Cancer Flashcards
Most common cancers
Lung (#2 in men, increasing in women)
Breast (#1 in women)
Colon/GI (#2 cause of death overall)
Prostate (#1 in men)
Head & Neck Metastatic tumors - brain, liver, spinal cord, superior vena cava compression
Pathological changes in hematologic system
Anemia: bone marrow suppression, GI ulcerations and anemia due to invasion Neutropenia Thrombocytopenia Hypercoagulable state: risk of thromboembolic event
What hematologic questions to ask pt?
have you been anemic infections do you bruise/bleed easily blood clots
Neuromuscular system pathologic changes
myofascial pain, peripheral neuropathies spinal cord compression
What neuromuscular questions to ask pt?
do you have numbness/tingling can you move all extremities do you have good strength are you in pain
Pulmonary system pathological changes
pulm edema/CHF recurrent pleural effusions (metastasis) pneumonitis pulmonary osteoarthropathy
Pulmonary osteoarthropathy definition
condition that affects some lung CA pts: clubbing spoon-shaped nails inflammation/swelling/pain of hands, fingers, knees, ankles
Squamous cell lung CA incidence and effect
25-40% hypercalcemia
Adenocarcinoma lung CA incidence and effect
30-50% hypercoagulable osteoarthritis
Large cell lung CA incidence and effect
10% gynecomastia
Small cell lung CA incidence and effect
15-24% inappropriate ADH secretion ectopic corticotropin secretion Eaton-Lambert syndrome (myasthenia syndrome)
Various pathological changes
anorexia/weight loss - hyperalimentation (artificial nutrients, typically IV) electrolyte abnormalities - hypercalcemia from bone metastasis Na & K changes from N/V/diarrhea adrenal insufficiency - tumors or corticosteroid therapy ectopic hormone production - from syndromes that release extra hormones (ADH)
Cardiac system pathological changes
malignant involvement of the pericardium (pericardiual effusions) electric alternans or paroxysmal A-fib/flutter pericardial tamponade (most common in lung CA) drug induced cardiomyopathy impairment of LVF for 3 years after therapy has stopped SVC obstruction - metastatic to mediastinum venous engorgement above waist: dyspnea, airway obstruction (especially when lying down) facial/neck edema, JVD
What cardiac questions to ask pt?
ask about exercise intolerance SOB recent echo manually feel pulse, look for JVD ask about masses
Renal pathological changes
decreased clearance drug induced nephrotoxicity/nephrotic syndrome ureteral obstruction - hydronephrosis hyperuricemia
Hepatic pathological changes
hepatocyte damage coagulopathies (hypercoagulable state in general) DIC common with hepatic metastasis
metabolic changes in CA pts
catabolic state: diarrhea poor nutritional status (check albumin, will affect protein bound drugs) volume depleted state - hypotension
Paraneoplastic syndrome incidence rate
8% of CA patients
Paraneoplastic neurologic changes
limbic encephalitis cerebellar degeneration myasthenia syndrome and gravis
Paraneoplastic endocrine changes
SIADH (headache, nausea, ataxia, lethargy, seizures) hypercalcemia Cushing’s syndrome hypoglycemia
Paraneoplastic renal changes
nephritis amyloidosis
Paraneoplastic other changes
fever cachexia dermatologic changes rheumatologic changes hematologic changes
Cancer staging
TNM T - tumor size 1-4 N - lymph node involvement 0-3 M - metastasis 0-no, 1-yes stage 1 best prognosis stage 4 worst prognosis
Lung CA surgery considerations
associated CAD pulmonary insufficiency after tissue resection potential for massive blood loss special equipment (double lumen ETT)
Lung CA surgery preop labs/testing
Pulm function tests DLCO VO2 max CXR ABGs baseline O2 sat cardiac stress test H/H, type and cross blood
Head and Neck CA surgery considerations
review imaging to assess airway needs ask about dysphagia, difficulty breathing potential for significant blood loss (H/H, type and cross) lack of accessible airway, get special equipment hypercalcemia related to metastasis often heavy drinkers, get liver function test
Breast CA surgery considerations
poor IV access limb at risk of lymphedema think about a PICC line
Colon/GI CA surgery considerations
possible aspiration risk - give prophylactic meds (no Reglan) possible dehydration from GI obstructions - give preop fluids
Prostate CA surgery
associated with increased bleeding
Cancer treatment types
traditional - when you can’t differentiate between cancer and normal cells, increased cell death targeted - given for specific cell division process radiation - external beam, pellet/implant Ablation - thermo, microwave, cold, electric field therapy
Doxorubicin & Daunorubicin adverse effects
dose related cardiomyopathy acute: 10% (benign and usually resolves in 1-2 months), disrhythmias, QT prolongation chronic/severe: 2%, progessive onset, 60% mortality in 3 weeks (unresponsive to mechanical/drug therapy) enhances myocardial depression with anesthetics acute LV failure during GA 2 months after cessation can develop years after having drugs - get an Echo
Fluorouracil adverse effects
pericarditis angina coronary artery vasospasm ischemia related ECG changes conduction defects
Bevacizumab, trastuzumab, sorafenib adverse effects
targeted therapy HTN vascular thromboembolic complications bleeding - must stop 4-8 weeks before surgery!
Radiation to chest cardiac adverse effects
myocardial fibrosis pericarditis valvular fibrosis conduction abnormalities get EKG, CXR, stress test, ECHO, vital signs, BNP level
Bleomycin adverse effects
anti-tumor antibiotic dose related toxicity, rare below 150mg/m2 pulmonary lymphomas, reproductive cancers pulmonary endothelial damage (looks like pneumonia, type 1&2 alveolar necrosis - pulmonary fibrosis Pulm hypertension increased A-a gradient induced hyperoxic pulmonary injury: free radical formation (don’t give 100% FiO2) Get PFT, CXR, ABG, SaO2, keep FiO2 < 30% colloid vs crystalloid, corticosteroids
Methotrexate adverse effects
antimetabolite - toxicity 8% immunosuppressant drug (RA, Chron’s) and chemo drug fulminant non-cardiogenic pulmonary edema progressive inflammation with infiltrates, effusions, pulm. edema
radiation to chest pulmonary adverse effects
interstitial pneumonitis, pulmonary fibrosis tracheal stenosis get O2sat, CXR, PFT, ABG
Cisplatin adverse effects
alkaline chemo agent - dose limiting effect decreased GFR within 3-5 days renal insufficiency, hypomagnesemia ATN - acute renal failure requiring hemodialysis peripheral neuropathy
Cyclophosphamide adverse effects
SIADH syndrome hemorrhagic cystitis (bladder bleeding) plasma cholinesterase inhibitor - succs will be prolonged
Ifosfamide adverse effects
tubule dysfunction proteinuria, glucosuria
High dose radiation renal effects
tumor cell lysis will release large amounts of uric acid, phosphate, potassium hyperuricemia - uric acid crystals precipitate in renal tubules - acute renal failure glomerulonephritis, glomerulosclerosis - chronic renal insuffiency, systemic HTN get BUN/Cr, urine analysis, phosphate and potassium levels
Ca treatment hepatic adverse effects
Methotrexate - associated with acute liver dysfunction radiation - associated with sinusoidal obstruction syndrome (severe liver dysfunction) get liver function test, albumin levels
Ca treatment airway/oral cavity issues
mucositis - from high dose chemo and radiation radiation - permanent tissue fibrosis limited mouth opening limited neck ROM limited tongue mobility tracheal stenosis pre - op airway assessment, cervical ROM, xray, ENT consult
Ca treatment GI/Endocrine adverse effects
N/V/Diarrhea, enteritis common with chemo/radiation abd radiation can produce permanent adhesions and stenotic lesions on GI tract hyperglycemia from glucocorticoid therapy SIADH with cyclophosphamide, ifosfamide, cisplatin hypothyroidism from radiation to neck get thyroid function test, chem panel, glucose level, urine specific gravity
Ca treatment hematologic system adverse effects
chemo: myelosuppression thrombocytopenia/platelet dysfunction tumors releasing procoagulants radiation: coagulation necrosis of vascular endothelium post radiation bleeding get CBC, PT/PTT, INR
Ca treatment nervous system adverse effects
high dose Cyclophosphamide - acute delirium, encephalopathy, ataxia Methotrexate - dementia Vinea Alkaloids (Vincristine) sensorimotor peripheral neuropathy autonomic neuropathy - usually reversible cisplatin - dose dependent damage to dorsal root ganglia - large fiber neuropathy Alkylating Agents (Cytoxan) plasma cholinesterase inhibition anticholinesterase effects - succs is prolonged
CA Nausea/Vomiting management
metoclopramide, droperidol, zofran provide reassurance that measures will be taken to control n/v
CA pain management
will have increased requirements for analgesia opioids are drug of choice dilaudid vs fentanyl non-opioids? antidepressants/convulsants, maybe Ketamine nerve blocks - neurolysis corticosteroids adrenal insufficiency preop supplemental steroids
Specific electrolytes to double check pre op
Na, K, Mg, and Ca if metastasis to bone
Full list of pre op lab values and studies to check for CA patient
CBC - anemia, thrombocytopenia, neutropenia Coags - PT, PTT, INR Complete Metabolic Panel - with Mg, Ca, BUN/Cr, Albumin, glucose Liver function tests, AST, ALT ABG CXR 12 lead EKG ECHO Pulmonary Function Test
What are you looking for in a CXR
tracheal deviation/compression masses aortic aneurysm cardiomegaly pulmonary edema pneumonia atelectasis chronic diseases
What are you looking for in an EKG
A fib/flutter, heart blocks, ST-T changes anything indicating ischemia, infarct, recent PE, PV, PACs, LVH, RVH, WPW, prolonged QT, shortened PR interval, peaked T waves
Primary location/Metastasis/treatment side effects
lung - oxygenation, cough, hemoptysis, wheezing, stridor, dyspnea, hoarseness mediastinum - SVC syndrome GI/Liver - metabolic/electrolyte/fluid changes Brain - headaches/seizures Throat/thyroid - dysphasia, stridor, hoarseness
CA patient airway evaluation
tracheal deviation/compression SOB dyspnea dysphagia colon obstruction? (aspiration risk) will they need one lung ventilation?
CA patient physical exam
breath sounds heart sounds airway exam jaundice? edematous? assess for IV insertion difficulty muscle weakness (myasthenia gravis like complications from ectopic hormonal release) fingernail clubbing
Pre op correction of abnormalities
nutrient deficiencies - give IVF electrolyte abnormalities - EKG changes anemia - type and cross - watch for transfusion problems coagulopathies - increased risk of bleeding intraop
