Hemo/Oncology Flashcards
Myelodysplastic Syndrome (MDS)
- Pre-leukemia
- Problem w/ common myeloid progenitor cells
- Pancytopenias
- 33% transform to AML
Incidence of MDS
- Median age 65-70
- M>F
S/S of MDS
- Symptoms of cytopenias
- Splenomegaly
What are the goals of MDS Management?
- Control symptoms
- Improve quality of life
- Prevent progression to AML
How is MDS managed?
- Supportive Care
- Blood transfusions
- Erythropoietin
- Chemotherapy
- Decitabine
- 5-azacytidine
- Stem Cell Transplant (BMT)
Types of Leukemias
- Acute Lymphoblastic Leukemia (ALL)
- Acute Myelogenous Leukemia (AML)
- Chronic Lymphoblastic Leukemia (CLL)
- Chronic Myelogenous Leukemia (CML) – Philadelphia Chromosome – 95%
Acute Myelogenous Leukemias
- Acute (fast & immature)
- Prolonged cell division →
- Maturation failure
- Too many immature WBC
- Crowd out bone marrow and “spill” into circulation
- Blast crisis
- Accounts for ≈ 1.2% of all new cancer cases
- ≈ 1.8% of all cancer deaths
- Five year survival ≈ 26.6%
- Prolonged cell division →
Chronic Myelogenous Leukemias
- Chronic (slow & mature)
- Myeloproliferative disorder
- Too many mature WBS
- Philadelphia Chromosome
- bcr-abl: a gene made by the Philadelphia Chromosome
- Accounts for ≈ 0.5% of all new cancer cases
- ≈ 0.2% of all cancer deaths
- Five year survival ≈ 65.1%
- Myeloproliferative disorder
Acute Lymphocytic Leukemia
- Most common type of leukemia in young children
- Accounts for ≈ 0.4% of all new cancer cases
- ≈ 0.2% of all cancer deaths
- Five year survival ≈ 68.1%
Chronic Lymphocytic Leukemia
- Most common chronic adult leukemia
- Accounts for ≈ 1.1% of all new cancer cases
- ≈ 0.8% of all cancer deaths
- Five year survival ≈ 82.6%
Laboratory & Diagnostics Findings of Leukemia
- CBC w/ differential
- ↑↑↑ WBC
- Blast %
- Peripheral blood smear
- Presence of blasts
- Presence of malignant cells
- Bone Marrow Biopsy
- Posterior Iliac Crest
- Elevated blast %
Leukemia Management
- Dependent of type of Leukemia
- Chemotherapy Purpose?
- Clean out marrow
- Achieve remission?
- Relapse? Refractory?
- Bone marrow transplant
- Splenectomy
- *Antibiotics*
- Serial monitoring for life
- Neupogen or Neulasta to regenerate BM after ablation
Chemotherapy Classes
Alkylating Agents
Antimetabolite Agents
Others
Alkylating Agents
- Alkylating Agents 1: Nitrogen Mustards
- Alkylates and crosslinks DNA
- Ex: cyclophosphamide, ifosfamide, melphalan
- Alkylating Agents 2: Nitrosoureas
- Alkylates and crosslinks DNA
- Ex: lomustine, carmustine, streptozocin
- Alkylating Agents 3: Platinum Analogs
- Binds and crosslinks DNA
- Ex: cisplatin, carboplatin, oxaliplatin
- Alkylating Agents 4: Other
- Alkylates and crosslinks DNA
Antimetabolite Agents
- Antimetabolite Agents 1: Folate Analogs
- Inhibits lymphocyte proliferation
- Ex: methotrexate, pemetrexed, pralatrexate
- Antimetabolite Agents 2: Purine Analogs
- Inhibits DNA synthesis
- Ex: clofarabine, cladribine, fludarabine, mercaptopurine, thioguanine, pentostatin
- Antimetabolite Agents 3: Pyrimidine Analogs
- Induces DNA hypomethylation – restores cellular control
- Ex: cytarabine, decitabine, fluorouracil, gemcitabine, azacitidine,
- Antimetabolite Agents 4: Other
- Inhibits ribonucleotide reductase, immediately inhibiting DNA synthesis
- Ex: hydroxyurea
Other Chemo Classes
- Kinase Inhibitors
- Ex: imatinib (Gleevec), ibrutinib (Imbruvica)
- Differentiating Agents
- Ex: arsenic trioxide (used in APL)
- Antitumor Antibiotic (Anthracyclines) – think cardiotoxicity!!!
- Doxorubicin
- Antitumor Antibiotics (Others)
- mitoxantrone, bleomycin
Combination therapy
- Given in divided doses per cycle
- Treatment is measured in similar fashion:
- “P.R. is a 73 year old ♂ with relapsed/refractory AML, currently on C2D15 of vidaza/busulfan/arsenic.”
Potential Nursing Dx for Leukemias
- Pain r/t overactive bone marrow AEB leukocytosis
- Altered Immunity r/t effects of chemotherapy AEB leukopenia
- Risk for injury r/t tumor lysis syndrome AEB declining renal function, hyperkalemia, hyperphosphatemia, and uric academia
- Risk for injury r/t fatigue and other chemotherapeutic effects
- Risk for Infection r/t deficient immunity AEB leukopenia
- Pain r/t stimulated bone marrow
- Knowledge Deficit
- Impaired Family Coping
Nursing Interventions
- Coordinate care to reduce traffic in and out of room
- Provide safe environment, reduce risk for falls, call button w/in reach, bedside toileting, adequate lighting
- Encourage deep breathing and UOB and/or use of incentive spirometer
- Auscultate breath sounds
- Examine skin for breakdown
- Encourage good oral care
- Prohibit live plants/flowers
- Restrict fresh fruits and only allow fruits with thick skin
- Change IV tubing according to hospital policy
- Change central line dressings according to hospital policy
Lymphomas
Hodgkin’s Lymphoma
and
Non-Hodgkin’s Lymphoma
Stages of Lymphoma
Stage I Lymphoma
- Disease is localized to single lymph node or group of nodes
Stage II Lymphoma
- Multiple lymph nodes or groups of nodes
- Confined to 1 side of diaphragm
Stage III Lymphoma
- Spleen involvement and/or
- Lymph nodes on both sides of diaphragm
Stage IV Lymphoma
- Liver or bone marrow involvement
Hodgkin’s Lymphoma
- Aka Hodgkin’s disease
- malignat condition charachterized by proliferation abnormal gian, multinucleated ccells, called Reed-Sternberg cells, which are located in lymph nodees
Hodgkins Lymphoma I & P
- M>F, Bi-modal age onset:
- avg age: 28
- Less common peak: 55
- Accounts for ≈ 0.5% all new cancer cases
- ≈ 0.2% of all cancer-related deaths
Hodgkin’s Lymphoma adenopathy
- Cervical & Mediastinal
- Spreads in a predictable fashion
- Uncommonly found outside of lymph nodes (4%)
- Reed sternberg cells
Non-Hodgkin’s Lymphoma
heterogeneous group of malignant neoplasms of primarily B-, T-, or natural killer (NK) cell origin affecting all ages
Classifications
- B-cell
- T- cell
- Natural Killer (NK)
B- Cell Lymphomas
about 85%
- Follicular B Cell
- Mantle Cell
- Marginal Zone
- Interfollicular
- Burkitt’s - most highly aggressive
- Diffuse Large B Cell - most common aggressive lymphoma
- Primary Effusion
T Cell NHLs
About 15%
- Anaplastic Large Cell
- T-cell Lymphoma
Lymphoma treatment and side effects
- XRT
- Sperm banking?
- Night sweats
- Compromised skin
- Diarrhea
- Pain
- Chemotherapy
- N/V/D
- BMT
- Treatment begins after radiographic exams and initial staging are complete!
Potential nursing dx for lymphomas
- Risk for ineffective breathing pattern r/t enlarged mediastinal nodes and/or radiation treatment to neck/chest
- Acute pain r/t injury of chemotherapy and/or radiation therapy
- Anxiety r/t new diagnosis
- Risk for Infection r/t potential bone marrow depression due to effects of chemotherapy
- Risk for Infection r/t compromised skin during radiation
- Fatigue r/t effects of cancer, chemotherapy, and radiation therapy
- Knowledge deficit
Nursing interventions for Lymphomas
- Assess and monitor respiratory rate, depth, and rhythm
- Note for signs of respiratory distress including use of accessory muscles, nasal flaring, and cyanosis
- Instruct and assist with deep-breathing techniques
- Encourage involvement of ADLs as tolerated
- Assess and monitor skin for signs of break down or infection related to radiation treatments
- Assess for pain and provide pain relief with relaxation techniques, and medication, as ordered
- Provide a quiet environment
- Provide therapeutic communication to patient and family regarding treatment and disease process
Tumor Lysis Syndrome (TLS)
- Metabolic disorders
- Destruction of cells
- Leukemia & Lymphoma
- ↑K+, ↑PO4-, ↓Ca++
- Hyperuricemia
- (↑ C5H4N4O3)
- Hyperuricosuria
- Acute Renal Failure (ARF)
- Acute uric acid nephropathy
- Commonly
- Poorly differentiated lymphomas
- Burkett’s Lymphoma
- ALL, AML
- Melanomas (rarely)
- Poorly differentiated lymphomas
Tumor Lysis Syndrome (TLS) prevention
- Allopurinol (IV or PO)
- Rasburicase
- Sevelamer
- Alkalinizing Urine
- NaCO3 or Diamox
TLS treatment
- Rasburicase, Loop diuretics, fluids
- HD - hemofiltration dialysis
- CVVHD continuous veno-venous hemofiltration dialysis
Cairo-Bishop Definition
- Lab TLS (2 or more, 3 days before or 7 days after Tx)
- Uric acid > 8mg/dL
- K+ > 6mEq/L
- PO4- > 4.5mg/dL
- Ca++ < 7mg/dL
- OR 25% ↑
- Clinical TLS (Lab TLS + 1 or more of the following)
- ↑ Cr (1.5x upper normal)
- Cardiac arrhythmia
- Seizure
Superior Vena Cava Syndrome
- Approximately 90% are caused by malignancy compressing the SVC
- Facial swelling
- Upper extremity swelling
- JVD
- Positive Pemberton’s Sign
- When patient raises both arms simultaneously:
- Facial flushing
- JVD
- Stridor
- When patient raises both arms simultaneously:
Superior Vena Cava Syndrome Diagnostics
- CXR
- CT
SVCS treatment
- Referral
- Treat the cause
- Chemotherapy
- XRT
- surgery
Thrombocytopenias
- Disseminated Intravascular Coagulopathy - DIC
- Thrombotic Thrombocytopenic Purpura (TTP)
- Idiopathic Thrombocytopenic Purpura (ITP)
- Disseminated Intravascular Coagulopathy (DIC)
- Pathologic activation of clotting cascade
- Numerous small clots (microemboli) consume platelets and clotting factors
- Normal clotting inhibited due to lack of platelets and clotting factors leading to bleeding
- Microemboli clog up microcirculation leading to end organ failure
DIC S/S
- Hemorrhage (oral, nasal, venipuncture sites, abnormal pupils)
- Bruising
- Renal Failure
- Gangrene
DIC Lab Values
- Thrombocytopenia
- ↓ Fibrinogen
- ↑ PT, PTT, INR
DIC treatment
- Must treat the underlying cause
- Heparin gtt
- Platelet transfusions
- Cryoprecipitate
- Fresh Frozen Plasma
- Tissue Plasminogen Activator (tPA)
Nursing DX for DIC
- Fluid volume deficit r/t blood loss
- Risk for injury r/t microemboli
- Impaired family coping
- Knowledge deficit
Thrombotic Thrombocytopenic Purpura (TTP)
- Like DIC – many microscopic thrombosis cause end organ failure
- Anti-ADAMTS13 (AA13) enzymes
- Schistocyte formation
- Shear stress from RBC
- Plasmapheresis to reduce number of AA13
Idiopathic Thrombocytopenic Purpura (ITP)
- Unknown reason for low platelet count and bruising
- Platelet antibodies?
ITP S/S
- Bruising
- Abnormal pupillary reactions
- AMS
ITP treatment
- Platelet transfusion
- Effective?
- Monitor count prior to and 1 hour after transfusion
- Ineffective?
- Anti-rheumatic drugs
- Methotrexate
- Rituximab
- IV Immunoglobulins
- Repeat transfusion
- Effective?
- Corticosteroids
- Splenectomy
- Origin of antibodies
Bleeding precautions (thrombocytopenias)
- Use soft toothbrush
- Electric Razor
- Avoid ASA
- Examine urine for Blood
- Medical emergency
- Examine stool
- Black tarry stools
- Medical emergency
Nursing DX for thrombocytopenias
- Risk for injury
- Impaired skin integrity
- Knowledge deficit
- Risk for bleeding
Supporative care for MDS
Blood transfustions & Erythropoietin
Chemotherapy for MDS
Decitabine & 5-azacytidine
Other than supportive care and chemortherapy, how else is MDS managed
Stem Cell Transplant (BMT)
How do Nitrogen Mustards & Nitrosoureas work?
Alkylates and crosslinks DNA
How do Platinutm Analogs work?
Binds and crosslinks DNA
How do other alkylating agents work?
Alkylates and crosslinks DNA
Examples of Nitrogen Mustards
Cyclophospamide, ifosfamide, melphalan
Examples of Nitrosoureas drugs?
lomustine, carmustine, streptozocin
Exampleas of Platinum Analogs?
cisplatin, carboplatin, oxaliplatin
How do Folate Analogs work?
Inhibits lymphocyte proliferation
Examples of Folate Analogs?
methotrexate, pemtred, pralatrexate
How do Purine Analogs work?
Inhibits DNA synthesis
Examples of Purine Anaglogs?
clofarabine, cladribine, fludaramine, mercaptopurine, thiguanine, pentostatin
How do Pyrimidine Analogs work?
Induces DNA hypotheylation - restores cellular control
Examples of Pyrimidine Analogs?
cytarabine, decitabine, fluorouracil, gecitabine, azacitidine
How do other antimetabolite agents work?
Inhibits ribonucleotide reductase, immediately inhibiting DNA synthesis
Example of other antimetabolite agents?
hydroxyurea
Examples of Kinase Inhibitors/
imatinib (Gleevec), ibrutinib (Imbruvica)
Differentiating agents examples
arsenic trioxide (used in APL)
Antitumor Antibiotic (Anthracyclines
think cardiotoxicity!!!: Doxorubicin
Other antitumber antibiotics
mitoxantrone, bleomycin
How is combination therapy given?
in divided doses per cycle
