Principles of Oncology 2 Flashcards
What is the order of goals for cancer treatment?
- Eradication
- Palliation
- Sx treatment
- Preservation of quality of live while possible extending life
What are the local treatments?
Surgery and radiation
What are systemic treatments?
Chemotherapy and biologic therapy
What is the most effective means of treating cancer?
Surgery, 40% of cancers can be cured by surgery alone
What is the goal of radiation?
Deprive cancer cells of their cell division potential
How does radiation work?
Breaks DNA to prevent replication and creates hydroxyl radicals from cell water that damages the cell membranes, proteins, and organelles
What do the systemic effects of radiation depend on?
Volume of tissue irradiated
Dose fractionation
Radiation fields
Individual susceptibility
What are the three ways to deliver radiation?
Teletherapy - xray or gamma photons
Brachytherapy
Systemic therapy
What is the most common effect of radiation?
Fatigue
What is radiofrequency ablation?
Focused microwave radiation to induce thermal injury within a volume of tissue
What is cryosurgery?
use of extreme cold to sterilize lesions in certain sites
What is chemoembolization?
Infusion of chemotherapeutic agents directly into the target area via vascular catheters
What are conventional cytotoxic chemotherapy agents?
Target DNA structure or segregation of DNA as chromosomes in mitosis
What are targeted agents?
Designed and developed to interact with a defined molecular target important in either maintaining the malignant state or selectively expressed by the tumor cells
What are hormonal therapies?
Work on the biochemical pathways underlying estrogen and androgen functions
What are biologic therapies?
Have a particular target or may have the capacity to regulate growth of tumor cells or induce a host immune response to kill tumor cells
What are the two valuable outcomes to chemotherapy?
Induce cancer cell death
Induce cancer cell differentiation or dormancy
What are the antimetabolites?
Methotrexate
5-fluorouracil (5-FU)
What is the MOA for 5-FU?
prevents thymidine formation (required for DNA replication)
What is the MOA for methotrexate?
Competes and counteracts folic acid, causing folic acid deficiency in cancer cell and cell death
What are SE of antimetabolites?
stomatitis, diarrhea, and myelosuppression
What drugs are mitotic spindle inhibitors?
Vincristine, Vinblastine, Paclitaxel
What is the MOA of mitotic spindle inhibitors?
Cause cell death during interphase
What are the SE of mitotic spindle inhibitors?
Alopecia, neuropathy, myelosuppression
What are the alkylating agents?
Cyclophorsphamide
Chlorambucil
Cisplatin
What is the MOA of alkylating agents?
Break down into reactive intermediates that covalently modify bases in DNA
What are the SE of cisplatin?
Neuro-toxicity (stocking-glove), hearing loss, renal failure
What is the antitumor antibiotic?
Doxorubicin
What is the MOA of doxorubicin?
Bind DNA and undergo electron transfer reactions to generate free radicals that damage DNA
What is the SE of doxorubicin?
Cardiotoxicity
What is the topoisomerase inhibitor?
Etoposide
What is the MOA of etoposide?
inhibits DNA synthesis by causing breaks in the DNA
What is the SE of etoposide?
Secondary leukemias
What is the treatment for neutropenia?
Colony stimulating factors (CSF): Filgrastim, pegfilgrastim, sargramostim
What are the side effects of colony stimulating factors?
MANY
What is the treatment for anemia?
Transfusion, EPO
What is the treatment for thrombocytopenia?
Conservative monitoring, maybe a platelet transfusion
What is the most common side effect of chemo therapy?
Nausea
What is mucositis, what causes it and how do you treat it?
Oral soreness and ulceration and severe diarrhea
Caused by cytarabine, 5-FU, methotrexate
Magic mouthwash
What causes diarrhea and how do you treat it?
5-FU is a common cause.
First give imodium, then octerotide if that doesn’t help
What is the treatment for skin toxicity?
Cold packs, sun protection
What is the treatment for alopecia?
Psychological support, chemo caps
What routine blood work should you order on cancer patients?
CBC, CMP, PT/PTT
What are the clinical manifestations of cancer?
Clinical manifestations of cancer usually due to pressure effects of local tumor growth, infiltration, or metastatic deposition of tumor cells in a variety of organs in the body, or certain systemic symptoms
What are paraneoplastic syndromes?
Disorders that accompany benign or malignant tumors but are not directly related to mass effect or invasion. Sometimes this is the creation of products that stimulate hormonal, hematologic, dermatologic, renal, and neurologic responses
What are the four categories of disorders that paraneoplastic syndromes resemble?
Endocrine
Metabolic
Hematologic
Neuromuscular
What are the three mechanisms of paraneoplastic syndromes?
- Effects initiated by a tumor product
- Effects of destruction of normal tissues by tumor
- Effects due to unknown mechanism
Why are paraneoplastic syndromes important?
- Early clue to presence of cancer
- May be a more urgent hazard to the patient’s life than the underlying cancer
- Effective CA treatment also resolves the paraneoplastic syndrome
What is hypercalcemia related to?
Usually parathyroid hormone related peptide
NSCLC, breast, renal, adrenal, prostate
What is hypoglycemia related to?
hepatocellular carcinoma 2/2 impaired gluconeogenesis
What is gonadotropin secretion related to?
SCLC
What is cushing’s syndrome related to?
Ectopic production of ACTH (Adrenocorticotropic hormone) by tumor
SCLC, adrenal, thymoma
What is SIADH related to?
Ectopic production of vasopressin by tumor
NSCLC, SCLC
What cancers is coagulopathy related to?
Breast, GI, prostate
What cancers is Erythrocytosis related to?
Renal, hepatocellular
Ectopic production of EPO
What cancers is Lambert-Eaton syndrome related to?
SCLC
is a immune mediated neurologic syndrome that causes limb muscle weakness
What cancers is subacute cerebellar syndrome related to?
SCLC
Immune mediated cerebellar degeneration characterized by dizziness, nausea, vertigo, tremor
What cancers is dermatomyositis related to?
SCLC, NSCLC
A system disorder causing inflammation of the muscles and skin as well as joints, lungs, esophagus, and heart
What cancers is Acanthosis Nigricans related to?
GI adenocarcinomas
Also in diabetes/obesity in folds of skin, cancer related will be in mucous membranes
What is a neutropenic fever?
Recurrent temp >38C or single temp >38.3C PLUS <500 absolute neutrophil count
What are the sx of a neutropenic fever?
Vague and mild progresses to sepsis and death. Sx based on source of infection
What are the most common viral causes of a neutropenic fever?
CMV (Cytomegalovirus)
HSV (herpes)
VZV (varicella)
What are the most common bacterial causes of a neutropenic fever?
Staph
Strep
Enterococcus
H flu
E coli
Klebsiella
Pseudomonas
What are the most common fungal causes of a neutropenic fever?
Candida
Aspergillosis
What cultures do we need for neutropenic fever?
all lumens, skin, and line sites including blood, urine, sputum, and stool for bacterial, fungal, and viral studies
What imaging should you order for a neutropenic fever?
Chest x-ray (might be normal even in PNA because not enough neutrophils to cause an infiltrate)
What Labs should you order for a neutropenic fever?
CBC
CMP
Coags
UA
What ABx therapy do we do for neutropenic fevers and what does it cover?
- Ceftazidime, cefipime, or imipenem for antipseudomonal
- Aminoglycoside for gram negative
- Vancomycin for MRSA
What is the clinical presentation of spinal cord compression?
Back pain aggravated by laying down, weight bearing, sneezing, or coughing
Mix of nerve root and spinal cord symptoms
What imaging should we order for a spinal cord compression?
MRI
What is the treatment for spinal cord compression
High dose IV corticosteroids
Surgical decompression
Radiation
What are the three mechanisms of hypercalcemia related to cancer?
- Systemic effects of tumor-released proteins
- Direct osteolysis of bone by tumor
- Increased absorption of calcium due to increased active metabolite of Vitamin D
What is the most common cause of hypercalcemia? Most common cancers?
A parathyroid hormone-related peptide secreted by the cancer cells
Myeloma
Breast
NSCLC
What does hypercalcemia typically indicate?
Advanced cancer with a median survival of 1-3 months
What are the symptoms of hypercalcemia?
Polydipsia, polyuria, weakness, lethargy, anorexia, N/V, constipation, abd pain, AMS, psychosis
“Bones, sones, groans, and psychiatric overtones”
What labs diagnose hypercalcemia?
Total serum calcium and ionized calcium levels
What EKG changes indicate hypercalcemia?
Short QT
ST depression
AV blocks
What is the treatment for hypercalcemia?
Hydrate and diuresis
Bisphosphonates
Calcitonin
Hemodialysis
What is tumor lysis syndrome? When does it occur?
Syndrome that occurs 1-3 days following radiochemotherapy of most commonly hematologic malignancies?
What cancer is most associated with tumor lysis syndrome?
Burkitt lymphoma
What is the cause of tumor lysis syndrome?
Massive release of cellular material including nucleic acids, protein, phosphorus, and potassium. Causes hyperuricemia, hyperphosphatemia, and hyperkalemia.
What is the biggest complications of tumor lysis syndrome?
AKI 2/2 uric acid and calcium phosphate deposits in the renal tubules which exacerbates hyperphosphatemia and hyperkalemia
Cardiac arrhythmias 2/2 high K and low Ca
What are the symptoms of tumor lysis syndrome?
lethargy, N/V, cloudy urine, neuromuscular irritability, spasms, seizures, AMS
What does an EKG look like in tumor lysis syndrome?
Peaked T waves (high K)
arrhythmias
What is the treatment for tumor lysis syndrome?
IV hydration and correction of electrolytes. Maybe dialysis
When to effusions occur during cancer?
Can be first finding but can also appear at any point
What is the most common cause of an effusion?
A tumor that has direct involvement with the serous surface
What are the most common causes of pleural and pericardial effusions?
Breast and lung cancers
What are the most common causes of malignant ascities?
Ovarian, colorectal, stomach, pancreatic cancers
What determines the hemodynamic instability of a patient with a pericardial effusion?
The rate of accumulation and the distensibility of the sac
What are the sx of a pericardial effusion?
Fatigue, chest heaviness, dyspnea, palpitations, cough, and syncope
What PEx findings are c/w a pericardial effusion?
Tachycardia, narrowed pulse pressure, hypotension, distended neck veins, muffled heart sounds, pulsus paradoxus (BP decreases on inhalation)
What does an x-ray of pericardial effusion show?
Enlarged cardiac silhouette and pleural effusion
What does an EKG of pericardial effusion show?
Sinus tachycardia, low QRS voltage, and electrical altemans
What is the diagnostic tool of choice for a pericardial effusion?
Transthoracic echocardiogram which will show a pericardial effusion with RA systolic collapse and RV diastolic collapse
What is the treatment of choice for a pericardial effusion?
Echo-guided percutaneous pericardiocentesis
What is superior vena cava syndrome?
The direct obstruction of the SVC by malignancies
What is the most common cause of superior vena cava syndrome?
Bronchogenic carcinoma
What are the symptoms of superior vena cava syndrome?
Dyspnea, CP, cough, facial and arm swelling, cerebral edema
What are the PEx findings c/w superior vena cava syndrome?
Distended neck, arm and chest veins, nonpitting edema of the neck, arm swelling, tongue and facial swelling, cyanosis
What is the test of choice for superior vena cava syndrome?
Chest CT with contrast
What is the treatment for superior vena cava syndrome?
Glucocorticoids to reduce inflammation
Intravascular stenting, chemo and radiation depending on tumor type
Why are cancer patient’s more prone to thromboembolic events?
- hypercoagulable state
- neoplastic cells and chemo can cause intimal injury
- Tumors can cause venous stasis
What are the sx of a thromboembolic event?
Dyspnea, fever, cough, DOE, pleuritic chest pain, leg pain/swelling, hemoptysis
What are the PEx findings c/w a thromboembolic event?
Fever, tachypnea, tachycardia, pleural rub, unilateral LE swelling
What imaging confirms a thromboembolic event?
Ventilation-perfusion scan
Spiral chest CT with contrast
What is the treatment for a thromboembolic event?
Anticoagulation, thrombolytic therapy if hemodynamic compromise and RV failure on echo
