Cancer Assessment 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 therapyectopic 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,
ook 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
TNMT -
tumor size 1-4N -
lymph node involvement 0-3M -
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 endothelial damage (looks like pneumonia, type 1&2 alveolar necrosis - pulmonary fibrosis - no Rx
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
radiation to chest pulmonary adverse effects
interstitial pneumonitis,
pulmonary fibrosis
tracheal stenosis
get pre op 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 - permanent injury marked by 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 of:
Cyclophosphamide
Methotrexate
Vinca Alkaloids
Cisplatin
Alkylating agents
high dose Cyclophosphamide - acute delirium, encephalopathy, ataxia
Methotrexate - dementia
Vinca 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, recentPE,
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
