Exam 3: Oncology Flashcards
Most common histology of cancer in children:
Nonepithelial (leukemia, CNS, sarcomas [connective tissue])
Most common histology of cancer in adults:
Epithelial/Organs (Carcinomas)
Most common location of cancer in children:
CNS, muscle, bone
Most common location of cancer in adults:
Breast, colon, lung, prostate
Most common pathogenesis of cancer in children:
Genetic
Most common pathogenesis of cancer in adults:
Environmental & Lifestyle factors
Cancer pharmacokinetics in children:
- tumors more responsive to chemotherapy
- tolerate higher doses
- less difficulty with acute toxicities
- more long-term consequences
Cancer pharmacokinetics in adults:
- less responsive to chemotherapy
- tolerate lower doses
- more difficulty with acute toxicities
- less long-term consequences
Long term consequences of cancer pharmacotherapy in children:
- secondary cancers
- thyroid problems
Risk factors for cancer in children include:
- prenatal diagnostic radiation
- DES exposure
- transplacental transmission of maternal cancers
- viral exposure (such as EBV)
- Secondary cancers r/t chemo
- In utero exposures to meds, pesticides, electromagnetic fields, motor vehicle exhaust
Clinical manifestations for all cancers:
- unusual mass or swelling
- unexplained paleness or loss of energy
- sudden tendency to bruise
- persistent localized pain or limping
- changes in coordination or behavior
- prolonged, unexplained fever or illness and frequent headaches often with vomiting
General diagnostic workup for cancer:
- Comprehensive history
- comprehensive physical exam
- lab work: CBC, CMP, LFTs, among many others
- Imaging: X-RAYS, CT, MRI, Bone Scan
- Biopsy
- Lumbar puncture if CNS involvement
What information is rendered by biopsy in cancer diagnosis:
- biological characteristics of the tumor or the marrow in staging
- extent of the disease at the time of diagnosis
What information is rendered by bone marrow aspiration/biopsy?
-extent of involvement of malignant cells in marrow
What cells are affected by Acute Lymphoblastic Lymphoma?
-Lymphoid cell line
What do myeloid cells break down into?
RBC, WBC, platelets
What do lymphoid cells break down into?
T-cells and B-cells
What cells are impacted by Leukemia?
-B cells and T cells
What is Acute Lymphoblastic Leukemia?
- Neoplastic accumulation of lymphoblasts in the bone marrow
- Most commonly arises in children: associated with Down syndrome
- Subclassified into B-ALL and T-ALL based on surface markers.
Most common presenting symptoms in acute lymphoblastic leukemia (ALL) are d/t disrupted hematopoiesis causing:
o Anemia
- Fatigue
- Weakness
- Pallor
- Dyspnea with exertion
- Tachycardia
- Exertional chest pain
o Thrombocytopenia
- Easy bruising
- Petechiae/purpura
- Bleeding mucosa, gums
- Heavy menstrual bleeding
o Neutropenia
- Risk of infections: bacterial, fungal, viral
- Fever
- Night sweats
o Organ infiltration by leukemic cells
- Enlarged liver, spleen, lymph nodes
- Bone marrow infiltration causes bone and joint pain
- Testicular infiltration causes testicular edema
- CNS penetration causes cranial nerve palsies, HA, visual or auditory symptoms, AMS, TIA
How are ALL classified?
-according to cell type and involvement, and by cellular differentiation
Patients with Trisomy 21 are at a much greater risk for which type of cancer?
Acute lymphoblastic leukemia (ALL)
What is the most common type of malignancy diagnosed in children 0 to 14?
T-cell acute lymphoblastic leukemia
In Africa, there is a huge relationship between EBV and what?
Lymphoma
How do patients with ALL present?
- Fatigue and pallor [anemia]
- bleeding, purpura, ecchymosis [thrombocytopenia]
- recurrent fevers & infections [neutropenia– typically they are still febrile after couple courses of several ABX-red flag]
Important sanctuary sites for leukemic cells:
CNS:
-child can present with headache, vomiting, lethargy, papilledema, nuchal rigidity during abdominal exam [some younger children won’t present with this], as well as cranial nerve deficits
Testes
-unilateral painless testicular enlargement
What are the 2 sanctuary sites for ALL?
CNS, Testes
Mediastinal masses tend to be associated with which lineage of ALL?
T-lineage
Red flag for mediastinal mass:
Stridor or respiratory distress
How is ALL treated
With chemotherapy
What are poor prognoses for ALL?
- high WBC at diagnosis
- age, usually less than 1 or greater than 10 years old
- T - cell origin is poorer prognosis
- patients that don’t respond at initial induction
What is chemotherapy induction therapy?
-treatment geared to get a patient into remission
What is consolidation or intensification treatment?
-treatment geared to keep a patient in remission
How long is the average treatment protocol for a female with standard risk ALL?
2.5 years
How long is the average treatment protocol for a male with standard risk ALL?
-about 3 years because of the sanctuary site of the testicles
What are the 4 components of leukemia classification?
- morphology
- cytochemistry
- Immunophenotyping
- cytogenics/chromosomal analysis
What treatment methodology has been critical for improving survival rates with ALL/AML?
-intrathecal chemotherapy to the CNS, a sanctuary site
What are lymphomas?
malignant neoplasms of the lymphoid tissue
-hodgkin’s & non-hodgkin’s
What is the difference between leukemia and lymphoma?
Leukemia is liquid cancer (bone marrow & blood)
Lymphoma is solid cancer (solid tumors of lymphatic tissues)
Etiology and risk factors of lymphomas:
- certain human leukocyte antigens (HLAs) will increase or decrease a patient’s risk
- pesticide exposure
- high birth weight with subsequent risk of childhood cancers
- Immunosuppression such as HIV
- organ or bone marrow transplantation
- EBV
- successfully treated for Hodgkin’s lymphoma
- previous exposure to malaria or genetics (chromosomal translocations involving genes for immunoglobulin or T cell preceptor molecules)
Non-hodgkin’s lymphoma accounts for ___ percent of all pediatric cancer and it occurs most frequently during the ______ decade of life
6%; second
What is the most frequent malignancy in children with AIDs?
non-hodgkin lymphoma
A child has a recent history of leg pain, unexplained bruising, and nosebleeds. The provider notes petechiae and diffuse lymphadenopathy. A complete blood count reveals a white blood cell (WBC) of 30,000 cells/mm3 and near normal red blood cell (RBC) and platelet counts.
What will the provider do next to manage this patient?
A. Order coagulation studies to evaluate for coagulopathies
B. Perform biochemical studies to look for hyperuricemias
C. Refer to a specialist for bone marrow aspirate and biopsy
D. Repeat the complete blood count in 2 weeks
C
Patients with acute lymphocytic leukemia (ALL) may have normal blood counts even when the marrow has been replaced with leukemic cells, so a bone marrow aspirate and biopsy is required for the definitive diagnosis.
Coagulation and biochemical studies may be performed after the diagnosis is known to evaluate for complications.
Waiting and repeating the CBC in 2 weeks is not recommended since the definitive diagnosis is made by bone marrow biopsy.
A patient reports a neck mass that has been present intermittently for 5 or 6 weeks which varies in size. The provider palpates a lymph node measuring 1.25 cm.
Which test will provide proper histologic diagnosis for this patient? A. Bone marrow aspirate B. CT scan with IV contrast C. Lymph node biopsy D. PET scan
C
The lymph node biopsy is used to provide proper histologic diagnosis and precise classification.
Bone marrow aspirate identifies the presence of dysplastic cells.
PET and CT scans will identify the presence of other lesions.
What is the most important role of the primary care provider in cancer management?
A. Counseling about healthy practices to reduce risk factors
B. Perform regular screenings to detect cancer
C. Referring patients for genetic testing to identify those at risk
D. Teaching patients about cancer management once diagnosed
A
About three-fourths of cancer risks are related to elements that patients can control themselves and include diet, tobacco, alcohol, sun exposure, physical activity, and risky sexual behaviors. Emphasizing healthy lifestyle practices is a principle component of primary care.
Screenings are next in importance and should be performed according to guidelines based on risk and age.
Genetic testing is useful in a small percentage of patients; a good family history is important before referral for testing.
The primary care provider may assist oncology specialists in teaching patients about cancer management.
A patient being treated for cancer has had chemotherapy within the past 2 weeks and comes to the primary care clinic with a fever of 38.5°C.
What is the initial action? A. Refer immediately to oncology B. Order a chest radiograph C. Order blood and urine cultures D. Prescribe empirical antibiotics
A
Patients receiving chemotherapy who have a temperature >38°C and an absolute neutrophil count (ANC) of less than 500/mm3 require immediate hospitalization and treatment. The primary provider should refer immediately to the oncologist who will order a CBC and admit to hospital.
Once hospitalized, the patient will have further workup to determine the cause of the infection and then antibiotics to treat the infection.
What is the purpose of radiation treatment prior to surgical resection of a tumor?
A. To debulk the tumor mass
B. To minimize local recurrence
C. To prevent metastases
D. To reduce pain and rectal bleeding
A. To debulk the tumor mass
Which situations are considered oncologic emergencies in a patient diagnosed with cancer and requires urgent referral to an oncologist? (Select all that apply)
A. Bone marrow suppression B. Metastasis of cancer cells C. Superior vena cava syndrome D. Syndrome of inappropriate antidiuretic hormone E. Tumor lysis syndrome
C, D, E
Superior vena cava syndrome, SIADH, and tumor lysis syndrome are all oncologic emergencies requiring urgent referral to the oncologist.
Bone marrow suppression and metastasis occur with cancer but are not emergencies.
What diseases are associated with non-hodgkin lymphoma?
AIDs, EBV, CMV
The duration of symptoms of ALL before diagnosis is usually about :
One month or less
Symptoms develop over days to weeks
What is the most common site of origin of lymphoma?
-lymphoid structures of intestinal tract
Common physical findings of lymphoma:
- firm, fixed, nontender cervical or supraclavicular masses or adenopathy
- thoracic dullness to percussion–> pleural effusion
- Dyspnea or stridor–> Mediastinal mass
- Abdominal distension or a mass with/without tenderness, rebound tenderness, and/or shifting dullness
- Distended neck veins and plethora–> Superior vena cava syndrome
- Obtundation, agitation, and meningismus–> CNS involvement
- Decreased breath sounds–> bronchial obstruction or pleural effusion
- Focal pain or swelling in the extremity –> primary bone lymphoma
Purpose of Chest X-Ray (PA & Lateral) with lymphoma:
- Assess for mediastinal masses
- Evaluate airway
- Exclude pulmonary parenchymal lesions and associated PNA
Patient presents with painless swelling of lymph nodes in the neck, armpits and groin and c/o fever/chills, night sweats, anorexia and unexplained weight loss. What are you thinking?
Hodgkin Lymphoma
A child presents with headaches upon waking, what could be a possible cause?
Brain tumor
A mother brings her 8 year old in with complaints of: fever, frequent infections, frequent nose bleeds, swollen lumps around the neck, underarms, abdomen and groin, pale skin, SOB, weakness, fatigue. The CBC shows high WBC, low RBC and low platelets. Possible dx? What tests should be ordered?
ALL
Bone Marrow Biopsy
Patient presents with a visible abdominal “bump” as the new FNP should you palpate this?
NO….possible Wilms Tumor
You have a patient who you believe has a Wilms Tumor, the patient has HTN. What test should you order to r/o extension to the IVC?
Abdominal US
Hypospadias and undescended testes are a risk factor for what?
Wilms Tumor
Upon physical examination you note Leukocoria when assessing red reflex, what are you thinking?
Retinoblastoma
What are the “different types” of chemo?
Immunotherapy, Targeted Therapy, Hormone Therapy
Patient with cancer begins experiencing more pain requiring more frequent dosing of his pain medication. When patients begin requiring more frequent dosing, should the NP begin looking for longer acting pain medications?
YES! Increasing pain = more frequent dosing, patient should be started on a longer acting pain medication to stay ahead of the pain and give relief for longer periods.
What does the nausea pneumonic VOMITS stand for?
V=Vestibular O=Obstruction M=Mass/Motility/Metabolic I=Infection/Inflammation T=Toxin (chemo) S=Stretch (kidney/liver capsule)
What is the best nausea medication for chemo induced n/v?
5HT3= Zofran
Can also use medical THC
How can fatigue caused by Cancer be treated?
Stimulants like Ritalin 2.5-5mg BID or Adderall
Help combat “chemo brain” and increase focus and concentration.
