Oncology part 2 Flashcards
chemo and radiation drugs
MoA of radiation
breaks in DNA that prevent replication and generates hydroxyl radicals from cell water that damages cell membranes, proteins, and organelles.
Damages cancer cells more because cancer cells aren’t as efficient at repairing themselves.
Why do systemic radiation symptoms appear despite radiation being local
it depends on volume of tissue, dose, where the fields are aimed at, and individual susceptibility
3 types of radiation and what they do
1)teletherapy, with focused beams of radiation generated at a distance and aimed at the tumor - xray and gamma
(2)brachytherapy, encapsulated/sealed sources of radiation implanted directly into or adjacent to tumor tissues
(3)systemic therapy, radionuclides targeted in some fashion to a site of tumor……radioactive iodine for thyroid cancer
What cancer can radiation CURE?
Breast cancer, Hodgkin’s disease, head and neck cancer, prostate cancer, and gynecologic cancers.
all gyn parts, just the prostate for males, then 2 H’s - Hodgkins and Head and neck
Radiation can be used for palliation for:
blocked airways, bone pain ,brain , spinal cord and SVC compression , shrink masses
BBB & SSS
Bone, brain, blocked airways
Spinal cord, Sup. vena cava, Shrink masses
What are the other localized therapies?
Radiofrequency, crysurgery, chemoembolizaiton.
What does radiofrequency ablation do
focused microwave radiation to induce thermal injury within a volume of tissue
local. think hot.
Cryosurgery
use of extreme cold to sterilize lesions in certain sites
local. think cold
Chemoembolization
Infusion of chemotherapeutic agents directly into the target area via vascular catheters
chemo that’s local. “embolis” is the key to remembering. an embolis of chemo would be local on the stuff around it
Chemotherapy mechanism
- Kill cancer cells
- increase the time until the disease progresses
- Tumor cell -> differentiated into a normal cell
sometimes can’t kill the cancer cells and patient live longer
methotrexate and 5-FU
MoA, toxic, class?
Antimetabolites
5-fluorouracil prevents thymidine formation (required for DNA replication)
Methotrexate competes and counteracts folic acid, causing folic acid deficiency in cancer cell and cell death
Common toxic manifestations include stomatitis, diarrhea, and myelosuppression
MTX = monster truck. picture a monster truck blowing through a folic acid supplement
rem 5-FU - thymidine. it says F U to thymidine formation
Toxic - DSM
Vincristine, Vinblastine
Paclitaxel
Mitotic spindle inhibitors
Toxic: alopecia, neuropathy, and myelosuppression.
toxic - M-MAN (man is toxic)
Cyclophosphamide
Chlorambucil
Cisplatin
– neuro-toxicity (stocking-glove), hearing loss, renal failure
Alkylating Agents
cell cycle phase–nonspecific agents
Break down to reactive intermediates that covalently modify bases in DNA, then perform cross-linkage of DNA strands. Looks like breaks in DNA
Stocking glove, hearing loss, renal fail
*picture someone with gloves covering their ears + renal
C’s = in orgo, a ‘c’ is carbon. for alkyl group
Doxorubicin
Produced by bacteria that in nature appear to provide a chemical defense against other hostile microorganisms.
As a class they bind to DNA directly and can frequently undergo electron transfer reactions to generate free radicals in close proximity to DNA, leading to DNA damage in the form of single-strand breaks or cross-links
-cardio toxicity
DOC
D: Doxorubicin
O: oxidative stress (free radicals)
C: Cardiotoxic
Etoposide
Topoisomerase inhibitor
- inhibits DNA synthesis by forming a complex with topoisomerase II and DNA, causing breaks in DNA, which prevents the mitotic phase of cell division, causing cell death
Toxic: secondary leukemia with high doses
TBL
Top - forms complex with and inhibits
Breaks DNA
Leukemia
Filgrastim, pegfilgrastim, sargramostim
used to treat neutropenia, a toxic SE of chemo
Colony stimulating factors (CSF)
Takes 24 h to induce peak neutrophils
Stimulate neutrophils, monocytes, and eosinophils
SE: allergies, warmth, blister, burn, numb, bleeding gums, ulcer
stimulates MEN in 24 h
SE: hot, bleed, numb
Epogen
Treats anemia in chemo toxicity (stimulates erythrocytes)
Ondansetron
treats nausea, chemo SE
Magic mouthwash
diphenhydramine, lidocaine, Maalox
Treats mouth sores (mucositis), chemo toxicity
Warlock Maalox has a caine and casts benadryl
Drugs MC mucositis in mouth and GI (mouth ulcer&diarrhea)
cytarabine,5-FU, and methotrexate
Loperamide is used to treat what
And b/c of what form of chemo
treat diarrhea chemo toxicicity
esp from 5FU
antimotility
Octerotide
Octerotide (somatostatin analogue) or opiate-based preparations if no response to Loperamide
Cold packs and sun protection
treat skin toxicity chemo
What does skin toxicity from chemo look like
-Hyperpigmentation, alopecia, photosensitivity, nail changes, acral erythema, and generalized rashes.
- Acral erythema manifests as painful palms or soles accompanied by erythema, progressing to blistering desquamation and ulceration in its worst forms.
dark, hairless, nails, blister and rash, burn easy
Painful red–>blister and shed–> ulcer
Chemo caps
Reduce scalp for alopecia, very controversial. should just give psychological support
Chemo routine blood
CBC, CMP, PT/aPTT
3 reasons why paraneoplastic syndrome are clinically important
- early clue
- the metabolic effects of tumor on other tissues can be more toxic than the cancer itself
- paraneoplastic syndrome should go away when the cancer does and vice versa
Hypercalcemia
endocrine paraneoplastic syndrome
- non small cell lung cancer, Breast, Renal cell, Adrenal, Prostate
Usually due to parathyroid hormone related peptide
L: Lung cancer
A: Adrenal gland tumors
R: Renal cell carcinoma
P: Prostate cancer
+
B: Breast cancer
Hypoglycemia
Hepatocellular carcinoma (impaired gluconeogenesis)
Gonadotropin secretion
small cell lung carcinoma
gonadotorpin is the one that regulates ovaries and testes. small cell cardinoma is the uncommon form of lung cancer
Cushings
SCLC, Adrenal, Thymoma
ectopic production of ACTH by tumor
-cushings causes fat pads, moon face, buffalo hump, apple shape body. its from being exposed to steroids too long
S: Small cell lung cancer (SCLC)
A: Adrenal tumors
T: Thymoma
ACTH: Ectopic production of ACTH by the tumor
SIADH
NSCLC, SCLC (both types of lung cancer)
-ectopic production of vasopressin by tumor
Coagulopathy
Breast, GI, prostate
Paraneoplastic syndrome
B(GI) Big PC (prostate, coag)
Erythrocytosis
Erythrocytosis - due to ectopic production of erythropoietin
Renal, Hepatocellular
H: Hepatocellular cancer
E: Erythrocytosis
R: Renal cancer
EPO: Ectopic production of erythropoietin
Lambert-Eaton syndrome
neurologic paraneo.
immune mediated
characterized by muscle weakness of the limbs
SCLC
Lame: Refers to muscle weakness (lameness)
Bert
Eats: Refers to Eaton
Small Cell Lung Cancer (SCLC)
Subacute cerebellae syndrome
immune mediated cerebellar degeneration
SCLC
Characterized by dizziness, nausea, vertigo, tremor, and sometimes dysphagia and blurry vision
Submarine: Subacute
Captain: Cerebellar
Trembling: tremor
Small: Small cell lung cancer (SCLC)
Dizzy: Dizziness
Boat: Blurry vision, Nausea, Vertigo
Dermatomyositis
SCLC, NSCLC ( both types of lung)
A system disorder causing inflammation of the muscles and skin, as well as joints, lungs, esophagus and heart
paraneoplastic syndrome
Dermy’s HELL J&M”
Breaking it down:
Dermy: Dermatomyositis
H: Heart
E: Esophagus
L: Lungs (SCLC, NSCLC)
L: Lungs again for emphasis
J Joints
M: Muscles
Acanthosis Nigricans
Acanthosis Nigricans - thickening of skin/brownish discoloration
Can occur with diabetes/obesity, typically in fold of neck, under breast
More likely to also involve the mucous membranes with cancer
GI adenocarcinomas
Fatties chew GUM
G: GI adenocarcinomas
U: Under fold (under fold of breast and neck. think of gum being stuck under tables)
M: Mucous membranes (involvement with cancer)
Whats the point of surgery
- CURES 40% of cancer patients
- most effective at treating cancer
- can also palliate, stage, diagnose, treat
MC form of radiation therapy
Teletherapy
Whats the point of radiation therapy
deprives cells of their division potential
Radiation Toxicity looks like:
- systemic effects: FATIGUE, anorexia,N/V
- Acute toxicities:mucositis, skin erythema (ulceration in severe cases), and BM toxicity.
- Chronic toxicities:
Radiation carcinogenesis with secondary malignancy; pericarditis; myocardial infarction; thyroid failure; cataracts; lung fibrosis; arteritis; spinal cord transection
more cancer, MI, pericarditis, thyroid, cataracts, lung scarring, arteritis, spinal cord issue
Categories for chemo
Conventional cytotoxic: try to hurt the DNA
Targeted: molecular target design
Hormonal: estrogen and androgen function
Biologic: Boost immune system or regulate tumor growth
Paraneoplastic syndromes - endocrine
hypercalcemia, hypoglycemia, gonadotropin, cushings, siadh
paraneoplastic syndromes - hematologic
coagulopathy, erythrocytosis
Paraneoplastic syndrome - neuologic
lambert eaton syndrome, subacute cerebellar syndrome
Paraneoplastic syndrome - dermatologic
Dermatocyositis, acanthosis nigricans
Oncologic complications
Neutropenic fever, spinal cord compression, hypercalcemia, tumor lysis syndrome, effusions, SVC syndrome, thromboembolic event
Neutropenic Fever
Recurrent above 38 C, or single above 38.3 C while ANC less than 500
Can be an infection thats viral fungal or bacterial. vague and mild b/c not enough WBC to show sx. then rapid sepsis and death.
Etiology - CMV, HSV, VZV, Klebsiella, Pseudomonas, E coli, H flu, staph strep
Fungal - yeast, aspergillosis
DUE TO CHEMO
Neutropenic fever sites of infection
central venous access catheter, skin, mouth, sinus, chest or lung, abdomen, perianal region, and CNS. NO DIGITAL RECTAL EXAM
Neutropenic fever tx
Ceftazidime, cefipime, imipenem
Aminoglycoside
Vancomycin
aminoglycoside = streptomycin, gentomycin
Neutropenic fever dx
Cultures from all lumens, skin, sinuses, blood, urine, sputum, stool
CXR but could be normal b/c not enough WBC
CBC, CMP, coag, UA
its an invisible infection that you can only find via culture. so your hunting in every possible site it could be before the patient dies.
Spinal Cord Compression
- Back pain at the level of the tumor mass, aggrivated by bearing down, supine
- nerve sx
- Progression of LE weakness, hyperreflexia, motor sensory loss, loss of reflexes, loss bowel/bladder fx, and lastly paraplegia
Spinal Cord compression tx & dx
MRI,
IV corticosteroids, surigcal decompression, radiate the lesion
Read only
hypercalcemia MoA
Hypercalcemia is caused by one of three mechanisms:
Systemic effects of tumor-released proteins
Direct osteolysis of bone by tumor
Increased absorption of calcium due to increased active metabolite of Vitamin D
Most commonly caused by a parathyroid hormone-related peptide secreted by the cancer cells
This activates the parathyroid hormone receptor, stimulating osteoclastic activity and promoting renal reabsorption of calcium
Usually a marker of advanced cancer, with median survival ranging from 1 to 3 months
Hypercalcemia etiology and presentation
- Happens to 20-30% cancer patients
- MC: NSCLC, myeoloma, breast
- thirsty, polyuria, AMS, lethargy, psychosis, CONSTIPATION, abdominal pain
Urine NOT cloudy which separates it from tumor lysis
Hypercalcemia Dx
total serum ca AND ionized ca are elevated
EKG: short QT, ST depression, AV block
Hypercalcemia treatment
1line. hydration, diuresis
bisphosphonates (zoledronic, pamidronate)
2 line. Calcitonin
Hemodialysis definitive
Tumor Lysis Syndrome Etiology
- 1 to 3 days following radiochemotherapy, usually hematologic type cancer
- Release of nucleuic acids, proteins, phosphorus, potassium
- If can’t metabolize/excrete, hyperuricemia, hyperphosphatemia, hyperkalemia
- AKI from deposition of uric acid and calcium in the renal tubules which makes K and phos worse
Tumor Lysis Syndrome clinical presentation
&dx, tx
- fatal cardiac arrhythmias
- lethargic, N/V, CLOUDY URINE, MSK spasm, seizure
- peaked T waves on EKG
-IV hydration, correct electrolyte abnormalities
+- emergency hemodialysis
Pleural effusion MC cause
lung and breast
pericardial effusions MC cause
lung and breast cancer
Malignant ascites MC cause (effusion)
ovarian, colon, stomach, pancreas
Everything in abdomen except liver, spleen, prostate
Pericardial effusion/Cardiac tamponade
- Fatigue, chest heaviness, dyspnea, palpitations, cough, syncope
-rate of accumulation and distensibility of the sac determines the degree of hemodynamic instability. - PE: tachyc, dec. pulse pressure, low BP, distended neck veins, muffled heart sounds, pulse paradoxus
Pericardial Effusion/Cardiac Tamponade Dx Tx
Dx, Tx
- Chest XRAY enlarged cardiac silhouette and pleural effusion
- EKG- sinus tachy, low QRS voltage
- transthoracic echocardiogram is diagnositc tool of choice - Tx of choice is echo- guided percutaenous pericardiocentesis under local anaesthesia
MC cause of SVC
Bronchogenic carcinoma
SVC clinical presentation
dyspnea, chest pain, cough, facial and arm swelling, cerebral edema rare
-distended neck, arm and chest veins, nonpitting edema of the neck, arm swelling, tongue and facial swelling and cyanosis
-CXR shows widened mediastinum
- CHEST CT W/ CONTRAST DIAGNOSTIC TEST OF CHOICE
Compare: cardiac tamp was CXray and echo. xray showed enlarged cardiac silhouette
Why w/ contrast? Want to visualize blockage
SCV syndrome treatment
glucocorticoids to decrease edema, intravascular stenting to get around mass
chemo and radiation
Thromboembolic event
clinical present, dx, tx
-hypercoag state
PE: fever, pleural rub, unilateral lower extremity swelling
Spiral chest CT with contrast or V/Q scan to CONFIRM dx
tx - Anticoagulation heparin or lmwh, thrombolytic therapy maybe
