hemolytic uremic syndrome
• C. Henoch-schonlein purpura
• D. Thrombotic thrombocytopenic purpura
• Ans. D. Thrombotic thrombocytopenic purpura

• Treatment of TTP: Plasma exchange

• HUS: triad of MAHA, thrombocytopenia, and renal failure

– Treatment: supportive care
• Q. What is the most common inherited bleeding disorder?

• A. Hemophilia A
• B. Hemophilia B
• C. von Willebrand disease
• D. Bernard Soulier syndrome
• Ans. C. von Willebrand disease

• Desmopressin (DDAVP): mainstay of treatment of vWD

• Q. What is the most sensitive test for DIC?

• A. D-dimer
• B. Fibrin degradation products
• C. PT/aPTT
• D. Thrombin time
• Ans. B. Fibrin degradation products

• Oozing from venipuncture sites: most common finding of DIC

IM-Oncology

Charlie A. Clarion, MD, FPCP, DPCCP

Fellow, Philippine College of Physicians
Diplomate, Philippine College of Chest Physicians
Fellow, MSc in Epidemiology (Clinical Epidemiology)
• A. Which of the following malignancy is associated with EBV
infection?

• A. Endometrial cancer
• B. AML
• C. Burkitt’s lymphoma
• D. Hepatoma
• Ans. C. Burkitt’s lymphoma

• EBV à Burkitt’s, Nasal T cell lymphoma

• H pylori à gastric CA, MALT lymphoma
• Hepa B, Cà Hepatoma
• Benzene à AML
• Schistosomiasis à Bladder CA (squamous cell)
• Vinyl chloride à Liver CA (angiosarcoma)
• Q. Which of the following has the lowest breast cancer risk?

• A. Menarche at age 9
• B. Menopause at age 58
• C. First full term pregnancy at age 18
• D. Estrogen/Progesterone replacement therapy
• Ans. C. First full term pregnancy at age 18

• Hormone Dependent Disease

– Low risk
• No functioning ovaries
• Early menopause
• Maternal nursing (longer duration, lesser risk)
• No estrogen/progesterone replacement therapy
– High risk
• Early menarche
• Late first full term pregnancy
• Late menopause
• Use of exogenous female hormones
• Q. This can be offered to women with genetic predisposition to
breast cancer?

• A. Tamoxifen therapy
• B. Prophylactic bilateral mastectomy
• C. Prophylactic chemotherapy
• D. Prophylactic breast radiation therapy
• Ans. B. Prophylactic bilateral mastectomy

• Secondary solid tumor: serious late complication of radiation

therapy

• Bone: most radioresistant

• Testis, ovary, bone marrow: most radiosensitive

• Q. What is the best breast cancer screening modality for patients
with genetic risk?

• A. Mammography
• B. Breast ultrasound
• C. Breast MRI
• D. Breast CT scan
• Ans. C. Breast MRI

• Screening Mammography: 40 years old, average risk, decreases

breast CA mortality by 1/4 to 1/3 in women >50 years old

• Breast MRI: screening for women with genetic risk, first degree
relative of patients with breast cancer, women with history of
chest radiation
– Positive predictive value of MRI is higher
• BRCA1 gene
– Chromosome locus 17q21
– 60-80% lifetime chance of developing breast CA
– 33% chance of developing ovarian CA
– More likely ER/PR/Her2 negative

• BRCA2 gene
– Chromosome 13q12
– More likely ER positive
– Men: higher risk of breast CA
• Q. Which of the following chemo drug should be administered
with 2-mercaptoethanesulfonate (mesna) to prevent hemorrhagic
cystitis?

• A. cisplatin
• B. doxorubicin
• C. chlorambucil
• D. ifosfamide
• Ans. D. ifosfamide

• Hypomagnesemia, hypocalcemia: electrolyte abnormality with

cisplatin use

• Doxorubicin and traztuzumab: cardiac toxicity

• Nausea with or without vomiting: most common side effect of

chemotherapy
• Q. What test will you request prior to administering trastuzumab to
breast CA patient?

• A. Chest Xray
• B. Kidney function test
• C. 2Decho
• D. Liver enzyme
• Ans. C. 2Decho

• HER2 status:
– if positive, give trastuzumab
– Toxicity of trastuzumab à cardiotoxic

• Fibrocystic changes: MC benign breast lesion

• Q. What is the most susceptible blood cells to myelosuppression
due to chemo drug?

• A. platelet
• B. RBC
• C. PMN
• D. all of the above
• Ans. C. PMN

• RBC: least susceptible

• Q. What cancer might have an elevated CD25 level?

• A. Hodgkin’s disease
• B. Myeloma
• C. Hairy cell leukemia
• D. Anaplastic large B cell lymphoma
• Answer: C. Hairy cell leukemia

• HCG: gestational trophoblastic disease, gonadal germ cell tumor

• Calcitonin: medullary thyroid cancer
• Catecholamine: pheochromocytoma
• AFP: HCC, gonadal germ cell tumor
• CEA: colon, pancreas, lung, breast, ovary
• Neuron-specific enolase: small cell lung CA, neuroblastoma
• LD: lymphoma, Ewing sarcoma
• PSA: prostate
• Monoclonal Ig: myeloma
• CA 125: ovarian, some lymphoma
• CA 19-9: pancreas, colon, breast
• CD30: Hodgkin, anaplastic large cell lymphoma
• CD25: hairy cell leukemia, adult t cell leukemia/lymphoma
• Q. Which cancer drug usually causes delayed emesis?

• A. Paclitaxel
• B. Cisplatin
• C. Doxorubicin
• D. Cyclophosphamide
• Answer: B. Cisplatin

• Acute emesis: within 24 hours of treatment

• Delayed emesis: after 1-7 days of treatment
• Anticipatory emesis: occurs before administration of chemo drug

• Nausea with or without vomiting: MC S/E of chemo drug

• Q. Components of Horner’s syndrome, EXCEPT:

• A. Anhydrosis
• B. Enophthalmos
• C. Mydriasis
• D. Ptosis
• Ans. C. Mydriasis

• Horner’s syndrome
– Sympathetic nerve paralysis due to
regional spread of lung cancer
• Enophthalmos, ptosis, miosis, anhydrosis
• Small cell lung CA and squamous lung
CA
– Tobacco smoking; central lesions
• Adenocarcinoma of the lung
– Non-smoker, women; peripheral lesions
• Lung Cancer and Paraneoplastic Syndrome

• Small Cell Lung CA

– Hypercalcemia from PTHrP, SIADH, ACTH
– Lambert-Eaton syndrome
• Non-small Cell Lung CA
– Clubbing

• Trousseau’s syndrome: migratory venous thrombophlebitis

• Q. Clinical feature that places a patient at increased risk to
develop breast CA?

• A. Nulliparity at 35 y/o
• B. Menarche at 16 y/o
• C. Menopause at 40 y/o
• D. First pregnancy at 18 y/0
• Ans. A. Nulliparity at 35 y/o

• Three dates in a woman’s life with major impact in breast cancer

incidence
– Age of menarche (the earlier, the higher the risk)
– Age at first full term pregnancy (the earlier, the lower the risk)
– Age at menopause (the earlier, the lower the risk)
• Q. Which of the following breast mass features is LEAST likely
malignant?

• A. irregularly shaped lesion

• B. hard lesion
• C. painful lesion
• D. tethered lesion
• Ans. C. painful lesion

• Most likely cancerous breast lesions

– Hard, irregular, tethered, fixed, painless
• Q. What type of colonic polyp with the highest probability of
malignant transformation?

• A. hyperplastic polyp
• B. juvenile polyp
• C. pedunculated adenomatous polyp
• D. sessile adenomatous polyp
• Ans. D. sessile adenomatous polyp

• Juvenile and hyperplastic polyps: non-neoplastic

• Adenomatous: pre-malignant
– Sessile > pedunculated
– Villous > tubuovillous > tubular

• Streptococcus bovis bacteremia: risk factor for colorectal CA

• Q. Location of colon cancer that presents as microcytic,
hypochromic anemia.

• A. ascending colon
• B. transverse colon
• C. descending colon
• D. rectosigmoid colon
• Ans. A. ascending colon

• Right sided colon CA (ascending colon): anemia

• Rectosigmoid: decreased caliber of stool

• Liver: initial and most frequent site of colon CA metastasis

• Carcinoid tumor: MC primary CA of the appendix, and small intestine

– Ileum: MC location of carcinoid tumor of the small intestine

• 5-Fluorouracil: backbone of systemic therapy for colon CA

– Administer with leucovorin
• Q. Most common type of Non-Hodgkin’s Lymphoma.

• A. Burkitt’s lymphoma
• B. Diffuse large B cell lymphoma
• C. Follicular lymphoma
• D. Mantle cell lymphoma
• Ans. B. Diffuse large B cell lymphoma

• Lymphoma as cause of Superior Vena Cava (SVC) Syndrome

– May give glucocorticoids

• Lung CA: most common cause of SVC syndrome

– Radiation: NSCL CA, metastatic solid tumors
– Chemo: SCLC, lymphoma, germ cell tumor

• Steroid: may have a role in lymphoma only

• Acute cecal dilation >12-14cm: surgical emergency

• Spinal cord compression: usually coming from lung, breast, and prostate
– Back pain worsened by lying supine

• Pemberton sign: (+) in SVC syndrome

Pemberton Sign
• Q. Which cancer may be prevented by aspirin intake?

• A. Lung cancer
• B. Breast cancer
• C. Colon cancer
• D. Cervical cancer
• Answer: C. Colon cancer

• Vaccination:
– HPV (nonvalent: 6,11,16,18,31,33,45,52,58)
– Hepatitis B

• Prophylactic bilateral mastectomy: BRCA1 and BRCA2 mutations

• Prophylactic salphingo-oophorectomy: ovarian and breast CA
• Q. Which is NOT a component of tumor lysis syndrome?

• A. Hyperuricemia
• B. Hyperkalemia
• C. Hyperphosphatemia
• D. Hypercalcemia
• Answer: D. Hypercalcemia

• TLS:
– Hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia
– Prevention: allopurinol, aggressive hydration
• Urinary alkalinization using NaHCO3: no longer recommended
• Q. Which skin cancer least likely metastasizes?

• A. Squamous cell cancer

• B. Basal cell cancer
• C. Merkel cell cancer
• D. Melanoma
• Answer: B. Basal cell cancer

• ABCDE of melanoma
– Asymmetry: benign lesions are usually symmetric
– Border irregularity: most nevi have clear-cut borders
– Color variegation: benign lesions are usually uniformly light or dark
pigment
– Diameter >6cm: size of a pencil eraser
– Evolving: any change in size, shape, color, elevation, new symptoms like
bleeding, itching, crusting)
• Squamous cell cancer
– Ulcerated erythematous nodule or superficial erosion on sun exposed
skin/sun-damaged area

• Basal cell cancer

– AKA Rodent ulcer
– Slowly enlarging, locally invasive

• Merkel cell cancer

– AKA cutaneous apudoma, primary neuroendocrine carcinoma of the skin
• Q. What is the typical histopathology of head and neck cancer?

• A. Adenocarcinoma
• B. Squamous cell cancer
• C. Lymphoma
• D. Sarcoma
• Answer: B. Squamous cell cancer

• Alcohol and Tobacco: most significant risk factors; synergistic

• Smokeless tobacco: oral cancer
• EBV: nasopharyngeal cancer, Burkitt’s lymphoma
• HPV: oropharyngeal CA, serotype 16, 18, better prognosis
• Salted fish consumption
• Q. Which salivary gland tumor is mostly malignant?

• A. Parotid gland tumor

• B. Submandibular gland tumor
• C. Sublingual gland tumor
• D. Minor salivary gland tumor
• Answer: D. Minor salivary gland tumor

• Generality of Salivary Gland Tumor

– Most parotid gland tumors are benign
– Half of submandibular and sublingual tumors are malignant
– Most of the minor salivary gland tumors are malignant

• Leukoplakia and erythroplakia: pre-malignant lesions in the oral

cavity
• Q. Which is a risk factor for squamous cell cancer of the
esophagus?

• A. Hot tea
• B. Obesity
• C. Barret esophagus
• D. Chronic GERD
• Answer: A. Hot tea
• Q. Which gastric cancer is highly responsive to H. pylori treatment
and eradication?

• A. GIST
• B. MALT lymphoma
• C. Gastric neuroendocrine tumor
• D. Metastatic tumor
• Answer: B. MALT lymphoma

• MALT lymphoma, H. pylori positive adenoCA: responsive to H.

pylori treatment and eradication
• GIST: commonly spindle cells seen under microscope, treated with
TKI like imatinib if with cKIT mutation
• Carcinoid tumor: MC small bowel neoplasm, commonly found in
the ileum
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