Oncology Flashcards by Nicole Herberger

Childhood cancers are typically?

Nonepithelial i.e. leukemias, CNS, and Sarcomas

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Adult cancers are typically?

Epithelial/organ (carcinomas)

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This is a group of malignant hematologic diseases where normal bone marrow elements are replaced by abnormal, poorly differentiated lymphocytes (blast cells). This uncontrolled increase in immature WBCs surpasses normal hematopoietic stem cells resulting in anemia, thrombocytopenia, and neutropenia.

Acute lymphoblastic leukemia ALL

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What is the most common malignancy diagnosed in children?

ALL

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ALL diagnosis peaks at what ages but can occur at what ages?

Peaks: 2-6

Can occur: 0-14

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Who is more at risk of ALL?

Whites more than blacks

Male more than females

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In ALL, when leukemic blasts replace the bone marrow, signs of bone marrow failure occur which are:

Anemia (fatigue, pallor)
Thrombocytopenia (petechia, bleeding, purpura)
Neutropenia (fever, recurrent infections)

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Other s/s of ALL?

Bone pain
limp
lymphadenopathy
hepatosplenomegaly

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CNS involvement in ALL s/s:

HA
Vomiting
Lethargy
Papilledema
Nuchal rigidity 
Cranial nerve deficits

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ALL testicular involvement:

Unilateral painless testicular enlargement

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Diagnostic work-up for ALL?

CBC with peripheral smear for the presence and morphology of lymphoblasts.
* Elevated leukocyte count of more than 10 x 10
* Pancytopenia
CMP (kidney/liver function)
Chest X-ray (respiratory distress, stridor to r/o mediastinal mass.
US for enlarged testes

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Further work-up done by oncology team for ALL?

Bone marrow aspiration and biopsy

Lumbar puncture for CNS involvement

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Treatment for ALL?

Chemo for systemic disease

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This is a diverse group of solid tumors of the lymphatic system that form from malignant proliferation of T cells, B cells, or indeterminate lymphocyte cells.

Non-hodgkin lymphoma

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Risk factors of non-hodgkins lymphoma?

Certain HLA types
Pesticide exposure
High birth weight and subsequent risk of childhood cancers
Immunosuppression 
Ebstein barr 
Successfully treated for Hodgkins disease 
Exposure to malaria 
Genetics

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Peak age for diagnosis of Non-hodgkins lymphoma?

5-15

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Symptoms of Non-hodgkins lymphoma are generally 1 month or less and common physical findings:

Firm, fixed and nontender cervical or supraclavicular masses or adenopathy.
Dyspnea/stridor- mediastinal mass
Distended neck veins
Decreased BS
Thoracic dullness
Abdominal distention or a mass with or without tenderness
Obtundation, agitation, meningismus- CNS involvement
Focal pain or swelling in the extremity- primary bone lymphoma

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Uncommon physical findings in Non-hodgkins lymphoma?

Nasopharyngeal mass
Parotid enlargement
Nephromegaly
Testicular enlargement

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Diagnostic work-up for Non-hodgkins lymphoma?

CBC with diff

PT, PTT, fibrinogen, D-Dimer

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This stage of Non-Hodgkins lymphoma is a single extra nodal tumor or single anatomic area (nodal) excluding mediastinum or abdomen.

Stage 1

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This stage of Non-Hodgkins lymphoma is a single extranodal tumor with regional node involvement; primary GI tumor with or without associated involvement of mesenteric nodes, with gross total resections. OR on the same side of the diaphragm, 2 or more nodal areas, or 2 single extra nodal tumors.

Stage 2

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This stage of Non-Hodgkins lymphoma is any primary mediastinal, pleural, or thyme intrathoracic tumor, any extensive and unresectable abdominal tumor; any primary paraspinous or epidural tumor regardless of other sites. OR On both sides of the diaphragm, 2 or more nodal areas or 2 single extra nodal tumors.

Stage 3

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This stage of Non-Hodgkins lymphoma is any of the above with initial CNS or marrow involvement.

Stage 4

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Treatment of Non-hodgkins lymphoma?

Immediate referral to Onco and a comphrehensive tertiary care center.
Chemo
Radiation
Lymph node excision and dissection

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This is a malignancy of the reticuloendothelial and lymphatic systems and involves B cells. Usually originates in the cervical lymph nodes and spreads to other lymph node regions then to organ systems.

Hodgkins lymphoma

With Hodgkins lymphoma, involvement of the CNS is:

Rare

Who is most often affected by Hodgkins lymphoma?

Young adults Peaks at age 25 second wave 50-60 years

What type of cells are diagnostic for Hodgkins lymphoma?

Reed- Sternberg cell

Physical findings of Hodgkins lymphoma?

Firm, nontender lymphadenopathy - Cervical most common (unresponsive to antibiotic therapy) Mediastinal mass- superior vena cava obstruction, respiratory sx Hepatosplenomegaly

Diagnostic workup for Hodgkins lymphoma:

``` CBC with diff ESR- elevated CRP- elevated Serum copper and ferritin Liver function Urinalysis- proteinuria ```

This stage of Hodgkins lymphoma is a single lymph node or region or single extra nodal site.

Stage 1

This stage of Hodgkins lymphoma is 2 or more lymph node regions on the same side of the diaphragm.

Stage 2

This stage of Hodgkins lymphoma is lymph node regions on both sides of the diaphragm.

Stage 3

This stage of Hodgkins lymphoma is diffuse or disseminated involvement of one or more extra lymphatic organs or tissues with or without lymph node involvement.

Stage 4

B designation in Hodgkins includes the presence of at least on of the following symptoms:

Drenching night sweats Unexplained fevers with temp more than 38 C for 3 consecutive days More than 10% loss of body weight in the past 6 months

Treatment of Hodgkins?

Chemo and or radiation

Most common primary ocular malignancy in childhood?

Retinoblastoma

This type of cancer generally arises from multipotential precursor cell that could develop into almost any type of inner or outer retinal cell.

Retinoblastoma

Greatest predictor of death in retinoblastoma?

Extraocular extension

Most common presenting sign in retinoblastoma?

Leukoria

Physical findings in retinoblastoma?

Leukoria Strabismus- result of visual loss Secondary changes to the eye proptosis

Treatment for retinoblastoma?

``` Surgery -Enucleantion - Cryotherapy - Photocoagulation External beam radiation Radioactive isotope plaques Chemo ```

This cancer arises from a primitive mesenchymal bone-forming cell and is characterized by production of osteoid.

Osteosarcoma

Mainstay of therapy with osteosarcoma is:

removal of tumor

Osteosarcoma can occur in any bone but most commonly occurs:

In long bones of the extremities near metphyseal growth plates. The femur is the most often site.

Patient with osteosarcoma may present:

With pain, particularly with activity **most common* Swelling Respiratory sx- metastases to the lungs

Physical findings with osteosarcoma?

Palpable mass Decreased range of motion lymphadenopathy- unusual

Diagnostic studies for osteosarcoma:

``` CBC Electrolytes CMP LDH and alkaline phosphatase- prognostic significance UA ```

Treatment of osteosarcoma:

Chemo and surgery to remove tumor. | No radiation as there is a high level of resistance.

Patient with Ewings sarcoma may present with:

Pain Palpable mass back pain- may indicate a paraspinal, retroperitoneal, or deep pelvic mass. Systemic systems- fever and weight loss

Physical findings in Ewings sarcoma:

Can occur anywhere Neuropathic pain from disease close to the bone Pathologic fracture Bone marrow metastases- petechia or purpura Lung metastases

Diagnostic studies for Ewings sarcoma:

``` No blood studies provide diagnosis X-ray MRI CT **Metastatic eval- chest CT, radioisotopic bone scan, and bilateral bone marrow aspirate and biopsy. ```

Ewing sarcoma treatment:

Multiagent chemo Radiation Surgery as needed

Most common extra cranial solid tumor of infancy?

Neuroblastoma

This is embryonal malignancy of the SNS arising from neuroblasts.

Neuroblastoma

What type of tumors are associated with neuroblastoma?

Small, round, blue cell tumors- undifferentiated

What is detectable in urine of a patient with neuroblastoma?

Urinary catecholamines such as elevated homovanillic acid and/or vanillylmandelic acid levels

General symptoms of neuroblastoma?

``` Abdominal pain emesis weight loss anorexia fatigue bone pain- bone/bone marrow involvement limp- bone/bone marrow involvement ```

Undifferentiated neuroblastoma histologically present as:

small, round, blue cell tumors with dense nests of cells in a fibrovascular matrix and Homer-Wright pseudorosettes.

Treatment of neuroblastoma?

``` Based on site and stage. Surgery Radiation Combo chemo Bone marrow transplantation- high risk patient s ```

Most common childhood abdominal and renal malignancy?

Wilm's tumor

This results from neoplastic proliferation of embryonal renal cells of the metanephros. It is caused by alterations in genes responsible for normal GU development.

Wilm's tumor

Associated abnormalities with Wilm's tumor?

``` Sporadic aniridia Hemihypertrophy Cryptorchidism Hypospadias Other GU anomalies ```

How is Wilm's tumor most often detected?

After incidental detection of an asymptomatic abdominal mass.

Physical findings of Wilm's tumor?

Firm, smooth abdominal or flank mass elevated BP- renal ischemia left varicocele if spermatic vein obstructed Need to r/o congenital anomalies** Do no palpate mass too vigorously- can cause rupture

Treatment of Wilm's tumor?

If unilateral- complete nephrectomy If bilateral- nephrectomy of more involved site; excision biopsy/partial nephrectomy of smaller lesion in remaining kidney; no surgery with radiation Multiagent chemo Radiation

Cancer pain often requires management with what?

Opiods | Usually combo of short and long-acting, however try short-acting before long-acting

What do you typically start with for opioid pain management for cancer?

5mg Oxycodone q4h prn

If patient is taking 5mg oxycodone q4hr around the clock with minimal relief:

Increase oxycodone Introduce long-acting opioid Dose to stay ahead of the pain *

Drugs to treat nausea and vomiting d/t chemo:

5-HT3 antagonist- zofran- specifically designed for chemo-induced N/V Dopamine 2 antagonist- Compazine- helps to stay ahead of nausea , less constipating then zofran Benzos- Ativan- can be helpful for anticipatory nausea Corticostroids- reduce liver capsule stretch, can help with nausea from metastatic brain disease Anitcholingeric- Reglan- can help with gastric motility

How to manage fatigue in cancer patients:

Nonpharm interventions: cluster activities, make a schedule, take naps, schedule walks Pharm interventions: Stimulants- Ritalin, Adderall