Principles of Oncology- part 2 Flashcards
Conversely, when the clinical goal is palliation, careful attention to minimizing the _____ becomes a significant goal
toxicity of potentially toxic treatments
What are the 4 types of cancer treatments. Most cancer treatments are _____
Surgery
Radiation therapy
Chemotherapy
Biologic therapy
Some combination of the above treatments
Surgery and radiation therapy are considered ____ treatments
local
Chemotherapy and biologic therapy are usually _____ treatments.
systemic
_____ is the most effective means of treating cancer
surgery
Name some reasons surgery is used
Cancer prevention (prophylactic mastectomy/colectomy)
Diagnosis
Staging
Treatment (for both localized and metastatic disease)
Palliation
____ of cancer patients cured by surgery
40%
Even if the surgery is not curable, name some benefits of surgery
Local control of tumor
Preservation of organ function
Debulking for subsequent treatments
Palliative/Supportive care
-Placement of lines
-Control of effusions and ascites
-Removal of adhesions/strictures
-Reconstructive surgery
What is the main goal of radiation therapy?
deprive cancer cells of their cell division potential
** Radiation causes breaks in DNA that prevent replication and generates _____ from cell water that damages cell membranes, proteins, and organelles
hydroxyl radicals
Cancer cells are not as ??? repairing the damage caused by radiation resulting in differential ____ killing
efficient as normal cells in
cancer cell
Name some factors that influence the development of systemic effects
volume of tissue irradiated
dose fractionation
radiation fields
individual susceptibility
____, ____ and _____ are features that make a particular cell more sensitive or more resistant to the biologic effects of radiation
total absorbed dose
number of fractions (delivering radiation in repeated doses to maximize exposure during cell division)
time of treatment
Type of radiation: ______ with focused beams of radiation generated at a distance and aimed at the tumor within the patient
teletherapy
Type of radiation: ______ with radionuclides targeted in some fashion to a site of tumor……radioactive iodine for thyroid cancer
systemic therapy
Type of radiation: ______ with encapsulated/sealed sources of radiation implanted directly into or adjacent to tumor tissues
brachytherapy
What type of radiation is the most common? With ____ or _____ photons
teletherapy
x-ray or gamma ray photons
What is a common way to treat prostate cancer? What type of radiation?
brachytherapy
insert radioactive encapsulated rods into the prostate
Radiation therapy is used in a curative manner in what types of cancer?
Breast cancer, Hodgkin’s disease, head and neck cancer, prostate cancer, and gynecologic cancers.
Radiation therapy is used in a palliative manner for ???
Relief of bone pain from metastatic disease, control of brain metastases, reversal of spinal cord compression and superior vena caval obstruction, shrinkage of painful masses, and opening of threatened airways.
What are some systemic toxic effects associated with radiation therapy?
fatigue, anorexia, nausea, and vomiting,
______ include mucositis, skin erythema (ulceration in severe cases), and bone marrow toxicity.
acute toxicities associated with radiation
Radiation carcinogenesis with secondary malignancy; pericarditis; myocardial infarction; thyroid failure; cataracts; lung fibrosis; arteritis; spinal cord transection are all examples of _____
chronic toxicities associated with radiation
______ use of extreme cold to sterilize lesions in certain sites
cyrosurgery
_______ focused microwave radiation to induce thermal injury within a volume of tissue
radiofrequency ablation
_________ Infusion of chemotherapeutic agents directly into the target area via vascular catheters
aka target vascular supply of the tumor
chemoembolization
Name the 4 broad categories of chemotherapy
Conventional cytotoxic chemotherapy agents
Targeted agents
Hormonal therapies
Biologic therapies
Types of chemo: ______ mainly target DNA structure or segregation of DNA as chromosomes in mitosis
Conventional cytotoxic chemotherapy agents
Types of chemo _____-: designed and developed to interact with a defined molecular target important in either maintaining the malignant state or selectively expressed by the tumor cells.
targeted agents
types of chemo: ______ work on the biochemical pathways underlying estrogen and androgen function
hormonal therapies
types of chemotherapy: ______ 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.
biologic therapies
The usefulness of a drug is determined by ?????
therapeutic effect vs toxic effect to the host
The _____ is the degree of separation between toxic and therapeutic doses.
therapeutic index
Unfortunately chemotherapy agents have a _____ therapeutic index
narrow
Chemotherapy can either ______ or _______
They can induce cancer cell death
They can induce cancer cell differentiation or dormancy with loss of tumor cell replicative potential and reacquisition of phenotypic properties resembling normal cells.
Name the 2 antimetabolites
Methotrexate
5-fluorouracil (5-FU)
**_______ MOA causes DNA damage indirectly, through misincorporation into DNA, abnormal timing or progression through DNA synthesis, or altered function of pyrimidine and purine biosynthetic enzymes
Antimetabolites:
Methotrexate, 5-fluorouracil (5-FU)
**antimetabolites: ______ prevents thymidine formation (required for DNA replication)
5-fluorouracil
**antimetabolites:_______ competes and counteracts folic acid, causing folic acid deficiency in cancer cell and cell death
methotrexate
**What are the toxic manifestations of antimetabolites?
stomatitis, diarrhea, and myelosuppression
**Name the mitotic spindle inhibitors. What the toxic manifestations?
Vincristine, Vinblastine
Paclitaxel
alopecia, neuropathy (especially in the hands and feet), and myelosuppression.
What are the Alkylating Agents?
Cyclophosphamide
Chlorambucil
Cisplatin
**______ MOA break down, either spontaneously or after normal organ or tumor cell metabolism, to reactive intermediates that covalently modify bases in DNA
Alkylating Agents
**What the toxic effects of Cisplatin?
neuro-toxicity (stocking-glove), hearing loss, renal failure
What is stocking glove neurotoxicity?
distal to proximal neuropathy in the hands
**_______ 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.
Antitumor antibiotics
Doxorubicin (Anthracyclines)
**What is the toxic effect of Doxorubicin (Anthracyclines)?
cardiotoxicity, arrthrymias and heart failure
Which chemotherapy agent is nicknamed “the red devil”? Why?
Doxorubicin (Anthracyclines) because it is physically a red liquid and causes cardiotoxicity
**_____ MOA 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
Topoisomerase inhibitor
Etoposide
** What is the toxic effect of Etoposide?
transient side effects but may lead to secondary leukemia with high doses
**How do you treat neutropenia caused by bone marrow suppression? When does it have the greater effect?
Filgrastim: colony stimulating factors
Stimulate the production of neutrophils, monocytes, and eosinophils.
peaks levels of neutrophils in 24 hours
bleeding gums, blistering, burning, coldness, discoloration of the skin, feeling of pressure, hives, infection, inflammation, itching, lumps, numbness, pain, rash, redness, scarring, soreness, stinging, swelling, tenderness, tingling, ulceration, or warmth at the injection site. Are all SE of _______.
Filgrastim, pegfilgrastim and sargramostim
**What is the treatment for anemia caused by bone marrow toxicity?
Transfusion; Epogen (erythropoiesis-stimulating agent)
**What is the treatment for thrombocytopenia caused by bone marrow toxicity?
monitoring
should be getting blood work every week
**_____ is the MC SE of chemotherapy. What is the treatment?
Nausea
Ondansetron (anti-emetic)
_______ is oral soreness and ulcerations (along with the severe diarrhea). What is the treatment?
Mucositis
“Magic” Mouthwash
diphenhydramine, lidocaine, Maalox
Drugs most commonly associated with causing mucositis in the mouth and the gastrointestinal tract are ????? name 3
cytarabine
5-FU
methotrexate
_____ is a common chemo toxicity and is especially with tx with 5FU infusions. What is the treatment?
diarrhea
1st- Loperamide (antimotility drug) (Imodium)
2nd- Octerotide (somatostatin analogue) or opiate-based preparations if no response to Loperamide
______ manifests as painful palms or soles accompanied by erythema, progressing to blistering desquamation and ulceration in its worst forms. What is the treatment for the blank and broad category?
Acral erythema
Broad category: Skin toxicity
Supportive care; cold packs; sun protection
What is the treatment for chemo associated alopecia?
Psychological support
- “chemo caps”
- reduce scalp temp - very controversial
_____ refers to the disorders that accompany benign or malignant tumors but are not directly related to mass effect or invasion.
Paraneoplastic syndromes
Neoplastic cells can produce a variety of products that stimulate ????? responses. 5 organ systems
hormonal, hematologic, dermatologic, renal and neurologic
paraneoplastic syndromes usually manifest as _____, _____, ____ or _______
Endocrine
Metabolic
Hematologic
Neuromuscular
Why are the paraneoplastic syndromes clinically important?
- can provide early clue of cancer
- the toxic effect of the syndrome may be a more urgent threat to the pt’s life
- treatment of the cancer should result in a resolution of the paraneoplastic syndrome
Name some common endocrine paraneoplastic syndromes?
hypercalcemia
hypoglycemia
gonadotropin secretion
cushing’s syndrome
SIADH
Name some common hematologic paraneoplastic syndromes?
coagulopathy
erythroyctosis- points to kidney or liver cancer
Name some common neurologic paraneoplastic syndromes? What type of cancer are they related to ?
Lambert-Eaton syndrome
Subacute cerebellar syndrome
Small Cell Lung Cancer (SCLC)
**neurologic paraneoplastic syndromes that is characterized by muscle weakness of the limbs
Lambert-Eaton syndrome
**neurologic paraneoplastic syndromes that is characterized by dizziness, nausea, vertigo, tremor, and sometimes dysphagia and blurry vision
Subacute cerebellar syndrome
Name some common dermatologic paraneoplastic syndromes?
Dermatomyositis
Acanthosis Nigricans
**dermatologic paraneoplastic syndromes that is characterized a system disorder causing inflammation of the muscles and skin, as well as joints, lungs, esophagus and heart. What cancers does it point to?
Dermatomyositis
SCLC, NSCLC
**dermatologic paraneoplastic syndromes that is characterized thickening of mucous membranes/skin and it presents with brownish discoloration. What cancers does it point to?
Acanthosis Nigricans
GI adenocarcinomas
Side note: Can occur with diabetes/obesity, typically in fold of neck, under breast
What is a neutropenic fever defined as?
recurrent temperatures above 38’C or a single temperature above 38.3’C in the presence of neutropenia
neutrophil count (ANC) less than 500 cells/mL
neutropenic fever is commonly the result of _______, not ______
chemotherapy NOT the underlying cancer
vague and mild initially, but may rapidly progress to sepsis and death
Symptoms also vary based on site of infection and source of infection
Infectious agents may be viral, fungal or bacterial
What am I?
neutropenic fever
**T/F: All immunocompromised pts should have a rectal exam as part of their PE work up
FALSE!!
It is an ABSOLUTE CI to perform a rectal exam on an immunocompromised pt!!
What should be part of a dx workup with a pt who is suspected of having neutropenic fever?
cultures (skin, blood, urine, sputum and stool)
CXR
CBC with diff, CMP, coag panel and UA
**What is the empiric treatment for a neutropenic fever? When should treatment be started?
Ceftazidime, Cefipime or Imipenem for antipseudomonal coverage
Aminoglycoside to cover gram – bacteria
Vancomycin to cover MRSA
All three!
start AFTER the culture is taken!!
Back pain at the level of the tumor mass, which may be aggravated by lying down, weight bearing, sneezing, or coughing
Mix of nerve root and spinal cord symptoms
What am I?
What is the dx tool of choice?
spinal cord compression
MRI
What is the usually worsening of symptoms that is common to see with a spinal cord compression?
LE weakness
hyperreflexia
motor/sensory loss
loss of reflexes
loss of bowel/bladder
paraplegia
What is the treatment for spinal cord compression?
High dose IV corticosteroids
Surgical decompression
Radiation
What are the 3 mechanisms that can cause hypercalcemia
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 MC cause of hypercalcemia?
a parathyroid hormone-related peptide secreted by the cancer cells
If hypercalcemia due to cancer is present, what does this indicate?
marker of advanced cancer
median survival range of 1-3 months
What are the top 3 cancers associated with hypercalcemia?
myeloma, breast carcinoma, and non-small cell lung carcinoma (NSCLC)
polydipsia, polyuria, generalized weakness, lethargy, anorexia, N/V, constipation, abdominal pain, AMS and psychosis
What am I?
What is the treatment?
hypercalcemia
Hydration and forced diuresis
and bisphosphonates
zoledronic acid or pamidronate IV are in the drug class ______. When are they commonly used?
Bisphosphonates
treatment of hypercalcemia
What is second line treatment for hypercalcemia? If that still doesnt work, use ______
2nd- Calcitonin
alternative: Hemodialysis-> will be the definitive treatment
Hypercalcemia labs will show elevated _____ and ______
Total serum calcium level
ionized calcium levels
What will the EKG show a pt with hypercalcemia?
may show shortened QT, ST depression and AV blocks
______ is a clinical syndrome that occurs 1-3 days following radiochemotherapy of most commonly hematologic malignancies. Especially _____
Tumor Lysis Syndrome
Especially Burkitt lymphoma
_____ is a massive release of cellular material including nucleic acids, proteins, phosphorus, and potassium. If both the metabolism and excretion of these breakdown products are impaired, hyperuricemia, hyperphosphatemia, and hyperkalemia will develop abruptly.
Tumor Lysis Syndrome
What is the pt at a huge risk for following Tumor Lysis Syndrome? Why?
Acute kidney injury may then develop from the crystallization and deposition of uric acid and calcium phosphate within the renal tubules further exacerbating the hyperphosphatemia and hyperkalemia.
**In Tumor Lysis Syndrome, combination of hyperkalemia and hypocalcemia, development of _____ may occur
fatal cardiac arrhythmias
**Patient may present with lethargy, N/V, cloudy urine, and neuromuscular irritability, muscular spasm, seizure and altered mentation associated with hypocalcemia.
What am I?
What is the treatment?
Tumor Lysis Syndrome
includes IV hydration and correction of electrolyte abnormalities
May require emergency hemodialysis
**What does the EKG show in a pt with tumor lysis syndrome?
may show peaked T waves of hyperkalemia, as well as arrhythmias
**____ and _____ most commonly caused by lung and breast cancers
Pleural and pericardial effusions
**_____ associated with ovarian, colorectal, stomach, and pancreatic cancers.
Malignant ascites
**fatigue, chest heaviness, dyspnea, palpitations, cough and syncope
Tachycardia, narrowed pulse pressure, hypotension, distended neck veins, muffled heart sounds, and pulsus paradoxus
What am I?
What is the dx tool of choice?
What is the treatment of choice?
Pericardial Effusion / Cardiac Tamponade
Transthoracic echocardiogram
echo-guided percutaneous pericardiocentesis under local anesthesia
What other dx tools can you use to dx Pericardial Effusion/Cardiac Tamponade?
Chest x-ray may demonstrate an enlarged cardiac silhouette and pleural effusion
EKG may show sinus tachycardia, low QRS voltage and electrical alternans
**Transthoracic echocardiogram is diagnostic tool of choice
_____ is caused by malignancies such as compression of the vessel wall by right upper lobe tumors or thymoma and/or mediastinal lymphadenopathy
Superior Vena Cava Syndrome
What is the MC malignancy that causes SVCS?
bronchogenic carcinoma
gradual onset of dyspnea, chest pain, cough and, facial and arm swelling; cerebral edema is rare
Distended neck, arm and chest veins, nonpitting edema of the neck, arm swelling, tongue and facial swelling and cyanosis
What am I?
What is the dx tool of choice?
What is the treatment?
SVC syndrome
Chest CT with contrast is diagnostic test of choice
**steroids
**Intravascular stenting
chemotherapy
radiation
What is Virchow’s triad?
Vessel wall injury
stasis
hypercoagulability
hx of dyspnea, fever, cough, DOE, pleuritic chest pain, leg pain or swelling, and rarely hemoptysis
include low-grade fever, tachypnea, tachycardia, pleural rub and unilateral lower extremity swelling
What am I?
What is the dx tool of choice?
What is the treatment?
DVT/PE
Chest CT with contrast or V/Q scan
IV heparin or lovenox immediately then follow up with DOAC
When is thrombolytic therapy necessary?
When the patient is tanking and their life in crisis
aka when systolic is below 90
