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CM 1A: Heme/Onc/Endo > Lecture 11: Principles of Onco Part 2 > Flashcards

Lecture 11: Principles of Onco Part 2 Flashcards

1
Q

What is the initial goal of cancer treatment?

A

Eradicating the cancer.

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2
Q

What are the secondary goals of cancer treatment if it cannot be cured?

A

Palliation
Treatment of symptoms
Preservation of quality of life

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3
Q

How is toxicity managed in cancer treatment?

A

If a cure is possible, we generally tolerate all the toxic risks of doing so.

If only palliative, we minimize toxicity as much as possible.

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4
Q

What are the 4 main types of cancer treatment?

A

Surgery
Radiation therapy
Chemotherapy
Biologic Therapy

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5
Q

What cancer treatments fall under local?

A

Surgery and radiation therapy

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6
Q

What treatments are systemic?

A

Chemotherapy and Biologic therapy

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7
Q

What falls under biologic therapy?

A

Immunotherapy and gene therapy

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8
Q

What is the most effective means of treating cancer?

A

Surgery

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9
Q

How curative is surgery for cancer?

A

40% of pts are cured by surgery.

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10
Q

What are some benefits of surgery even if it cannot excise the tumor fully?

A

Local control
Preservation of organ function
Debulking for subsequent treatments
Pallative/supportive care

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11
Q

What is the goal of radiation therapy?

A

Depriving cancer cells of division potential

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12
Q

What does radiation do exactly?

A

DNA breaks, preventing replication and generating hydroxyl radicals from cell water to damage other cell parts.

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13
Q

Why does radiation work?

A

Differential cancer cells generally have poorer repair capabilities.

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14
Q

What factors affect how systemic the effect of radiation therapy is?

A

Volume of tissue irradiated
Dosage
Radiation fields
Physiologic reserve/susceptibility

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15
Q

What are the 3 types of therapeutic radiation?

A

Teletherapy
Brachytherapy
Systemic therapy

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16
Q

What is teletherapy?

A

Focused beams of radiation generated at a distance and aimed at tumor.

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17
Q

What is brachytherapy?

A

Encapsulated/sealed sources of radiation implanted directly into tissues.

Internal insertion of radiation into a patient.
Used commonly in GU cancers.

b for bomb, like placing a bomb.

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18
Q

What is systemic therapy in terms of radiation?

A

Radionuclides targeted to site.

EX: Radioactive iodine in thyroid cancer.

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19
Q

What is the most common form of radiation therapy?

A

Teletherapy via XRAY or Gamma-rays.

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20
Q

What is the example of brachytherapy we saw in class?

A

Tandem and ring brachytherapy.

The tandem is a stick that is inserted to deliver the radiation.

The ring is placed on the tandem and combined.

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21
Q

What cancers is radiation therapy curative in?

A

Breast cancer
Hodgkin’s disease
Head and Neck cancer
Prostate
Gynecologic

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22
Q

What are the systemic effects of radiation toxicity?

A

FATIGUE
Anorexia
N/V

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23
Q

What are some acute toxicities of radiation toxicity? How do they resolve?

A

Mucositis
Skin erythema
Bone marrow toxicity.

Should be alleviated if treatment is interrupted.

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24
Q

What are the other localized therapy options for cancer?

A

Radiofrequency ablation
Cryosurgery
Chemoembolization

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25
Q

What is radiofrequency ablation?

A

Focused microwave radiation to induce thermal injury within a volume of tissue.

AKA like burning a tumor.

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26
Q

What is chemoembolization?

A

Infusion of chemotherapeutic agents directly into the target area via vascular catheters.

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27
Q

What is the primary ingredient in cryosurgery?

A

Compressed nitrogen gas

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28
Q

When is chemotherapy indicated?

A

Primarily for an ACTIVE, clinically apparent cancer.

Can be given in addition to surgery or for palliative effects depending on the tumor.

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29
Q

What are the 4 primary cancer drug treatments?

A

Conventional cytotoxic chemotherapy agents
Targeted agents
Hormonal therapies
Biologic therapies

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30
Q

What is the main target of conventional cytotoxic chemotherapy agents?

A

DNA structure

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31
Q

What is the main target of hormonal therapies?

A

Estrogen and androgen function

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32
Q

What is the main goal of biologic therapies?

A

Induce host immune issue
Regulate growth of tumor cells.

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33
Q

What is therapeutic index? What is the TI of chemotherapy agents?

A

The degree of separation between toxic and therapeutic doses.

All chemotherapy agents have narrow TIs.

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34
Q

What are the two valuable outcomes of chemotherapy?

A

Inducing cancer cell death
Inducing cancer cell differentiation or dormancy, making them lose their tumor potential.

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35
Q

What are the two primary antimetabolites?

A

Methotrexate
5-FU (5-Fluorouracil)

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36
Q

What do antimetabolites do? SE?

A

Cause DNA damage directly.

SE: stomatitis, diarrhea, and myelosuppression.

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37
Q

What does 5-FU do?

A

Prevents thymidine formation (DNA replication inhibitor)

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38
Q

What does methotrexate do?

A

Competes and counteracts folic acid, so cancer cells die from lack of folic acid.

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39
Q

What are the mitotic spindle inhibitors and their SE?

A

Vincristine, Vinblastine
Paclitaxel

Alopecia, neuropathy, myelosuppression
Vin no spin

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40
Q

What are the alkylating agents and what do they do?

A

Cell-cycle phase-nonspecific agents.

Covalent modification of bases, causing DNA breaks.

Cyclophosphamide
Chlorambucil
Cisplatin

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41
Q

What does Cisplatin cause in terms of SE?

A

Neuro-toxicity (STOCKING GLOVE)
Hearing loss
Renal failure

Glove holds the plate

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42
Q

What is the antitumor antibiotic and its MOA?

A

Made by bacteria. Binds to DNA to cause free radical damage.

Doxorubicin (Anthracycline), causes cardiotoxicity.

43
Q

What is the topoisomerase inhibitor?

A

Etoposide, which inhibits DNA synthesis, causing DNA breaks.

44
Q

What is the danger of etoposide?

A

Secondary leukemia in high dosages.

45
Q

How is neutropenia treated due to chemotherapy?

A

Filgrastim (Colony stimulating factor)
Pegfilgrastim
Sargramostim

46
Q

What are G-CSFs indicated for?

A

Production of functionally active neutrophils.

Severe, chronic neutropenia patients use these.

47
Q

How long does it take CSFs to work generally?

A

24 hours.

48
Q

How is anemia due to chemotherapy treated?

A

Transfusions
Epogen (erythropoiesis-stimulating agent)

49
Q

How is thrombocytopenia due to chemotherapy treated?

A

Conservative monitoring

50
Q

How is nausea due to chemotherapy treated?

A

Zofran

51
Q

How is mucositis due to chemotherapy treated?

A

Magic mouthwash (1/3 lidocaine, maalox, benadryl)

52
Q

What chemotherapy drugs are most likely to cause mucositis?

A

5-FU
Methotrexate
Cytarabine

53
Q

How is diarrhea due to chemotherapy treated?

A

Loperamide first.
Octerotide/opiate-based preps second.

54
Q

What chemotherapy drug is most likely to cause diarrhea?

A

5-FU

55
Q

How is skin toxicity due to chemotherapy treated?

A

Supportive care
Cold packs
Sun protection

56
Q

How is alopecia due to chemotherapy treated?

A

Psychological support

Chemo caps (expensive, reduces scalp temp)

57
Q

What are the primary blood tests we order to monitor chemo?

A

CBC
CMP
PT/aPTT

58
Q

What are paraneoplastic syndromes?

A

Disorders that accompany benign or malignant tumors. NOT DIRECTLY RELATED to mass effect or invasion by a tumor.

59
Q

What are the general effects of paraneoplastic syndromes?

A

Hormonal
Hematologic
Dermatologic
Renal
Neurologic

60
Q

What 4 systemic disorders does paraneoplastic syndrome often mimic?

A

Endocrine
Metabolic
Hematologic
Neuromuscular

61
Q

What are the 3 mechanisms paraneoplastic syndromes are grouped by?

A
  1. Effects initiated by a tumor product
  2. Destruction of normal tissue by tumor
  3. Unknown
62
Q

Why is it important to be able to recognize paraneoplastic syndrome?

A

Early clue about type of cancer.
Could be more immediately life-threatening than the cancer itself.
Syndrome should resolve if cancer is resolved.

63
Q

What are some endocrine disorders that can be caused by paraneoplastic syndrome?

A

Hypercalcemia
Hypogylcemia
Gonadotropin secretion
Cushing’s syndrome
SIADH

64
Q

What are some key PE findings of someone with Cushing’s?

A

Red moon face
Thin skin
High BP
Poor wound healing
Pendulous abdomen

65
Q

What are some hematologic disorders caused by paraneoplastic syndrome?

A

Coagulopathy
Erythrocytosis

66
Q

What are some neurologic disorders caused by paraneoplastic syndrome?

A

Lambert-Eaton syndrome (immune mediated neurologic syndrome)

Subacute cerebellar syndrome (immune mediated cerebellar degeneration)

67
Q

What are some dermatologic disorders caused by paraneoplastic syndrome?

A

Dermatomyositis (small cell lung cancers most commonly)

Acanthosis Nigricans (Thickening of skin/brownish discoloration)
Most common in GI adenocarcinomas!!!

68
Q

What is the criteria for neutropenic fever?

A

Recurrent temp above 38C or single temp above 38.3C in presence of severe neutropenia.

Neutropenia is an ANC < 500.
Usually due to chemo, not the cancer itself.

69
Q

What are the common causes of neutropenic fever?

A

Infectious.
CMV, HSV, VZV
Staph, Strep, Enterococcus, H. flu, E. coli, Klebsiella, Pseudomonas

Candida or aspergillosis

70
Q

What is absolutely CId in a patient with neutropenic fever?

A

RECTAL EXAM on an immunocompromised patient.
NEVER DO IT.

71
Q

How do we diagnose and treat neutropenic fever?

A

Cultures of everything.
CXR
Labs (CBC w/ diff, CMP, coag panel, UA)

Empiric IV ABX post culture.
Antipseudomonal (Ceftazidime, cefepime, imipenem) + Aminoglycoside (G- bacteria) + Vanco (MRSA)

72
Q

What causes spinal cord compression due to cancer?

A

Any cancer that metastasizes to vertebral bodies, causing physical damage.

Will eventually cause irreversible myelin damage.

73
Q

How does spinal cord compression present?

A

Back pain at level of the tumor.
Aggravated by many movements.
LE weakness
Hyperreflexia => loss of reflexes
Motor/sensory loss
Loss of bladder/bowel function
Paraplegia

74
Q

What is the diagnostic study of choice for spinal cord decompression?

A

MRI

75
Q

How do we treat spinal cord compression?

A

High dose IV corticosteroids
Surgical decompression
Radiation

76
Q

What are the 3 ways hypercalcemia is caused?

A

Systemic effects of tumor-released proteins
Direct osteolysis of bone by tumor
Increased absorption of calcium due to increased active metabolite of Vit D

77
Q

What is the most common cause of hypercalcemia?

A

Parathyroid-hormone related peptide.

78
Q

What does hypercalcemia often suggest?

A

Advanced cancer ):

79
Q

What are the MC cancers that cause hypercalcemia?

A

Myeloma
Breast carcinoma
Non-small cell lung carcinoma

80
Q

What is the mnemonic for hypercalcemia?

A

Bones, stones, groans, and psychiatric moans

81
Q

How is hypercalcemia diagnosed and treated?

A

Labs: Total serum Ca + ionized calcium will be elevated.
EKG: short QT, ST depression, AV blocks

Treatment: (in order)
Hydration + forced diuresis
Bisphosphonates
Calcitonin
Hemodialysis

82
Q

What is tumor lysis syndrome?

A

Presents 1-3 days post radiochemotherapy, usually due to hematologic malignancies.

83
Q

What is the main concern with tumor lysis syndrome?

A

AKI

Resulting in hyperuricemia, hyperphosphatemia, and hyperkalemia.

84
Q

What can tumor lysis syndrome cause cardiac-wise?

A

Fatal cardiac arrhythmias due to hyperkalemia and hypocalcemia.

85
Q

What are the S/S of tumor lysis syndrome?

A

Lethargy
N/V
Cloudy urine
Neuromuscular irritability
Muscular spasm
Seizure
Altered mentation w/ hypocalcemia

86
Q

How does an EKG of someone with tumor lysis syndrome look like?

A

Peaked T waves
Arrhythmia

87
Q

How is tumor lysis syndrome treated?

A

IV hydration + correcting the electrolyte abnormalities.

May require emergent hemodialysis.

88
Q

What are the 3 types of effusions?

A

Pleural, pericardial, and peritoneal

89
Q

What do lung and breast cancers commonly cause effusion-wise?

A

Pleural and pericardial (AKA the ones they are near)

90
Q

What usually causes malignant ascites/peritoneal effusions?

A

Ovarian
Colorectal
Stomach
Pancreatic

91
Q

When do effusions appear?

A

Can present initially, and be the first clue to a cancer!

92
Q

What is the complication that can arise from pericardial effusions?

A

Cardiac tamponade

93
Q

How do we diagnose a cardiac tamponade or pericardial effusion?

A

EKG and CXR

Diagnostic test of choice:
Transthoracic echocardiogram (TTE)

94
Q

What is the treatment of choice for a pericardial effusion?

A

Echo-guided percutaneous pericardiocentesis under local anesthesia

95
Q

What is superior vena cava syndrome?

A

Direct obstruction of SVC by either tumor growth or mediastinal LAN.

96
Q

What is the MCC of SVC syndrome?

A

Bronchogenic carcinoma

97
Q

What are the PE findings for someone with SVC syndrome?

A

Distended neck veins
Arm and chest veins popping out
Non-pitting edema of neck
Arm swelling

(essentially all due to SVC being compressed and blood getting back up)

98
Q

How is SVC syndrome diagnosed?

A

CXR

Test of choice: CT Chest WITH contrast

99
Q

How is SVC syndrome treated?

A

Glucocorticoids (often affects lymphomas best)
Intravascular stenting, chemotherapy, and radiation

100
Q

What kind of hematologic state does malignancy put you in?

A

Hypercoagulability

101
Q

What is Virchow’s triad?

A

Hypercoagulability
Venous stasis
Vessel Wall Injury

102
Q

What are the PE findings that may suggest a thromboembolic event?

A

Low-grade fever
Tachypnea
Tachycardia
Pleural rub
Unilateral LE swelling

103
Q

How do we diagnose a thromboembolic event?

A

VQ Scan + Spiral CT Chest WITH CONTRAST

104
Q

How do we treat thromboembolic events?

A

AC

Thrombolytic therapy is indicated if hemodynamic instability + RV failure

CM 1A: Heme/Onc/Endo (28 decks)

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