Treatment and Symptom Management Flashcards
What is a peripheral cannula, length, and maximum dwell time?
Is this type of cannula appropriate for prolonged IV therapy?
Short device (up to 2”) usually inserted into hand/forearm for short-term use, with dwell time limit of 96 hours/4 days.
No, not appropriate for prolonged IV therapy.
Describe a Midline catheter:
Peripheral or central device?
Length
Where inserted
Where tip is located
# lumens?
Materials
Maximum dwell time
A Midline catheter is:
- A Peripheral device
- 8-24cm in length
- Inserted AC fossa region
- Tip located in the basilic, cephalic or median cubital veins, below the level of the axilla
- Silicone or polyurethane
- Can be single or double lumen
- Some are CT compatible
- Dwell time 1–4 weeks
What is a CVAD?
Where is tip located?
When indicated? 7 listed.
A CVAD = Central Venous Access Device
- Tip located in the superior vena cava or right atrium.
Indicated when:
1. Poor Peripheral venous access
2. Prolonged IV chemotherapy
3. TPN (total parenteral nutrition)
4. repeated blood products expected
5. IV therapy involves venous sclerosant drugs
6. Continuous therapy
7. Fequent blood sampling / phlebotomy
Name 3 indications for PIV
- Short duration w/non-irritating therapies
- one-time use therapies (ie. IV push)
- Patients with a short life expectancy
Name 5 contraindications to PIVs
- Continuous vesicant therapy
- pH <5 or >9
- Glucose >10%
- protein >5%
- osmolarity >900 mOsm/L
- No definitive recommendation can be made regarding blood specimen collection
Name 3 types of PVADs
- Peripheral (96h/4days)
- Midline: Therapy (1-4 weeks)
- Subcutaneous: Continuous long- or short-term
List 5 General principles of PVAD placement/use.
- Select vein based on type of fluid, rate, and duration
- Use most distal site possible (but proximal to previous venipuncture)
- Smallest gauge and shortest length possible for indicated use
- Avoid extremities/sites with impaired circulation such as:
- antecubital veins
- lymphedema
- injury
- swelling
- hematoma
- site of axillary LN dissection
- infection
- phlebitis
- where previous venipuncture has been performed in the past 24 hours - Assess for blood return and patency prior to use
True or False
Some studies support the practice of changing peripheral lines only as clinically indicated versus every 72 - 96 hours
True
Within what time frame should you AVOID new PVAD placement at same location where previous venipuncture has been performed?
24 hours
List 4 PVAD complications and what is most common?
- Phlebitis (most common)
- Infltration (2nd most common)
- Extravasation
- Infection
What is Phlebitis
What are S&S
How do you prevent?
Phlebitis = the most common complication of PVAD = inflammation of the vein
S&S: Pain, erythema, streak formation, palpable
cord, and edema
Prevent:
- Aseptic technique
- Careful insertion placement
- Maintenance care
What is infiltration?
S&S?
How do you prevent?
Infiltration = second most common PVAD complication caused by leaking around catheter with NON-vesicant therapy
S&S: skin is cool, pale with edema, tenderness, skin tightness, decreased infusion rate
Prevention:
- Use appropriate syringe sizes to prevent vein rupture
What is Extravasation?
S&S?
How do you prevent?
How do you manage?
Extravasation = PVAD complication caused by leaking around catheter WITH vesicant therapy
Burning /stinging, pain, erythema, decreased infusion rate, absence of blood return during or following infusion, followed by blistering, tissue necrosis and ulceration.
Prevention:
- Aseptic technique
- Avoid multiple IV attempts
- Avoid impaired areas
- Avoid previous IV sites
- frequent blood return check during vesicant administration.
Management:
- Stop infusion
- Aspirate residual drug
- Assess site and estimate amount of vesicant extravasated
- give antidote as indicated
- remove peripheral catheter
- apply heat/cold as indicated.
In terms of PVAD, describe infection.
What are S&S
How do you prevent?
Infection = PVAD complication
S&S: Fever, redness, erythema at insertion site, purulent drainage, and warmth to
extremity
Prevention: strict aseptic technique
Name 4 types of CVAD (Central Venous Access Devices)
- Non-tunneled
- Tunneled
- Implanted subcutaneous ports
- PICC
Is a Non-tunneled CVAD common?
What level of care most often?
Name the 3 main insertion sites.
RE: Antimicrobial/antiseptic impregnated catheters:
1. when are these recommended?
2. Name two cons
Yes, Non-tunneled is the most common CVAD.
Most common in acute and critical care.
3 Main insertion sites:
1. Internal jugular vein
2. subclavian vein
3. femoral vein
- Antimicrobial/antiseptic impregnated catheters are recommended for adults at high risk for infection with duration expected <10 days (short term)
- Debate about antibiotic resistance and occasional severe allergic reactions.
When are Tunneled CVAD Recommended?
Higher or lower risk of infection (compared to non-tunneled?
Catheter fixation within how many weeks? How?
Do valved catheters require heparin flush? And cost?
Tunneled CVAD recommended with long-term use >6 months
Associated
with lower infection rates (compared to non-tunneled)
Catheter fixation usually 3–4 weeks of insertion. Cuff induces infammatory
reaction within the subcutaneous tunnel, leading to fibrosis/fixation.
Valved catheters do not
require heparin fushes but may need pressurized infusions for blood products.
MORE cost.
About CVAD: Implanted subcutaneous ports:
When indicated?
What is infection risk of ports compared to other CVAD options (Non-tunneled/ Tunneled)?
Most ports have how many lumens?
Name two drawbacks.
Implanted subcutaneous ports:
Indicated for:
- long-term intermittent therapy
- often in pediatrics and solid-tumor
- poor PIV access
Have lowest rates of catheter-related bloodstream
infections (compared to tunneled and non-tunneled)
Most = single lumen
1.Expensive
2. Larger scars
CVAD Peripherally inserted central catheters (PICCs)
Duration?
Where typically inserted? What vein?
Lumen(s)?
Power injector compatible?
AE drawback?
PICC duration = intermediate
Usually inserted bedside
Antecubital vein
Lumens = single or multiple lumens,
Yes some compatible with power injection
Associated with higher incidence of thrombosis
What is Radiation therapy (RT)?
Radiation therapy (RT) uses high-energy particles or waves, (such as x-rays, gamma rays, electron beams, or protons) to create ionizing radiation (IR) which damages DNA & ultimately destroys targeted cancer cells.
About what percent (%) of patients with cancer receive some type of RT during the course of their treatment?
About half (~50%)
How does RT work?
What are two ways RT can damage cells?
RT kills cancer cells by using high-energy radiation to damage the DNA, leading to cell death (of targeted cancer cells) and tumor shrinking.
DIRECTLY - (energy damaging DNA)
INDIRECTLY - by creating charged particles (free radicals) within the cells that can, in turn, damage the DNA.
Cancer cells whose DNA is damaged beyond repair
stop dividing or die
RT can cause Free Radicals.
What are Free Radicals?
How does RT cause them?
What are the most common type of free radicals produced in living tissue?
Free radicals are highly reactive chemicals that have the potential to harm cells. They are created when an atom or a molecule either gains or loses an electron (a small negatively charged particle found in atoms).
When ionizing radiation hits an atom or a molecule in a cell, an electron may be lost, leading to the formation of a free radical. The production of abnormally high levels of free radicals is the mechanism by which ionizing radiation kills cells (DNA damage).
Free radicals that contain the element oxygen are the most common type of free radicals produced in living tissue. Another name for them is “reactive oxygen species,” or “ROS”
Name the 3 ways that RT can be given
- External radiation (external beam radiation)
- Internal radiation (brachytheraopy)
- Systemic radiation (typically IV or PO)
What is the terminology for RT delivered by a machine from outside the body?
What are 3 beams used in EBRT - What is the machine used to generate the beams?
External-beam RT
- Photon beam RT (x-ray, gamma ray) - Linear accelerator (LINAC)
- Particle Beam (Protons, neutrons) - particle accelerators (such as a cyclotron or synchrotron)
- Electron Beam - Linear accelerator OR particle accelerator can be used
What is the terminology for RT delivered from radioactive material placed in the body near cancer cells?
Internal RT
aka
Brachytherapy
What is Systemic RT?
When radioactive substances are infused to kill cancer cells (ie. radioactive iodine to treat thyroid cancer)
What is Ionizing radiation?
How does it cause cell death?
Ionizing radiation is a form of energy that acts by removing electrons from atoms and molecules.
When ionizing radiation interacts with cells, it can cause cellular damage including damage to DNA leading to cellular death.
What are the 3 goals of RT?
- Cure
- Control (ie PCI)
- Palliation (relieve symptoms)
What RT is the most common?
External beam RT (EBRT)
Is proton therapy a form of EBRT?
Yes
What 2 RT therapies uses particle accelerators (cyclotrons or synchrotrons) to produce charged atoms that destroy tumors?
Particle beam RT (protons or neutrons)
Electron beam RT - NOTE can also be generated by linear accelerator if converted to photons
What type of RT is put inside the body, sealed in needles, seeds, wires, or catheters, and implanted directly into or near a tumor on a temporary or permanent basis?
Internal RT
aka
Brachytherapy
Brachytherapy is a common treatment for what type of cancer (4)?
- Prostate
- Uterus
- Cervix
- Breast
Is RT ever used alone to treat /cure cancer?
Yes
What two cancers are commonly treated by RT alone?
- Prostate
- Larynx
Name a type of cancer / situation where it is common for RT to be given in the adjuvant (post-surgery) setting.
In Breast cancer after breast-conserving surgery.
Name three types of cancer where RT is commonly given in the Neoadjuvant setting.
What is another name for Neoadjuvant therapy?
What are 2 goals for Neoadjuvant RT?
- Esophageal
- Rectal
- Lung
Induction RT
- Improve cure rates
- Make surgery easier to perform
What is the phrase that can be used if multiple treatments used (ie. RT, chemo, surgery)?
What is one cancer where the organ may be preserved in this way?
What are 3 types of cancer that can avoid surgery in this way?
Combined modality therapy
Bladder cancer
- Lung
- Head and neck
- Cervix
A TYPE of EBRT, what is IMRT?
What type of beam is used to generate IMRT?
It is safer for delivery of what type of RT?
Three-dimensional conformal radiation therapy (3D-CRT): delivers radiation beams from different directions designed to match the shape of the tumor.
IMRT = Intensity-Modulated RT, a type of EBRT is generated by a photon beam.
IMRT is like 3D-CRT, but it also changes the strength (intensity) of some of the beams in certain areas. This allows stronger doses to be aimed at certain parts of the tumor and helps lessen damage to nearby normal body tissues.
Safer for delivery of higher than conventional doses of RT
A TYPE of EBRT, what is IGRT?
In what 3 ways is it helpful?
What type of RT therapy is it often used in conjunction with IGRT?
What are the results of combining these therapies?
IGRT = Image-Guided RT. Images are made using CT, ultrasound, x-ray, MRI, or other imaging techniques before EACH treatment session. Can be applied to many RT treatment choices.
Helpful because:
1. more accurate
2. spares surrounding healthy tissue
3. can allow for adjustments during treatment in areas of the body that are prone to movement.
Often used along with IMRT (Intensity-Modulated RT)
Together IGRT + IMRT can deliver precise radiation doses to a malignant tumor or even specific areas within the tumor.
What is Stereotactic radiosurgery (SRS)?
What energy is highly focused in this technique?
How many sessions?
What type of cancer is this often used for?
What is this therapy called when used for other areas of the body?
What are are 3 other names for this type of RT?
Stereotactic radiosurgery (SRS) = a type of EBRT (not a surgery) that uses 3D imaging to determine the exact coordinates of the tumor (ultra-precise) then gives a LARGE dose of radiation to the tumor. Called “radiosurgery” because of how exact it can be in terms of where it delivers the radiation.
Energy used = Photons (Typically high energy X-rays or gamma rays)
Brain cancer
SBRT = Stereotactic body radiation when this type of therapy is used for areas outside of the brain.
- Radiation surgery
- Radiosurgery
- Stereotaxic radiosurgery
Which RT therapy uses radioactive cobalt sources to focus multiple beams of RT on a small area?
Gamma Knife.
Uses about 200 small beams of radiation at one time, creating a very large dose. It’s usually given in one treatment session. It’s important to remember it doesn’t use a knife and there’s no cutting.
What types of RT can linear accelerators (LINAC) deliver?
- Photon beam RT
- Electron beam RT (electrons can be converted to photon beams)
What is radioembolization?
What effect does it achieve?
A RT technique that uses microspheres filled with radioactive isotopes which are then delivered to a tumor.
Radioembolization cuts off blood flow to a tumor (ie in vascular organs such as the liver).
EBRT most often is delivered in the form of what type of energy beams?
Photon (ie high energy x-rays or gamma rays)
What is a photon?
Can the human eye see photons?
Which wavelengths have the least energy, which wavelengths the most?
A bundle of energy, the basic unit of light and other forms of electromagnetic radiation.
Human eyes can see some photon wavelengths (visible light), others wavelengths cannot be seen.
Ordered least-> most energy: Radio waves, microwaves, infrared, (visible spectrum), UV, X-Ray, Gamma ray
Do all photons have the same amount of energy?
No not all photons have the same amount of energy.
Ordered least-> most energy: Radio waves, microwaves, infrared, (visible spectrum), UV, X-Ray, Gamma ray
How does a Linear Accelerator (LINAC) work?
It uses electricity to form a stream of fast-moving subatomic particles = high-energy radiation that can be used to treat cancer.
What type of RT is APBI?
A newer approach for what early-stage cancer?
Accelerated Partial Breast Irradiation = higher fractions and shorter time intervals
A newer approach for early-stage breast cancer.
What is 3D-CRT?
3D-CRT is one of the most common types of EBRT. It uses sophisticated computer software and advanced treatment machines (beams from different direction) to deliver RT to precisely shaped target areas designed to match the shape of the tumor. This helps to reduce radiation damage to normal tissues.
What is Tomotherapy? It is a form of what type of RT?
How is the patient treated?
What is another name for Tomotherapy?
Tomotherapy = A type of EBTR (External Beam Radatian Therapy) called IMRT (Intensity-Modulated RT) where radiation is aimed at a tumor from many different directions.
Patient lays on a table and is moved through a donut-shaped machine. The radiation source in the machine rotates around the patient in a spiral pattern.
Tomotherapy = Helical tomotherapy
How does Proton therapy work?
What type of beam is used?
What does this type of therapy reduce?
What are common cancers in which it is used?
Is this a cheaper therapy alternative?
Proton therapy: A type of EBRT that uses streams of protons to kill tumor cells. The main difference between proton and photon radiation is that protons only travel a certain distance and can be slowed down when they get to the tumor. This means less radiation goes through healthy tissue around the tumor.
Beam = A particle beam.
Reduces radiation damage to healthy tissue near a tumor.
Therefore used to treat malignancies near critical structures such as:
1. Head and neck and organs
2. Brain
3. Eye
4. Lung
5. Spine
6. Prostate
7. Sarcomas near the base of the skull
8. Childhood cancers
Cost = Expensive. Proton radiation is newer, and the machines cost much more than photon radiation machines. Not all insurance companies cover proton therapy and they’re only available at certain treatment centers.
Along with Proton beams, electron beams are also charged particle beams used in RT
Can electron beams be used for internal organs?
Electron beams are NOT used for internal organs as they cannot travel very far through tissue.
Electron beams are used to irradiate superficial tumors, ie skin cancer or tumors near the body surface.
What 3 particles can be used for EBRT?
What BEAM is used to generate them?
- Protons - particle accelerator (cyclotron or synchrotron)
- Neutrons - particle accelerator (cyclotron or synchrotron)
- Electrons - particle accelerator (cyclotron or synchrotron) OR a Linear accelerator (LINAC) if converted to photons
Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) often referred to/ called by the name of the company that makes the machine.
Name 8 machines synonymous with SRS/SBRT therapy.
These machine moves around to target the tumor from many different angles: 1. X-Knife
2. CyberKnife
3. Clinac
4. Synergy-S
5. Edge
6. Novalis
7. TrueBeam.
8. Gamma Knife
What is the typical fraction # for SRS?
When more fractions used, what terms is this given?
Most patients will be given the full radiation dose in one session with stereotactic radiosurgery
Fractionated radiosurgery or Fractionated stereotactic radiotherapy = radiation in several smaller treatments to deliver the same or slightly higher dose
True or false:
Brachytherapy is never permanent
False.
In brachytherapy, radioactive isotopes are sealed in tiny pellets or “seeds.” that are placed in patients using delivery devices (needles, catheters, or other type of carrier). As the isotopes decay naturally, they give off radiation that damages nearby cancer cells.
If left in place, after a few weeks or months, the isotopes decay completely and no longer give off radiation. The seeds will not cause harm if they are left in the body (see permanent
brachytherapy, described below).
What is Interstitial brachytherapy?
Interstitial brachytherapy uses a radiation source placed within tumor tissue, such as within a prostate tumor.
What is Intracavitary brachytherapy?
Intracavitary brachytherapy uses a source placed within a surgical
cavity or a body cavity, such as the chest cavity, near a tumor.
What is Episcleral brachytherapy?
Episcleral brachytherapy uses a source that is attached to the eye, which
is used to treat melanoma inside the eye.
True or False:
Brachytherapy can only be given as low-dose.
False
Brachytherapy can be given as a low-dose OR high-dose treatment.
Low-dose rate treatment = cancer cells receive continuous low-dose radiation from a source over a period of several days.
High-dose rate treatment, a robotic machine attached to delivery tubes placed inside the body guides one or more radioactive sources into or near a tumor and then removes
the sources at the end of each treatment session. High-dose rate treatment can be given in one or more treatment sessions. (ie. MammoSite system used to treat patients with breast cancer who have undergone breast-conserving surgery.)
What is permament brachytherapy?
What type of dosing is this?
Permament brachytherapy = the sources are surgically sealed within the body and remains even after all of the radiation has been given ff. The remaining material (in which
the radioactive isotopes were sealed) does not cause any discomfort or harm to the patient
Permanent brachytherapy =low-dose rate brachytherapy
What is systemic RT?
Name 3 drug examples
Systemic RT, a patient swallows or receives an injection of a radioactive substance.
Examples:
1. Radioactive iodine (oral cocktail) commonly used to help treat thyroid cancer
2. ibritumomab tiuxetan (Zevalin®) = antibody joined to the radioactive substance FDA for certain types of B-cell non-Hodgkin lymphoma (NHL).
3. The radioactive drugs samarium-153-
lexidronam (Quadramet®) and strontium-89 chloride (Metastron®) are
radiopharmaceuticals used to treat pain from bone metastases.
Radiation side effects can be acute or late.
What is the difference in onset Acute vs. Late?
Acute SE occur during treatment, caused by damage to rapidly dividing cells, effects depend on area of RT.
Late SE occur days-years after treatment ends
With RT, are Late effects the same as Chronic effects?
No. Late SE are DIFFERENT from Chronic SE.
Name 5 examples of RT Late effects
- Fibrosis = the replacement of normal tissue with scar tissue
- Damage to the bowels = diarrhea and bleeding
- Memory loss
- Infertility (inability to have a child)
- Rarely, a secondary malignancy
Radiation Safety - What does the Acronym ALARA stand for?
As Low as reasonably achievable
Three main principles of RT safety are
- Time - minimize time of exposure
- Distance - double distance = reduces exposure by a factor of 4
- Shielding - absorber materials Plexiglass for beta particles:. Lead for x-rays and gamma rays.
Brain RT - Nursing Education
Name 8 potential AEs Related to Brain RT
List two items of advice
Potential AE associated with brain RT:
1. headaches
2. hair loss
3. nausea and vomiting
4. hearing loss
5. skin and scalp
changes
6. memory
7. speech
8. seizures.
Advise your patient:
1. Use recommended moisturizers and shampoos on scalp to decrease irritation.
- Protect your
scalp with a hat or frequent application of sunscreen if exposed to the sun.
Breast RT - Nursing Education
List two items of advice
Advise the patient to:
1. avoid bras with underwires, nylon, or lace (OK = breathable cotton bra or camisole)
- OK to use deodorant but avoid shaving the armpits to avoid skin irritation.
Head or neck area radiation:- Nursing Education
List two nursing considerations
- Dry mouth:
- suggest Swish and spit mouthwash either homemade (such as: 1 qt of water, 1 tsp of salt, and 1 tsp of baking soda) OR prescription mouthwash. Repeat several times per day.
- Reduce source of oral infection prior to RT: If possible, dental cleaning/eval recommended prior to initiation of RT to check for severely decayed teeth or an oral infection.
Pelvic radiation: List one important Nursing Education item for younger patients
- Provide information about sexuality and possible infertility before RT begins.
As appropriate:
banking sperm or egg-harvesting options.
RT Early side effects:
Onset time?
Duration, Severity?
When typically end?
What are 3x most common Early SE?
- Occur during or shortly after treatment.
- Tend to be short-term, mild, and treatable.
- Usually gone within a few weeks after treatment ends.
The most common:
1. Fatigue
2.. Skin changes
3. Other early side effects usually are related to the area being treated (ie. hair loss and mouth problems when radiation treatment is given to this area.most common AE
Name facts about RT Late side effects.
1. Onset
2. where in the body
3. Two factors that can influence
- Late side effects can take months to years to develop.
- Late side effects can occur in any tissue in the body that has received radiation.
- The risk of late side effects depends on the area treated as well as the radiation dose that was used.
Radioprotective drugs can reduce RT side effects.
- Name the most commonly used drug.
- What is the MoA?
- What is the typical cancer it is used for and what is the benefit?
- Amifostine is most commonly used Radioprotective drug.
- It is a Cytoprotective Agent. that acts to bind free Radicals (nucleophiles) thereby stabalizing DNA.
- Head and neck cancer - used to decrease dryness in the mouth caused by RT
Acute lymphocytic leukemia (ALL) List 4 Etiology and Risk Factors
- EBV
- human T-cell leukemia virus (HTLV-1)
- exposure to radiation and chemicals
- chromosomal abnormalities
Acute lymphocytic leukemia (ALL) Pathophysiology
- Disease of?
- Originates where in body?
- List 3x Types: L1-L3
- Diagnosed by?
- Malignant disease of lymphoid progenitors (T,B,NK cells).
- Orginates in the marrow, thymus, and lymph nodes
- Three Types of ALL
* L1: childhood (pre-B and T cell); 85% of cases are children
* L2: adult type (pre-B and T cell)
* L3: Burkett type (B cell)
* Diagnosis with marrow blasts > or = to 20%.
Acute lymphocytic leukemia (ALL) Clinical Manifestations (12)
- Recurrent infections
- pancytopenia
- fever
- fatigue
- weight loss
- swollen and bleeding gums
- slow-healing abrasions
- petechiae and bruising
- prolonged bleeding time
- bone pain
- organ infiltration (abdominal pain)
- swollen lymph nodes
Acute lymphocytic leukemia (ALL) Treatment and Management;
Add what for CD20?
Add what for Philadelphia chromosome?
- Hyper-CVAD, methotrexate and cytarabine,
CNS prophylaxis (Ara-C or methotrexate intrathecal) - Add rituximab if CD 20 positive (Burkett)
- Add imatinib if Philadelphia-chromosome– positive
- Bone marrow transplantation recommended
following first remission
Acute myelogenous
leukemia (AML) and acute nonlymphocytic leukemia Etiology and Risk Factors
- Correlated with what three risk factors?
- Peak age?
- Etiology unclear
- Genetics
- Down syndrome
- Correlation with benzene, chemotherapy,
radiation, and tobacco
exposure - Peak age is in the 50s.
Acute myelogenous
leukemia (AML) and acute nonlymphocytic leukemia Pathophysiology
What is early vs late stage?
What %blasts is diagnostic?
- Disease of the pluripotent myeloid stem
cell; chromosomal abnormalities of undifferentiated stem cells - Early stage: depletion of normal myeloid
cells (pancytopenia) - Later stage: Lack of apoptosis in malignant blast cells leads to accumulation in
marrow, blood, and organs. - Blast cells unable to fight infection; more
than 30% blasts in marrow is diagnostic.
Acute myelogenous
leukemia (AML) and acute nonlymphocytic leukemia Clinical Manifestations - name two primary
- Recurrent infections: susceptible to
cytomegalovirus, Pneumocystis carnii pneumonia, herpes simplex virus, and vancomycin resistant enterococcus - Pancytopenia, fever, fatigue, weight loss,
swollen or bleeding gums, slow-healing
abrasions, petechiae and bruising, prolonged bleeding time, bone pain, organ
infiltration (abdomi
Acute myelogenous
leukemia (AML) and acute nonlymphocytic leukemia Treatment and Management
- Cytarabine plus daunorubicin; cytarabine
plus idarubicin; cytarabine, daunorubicin,
and thioguanine; and mitoxantrone plus etoposide - For CNS, cytarabine or methotrexate
- Autologous or allogeneic bone marrow transplantation
- Blood product support (red blood cells,
platelets, and WBCs), broad spectrum antimicrobial, and antifungals
Etiology and Risk Factors Acute
promyelocytic leukemia
- Subtype of acute
myelogenous leukemia
Pathophysiology Acute promyelocytic leukemia
- Myeloid cell line: Myeloid cells can develop into red blood cells, white blood cells (other than lymphocytes NOT B or T cells), or platelets.
Clinical Manifestations Acute promyelocytic leukemia
- Recurrent infections, pancytopenia, fever, fatigue, weight loss, swollen or bleeding gums,
slow-healing abrasions, petechiae and bruising, prolonged bleeding, bone pain, organ
infiltration, swollen lymph nodes, and bleeding (disseminated intravascular coagulation,
fibrinolysis, and proteolysis)
Treatment and Management Acute promyelocytic leukemia
- Arsenic trioxide (the most common treatment), all-transretinoic acid, interleukin-2, and
anthracycline-based chemotherapy regimens - Autologous or allogeneic stem cell transplantation
Burkitt lymphoma (non-Hodgkin lymphoma) Etiology and Risk Factors
- Related to EBV
- Median survival is weeks, if left untreated.
Burkitt lymphoma (non-Hodgkin lymphoma) Pathophysiology
- Very aggressive and fast growing lymphoid progenitor (B or T cells); involvement with bone marrow, meninges, CNS, and blood
- Risk for tumor lysis; CNS a common site of relapse
- Potentially curable with aggressive therapy
Burkitt lymphoma (non-Hodgkin lymphoma) Clinical Manifestations
- Commonly presents at extranodal sites; typically present with rapidly growing, bulky
disease. - Elevated serum uric acid and LDH levels are
commonly found.
Burkitt lymphoma (non-Hodgkin lymphoma) Treatment and Management
- CODOX-M (cytoxan, vincristine, doxorubicin, and high-dose methotrexate)
- Hyper-CVAD —(cyclophosphamide, vincristine, doxorubicin, and dexamethasone)
- High risk: CODOX-M (cytoxan, vincristine, doxorubicin, and high-dose methotrexate) with ifosfamide, etoposide, and cytarabine
- Rituximab and hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with methotrexate and cytarabine
Chronic lymphocytic leukemia (CLL) Etiology and Risk Factors
- No known occupational or environmental
risk factors - Genetic link: high familial risk
- Most common adult
leukemia
Chronic lymphocytic leukemia (CLL) Pathophysiology
- Progressive accumulation of nonproliferating, morphologically mature but immunologically less mature lymphocytes
Chronic lymphocytic leukemia (CLL) Clinical Manifestations
- 40% asymptomatic at diagnosis
- B or constitutional symptoms
- Fatigue; weakness; malaise; bacterial infections; herpes zoster; exaggerated skin
reaction to insect bites or bee sting; and enlarged spleen (less frequently hepatomegaly), abdominal discomfort, and early satiety
Chronic lymphocytic leukemia (CLL) Treatment and Management
- FCR (fludarabine, cyclophosphamide, and rituxan), FC (fludarabine and cyclophosphamide), CFAR (cyclophosphamide, fludarabine, alemtuzumab, and rituximab (campath–found to “clean up” minimal residual disease), and stem cell transplantation
Chronic myelogenous
leukemia (CML) Etiology and Risk Factors
- Also called chronic
granulocytic leukemia - Chromosomal abnormalities
- No known specific
cause except exposure
to ionizing radiation
Chronic myelogenous
leukemia (CML)Pathophysiology
- Disorder of the myeloid stem cells characterized by marked splenomegaly and
increased production of granulocytes - About 90% of patients are Philadelphiachromosome–positive.
- Mature-appearing dysfunctional cells in three phases: chronic, accelerated,
and blast phase; blast crisis presents like acute leukemia, granulocytes replacing marrow - Average age of diagnosis is in 30s–40s; most diagnoses are in the chronic phase.
Chronic myelogenous
leukemia (CML)Clinical Manifestations
- Initial S&S: massive splenomegaly, fatigue, malaise, headache, weakness, weight loss, bone or joint pain, excessive (night) sweats, fever, abdominal pain (left upper quadrant), early satiety, vague abdominal fullness, hepatosplenomegaly,
lymphadenopathy, easy bruising, petechia, elevated basophils and neutrophils, blasts present, high B12 levels, and low alkaline
phosphatase - Chronic phase: high WBC count (10–150 times the normal level).
- Blastic phase presents with hypercatabolism, pancytopenia, and infection.
Chronic myelogenous
leukemia (CML)Treatment and Management
- Interferon alpha, imatinib, dasatinib, nilotinib, and stem cell transplantation (last resort, mostly allogeneic)
Diffuse large B-cell lymphoma (non-Hodgkin lymphoma) Etiology and Risk Factors
- Median age is 64 years;
affects more men than women - Overall survival is 50% at five years.
Diffuse large B-cell lymphoma (non-Hodgkin lymphoma) Pathophysiology
- Most common type of non-Hodgkin lymphoma
- Encompasses a diffuse group of large, neoplastic B lymphocytes with large nuclei.
- Destruction of the normal architecture of the involved lymph node occurs in a diffuse pattern.
- Frequently express B-cell markers (CD19, CD20, CD22, CD79a)
Diffuse large B-cell lymphoma (non-Hodgkin lymphoma) Clinical Manifestations
- Disseminates rapidly
- ”B” symptoms (unexplained fever, night sweats, and unexplained weight loss)
- Anemic
- Most present with nodal and extra nodal (gastrointestinal, skin, sinus, and stomach).
- Potentially curable
- Presents either as primary lymph node disease or at extranodal sites
Diffuse large B-cell lymphoma (non-Hodgkin lymphoma) Treatment and Management
- Stage I: R-CHOP (R-CHOP—rituxan, cyclophosphamide, doxorubicin, vincristine, and prednisone) six times with radiation therapy
- Stage I/II: R-CHOP (rituxan, cyclophosphamide, doxorubicin, vincristine, and prednisone) 6–8 times plus radiation therapy
- Stage III/IV: clinical trial of R-CHOP (rituxan, cyclophosphamide, doxorubicin, vincristine, and prednisone) and
Hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) every 14 days or 6–8 courses (rituximab eight times) - Second line: rituxan, ifosphamide, etoposide,
and carboplatin (RICE), R-ESHAP (rituxan, etoposide, methylprednisolone, cytarabine, and cisplatin) salvage (dexamethasone, cisplatin, and cytarabine [DHAP]), and carmustine, etoposide, cytarabine, and melphalan (BEAM)
Follicular lymphoma (non-Hodgkin lymphoma) Etiology and Risk Factors
- Accounts for 35% of
all non-Hodgkin lymphoma cases - Median age is 60;
median survival from
diagnosis is 10 years.
Follicular lymphoma (non-Hodgkin lymphoma) Pathophysiology
- Neoplasm of follicle center (germinal center) B cells
Follicular lymphoma (non-Hodgkin lymphoma)Clinical Manifestations
- B-cell symptoms: unexplained fever, night sweats, and unexplained weight loss
- Lymphadenopathy (cervical, supraclavicular,
and maxillary)
Follicular lymphoma (non-Hodgkin lymphoma)Treatment and Management
- Treatment usually not curative. Responds well initially, but high incidence of recurrence
- Watch and wait, radiation therapy alone, chemotherapy, or chemotherapy with radiation therapy
- High risk: CODOX-M (cytoxan, vincristine, doxorubicin, and high-dose methotrexate) /VAC
- Rituximab and hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) alternating with
methotrexate and cytarabine
Hodgkin lymphoma Etiology and Risk Factors
- Affects more men than
women - Genetics, EBV, HIV, herpes virus 6
- Occupational (woodworking, chemical exposures)
Hodgkin lymphoma Pathophysiology
- B-cell origin (Reed-Sternberg cells)
- Nodular sclerosis (grades 1 and 2),
lymphocyte-rich, mixed cellularity, lymphocyte depleted
Hodgkin lymphoma Clinical Manifestations
- Most present with peripheral lymphadenopathy above the diaphragm.
- B cell symptoms: unexplained fever, night
sweats, unexplained weight loss (greater
than 10%) - Pruritis
- Lymphadenopathy (cervical, supraclavicular,
and maxillary) - Fatigue; pain with alcohol consumption
Hodgkin lymphoma Treatment and Management
- Staging dependent
- Radiation therapy
- Chemotherapy: doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD)
- Mechlorethamine, vincristine, procarbazine,
and prednisone (MOPP) - Stem cell transplantation
Mantle cell (non-Hodgkin lymphoma) Etiology and Risk Factors
- Median age is 60 years;
median survival is 3–5
years. - Aggressive, cure is rare.
Mantle cell (non-Hodgkin lymphoma) Pathophysiology
- B-cell neoplasm
- Strong surface immunoglobulin M
- Monoclonal lymphoid proliferation destroys the architecture of the lymph node.
- A nodular, diffuse, or mantle zone
growth pattern is observed.
Mantle cell (non-Hodgkin lymphoma) Clinical Manifestations
- Hepatomegaly and splenomegaly are common findings.
- Most common extranodal sites reported include the gastrointestinal tract and Waldeyer ring found on the tonsils.
- Anemic
- May include gastrointestinal tract, marrow, blood, liver, brain, and cerebrospinal fluid
