Cancer Flashcards
Cancer is the ___ leading cause of death in US
Cancer is the __2nd_ leading cause of death in US
Second only to heart disease
Lifetime risk of developing cancer is 1 in 4 for men and 1 in 5 for women.
90% of patients with cancer will require surgery
Most common cancer types among genders?
Male
- prostate
- lung
- colon
Female
- breast
- lung
- colon
Common adverse effects of radiation therapy? (Skin, GI, cardiac, resp, renal, hepatic, endocrine, hematologic)
15
Can cause
- rash/erthyema
- fibrosis/sclerosis/telangioectasis
- malnutrition/mucositis/nausea
- adhesions/fistulas/strictures
- conduction defects
- perciardial effusion / pericardial fibrosis
- pulmonary fibrosis / pneumonitis
- tracheal stenosis
- Glomerulonephritis
- Glomerulosclerosis
- Sinusoidal Obstruction syndrome
- Hypothyroidism
- Panhypopituitarism
- Bone marrow suppression
- Coagulation necrosis
“Focuses” of preop assessment for Ca patient?
+ anesthetic considerations
-
Malignancy in head/neck
- airway exam and possible need for trach
- recurrent laryngeal nerve damage
- if they have had radiation - be aware of risk for trachel stenosis, sclerosis of joints, fragility of blood vessels
- maybe consider a smaller ETT
-
Mediastinal masses obstructing great vessels
- dyspnea, dysphagia, stridor, wheezing, coughing–> recumbent positon
- compression of SVC–> JVD, Facial, chest , neck, UE edema
- be aware that laying down may compress trachea
- Preop testing: CXR, CT, MRI, EKG, Echo
EKG/ECHO - conduction abnormalities r/t radiation, myopathy r/t chemo agents.
- Anesthetic concerns
- airway cart
- emergency suppy
- trach
- spontaneous awake intubation
- ENT at bedside
What is SVC syndrome?
5
- Obstruction of superior vena cava caused by spread of Ca into mediastinum or into caval wall
- veins above level of heart, particularly with jugular veins and veins in arms, become engorged
- edema of face and UE prominent
- increased ICP manifests as nausea, sz, decreased LOC
- May cause syncope
What is superior mediastinal syndrome?
4
- combo of SVC syndrome and tracheal compression
- Hoarseness, dyspnea and airway obstruciton may be present b/c tracheal compression
- txmt consist of radiation therapy or chemo
- bronchoscopy/mediastinoscopy to obtain tissue dx can be hazardous
What to look for in airway assessment of Ca patient?
5
- tracheal deviation or compression
- SOB
- dificulty breathing
- dysphagia
- cervical ROM, cervical Xray, ENT consult
What can radiation to head/neck be concerning for?
5
- permanent tissue fibrosis
- carotid artery dx
- hypothyroidism
- difficult vent
- difficult intubation
Special anesthesia preop consideration of head and neck ca?
- Review imaging studies to determine if alternate airway mgmt plan should be used
- question pt regarding dysphagia and difficulty breathing
- sx blood loss can be sig T&C, CBC
- Lack of accessibility to airway during case
- hypercalcemia related to METS
- alchol induced liver dx
- chornic smoking hx PFT, pulm toilet, inhalers
- May need nutritional therapy preop
- plan for difficult airway
- may need invasive monitorign ie aline
Concerns for geriatrics with ca?
4
- Greater comorbidities,
- fraility,
- polypharmacy
- risk of delirium
- chemobrain- chemo induced cognitive dysfunction
Education and prevention around sx with ca patient?
2
- management of comorbidities
- exercise routine prior to sx- improves surgical recovery and overall survivorship
Concerns during assessment of CV system in Ca patient?
- HR, pulse, carotid arteries
- if bruits present-> ask patient to stop breathing 15 sec
- if severe stenosis and large intraop fluid shifts are expected, revascularization is considered
- mild stenosis= pharm therapy
- sig fatigue and loss of functional status
- echo ordered and result WNL may not mean much under stress of sx
- Cardiac stress testing might be considered?
- maybe BNP
What is one drug that strongly affects CV system?
doxorubicin (adriamycin)
- Acute/chronic
- QT prolongation
- dysrhythmia
- ischemia-related EKG changes
- HTN (monoclonal antibodies and tyrosine kinase inhibitors)
Considerations for respiratory system assessment for Ca pt?
- Baseline and serial PFT
- Chest radiography
- pleural effusion
- bleomycin?
What are some complications with adenocarcinoma? large cell lung Ca? small cell lung Ca?
- Adenocarcinoma (30-50%)- blood clots
- large cell- gynecomastia
- small cell- muscle weakeness, paraneoplastic syndromes
Which cancers are known for secreting ADH?
- Duodenal
- lung (small cell)
- lymphoma
- pancreatic
- prostate
Which cancers can secrete human chorionic gonadotropin?
- Adrenal
- breast
- lung (large cell)
- ovarian
- testicular
causes gynecomastia, galactorrhea, precocious puberty
Which Ca can secrete adrenocorticotropic hormone?
- Carcinoid
- lun g(small cell)
- thymoma
- thyroid
manifestation: cushing syndrome
How can the renal system be impacted with cisplatin and cyclophosphamide?
- Cisplatin (and methotrexate)
- renal insuff– usually resolve with cessation of drug
- Cyclophosphamide
- SIADH
- cystitis
- medication concern: mivacurium, succinylcholine
- renal labs
- tumor cell lysis
- uric acid crystal buildup
How many days after chemo does nadir happen?
7-14 days
What are some various neuro system implications with vincristine, coritcosteroid and radiation+ methotrexate
- Vincristie- parasthesias, peripheral neuropathy, encephalopathy
- corticosteroid- induced neuromuscular toicity (prednisone 60-100mg/day)
- radiation +methotrexate–> irreversible dementia
GI system consideration for Cancer patient?
- Almost all chemo and radiation produce GI se
- mucositis
- n/v/d
- electolyte imbalances, dehydration, malnutrition
- radiation–> stenotic lesions throughout GI tract
- sinusoidal obstruction syndome–> can be fatal
- reactivation hep B
Why are steroids used during Ca txmt?
- Addition to chemotherapy regimen–> reduce inflammation, reduce N/V, boost appetitis
- might unmask undx diabetes
- might make known dm more difficult to tx
- increase risk of adrenal insufficiency (suppression of HPY axis)
- radiation to neck might alter thyroid function
What is the multiple hit hypothesis for cancer deconditioning?
- Chemo
- radiotherapy
- sx
- cancer
- age
- medical comorbidities
- sedentary lifestyle
- cancer fatigue
What are some preoperative considerations to optimize patient for sx?
- Nutrient deficiencies
- electrolyte abnormalities
- anemia
- coags
- steroid replacement
Common sites of mets for breast ca? prostate ca? lung ca? colon ca?
- Breast ca–> bone
- prostate ca–> bone
- lung ca (Esp small cell)–> brain
- colon ca–> liver
What are you looking for on CXR for Ca patient?
- Tracheal deviation or compression
- masses
- aortic aneurysm
- fractures (ribs, clavicle, vertebrae)
- cardiomegaly
- pulmonary edema
- PNA
- atelectasis
- chronic dx
Spinal cord compresion in Ca?
- urinary or bowerl incontinence
- peripheral neuropathies
- gait distubrances
Cardiac tamponade s/s?
- muffle heart tones
- elevated JVD
- distended neck veins
- progressiv edyspnea
Neutropenia sepsis s/s?
- Low grade fever or none
- cough
- arthralgia
CNS metastasis s/s?
- HA
- visual disturbance
- balance and gait disturbance
- confusion
- n/v
Tumor lysis syndrome s/s?
- Elevated uric acid, K, phos level
- often seen 12-72 hours post chemo tx for hematologic malignancy
*
What to consider with cancer to head/neck -4
and
Radiation to Head and Neck -6
These patients need an airway assesment that also includes -5
WHAT TO CONSIDER WITH CANCER TO HEAD/NECK:
- airway exam, evaluate for possible need for tracheostomy
- assess for recurrent larygneal nerve damage - affect ability to open vocal cords
- mediastinal masses! Can obstruct great vessels, lead to JVD, face, neck, UE edema.
- mediastinal masses- can also lead to dyspnea, dysphagia, stridor, wheezing, coughing, can be worse when laying down and lead to tracheal compression
RADIATION TO HEAD/NECK
- possibility of permanent tissue fibrosis
- carotid artery ds (assess for bruits, could be stenosis of carotid artery, vascular consult)
- hypothyroidism (can lead to goiter affecting airway)
- Tracheal stenosis
- difficult ventilation
- difficult intubation
WHEN DOING AN AIRWAY ASSESMENT;
- look for tracheal deviation or compression
- SOB
- Dyspnea/difficulty breathing
- dysphagia
- CERVICAL ROM, consider cervical XRAY
CXR, CT, MRI, echo? EKG?
Cancer Surgery for Head and Neck cancer - what to consider
6
- Review imaging studies to determine if alternate airway management plan should be used, i.e. assess for r/f tracheal compression
- Assess for dysphagia, diffilculty breathing, signs of airway obstruction
- Be aware surgical blood closs can be significant, consider type and cross, CBC
- May not have accessiblity to airway during case, may need special equipment
- Plan for difficult airway
- May need invasive monitoring
Perioperative assessment of Cancer pt - CV system
5
EFFECT OF RADIATION ON CV SYSTEM
- Assessment of HR, pulse, carotid arteries
- if bruits are present, 70% occlusion already, depending on surgery, if large fluid shifts are expected - may need to do revasc first.
- significant fatigue and loss of functional status - ECHO, results WNL - cardiac stress testing if high risk surgery, check BNP
- EKG - QT prolongation, cardiomyopathy, dysrthymias, ischemia related EKG changes
- HTN may be from monoclonal antibodies
EFFECT OF RADIATION ON CV SYSTEM:
acceleated CAD, valvular fibrosis, conduction abnormalities, need perioidc ECHO.
if doxorubicin - perioidic ECHOs
Lung Cancers:
Adenocarcinoa
Large Cell Carcinoma
Small cell carcinoma
Adenocarcinoma:
- peripheral location
- hypercoaguable state
- arthritis
Large Cell Carcinoma
- Peripheral location
- gynecomastia r/t tumor secreting HCG
Small Cell Carcinoma:
- SIADH - ADH secreting
- Cushingoid symptoms- inc. cortisol
- Eaton Lambert - muscle weakness
- PTH secreting tumor - hyper Ca++
- central origin
Effect of Chemo/radiation on GI system
8+
- Mucositis
- N/V
- diarrhea
- electrolyte imblanaces
- dehydration
- malnutrition
- radiation -> stenotic lesions throughout the GI tract,
- sinusoidal obstruction syndrome -TBI
- ?reactivation of HEP b?
What to consider with cancer pts - endocrine system
- steroids are frequently used for tx, reduce inflammation, reduce N/V, stimulate appetite
- could cause HPA , may need stress dose in surgery
- might lead to DM or make DM harder to tx
- radiation to neck may lead to hypothyroidism, which may ultimately cause goiter
For cancer patients, we want pre-operative correction of
5
- Nutrient deficiencies
- Electrolyte Abnormalities
- Anemia
- Coagulopathies
- Steroid Replacement
what metastasizes where
breast -> bone
prostate -> bone
lung cancer -> brain
colon cancer -> liver
