Treatment Flashcards
What is the treatment of choice for stage I and most stage II NSCLC?
Surgery
Whipple
Pancreaticoduodenectomy
Removal of distal portion of stomach, 1st & 2nd portions of duodenum, head of pancreas, CBD, and gall bladder
What are common chemos for endometrial cancer?
Paclitaxel, doxorubicin, cisplatin
What is treatment for low grade nonseminoma or high grade testicular cancer?
BEP
bleomycin, etoposide, cisplatin
What is treatment for low grade seminoma testicular cancer?
Surveillance or radiation or Adjuvant Carboplatin
What is the treatment for stage I bladder cancer?
Transurethral resection of bladder with fulguration + intravesical chemo (gemcitabine or mitomycin)
What is the treatment for stage II & III bladder cancer?
Neoadjuvant cisplatin
What is the treatment for stage I prostate cancer?
Watchful waiting, possible prostatectomy or cryotherapy
What is the initial treatment for malignant melanoma?
Complete excision with disease free margins
Standard treatment for most early stage head and neck cancers
Surgical resection
What is 1st treatment for neurologic system cancers?
Surgery
What is treatment for CLL?
Watchful waiting
What is the treatment for AML?
Induction: cytarabine and anthracycline
Consolidation: daunorubicin or idarubicin and etoposide
What is the treatment for CML?
Imatinib, dasatinib or nilotinib, allogenic bone marrow transplant or stem cell transplant
What is the treatment for ALL?
Induction and CNS prophylaxis: Imatinib, cyclophosphamide, vincristine, doxorubicin, dex alternated with high dose MTX and cytarabine
What is 1st line treatment for Hodgkin’s lymphoma?
ABVD: adriamycin/doxorubicin, bleomycin, vincristine, dacarbazine)
What risks arise after mantle radiation in teens and young adults?
Increase risk of breast cancer and cardiac toxicity
What targeted therapy is used to treat Non-Hodgkin’s lymphoma?
Rituximab and obinutuzimab
What is the treatment for Ewing sarcoma?
Systemic chemo + RT(if unresectable), surgery (is resectable) or both
Doxorubicin, ifosfamide, etoposide, cyclophosphamide, vincristine
Stem cell transplant is high risk for relapse
What can help avoid amputation in soft tissue sarcoma?
Pre and post-op radiation decreases the risk of local recurrence
What is treatment for Kaposi sarcoma?
Antiretroviral therapy (ART)
If advanced or not responding, chemo or RT
What are the potential side effects of radiation?
Nausea, appetite changes, diarrhea, fatigue, leukopenia, thrombocytopenia
What is the most appropriate vascular access device for an AML for pt going through induction therapy?
Port
Minimize radiation exposure
Type of radiation source
As Low As Reasonably Achievable
Lead shielding (or plexiglass for beta particles)
Time exposed
Distance from radiation source: double the distance between you and source
What are signs of phlebitis?
Pain, erythema, steak formation, palpable cord, edsma
What are signs of infiltration?
Leaking at site, cool skin, tightness, edema, decreased infusion rate
What are signs of extravasation?
Difficulty infusing, leaking around site, redness, edema, pain, burning, lack of blood return
What type of central line is good for ambulatory or outpatient therapy as opposed to intensive inpatient therapy?
PICC
Which is associated with a higher incidence of thrombosis in patients with hematologist malignancies? Port or PICC
PICC
About what % of cancer patients will receive radiation?
1/2
How does radiation therapy work?
Kills cells by destroying their DNA either directly or creating charged particles (free radicals) within the cells that can damage the DNA
What type of radiation is the most common?
External beam
What is stereotactic radiosurgery?
A single large dose of radiation to a tumor
—>Brain tumors that can’t be treated with surgery
What is used with stereotactic body RT?
Special equipment to position patient
CANNOT be used on the brain
Emerging areas: lung, liver, bone
Which cancers are a brachytherapy common treatment for?
Prostate, uterus, cervix, breast
Why is radiation done before surgery?
=neoadjuvant
Improves cure rate or makes surgery easier (esophageal, rectal, lung)
What does radioembolization do?
Used microspheres filled with radioactive isotopes to block a tumor’s blood supply and starve it
What type of cancer is radioactive iodine used for?
Thyroid cancer
What is system radiation?
Pt swallows or receives injection of radioactive substance bound to a mab - this helps the substance locate tumor cells
What are early side effects of radiation therapy?
Aka acute
Occur during treatment, most disappear after treatment
-caused by damage to rapidly dividing normal cells in the area being treated
-skin irritation, salivary glands, hair loss, urinated or bowel problems
What are chronic side effects of radiation therapy?
Continue for weeks, months, or years after treatment ends
-salivary gland damage can be permanent (amifostine can be given IV as a cytoprotectant if given during head & neck radiation)
What are systemic side effects of radiation therapy?
Fatigue
Nausea +/- vomiting common when abdomen and brain treated
What are late side effects of radiation therapy?
Depends on other factors (chemo? Genetics? Smoking?)
Fibrosis of the affected area
Damage to bowels, causing diarrhea and bleeding
Memory loss
Infertility
Rarely, a 2nd cancer (highest in people treated as children or adolescents)
What do women who have been treated with radiation to the chest for Hodgkin’s lymphoma have an increased risk for later in life?
Breast cancer
When does a tandem transplantation occur for a patient with multiple myeloma who did not achieve a very good partial response after 1st transplantation?
<= 6 months
What cancers are autologous stem cell transplants used to treat?
Multiple myeloma, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, neuroblastoma, germ cell tumors
What are the risks and benefits of autologous stem cell transplants?
No graft vs host disease
No benefit of graft vs tumor effect
Potential for contamination with cancer cells
What diseases are allogenic stem cell transplants used to treat?
Leukemia, NHL, MDS, aplastic anemia, sickle cell, thalassemia, falcons anemia
What are the risks and benefits of allogenic stem cell transplants?
Complication of infection or long-term organ damage from treatment regimens
Graft vs host
Length of time to locate compatible donor
Benefits: no malignant cells in graft
What is the function of HLAs?
They differentiate self from non-self
Located on surface of WBCs
What happens in graft vs host disease?
T-lymphocytes recognize a non-self major histiocompatibility complex (MCH) and rallies the immune system to destroy it
What is a myeloablative regimen?
Lethal doses of chemo to eradicate cancer cells and produce severe immunosuppression
What is a myeloablative regimen used for?
Allogenic and autologous stem cell transplant
It decreases the ability of the host to reject the donor
What is a non-myeloablative regimen?
Reduced intensity of chemo and total body irradiation
What is a non-myeloablative regimen used for?
Older patient or those with major comorbidities
What is given to diminish the reaction to the preservative DMSO before the infusion of the stem cells?
Diuretics, diphenhydramine, acetaminophen, corticosteroids
(+aggressive hydration)
What side effects may occur with the infusion of stem cells?
Pink-tinged urine due to breakdown of RBCs, garlic smell or taste from DMSO, HTN/hypo, tachycardia, Bradycardia, chest tightness, dyspnea, cough, flushing or hives, fever/chills, nausea, vomiting, diarrhea
Typically all resolve within 24-48hrs
Less common with fresh vs frozen
When has engraftment occurred?
ANC >500/mm^3 and platelets>20,000/mm^3
Generally 14-21 days
How is graft vs host disease diagnosed?
Biopsy of affected organs
What are risk factors for developing graft vs host disease?
Matched unrelated donor and haploidentical transplantation
Older patients
Peripheral stem cell collection
What is the treatment for GVHD?
Corticosteroids
What is considered acute GVHD?
During 1st 100 days
What 3 organs are affected in acuteGVHD?
Skin (rash, pruritis)
GI (N/V/anorexia, large volume diarrhea)
Liver (elevated bilirubin, weight gain)
What organs are affected in chronic GVHD?
Eyes, mouth, lung, liver, skin, GI, hematologic
What is the most common side affect of hematopoietic stem cell transplantation (HSCT)?
Neutropenia and the associated infections
Bacteria, gram + and - are most common cause of infection
Common sites: oral mucosa, CVAD
Prophylactic quilonlone recommended if neutropenia expected >=7 days
What is Mohs surgery and what is it used for?
Microscopically controlled surgery to shave off one very thin layer at a time. Used when extent of cancer not known it when as much healthy tissue as possible need to be saved (e.g. around eye)
What are patients going through CAR T cell immunotherapy at high risk for?
Cytokine release syndrome
—> extremely high fever, unstable BP, vascular leak, pulmonary edema, coagulopathies or multi organ failure
What is the treatment for cytokine release syndrome?
High dose steroids or tocilizumab
What are the most frequent immune-related adverse events from immunotherapy?
Derm and GI
How many patient going through HSCT experience mucositis?
70%
What late effects can patients have from HSCT?
Secondary malignancy: AML, MDS, post-transp lymphoproliferative disorders, solid tumors (the radiation may cause melanoma, oral cavity, bone, thyroid, breast)
Ocular conditions, bone density concerns, pulmonary infections
What is hepatic sinusoidal obstructive syndrome (HSOS)?
Result of TBI + conditioning regimens that contain melphalan, busulfan, cyclophosphamide
Injury to the endothelial tissue results in coagulation and thrombosis within the hepatic sinusoids and venules
During 1st 4 weeks post-transplant
About 1/3 of patients going through HSCT will require what?
Dialysis
What does persistent thrombocytopenia indicate following HSCT?
If after 3 months, Poor prognosis
When is a blood transfusion indicated?
If stable, Hgb between 7&8
If hx CV disease and exhibiting symptoms with Hgb 8
What are the ONS recommendations for patients at high risk (<= 20% chance) of developing neutropenia?
CSFs
Influenza vaccine
Pneumococcal vaccine
Antifungals, antibacterial prophylaxis
LIKELY to be effective
Private room
HEPA filters/masks
No fresh fruit, veg, fresh or dried flowers
Clean O2 humidifiers and nebs
Automatic ice machines
No animal feces, saliva, urine, litter boxes, cages
Promptly treat animal or insect bites or scratches
No reptiles
Awareness of any construction debris/aerosolization
What causes thrombocytopenia?
BM infiltrates by primary or metastatic malignancy
DIC or TTP
Splenomegaly
May occur 8-14days after chemo
Meds: NSAIDs, aspirin, thiazide diuretics, tricyclic antidepressant, some abx (pipercillin, ampicillin), heparin
When is a platelet transfusion indicated?
<10k for patients with acute leukemia, transplant patients and those with solid tumors
<20k if undergoing minor procedure
What are dose limiting toxicities?
Mucositis, peripheral neuropathy
5 phases of mucositis
I. Initiation (DNA damage, appears normal)
II. Primary damage response (transcription factor nuclear factor-KB is activated, causes cell death, pt may not feel damage)
III. Signal amplification (cytokines amplify injury, tissue altered but may appear normal)
IV. Ulceration (fibrous exudate thinly covers which can fill with bacteria - pain, dysphasia, decreased intake, difficulty talking, increased risk of bleeding)
V. Healing (once chemo and/or radiation d/c)
Who is more at risk of delayed (at least 24hrs after treatment) CINV?
Women and patient with previous CINV (cisplatin, carbo, cyclophosphamide, anthracyclines)
What are risk factors for CINV?
Younger age <50, low chronic alcohol intake, tumor burden, pancreatitis, hepatic mets
What are S&S of cachexia?
Amenorrhea, polyuria, cold intolerance, poor skin turgor/dry skin, cardiac arrhythmias, loss of muscle mass
Decreased Na, K, albumin, glucose, folate
Increased BUN/Cr ratio
What is recommended to manage anorexia?
Corticosteroids and progestins
What are risk factors for cardiopulmonary toxicities?
> 65yo, hx of cardiac or pulmonary, cigarettes, hepatic or renal dysfunction, combination therapy, mediastinal radiation, volume of heart irradiated >30Gy (NH and Hodgkin, left sided breast cancer have large treatment fields that include the heart), daily radiation dose fraction >2Gy/day, cumulative doses of chemo (esp anthracyclines), longer duration of survival
What are S&S of chemo induced pneumonitis?
Dyspnea, tachypnea, dry cough, anxiety, hypoxenia, hemoptysis, pleuritic pain, use of accessory muscles to breath
Ground glass infiltrates, ABGs, PFTs
Bleomycin
What is the treatment for pneumonitis?
Cough suppressants, antipyretics, glucocorticoid therapy, cautious use of O2, establish fluid homeostasis, bronchodilators, elevate HOB
What are risk factors for developing peripheral neuropathy?
Age>60, precious neurologic damage from RT to spine, preexisting peripheral neuropathy, concurrent use of neurotoxic agents, hx of cum dose of some neurotoxic agents (cisplatin, vincristine, taxanes), concurrent use of diuretics, excessive alcohol use, metabolic imbalances, HIV, paraneoplastic syndrome, diabetes, certain chemo, RT
