Oncology III

Question 1

What the patient tells us

Answer 1

• About themselves
• About there mental state
• Co-morbidities
• Medication
• Support

Question 2

Toxicity the questions we should be asking

Answer 2

• Duration vs Severity
• Single vs Multiple
• Visible vs Invisible
• Preventable vs Manageable

Question 3

Signs and symptoms of anaphylaxis

Answer 3

Question 4

Anaphylactic reaction pathway

Answer 4

• ABCDE (Airway Breathing Circulation Disability Exposure) =>
• Diagnosis: Acute onset of illness, life-threatening airway/breathing/circulation problems =>
• Call for help: Lie patient flat, raise patient legs =>
• Adernaline =>
• When skills and equipment available
  
  • Establish airway, high O2 flow, IV fluid challenge, Chlorphenamine, hydrocortisone
  • MONITOR: Pulse, ECG, BP

Question 5

Extravasation is

Answer 5

• The leakage of one drug from its intended compartment of delivery into one or more adjacent compartments
• It has a number of euphemisms- infiltration, tissuing, displacement- but at the end of the day they are all the same injury
• It is a complex interaction of factors
• It is a whole spectrum of reactions from a pre-extravasation syndrome to a complete necrotic breakdown of tissue
• It is an oncological parenteral therapy emergency

Question 6

Difficult to diagnose, varied and unpredictable development & outcome

Answer 6

Question 7

Factors known to be involved

Answer 7

• Patient
• Practical
• Personnel
• Pharmacological
• An individual extravasation injury will be a mix of all of the above
• Some factors are causative of injuries whilst others are contributory too it

Question 8

Basis of treatment

Answer 8

• ALWAYS
  
  • Aspirate
  • Palliate the immediate symptoms
• THEN
  
  • Localise and Neutralise- followed by
  • Dilute and spread
• For established or missed extravasations
  
  • treat as for other ulcerated tissue- de-bride and granulate

Question 9

There should be a national protocol for the treatment of extravasation, and a standard approach to antidotes

Answer 9

Question 10

Chemotherapy-induced N&V (CINV)

Answer 10

• Can lead to serious complications
  
  • Dehydration
  • Malnutrition
  • Electrolyte disturbance
• May result in delay, dose reduction or discontinuation of SACT
• Effective management is an important part of patient care

Question 11

Risk factors

Answer 11

• Gender
• Age
• Chemotherapy (previous treatments)
• History of lifestyle

Question 12

Emetogenic risk with SACT

Answer 12

• CINV is complex
• Main risk factors
• SACT emetogenic potential
• SACT categorised for emetic risk
  
  • Minimal (0-10%)
  • Low (10-30%)
  • Moderate (>30-90%)
  • High (90%)

Question 13

Types of N+V associated with chemotherapy

Answer 13

• Acute vomiting
  
  • Occurs within 24 hrs of SACT, peaks after 5-6 hours
• Delayed N&V
  
  • >24hrs post SACT, lasts 3-7 days
• Anticipatory N&V
  
  • Conditioned response; associated poor control previously
• Breakthrough N&V
  
  • CINV despite prophylaxis
• Refractory vomiting
  
  • CINV despite interventions, recurs in subsequent cycles

Question 14

Antiemetic prophylaxis for chemotherapy-induced N&V

Answer 14

Question 15

Emetic reflex

Neurotransmitters: targeting key pathways

Answer 15

• DA
• Histamine
• 5-HT
• Endorphins
• Substance P
• GABA
• Cannabinoids
• ACh

Question 16

CINV classification & examples of anti-emetics

Answer 16

• Acute- 5-HT3 receptor anatagonist, metoclopramide, dexamethasone
• Delayed- dexamethasone, NK1-blocker
• Breakthrough- Metoclopramide, cyclizine
• Anticipatory- lorazepam
• Refractory- Levomepromazine, NK1-blocker, nabilone

Question 17

MRHA advice- domperidone, metoclopramide, ondansetron

Answer 17

• Domperidone (May 2014): cardiac side effects inc. QT prolongation
  
  • Lowest effective dose (30mg) for the shortest possible time (max 48hrs)
• Metoclopramide (Aug 2013): neurological effects
  
  • Maximum 30mg/24 hours (or o.5mg/kg)
  • Short term use; upto 5-days; IV slow over >3mins
• Onsansetron (July 2013); QT prolongation, cardiac arrhythmia
  
  • Max dose restrictions for CINV
    
    • <75yrs 16mg
    • >75yrs 8mg
  • 15 minute infusion
  • Repeat doses (at least 4hr intervals)

Question 18

Overview of guidelines for acute N&V

Answer 18

Question 19

Risking factors- summary

Oral mucositis

Answer 19

Question 20

Effect of radiation on oral mucositis

Answer 20

Question 21

Treatment of oral mucositis

Answer 21

Question 22

Why do we give chemotherapy every 3 weeks

Neutropenia

Answer 22

Question 23

Predisposing factors

Answer 23

• Infectious complications are a major cause of morbidity and mortality in cancer patients
  
  • 8% mortality in patients admitted with febrile neutropenic episodes
• Predisposing factors include
  
  • Neutropenia
  • Loss of cell-mediated and humoral immunity
  • Disruption of skin or mucosal barriers

Question 24

Predisposing factors- neutropenia

Answer 24

Question 25

Prevention of infection

Answer 25

• Protective isolation
• Good oral hygiene
• Antimicrobial prophylaxis
  
  • Anti-bacterial (inc gut decontamination)
  • Anti-fungal
  • Anti-viral- surveillance of viral load
• Neutropenic diet

Question 26

Diagnosis of febrile neutropenia

Answer 26

• Definition vary
• Temp >38’C
• Neut- <0.5 x10⁹/L or <1x10⁹/L and falling
• Usual inflammatory signs of infection often absent due to lack of neutrophils
• Caution- patients in septicaemic shock may present with tachycardia, hypotension and no fever

Question 27

Management of febrile neutropenia

Answer 27

• Investigations
  
  • Take history
  • Clinical examination
  • Peripheral and Hickman line blood cultures
  • FBC, U&E
  • Sputum, MSU, Stool, swab sites of infection
  • Chest X-ray and nasopharyngeal aspirate if necessary
• Most crucial factor is prompt initiation of antibiotics

Question 28

Treatment schedule

Answer 28

• Tazocin monotherapy unless significant hypotension (diastolic BP <60 mmHg) or septic shock- then add gentamycin
• Vancomycin only if obvious line infection and/or severe mucositis
• Reassess at 48 hours, if significant isolate amend therapy

Question 29

Antibiotic prophylaxis- quinolones

Answer 29

• Two large trials and a meta-analysis published in 2005
  
  • Gafter-Gvilli A et al. Ann Intern med 2005; 142: 979-95
  • Bucaneve G et al
  • Cullen M et al
• Meta-analysis: Decrease mortality risk cf placebo or no treatment
• Both studies included solid tumour & lymphoma patients
  
  • Bucaneve et al: higher risk group (inc autos, acute leukaemia)
• Cullen: decrease febrile episodes, probable infection, hospitalisation
• Bucaneve: decrease clinically significant bacterial infections, including G-ve rod bacteraemias

Question 30

Effect of antimicrobial prophylaxis on the rate of and time of infection

Answer 30

Question 31

Antibiotic prophylaxis- other

Answer 31

• Co-trimoxazole (960mg M/W/F0 recommended as prophylaxis if significant T-cell immunosuppression
  
  • E.g. fludarabine, cladribine, alemtuzumab, ciclosporin, corticosteroids
• Dapsone
• Penicillin V (500mg BD) post-transplant

Question 32

Antifungal prophylaxis

Answer 32

Question 33

Antiviral prophylaxis

Answer 33

• Low risk patients do not require aciclovir prophylaxis (unless prior HSV)
• Aciclovir prophylaxis for intermediate/high risk patients (HSV)
  
  • Historically, high dose aciclovir used in high risk patients to prevent VZV/CMV, alternatives ganciclovir, foscarnet or cidofovir
  • HSV- Herpes Simplex Virus
  • VZV- Vermicelli-Zoster Virus
  • CMV- CytoMegaloVirus