Exam 3: Oncology and Chemotherapy Flashcards
Normal cell process, and cancer cell process
- normal cells grow and divide as needed then perform apoptosis when they are old of damaged
- Cancer cells survive when they should die or they form when they aren’t needed
S2
What are tissue changes seen in cancer cells?
- Number of cells increases (hyperplasia).
- Organization changes (dysplasia)
S3
What is the progression from normal cells to cancerous cells?
S3
Definition of Cancer
- A collection of related diseases of cells that begin to divide without stopping and can spread into surrounding tissues
- may form solid tumors or leukemias
- Caused by genetic changes inherited from parents or mutations to DNA
S4
Characteristics of Cancer Cells
- Less specialized
- Can ignore pre-programmed apoptosis signals
- Abnormally influence normal cells (ex. make normal cells form blood vessels which feed a tumor - angiogensis)
- Can evade the immune system
S5
What are the three “drivers” that increase the proliferation of cancer cells?
-
Proto-oncogenes
Involved in normal cell growth and division
Become cancer-causing…allow cells to grow and survive -
Tumor suppressor genes
Alterations allow genes to divide uncontrollably -
DNA repair genes
Incorrect damage repair; cause other mutations
S6
How many types of cancers are there?
More than 100
named for organs, tissues, or types of cells that the cancer orginates from
S7
Where do basal cell cancers originate from?
Basal layer of the epidermis
S7
Where do squamous cell cancers originate from?
Epithelial cells:
- Beneath skin
- GI tract
- lungs
- Bladder
S7
Where do adenocarcinoma’s originate from?
- Mucous producing cells
- Gland tissue (breast, prostate)
S7
Attorney General
Where do sarcoma’s originate from?
Bone and soft tissue
Ex: osteosarcoma
S7
Where do leukemia’s originate from?
Bone marrow
S7
Where do lymphoma’s originate from?
Lymphocytes (T or B cells)
These tend to build up on lymph nodes and lymph vessels.
S7
What are some problems in cancer screenings?
- Can cause problems: Colonoscopy perforation
- Can have false-positives
- Can have false-negatives
we want a screening that is easy to treat and curable
S9
Screenings are working if statistics show:
- More early-stage cancers found
- Less late-stage cancers found
- Less deaths occur
S9
What is absolute risk?
Absolute risk
- How many people get “x” in a certain period.
Ex. If 4 people out of a group of 100,000 get “x” then risk is 4 in 100,000
S10
Explain relative risk.
% of people in exposed group that develop cancer
vs.
% of people in unexposed group with diagnosis.
S10
Give an example of a relative risk that is greater than 1.
Smoking
Smoking increases risk relative to the rest of the population.
A relative risk >1 there is a positive correlation
S10
Give an example of a relative risk that is less than 1.
Exercise
Exercise decreases risk relative to the rest of the population.
A relative risk <1 will be a negative correlation
S10
What cancer screenings are typically standard now?
- Colonoscopy
- Mammograms
- Pap Smears
S11
What are the factors measured in tumor staging?
- T: size/extent of primary tumor
- N: # of nearby lymph nodes which are +
- M: is there metastasis
S12
The staging is done at diagnosis. No later evaluation.
What are all the measurements for size of the Tumor?
- TX: tumor cannot be measured.
- T0: tumor cannot be found.
T1-T4 refers to larger and larger size and extent
* T1= least invasive
* T4 = most invasive
S13
What are all the Lymph node measurements?
- NX: cancer in nearby lymph nodes cannot be measured.
- N0: no cancer in nearby lymph nodes.
N1-N3 is the number and location of lymph involved
* N1 = limited cancer found in regional lymph nodes
N3 = cancer is all up in these lymph nodes
S13
How is metastasis measured in the tumor staging system?
- MX:cannot be measured.
- M0: has not spread to other parts of the body.
- M1: has spread to other parts of the body.
S13
What are other staging systems?
- In situ: abnormal cells are present but have not spread to nearby tissue
- Localized: limited to place where it started; no sign of spread
- Regional: has spread to nearby lymph nodes, tissues, or organs
- Distant: spread to distant parts of body
- Unknown: not enough information to figure out the stage
S14
For median survival of 6 months or less what two factors are more important that type of cancer?
- Functional status
- Laboratory values
S15
What factors are associated with a survival rate that is 6 months or less?
S15
Serum Calcium will likely indicate bone break-down or kidney involvement
What type of cancers will frequently radiate to the bone?
- Breast
- Lungs
- Kidney
- Prostate
S16
Osteolytic, osteoblastic or both lesions
What can be helpful in treating cancer metastasis to the bone?
- Radiotherapy/chemotherapy
- NSAID +/- opioids
- Vertebroplasty (cement that can be injected into the vertabra to stabalize and prevent collapse)
S16
Hormonal therapy is often helpful for what types of cancer?
Breast
Lung
Kidney
Prostate
S16
These are the same that radiate to bones
Why does cancer typically cause pain?
- Invasion of tumor into tissues innervated by afferent neurons
- Directly invades nerve plexus
S17
Pain is mostly d/t cancer itself not treatment
WHO “Cancer Pain Stepladder”
- Prompt administration fo pain meds
- On schedule; not prn (prophylactic)
- Add antianxiety drugs as necessary
- 80-90% effective (simple things can go a long way)
S18
Common nerve blocks used to treat cancer patients
- Celiac plexus
- Intercostal nerves
- Lumbar sympathetic
These are used when pharmacologic treatment has failed - hopefully soon we can start using regional as a sooner treatment
S20
What areas are anesthetized with a celiac plexus block?
- Sympathetic fibers of T5-T12
- Parasympathetic celiac plexus fibers
S20
For what types of cancer are celiac plexus blocks typically performed?
Unresectable:
- Pancreatic
- Hepatic
- Gastric
S20
What injection is used with a neurolytic celiac plexus block?
How long does this typically last?
Isopropyl alcohol - kills the nerve (but then be aware of sympathectomy)
Destruction of nerves typically lasts 3-6 months.
S20
What is the principal benefit of continuous infusion via catheters for cancer pain?
- ↓ systemic side effects
- Technique and equipment very available.
S21
What are the drawbacks to continuous catheters for cancer pain?
- limited duration of therapy because of migration, granulomas, lack of homogenous drug distribution, infection rates etc
- no randomized control trials
S21
What can chemotherapy drugs be used for?
- Kill cancer cells
- Shrink tumors
- prepare pts for bone marrow transplant
- Control overactive immune diseases (SLA and RA)
S23
Chemotherapy target cells in different phases of their ____.
- Cell cycle
Idea is they inhibit growth in different phases
S23
How do alkylating agents work?
Whats an example of an alkylating agent?
Cisplatin (Nitrosurea)
- Damage cell DNA in all phases of the cell cycle, therefore can treat many different cancers.
- Can cross BBB so its effective at treating brain cancers
S24
What is a severe side effect of alkylating agents?
Dose-dependent cause of leukemia 5-10 years after treatment because these agents will damage blood cells.
S24
Other side effects and interactions
- SE: peripheral neuropathy
- SE: Acute renal failure if taken with NSAIDs
S24 and S54 (Neuropathy was S36)
What types of cancers do antimetabolites treat?
- Breast
- Ovary
- Intestines
- Leukemias
S25
A BOIL
How do antimetabolites work?
Interfere with DNA and RNA - act as subsitute for normal building blocks
S25
What are two examples of antimetabolites?
- Methotrexate
- 5-Fluorouracil
S25
Its 5 AM somewhere
How do Anti-tumor antibiotics treat cancer?
- Interfere with DNA copying enzymes
Used for a large variety of cancers
S26
What are examples of anti-tumor antibiotics?
-cins
Doxorubicin, bleomycin, Mitomycin-C etc
S26
What type of cancer drugs have life-time dosing limits?
Why is this?
Anti-tumor antibiotics because they permanently damage cardiac tissue in large doses.
S26
Anesthesia Implication of Bleomycin
Increases risk of Pulmonary O2 toxicity with high FiO2
S26
Which chemotherapy increases the risk of a second cancer developing?
Topoisomerase Inhibitors
S27
MOA for Topoisomerase inhibitors and what cancers do they treat?
- Plant alkaloids: prevent strands of DNA from being separated to copy
- Treat: Leukemias, Lung, ovarian, GI, Colorectal and pancreatic
DNA is PLANTED together
PC - LLOG
S27
Which chemotherapeutic agent damages cells in all phases through the prevention of protein synthesis?
Mitotic Inhibitors
S28
Which other chemotherapeutic class may cause peripheral neuropathy?
Mitotic inhibitors
(-Taxels and vincristine, vinblastine, etc.)
S28
What agents are the plant alkaloids?
- Topoisomerase inhibitors
- Mitotic inhibitors
S27 and 28
What other types of treament are there for cancer?
- Targeted Therapy (newer drugs): specific proteins or receptors on cancer cells
- Hormone therapy: prevent body from making specific hormones (slower growth of hormonal tumors)
- Immunotherapy: boost immune system to better recognize cancer cells
S29
What cells are most likely to be damaged due to chemotherapy?
- Bone marrow (neutrophenia)
- Hair follicles
- GI tract (including mouth)
- Reproductive systems
S30
What drug can inhibit hormonal contraceptives by 28 days?
And thus result in unexpected baby’s.
Aprepitant (neurokinin 1 antagonist)
S31
How does marijuana treat nausea/vomiting?
- Depresses CNS vomiting center
- more effective than phenothiazines
- decreases anesthetic requirements 15-30%
S31
What is radiation’s effects on the peripheral vascular system?
Coagulopathy
6x increase!
S34
What is radiation’s effects on tissues afflicted by head and neck cancers?
- ↓ Thyroid function
- Carotid artery disease
- Possible airway issues (stiff tissues (kahoot) have rescue airway devices available)
S34
What is radiation’s effects on the chest wall and/or breasts?
- Pericarditis
- Cardiomyopathy
- Valvulopathies
- Dysrhythmias/conduction abnormalities
S35
What is the possible effect of radiation on the lungs??
Radiation pneumonitis
can also be prone to esophageal errosion
S35
What chemotherapeutic agent is known to cause cardiomyopathy?
Doxyrubicen (Adriamycin)
S36
What chemotherapeutic agent is known to cause pulmonary toxicity?
Bleomycin
S36
What chemotherapeutic agents are known to cause peripheral neuropathy?
- Cisplatin
- Vincristine (mitotic inhibitor)
S36
What preoperative abnormalities might be seen in a cancer patient?
- ↓ RBCs (anemia)
- ↓ WBCs (neutropenia)
- ↓ PLTs (thrombocytopenia)
- ↑ Ca⁺⁺ (hypercalcemia)
- Adrenal insfficiency related to steriods
S37
Why is hypercalcemia common in cancer?
Many drugs are toxic to bone marrow, liver and kidneys thus causing breakdown and releasing Ca⁺⁺ into the bloodstream.
S37
What test is useful for testing for adrenal insufficiency?
ACTH stimulation test
S37
Why is tumor resection a risk factor for tumor recurrence?
- Tumor cells can spread into blood stream
- Residue remains behind
- Localized spread via lymphatics
S38
Why is inflammation and surgical stress bad for cancer patients?
Surgical stress → elevation COX expression → PG’s and thromboxanes catalyzed → promote cell survival and cancer cell growth
- inflammation and stress may suppress NK cells
S39
How long can inflammation and stress last post surgery?
weeks
S39
β adrenergic receptors at the sites of tumor growth will upregulate cancer cell activity via nerve fiber delivery of ____.
norepinephrine (catecholamine surge)
S39
How do Opioids effect cancer cells?
Opioids directly:
* stimulate cancer cell proliferation and invasion
* inhibits leukocyte migration
* inhibits NK cell activity
S40
How do volatiles adversely effect cancer patients?
- Increase migration and invasion of cancer cells by affecting platelets
- Induce chemo resistance
- Inhibit NK cells
S40
What effects does propofol have on cancer cells?
- Decreases migration by down regulating signaling pathways
- Promotes apoptosis by increasing cytotoxicity of NK cells
Propofol on top as always.
S40
Long term administration of NSAIDS ____ proliferation of cancer cells.
decreases
S40
Cancer types diagram
Flip Card
S44
What is the major cause of lung cancer?
Tobacco smoke (90%)
3 decade lag time in cancer occurrence
S45
What substances cause lung cancer other than tobacco?
- Asbestos
- Radon gas
S45
What are the types of lung cancer?
- Small cell
- Non-small cell (75-80%)
- Carcinoid
- Mesothelioma
S46
What are the subtypes of non-small-cell lung cancer?
NSMC Lung cancer:
- Squamous
- Adenocarcinoma
- Large cell
S46
What is the typical origin of small cell lung cancer?
Neuroendocrine
Thus the cancer is typically metastatic on presentation
S47
What lung cancer always recurs and is resistant to further treatment?
Small cell lung cancer
S47
What are possible large side effects of small cell lung cancer?
- ↓ Na⁺ (SIADH)
- Hypercortisolism (Cushings presentations)
- Lambert-Eaton Syndrome
S48
Lambert-Eaton syndrome involves symptoms that ____ with exercise/movement.
improve
S48
Myasthenia Gravis involves symptoms that ____ with exercise/movement.
deteriorate
S48
How does Lambert-Eaton Syndrome react with some of our anesthesia drugs?
- Lack of improvement with acetylcholinesterase inhibitors (Myesthenia gravis improves with these)
- extreme sensitivity to non-depolarizing neuromuscular blockers
S48
(Carcinoid tumors)
What tumor type is mostly benign and has great (>90%) 5 year survival rates?
Neuroendocrine tumors
S49
Carcinoid syndrome usually results from tumor originating from where?
GI tract
S49
What are characteristics of Carcinoid Syndrome?
- Tumor secretion of serotonin, histamine, PG’s, tachykinins, kallikrein
- Unresponsive to pressors (hemodynamic collapse)
- Coronary artery spasm
TUC
T= His Sloppy Pigs Kill Turtles
S49
How is carcinoid syndrome treated?
Octreotide & Somatostatin
These inhibit tumor growth, angiogenesis, and the hormones secreted from the tumor.
S49
These help GI symptoms and octreotide helps with GI bleeds.
What type of lung cancer has a 5-year survival rate that greatly improves with surgery?
Non-small cell lung cancer
- 10% w/o surgery
- 40% w/ surgery
S50
Squamous cell lung cancers grow to a large size but ____ late.
metastasize
S50
What are possible consequences of squamous cancer’s large growth?
Mass Effect:
- Hemoptysis
- Obstructive PNA
- Superior Vena Cava syndrome
- Endobronchial tumor
S51
What is the most common subtype of non-small cell lung cancers?
Adenocarcinomas (these metastasize early)
S52
Where are Adenocarcinomas commonly found?
- Brain
- Bone
- Liver
- Adrenal glands
- Chest wall
- Diaphragm
- Pericardium
Brian Breaks Little CRNAs And Dirty Pimps
S52
What two hormones are typically secreted by adenocarcinomas?
- Growth Hormone
- ACTH (Cushings presentation)
S52
What is the least common non-small cell lung cancer subtype?
What should be known about its metastatic characteristics?
- Large cell
- Metastasizes rapidly and usually are large cavitating tumors
S53
4 M’s assessment of pts with lung cancer
- Mass effect: is it compromising other structures
- Metabolic abnormalities: hypercalcemia, hyponatremia, hyperglycemia (Cushings)
- Metastases
- Medications and what do we need to keep in mind with the meds (bleomycin, cisplatin etc)
S54
What factors can help predict one lung desaturation?
- High % of with ventilation or perfusion to operative lung on the preoperative V/Q scan.
- Poor PaO₂ during two lung ventilation (especially in lateral position)
- Right sided thoracotomy (pt will be in L decubitus)
S57
This is a VQ scan - the dark is perfusion
What is the formula for predicted post-operative FEV₁ ?
S59
A patient has had a right upper and right middle lobectomy done. The patients preoperative FEV₁ was 60%. What is the predicted post-operative FEV₁ ?
RUL + RML = 6 + 4 = 10 lung segments
10 segments/42 total = 23.8% of the lung resected
ppoFEV₁ = 60 x (1 - 23.8/100)
ppoFEV₁ = 45.72%
S59
Please look at this…. I think the equation is technically wrong. Same result, but wrong way of using the forumla. There is 10 lung segments missing so I think this should read ppoFEV₁ = 60 x (1 - 10/100). Maybe this is your way of doing it, which is cool too.
What anticoagulative drug class requires discontinuation 7 days prior to surgery?
- -grel drugs ( P2Y12 Inhibitors)
- Ticagrelor
Clopidogrel, prasugrel, etc
S62
Flip card to see anticoagulative medication hold times.
S62
How many dermatomes are typically covered via a paravertebral block?
4-6 dermatomes for 1 shot
S63
What are contraindications for paravertebral blocks?
- Site infection
- Empyema
- Paravertebral tumor
- Kyphoscoliosis
S63
A paravertebral block at ___ is necessary for a sternotomy.
T4
S64
A paravertebral block at ___ is necessary for a thoracotomy.
T6
S64
A paravertebral block at ___ is necessary for abdominal procedures.
T10
S64
What is required for intercostal nerve block?
Blockade 2 dermatomes above and 2 dermatomes below incision.
(innervates musculature of chest and abd wall)
S65
What are indications for intercostal nerve block?
- Thorax surgery
- Upper abdomen surgery
- Mastectomy
S65
What are disadvantages associated with intercostal nerve block?
- Pneumothorax
- Bleeding
- LA toxicity (especially if multiple levels are blocked bc this is a very vascular area).
S65
Flip for intercostal nerve block pictures.
S66
