Lecture 11: Principles of Onco Part 2 Flashcards
What is the initial goal of cancer treatment?
Eradicating the cancer.
What are the secondary goals of cancer treatment if it cannot be cured?
Palliation
Treatment of symptoms
Preservation of quality of life
How is toxicity managed in cancer treatment?
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.
What are the 4 main types of cancer treatment?
Surgery
Radiation therapy
Chemotherapy
Biologic Therapy
What cancer treatments fall under local?
Surgery and radiation therapy
What treatments are systemic?
Chemotherapy and Biologic therapy
What falls under biologic therapy?
Immunotherapy and gene therapy
What is the most effective means of treating cancer?
Surgery
How curative is surgery for cancer?
40% of pts are cured by surgery.
What are some benefits of surgery even if it cannot excise the tumor fully?
Local control
Preservation of organ function
Debulking for subsequent treatments
Pallative/supportive care
What is the goal of radiation therapy?
Depriving cancer cells of division potential
What does radiation do exactly?
DNA breaks, preventing replication and generating hydroxyl radicals from cell water to damage other cell parts.
Why does radiation work?
Differential cancer cells generally have poorer repair capabilities.
What factors affect how systemic the effect of radiation therapy is?
Volume of tissue irradiated
Dosage
Radiation fields
Physiologic reserve/susceptibility
What are the 3 types of therapeutic radiation?
Teletherapy
Brachytherapy
Systemic therapy
What is teletherapy?
Focused beams of radiation generated at a distance and aimed at tumor.
What is brachytherapy?
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.
What is systemic therapy in terms of radiation?
Radionuclides targeted to site.
EX: Radioactive iodine in thyroid cancer.
What is the most common form of radiation therapy?
Teletherapy via XRAY or Gamma-rays.
What is the example of brachytherapy we saw in class?
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.
What cancers is radiation therapy curative in?
Breast cancer
Hodgkin’s disease
Head and Neck cancer
Prostate
Gynecologic
What are the systemic effects of radiation toxicity?
FATIGUE
Anorexia
N/V
What are some acute toxicities of radiation toxicity? How do they resolve?
Mucositis
Skin erythema
Bone marrow toxicity.
Should be alleviated if treatment is interrupted.
What are the other localized therapy options for cancer?
Radiofrequency ablation
Cryosurgery
Chemoembolization
What is radiofrequency ablation?
Focused microwave radiation to induce thermal injury within a volume of tissue.
AKA like burning a tumor.
What is chemoembolization?
Infusion of chemotherapeutic agents directly into the target area via vascular catheters.
What is the primary ingredient in cryosurgery?
Compressed nitrogen gas
When is chemotherapy indicated?
Primarily for an ACTIVE, clinically apparent cancer.
Can be given in addition to surgery or for palliative effects depending on the tumor.
What are the 4 primary cancer drug treatments?
Conventional cytotoxic chemotherapy agents
Targeted agents
Hormonal therapies
Biologic therapies
What is the main target of conventional cytotoxic chemotherapy agents?
DNA structure
What is the main target of hormonal therapies?
Estrogen and androgen function
What is the main goal of biologic therapies?
Induce host immune issue
Regulate growth of tumor cells.
What is therapeutic index? What is the TI of chemotherapy agents?
The degree of separation between toxic and therapeutic doses.
All chemotherapy agents have narrow TIs.
What are the two valuable outcomes of chemotherapy?
Inducing cancer cell death
Inducing cancer cell differentiation or dormancy, making them lose their tumor potential.
What are the two primary antimetabolites?
Methotrexate
5-FU (5-Fluorouracil)
What do antimetabolites do? SE?
Cause DNA damage directly.
SE: stomatitis, diarrhea, and myelosuppression.
What does 5-FU do?
Prevents thymidine formation (DNA replication inhibitor)
What does methotrexate do?
Competes and counteracts folic acid, so cancer cells die from lack of folic acid.
What are the mitotic spindle inhibitors and their SE?
Vincristine, Vinblastine
Paclitaxel
Alopecia, neuropathy, myelosuppression
Vin no spin
What are the alkylating agents and what do they do?
Cell-cycle phase-nonspecific agents.
Covalent modification of bases, causing DNA breaks.
Cyclophosphamide
Chlorambucil
Cisplatin
What does Cisplatin cause in terms of SE?
Neuro-toxicity (STOCKING GLOVE)
Hearing loss
Renal failure
Glove holds the plate
What is the antitumor antibiotic and its MOA?
Made by bacteria. Binds to DNA to cause free radical damage.
Doxorubicin (Anthracycline), causes cardiotoxicity.
What is the topoisomerase inhibitor?
Etoposide, which inhibits DNA synthesis, causing DNA breaks.
What is the danger of etoposide?
Secondary leukemia in high dosages.
How is neutropenia treated due to chemotherapy?
Filgrastim (Colony stimulating factor)
Pegfilgrastim
Sargramostim
What are G-CSFs indicated for?
Production of functionally active neutrophils.
Severe, chronic neutropenia patients use these.
How long does it take CSFs to work generally?
24 hours.
How is anemia due to chemotherapy treated?
Transfusions
Epogen (erythropoiesis-stimulating agent)
How is thrombocytopenia due to chemotherapy treated?
Conservative monitoring
How is nausea due to chemotherapy treated?
Zofran
How is mucositis due to chemotherapy treated?
Magic mouthwash (1/3 lidocaine, maalox, benadryl)
What chemotherapy drugs are most likely to cause mucositis?
5-FU
Methotrexate
Cytarabine
How is diarrhea due to chemotherapy treated?
Loperamide first.
Octerotide/opiate-based preps second.
What chemotherapy drug is most likely to cause diarrhea?
5-FU
How is skin toxicity due to chemotherapy treated?
Supportive care
Cold packs
Sun protection
How is alopecia due to chemotherapy treated?
Psychological support
Chemo caps (expensive, reduces scalp temp)
What are the primary blood tests we order to monitor chemo?
CBC
CMP
PT/aPTT
What are paraneoplastic syndromes?
Disorders that accompany benign or malignant tumors. NOT DIRECTLY RELATED to mass effect or invasion by a tumor.
What are the general effects of paraneoplastic syndromes?
Hormonal
Hematologic
Dermatologic
Renal
Neurologic
What 4 systemic disorders does paraneoplastic syndrome often mimic?
Endocrine
Metabolic
Hematologic
Neuromuscular
What are the 3 mechanisms paraneoplastic syndromes are grouped by?
- Effects initiated by a tumor product
- Destruction of normal tissue by tumor
- Unknown
Why is it important to be able to recognize paraneoplastic syndrome?
Early clue about type of cancer.
Could be more immediately life-threatening than the cancer itself.
Syndrome should resolve if cancer is resolved.
What are some endocrine disorders that can be caused by paraneoplastic syndrome?
Hypercalcemia
Hypogylcemia
Gonadotropin secretion
Cushing’s syndrome
SIADH
What are some key PE findings of someone with Cushing’s?
Red moon face
Thin skin
High BP
Poor wound healing
Pendulous abdomen
What are some hematologic disorders caused by paraneoplastic syndrome?
Coagulopathy
Erythrocytosis
What are some neurologic disorders caused by paraneoplastic syndrome?
Lambert-Eaton syndrome (immune mediated neurologic syndrome)
Subacute cerebellar syndrome (immune mediated cerebellar degeneration)
What are some dermatologic disorders caused by paraneoplastic syndrome?
Dermatomyositis (small cell lung cancers most commonly)
Acanthosis Nigricans (Thickening of skin/brownish discoloration)
Most common in GI adenocarcinomas!!!
What is the criteria for neutropenic fever?
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.
What are the common causes of neutropenic fever?
Infectious.
CMV, HSV, VZV
Staph, Strep, Enterococcus, H. flu, E. coli, Klebsiella, Pseudomonas
Candida or aspergillosis
What is absolutely CId in a patient with neutropenic fever?
RECTAL EXAM on an immunocompromised patient.
NEVER DO IT.
How do we diagnose and treat neutropenic fever?
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)
What causes spinal cord compression due to cancer?
Any cancer that metastasizes to vertebral bodies, causing physical damage.
Will eventually cause irreversible myelin damage.
How does spinal cord compression present?
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
What is the diagnostic study of choice for spinal cord decompression?
MRI
How do we treat spinal cord compression?
High dose IV corticosteroids
Surgical decompression
Radiation
What are the 3 ways hypercalcemia is caused?
Systemic effects of tumor-released proteins
Direct osteolysis of bone by tumor
Increased absorption of calcium due to increased active metabolite of Vit D
What is the most common cause of hypercalcemia?
Parathyroid-hormone related peptide.
What does hypercalcemia often suggest?
Advanced cancer ):
What are the MC cancers that cause hypercalcemia?
Myeloma
Breast carcinoma
Non-small cell lung carcinoma
What is the mnemonic for hypercalcemia?
Bones, stones, groans, and psychiatric moans
How is hypercalcemia diagnosed and treated?
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
What is tumor lysis syndrome?
Presents 1-3 days post radiochemotherapy, usually due to hematologic malignancies.
What is the main concern with tumor lysis syndrome?
AKI
Resulting in hyperuricemia, hyperphosphatemia, and hyperkalemia.
What can tumor lysis syndrome cause cardiac-wise?
Fatal cardiac arrhythmias due to hyperkalemia and hypocalcemia.
What are the S/S of tumor lysis syndrome?
Lethargy
N/V
Cloudy urine
Neuromuscular irritability
Muscular spasm
Seizure
Altered mentation w/ hypocalcemia
How does an EKG of someone with tumor lysis syndrome look like?
Peaked T waves
Arrhythmia
How is tumor lysis syndrome treated?
IV hydration + correcting the electrolyte abnormalities.
May require emergent hemodialysis.
What are the 3 types of effusions?
Pleural, pericardial, and peritoneal
What do lung and breast cancers commonly cause effusion-wise?
Pleural and pericardial (AKA the ones they are near)
What usually causes malignant ascites/peritoneal effusions?
Ovarian
Colorectal
Stomach
Pancreatic
When do effusions appear?
Can present initially, and be the first clue to a cancer!
What is the complication that can arise from pericardial effusions?
Cardiac tamponade
How do we diagnose a cardiac tamponade or pericardial effusion?
EKG and CXR
Diagnostic test of choice:
Transthoracic echocardiogram (TTE)
What is the treatment of choice for a pericardial effusion?
Echo-guided percutaneous pericardiocentesis under local anesthesia
What is superior vena cava syndrome?
Direct obstruction of SVC by either tumor growth or mediastinal LAN.
What is the MCC of SVC syndrome?
Bronchogenic carcinoma
What are the PE findings for someone with SVC syndrome?
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)
How is SVC syndrome diagnosed?
CXR
Test of choice: CT Chest WITH contrast
How is SVC syndrome treated?
Glucocorticoids (often affects lymphomas best)
Intravascular stenting, chemotherapy, and radiation
What kind of hematologic state does malignancy put you in?
Hypercoagulability
What is Virchow’s triad?
Hypercoagulability
Venous stasis
Vessel Wall Injury
What are the PE findings that may suggest a thromboembolic event?
Low-grade fever
Tachypnea
Tachycardia
Pleural rub
Unilateral LE swelling
How do we diagnose a thromboembolic event?
VQ Scan + Spiral CT Chest WITH CONTRAST
How do we treat thromboembolic events?
AC
Thrombolytic therapy is indicated if hemodynamic instability + RV failure
