A Pain in the Knee Dexter Robertson is a 15 year old high school student from th
ID: 259420 • Letter: A
Question
A Pain in the Knee
Dexter Robertson is a 15 year old high school student from the Bronx, New York City, who presents to the ER in February 1998 with a complaint of “dull, aching pain” in his left knee for the past month. Dexter is a track athlete on his high school team, and reports accidentally tripping and falling on his left leg during practice about the same time the pain began. He lives with his mother and two younger siblings. In addition to attending high school, he works at the local supermarket to help support his family. He says that his leg pain has been interfering with his ability to concentrate in school and to have a good social life.
Dexter’s past medical history is unremarkable; he has never been hospitalized. His family history is positive for hypertension and alcoholism on his mother’s side. The physical exam is notable for tenderness in the left knee. The knee is slightly swollen, and there is a decrease in the range of motion of the left leg. A radiograph is taken, revealing a left proximal tibial mass. A tentative diagnosis is made, and Dexter is referred to Dr. Hardiman, an orthopedic surgeon at New York Presbyterian Hospital, for a definitive biopsy. The biopsy is done in March 1998, confirming the diagnosis of osteosarcoma. Dr. Hardiman discusses the nature of this cancer with Dexter and his parents, and recommends an above the knee amputation. Dexter refuses to consider this option, and asks for a second opinion. Dr. Hardiman refers Dexter to Dr. Ramirez at Mt. Sinai Hospital. Dr. Ramirez offers to try a new limb salvage procedure involving a total knee replacement and the placement of an expandable metal rod after resection of the tibial tumor. Dr. Ramirez informs Dexter that the operation is long (8-10 hours) and painful.
On the tenth post-operative day, Dexter is discharged home with recommended medications; some are NSAIDS.
He is also given instructions to begin outpatient physical therapy. He does very well over the ensuing months as he adapts to the metal prosthesis. He experiences occasional episodes of pain in his left leg, which is usually responsive to medications. Overall his prognosis and recovery are good.
Questions:
1. What is cancer? How does it occur?
a. Distinguish between cancer and tumor. Sarcoma vs Adenocarcinoma.
2. What are oncogenes and tumor suppressor genes? Give a specific example (name) of each.
3. In general, how does the immune system respond to cancer?
4. Why does radiation therapy often lead to hair loss and skin problems?
5. Discuss the use of non-steroidal anti-inflammatory drugs (NSAIDS) in the treatment of chronic pain
6. Describe several ways cancer/cancer cells evade the immune system
7. In the past decade, many investigations recorded heightened interest in immunotherapy
a. What is immunotherapy?
b. Imagine you are an immunologist presented with the task of using immunotherapy for Dexter’s
cancer. Devise an experimental plan for course of treatment.
Explanation / Answer
Please find the answers below:
Answer 1: Cancer can be defined as uncontrolled and rapid cellular division of any type of cells in the body leading to impairment in normal functioning of the body. The condition can be lethal, if untreated. Since cancer involves non-controlled cellular division, spontaneous mutations due to biotic/abiotic stressors/stimuli generally cause cancer.
Answer 2: Technically, the genes related to cancer have been distinguished into two categories, oncogenes and tumor suppressor genes. Whereas oncogenes are related to up-regulation of cancerous growth of cells such as Rb or retinoblastoma, tumor suppressor genes are involved in down-regulation or suppression of cancerous genes in the body such as p53..
Answer 3: In general, the cell-mediated immune response is highly active against the cancerous cells in the body. The Th1 and Th2 mediated anti-cancer response in the immune system secondary to MHC recognition causes activation of numerous cyto-toxic and cyto-phagic cells leading to destruction of cancerous cells.
Answer 4: Radiation therapy is a mitotic inhibitor therapy which is a routinely used non-surgical method to reduce or eliminate cancerous cells and their growth in the body. Since radiation is a non-specific mitotic inhibitor and hairs/skin are highly active in terms of mitotic cell growth, these appendages/extensions suffer deleterious effects from radiation therapy and thus, hair loss occurs along with multiple skin problems.
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