Weeks 5 & 6: Oncology Overview Flashcards
definition of cancer?
group of disease characterized by uncontrolled growth & spread of abnormal cells
definition of proto-oncogenes
genetic portion of DNA that regulates normal cell growth & repair
definition of tumor suppressor genes
genetic portion of DNA that stops, inhibits or suppresses cell division.
may also inhibit formation of cancers
mutation and loss of this function may allow cells to proliferate beyond normal body needs
most common mutated tumor suppressor gene?
p53
oncogenes?
altered forms of normal proto-oncogenes
interfere with normal cell growth, differentiation, apoptosis
risk factor for cancer
tobacco
alcohol
diet high in fat
UV radiation (dependent on latitude, altitude, humidity & personal behaviors)
ionizing radiation (miners & Hiroshima)
chemicals & other substances - asbestos
close relatives with certain types of cancer genetic predisposition
hormone replacement therapy
age (length of time exposed to cancer inducing agents & natural decline in immune system)
virus: HPV, Hep B
modifiable risk factors for cancer
tobacco alcohol overweight/obesity physical inactivity low fruit/vegetable consumption unsafe sex urban air pollution indoor smoke from household fuels contaminated injections in health care setting
signs & symptoms of cancer
local symptoms: unusual lumps/swelling; hemorrhage; pain and/or ulcerations; compression of surrounding tissues or obstruction (jaundice)
systemic symptoms: weight loss; poor appetite; cachexia; excessive sweating (night sweats); paraneoplastic phenomena
7 warning signals for cancer
- change in bowel/bladder habits
- unusual bleeding/discharge
- sore that doesn’t heal
- obvious change in a wart/mole
- thickening/lump in breast or elsewhere
- nagging cough or hoarseness
- indigestion/difficulty swallowing
definition of angiogenesis
the proliferation of a network of blood vessels that penetrates into cancerous growths, supplying nutrients, oxygen and removing waste products. this process is necessary for tumor growth & spread
carcinogenesis?
multi-step process by which a normal cell is transformed into a malignancy
INITIATION: a carcinogen causes a genetic change or damage to the DNA in a normal cell
PROMOTION: an initiated cell is exposed to an agent that enhances its growth into a larger mass
PROGRESSION: metastatic spread via circulatory and lymphatic systems.
metastasis?
spread of cancer cells from a primary tumor to a distant site in the body
how can cancer cells spread?
direct invasion
seeding throughout a body cavity
dissemination via lymphatic system
dissemination via circulatory system
incisional biopsy?
aspiration, fine needle, core sentinel lymph node
what is a sentinel lymph node?
where the injected tracer goes first after injection
excision biopsy?
removal of tissue
cytology biopsy?
exam of fluid containing cells
prostate cancer tumor marker
PSA
ovarian cancer tumor marker
CA 125
colorectal cancer tumor marker
CEA
primary liver/germ cell tumor marker
alpha fetoprotein
choriocarcinoma/pancreas cancer tumor marker
HCG
pancreas/stomach cancer tumor marker
CA 19-9
most cancers tumor marker
LDH
small cell lung cancer tumor marker
neuron specific enolase
what is TNM staging?
most common way to stage cancer
T-tumor
N-nodes
M-metastasis
T in TNM staging
Tx: primary tumor cannot be evaluated
To: no evidence of primary tumor
Tis: carcinoma in situ (early cancer that has not spread to the neighboring tissue)
T1, T2, T3, T4: size and/or extent of the primary tumor
N in TNM staging
regional lymph node
Nx: regional lymph nodes cannot be evaluated
N0: no regional lymph node involvement (no cancer found in the lymph nodes)
N1, N2, N3: involvement of regional lymph nodes (number and/or extent of spread)
M in TNM staging
distant metastasis
Mx: distant metastasis cannot be evaluated
M0: no distant metastasis (cancer has not spread to other parts of the body)
M1: distant metastasis (cancer has spread distant parts of the body)
stage 0 definition
carcinoma in situ
early cancer that is present only in the layer of cells in which it began
stage I, II, III definition
higher numbers indicate more extensive disease: greater tumor size and/or spread of the cancer to nearby lymph nodes and/or organs adjacent to the primary tumor
stage IV definition
the cancer has spread to another organ
primary treatment?
major modality used to treat a cancer
adjuvant therapy
therapy given after the primary treatment to control potential or known sites of metastasis
me-adjuvant treatment
therapy given before the primary treatment to control potential or known sits of metastasis
goal of therapy: cure
eradication of tumor cels
goal of therapy: control
containment of the growth of cancer cells without complete eradication
goal of therapy: palliation
comfort and relief of symptoms when cure is no longer possible
goal of therapy: reconstruction
to return an individual to his/her optimum functional status
types of cancer treatment modalities
surgery radiotherapy chemotherapy hormone therapy immunotherapy biotherapy molecular targeted therapy gene therapy nanobiotherapy
eco performance status?
eastern cooperative oncology group
0: fully active, able to carry on all pre-disease performance without restriction
1: restricted in physically strenuous activity by ambulatory and able to carry out work of a light or sedentary nature (light house work, office work)
2: ambulatory and capable of all self care but unable to carry out any work activities. up and about more than 50% of waking hours
3. capable of only limited self care, confined to bed or chair more than 50% of waking hours
4. completely disabled. cannot carry on any self care. totally confined to bed or chair
5. dead
karnofsky performance status score
100: normal: no complaints, no evidence of disease
90: able to carry on normal activity; minor symptoms
80: normal activity with effort; some symptoms
70: cares for self; unable to carry on normal activities
60: requires occasional assistance; cares for most needs
50: requires considerable assistance and frequent care
40: disabled: requires special care and assistance
30: severely disabled: hospitalized but death not imminent
20: very sick: active supportive care needed
10: moribund: fatal processes are progressing rapidly
0: dead
lung cancer facts
3rd most common cancer
most common cause of death
is there effective screening program?
no - 3D CT scan is now recommended for high risk persons
are people with lung cancer symptomatic at diagnosis?
not generally, on 6% are
how many lung cancers are related to smoking?
more than 85% of all lung cancers are related to smoking
major histologies of lung cancer?
small cell lung cancer (25% of all lung cancers) - a norendocrine tumor - harder treat
non small cell lung cancer -
risk factors for colorectal cancer
- men & women > 50 years old
- personal/family h/o colorectal cancer or benign colorectal polyps
- personal family h/o inflammatory bowel disease/ulcerative colitis or Crohn’s disease
- family h/o inherited colorectal cancer
- tobacco, obesity, sedentary lifestyle
common symptoms of colorectal cancer
- change in bowel habits
- diarrhea, constipation or feeling that bowel does not empty completely) tensenums
- blood (bright red, very dark) in the stool
- stools that are narrower than usual
- general abdominal discomfort (frequent gas pains, bloating, fullness and/or cramps)
- unexplained weight loss
- abdominal / pelvic pain
ACS screening guidelines for average risk patients
-fecal occult blood test or fecal immunochemical test every year
-flexible sigmoidoscopy every 5 years
fecal occult blood test or fecal immnochemical test every year plus flexible sigmoidoscopy every 5 years
-double contrast barium enema every 5 years
-colonoscopy every 10 years
recommendations are for persons 50+ y/o with average risk
early detection of colorectal cancer for people at average risk
- regular screening at age 50
- fecal occult blood test annually
- flexible sigmoidoscopy every 5 years, alone or in combination with FOBT
- barium enema or colonoscopy every 10 years when the last test was normal
people at greater risk need to begin colorectal cancer screening at an earlier age
what are stool based screening tests for colorectal cancer
fecal occult blood test
fecal immunochemical test
what are direct visualization tests for screening for colorectal cancer
colonoscopy - every 10 years flexible sigmoidoscopy - 5 years ct colonography (virtual colonoscopy) - 5 years
risk factors for breast cancer
- older age
- family age
- increased breast density
- long menstrual history
- obesity after menopause
- recent use of oral contraceptives or post menopausal estrogens/progestin
- having no children or having first child late in life
- consume alcoholic beverages
- biopsy confirmed atypical hyperplasia
clinical manifestations of breast cancer
- breast lump or thickening
- swelling
- distortion
- tenderness
- skin irritation
- dimpling
- nipple pain
- scaliness
- ulceration
- retraction
ways to decrease risk of breast cancer
- physical activity
- maintain healthy body weight
- certain medications (tamoxifen)
- screening high risk populations for BRCA/BRCA2 to assess for mutations associated w breast and ovarian cancer
risk factors for prostate cancer
- cause is unknown
- associated w/ increased testosterone level
- family history
- high fat diet
- increased age
- most common in African American males
- incidence continues to rise
clinical manifestations of prostate cancer
- usually asymptomatic
- often discovered by DRE or PSA
- frequent urination as an early symptom
- difficulty starting urinary stream or holding back urine
- weak flow of urine
- painful urination
- difficulty having an erection/painful erection
- blood in urine
- frequent pain/stiffness in lower back/hips/upper thighs
types of lymphoma
Hodgkin lymphoma
non-Hodgkin lymphoma
hematologic malignancies
- lymphoma
- multiple myeloma
- leukemia
types of leukemia
acute lymphocytic leukemia (ALL) chronic lymphocytic leukemia (CLL) acute myeloid leukemia (AML) chronic myeloid leukemia (CML) other leukemias
definition of hodgkins lymphoma
-malignant disease of the lymphatic system
characterization of hodgkins lymphoma
painless, enlargement of lymph nodes, the spleen, other lymphatic tissue
other symptoms: fever, weight loss, fatigue, night sweats
types of non-hodgkin lymphoma
B cell lymphoma Burkitt's lymphoma diffuse cell lymphoma follicular lymphoma immunoblastic large cell lymphoma lymphoblastic lymphoma mantle cell lymphoma mycosis fungoides post transplantation lymphoproliferative disordder small non-cleaved cell lymphoma t-cell lymphoma
staging for non-hodgkin lymphoma
Stage 1: limited to one lymph node group (neck, axilla, groin, etc) above or below the diaphragm, or in an organ or site other than the lymph nodes (extra nodal) but has not spread to the other organs or lymph nodes
Stage 22: limited to 2 lymph node groups on the same side of the diaphragm, or limited to one extra nodal organ and has spread to one or more lymph node groups on the same side of the diaphragm
Stage 3: two lymph node groups, with/without partial involvement of an extra nodal organ or site above and below the diaphragm
Stage 4: extensive involvement of one organ or site with/without disease in distant lymph nodes
grades of lymphoma
low grade or indolent: slow growing lymphomas that can go for many years without treatment
intermediate grade or aggressive: faster growing lymphomas
high grade or highly aggressive: very fast growing lymphomas
definition of leukemia
malignant disease of the bone marrow and blooed
how is leukemia characterized
uncontrolled accumulation of blood cells
most common types of leukemias in adults
AML, CLL
how do you diagnose leukemia
heme 8 w/ differential
bone marrow aspiration/biopsy
cytogenetics/chromosomal analysis
-flow cytometry measures and identifies DNA characters and cell surface markers
treatment modalities hematologic malignancies
surgery (remove spleen) chemotherapy radiation therapy biotherapy bone marrow transplant
how do you assess response to treatment
complete response: complete disappearance of signs and symptoms of cancer lasting at least 1 month
partial response: a >50% reduction lasting at least 1 month without developing any new lesions
progression: > 25% increase
stable disease: non of the above
oncologic emergencies:
spinal cord compression
definition of spinal cord compression
pressure on the spinal cord by tumor or collapsed vertebrae
etiology of spinal cord compression
malignant neoplasm compresses spinal cord
most common metastatic tumors are lung/breast/prostate
less frequently: lymphoma, myeloma, renal cell cancer, previous radiation to spine
pathophysiology of spinal cord compression
mechanisms of malignant invasion: direct tumor invasion, lymph node growth into epidural space, hematogenous seeding of tumor cells along brain and spinal cord
mechanisms of compression causing neurologic deficits: direct tumor encroachment of spinal cord, interruption of vascular supply, compression from collapsed vertebrae
clinical manifestations of spinal cord compression
pain->motor weakness ->sensory loss->autonomic nervous system dysfunction
pain, present on movement->spinal instability
pain in 90% of patients
localized: over area of tumor, increased when supine
radicular: nerve root compression, radiates along dermatome of the affected nerve roots
- increase when lying down, more common in lumosacral lesions
what does thoracic area spinal cord compression feel like?
tight band across chest
physical examination of spinal cord compression
motor weakness 60-86% of patients: stiffness, heaviness of extremity; ataxic gait (especially w/ back pain), loss of coordination
sensory weakness: numbness, tingling, paresthesias, coldness
autonomic nervous system dysfunction: bowel-lack of urge to defecate; bladder-retention, incontinenece hesitancy; sexual-impotence
diagnostic studies for spinal cord compression
MRI-procedure of choice, distinguishes extra vs. intramural and extra vs. intramedullary lesions, no contrast required
pyelography - replaced by MRI
CT of spine/plain spine x-rays
lumbar puncture: CSF sampling can detect meningeal carcinomatosis, but not specifically spinal cord compression
management of spinal cord compression
goals: pain control, avoid complications-local disease progression; preservation/improvement of neurologic function
pain management: narcotic analgesics
corticosteroids: initial treatment
surgery/radical + RT; vertebropasty & kyphoplasty + RT
stereotactic radiotherapy over external beam radiotherapy
principles of treatment for spinal cord compression
pain management
bed rest
anticoagulation
prevention of constipation
definition of superior vena cava syndrmoe
mechanical obstruction occludes superior vena cava
could be tumor, lymph node, thrmobosis
compression or obstruction of superior vena cava causes
blocked venous drainage
edema of face, arm, trachea
pleural effusions
severe superior vena cava causes
cerebral edema and impaired cardiac filling
etiology of superior vena cava syndrome
- males 50-70 y/o
- malignant disease most common cause-tumors of mediastinum; advanced lung cancer (75% of cases); breast cancer with metastases to mediastinum
iatrogenic causes: venous thrombosis in ventral venous catheters; fibrosis d/t radiation therapy
tumors that are rapidly proliferating and have high growth rate: lymphoma, acute leukemia, small cell lung cancer
large tumor burden: non small cell lung cancer, breast cancer
history of renal disease: renal insufficiency, acute renal failure, increased creatinine, oliguria, anuria
pathophysiology of superior vena cava syndrome
located in right anterior superior medistinum
collects venous drainage from head, neck, upper extremities and upper thorax,
transports blood to right atrium
superior vena cava is vulnerable to compression: it’s a thin walled vessel in a tight compartment
development depends on: growth rate of tumor, extent and location of blockage, ability to develop collateral circulation - bypass the obstruction, redirects blood flow from the upper thoracic venous system and the obstructed superior vena cava to the inferior vena cava to the right atrium
what causes impaired venous drainage of the superior vena cava
congestion of the veins draining into the superior vena cava
- head, neck, upper extremities and upper thorax
- venous hypertension
- veous stasis
- decreased cardiac output
what does untreated superior vena cava syndrome lead to?
stupor, coma, death
clinical manifestations of superior vena cava syndrome
depends on the onset
Gradual onset: subtle symptoms due to venous engorgement
Rapid onset: life threatening presentation, absence of collateral circulation
early symptoms of superior vena cava syndrome
- swelling of face, arms, fingers, neck
- dyspnea (most common)
- cough
- feeling of fullness in head
- difficulty buttoning shirt collar (Stroke’s sign)
- breast swelling
- dysphagia & hoarseness
- chest pain
late symptoms of superior vena cava syndrome
- laryngeal and cerebral edema
- life threatening respiratory distress
- orthopnea
- headache
- visual disturbances
- dizziness
- syncope
- lethargy, irritability and mental status changes
physical examination early signs of superior vena cava syndrome
- edema of face, neck, upper thorax, breasts and upper extremities
- prominent venous pattern due to dilated veins of face, neck and thorax
- jugular vein distention
- peri-orbital edema and erythema and edema of conjunctiva
- compensatory tachycardia
physical examination late signs of superior vena cava syndrome
- cyanosis of face or upper torso
- engorged conjunctiva
- mental status changes
- tachypnea, orthopnea, stridor, respiratory distress
- stupor, coma, seizures, and death
diagnostic studies for superior vena cava syndrome
- need to be able to visualize vessels so need contrast
- chest CT w/ IV contrast
- MRI if patient has contrast dye allergy
- superior vena cavogram
- histologic diagnosis-least invasive technique
- sputum for cytology (bronchogenic cancer)
- biopsy of palpable lymph node
- bronchoscopy or medistinoscopy
- throacentesis (pleural effusion)
- bone marrow biopsy
management of superior vena cava syndrome
-treatment is based on histologic diagnosis of primary tumor, rate of onset, type of obstruction (intrinsic or extrinsic)
main treatment modalities
-radiation therapy (non-small lung cancer)
-endovascular stent-restores venous return and rapid symptom palliation
-chemotherapy (small cell lung cancer & lymphoma)
-pharmacologic therapy - corticosteroids, diuretics, thrombolytic therapy
definition of tumor lysis syndrome
abnormal complication of metabolism caused by rapid breakdown (lysis) of large number of tumor cells
- lysis of tumor cells cause release of contents of the damaged cells into the circulation
- causes imbalance in circulation and interferes w/ norma metabolism
what can cause tumor lysis syndrome?
-cell lysis and subsequent necrosis and breakdown of tumor cells is an intended effect of cytotoxic therapy
-cytotoxic chemotherapy or radiation therapy can cause
massive lysis of tumor cells if tumor has a rapid proliferation rate, or if later tumor burden (tumor > 8-10 cm)
common malignancies for tumor lysis syndrome
- acute lymphoblastic leukemia-cell ALL, Burkitt
- Acute myeloid leukemia
- chronic lymphocytic leukemia
- chronic myeloid leukemia
- non-hodgkin’s lymphoma
- hodgkin’s disease
- multiple myeloma
- solid tumor - small cell lung cancer, neuroblastoma, germ cell tumors
pathophysiology of tumor lysis syndrome
concentration of phosphorous, nucleic acids and potassium increases in blood vessels
- liver metabolizes the nuclei acids into uric acid
- hyperphostatema, hyperuricemia and hyperkalemia
- hypocalcemia occurs w/ tumor lysis syndrome b/c hyperphosphatemia causes excretion of calcium
metabolic changes with tumor lysis syndrome
hyperphosphatemia hyperuricemia hyperkalemia hypocalcemia azotemia & renal failure
increase phosphate
increase uric acid
increase K+
decrease Ca+
clinical manifestations of tumor lysis syndrome
nausea, vomiting, diarrhea, anorexia, lethargy, hematuria, heart failure, cardiac dysrhythmias, seizures, muscle cramps, tetany, syncope, possible sudden death
what can you give for elevated uric acid
raspuricase, helps uric acid to be excreted.
more clinical manifestations of tumor lysis syndrome
may occur 24-48 hours after cytotoxic therapy is initiated
- may continue for 5-7 days
- severity & duration of tumor lysis syndrome depends on: status of patient’s renal function, amount of tumor burden, recognition and treatment
signs and symptoms of tumor lysis syndrome
direction related to metabolic abnormalities
diagnostic studies for tumor lysis syndrom
potassium phosphorus uric acid calcium creatinine blood urea nitrogen (azotemia)
management of tumor lysis syndrome
- prevention of renal failure: aggressive IV hydration (3L/m2), allpurinol to decrease uric acid formation - watch drug/drug interactions; rasburicase rapidly reduces uric and concentration (first screen for G6PD deficiency, if they have the deficiency then rasburicase won’t work); HD may be necessary
- prevention of electrolyte imbalances: monitor serum electrolytes, BUN, creatinine, phosphorus, magnesium and calcium Q6-12 hours & correct abnormal chemistries
