APL and Supportive Care

Question 1

How does APL arise

Answer 1

from a single translocation

Question 2

Why is APL an oncologic emergency?

Answer 2

Rapidly evolving clotting abnormalities, risk for fatal hemorrhage

Question 3

RNF4

Answer 3

E3 ubiquitin ligase that marks PML for destruction

Question 4

ATRA

Answer 4

all trans retinoic acid

Question 5

As2O3 mechanism

Answer 5

RNF4 marks PML for destruction as sulfur coordinates to As, results in conformational change in PML

Question 6

In APL what is the relation between PML and RAR-alpha?

Answer 6

juxtaposed

Question 7

What does RAR-alpha do normally?

Answer 7

Signal for terminal differentiation for pro-lymphocytes

Question 8

What happens when PML and RAR-alpha are juxtaposed?

Answer 8

Low affinity for RA, less terminal differentiation

Question 9

What happens when give ATRA?

What happens if you stop ATRA?

Answer 9

• Therapeutically drives RAR-alpha, pro-lymphocyte differentiation - hematologic remission
• Disease comes back

Question 10

ASO3 and ATRA together?

Answer 10

AsO3 Induces degradation of chimeric protein
(Induces apoptosis)
ATRA addresses maturation block

Question 11

3 contexts of nausea?

Answer 11

Anticipatory
Acute
Delayed (>24 hours)

Question 12

Differential of nausea (besides emetogenic potential of drugs)

Answer 12

Anxiety, GERD, mechanical obstruction, increased intra-abdominal pressure, intraperitoneal blood, increased intracranial pressure, biliary/uretral colic, pregnancy

Question 13

What is true about pregnancy and young women?

Answer 13

They are all pregnant until proven otherwise

Question 14

Mech of acute nausea?

Answer 14

In GI tract, 5HT stimulates vagus nerve

Peripheral Pathway

Question 15

Mech for treating acute nausea?

Answer 15

5HT receptor antagonist

Question 16

Mech of chronic nausea?

Answer 16

chemical trigger in brainstem, NK-receptor

Question 17

Mech for treating chronic nausea?

Answer 17

NK1-receptor antagonists (block substance P)

Question 18

ABCD of nausea drugs?

Answer 18

Ativan (lorazepam)
Benadryl (diphenhydramine)
Compazine (chlorpromazine) or haliperidol or olanzapine
Dexamethasone

Question 19

Cancers known for thrombotic diathesis?

Answer 19

Pancreas
Breast
Prostate
Bladder
Lung 
CNS

Question 20

What correlates with poor survival in cancers?

Answer 20

elevated D-dimer
elevated INR
other measures of hypercoagulability

Question 21

Relationship between high BMI and clotting?

Answer 21

BMI high results in more estrogen, estrogen goes to liver and makes clots

Question 22

Most active agent to manage DVT in cancer?

Answer 22

low molecular weight heparin (LMWH)

Question 23

How long should cancer patients stay on LMWH?

Answer 23

at least two weeks, ideally until thrombogenic stimulus is removed.

Question 24

Why metastasis to bone?

Answer 24

good ‘soil’ for cancers

Question 25

What two cancers universally affect bone?

Answer 25

Breast and Prostate

Question 26

Bone directed treatment extends survival in what three cancers?

Answer 26

Myeloma Breast Renal (NOT prostate)

Question 27

Classic anti-resorptive therapy

Answer 27

bisphosphonates

Question 28

Most potent anti-resorptive therapy

Answer 28

zoledronic acid

Question 29

What cancer drugs make gut sluggish?

Answer 29

Vica alkaloids and microtubule poisons

Question 30

Best drugs that cause diarrhea?

Answer 30

Irinotecan and 5-FU

Question 31

Why is polyethylene glycol good at treating constipation?

Answer 31

gentle, doesn't cause gas

Question 32

Mineral oil

Answer 32

prevents tearing (constipation)

Question 33

Never write a prescription for narcotics...

Answer 33

without discussing specific measures for constipation

Question 34

Fiber?

Answer 34

Don't forget to supplement (on both ends of spectrum)

Question 35

First step in treating diarrhea?

Answer 35

Electrolyte supplementation

Question 36

What is useful in secondary diarrhea (unresponsive to other treatments?)

Answer 36

Somatostatin analogues

Question 37

Tincture of opium

Answer 37

Treatment of diarrhea (quite useful)

Question 38

Do not write a prescription to treat diarrhea...

Answer 38

without electrolytes

Question 39

Myelosuppression treatment

Answer 39

G-CSF available as recombinant peptide

Question 40

G-CSF side effect

Answer 40

Low back pain

Question 41

Use of EPO in cancer patients?

Answer 41

restricted to transfusion dependent marrow failure

Question 42

Hgb above 10

Answer 42

associated with worse outcomes (if previously anemic)

Question 43

FDA drugs approved for chemo induced thrombocytopenia?

Answer 43

Eltrombopag | Romiplostim