Treatment and Symptom Management Flashcards

Question

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?

Answer 1

External-beam RT 1. Photon beam RT (x-ray, gamma ray) - Linear accelerator (LINAC) 2. Particle Beam (Protons, neutrons) - particle accelerators (such as a cyclotron or synchrotron) 3. Electron Beam - Linear accelerator OR particle accelerator can be used

Answer 2

Internal RT aka Brachytherapy

Answer 3

When radioactive substances are infused to kill cancer cells (ie. radioactive iodine to treat thyroid cancer)

Answer 4

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.

Answer 5

1. Cure 2. Control (ie PCI) 3. Palliation (relieve symptoms)

Answer 6

External beam RT (EBRT)

Answer 7

Particle beam RT (protons or neutrons) Electron beam RT - NOTE can also be generated by linear accelerator if converted to photons

Answer 8

Internal RT aka Brachytherapy

Answer 9

1. Prostate 2. Uterus 3. Cervix 4. Breast

Answer 10

1. Prostate 2. Larynx

Answer 11

In Breast cancer after breast-conserving surgery.

Answer 12

1. Esophageal 2. Rectal 3. Lung Induction RT 1. Improve cure rates 2. Make surgery easier to perform

Answer 13

Combined modality therapy Bladder cancer 1. Lung 2. Head and neck 3. Cervix

Answer 14

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

Answer 15

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.

Answer 16

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. 1. Radiation surgery 2. Radiosurgery 3. Stereotaxic radiosurgery

Answer 17

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.

Answer 18

1. Photon beam RT 2. Electron beam RT (electrons can be converted to photon beams)

Answer 19

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).

Answer 20

Photon (ie high energy x-rays or gamma rays)

Answer 21

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

Answer 22

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

Answer 23

It uses electricity to form a stream of fast-moving subatomic particles = high-energy radiation that can be used to treat cancer.

Answer 24

Accelerated Partial Breast Irradiation = higher fractions and shorter time intervals A newer approach for early-stage breast cancer.

Answer 25

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.

Answer 26

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

Answer 27

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.

Answer 28

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.

Answer 29

1. Protons - particle accelerator (cyclotron or synchrotron) 2. Neutrons - particle accelerator (cyclotron or synchrotron) 3. Electrons - particle accelerator (cyclotron or synchrotron) OR a Linear accelerator (LINAC) if converted to photons

Answer 30

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

Answer 31

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

Answer 32

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).

Answer 33

Interstitial brachytherapy uses a radiation source placed within tumor tissue, such as within a prostate tumor.

Answer 34

Intracavitary brachytherapy uses a source placed within a surgical cavity or a body cavity, such as the chest cavity, near a tumor.

Answer 35

Episcleral brachytherapy uses a source that is attached to the eye, which is used to treat melanoma inside the eye.

Answer 36

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.)

Answer 37

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

Answer 38

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.

Answer 39

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

Answer 40

No. Late SE are DIFFERENT from Chronic SE.

Answer 41

1. Fibrosis = the replacement of normal tissue with scar tissue 2. Damage to the bowels = diarrhea and bleeding 3. Memory loss 4. Infertility (inability to have a child) 5. Rarely, a secondary malignancy

Answer 42

As Low as reasonably achievable

Answer 43

1. Time - minimize time of exposure 2. Distance - double distance = reduces exposure by a factor of 4 3. Shielding - absorber materials Plexiglass for beta particles:. Lead for x-rays and gamma rays.

Answer 44

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. 2. Protect your scalp with a hat or frequent application of sunscreen if exposed to the sun.

Answer 45

Advise the patient to: 1. avoid bras with underwires, nylon, or lace (OK = breathable cotton bra or camisole) 2. OK to use deodorant but avoid shaving the armpits to avoid skin irritation.

Answer 46

1. 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. 2. 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.

Answer 47

1. Provide information about sexuality and possible infertility before RT begins. As appropriate: banking sperm or egg-harvesting options.

Answer 48

1. Occur during or shortly after treatment. 2. Tend to be short-term, mild, and treatable. 3. 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

Answer 49

1. Late side effects can take months to years to develop. 2. Late side effects can occur in any tissue in the body that has received radiation. 3. The risk of late side effects depends on the area treated as well as the radiation dose that was used.

Answer 50

1. Amifostine is most commonly used Radioprotective drug. 2. It is a Cytoprotective Agent. that acts to bind free Radicals (nucleophiles) thereby stabalizing DNA. 3. Head and neck cancer - used to decrease dryness in the mouth caused by RT

Answer 51

1. EBV 2. human T-cell leukemia virus (HTLV-1) 3. exposure to radiation and chemicals 4. chromosomal abnormalities

Answer 52

1. Malignant disease of lymphoid progenitors (T,B,NK cells). 2. Orginates in the marrow, thymus, and lymph nodes 3. 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%.

Answer 53

1. Recurrent infections 2. pancytopenia 3. fever 4. fatigue 5. weight loss 6. swollen and bleeding gums 7. slow-healing abrasions 8. petechiae and bruising 9. prolonged bleeding time 10. bone pain 11. organ infiltration (abdominal pain) 12. swollen lymph nodes

Answer 54

* 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

Answer 55

* Etiology unclear * Genetics * Down syndrome * Correlation with benzene, chemotherapy, radiation, and tobacco exposure * Peak age is in the 50s.

Answer 56

* 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.

Answer 57

* 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

Answer 58

* 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

Answer 59

* Subtype of acute myelogenous leukemia

Answer 60

* Myeloid cell line: Myeloid cells can develop into red blood cells, white blood cells (other than lymphocytes NOT B or T cells), or platelets.

Answer 61

* 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)

Answer 62

* Arsenic trioxide (the most common treatment), all-transretinoic acid, interleukin-2, and anthracycline-based chemotherapy regimens * Autologous or allogeneic stem cell transplantation

Answer 63

* Related to EBV * Median survival is weeks, if left untreated.

Answer 64

* 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

Answer 65

* Commonly presents at extranodal sites; typically present with rapidly growing, bulky disease. * Elevated serum uric acid and LDH levels are commonly found.

Answer 66

* 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

Answer 67

* No known occupational or environmental risk factors * Genetic link: high familial risk * Most common adult leukemia

Answer 68

* Progressive accumulation of nonproliferating, morphologically mature but immunologically less mature lymphocytes

Answer 69

* 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

Answer 70

* 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

Answer 71

* Also called chronic granulocytic leukemia * Chromosomal abnormalities * No known specific cause except exposure to ionizing radiation

Answer 72

* 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.

Answer 73

* 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.

Answer 74

* Interferon alpha, imatinib, dasatinib, nilotinib, and stem cell transplantation (last resort, mostly allogeneic)

Answer 75

* Median age is 64 years; affects more men than women * Overall survival is 50% at five years.

Answer 76

* 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)

Answer 77

* 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

Answer 78

* 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)

Answer 79

* Accounts for 35% of all non-Hodgkin lymphoma cases * Median age is 60; median survival from diagnosis is 10 years.

Answer 80

* Neoplasm of follicle center (germinal center) B cells

Answer 81

* B-cell symptoms: unexplained fever, night sweats, and unexplained weight loss * Lymphadenopathy (cervical, supraclavicular, and maxillary)

Answer 82

* 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

Answer 83

* Affects more men than women * Genetics, EBV, HIV, herpes virus 6 * Occupational (woodworking, chemical exposures)

Answer 84

* B-cell origin (Reed-Sternberg cells) * Nodular sclerosis (grades 1 and 2), lymphocyte-rich, mixed cellularity, lymphocyte depleted

Answer 85

* 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

Answer 86

* Staging dependent * Radiation therapy * Chemotherapy: doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) * Mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) * Stem cell transplantation

Answer 87

* Median age is 60 years; median survival is 3–5 years. * Aggressive, cure is rare.

Answer 88

* 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.

Answer 89

* 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

Answer 90

* First line: hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) * Second line: fludarabine, cytoxan, and rituximab (FCR) * Pentostatin, cytoxan, and rituximab (PCR) * Bortezomib

Answer 91

* Accounts for 0.5%–3% of non-Hodgkin lymphoma cases * Median age is 55–60 years; affects more men than women

Answer 92

* T-cell lymphocytes become cancerous and affect the skin. * Infiltration of the epidermis and dermis with T cells

Answer 93

* Skin lesions, initially seen on the trunk * May involve lymph nodes, liver, spleen, lungs, and blood * Bone marrow involvement is rare

Answer 94

* Steroids and chemotherapy applied to the skin in early phase * Treatment usually is palliative.

Answer 95

* Group of hematologic disorders with an increased risk of transformation to acute myelogenous leukemia; occur as result of altered stem cells * Chromosome abnormalities are present at the level of stem cell in 50% of patients with primary MDS and 75% of patients with therapy-related MDS. * 80%–90% of patients older than age 50 * Median survival is 28 months.

Answer 96

* Characterized by one or more peripheral blood cytopenias secondary to bone marrow dysfunction * Anemia, bleeding, easy bruising, and fatigue

Answer 97

* Bone marrow transplantation (successful if marrow comes from human leukocyte antigen donor and if the patient is younger than age 55)—only curative therapy * High-dose chemotherapy for ablation can induce remission in 40%–60% of patients.

Answer 98

* Unknown * Monoclonal gammopathy of undetermined significance (MGUS): possible precursor * Abnormal level of serum protein that does not cause tumors

Answer 99

* Cancer of plasma or B cell * Serum or urine protein (monoclonal immunglobulin M protein) * No cure; relapse inevitable * Plasmablastic cells (plasma stem cell) colonize the bone marrow. * Research suggests correlation with deletion of chromosome 13 in MM. * Bone destroyed by osteolytic action of malignant plasma cells

Answer 100

* Bone pain, anemia, and recurrent infections (related to impaired T cells) * Lytic bone lesions: risk for fractures, spinal cord compression, and loss of weight bearing ability * High-protein serum (M protein) * Pallor: Most common physical finding * Liver or spleen palpable in many patients * Mental status changes related to hypercalcemia, hyperviscosity syndrome, or renal insufficiency * Limitations in range of motion * Hypercalcemia, elevated blood urea nitrogen, creatinine, and uremia

Answer 101

* Bortezomib, thalidomide, and lenalidomide Primary: * Melphalan and prednisone * Vincristine, carmustine, melphalan, cytoxan, and prednisone * Vincristine, carmustine, doxorubicin, and prednisone * Vincristine, doxirubicin, and dexamethasone Maintenance therapy: * Steroids and interferon * Radiation therapy: limited, can further deplete bone marrow reserve; used for palliative therapy * Autologous transplantation

Answer 102

* Occurs in 1 of 20 patients with chronic lymphocytic leukemia

Answer 103

* Rare, progresses rapidly, aggressive * Related to EBV * Richter syndrome transforms into highgrade non-Hodgkin lymphoma, acute leukemia, prolymphocytic leukemia, and Hodgkin leukemia * Median survival five to eight months.

Answer 104

* Rapid onset lymphadenopathy * Bulky retroperitoneal adenopathy * Fever, night sweats, and weight loss; massive hepatosplenomegaly; clinical deterioration * Extranodal involvement (skin, CNS, gastrointestinal tract, eye, testes, lung, and kidney)

Answer 105

* Chemotherapy: lenalidomide, lumiliximab, clofarabine, and dasatinib * Monoclonal antibodies and biologic therapy * Allogeneic stem cell transplantation * Radiotherapy

Answer 106

* Median age: 61 * Cutaneous T cell: skin involvement and mycosis fungoids * Viral cause: human T-cell lymphotrophic virus type 1, EBV * Genetics, radiation, and immunosuppression

Answer 107

Unknown "-"

Answer 108

* Lymphadenopathy, ”B” symptoms (unexplained fever night sweats, and unexplained weight loss), and fatigue

Answer 109

* Hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) plus etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (EPOCH) * Relapsed: transplantation, DHAP, R-ESHAP (rituxan, etoposide, methylprednisolone, cytarabine, and cisplatin), and ifosphamide, etoposide, and carboplatin (ICE) * Nontransplantation: velcade, gemcitabine, and ontak

Answer 110

EGFR inhibitors: e.g., cetuximab, erlotinib

Answer 111

HER2 inhibitors: e.g., trastuzumab, pertuzumab

Answer 112

BCR-ABL inhibitors (also called tyrosine kinase inhibitors): e.g., imatinib, dasatinib

Answer 113

ALK inhibitors (also called multikinase inhibitors): e.g., crizotinib, ceritinib

Answer 114

BRAF kinase inhibitors (also called multikinase inhibitors): e.g., vemurafenib, dabrafenib

Answer 115

Cells: CD20 is expressed on pre-B and mature B cell lymphocytes (Lymphoid lineage) Therapy: Rituximab = monoclonal antibody that targets CD20 tumor specific antigen Certain leukemias and lymphomas, including non- Hodgkin lymphoma and lymphocyte predominant subtype of Hodgkin lymphoma

Answer 116

Cells: CD33 is expressed primarily on Myeloid lineage cells and some lymphoid cells; Myeloid colony forming cells + Leukemic blasts - Megakaryocyte (platelet precursor) - Erythrocyte (RBC precursor) - Mast cell - Myeloblast (Basophil, Neutrophil, Eosinophil, Monocyte=Macrophage precursor) Therapy: Gemtuzumab ozogamicin (removed from market June 2010) targeted CD33 Cancer: Treats AML (acute myeloid leukemia)

Answer 117

Cells: CD52: is expressed on 1)Mature lymphocytes (B & T cells), but not on Lymphocyte stem cells 2)Monocytes 3)Macrophage (& dendritic cells) Therapy: Alemtuzumab Cancers treated: 1)some types of lymphoma 2)CLL (chronic lymphocytic leukemia)

Answer 118

Two targeted therapies - Apoptosis Inducers via Proteasome inhibitor: bortezomib and carfilzomib

Answer 119

Name two targeted therapy - Angiogenesis Inhibitor PATHWAYS: 1)Agents that interfere with the action of vascular endothelial growth factor (VEGF) - Bevacizumab 2)Agents that target other receptors on the surface of endothelial cells or other proteins in the downstream signaling pathways that stimulate new blood vessel growth (cytosolic TF phosphorylation: RAS, RAF, MAP; Nucleus gene transcription leading to protein synthesis: Fos, ATF-2, Jun, Mac) - Sorafenib = oral dual action kinase inhibitor with MULTIPLE targets: RAF/MEK/ERK pathway in tumor cells and tyrosine kinases VEGFR/PDGFR in tumor vasculature - Sunitinib = an oral oxindole receptor tyrosine kinase (RTK) inhibitor with MULTIPLE targets, similar to Sorafenib

Answer 120

Tyrosine Kinase inhibitors (TKIs) TKI MOA: Binds EGFR and/or VEGF inactivates or limits its activity Orally administered -tinib Drug examples: - dasatinib (CML w/ (+) philadelphia chr) - erlotinib (advanced NSCLC & pancreatic) - gefitinib - ibrutinib (Mantle cell lymphoma, CML) - imatinib (CML w/(+) philadelphia chr) - lapatinib - ponatinib (CML) - sunitinib (advanced RCC & GIST tumors) - vandetanib - odd one out: ziv-aflibercept

Answer 121

Tyrosine Kinase inhibitor (TKI) MOAB TKI MOAB MOA: Binds EGFR and/or VEGF inactivates or limits its activity Administered by IV Drug examples: cetuximab, panitumumab

Answer 122

Kinase inhibitors MOA: target the RAF/RAS/MET pathway - nib Administered: PO Examples: * Sorafenib, * Dabrafenib * Trametinib * Vemurafenib

Answer 123

PI3K inhibitors MOA: PI3K inhibitors target the PI3K pathway - lisib Administered: PO Idelalisib - follicular B-Cell non-Hodgkin Lymphoma and relapsed CLL

Answer 124

hedgehog pathway inhibitor MOA: inhibit hedgehog pathway, normally controls cell division of adult stem cells and cell differentiation - gib Administered: PO Examples: - Sonidegib locally advanced Basal cell carcinoma - Vismodegib - metastatic or recurrent locally advanced Basal cell carcinoma

Answer 125

G0 phase (resting stage, temporarily out of cell cycle): The cell has not yet started to divide. Duration: from a few hours to a few years. Next phase: When the cell gets a signal to reproduce, it moves into the G1 phase.

Answer 126

G1 = Gap 1 Action: During this phase, the cell starts making more proteins and growing larger, so the new cells will be of normal size. Duration: 18–30 hours Next phase: S phase

Answer 127

Synthesis phase Action: the chromosomes containing the genetic code (DNA) are copied, so both of the new cells formed will have matching strands of DNA. Duration: from 18–20 hours Next Phase: G2 phase

Answer 128

Gap 2 Phase Action: cell checks the DNA and gets ready to start splitting into two cells. Duration: form 2–10 hours Next Phase: M phase

Answer 129

Mitosis Action: Cell splits into two new cells. Duration: 30-60 min Next phase: G1 or G0 phase

Answer 130

No. Alkylating agents are cell-cycle NONspecific and therefore exert effects in ALL phases of the cell cycle.

Answer 131

Alkylating Agents break the DNA helix strand, which interferes with the DNA replication process and results in cell death. Yes, given intermittently allowing patient to recover.

Answer 132

Types of alkylating agents include: NON-Platins: 1* Nitrogen mustards (melphalan, ifosfamide, cyclophosphamide, bendamustine) 2* Nitrosoureas (cross the blood-brain barrier) (lomustine, carmustine, streptozocin) 3* Triazines and hydrazines (dacarbasine, procarbazine, temozolomide) 4* Alkyl sulfonates (busulfan) 5* Ethylenimines: (thiotepa and altretamine (hexmethylmelamine) Platins: 6* Platinums (cisplatin, oxaliplatin, carboplatin)

Answer 133

Alkylating agent - Dose-Limiting Toxicities: 1. Bone marrow suppression 2. Organ-specific toxicities dependent on medication and dose (e.g., renal, and hepatic toxicities, pulmonary and cardiac toxicities, urotoxicity). 3. Hemorrhagic cystitis 4. Peripheral neuropathy.

Answer 134

Type of alkylating agent (cell-cycle NONspecific) Examples 1. melphalan 2. ifosfamide, 3. cyclophosphamide 4. bendamustine

Answer 135

Type of alkylating agent (cell-cycle NONspecific) Examples 1. lomustine. 2. carmustine 3. streptozocin **cross the blood-brain barrier

Answer 136

Type of alkylating agent (cell-cycle NONspecific) Examples 1. cisplatin 2. oxaliplatin 3. carboplatin

Answer 137

Type of alkylating agent (cell-cycle NONspecific) Examples 1. dacarbasine, 2. procarbazine, 3. temozolomide

Answer 138

Type of alkylating agent (cell-cycle NONspecific) Example 1. busulfan

Answer 139

Expected SE of alkylating agents: * GI (e.g N/V anorexia, diarrhea, mucositis, stomatitis). * Neurological (e.g., peripheral neuropathy). * Tumor lysis syndrome * Risk of new malignancy * Other rapidly dividing cells are affected, often causing alopecia rashes, or infertility.

Answer 140

Pre- and Post- administration considerations for alkylating agents: * Monitor blood counts and reference treatment parameters - GCSF with treatment plan or PRN - Blood transfusion PRN - Dose hold vs. reduction PRN - regular UA depending on treatment plan - Negative pregnancy test before treatments. * Conduct baseline assessment, closely monitor during therapy for SE, intervene early if issues.

Answer 141

Antitumor Antibiotics MOA: They work by binding with DNA, thereby inhibiting DNA and RNA synthesis. NO. This class of chemo is cell cycle phase NON-specific (except for bleomycin)

Answer 142

Types of antitumor antibiotics include: * Anthracyclines (e.g., daunorubicin, doxorubicin, epirubicin, idarubicin, valrubicin) * Non-anthracyclines (e.g., bleomycin, mitomycin C, mitoxantrone, dactinomycin)

Answer 143

DLTs of Antitumor Antibiotic, cell cycle NON-specific * Myelosuppression * Cardiotoxicity (Anthracyclines) * Pulmonary fibrosis (Bleomycin w/lifetime dose <400 units) * Organ-specific toxicities depending on drug/dose (hepatic, renal) *

Answer 144

Expected SE of Antitumor Antibiotic, cell cycle NON-specific: * GI (e.g., N/V, anorexia, diarrhea, mucositis, stomatitis). * Radiation recall =inflammation to areas of prior RT weeks or years after RT completed, especially skin. * Discolored urine based on medication color (e.g., doxorubicin = red-colored urine, mitoxantrone = blue- or green-colored urine) * Other rapidly dividing cells are affected causing alopecia, rashes, and hyperpigmentation.

Answer 145

Pre- and Post administration considerations of Antitumor Antibiotic, * Monitor blood counts and reference treatment parameters - GCSF with treatment plan or PRN - Blood transfusion PRN - Dose hold vs. reduction PRN - regular UA depending on treatment plan - Negative pregnancy test before treatments. * Conduct baseline assessment, closely monitor during therapy for SE, intervene early if issues. * vesicant precautions: many antitumor antibiotic agents are vesicants (highly toxic and corrosive to soft tissue). - IV assessment - Central line for some meds - Consider central line for poor venous access

Answer 146

4x Antracyclines: 1. daunorubicin 2. doxorubicin 3. epirubicin 4 idarubicin Class of chemo: Antitumor antibiotics, derived from Streptomyces bacteria No. Cell cycle phase NON-specific (except for bleomycin) MOA: bind DNA, thereby inhibiting DNA and RNA synthesis

Answer 147

Nitrosoureas are alkylating agents MOA: Break DNA, interferes with DNA replication Cell cycle NON-specific Special: cross the blood–brain barrier 3x Examples: 1. Carmustine (IV or implantation ie wafer) 2. Lomustine (PO) 3. Streptozocin (IV)

Answer 148

DLTs for Nitrosoureas, alkylating agents that cross the blood–brain barrier 1. Bone marrow suppression (PLT, HGB, and ANC) Nadir = 4-6 wks = 6-8 week cycle for count recovery 2. Pulmonary tox (irreversible) 3. Implanted wafer (Carmustine) has specific tox: intracranial HTN, seizures, meningitis, delayed neurological surgery wound healing 4. Organ spec. tox depending on agent (renal / hepatic etc)

Answer 149

4x expected Nitrosoureas AEs: 1. GI 2. Secondary malignancy 3. Streptozozin can alter glucose metabolism 4. Other (fatigue, alopecia, proteinuria, confusion)

Answer 150

1. Blood counts/reference treatment parameters - dose hold/reduce PRN 2. conduct baseline assessment, closely monitor during therapy for SE, intervene early if issues 3. Anti-emetic 30-60min pre-dose 4. PFTs - Recognize cumulative dose maximums 5. IV site assessment prior to administration

Answer 151

Yes! MOA suring S Phase (DNA synthesis/ replication)

Answer 152

1. Folic acid analogs 2. Pyrimidine analogs 3. Purine analogs 4. Ribonucleotide reductase inhibitors

Answer 153

2x Folic acid analogs a type of Antimetabolite 1. Methotrexate 2. Pemetrexed

Answer 154

4x Pyrimidine analogs, a type of Antimetabolite 1. 5-fluorouracil 2. cytarabine 3. gemcitabine 4. azacytidine

Answer 155

4x Purine analogs, a type of Antimetabolite 1. fludarabine 2. cladribine 3. mercaptopurine 4. nelarabine

Answer 156

3x Antimetabolite DLTs: 1. Bone marrow suppression 2. Neuro tox. including CEREBELLAR + PSN 3. Organ specific depending on agent and dose (ie. renal, hepatic, pulmonary, cardiac)

Answer 157

Name 4x Antimetabolite expected AEs 1. GI (N/V, anorexia, diarrhea, mucositis, stomatitis) 2. TLS 3. secondary malignancy risk 4. Other rapidly dividing cell tox. (alopecia, skin issues including rash/photosensitivity, infertility)

Answer 158

Antimetabolite 10x Pre- and Post administration considerations 1. Monitor cell counts/treatment parameters - PRN GCSF - PRN transfusions - PRN Dose Hold/reduce - Pregnancy testing Antimetabolites = teratogens 2. Baseline assessment, monitor, intervene early 3. Pre-dose Cerebellar assessment for some meds (ie. high dose cytarabine) 4. Anti-emetic pre-meds 30-60min pre-dose 5. TLS (ie. allopurinol, hydration) 6. PFT & monitoring 7. 365day photosensitivity precautions 8. assess IV site, vesicant & irritant precautions 9. Reference black-box warnings for individual agents 10. Fertility preservation

Answer 159

Angiogenesis Inhibitors are MOA = targeted therapy that interferes with the process of creating new blood vessels (angiogenesis) which "starve" the tumors 2x Main ways can work: 1. Some drugs recognize and bind vascular endothelial growth factor (VEGF) receptor which disables the receptor. 2. Other angiogenesis inhibitors work on different parts of the pathway to block activity downstream or on other molecules.

Answer 160

1. Fewer AE (targets one process0 2. Available by PO, allowing continuous administration at lower doses

Answer 161

4x limitations of Angiogenesis inhibitors: 1. Does not kill cancer cells, must be used in combination with other therapies 2* Delayed wound healing (planning around surgeries/procedures) 3* Risks: HTN, internal bleeding, or rare perforation of the intestine 4* Patient adherence PO therapy

Answer 162

Derived from the Madagascar periwinkle plant (Catharanthus rosea) Yes, cell cycle specific (predominantly M phase) MOA: Vinca alkaloids are cytoxic to microtubules and cell cycle arrests in metaphases

Answer 163

1. myelosuppression 2. peripheral neuropathy 3. nausea 4. vomiting

Answer 164

1. Vinblastine 2. Vincristine 3. Vinorelbine

Answer 165

Camptothecans are derived from the Asian "happy tree" (Camptotheca acuminata) Podophyllotoxins are derived from the May apple plant. Yes, cell cycle specific (Late S and G2 phases) MOA: forms a complex with topoisomerase and DNA resulting in the inhibition of the topoisomerase enzyme

Answer 166

1. Diarrhea 2. Neutropenia

Answer 167

4x Plant Alkaloid: Epipodophyllotoxins chemo drugs: 1. Etoposide (VP-16) 2. Teniposide (VM 26) 3. Camptothecan (CPT) 4. Topotecan hydrochloride

Answer 168

Plant Alkaloid: Taxanes Derived from: Pacific yew tree Yes, cell cycle specific (M phase, G1 to S transition phase) MOA: inhibit the microtubules necessary for cellular division

Answer 169

Plant Alkaloid, Taxanes, potential DLT peripheral neuropathy

Answer 170

1. Paclitaxel 2. Docetaxel 3. Cabazitaxel 4. Paclitaxel protein bound

Answer 171

Glucocorticoids 3x MOA: 1. modify transcription and protein synthesis 2. reverse capillary permeability 3. inhibit glucose transport and phosphorylation to induce apoptosis

Answer 172

Used to prevent 4x AEs: 1. nausea 2. vomiting 3. infusion reactions (hypersensitivity reactions) 4. skin reactions (topical) Treats 2x Oncology Emergencies: 1. superior vena cava syndrome 2. spinal cord compression

Answer 173

1. prednisone 2. hydrocortisone 3. methylprednisolone 4. dexamethasone

Answer 174

Hazardous drugs (HDs) exhibit one or more of the following characteristics: 1. Carcinogenicity 2. Teratogenicity 3. Reproductive toxicity 4. Organ toxicity at low doses 5. Genotoxicity 6. Any drug similar in structure or toxicity to drugs classified as hazardous

Answer 175

1. Absorption 2. Injection 3. Ingestion 4. Inhalation

Answer 176

1. gloves 2. gown 3. mask/shield/goggles 4. mask/respirator

Answer 177

1. 2x pairs gloves tested for HD 2. gown: disposable solid front, long sleeves, tight cuffs, back closure 3. Eye/face protection 4. Respirator PRN (specific drugs or spill clean up)

Answer 178

1. Wash hands (soap and water) 2. 1st pair of gloves on 3. Gown on, fasten tie closure at back, gloves INSIDE gown arms/cuffs 3. 2nd pair of gloves on (OVER gown cuffs) 4. Face/eye protection

Answer 179

1. Remove outer gloves, turning inside out 2. Remove gown, turning inside out 3. remove face shield 4. Remove 2nd set of gloves 5. Dispose of ALL contaminated items 6. Remove gloves LAST 7. Wash hands (soap and water)

Answer 180

Chemo: Altretamine (Hexalen®) 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: Ovarian 4. DLTs: neuro. tox, PSN, myelosup., n/v, skin rash, hypersensitivity RXN 5. Special Considerations for this agent: - PO administration - Take after meals and at bedtime - Monitor for progressive neuro tox. - AVOID concurrent MAOI Monoamine oxidase Inhibitor anti-depressants -> can cause severe orthostatic hypotension

Answer 181

Chemo: Bendamustine (Treanda® Bendeka®) 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: HEME CLL and Indolent NHL 4. DLTs: Myelosup. Pyrexia, n/v, skin RXNs, TLS, hepatic tox. vein irritation 5. Special Considerations this agent: - Irritant and Vesicant - Infusion RXN cycles 2+ - Monitor for TLS (high risk patients - Concurrent Allopurinol may increase severe Skin Tox. - Not compatible with polycarbonate or acrylonitrile-butadiene-styrene lines

Answer 182

Chemo: Busulfan (IV: Busul- fex®; oral: Myl- eran®) 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: Heme: CML & transplant prep 4. DLTs: Myelosup. Pulmonary Fibrosis, profound tachycardia, HTN, chest pain, hyperpigmentation, gamete sup., AMS (confusion), seizures, n/v, mucositis, hyperglycemia, blurred vision, risk of hepatic sinusoidal obstruction syn- drome (previously known as veno-occlusive disease) at AUC > 1,500 mcm × min 5. Special Considerations this agent: - IV (central line) & PO - Monitor cell counts, dose hold WBC<15,000 - Seizure PPX - IV admin. asssoc. w/ inflammation and pain during infusion - IV not compatible with polycarbonate line

Answer 183

Chemo: Carboplatin 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: Ovarian 4. DLTs: Thrombocytopenia, Neutropenia (worse in renal impairment), n/v, hypersensitivity RXN, mild alopecia, skin rash 5. Special Considerations this agent: - AUC dosing - Irritant - Hypersensitivity RXN possible with any dose - Renal tox. < Cisplatin (creatinine prior to each dose) - Monitor cell counts, most toxic to platelet precursor, monitor for bleeding

Answer 184

Chemo: Chlorambucil (Leukeran®) 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: Heme: CLL, HL, NHL 4. DLTs: Myleosup., skin RXN, gamete suppression, n/v, hyperuricemia, pulmonary fibrosis, seizure (increased risk in children with nephrotic syndrome), secondary malignancy 5. Special Considerations this agent: - PO, take on empty stomach - Caution in pts. w/ seizure Hx & w/i one month RT/Cytotoxic therapy (PULMONARY fibrosis)

Answer 185

Chemo: Cisplatin 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: Ovarian, Testicular, Bladder 4. DLTs: Severe Nephro. tox., myelosuppression, SEVERE acute/delayed n/v, ototoxicity, hyperuricemia, Hypersensitivity RXN, hypomag + electrolyte disturbances, PSN 5. Special Considerations this agent: - Mannitol + aggressive hydration (pre&post), creatine prior to EACH dose (administer next dose when creatinine = BL) - Delayed n/v up to 6 days post-dose - Baseline audiogram - electrolyte correction PRN

Answer 186

Chemo: Cyclophos- phamide 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: MANY: breast, ovarian, MM, Leukemias, Lymphomas, Neuroblastoma, Retinoblastoma, Mycosis, Fungicides 4. DLTs = Hemorrhagic cystitis, + myelosup., n/v, alopecia, maxillary burning if infused too rapidly, gamete failure, secondary malignancy; HIGH DOSE = acute cardiomyopathy & SIADH 5. Special Considerations this agent: - IV & PO admin - Bladder tox, aggressive hydration + frequent urination + Mesna can help reduce risk for Hemorrhagic cystitis - Prior or concurrent RT can increase tox. - Dose holds ANC <1.5, PLT <50,000

Answer 187

Chemo: Dacarbazine 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: Melanoma (mets/malignant), HL 4. DLTs: Severe neutropenia and thrombo- cytopenia (nadir 2–3weeks(+)) 5. Special Considerations this agent: - Irritant. - Protect from light - Flu-like syndrome possible up to 7 days post-admin; treat symptoms

Answer 188

Chemo: Ifosfamide (Ifex®) 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: Testicular 4. DLTs: Hem- orrhagic cystitis, myelosup- pression; n/v, alopecia, neurotoxicity (somnolence, confusion, hallucinations, depressive psychoses, and encephalopathy), urotoxic- ity, cardiotoxicity, pulmonary toxicity, Methylene blue to treat ifosfamide-induced encephalopathy which may also spontaneously resolve 5. Special Considerations this agent: - Hemorrhagic cystitis can be severe w/ risk reduced by mesna + extensive hydration (min 2L/per day). .

Answer 189

Chemo: Mechlorethamine (nitrogen mustard, Mustargen®, Valchlor®) 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: HL, NHL, CLL, CML, Polycythemia vera, Mycosis fungicides, Bronchogenic carcinoma 4. DLTs: Severe n/v, alopecia, myelosupression, pain or phle- bitis at IV site, chills, fever, testicular or ovarian failure Topical: Dermatitis, pruritus, skin infection, ulceration, hyperpigmentation 5. Special Considerations this agent: - Vesicant and irritant. Administer through the side arm of a free-flowing IV. Flush with 125–150 ml NS following infusion to minimize phlebitis. If extravasation occurs, antidote = sodium thio- sulfate. Use mechlorethamine as soon after preparation as possible (15–30 minutes); it is extremely unstable.

Answer 190

Chemo: Melphalan (Alkeran®, Evomela®) 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: Multiple myeloma Ovarian 4. DLTs: Dose-limiting toxicity: Myelosuppression, Nausea, vomiting, mucositis,, hypersensitivity reactions 5. Special Considerations this agent: - IV & PO (on empty stomach) - Ice chips during high-dose to prevent oral mucositis - Irritant and vesicant - infuse over 15–20 minutes into fast-running IV solution, inject into into IV tubing; do not administer by direct PIV injection. - Alkeran within 1 hour of reconstitution, Evomela stable 4 hours - Dose reduce in renal insufficiency (blood urea nitrogen ≥ 30 mg/dl)

Answer 191

1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: 4. DLTs: 5. Special Considerations this agent:

Answer 192

Chemo: Oxaliplatin (Eloxatin®) 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: Colorectal 4. DLTs: Dose-limiting toxicities: -myelosuppression (worsens over time), PSN, COLD intolerance and paresthesia, dysesthesia, or hypesthesia within 1–48 hours, to 14 days, Anaphylactic reaction, nausea, vomiting, diarrhea, pulmo- nary fibrosis, fatigue, fever, increased transaminases and alkaline phosphatase 5. Special Considerations this agent: - Not compatible with NaCl or other chloride-containing solutions. Flush with D5W - Persistent (> 14 days) - see DLT section above - Irritant and vesicant. - Dose reduce in patients with severe renal impairment (CrCl < 30 ml/min).

Answer 193

1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: 4. DLTs: 5. Special Considerations this agent:

Answer 194

Chemo: Temozolomide (Temodar®) 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: Refractory anaplastic astrocytoma Newly diagnosed glioblastoma multiforme 4. DLTs: Dose-limiting toxicity: Myelosuppression; Nausea, vomiting, headache, fatigue, hepatic toxicity, constipation, rash, alopecia 5. Special Considerations this agent: - IV & PO (on empty stomach) to decrease n/v (ie bedtime) - IV: Infuse 90 min - Do not administer if patients have allergic RXN to dacarbazine - compatible with 0.9% NaCl - PPX: pneumonia pro- phylaxis (trimethoprim sulfamethoxazole) when RT combo for 42-day regimen

Answer 195

Chemo: Thiotepa 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: Bladder, Breast, Ovarian, HL, NHL 4. DLTs: Myelosuppression; Fatigue, weakness, fever, hypersensitivity RXN, gamete suppression, n/v, pain at infusion site, rash, alo- pecia, skin burn, mucositis, hemorrhagic cystitis 5. Special Considerations this agent: - IV, IT, intravesical, intracavitary, PO - Caution in renal or hepatic dysfunction - Dose hold WBCs < 3,000/mm3 or PLT< 150,000/mm3 - used in the transplant setting can cause severe skin irritation. Frequent showering immediately following and during the first 48 hrs help prevent skin tox. - Avoid tapes / skin adherents during treatment to 48h - In line 0.22 micron filter

Answer 196

Chemo: Trabectedin (Yondelis®) 1. Class: Alkylating agent 2. MOA: Break DNA helix strand, thereby interfering with DNA replication 3. Indications: Liposarcoma Leiomyosarcoma 4. DLTs: Dose-limiting toxicities: Myelosuppression (neutropenic sepsis), hepatotoxicity, cardiomyopathy Rhabdomyolysis, capillary leak syndrome, nausea, fatigue, vomiting, constipation, decreased appetite, diarrhea, peripheral edema, dyspnea, headache 5. Special Considerations this agent: - 24h continuous infusion and must be given through a central line with a 0.2 micron filter - vesicant; extravasation= severe tissue injury - Premedicate 20 mg IV dex 30min pre-dose - Dose reduce if hepatic impairment. - metabolized through CYP3A pathway; caution when administering concurrently with CYP3A inducers or inhibitors

Answer 197

Chemo: Azacitidine (Vidaza®) 1. Class: Antimetabolites 2. MOA: DNA hypomethylation and direct cytotoxicity on abnormal hematopoietic cells in BM. Abnormal cells (ie cancer) no longer respond to normal growth control mechanisms 3. Indications: Specific sub- types of MDS 4. DLTs: Myelosuppression, elevated SCr, renal failure, hepatic tox.; TLS, n/v, diar- rhea, fatigue, fever, erythema at injection site, constipation IV only: Petechiae, rigors, weakness, hypokalemia 5. Special Considerations this agent: - IV & SC - SC multiple considerations: roll syringe in hands to resuspend prior to injection -stable 1hr at room temp 8hrs if refrigerated - Admin. completed within 1hr of reconstitution - Contraindicated in patients with hypersensitivity to azacitidine, mannitol, and if advanced malignant hepatic tumors

Answer 198

Chemo: Capecitabine (Xeloda®) 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid). 3. Indications: Colon and Colon mets, Metastatic breast 4. DLTs: Diarrhea, hand-foot syndrome, mucositis; n/v, myelosuppression, increased bilirubin, fatigue 5. Special Considerations this agent: - PO (with food/water) - Pt. education: reporting toxicity critical for evaluating dose reductions - contraindicated in patients with known hypersensitivity to 5-FU -PT/INR closely because capecitabine increases warfarin effect - Dose reduce if CrCl < 50 ml/min. - Uridine triacetate (Vistogard®) is prodrug of uridine (RNA synthesis) = antidote to 5-FU or capecitabine if severe cardiac, CNS, GI, or neutropenia tox. within 96 hours of admin

Answer 199

Chemo: Cladribine 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: Hairy cell leuke- mia 4. DLTs: Myelosuppression, neurotoxicity, Fever, n/v, hyper- sensitivity, TLS, nephrotoxicity (high-dose therapy) 5. Special Considerations this agent: - caution in patients with liver and renal dysfunction.

Answer 200

Chemo: Clofarabine (Clolar®) 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: Relapsed or refractory ALL (age 1–21) 4. DLTs: myelosuppression, infection, hepatic and renal tox, n/v, diarrhea RARE: SIRS/capillary leak syn- drome, cardiotox (tachycardia, pericardial effusion, and left ventricular systolic dysfunction; TLS, headache, pruritus, rash, hand foot syndrome 5. Special Considerations this agent: - Continuous IV fluid + alkalization of urine 5day pre-dose encouraged to reduce TLS and other AEs. - D/C for hypotension 5day pre-dose - PPX steroids to help prevent SIRS/Capillary leak - PPX allopurinol if hyperuricemia TLS expected - Monitor RR & BP, renal and hepatic function - Dose reduce renal impairment (< 60 ml/min)

Answer 201

Chemo: Cytarabine 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: ALL, AML, CML, CNS leukemia 4. DLTs: Myelosuppression n/b, anorexia, fever, mucositis, diarrhea, hepatic dysfunction, rash, pruritus, localized pain and thrombophlebitis High-dose (1–3 g/m2): Cere- bellar toxicity, keratitis (treat with dexamethasone ophthal- mic drops), dermatologic toxicities 5. Special Considerations this agent: - IT, IV, SC - Determine if standard vs. high dose - Toxicities vary depending on rate of high-dose cytarabine administration. - - - -- - Continuous infusion possible pulmonary tox (fluid overload) - Bolus admin possible cerebellar toxicities

Answer 202

Chemo: Cytarabine liposomal (DepoCyt®) 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: Lymphomatous meningitis 4. DLTs: Neurotoxicity, mucositis, chemical arachnoiditis (n/v, headache, fever), seizure, n/v, constipation, weakness 5. Special Considerations this agent: - IT only -NOT for pediatric patients - lie flat for 1hr post LP procedure -PPx dexamethasone 4 mg BID (PO or IV) for 5 days (D1=dosing day) to decrease symptoms of chemical arachnoiditis

Answer 203

Chemo: Decitabine (Dacogen®) 1. Class: Antimetabolites 2. MOA: DNA hypomethylation and direct cytotoxicity on abnormal hematopoietic cells in BM. Abnormal cells (ie cancer) no longer respond to normal growth control mechanisms 3. Indications: MDS 4. DLTs: Myelosuppression, fever, fatigue, n, cough, diar- rhea, hyperglycemia, petechiae, peripheral edema 5. Special Considerations this agent: - Stable 4 hrs if prepared using cold infusion fluids and refrigerated - use within 15 minutes if prepared w/ room-temp fluids

Answer 204

Chemo: Floxuridine 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: GI adenocarcinoma with mets to liver 4. DLTs: Myelosuppression, n/v, diarrhea, stomatitis, mucositis, localized erythema, alopecia, photosensitivity, darkening of the veins, abdominal pain, gastritis, enteritis, hepatotoxicity 5. Special Considerations this agent: -Intra-arterial - NO pediatric pts - Irritant

Answer 205

Chemo: Fludarabine 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: CLL 4. DLTs: Myelosuppression; TLS, n/v, diarrhea, rash, neurotoxicity, pneumonitis, weakness, hemolytic anemia, cough, infection 5. Special Considerations this agent: - IV, PO (with our without food) - IV = 30-minute infusion - Monitor PFTs - PPX Allopurinol and IV hydration new CLL or high tumor burden to prevent TLS -Contraindicated w/ pentostatin because possible severe pulmonary toxicity -Caution with renal impairment

Answer 206

Chemo: 1. Class: Antimetabolites 2. MOA: Drug is a combination of a thymidine-based nucleoside analog and a thymidine phosphorylase inhibitor. Incorporates into DNA, interferes with DNA synthesis 3. Indications: 2nd + line meta- static colorectal 4. DLTs: Anemia, neutropenia, fatigue, nausea, vomiting, diarrhea, abdominal pain, pyrexia, embryo-fetal toxicity 5. Special Considerations this agent: -PO BID within 1 hour after meals (12 hours apart) on days 1–5 and days 8–12 of each 28-day cycle - Dose hold if ANC < 50,000/mm3 or PLT < 50,000/mm3

Answer 207

Chemo: 5-FU (Adrucil®) 1. Class: Antimetabolites 2. MOA: Nucleoside metabolic inhibitor that interferes with the synthesis of DNA and to a lesser extent inhibits the formation of RNA 3. Indications: Colorectal, Breast, Pancreatic, Gastric, Pancreatic 4. DLTs: Mucositis, myelosuppression n/v, anorexia, diarrhea, alopecia, ocular toxicities (e.g., increased lacrimation), photosensitivity), darkening of the veins, dry skin, cardiotoxicity (rare), neurotoxicity, hand-foot 5. Special Considerations this agent: - IV, topical - year-round photosensitivity precautions & sunscreen - Leucovorin concurrently to enhance activity - ice chips in mouth 10–15min pre- and post to reduce oral mucositis- ice chips contraindicated w/capecitabine or oxaliplatin because cold intolerance Uridine triacetate (Vistogard®) is prodrug of uridine (RNA synthesis) = antidote to 5-FU or capecitabine if severe cardiac, CNS, GI, or neutropenia tox. within 96 hours of admin

Answer 208

Chemo: Gemcitabine (Gemzar®) 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: Pancreatic, Breast, Ovarian, NSCLC 4. DLTs: Myelosuppression (especially thrombocytopenia) n/v; flu-like symptoms including fever, headache, arthralgias, and myalgias); rash, peripheral edema, dyspnea, pulmonary toxicity with increased infu- sion time, hepatotoxicity 5. Special Considerations this agent: - Irritant. Infuse over 30min; if > 60min or more than weekly can increase hematologic toxicity - caution in patients with renal impairment - Potential for severe life-threatening tox. when administered within 7 days of RT

Answer 209

Chemo: 6-Mercaptopurine (6-MP; Purinethol®) 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: ALL 4. DLTs: Myelosuppression, hepatotoxicity, mucositis, n/v, anorexia, hyperuricemia, hyperuricosuria, alopecia, rash, hyperpigmentation 5. Special Considerations this agent: - PO (take on empty stomach) - Reduce oral dose by 75% when used concurrently with allopurinol

Answer 210

Chemo: Methotrexate 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: NHL, Leukemia CNS mets, Lung, Breast, Head and neck, Gestational trophoblastic tumor, Osteosarcoma, RA, Psoriasis Gestational choriocarcinoma, Chorioadenoma destruens, Hydatidiform mole 4. DLTs: Hepatotoxicity, renal toxicity Mucositis, n/v, myelosuppression, oral or GI ulceration, pneumonitis, photosensitivity, HIGH DOSE: neurotoxicity 5. Special Considerations this agent: - IM, IT, IV, PO, SC - High doses: 1) adjust for renal dysfunction 2)followed by timely administration of leucovorin + alkaline hydration - Monitor serum levels until ≤ 0.1 mcmol/L - Monitor urine pH and maintain ≥ 7 before and until serum methotrexate levels ≤ 0.05 mcmol/L (depending on clearance, some patients may require additional leucovorin rescue and serum monitoring) -strict mouth care - avoid taking multivitamins with folic acid - Multiple possible drug interactions (ie NSAIDs, alcohol, aspirin, warfarin, aminoglycosides) - Glucarpidase (Voraxaze®) used when delayed clearance from renal impairment. This drug reduces levels by rapidly converting methotrexate to glutamate and 4-deoxy-4-amino-N10-methylpteroic acid

Answer 211

Chemo: Nelarabine (Arranon®) 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: T-cell ALL, T-cell lymphoblastic lymphoma 4. DLTs: Neurotoxicity, myelosuppression, headache, n/v, diarrhea, constipation, cough, fatigue, peripheral neuropathy, dyspnea, neurologic toxicities (somnolence, seizures, ataxia) 5. Special Considerations this agent: -Administer undiluted infusion 2hr adults /1hr pediatrics - Administer with PPX for hyperuricemia and TLS - D/C for ≥ grade 2 neurologic events (severe somnolence, seizure, and PSN - Caution with renal or hepatic dysfunction

Answer 212

Chemo: Pemetrexed (Alimta®) 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: Mesothelioma Nonsquamous NSCLC 4. DLTs: Myelosuppression, fatigue, n/v, anorexia, chest pain, and dyspnea. Vitamin supplementation reduces these AE. Can cause Renal and liver toxicity 5. Special Considerations this agent: - Infuse 10min - reduce treatment-related hematologic and GI toxicities by administering folic acid 400–1,000 mcg PO daily starting 1 week prior to C1D1 and daily for 3 weeks after final cycle. - Vitamin B12 injection 1,000 mcg 1 week prior to C1D1 and repeat every 9 for duration - Dexamethasone 4 mg BID for 3 days starting C1D(-1) to decreas incidence of rash - HOLD if ANC < 1,500/mm3, platelets < 100,000/mm3, or CrCl < 45 ml/min - Monitor renal and hepatic function. - Concurrent NSAIDs may increase the risk of renal damage.

Answer 213

Chemo: Pentostatin (Nipent™) 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: Hairy cell leukemia 4. DLTs: Myelosuppression, acute pulmonary edema, hypotension, fever, chills, n/v, rash, renal toxicity, confusion, hepatic enzyme elevation, infection risk, cough, cardiac 5. Special Considerations this agent: -Administer with 500–1,000ml 5% dextrose in ½NS pre-dose + additional 500ml post-dose - Do not administer with fludarabine, carmustine, etoposide, or high-dose cyclophosphamide

Answer 214

Chemo: Pralatrexate (Folotyn®) 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: Peripheral T-cell lymphoma 4. DLTs: Myelosuppression, mucositis, dermatologic RXNS, TLS, hepatotoxicity, edema, fatigue, nausea 5. Special Considerations this agent: - IV push over 3–5min - Consider dose reduction with impaired renal function (EGFR < 30 ml/min/1.73 m2). -MUST supplement: folic acid (1–1.25 mg PO daily) + vitamin B12 (1mg IM Q8-10wks) - Monitor liver and renal function

Answer 215

Chemo: Thioguanine (6-TG; Tabloid®) 1. Class: Antimetabolites 2. MOA: interfere with one or more enzymes or RXNs necessary for DNA syn- thesis. Acting as a substitute to metabolites (e.g., antifolates interfere with the use of folic acid) 3. Indications: ANLL 4. DLTs: Myelosuppression, hyperuricemia, nausea, hepatotoxicity, diarrhea 5. Special Considerations this agent: -PO -Monitor hepatic function

Answer 216

Chemo: 1. Class: Anti-Tumor Antibiotics 2. MOA: Bind with DNA thereby inhibiting DNA and RNA synthesis 3. Indications: Malignant pleural effusion, Testicular, HL, NHL [Squamous cell: head & neck, cervix, vulva, penis] 4. DLTs: Hypersensitivity or anaphylactic (rare), pulmonary toxicity, Hyperpigmentation, alopecia, photosensitivity, renal toxicity, hepatotoxicity, fever, chills, erythema, rash, mucositis 5. Special Considerations this agent: - Ordered in units - MAX lifetime dose >400units, must track lifetime amounts - Pulmonary fibrosis (dose-related ) - PFTs baseline, then Q1-2Months during therapy; consider D/C if PFT shows 30%–35% decrease f/ baseline - Not compatible with D5W - Lymphoma higher incidence of anaphylaxis (usually after first or second dose). Institution may test doses of 1–2 units IV, IM, or SC before first regular dose - PRIOR bleomycin increases risk for pulmonary toxicity to oxygen during surgery. EDUCATION: lifelong necessity of disclosing prior bleomycin for future anesthesia/surgery to prevent fatal pulmonary failure - Acetaminophen and an antihistamine may decrease fever and chills in first 24 hours after administration. - Consider dose reductions in patients with CrCl <50 ml/min.

Answer 217

Chemo: Dactinomycin (Actinomycin-D; Cosmegen®) 1. Class: Anti-Tumor Antibiotics 2. MOA: Bind with DNA thereby inhibiting DNA and RNA synthesis 3. Indications: Wilms tumor Childhood rhabdomyosarcoma, Testicular, Ewing sarcoma, Gestational trophoblastic disease 4. DLTs: Myelosuppression Nausea, vomiting, alopecia, mucositis, diarrhea, ovarian or sperm suppression, radiation recall (hyperpigmentation of previously irradiated areas), sinusoidal obstruction syndrome, renal & hepatic tox. 5. Special Considerations this agent: -vesicant; extravasation can result in severe tissue injury - Administer through the side port of a free-flowing IV - Highly toxic and corrosive to soft tissues; avoid inhalation and eye contact - Ordered in mcg (micrograms), check dose carefully - Contraindicated in concurrent or recent chicken pox / herpes zoster (shingles) due to risk of severe disease - Avoid within 2 months of RT for right-sided Wilms tumor / RT will exagerate toxicities

Answer 218

Chemo: Mitomycin C (Mutamycin®) 1. Class: Anti-Tumor Antibiotics 2. MOA: Bind with DNA thereby inhibiting DNA and RNA synthesis 3. Indications: Pancreatic, Stomach, Bladder 4. DLTs: Myelosuppression, n/v, anorexia, fever, renal toxicity, pulmonary toxicity, fatigue 5. Special Considerations this agent: -Intravesical and IV - Drug is purple/blue in color -Vesicant; extravasation can result in severe tissue injury - Administer through the side port of a free-flowing IV - Nadir within 8 weeks after treatment begins (average 4wks) - Acute shortness of breath and bronchospasm can occur very suddenly when given with a vinca alkaloid - Withhold doses for PLT < 100,000/mm3 or WBCs < 4,000/mm3 HOLD if SCr > 1.7 mg/dl - Hemolytic uremic syndrome possible with a single dose ≥ 60 mg - Contraindicated if coagulation disorders

Answer 219

Chemo: Mitoxantrone 1. Class: Anti-Tumor Antibiotics 2. MOA: Bind with DNA thereby inhibiting DNA and RNA synthesis 3. Indications: Prostate, ANLL (acute nonlymphocytic leukemia, also called AML, acute myelogenous leukemia or acute myeloid leukemia), Multiple sclerosis 4. DLTs: Myelosuppression, cardiotoxicity (risk increased if treated with other cardiotoxic drugs), n/v, mucositis, alopecia, fever, weakness, hyperuricemia, amenorrhea, blue-green colored urine, bluish skin or sclera 5. Special Considerations this agent: -Drug is blue in color - Fatal if given intrathecally - Irritant with vesicant potential - HOLD for ANC < 1,500/mm3 - Cardiotoxicity risk < Doxorubicin; prior anthracycline, chest RT, or cardiac disease increases risk - Baseline cardiac assessment: MUGA/ECHO, EF eval., ECG - Contraindicated if hepatic impairment

Answer 220

Chemo: Daunorubicin 1. Class: Anti-Tumor Antibiotics: ANTHRACYCLINES 2. MOA: Bind with DNA thereby inhibiting DNA and RNA synthesis 3. Indications: ALL in children, AML 4. DLTs: Myelosuppression, cardiotoxicity, n/v, alopecia, hyperuricemia, radiation recall, red-colored urine 5. Special Considerations this agent: - Drug is red in color. - Vesicant; extravasation can result in severe tissue injury - Administer through the side arm of a free-flowing IV - Dose reduce if hepatic or renal impairment - Baseline cardiac EF needed - Total lifetime dose in adults is - 550 mg/m2 without cardiovascular risk factors and 400 mg/m2 in adults receiving chest RT

Answer 221

Chemo: Daunorubicin and cytarabine liposome (Vyxeos™) 1. Class: Anti-Tumor Antibiotics: ANTHRACYCLINES 2. MOA: Bind with DNA thereby inhibiting DNA and RNA synthesis 3. Indications: AML 4. DLTs: Myelosuppression, cardiotoxicity, hypersensitivity reaction, Hemorrhage events, copper overload 5. Special Considerations this agent: - Administer over 90 minutes through a central line -Vesicant; extravasation can result in severe tissue injury - LIFETIME dose in adults is 550mg/m2 in those without cardiovascular risk factors and 400mg/m2 in adults receiving chest RT - Vyxeos contains copper gluconate; copper toxicity is possible in patients with Wilson disease (inability to process copper)

Answer 222

Chemo: Doxorubicin (Adriamycin®) 1. Class: Anti-Tumor Antibiotics: ANTHRACYCLINES 2. MOA: Bind with DNA thereby inhibiting DNA and RNA synthesis 3. Indications: MANY: Breast, ALL, AML, HL, NHL, Wilms tumor, Neuroblastoma, Sarcoma, Ovarian, Bladder, Thyroid, Stomach, Bronchogenic carcinoma 4. DLTs: Myelosuppression, cardiotoxicity, hepatotoxicity, n/v, alopecia, mucositis,, radiation recall, hyperuricemia, photosensitivity, red-colored urine 5. Special Considerations this agent: - Drug is red in color - Vesicant; extravasation can result in severe tissue injury - Administer through the side arm of a free-flowing IV or via continuous infusion through a central catheter only - Dexrazoxane if extravasation - Dose reduce if elevated serum total bilirubin - Obtain baseline cardiac EF - LIFETIME cumulative dose max 550mg/m2 (450 mg/m2 if prior chest RT or concomitant cyclophosphamide) - Consider dexrazoxane (cardio protective) for pediatrics and for patients who have received a cumulative dose of 300mg/m2 and are continuing treatment

Answer 223

Chemo: Doxorubicin liposomal (Doxil®) 1. Class: Anti-Tumor Antibiotics: ANTHRACYCLINES 2. MOA: Bind with DNA thereby inhibiting DNA and RNA synthesis 3. Indications: Ovarian, AIDS-related Kaposi sarcoma, Multiple myeloma 4. DLTs: Myelosuppression, cardiotoxicity, infusion-related reactions, n/v, alopecia, mucositis, arrhythmia, amenorrhea, radiation recall, hand-foot syndrome, hypersensitivity 5. Special Considerations this agent: - Drug is red in color - Irritant with vesicant properties; caution to avoid extravasation - The same warnings as conventional doxorubicin regarding cardiovascular complications [- Baseline cardiac EF - LIFETIME cumulative dose max 550mg/m2 (450mg/m2 if prior chest RT or concomitant cyclophosphamide) - Consider dexrazoxane (cardio protective) for pediatrics and for patients who have received a cumulative dose of 300mg/m2 and are continuing treatment] - Do not substitute for doxorubicin - Do not use an in-line filter

Answer 224

Chemo: Epirubicin (Ellence®) 1. Class: Anti-Tumor Antibiotics: ANTHRACYCLINES 2. MOA: Bind with DNA thereby inhibiting DNA and RNA synthesis 3. Indications: Breast 4. DLTs: Myelosuppression, cardiotoxicity, n/v, mucositis, diarrhea, alopecia, amenorrhea, infection, hyperuricemia, radiation recall, flushing, red-colored urine 5. Special Considerations this agent: - Drug is red in color - esicant; extravasation can result in severe tissue injury - Infuse into the side port of a free-flowing IV - HOLD if ANC is < 1,500/mm3 . Consider dose reduction if hepatic and severe renal impairment (SCr > 5 mg/dl) - LIFETIME cumulative dosing <900mg/m2 - Baseline cardiac EF

Answer 225

Chemo: Idarubicin (Idamycin®) 1. Class: Anti-Tumor Antibiotics: ANTHRACYCLINES 2. MOA: Bind with DNA thereby inhibiting DNA and RNA synthesis 3. Indications: AML 4. DLTs: Myelosuppression, cardiomyopathy, Hyperuricemia, n/v, alopecia, vein itching, radiation recall, rash, mucositis, diarrhea, severe enterocolitis with perforation, red-colored urine 5. Special Considerations this agent: - Drug is red-orange in color - Vesicant; extravasation can result in severe tissue injury - Inject slowly over 10–15min into free-flowing side-arm infusion - Cardiotoxicity < Daunorubicin - LIFETIME cumulative doses >150 mg/m2 associated with decreased EF - Local reactions (hives at injection site) may occur - Consider dose reduction if renal or hepatic impairment

Answer 226

Chemo: 1. Class: Anti-Tumor Antibiotics: ANTHRACYCLINES 2. MOA: Bind with DNA thereby inhibiting DNA and RNA synthesis 3. Indications: Intravesical therapy of bacillus Calmette Guérin–refractory in situ bladder cancer 4. DLTs: Dysuria, bladder spasm and irritation, urinary incontinence, leukopenia, hyperglycemia; drug may turn the urine red 5. Special Considerations this agent: - Intravesical route ONLY - Not for use in pediatrics - Vesicant; extravasation can result in severe tissue injury if perforation of bladder occurs - non-PVC, non-DEHP containing tubing

Answer 227

Chemo: 1. Class: 2. MOA: 3. Indications: 4. DLTs: 5. Special Considerations this agent:

Answer 228

Surgeries Used for Prophylactic purposes: The excision of premalignant lesions

Answer 229

Surgeries Used for Various Purposes Diagnostic purposes: Biopsies for definitive histological diagnosis

Answer 230

Surgeries Used for Various Purposes Staging purposes: The extent of the carcinoma must actually be observed inside the patient

Answer 231

Surgeries Used for Various Purposes Treatment purposes: The simple removal of the entire carcinomatous tumor for curative reasons

Answer 232

Surgeries Used for Various Purposes Palliation purposes: Not for altering the outcome of the disease, but to maintain the best quality of life for the patient and to allow death with dignity and maximum comfort

Answer 233

Incisional biopsy: Small sample of suspected tissue is removed for testing

Answer 234

Excisional biopsy: The entire suspected tissue is removed.

Answer 235

Surgical Excision: Can involve removal of just the involved tissue with a margin of healthy tissue. It may be more extensive and include removal of the affected tissue and surrounding lymph nodes and other tissues.

Answer 236

Electrosurgery : Iinvolves applying an electric stimulus to the area affected by the malignancy and destroying the cancer cells.

Answer 237

Cryosurgery: Involves applying liquid nitrogen to the cancer tissues. This causes destruction of the malignant cells through a freezing process.

Answer 238

Laser treatments: Can be applied directly to the malignant tissue to cause destruction of the malignant cells. This is performed using a specialized scalpel that emits laser stimulus.

Answer 239

Stereotactic surgery (SRS): Is used with brain tumors (or SBRT for tumors next to important body structures outside of the brain) to provide an exact location of the tumor in a three-dimensional appearance. Special equipment is used for positioning the patient to utilize this type of surgery.

Answer 240

1. Pneumonectomy: complete removal of a lung 2. Lobectomy: to remove one lobe of a lung 3. Resection: removal of various-sized small portions of the lung

Answer 241

End stoma: Created by cutting the bowel and diverting it through the abdominal wall. The rest of the bowel that is left distally may be removed from the body or sewn off.

Answer 242

Loop stomas: Bring a section (loop) of the colon out through an incision in the abdomen. Usually temporary (ie a bowel obstruction or symptom treatment at the end life). Another surgical procedure can be performed in the future to correct the colostomy so that the bowel will function normally.

Answer 243

Double-barrel stomas: Two stomas present in the abdominal wall. The stoma that is formed from the proximal portion of bowel will excrete stool while the distal portion only secretes mucus. The consistency of the stool from the proximal end will vary depending on its location; * More distal in bowel = stool that is more formed. * More proximal in bowel = stool will be more watery.

Answer 244

Urinary Diversion Surgery Two main types: 1. Incontinent urinary diversions 2. Continent urinary diversions

Answer 245

Urinary Diversion Surgery Incontinent urinary diversions: Patient cannot control voiding, urine generally drains into the bag as it is made. Created from a portion of the small intestine. A stoma is created with the small intestine, and the ureters are attached to the section of intestine to drain urine from the body. Risks: Urinary reflux can occur and the patient is at a high risk for developing: 1) infections in the urinary tract 2) kidney infections

Answer 246

Urinary Diversion Surgery Continent urinary diversions Diversions which allow the patient to have control of when they will void. 1. One option = diversion by connecting the ureters from the kidneys to a section of the large intestine. Urine flows through the intestine and colon to be exited through the anus. A valve is created which allows the patient to maintain continence. 2. Another option = Orthotopic neobladders. Neobladders are made from a portion of the stomach or intestine, connected to ureters (to collect urine) and connected to the urethra (to enable urine to flow normally out of the body). This procedure is usually performed when there is bowel disease or damage from disease.

Answer 247

Surgical Management of Lymphedema indicated when: 1. Medical procedures have failed. 2. Swelling is extreme enough to prevent use of limb. 3. Significant skin changes. 4. Persistent Infections

Answer 248

Surgical Management of Lymphedema - Reestablishment of proper drainage: 1. Lymphaticovenous anastomosis (LVA): Jjoins lymphatic vessel to a vein. 2. Lymphatic-lymphatic anastomosis (L-L), Creates new lymphatic connections 3. lymph nodal-venous shunt is also occasionally done.

Answer 249

Surgical Management of Lymphedema: Excisional procedures strive to remove skin layers and subcutaneous tissue where most lymphedema is localized

Answer 250

1. Allogenic: Infusion of bone marrow from one individual to another. Also use of peripheral blood stem cells or cord blood from another. 2. Autologous: Infusion of a patient’s own bone marrow previously removed and stored. 3. Syngeneic: Infusion from one identical twin to another.

Answer 251

Sinusoidal Obstruction Syndrome (previously known as veno-occlusive disease) * Life-threatening complication that occurs in 15-20% of hematopoietic stem cell transplant patients * It occurs when fibrous material accumulates, resulting in obstruction of venules in the liver, which in turn causes portal hypertension and destruction of the liver cells.

Answer 252

Clinical mainifestations of Hepatic Sinusoidal Obstruction Syndrome: 1. elevated serum bilirubin 2. weight gain 3. ascites 4. right upper quadrant pain 5. hepatomegaly 6. splenomegaly 7. jaundice

Answer 253

SOS Timeframe: Should be considered in any patient that has these symptoms after stem cell transplant, especially in the first three weeks SOS Treatment: 1. Maintain intravascular volume 2. Maintain renal perfusion 3. Minimize fluid accumulation SOS Prevention includes minimizing risk factors 1. decrease hepatotoxic medications 2. iron chelation (for patients with liver disease related to increased iron levels) 3. ursodeoxycholic acid PPx for allogenic transplants, beginning the day before stem cell transplant and continuing three months after the procedure.

Answer 254

Graft-versus-host disease occurs when the patient develops a rejection reaction to bone marrow received from a donor that may not be a perfect genetic match. Can affect up to 50% of bone marrow recipients. 1. High doses of steroids 2. PPx: Other medications that decrease immune reactions for prevention

Answer 255

Interstitial pneumonitis is inflammation in lung tissue. Higher risk: 1. Prior RT to the chest 2. Prior bleomycin 3. Carriers of CMV cytomegalovirus. Pneumonitis infections can be caused by viruses, bacteria, or fungi. Antimicrobial medications are used to treat this infection.

Answer 256

Target Theory of Radiation RT damage results from ionization causing: 1. Direct hits and 2. Indirect hits #1) Direct hits Lead to impaired cell function and cell death: 1. Change or loss of a DNA base 2. Hydrogen bond breaks between DNA chains 3. Breaks in one or both DNA chains. 4. Cross-linking after breakage #2) Indirect hits Ionization of water, the medium surrounding the molecular structures within the cell, which causes a change in the cellular environment.

Answer 257

Radiation physics is the study of the effects of radiation exposure on cells.

Answer 258

Radiobiology is the study of the living cell after radiation treatment has been applied to the cell. Focus: 1. Specific actions that occur to promote cell destruction 2. Length of time necessary for cell death 3. Dose necessary to destroy cells (minimum dose = most desirable) 4. Effects of RT on normal tissues

Answer 259

1. Cure 2. Control 3. Adjuvant 4. Palliation

Answer 260

1. Roentgen (R) = unit of radiation exposure, does NOT reflect dose; established in 1928 in honor of Wilhelm Conrad Roentgen (discoverer of x-rays in 1895) 2. rad = Radiation absorbed dose (rad) = 100 ergs absorbed per gram of tissue (1 erg = a unit of energy equal to 10−7 joules (100 nJ)) 3. Gray (Gy) or sievert (Sv) units = 100 rads = 1 joule absorbed per kg of tissue.