Test 1 Flashcards
6 cancer treatments
Surgery Radiation therapy Chemotherapy Hormonal therapy Immunotherapy Hyperthermia
Oldest method of cancer treatment
Useful for treatment (removing tumor), diagnosis/pathology, staging (histology), palliation (debulking), and cosmesis
Surgery
____% of cancer treated with surgery alone and ____ cured
40%, 1/3
____% of cancers receive RT; first treatment in 1809 on basal cell
60%
Changing levels of hormones in body to slow or stop growth of tumor; ex: prostate, blood, etc.
Hormonal therapy
As early as 1500s: very heavy, toxic metals; still toxic
Systemic treatment works well with systemic disease; most systemic but also topical for skin disease
GIven through installation (IV); ex: CSF through meninges, pericardium for malignancy of pericardium, intraperitoneal for ovarian disease, intraarterial for direct flow to disease, etc.
Chemotherapy
Removal of large tumor even if some tumor is left behind due to inaccessibility because of vascular structures (palliation)
Debulking
Killing cells of the primary tumor and those that may be circulating through entire body
Systemic treatment
Uses body’s immune system to attack/fight cancer
Immunotherapy
Process of increasing the temperature of an area in conjunction with an effort to increase cell kill; applying heat to an area to increase radiation sensitivity
Add heat to intensify affect of radiation with hot bags, radio-frequencies, microwaves, etc.; problem: hard to get heat to treatment area
Hyperthermia
6 ways to establish a rapport with the patient
Listen Connect Compassion Honesty Get the patient involved (help them select appointment time) Communicate (educate patient)
Communication between two people
Rapport
Provides structure for the delivery of difficult information
SPIKES protocol (setting, perception, invite/information, knowledge, empathy, summarize and strategize)
4 important steps before treatment
Positive diagnosis: biopsy
Stage
Goal of therapy set (adjuvant, palliative, etc.)
Treatment plan
Step-by-step process to determine the size and location of a tumor and the degree to which it has spread; extent of disease
Essential in determining treatment options; tumor size and extension, regional lymph node involvement, presence of distant metastasis, and tumor grade or differentiation
Stage
Know how we are going to treat based on patient preference, extent of disease, age, protocols, etc.
Treatment plan
2 aims of treatment
Curative
Palliative
Eradicate disease, very aggressive
Curative
Alleviate symptoms and improve quality of life; may extend survival
Palliative
Use of combination therapy, therapy given after primary treatment has been given (ex: chemo); aim to increase cure rate
Adjuvant
Therapy given before treatment; done to reduce extensiveness of disease before primary treatment (ex: chemo before lung treatment)
Neoadjuvant
Neo-
Before
6 cancers with microscopic disease that can be cured with chemotherapy
Testicular
Hodgkin’s disease
High-grade non-Hodgkin’s lymphoma
Acute leukemia
Small cell lung (nonmetastatic; spreads fast)
Ovarian (widespread once found in peritoneum)
4 responses to therapy
Complete
Partial
Stable
Progressive
Disappearance of all measurable disease for 1 month or more
Complete
At least 50% decrease in measurable tumor mass without appearance of new lesion for 2 months or more
Stable
Increase of tumor mass by more than 25% or appearance of new lesion/tumor
Progressive
Usually primary recurs within ___-___ months, buts sometimes breast disease has a slow doubling time and can show up way later, not as common after ____ years
18-24 months, 5 years
Patient alive 5 years post-treatment; good
5 year survival
Chemo doses based off body size/surface area; loss of ___-___ pounds can change treatment
Weigh patient weekly; weight change can affect therapy dose distribution
5-10 lb
8 goals of surgery in cancer treatment
Prophylactic Diagnostic Staging Definitive/curative Palliative Adjuvant/supportive Reconstructive/rehabilitative Salvage
Preventative treatment given there’s no evidence of disease but the risk is high; surgery for precancerous lesions
Ex: remove organ that may have disease; breast, cervix, polyps, etc.; brain irradiation for small cell lung CA
Surgery: mastectomy or oophorectomy
Prophylactic surgery
Removal of tissue for histologic examination
Biopsy (diagnostic)
Surgery involves removal of entire primary CA, including a margin of normal tissue surrounding the CA
Need to find it as early and encapsulated as possible before surgery (ex: breast, skin, etc.)
Definitive/curative
Take whole tumor with margins and nodes
Final/conclusive surgery
Surgery to treat symptoms; ex: obstruction, fistula, tumor compressing spinal cord, etc.
Palliative
Surgery after treatment; ex: debulking, feeding tube, tracheostomy, etc.
Adjuvant/supportive
Plastic surgery for cosmesis
Reconstructive/rehabilitative
Surgery for recurrence
Salvage
6 facts to consider before surgery
Cancer facts: growth rate, invasiveness, metastatic potential (high = don’t do surgery), location (brain is hard area), etc.
Patient’s health
General health habits
Nutritional status: can affect wound healing, blood (anemia), infections; increase morbidity rate
Rehabilitation potential
Age (harder recovery if older)
___-___% of patients show malnutrition; weigh patient weekly
30-50%
7 surgical biopsy techniques
Fine-needle aspiration Percutaneous needle aspiration: take lung tissue sample Core needle Incisional Excisional Endoscopic Laparoscopic
Small sample biopsy
Fine-needle aspiration
Core of tissue collected by needle in tumor; larger than fine but still a small chunk
Core needle biopsy
Remove small portion of lesion
Incisional biopsy
Removal of an entire tumor/lesion
Excisional biopsy
Go into organ from inside-out
Flexible biopsy tool passed through scope and tiny pincers used to collect suspicious tissue sample; ex: bronchoscopy, colonoscopy, etc.
Endoscopic biopsy
Scope to view outside of organ; scope and cutting utensil for tissue samples (ex: laparoscopy)
Laparoscopic biopsy
___-___ weeks after surgery, chemo/radiation can start to allow healing
3-6 weeks
Cancer has spread in surgical area
Seeding
Normal surgical margin
2-5 cm
Surgical method in which tumor (usually skin) is removed one layer at a time and examined microscopically
Doctor starts removing tumor and margin around it; pathologist views margins under microscope and says if cells are normal or not
If not, keep removing until they’re gone or can’t remove anymore tissue
Make sure there’s clear margin before closing
Mohs procedure
Goal of radiation therapy
Destroy tumor cells while sparing normal cells; breaks chromosomes so cells cannot divide and then they die
3 stages of rad-bio leading to cell destruction
Physical: ionization of atoms
Radiochemical: formation of free radicals
Biologic: DNA damage
5 roles of radiation in CA treatment
Curative/definitive: early head and neck (lymph nodes), cervical, anal, prostate, and early stage larynx CA
Neoadjuvant
Adjuvant
Prophylactic: treat brain for small cell lung CA
Palliative: usually larger dose in first few days of treatment (goes faster); reduce bleeds, pain, seizures, obstruction, mass or node against spinal cord, etc.
Radiation before primary treatment; esophageal and rectal CA debulking before surgery
Neoadjuvant
Radiation after surgery; ex: remove affected testicle and treat inguinal lymph nodes, lumpectomy, and treat breast, remove lung tumor and hilar nodes, etc.
Adjuvant
2 types of radiation
Teletherapy/external beam RT
Brachytherapy
Treatment at a distance, linac generates ionizing radiation by accelerating electrons along a tube
Teletherapy/external beam RT
4 types of teletherapy/external beam RT
3D CRT
IMRT
IGRT
VMAT
Treatment at short distance; temporary or permanent placement of a radioactive source within a body cavity, interstitially, or on the body’s surface (implants, inject source, etc.)
Used as boose
Can be used alone or in conjunction with EBRT, ex: treatment of cervical or endometrial CA’s
Prime advantage is ability to deliver high doses of radiation delivery to tumor
Brachytherapy
2 types of brachytherapy
Low dose rate (LDR)
High dose rate (HDR)
Brachytherapy takes 24-144 hours to give treatment
Inpatients; nurses instructed to observe the important precautions of time, distance and shielding to protect themselves from radiation
Ex: oral cancers, prostate “seeds” of iodine-125 or palladium-103, etc.
Low dose rate (LDR)
Minutes for brachytherapy treatment, no staff exposure
Commonly use iridium; early stage disease
Usually bi-daily (BID), have to have 6 or more hours between
High dose rate (HDR)
Place source inside cavity
Intracavity
Place source directly in patient
Interstitial
Bowl in eye with sources
Plaque therapy
Source in lumen or vessel
Intraluminal
Source in bronchiole
Endobronchial
2 cancers that use intracavitary radium and cesium
Endometrial
Cervical
Cancer that uses interstitial iodine and gold
Prostate
Cancer that uses interstitial iridium
Breast
Cancer that uses plaque therapy cobalt, iodine, and palladium
Ocular melanoma
Cancer that uses interstitial thermal iridium and cesium
head and neck
Cancer that uses interstitial cesium
Rectal
Cancer that uses intraluminal cesium
Esophageal
Cancer that uses endobronchial iridium and iodine
Bronchogenic
How many sources does cobalt-60 have?
192-196 sources
Cobalt-60, emits gamma rays
SRS has a very confined fractionated dose
Gamma knife
Largest field size that can be treated with gamma knife
18 mm (1.8 cm)
4 steps in planning RT
Construction of patient immobilization or positioning devices: breast board, wings, alpha cradle, etc.
Simulation: accuracy and reproducibility of 1-2 mm
Delineation of tumor volume and evaluation of field arrangements: treatment field larger than tumor volume to include lymph nodes, microscopic disease, etc.
Organ shielding a beam modification: MLC’s, port film used to verify accuracy
4 R’s of rad bio
Repair
Repopulation
Redistribution (reassortment)
Reoxygenation
Cancer cells can’t fix themselves, normal can; why fractionation is important (if we allow too much time between treatments, cancer cells have time)
Repair
Mitosis and proliferation of cells
Repopulation
Division delay results in cells in interphase at the time of irradiation to be delayed in G2
Cell delay of RT, delays CA cells from moving into mitosis (phase)
Cells become partially synced; CA cells all in mitosis at same time and more sensitive to radiation
Redistribution (reassortment)
Mitotic delay
Side effects of RT that occur during treatment and can be predicted from the volume of normal tissue exposed to the beam, the total dose delivered, and the sensitivity of the normal tissue to radiation
Usually clear up after the completion of treatment
Within region being treated, usually site specific
Know how to prepare patient mentally, before and during treatment
A lot can be managed with medication (ex: give patient with diarrhea imodium)
Acute side effects
Inflammation of bladder
Cystitis
Man can’t keep an erection
Impotence
Swelling of brain caused by the presence of excessive fluid
Cerebral edema
Late side effects of RT are local, usually permanent reactions that may develop several months to years after radiation
Daily fraction tends to predict severity, increase with increased daily dose; normal tissue doesn’t repair like with low doses
Occur from 2 months to years after RT
Constantly happening
Chronic side effects
Disease of the spinal cord
Myelopathy
Irradiated bone doesn’t heal correctly
Osteonecrosis
Scar tissue causes obstruction
Bowel adhesions
3 things to be considered radiation-induced secondary malignancy (5%)
New primary/different histology from first CA
Must take place/occur in previously irradiated/treated area
Must occur 10-15 years after original tumor was treated (takes time for radiation to cause malignancy, doesn’t happen in short time)
4 ways to encourage patients
Educate them about treatment and disease
Acknowledge their feelings
Include them as primary members or planners in their healthcare
Provide nonjudgemental support
3 radiosensitizers
5FU (common)
Cisplatin
Mitomycin C
Chemo drugs enhance effects of radiation on cells and CA used before or along with exposure based on type of treatment, doctor, etc. (mostly by IV)
Usually see complications with skin problems (erythema, moist desquamation, etc. treated with corn starch, airing out, fan)
Patient may be able to take break if symptoms too severe (2-3 days)
Radiosensitizers
7 treatments for oral side effects of swelling and irritation
Rinse with baking soda/saline: keep mouth clean because at greater risk for infection
Liquid NSAIDs reduce swelling and pain to help with swallowing (ex: swish and swallow, Brompton cocktail, etc.): nutritional issues arise and affect immune system, maintain calorie intake and weight; patient may need gastrostomy (G-) tube
Mylanta and lidocaine for heart burn
Some may need a break
Refer to dentist for prophylactic treatment before oral RT to reduce dental decay/caries
Inform patient of how challenging treatment can be and maximize nutritional status before treatment
Stop smoking and drinking
4 assessments of patient
Daily assessment for potential reactions: therapists
Weigh patient weekly unless indicated more by doctor
Dietitian: a lot of times for head and neck patients
Blood counts weekly on doctor day or more frequently if counts rapidly falling
3 things we focus on with skin reactions
Patient comfort
Promotion of healing, reduce side effects
Prevention of infection
3 treatments of dry desquamation (leads to moist if untreated)
Creams with aloe
Lanolin
Vitamin A and D
4 treatments of moist desquamation
Antibiotics
Silver sulfadiazine cream
Rinse with peroxide
Keep open to air
Treatment for pruritus
1% hydrocortisone cream
Severe itching
Pruritus
6 factors that contribute to fatigue
Pain Anemia Insufficient intake/dehydration Decreased activity (balance between rest and activity) Fever Anxiety/depression
RT to reduce tumor volume/pain control
Open airway of esophagus, brain irradiation for headaches, seizures, loss of motor control, spine to relieve pain/paralysis, and relieve bleeding/obstruction
Weigh benefits with side effects and amount of treatment time (high dose, low fractions)
If total dose reached in area, may have to look into other treatment
Palliative radiation
7 considerations of childhood radiation
Need to be very careful
Greater risk of toxicity because cells are more mitotic/developing
Developmental problems
Chance of second cancer because of longer lifespan (10-15 years); ex: sarcoma, meningioma, thyroid CA, etc.
Usually requires sedation
Hyperthermia
TBI for bone marrow transplant or leukemia treatment
4 patient teaching priorities
Explain process: consultation, simulation, treatment planning, treatment, and follow-up
Time frame for all procedures
Side effects to expect from treatment
How to minimize treatment side effects
3 geriatric considerations
Side effects can develop sooner and with greater severity
Increased fatigue
Social concerns: transportation, fixed income (expensive)
Malignancy of unknown etiology usually arising in lymph nodes
Very curable, good survival rate
Common among young people, higher incidence in males
Associated with Reed-Sternburg cell
1832: Thomas discovered nodes in cadaver lymph nodes
Bimodal age distribution
Hodgkin’s disease/lymphoma (HL)
Giant abnormal, high- or multinucleated center
Must be present to be considered cancerous HL
Reed-Sternburg cell
3 viral infections HL correlates with
Epstein-Barr (EBV) in the herpes family and causes mono; often asymptomatic
HIV or measles
Dysregulatory inflammatory response
Peaks at two different age groups
Bimodal age distribution
2 peaks of incidence of HL
15-34 years old
50
HL rarely diagnosed in kids ___ years or younger; median age of diagnosis is ____ years
5 years
32 years
HL represents about ____% of all lymphomas and ___% of all cancers; ____% of population diagnosed with HL in lifetime
- 2%
- 6%
- 2%
HL greatest in age range ___-___ years with ___% or more of all new cases
20-34 years
31%
Between ___-___% of cases involved kids younger than 17
10-15%
HL has a ___-fold increase in same sex siblings and ___-fold increase in opposite genders; first degree relative with Hodgkin’s has a ___-fold increase
9
5
3
2 categories of HL
Classic Hodgkin lymphoma (CHL)
Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL)
4 subcategories of CHL
Lymphocyte-rich/predominant (LRHL) Mixed cellularity (MCHL) Nodular sclerosis (NSHL) Lymphocyte-depleted (LDHL)
Main characteristic of Reed-Sternberg cells, 95% of HL
Classic Hodgkin lymphoma (CHL)
Early stage I-II CHL, 5%
Infrequent systemic symptoms = 10%
More frequent in males
Usually diagnoses in upper body above diaphragm
Lymphocyte-rich/predominant (LRHL)
Percentage of CHL that is MCHL and NSHL (most common)
80-90%
Mixture of cell types within histology: combination of lymphocytes, epithelioid histiocytes, eosinophils, neutrophils, and plasma cells (inflammatory cells in blood)
Associated with EBV and HIV
More prominent in males, usually presents in abdomen and spleen (below diaphragm)
Less common than NSHL)
Average age of 38 years
Mixed cellularity (MCHL)
Most common CHL = 75%
Ages 20-30’s and 50-55 years or older
Closer to equal distribution between sexes
Usually presents in chest and neck
Nodular sclerosis (NSHL)
Less than 5% of all subtypes of CHL, rarest of the four
More common in men
Affects patients in 30’s especially with HIV
Usually presents with worst prognosis; advanced disease and B-symptoms
Patient usually presents with abdominal adenopathy; spleen, liver, and bone marrow often involved
Lymphocyte-depleted (LDHL)
Large or swollen lymph nodes
Adenopathy
5%, asymptomatic young men
Usually identified in cervical, axillary, and inguinal lymph nodes but no mediastinal involvement
30-50 year olds
Early stage disease, longer survival times
Popcorn cell (variant of Reed-Sterburg cell)
Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL)
Direct contact, touching
Contiguous
9 signs and symptoms of HL (routine spread)
Cervical, supraclavicular, mediastinal lymph node splenomegaly
B-symptoms
Elevated sedimentation rate (detects inflammation in body, blood cells drop in test tube fast because inflammation attached) and elevated alkaline phosphatase/alk-phos (shows blockages and inflammation)
Puritis
Fatigue
Malaise
Weakness
Erythematous rash/reddening of skin
Pain in lymph node after drinking alcohol
General feeling of discomfort/uneasiness
Malaise
About ___% of time HL above diaphragm, about ___% have subdiaphragm spread (bad)
80%
10%
4 ways to diagnose HL
History and physical: enlarged lymph nodes, family history, blood counts, B-symptoms if they have any and how long
X-rays: chest x-ray, CT chest and abdomen, PET, etc.
Labs: CBC’s sedimentation rate, HIV, etc.
Biopsy of large lymph node: bone marrow more likely involved in stages 1B, 2B, 3, and 4
3 treatments of HL based on stage and prognostic factors
Radiation involved field
Chemo intensive
Combination yields 90% cure rate (greatest)
About ___% if early stage HL curable and about ___% of advanced stage curable
90%
80%
8 radiation of HL side effects
Hypothyroidism (treat with hormones) Myelosuppression Pericarditis Pneumonitis Myelopathy Transient aspermia Secondary CA's from treatment Lhermitte syndrome
Reduction in bone marrow/RBC’s
Myelosuppression
Patient lacks ability to ejaculate semen
Transient aspermia
7 chemo of HL side effects
Nausea and vomiting Alopecia Sterility Myelosuppression Neuropathy Cardiomyopathy Aseptic necrosis of femoral head
HL radiation field when treating lymph nodes above diaphragm
Mantle field
HL radiation field when treating wherever disease is and with chemo
Involved field irradiation
HL radiation field when treating ipsilateral testicular disease
Hockey stick
HL radiation field when treating box pelvic field
Chimney
Newer chemotherapy treatment of HL with reduced risk factors of secondary leukemia but increased heart toxicity because of adriamycin
ABVD: adriamycin (doxorubicin), bleomycin, vinblastine, dacarbazine
Chemotherapy treatment of HL that is more toxic but risks outweigh benefits especially with younger patients with aggressive disease
BEACOPP: bleomycin, etoposide, adriamycin, cyclophosphamide, oncovin (vincristine), procarbazine, and prednisone
Older chemo for HL
MOPP: mechlorethamine (nitrogen mustard), oncovin (vincristine), procarbazine, and prednisone
Breast CA in ___-___% of patients 15 years post-radiation for HL more common in girls and young women who’ve received a mantle field
20-50%
Cancer of the blood forming elements that clones abnormal hematopoietic cells within blood; overproduce and mess up function of blood (clotting, etc.)
More common in men
Lympho- or myelocytic cells
Leukemia
2 types of leukemia
Acute
Chronic
Mature and functioning cells, unregulated proliferation of mature cells
Blast cells can be present
Mainly in myeloid stem cells
Chronic leukemia
2 types of acute leukemia that arise in bone marrow, thymus and lymph
Acute myelocytic leukemia (AML)/acute nonlymphocytic leukemia (ANLL)
Acute lymphocytic leukemia (ALL)
Most common leukemia
Myeloid or monocytic stem cells
Incidence increases exponentially after 40 years old, median age of diagnosis is 67
40% cure rate, only survive months if left untreated (aggressive)
Frequency equal among all decades of life but more common at older than 50 years
More common in whites and older men
Treatment with induction and consolidation chemo; bone marrow transplant
Acute myelocytic leukemia (AML)/acute nonlymphocytic leukemia (ANLL)
Most common in kids; 30% of all new cases in kids, most common childhood CA = 25% of all childhood malignancies
Bimodal peaks between ages 2-4 and again after age of 50
Ages 1-4 have 9x the incidence rate compared to ages 20-24
More common in males
If identical twin has it, 100% risk the other will develop it
Sometimes goes to brain; prophylactic radiation of brain or intrathecal chemo to prevent spread through CNS
Before prophylactic treatment, 40% used to have brain involvement
CNS involvement in 5% of kids, less than 10% develop CNS involvement
Treatment with induction, consolidation/intensification, and maintenance chemo; CNS prophylaxis, whole brain irradiation
Causes unknown, but some correlation to factors of radiation exposure (atomic bomb), genetic disorders, and viruses
20% could have Philadelphia (Ph) chromosome
Acute lymphocytic leukemia (ALL)
5 risk factors for AML
Exposure to ionizing radiation: 50-fold increase as a result of atomic bomb, continued for 14 years after bombing in all decades of life; increase in radiologists and HL treated patients
Exposure to chemicals: benzene used in paint shops, cleaning chemicals, gas, etc.; 20% of cases associated with cigarette smoke (older than 60 years)
Chemotherapy: alkylating agents (melphalan, cyclophosphamide, and mechlorethamine) correlate to development of leukemia especially with RT
Genetics: down syndrome = 20-fold increase in incidence; falconi and rickett’s (kids have soft bones that fracture easily) anemia, bloom syndrome (rare disease, short stature and high voice), etc.
Viruses: EBV, HIV, etc.
Rapid heart rate
Tachycardia
3 most common symptoms affected by acute leukemia
Oropharynx
Lungs
Perianal area
4 ways to diagnose acute leukemia
Abnormal blood count
Bone marrow aspiration and biopsy
Chest x-rays show masses within chest
Lactic dehydrogenase (LDH) elevated reflects high tumor burden and at greater risk for CNS involvement
Diagnosis of acute leukemia given with greater than ___% blast cells present; ALL and AML considered hypercellular with greater than ___% blasts
30%
50%
5 prognostic factors of acute leukemia
Older patients that are ill do worse
Elevated BC’s; WBC counts over 50,000 per mm^3 (normal = 5,000-10,000)
Sepsis: severe blood infection because WBC’s not functioning correctly
CNS involvement
Leukemia from myelodysplastic syndrome/preleukemia
Heterogenous stem cell disorder; causes unknown, without identifiable predisposing factors
Median age is 60-70 years old
Symptoms typically develop gradually and are usually seen with advanced disease; asymptomatic (low stage) to fatigue, malaise, etc.
Treatment: curative stem cell transplant
Cause of death: transforms into AML or cytopenia, hemorrhage, infection, etc.
Ineffective blood cells in body; group of bone marrow disease involuntary stem cell that can be treated with infusions
Myelodysplastic syndrome/preleukemia
Peripheral greater than 50,000-100,000 per mL, greater than 50% blasts
End up with leukostasis (poor blood flow) because large cells clog arteries and infiltrate perivascular tissue
Can be fatal if it travels to brain or lungs
Headaches due to increased cranial pressure
Can treat with corticosteroids and high dose chemo
Blast crisis
5 year survival rate of acute leukemia in adults in kids
Adults = 67% Kids = 90%
Results from a reciprocal translocation between chromosomes 9 and 22; the DNA transfer results in 1 chromosome 9 that’s longer and 1 chromosome 22 that’s shorter than normal
Philadelphia (Ph) chromosome
Accounts for 7-20% of all leukemias
Correlation of Ph chromosome
Median age of 64, slight male preference
10% of ages 5-20 (3% of childhood leukemias)
Risk of ionizing radiation: atomic bomb and RT (cervix and ankylosing spondylitis); most haven’t received radiation
Signs and symptoms: usually asymptomatic but can see fatigue, anorexia, early satiety due to splenomegaly, weight loss, excessive sweating, priapism, gout, abdominal pain, and mental status change
Time from diagnosis of CML to blast crisis = 5 years; if blast crisis infiltrates, can occur in CNS, lymph nodes, bone, and skin
Primary mets sites: bone marrow and peripheral blood
Treatment: tyrosine kinase inhibitors (TKI) [imatinib mesylate, nilotinib, or dasatinib]; bone marrow transplant reserved for those who fail TKI, usually for younger patients
Overall survival = 4-5 years
Patients usually have inefficient/compromised immune system, increased risk of infection
Chronic myelogenous leukemia (CML)
Feeling full/loss of appetite
Early satiety
Prolonged erection
Priapism
Uncosciousness
Stupor
3 stages of CML
Chronic phase
Accelerated phase
Blast phase
Asymptomatic, most patients in this phase at diagnosis = 95%
WBC’s above 25,000-100,000, less than 10% blast cells
Median survival of 5-6 years
Infiltration to CNS, lymph nodes, bones, skin, bone marrow, and peripheral blood (not as common)
Chronic phase
10-19% blasts in peripheral blood or bone marrow
Over 30% blase and myelocyte cells (young cells of granulocytic series in bone marrow)
Over 20% basophils and less than 100,000 platelets
Median survival = 6-9 months
Accelerated phase
Resembles acute leukemias with over 20% blasts
Worst and most aggressive phase
Increased weight loss, fevers, sweats, and bone pain
Tumors develop
Median survival of less than 6 months
Blast phase
4 treatments for CML
Chemotherapy: ALL treatment, hydroxyurea can help relieve symptoms but doesn’t increase survival
Splenectomy only done in chronic phase to control hypertension
Bone marrow transplantation treatment for CML best done within one year of diagnosis
Interferon works with immune system
Spectrum of electrolyte abnormalities that can occur after the initiation of cytotoxic therapy that causes the breakdown of large numbers of malignant cells
Metabolic imbalance because dying CA cells give off potassium which affects and creates arrhythmias of heart
Tumor lysis syndrome (TLS)
Accumulation of lymphocytes in marrow, blood, and lymph
Age 55 or greater, rare in younger than 30 years old; median age of diagnosis is 71
Affects whites more than blacks and men more than women
Correlation to smoking and increased age, no known cause
Risk factors: positive family history for leukemias (first degree relatives), inherited, acquired immunodeficient syndromes and lymphoproliferative neoplams
Constitutional symptoms (group of symptoms that can affect many different body systems): fatigue, malaise, weakness, lymphadenopathy, abdominal pain, enlarged lymph node, and infection
Major symptoms: hepatosplenomegaly, pancytopenia specific with bone marrow packed with malignant cells (transfusion), autoimmune anemia, and thrombocytopenia
Goes to liver and spleen after bone marrow and lymph nodes
Good survival: low risk median survival greater than 10 years, intermediate = 1-7 years, and high = 1 year
Treatment usually pretty conservative because patients are usually older; decision depends on the patient’s functional status, symptoms, prognostic factors, stage of disease, disease recurrence, and response to prior therapies
No cure; chemotherapy (alkylating agents with or without prednisone for first treatment), radiation and splenectomy for palliation (local control), and bone marrow transplants investigational
Chronic lymphocytic leukemia (CLL)
When symptoms of CLL start and when RT is started
Symptomatic anemia Symptomatic adenopathy (enlarged lymph node)
Duplication
Clonality
Suspend cells in a stream of fluid and passing them through an electronic detection apparatus
Flow cytometry
2 common complications of leukemias
Infection treated with antibiotic therapy
Bleeding treated with transfusion when platelets are below 10,000 per mm^3 or active bleed
Subtype of CLL
No known cause, rare
Usually diagnosed in middle aged patients
Less than 2% of all leukemias, 500-600 cases annually
Hairy cell leukemia (HCL)
