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Clinical medicine A > Lecture 11: Principles of Onco Part 2 (enoch) > Flashcards

Lecture 11: Principles of Onco Part 2 (enoch) 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 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.

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18
Q

What is systemic therapy in terms of radiation?

A

Radionuclides targeted to site.

EX: Radioactiv 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
What is radiofrequency ablation?
Focused microwave radiation to induce thermal injury within a volume of tissue. AKA like burning a tumor.
26
What is chemoembolization?
Infusion of chemotherapeutic agents directly into the target area via vascular catheters.
27
What is the primary ingredient in cryosurgery?
Compressed nitrogen gas
28
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.
29
What are the 4 primary cancer drug treatments?
Conventional cytotoxic chemotherapy agents Targeted agents Hormonal therapies Biologic therapies
30
What is the main target of conventional cytotoxic chemotherapy agents?
DNA structure
31
What is the main target of hormonal therapies?
Estrogen and androgen function
32
What is the main goal of biologic therapies?
Induce host immune issue Regulate growth of tumor cells.
33
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.
34
What are the two valuable outcomes of chemotherapy?
Inducing cancer cell death Inducing cancer cell differentiation or dormancy, making them lose their tumor potential.
35
What are the two primary antimetabolites?
Methotrexate 5-FU (5-Fluorouracil)
36
What do antimetabolites do? SE?
Cause DNA damage directly. SE: stomatitis, diarrhea, and myelosuppression.
37
What does 5-FU do?
Prevents thymidine formation (DNA replication inhibitor)
38
What does methotrexate do?
Competes and counteracts folic acid, so cancer cells die from lack of folic acid.
39
What are the mitotic spindle inhibitors and their SE?
Vincristine, Vinblastine Paclitaxel Alopecia, neuropathy, myelosuppression
40
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
41
What does Cisplatin cause in terms of SE?
Neuro-toxicity (STOCKING GLOVE) Hearing loss Renal failure
42
What is the antitumor antibiotic and its MOA?
Made by bacteria. Binds to DNA to cause free radical damage. Doxorubicin (Anthracycline), causes cardiotoxicity.
43
What is the topoisomerase inhibitor?
Etoposide, which inhibits DNA synthesis, causing DNA breaks.
44
What is the danger of etoposide?
Secondary leukemia in high dosages.
45
How is neutropenia treated due to chemotherapy?
Filgrastim (Colony stimulating factor) Pegfilgrastim Sargramostim
46
What are G-CSFs indicated for?
Production of functionally active neutrophils. Severe, chronic neutropenia patients use these.
47
How long does it take CSFs to work generally?
24 hours.
48
How is anemia due to chemotherapy treated?
Transfusions Epogen (erythropoiesis-stimulating agent)
49
How is thrombocytopenia due to chemotherapy treated?
Conservative monitoring
50
How is nausea due to chemotherapy treated?
Zofran
51
How is mucositis due to chemotherapy treated?
Magic mouthwash (1/3 lidocaine, maalox, benadryl)
52
What chemotherapy drugs are most likely to cause mucositis?
5-FU Methotrexate Cytarabine
53
How is diarrhea due to chemotherapy treated?
Loperamide first. Octerotide/opiate-based preps second. Flamingos cause diarrhea and Leopards and Octopuses dont.
54
What chemotherapy drug is most likely to cause diarrhea?
5-FU
55
How is skin toxicity due to chemotherapy treated?
Supportive care Cold packs Sun protection
56
How is alopecia due to chemotherapy treated?
Psychological support Chemo caps (expensive, reduces scalp temp)
57
What are the primary blood tests we order to monitor chemo?
CBC CMP PT/aPTT
58
What are paraneoplastic syndromes?
Disorders that accompany benign or malignant tumors. NOT DIRECTLY RELATED to mass effect or invasion by a tumor.
59
What are the general effects of paraneoplastic syndromes?
Hormonal Hematologic Dermatologic Renal Neurologic
60
What 4 systemic disorders does paraneoplastic syndrome often mimic?
Endocrine Metabolic Hematologic Neuromuscular
61
What are the 3 mechanisms paraneoplastic syndromes are grouped by?
1. Effects initiated by a tumor product 2. Destruction of normal tissue by tumor 3. Unknown
62
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.
63
What are some endocrine disorders that can be caused by paraneoplastic syndrome?
Hypercalcemia Hypogylcemia Gonadotropin secretion Cushing's syndrome SIADH
64
What are some key PE finds of someone with Cushing's?
Red moon face Thin skin High BP Poor wound healing Pendulous abdomen
65
What are some hematologic disorders caused by paraneoplastic syndrome?
Coagulopathy Erythrocytosis
66
What are some neurologic disorders caused by paraneoplastic syndrome?
Lambert-Eaton syndrome (immune mediated neurologic syndrome) Subacute cerebellar syndrome (immune mediated cerebellar degeneration)
67
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!!!
68
What is the criteria for neutropenic fever?
Recurrent temp above 38C or single temp above 38.3C in presence of neutropenia. Neutropenia is an ANC < 500. Usually due to chemo, not the cancer itself.
69
What are the common causes of neutropenic fever?
Infectious. CMV, HSV, VZV Staph, Strep, Enterococcus, H. flu, E. coli, Klebsiella, Pseudomonas Candida or aspergillosis
70
What is absolutely CId in a patient with neutropenic fever?
RECTAL EXAM on an immunocompromised patient. NEVER DO IT.
71
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 (Rocephin, cefepime, imipenem) + Aminoglycoside (G- bacteria) + Vanco (MRSA)
72
What causes spinal cord compression due to cancer?
Any cancer that metastasizes to vertebral bodies, causing physical damage. Will eventually cause irreversible myelin damage.
73
How does spinal cord compression present?
Back pain at level of the tumor. Aggravated by many movements. LE weakness Hyperreflexia Motor/sensory loss loss of reflexes Loss of bladder/bowel function Paraplegia
74
What is the diagnostic study of choice for spinal cord decompression?
MRI
75
How do we treat spinal cord compression?
High dose IV corticosteroids Surgical decompression Radiation
76
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
77
What is the most common cause of hypercalcemia?
Parathyroid-hormone related peptide.
78
What does hypercalcemia often suggest?
Advanced cancer ):
79
What are the MC cancers that cause hypercalcemia?
Myeloma Breast carcinoma Non-small cell lung carcinoma
80
What is the mnemonic for hypercalcemia?
Bones, stones, groans, and psychiatric moans
81
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
82
What is tumor lysis syndrome?
Presents 1-3 days post radiochemotherapy, usually due to hematologic malignancies.
83
What is the main concern with tumor lysis syndrome?
AKI Resulting in hyperuricemia, hyperphosphatemia, and hyperkalemia.
84
What can tumor lysis syndrome cause cardiac-wise?
Fatal cardiac arrhythmias due to hyperkalemia and hypocalcemia.
85
What are the S/S of tumor lysis syndrome?
Lethargy N/V Cloudy urine Neuromuscular irritability Muscular spasm Seizure Altered mentation w/ hypocalcemia
86
How does an EKG of someone with tumor lysis syndrome look like?
Peaked T waves Arrhythmia
87
How is tumor lysis syndrome treated?
IV hydration + correcting the electrolyte abnormalities. May require emergent hemodialysis.
88
What are the 3 types of effusions?
Pleural, pericardial, and peritoneal
89
What do lung and breast cancers commonly cause effusion-wise?
Pleural and pericardial (AKA the ones they are near)
90
What usually causes malignant ascites/peritoneal effusions?
Ovarian Colorectal Stomach Pancreatic
91
When do effusions appear?
Can present initially, and be the first clue to a cancer!
92
What is the complication that can arise from pericardial effusions?
Cardiac tamponade
93
How do we diagnose a cardiac tamponade or pericardial effusion?
EKG and CXR Diagnostic test of choice: Transthoracic echocardiogram (TTE)
94
What is the treatment of choice for a pericardial effusion?
Echo-guided percutaneous pericardiocentesis under local anesthesia
95
What is superior vena cava syndrome?
Direct obstruction of SVC by either tumor growth or mediastinal LAN.
96
What is the MCC of SVC syndrome?
Bronchogenic carcinoma
97
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)
98
How is SVC syndrome diagnosed?
CXR Test of choice: CT Chest WITH contrast
99
How is SVC syndrome treated?
Glucocorticoids (often affects lymphomas best) Intravascular stenting, chemotherapy, and radiation
100
What kind of hematologic state does malignancy put you in?
Hypercoagulability
101
What is Virchow's triad?
Hypercoagulability Venous stasis Vessel Wall Injury
102
What are the PE findings that may suggest a thromboembolic event?
Low-grade fever Tachypnea Tachycardia Pleural rub Unilateral LE swelling
103
How do we diagnose a thromboembolic event?
VQ Scan + Spiral CT Chest WITH CONTRAST
104
How do we treat thromboembolic events?
AC Thrombolytic therapy is indicated if hemodynamic instability + RV failure

Clinical medicine A (32 decks)

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