Treatment Flashcards
When is a bone marrow/stem cell transplant used?
Used when the cancer is likely to come back or other treatment has failed to work.
What is the difference between stem cell and bone marrow transplant?
In a stem cell transplant, cells are taken from the blood whereas in a bone marrow transplant cells are taken from the bone marrow.
What are the side effects of a stem cell or bone marrow transplant?
The side effects are either caused by high dose chemo, targeted drugs if you hVe them. You may have extra side effects if you have whole body radiotherapy (total body irradiation)
. The side effects are often worse straight after the transplant
. Infection risk- patients often have abx, anti fungals and mouthwashes
. Diet- certain things in diet can cause infection (wash salad thoroughly, avoid soft cheese and lightly cooked eggs).
. Anaemia (may need blood transfusion)
. Risk of bleeding and easy bruising due to low platelet level
. Sickness and diarrhoea
. A sore mouth
. Feeling tired and run down
. Loss of fertility in the long term
. Graft versus host disease
What are the signs of graft versus host disease?
Diarrhoea Weight loss Jaundice (yellowing of skin and eyes) Sore eyes or mouth Skin rashes Shortness of breath
How does a transplant using the patients own stem cells work (autologous chemotherapy)?
Preparation- various tests and a central line is put in
Growth factors- injections which make your bone marrow produce more stem and blood cells (subcut)
Collection of stem cells through a drip if it is from your bloodstream or under GA if they are collecting from your bone marrow (your hip bone)
After stem cell collection you have high dose treatment- conditioning
Chemo and possibly targeted drugs
Drugs are through central line, with also antibiotics and anti sickness meds
You have your stem cells back through central line
Blood count recovery- stem cells find their way back into the bone marrow where they make the blood cells you need
If it is autologous- 3-4 week hospital stay
If it is a graft then 6-8 week hospital stay
What are the types of radiotherapy?
External beAm
Brachytherapy
Systemic treatments- radioactive iodine
What is radical radiotherapy?
This is used to treat cancer as part of a curative strategy
When is radical radiotherapy used?
Neoadjuvant before surgery
Adjuvant during surgery
Definitive- used with chemo
What are the types of radiotherapy?
External beAm
Brachytherapy
Systemic treatments- radioactive iodine
What is radical radiotherapy?
This is used to treat cancer as part of a curative strategy
When is radical radiotherapy used?
Neoadjuvant before surgery
Adjuvant during surgery
Definitive- used with chemo
What is important to consider in terms of haematological malignancy treatment?
It is important to consider co- morbid conditions (cardiac, pulmonary and renal disease)
It is important to consider the normal daily living of a patient using ECOG (eastern co-operative oncology group)
When would you give blood product support for people with haematological malignancies?
Red cell and platelet transfusions are used to treat anaemia and thrombocytopenia, normally it is treated when the Hb <80g/L however the threshold also depends on factors like the speed and onset of anaemia and the clinical features.
When would you avoid giving red cell transfusions?
Should avoid if the patient has a high white blood cell count because of hyperviscosity and so the risk of precipitating thrombotic episodes as a result of white cell stasis.
What would you give first, platelets or red blood cells and why?
Platelets are given first to reduce the risk of a further fall in platelet count.
What is the usual trigger level for platelet transfusion?
Typically a platelet count below 10x10^9/L but the threshold should be increased in fever/active bleeding
When do you use fresh frozen plasma/cryoprecipitate?
Fresh frozen plasma is given when they have low clotting factors.
Cryoprecipitate is for fibrinogen, therefore you normally always give it as you can’t clot without fibrinogen.
What should be given to all patients recieving a transplant/blood transfusion?
CMV or leuco depleted blood this is to prevent transmission of CMV to uninfected patients.
What should be done to blood products before they are given to highly immunosuppressed people?
They should be irradiated prior to administration to prevent transfusion associated graft vs host.
What can be given to to accelerate neutrophil recovery after certain invasive chemotherapy treatment?
G-CSF
What can be given to patients to reduce haemorrhage in patients with chronic low grade blood loss despite platelet transfusion or thrombomimetic therapy?
Tranexamic acid or aminocaproic acid
What should be screened for regularly when a patient is undergoing chemo?
A coagulation screen should be performed regularly; support with vit K/FFP may be required.
What is the best anti emetic to use for chemo?
Serotonin 5-HT3 receptor antagonists such as: ondansetron can control nausea from intensive chemo in over 60% of cases, the addition of dexamethasone increases this by 20%
What is tumour lysis syndrome most likely to occur in?
Rapidly dividing neoplasias like leukaemia or lymphoblastic lymphoma.
How do you prevent TLS?
Electrolyte replacement, allopurinol, IV fluids
When do you give nutritonal support to a patient undergoing chemo?
If a weight loss more than % occurs
Either centrally through a NG tube or parenterally through a central venous catheter
What bacteria are usually responsible for sepsis in a patient with neutropaenia?
The patients own commensal bacterias
Gram +ve skin organisms (staph and strep)
Commonly colonize central lines
Gram -ve gut (pseudomonas aeruginosa, E coli, proteus, klebsiella, anaerobes)
How do you treat candida?
Prophylactic treatment with fluclonazole, itraconazole
Or actual treatment with fluclonazole
How do you treat CML?
Allogenic stem cell transplant from a Human leukocyte antigen matched donor if patient is young and suitable, if patient is unsuitable then tyrosine kinase inhibitors can be used (imatinib)
Lymphoblastic transformations can be treated as ALL
Myeloblastic transformations need allogenic transplant
How do you treat AML?
Cyclophosphamide used (chemo) which is very intense and causes long periods of neutropenia and thrombocytopenia Bone marrow transplant and allogenic SCT
What is the aim of treatment for multiple myeloma?
It is an incurable condition, the aim is to increase periods of remission.
There are four main areas of management for multiple myeloma, what is induction therapy?
Combination of three drugs (velcade, revlimid, dexamethasone)
There are main areas of management for multiple myeloma, what is maintenance therapy?
bortezomib or lenalidomide
What are the four main areas of management for multiple, what is relapse therapy?
ASCT
Previous or new regime
There are four main areas of management for multiple myeloma, what is autologous stem cell therapy?
Provides best option for long term remission
Stem cells are mobilised, harvested and stored following induction
High dose chemo is then given
Stem cells are then reinfused
How should chronic phase CML patients be managed?
If WCC >100 then cytoreduction
Oral hydration and allopurinol
First line is imatinib
Targeted cancer drugs called tyrosine kinase inhibitors are the most common treatment. There are several TKI’s available and most people start with a TKI called imatinib (Glivec). Most people respond well to this treatment and the CML can stay under control for several years.
Imatinib may not work for some people, or it stops working after a period of time. In this situation, you will be offered one of the other TKI’s.
Name a first generation Tyrosine Kinase inhibitor
Imatinib
Name a second generation tyrosine kinase inhibitor
Dasatinib
Nilotinib
What is the chronic phase of CML?
The chronic phase is when the leukaemia is most stable and still developing slowly. Most people are in this phase when they are diagnosed.
Not everyone has symptoms in this phase. If you do have symptoms they might be mild and vague. You might feel tired and lose a little weight. Your tummy (abdomen) might be swollen due to an enlarged spleen.
The number of white cells in your blood might be raised, as well as the number of platelets.
In this phase, typically fewer than 1 in 10 (10%) of the blood cells in your bone marrow are immature white blood cells known as blasts.
what is the accelerated phase of CML?
In the accelerated phase, you have more obvious symptoms. You might notice that you feel more tired than usual. You may lose weight. Your tummy (abdomen) might be swollen due to an enlarged spleen. This might give you an uncomfortable or painful feeling to the left of your stomach, under your ribs.
In this phase between 10% and 30% of the blood cells in your bone marrow are immature blasts.
How is accelerated phase of CML treated?
The treatment for the accelerated phase depends on the treatment you have already had. Imatinib (Glivec) is normally the first choice unless you have already had it in the chronic phase.
Some people who have imatinib for the first time in the accelerated phase might have a good response to treatment. It might put their CML back into the more stable chronic phase for a time.
If you have already had imatinib you might be treated with a different drug. Other drugs include nilotinib (Tasigna), dasatinib (Sprycel), bosutinib (Bosulif) and ponatinib (Iclusig).
Other treatment options include chemotherapy. Or your doctor might recommend more intensive treatment using a bone marrow or stem cell transplant. This is more likely if you are younger and fairly fit and well and have failed to respond to TKI treatment.
what is the blast phase?
The blast phase is also called the acute phase, blast crisis or blast transformation. This is when the leukaemia transforms into an acute leukaemia (usually acute myeloid leukaemia).
In this phase many blast cells fill the bone marrow. There are also more blast cells in the blood.
You can feel quite unwell and your symptoms could be troublesome. Your spleen is enlarged.
In this phase, more than 30% of the blood cells in your bone marrow or blood are immature blast cells. The leukaemic cells might have spread to other organs.
How is the blast phase treated?
Your doctor might suggest treatment with a TKI and if the response is not adequate then other options include:
chemotherapy with a combination of drugs that’s usually used for acute leukaemia
a bone marrow or stem cell transplant
You might have treatment to relieve symptoms. For example, radiotherapy to shrink an enlarged spleen. Or radiotherapy to reduce pain in the bones.
How do you treat ALL?
Main treatment is chemotherapy other treatments include: - targeted cancer drugs - radiotherapy - growth factors - stem cell or bone marrow transplants - steroids
What are the 3 stages of ALL treatment?
1) complete remission- this is to destroy all leukaemia blood cells, meaning there is no signs of leukaemia in your blood or bone marrow
2) treatment to stop ALL coming back- this is consolidation/ intensification therapy
3) keeping ALL away long term (maintenance)
What should be done pre ALL management?
steroids
IV hydration
allopurinol
all of the above to prevent TLS
Anaemia and thrombocytopaenia mx
G-CSF for neutropenia
What is complete remission in ALL?
Leukaemia not seen in bone marrow, the CSF or peripheral blood
What does the maintenance therapy for ALL involve?
Daily 6 mercaptopurine and weekly methotrexate
You usually have low dose chemotherapy and short courses of steroids for around 2 years. You also have intrathecal chemotherapy. You have your treatment in cycles, also known as blocks.
You see your doctor every few months to check how you are getting on and to keep an eye on your blood counts.
Sometimes you may need blood transfusions or antibiotics if you have an infection.
What about if the patient has ALL that is philadelphia positive?
They will have a drug alongside the chemo which is called imatinib.
What does consolidation therapy for ALL involve?
more chemotherapy
a donor transplant
a transplant with your own blood stem cells, but this is rare
The treatability of Hodgkins lymphoma is good, the issues is with the toxicities of treatment, what are 3 toxicities?
Secondary malignancies
fibrosis
Coronary artery disease
How is early stage hodgkins treated?
2-4 cycles of ABVD chemotherapy and radiotherapy
What is ABVD chemo?
Doxorubicin (inhibits DNA synthesis)
Bleomycin (Inhibits DNA synthesis)
Vinblastine (Inhibits microtubule formation)
Decarbazine (alkylating agent)
What is the difference between grade and stage in terms of non hodgkins lymphoma?
The stages of non-Hodgkin lymphoma (NHL) tell you about the number and places in the body that are affected by lymphoma.
There are 4 different stages of NHL. But in practice, doctors put the stages into 2 main groups to decide on treatment. These are called:
limited disease
advanced disease
Doctors put NHL into groups depending on whether they tend to grow faster or slower. This is called the grade. NHL can be low grade (also called indolent). These tend to grow slowly. Or they can be high grade (also called aggressive). These tend to grow more quickly.
What is the aim of treatment for low grade non hodgkins lymphoma?
the treatment aim is to control it for as long as possible, put the patient into remission, low grade non hodgkins lymphoma tends to come back and each time the remission period is shorter
How do you treat limited disease low grade non hodgkins lymphoma? (stage 1-2)
The most common type of low grade NHL is follicular lymphoma. For limited disease, you are most likely to have radiotherapy to the affected lymph nodes. This can help control the lymphoma for a long time, and may cure it.
How do you treat advanced low grade non hogkins lymphoma? (stage 3-4)
There are several phases of treatment for advanced low grade NHL. These are:
watch and wait
first line treatment
maintenance treatment
second line treatment
Watch and wait is often an option for low grade non hodgkins lymphoma as it is often slow growing and does not produce any symptoms, therefore the disadvantages of treatment (side effects of treatment) are better than the advantages, however when first line treatment is used what is it?
Combination chemotherapy and a monoclonal antibody (immunotherapy) This is called R-CVP which stands for... R= rituximab C= cyclophosphamide V= vincristine P= prednisolone
What maintenance therapy is used for low grade lymphoma?
for follicular lymphoma you will have rituximab every 2 months for 2 years
What is second line treatment for low grade lymphoma?
This means the treatment that is used when low grade lymphoma comes back
There are lots of different options for second line treatment. You might have a combination of chemotherapy drugs and a drug like rituximab. Or you might have a drug on its own, such as the chemotherapy drug bendamustine.
If it is difficult for you to make trips to the hospital, your doctor may choose a treatment that means you don’t have to go so often.
You might have maintenance treatment again if your disease goes into remission. Your doctor will discuss the possibility of further treatment if your lymphoma comes back again.
How is limited high grade lymphoma treated?
Short course of chemotherapy and a targeted drug followed by radiotherapy to the affected lymph node
Or you might have a longer course of chemotherapy and a targeted drug, without radiotherapy. Whether you have radiotherapy depends on factors such as where the lymphoma is in the body and how fit you are.
For diffuse large B cell lymphoma, you are most likely to have CHOP chemotherapy. You have it with a targeted immunotherapy drug called rituximab. This treatment is known as R-CHOP.
What is the treatment for high grade extensive lymphoma (stage 3-4)?
Intensive chemotherapy with 3 or 4 different drugs up to 6-8 months
depends on what type but most have chemo combinations contain a drug called doxorubicin this works well for many types of advanced high grade NHL
For advanced diffuse large B cell lymphoma, you have a combination treatment called R-CHOP. This is CHOP chemotherapy together with a targeted immunotherapy drug called rituximab.
When does a patient need a stem cell transplant or bone marrow transplant in terms of NHL treatment?
When using really intensive chemotherapy
What is intrathecal chemo?
this is chemotherapy that goes into the spine and prevents
What is intrathecal chemo?
this is chemotherapy that goes into the spine and prevents cancer spreading to the brain
