Exam 3: Oncology Flashcards
1
Q
Causes of Cancer
A
- Genetic
- Mutation in DNA causing photo-onco genes to turn on when they shouldn’t, leading to increased cell division as well as turning off tumor suppressing genes
- Failure of immune system to distinguish between normal and abnormal cells
- T cells responsible for monitoring cancer cells: CD8
- Carcinogens (tobacco, UV light, radiation, etc)
~There are a lot of overlap of symptoms with children; sometimes cancer is misdiagnosed or not diagnosed
Ex:
*Tired, bruising, pain, lymphadenopathy
*Universal symptoms in infants: poor feeding, irritability, fever
2
Q
Pediatric Cancer Protocols (3)
A
Include:
- Diagnostic workup for that type of cancer
- Treatment: Type, dosage and frequency of the chemo
- Follow up for the patient (especially looking at the cognitive/neurological impact the tx had)
3
Q
Cancer Reoccurence post-treatment
A
Causes of reoccurrence of initial cancer or initiation of a new cancer:
- Treatment of the cancer itself due to suppressed immune system and/or radiation
- Improper treatment of the original cancer
4
Q
Chemotherapy
A
A type of antineoplastic drugs, it kills both the bad and good type of cells
*Tumors poses ability to develop resistance to chemo, so variety of drugs are frequently used; Children will usually be on several types of chemo due to this
5
Q
Pre-chemotherapy treatment
A
An evaluation is required of physiological preparation and psychological preparation
*Make sure to get baseline of function of different organs in the body
- Certain chemos are very toxic to organs,
- for example, Adriamycin is toxic to the heart, will need full cardio workup
6
Q
Chemotherapy routes
A
Oral, IM, IV, subcutaneous, intrathecal
*It will usually be given via IV
- IM and subq is rare
- Intrathecal: in spinal cord; will be getting spinal tap and chemo is administered directly into spinal column
- Intrathecal is part of ALL chemotherapy protocol
7
Q
Types of chemotherapy (6 with examples)
A
- Alkylating agents – Cytoxan
- Antimetabolite – methotrexate
- Plant Alkoids – Vincristine
- Antitumor Antibiotics – Adriamycin
- Hormones – Prednisone
* *Will be on very large doses of prednisone
* *Prednisone may bind to DNA and help alter the transcription process to alter the mutation that occurs - Enzymes – L-asparaginase
8
Q
Side effects of chemotherapy (7)
A
Many side effects because chemotherapy non-selectively kills rapidly diving cells
- Bone marrow suppression – neutropenia, anemia and thrombocytopenia
- Gastrointestinal
- Very bad/metallic taste in mouth
- Alopecia
- Organ damage
- Mucositis and oral candidiasis/thrush
- Anorexia (associated with the very bad taste in mouth)
9
Q
Bone marrow suppression side effect of chemotherapy (and when does it reach its peak?)
A
Reaches it’s peak about 7-10 days after initiating chemo
- Neutropenia: low WBC levels
- Anemia: low RBC levels
- Thrombocytopenia: low platelets
- Will need to monitor patient for bleeding, infections, platelet count
- May require isolation by looking at absolute neutrophil count
10
Q
GI side effects of chemotherapy (4)
A
- N/V (Give zofran or kytrel ~30min before chemo and give it post chemo)
- Constpiaton
- Mucosal ulcerations
- Esophagitis
11
Q
Organ damage side effect of chemotherapy
A
Organ effected depends on type of chemo treatment, but KIDNEYS ARE ALWAYS AFFECTED!
- May have hearing loss, heart defects, etc.
- Know from protocol what organ specific damage may occur
- Since kidneys are always affected, you will need to obtain urine test/pH test prior to chemotherapy
12
Q
Mucositis and oral candidiasis/thrush
A
- Makes it difficult to tolerate foods and fluids
- May be getting IV fluids
- Give magic mouth wash (nalox, Benadryl, lidocaine; watch for seizures with lidocaine)
- Can also suck on ice pops
13
Q
Radiation treatment
A
- Slows tumor cell and kills rapidly dividing cells
- Can be curative or palliative
- -Palliative to shrink tumor or prevent it from getting better to decrease pain associated with the tumor - Can be used to prepare children for BMT because total body radiation suppresses the immune system to try and prevent host vs graft syndrome
* Always try and have the children see the radiation site before they go for treatment, as the site can be frightening
14
Q
Side effects of radiation treatment
A
- Rash or burns
- Can affect bone growth
- Side effect of cranial radiation: cognitive changes/delays, especially to younger children under 3!!**
15
Q
Pre-radiation interventions (2)
A
- Patient will be tattooed before getting radiation
* Small, permanent mark to know where to focus the beam - May need to get conjusidation (pooposed?!) because they need to lay totally still during it
16
Q
Surgery treatment
A
Can be to:
1. Biopsy a tumor
- Debulk and resect
- Insert broviac or portocatheter
17
Q
Surgery: debulk and resect
A
Debulk: try to make tumor smaller then give chemo and/or radiation to remove the remainder
Resect: totally remove the tumor
18
Q
Broviac or Portocatheter Placement
A
A central line with chemotherapy because peripheral veins don’t tolerate chemotherapy
*Goes right into right atrium
Broviac: Double lumen for meds and drawing blood, get sterile dressing changes once a week
*Both you and the child have to be masked during these procedures
Portocatheter: has skin over it/reservoir it’s closed to prevent infections
- Benefits:
- Much less risk of infection
- Can shower, swim, etc.
*Drawback:
-Needle is quite big
-May be more difficult to access
~Use emlocream to numb it so it’s not uncomfortable for the child
19
Q
Bone Marrow and Stem Cell Transplant
A
For children who have malignancies that can not be cured by other means (surgery, chemo, radiation)
Types:
- Allogenic
- Syngeneic
- Autologous
- Patients will be getting chemo until they can receive BMT
- WBC is transplanted via an IV then goes to patient’s bone marrow
20
Q
Allogenic BMT
A
From a donor
21
Q
Syngeneic BMT
A
From an identical twin
*Not usually used anymore because getting the identical twin’s BMT may actually cause the genetic component of cancer
22
Q
Autologous BMT
A
From self; when patient gets their own stem cells/bone transplant
- Used to try and prevent GVHD
- Used to try and eradicate as much of the cancer before it’s harvested because when harvesting the stem cells, they end up harvesting a lot (purging: to try and get rid of whatever cells are left that are abnormal cells)
- Won’t have to be on immunosuppresants post transplant
23
Q
Preparation for Transplant
A
Known as “conditioning phase”
- Will get high dose chemotherapy with or without radiation
- During this phase, they are going to be very susceptible to infection; will be on isolation precautions for a long time
*Will have a timeline
A.-14, -13, etc = conditioning phase leading up to the transplant
B. 0 = day patient is getting transplant
C. +1, +2, etc is the time after receiving transplant
*Look at these to know where they are in conditioning/receiving the BMT
24
Q
ALL type that has poor prognosis
A
Philadelphia chromosome (+) ALL
95% will relapse during first year of chemotherapy
25
Some cancers that require BMT
1. Philadelphia chromosome (+) ALL
2. Neuroblastoma (b/c it's usually not diagnosed until ~4 years old so there is poor prognosis)
3. Hotchkins or Non-Hotckins and relapse during treatment (because generally they have a good prognosis, so relapsing during treatment will require BMT)
4. AML type Leukemia
* Because these don't respond to chemo, radiation, or surgery, and BMT is part of the protocol
* Will be getting chemo until the BMT
26
Engraftment
Usually occurs 2-4 weeks after transplant.; WBC, RBC, and platelet production indicates “engraftment”
* When they start making their on WBC, RBC, and platelets
* If it’s day 21 and you don’t see an increase in these, that is a major concern that maybe they are not engrafting
* Important to follow blood work before, during, after transplant!!
27
Post-BMT Complications: GVHD
Occurs when WBC from donor identify patient’s bone marrow as foreign and attack them.
* IF YOU START TO SEE SYMPTOMS AROUND DAY 4, IT IS MOST LIKELY NOT GVHD!
* GVHD takes 2-4 weeks to develop
*If a patient has an allogeneic transplant and gets GVHD, they can increase the immunosuppresents, may give extra prednisone, etc. to try and counteract reaction and prevent it from going further
28
GVHD Signs and Symptoms
1. Fever
2. Rash (will biopsy rash to dx GVHD)
3. V/D
4. Can attack liver; elevation in liver enzymes
*Not 3 days post transplant, needs to be ~2 weeks after
29
Post-Transplant Interventions (3)
1. Immunosuppressants (unless autologous BMT)
2. Watching for complications such as GVHD
3. May need to get new immunizations/boosters because the antibiotics have been wiped out
30
Biotherapy Treatment (5)
An alternative to chemotherapy
1. Using part of the human body that are programmed to destroy cells and applies them to cancer cells
- -->Developing tumor specific antibodies, specific to cancer type to destroy it
2. Group of drugs that stimulate the body's immune system, such as Inteferon (used to boost immune system to fight cancer)
3. Vaccines, such as for HPV
* HPV puts you at risk for oral cancer
* HPV vaccine only for 9+
4. Molecular Targeting
5. Gene therapy (replace faulty gene with normal cell)
31
Biotherapy: Molecular Targeting
- Interference with metabolic pathways through enzyme destruction
- Trying to prevent nutrition to the tumor
32
Supportive Therapies for Pediatric Cancers (7)
1. Pain Management (ex: PCA)
2. Antiemetics
3. Nutrition (may need neutropenic diet)
4. Growth factors
5. Blood products
6. Psychological support for patient and family, especially siblings
7. Alternative therapies (know about all alternative therapies, especially herbs, that patient is using)
* Certain herbs can interfere with chemo mechanism of action
33
Supportive therapy: Growth Factors
Things that can stimulate RBC, WBC
1. Epogen: stimulates RBC production
2. Nupogen, procrip: stimulates WBC production
* Side effect → soreness or bone pain
34
Absolute Neutrophil Count (with calculation)
The Total % of neutrophils (“polys or segs” and “bands”)
* Poly/segs: mature neutrophils
* Bands/non-segs: immature neutrophils
* Normal ANC is over 1,000
* In order to be discharged, you have to have an ANC of >500
* Isolation precautions with ANC 300 or lower (number may increase during flu season)
CALCULATION:
Multiply WBC x % of neutrophils
Example: if WBC= 1,000, poly/segs= 7%, bands=7%
1st: Add total neutrophil --> 7+7= 14% = 0.14
2nd: 1,000 x 0.14 = 140 ANC
35
Tumor Lysis Syndrome (and what is it commonly seen with?)
Can result from cancer itself or side effect of chemotherapy treatment
* Lysis of tumor cells and rapid release of contents of tumor cells into the blood.
1. High levels of uric acid, K+ and phosphate.
- --Can cause cardiac arrhythmias and renal failure.
2. If they find these high levels prior to the chemo it needs to be corrected before they even start chemotherapy
A. Elevated uric acid treatment: allopurinol
B. Also will give sodium bicarbonate
*Seen more commonly with ALL and Non-Hodgkin’s Lymphoma
36
Allopurinol
treats elevated uric acid
37
Leukemia
Proliferation of immature WBCs (bone marrow) in blood forming tissues of body
1. Most common cause of childhood cancer
2. Males > females
3. Peak at 2-6 years of age
4. Types: ALL, AML, CLL, CML
* ALL: Acute lymphoblastic leukemia, responsible for 75% of leukemia
*Long term disease-free survival rates for ALL is 80%
38
ALL Pathophysiology
1st: Alteration in genetic makeup of WBC
- -This prevents maturation of WBC
- -Proliferation of immature WBC
2nd: Replicates quickly forming immature or blast cells in bone marrow, crowding other cells in the bone marrow
- -Replicate in great numbers and released into circulation
3rd: Blast cells take over marrow, RBC and platelet cell production is altered→ anemia and thrombocytopenia
* At the same time, cells compete and normal cells are deprived of essential nutrients of metabolism→ cellular destruction
*Immature WBC don’t have biofeedback system, so they continuously proliferate
39
ALL Infiltration of Bone Marrow Signs and Symptoms
1. Anemia
2. Infection
3. Bleeding (bruising)
4. Fractures and bone pain
40
Extramedullary Sites Infiltrated in ALL (4 with symptoms)
1. Lymph nodes; will have enlarged lymph nodes)
2. Liver or spleen; hepatomegaly, speenomegaly
3. CNS; May see signs of ICP (headache, nausea, vomiting)
4. In males it can spread to the testes
41
ALL Classification
Classified according to type of cell involved: T, B, early pre-B or pre-B
*Helpful in telling us prognosis of treatment
42
ALL Clinical Manifestations (8)
1. Fever
2. Pallor
3. Excessive bruising, petechie
- -Petechie: little red dots/broken capillaries
- -Petechie from nipple up (not including the arms) you should NOT worry about because it could be due to vomiting or coughing
- -Petechie from nipple down is worrisome
4. Bone and joint pain
5. Lymphadenopathy
6. Malaise
7. Hepatosplenomegaly
8. Anemia, thrombocytopenia and ↑ in WBC
* *CBC without differential you will see high WBC, but you should be doing differential to look at immature WBC level
43
ALL Diagnosis (3)
1. CBC shows immature leukocytes
2. Definitive diagnosis – bone marrow aspiration; usually comes from hip (ileac crest)
- -Very painful, should get sedation
3. Lumbar puncture to assess extramedullary spreading → has it spread to CNS?
44
ALL Prognostic Factors (4)
*Most important prognostic factors in determining long-term survival for children with ALL are:
1. Initial WBC
2. Age at diagnosis
3. Cytogenetics
3. Sex
4. Immunological Subtype
45
ALL Treatment (4)
1. Chemotherapy w/ or w/o cranial radiation
* cranial radiation is not favorable anymore and no longer used at St. Jude's
2. Induction
3. Intensification or consolidations
4. Maintenance
46
ALL Treatment: Induction
The 1st month of chemo, patient will be in hospital
* Induces remission
* Trying to get blast cells under 5%
* IV and Intrathecal chemo (using broviac catheter)
47
ALL Treatment: Intensification or Consolidations
Over several months
- May be in outpatient
- Residual leukemic cell and prevents resistant leukemic clones
- Will also be getting intrathecal chemo
48
ALL Treatment: Maintenance
- Over 2 years
- Preserve remission
- Not as aggressive, can participate in more activities
- Will still be getting intrathecal chemotherapy
49
Nursing Care for ALL (6)
1. Prepare child and family
2. Relieve pain
3. Prevent complications of myelosupression
* *Ex: should not have cats; can cause toxoplasmosis
4. Drug administration
**After giving the chemo, observe for 20 minutes to ensure no anaphylactic reaction
**Take care of yourself during administration
Ex: be careful with methotrexate, it’s being excreted in the child’s urine
5. Drug toxicity
6. Body image
* *Especially with prednisone, alopecia, etc.
50
Brain tumors
*Most common solid tumor
*Confined to brain and spine
*Cause – unknown
(Radiation can be a cause)
* 60% are infratentorial - 50% are cerebella astrocytomas
- Classified according to cell histology and rate of tumor proliferation
51
Brain Tumor Clinical Manifestations
Symptoms depend on tumor size and location
**Ataxia, visual disturbances, fatigue, loss of milestones, poor school performance
Hallmark symptoms – headache with morning vomiting related to child rising
**Will be complaining of severe headache when they wake up and then beginning to vomit
52
Diagnosis of Brain Tumor
CT or MRI
| *MRI is preferred
53
Management of Brain Tumors
1. Surgery
2. Radiation
3. Chemotherapy
*All three unless:
A. The child is below 3 (no radiation)
B. The surgery risk outweighs the tumor risk
54
Brain Tumor Management: Surgery
*May not always be an option because it depends on where the tumor is
1. Rule of thumb: the risk of the surgery cannot outweigh the risk of the tumor
**Anything that has risk to neurological function outweighs the benefits
Ex: brainstem or optic pathway; just get chemo and radiation
2. Besides having surgery to remove the tumor, they may also have surgery to put in a VP shunt
55
Brain Tumor Management: Radiation
Avoided in children↓ 3 years (will just do surgery and chemo)
56
VP Shunt for Tumors
1. VP shunt is usually temporary until tumor is removed
* *When tumor is removed it will not be causing the occlusion, so CSF will stay up in the ventricles
2. A catheter into ventricle to drain fluid from ventricle and it empties into peritoneum and reabsorbed
* Continuous process
3. Biggest concerns of VP shunt are infection and obstruction
* With fever: monitor for peritonitis because the fluid is draining into the peritoneum
57
Signs and Symptoms of VP Shunt Obstruction
1. Change in LOC
2. Headaches
3. Bulging fontanel
4. Any signs of ICP
58
Brain Tumor: Pre-Surgery Interventions (4)
1. Need a very thorough neurological assessment
2. Prepare for diagnostic and operative procedures
* Putting gauze around a head of the doll to show what will happen to the child
3. Child may be almost comatose for 24-48 hours post surgery; prepare parent for this
4. If patient is under 1 year old, get head circumference
59
Brain Tumor: Post-Operative Interventions (8)
1. Vital Signs
2. Neuro checks
3. Dressing
4. Positioning
5. Fluid Regurgitation
6. Nutrition
7. Medications
8. Check head circumference if child is under 1
60
Vital Signs for post-op brain tumor surgery
Check for fever!
- Post op fever in first 48 hours could be due to inflammation or hypothalamus being impacted
- Concern for infection if patient is still febrile after 48 hours
61
Post-Op Brain tumor dressing
* Looking at drainage and color of drainage
* Serosangenous is normal
* Clear drainage is not normal, could be CSF
62
Post-Op Brain Tumor Positioning
1. Need to have patient aligned well for turning
| 2. No hyperextension or flexing!
63
Post-Op Brain Tumor Fluid Regurgitation
1. Keep hydrated but do not overhydrate! (Risk for developing cerebral edema)
2. Strict Ins and Outs
64
Post-Op Brain Tumor Medications (4 categories)
1. Medications to help reduce or prevent cerebral edema
- -Mannitol, an osmotic diuretic to pull extra cerebral fluid out
2. Drugs to reduce inflammation
- -Steroids, usually Dexamethezone (Decedron)
3. May also be on anticonvulsants
4. Pain medication
- -Give if very irritable
- -Concern about not being able to tell if pain medication is causing change in LOC or if the surgery is; need to be able to assess neuro status by having a good baseline
65
Neuroblastoma (4)
1. Most common malignant extracranial (not in the brain) solid tumor of childhood
2. ½ of all cases under 2
3. Under 12 months may experience spontaneous remission male > female, ↑ in whites
4. 80% present with metastasis with symptoms in non-primary sites
66
Clinical Manifestations of Neuroblastoma (9)
1. 65% have abdominal mass and protuberant firm abdomen **This is the most common presenting symptom
2. Impaired ROM and mobility
3. Pain with walking and may be limping
4. Impaired bowel and bladder function
* *Especially if in sympathetic chain in lower back
5. If it spreads to chest: cough and respiratory compromise
6. If it spreads to neck: facial, periorbital edema and bruising
7. If it spreads to spinal chord: inability to walk
8: . If it spreads to adrenal gland: fever and hypertension
9. Racoon’s Eyes if metastasis to skull
67
Neuroblastoma extramedullary sites
head, neck, chest, and pelvis
68
Neuroblastoma Pathophysiology
Originate form neural crest cells which normally develop into sympathetic nervous system and adrenal medulla
*Most common site – adrenal gland and retroperitoneal sympathetic chain
69
Cause of Neuroblastoma (2)
It is a genetic type of cancer!!!
1. Genetic abnormalities involving chromosome #1, where a deletion or rearrangement is found on the short arm of this chromosome. Leading to:
2. Amplification of an oncogene called MYCN
70
Racoon's Eyes
Orbital metastases can be found in up to 20% of children with stage IV neuroblastoma.
*The characteristic "raccoon eyes" appearance associated with neuroblastoma and metastasis to the skull is probably related to obstruction of the palpebral vessels (branches of the ophthalmic and facial vessels) by tumor tissue in and around the orbits
71
Neuroblastoma Diagnosis
1. Chest X-ray
2. CT of chest, abdomen and pelvis
3. Bone marrow aspiration and IVP
4. Skeletal survey
* The above tests are done to see if it has spread, because 80% of cases spread
5. Tumor samples: done to stage tumor (1-4S)
* 4S is for children under 1 year old
6. Urinary excretion of catecholamines
* *Vanillylmandelic Acid (VMA) and Homovanillic Acid (HVA)
* *95% of children with neuroblastoma will have elevated HVA and VMA
72
Neuroblastoma Therapeutic Managment
1. Staging: I – IV and IVS (localized to distant spread)
* Stage IV will automatically be receiving autologous BMT (not allogeneic)
2. Surgery
3. Treatment depends on stage – may also need chemo and radiation
* *It is usually surgery, chemo, and radiation, unless they are under 1 year old (then they will not receive chemotherapy)
4. Autologous BMT
73
Neuroblastoma Prognosis
*Depends on age at diagnosis and stage of disease
1. The younger the better
* *Under 1 year of age, better prognosis
2. Infants who remain disease free for 1 year after treatment are usually cured
* *Or with spontaneous regression in infants
74
Neuroblastoma Nursing Care (5)
1. Pain management
2. Anxiety, mainly with parents
3. Nutrition
* *Big issue due to location of tumor; usually appetite is poor and they may need alternate forms of nutrition such as NG tube feedings
4. GI Obstruction (from tumor obstruction)
5. Immobility
75
Hodgkin's Disease
1. Most common in adolescence and young adult
2. Rarely see it under 15 years old
3. Originates in lymphoid system, and can spread from lymph nodes to non-nodular sites
76
Hodgkin's Extranodular Sites
1. Spleen
2. Liver
3. Lungs
4. Bone marrow
77
Hodgkin's Staging
1. Number/percent of lymph node sites involved
* Staged by the number of sites involved
2. Extranodular disease
* Stage number is number of sites involved
3. History of symptoms
* Stages A or B
* Hodgkins: firm, non-tender nodes (Conversely, infection will have tender nodes)
78
Stage A Hodgkins
no symptoms that are in stage B
Asymptomatic, enlarged cervical or supraclavicular lymphadenopathy
79
Stage B Hodgkins
1. Fever greater than 100.4 for at least 3 consecutive days
2. Drenching night sweats
3. Weight loss over 6 months, greater than 10% of body weight
80
Hodgkin's Clinical Manifestations (7)
1. Stage A: Asymptomatic, enlarged cervical or supraclavicular lymphadenopathy
2. Low grade intermittent fever
3. Weight loss, night sweats
4. Nausea
5. Pruritus (Very distinguishable symptom!!)
6. If it spreads to lungs:
* Mediastinal (area of the chest) lymphadenopathy – persistent non-productive cough
7. If it spreads to liver or spleen
* Abdominal pain
81
Hodgkin's Diagnosis (4)
1. Biopsy of lymph nodes- will see “Sternberg-Reed cells”
2. CT scan and gallium scan
3. X-ray with chest, abdomen and pelvis
4. Bone marrow
**All these are done to see where it has spread in order to stage it properly
82
Hodgkin's Ann Arbor Staging (I-IV)
Stage I: disease in single lymph node or lymph node region
Stage II: disease in two or more lymph node regions on same side of diaphragm.
*Stages I and II have a 90-95% cure rate
Stage III: disease in lymph node regions on both sides of the diaphragm are affected.
*Stage III has 80% cure
Stage IV: disease is wide spread, including multiple involvement at one or more extranodal (sites such as the bone marrow)
*Stage IV has 70% cure
83
Hodgkin's Management and Prognosis (5)
1. Depends on age, disease stage and histologic type
2. Chemo, radiation either alone or combined
- --Long term survival
3. Really good cure rate! The earlier it’s diagnosed, the better
4. If post-pubescent, it is recommended to harvest eggs and sperm because they may become infertile
5. If they relapse during treatment, they should get BMT
84
Osteogenic Sarcoma (Osteosarcoma) (4)
1. Most common bone cancer
2. Peak at 10 – 25 years of age
3. Primary sites – more than 1/2 in femur
* *Usually in metaphysis
* *Also a common site for osteomyelitis so need differential diagnosis
4. 20% of time it will spread, mostly to lungs
85
Osteosarcoma Clinical Manifestation (5)
1. Progressive, insidious or intermittent pain at tumor site relived by position change
2. Relief of pain when they flex the knee
3. Palpable mass
4. Limited ROM
5. Pathologic fracture at tumor site
* *May come in with fracture and get an X-ray and you will see osteocaroma on the X-ray
86
Osteosarcoma Diagnosis (6)
1. Rule out other causes/do differential diagnosis (osteomyelitis)
2. History regarding pain to get an idea of how long the tumor has been present
3. CT scan or MRI
4. Bone scan to see spread of tumor
5. Needle or surgical bone biopsy
6. CBC, serum Alkaline Phosphate (ALP) and Lactase Dehydrogenase (LDH)
* *The higher these tests are at diagnosis, the poorer the response to treatment
* *Helps to see how well patient will respond to treatment and help decide the type of treatment
87
Osteosarcoma Management and Prognosis (5)
1. Surgery and chemo
2. Unresponsive to radiation
3. Limb salvage procedure or amputation
* *Limb salvage procedure: remove area of tumor and put in a metal device
* *Leaning towards amputation because it has been found that with limp salvage there is a higher recurrence rate than with amputation
4. Prognosis depends on extent of disease at diagnosis
5. Alkaline Phosphatase (ALP) and Lactate Dehydrogenase (LDH) levels
88
The Mirror Box
1. The patient places his normal hand on one side and looks into the mirror, thus creating the illusion that the amputated hand has returned and allowing the patient to visualize the unclenching of the phantom spasm. Preliminary evidence has shown this technique to be very useful in relieving these unpleasant spasms.
* *Spasm occurs with phantom limb pain
* *Found to be very successful
89
Phantom Limb
Complain of phantom limb pain at site of where amputation occurs
* Burning, tingling, cramping, itching
* Can be treated with certain drugs such as Elavyl
* Mirror box helps with cramping from phantom limb pain
