Oncology Flashcards
(144 cards)
1
Q
type of blood cancers
A
- leukemias
- lymphomas
- plasma cell disorder
2
Q
solid tumor types
A
- diff. by type (breast, prostate, colon, lung-most common)
3
Q
types of cancer treatments
A
- chemo
- immunotherapy
- radiation
- surgery (solid only)
- stem cell transplant
- CAR-T therapy
4
Q
what are blood cancers
A
- malignancy originating from hematopoietic (blood producing) cells in the bone marrow
5
Q
types of myeloid blood cancer
A
-MDS, AA, AML, CML
6
Q
Types of lymphoid blood cancer
A
-acute lymphocytic leukemia, MM, lymphomas
7
Q
acute leukemia
A
abnormal blood cells are immature blood cells (blasts) that cant carry out their normal function and they multiply rapidly which means it can worsen quicker
8
Q
DX of acute leukemia
A
- peripheral blood tests (blasts)
- bone marrow biopsy
- lumbar puncture
- imaging
9
Q
systemic symptoms of acute leukemia
A
- weight loss
- fever
- lots of infections
10
Q
lung symptoms of acute leukemia
A
-sob
11
Q
Muscular symptoms of acute leukemia
A
-WEAKNESS
12
Q
bone and joint symptoms of acute leukemia
A
-pain and tenderness
13
Q
psychological symptoms of acute leukemia
A
- fatigue
- loss of appetite
14
Q
lymph node symptoms of acute leukemia
A
-swelling
15
Q
spleen and liver symptoms of acute leukemia
A
-enlargement
16
Q
skin symptoms of acute leukemia
A
- night sweats
- easy bleeding and bruising
- purplish patches or spots
17
Q
difference between AML and ALL
A
- AML: fatigue, DIC, Bleeding (sicker on presentation)
- ALL: hepatosplenomegaly
18
Q
B-symptoms
A
- will be seen with lymphoid lineage cancers (ALL, lymphomas, CLL)
- unintentional weight loss
- drenching night sweats
- fever (unknown why)
- painless lymphadenopathy
19
Q
chemo induction phase
A
- initial chemo treatment
- meant to induce remission
- response to induction can predict outcomes/response to future treatment
20
Q
chemo consolidation phase
A
- goal to eradicate disease that is below the level of detection
- can be done with chemo or stem cell transplantation
21
Q
chemo maintenance phase
A
-lower doses of treatment for prolonged periods of time to improve chances of cure
22
Q
what is chronic leukemia
A
- no blasts
- slow progression and could go diagnosed for long time
- some of these cancers produce too many cells and some produce too little cells
- involves more mature blood cells that replicate or accumulate more slowly and can function normal for some time
- if white count is increased thats okay until see blasts
23
Q
CLL symptoms
A
- b symptoms
- early satiety (getting full)
- increased risk of infection
- hyperkalemia (wbc blow up while drawing blood so now k+ is outside the wbc and in plasma so the sample you drew has high k+ but your actual blood is not)
24
Q
CLL treatment
A
- BTK- inhibitors like ibrutinib or acalabrutinib
- BCL-2 inhibitors like venetoclax
25
CML symptoms
-weakness, fatigue, SOB, fevers, bone pain
26
treatment of CML
-tyrosine kinase inhibitors like ponatinib, imatinib, nilotinib
27
what is lymphoma
- arises infection fighting cells of the immune system (lymphocytes-a type of WBC made in the bone marrow)
- when bacteria and other invaders are found in the lymph fluid, lymphocytes will multiply within the lymph nodes including b, t and natural killer cells
- lymphomas develop when these lymphocytes transform from healthy to malignant cells
28
how do lymphocytes normally circulate the body
-via the lymphatic system
29
function of lymph nodes
-key structure of lymphatic system found throughout the body and help filter lymph fluid to remove foreign particles
30
hodgkin lymphoma
- presence of reed stern-berg cells (large cancerous B cell derived cells with distinct appearance)
- one of most treatment responsive cancers that most pt can be cured
31
Non-hodgkin lymphoma
- diverse group of diseases distinguished by characteristics of the cancer cells associated with each disease type
- most people with NHL have b cell type others will have t cell type or NK cell type lymphoma
- more aggressive but still may be completely cured for fast growing
- slow growing tx effective in stabilizing disease for long time
32
symptoms of lymphoma
-b symptoms: night sweats, early statiety= weight loss, painless lymphadenopathy, fever
33
DX for lymphoma
- lymph node biopsy
- Imaging: PET/CT: hot spots may appear
- peripheral labs
- bone marrow biopsy
34
tx for lymphoma
- immunotherapy
- chemo
- radiation
- stem cell transplant
- CAR-T therapy
35
multiple myeloma (MM)
- cancerous plasma cells accumulate in bone marrow and crowd out the healthy cells and make abnormal proteins (antibodies)
- forms in the WBC (the plasma cell)
- normally healthy plasma cells would help fight infection by making antibodies that recognize and attack germs but with MM cant
36
symptoms of MM
- CRAB
- c= high calcium
- R= renal (kidney) problems- AKI
- A= anemia or low HgB
- B= bone problems
-I= infection
37
DX if MM
- peripheral labs: serum free light chains, immunoglobulins, M protein
- Bone marrow biopsy
- PET/CT: hot spots
38
TX for MM
- NOT CURABLE
- want to: have longest deepest remission
- immunotherapy
- chemo
- radiation
- stem cell transplant
- CAR-T therapy
39
Stem cell transplant
- process of administering CD 34 (STEM CELLS) into the host after preparative chemo regimen
- essentially eradicate disease via high dose chemo that people cant survive without stem cell transplant then rescue them with stem cells and or initiating graft vs disease effect
- now new healthy immune system can function and you have functional bone marrow that can provide hematopoiesis
40
Autologous stem cell source
- patients own stem cell
| - collected after mobilization with high dose neupogen
41
Allogenic stem cell source
- donor stem cell
- matched related donor (sibling)
- matched unrelated donor
- cord (fetal umbilical cord) donor
- syngenic (identical twin)
- Haplo-identical (1/2 matched donor)
42
major complications of stem cell transplant
- Sinusoidal Obstructive Syndrome
| - Graft Versus Host Disease
43
Sinusoidal Obstructive Syndrome
- rare
- gumming up of the liver
- actegol can help
44
Graft Versus Host Disease (GVHD)
- donors T cells (graft) view the patients healthy cells (the host) as foreign and attack and damage them
- mild, mod, or severe
- could be threatening
45
TX of Graft Versus Host Disease (GVHD)
-increased immunosuppression in the form of corticosteroids (medicines such as prednisone, methylprednisolone, dexamethasone, beclomethasone and budesonide)
46
Chronic GVHD
- syndrome that may involve one organ or many
| - leading cause of medical problems and death after allogenic stem cell transplant
47
hard thing about GVHD
- want some of this to kill of the remaining cancer cells but dont want too much
- very fine balance
48
cancers that can use autologous stem cell
LETS MAKE CANCER AA TABOO NAME
- Lymphoma
- Multiple Myeloma
- CLL
- Amyloidosis
- Some autoimmune disorders
- Testicular
- Neuroblastoma
49
cancers that can use allogenic stem cell transplant
- ALL / AML / MDS
- Some refractory Lymphomas
- PNH
- CML/CLL
- Sickle cell disease
- Some autoimmune disorders
- Myelofibrosis
- Aplastic Anemia
50
CAR-T therapy
- type of immunotherapy that genetically modifies a patient’s own T cells to recognize and bind to specific proteins (tumor-associated antigens) on the surface of antigen-expressing cells
- The external targeting domain binds to the antigen, activating the CAR T cell.
- Once activated, CAR T cells release cytokines and other soluble mediators that may play a role in the killing of antigen-expressing target cells.
51
benefit of CAR-t therapy
- manufactured for each individual patient using their own T cells.
- After a one-time treatment, CAR T cells can continue to multiply in a patient’s body (cell expansion) and have the potential to remain in the blood for up to 1 year following administration
52
What is CAR T currently used in
- Multiple Myeloma
- Lymphoma
- ALL (Acute Lymphocytic Leukemia)
53
CAR-T therapy toxicity
1. Cytokine Release Syndrome (CRS)
| 2. Immune Effector Cell-Associated Neurotoxicity
54
Cytokine release syndrome (CRS)
-response to the over-activation of the immune system response with a supraphysiological release of inflammatory cytokines
55
symptoms of CRS
- MIMIC SEPSIS
- can be quickly progressive
- fever
- hypotension
- hypoxia
- organ dysfunction
*occur rapidly and without warning within the first 8 weeks (average at 5-7 days) after CAR T-cell infusion
56
life threatening complications of CRS
- cardiac dysfunction
- ARDS from capillary leak
- renal or hepatic failure
- DIC
- HLH
57
Immune effector cell associated neurotoxcicty (ICANS)
-diverse adverse event associated with immune effector cells (IEC) and may involve blood-brain barrier disruption, elevated levels of excitatory neurotransmitters as well as pro-inflammatory cytokines and activated lymphocytes in the CNS
58
symptoms of ICANS
-aphasia (expressive), altered mental status, impaired cognition, motor weakness, seizures or cerebral edema, encephalopathy
59
non specific symptoms of ICANS
headache, tremor, myoclonus (quick, involuntary muscle jerk), asterixis (loses motor control), hallucinations, weakness, and intracranial hemorrhage
60
Stages of CRS
- grade 1: fever
- Grade 2: hypotension, hypoxia
- grade 3: requires one pressor for hypotension and at least 6 L of O2
- stage 4: requires at least 2 pressers and ventilator
61
TX for CRS grade 2 or higher
- tociluzumab
- if the symptoms then dont resolve add steroids
- if have neuro toxcicity add anakinra
62
Neurotoxcicity scoring questions to ask
- who
- where
- year (anything for time)
- one more orientation
- name 3 objects
- follow a command
- count backwards from 100 by 10's
- write a sentance
63
grades for neurotoxcicity
- GR 1: score of 7-9
- GR 2: 5-7
- GR 3: 3-5
- GR 4: 3-0
64
what is an oncologic emergency
- Any acute, potentially life-threatening event in the oncology patient
- Directly or indirectly related to cancer or treatment
- May develop at any stage of treatment
- Immediate intervention is required `
65
Onc emergency category: Metabolic
-TLS, Hypercalcemia, SIADH, Hyper/hypoglycemia
66
categories of onc emergencies
- metabolic
- structural
- hematologic
- infusional
67
Onc emergency: structural
-SVC obstruction, Airway obstruction, Cord compression, Effusion, increase ICP, Seizure
68
Onc emergency: hematologic
-Fever, Leukostasis/Viscosity, Bleeding, Thrombosis, DIC, CRS/ICANS
69
Onc emergencies: infusional
-Extravasation, Anaphylaxis, Reactions
70
Tumor lysis syndrome (TLS)
- Life threatening condition occurring after cellular destruction of rapidly growing tumors
- Release of intracellular components of tumor cells causing hyperkalemia, hyperuricemia, hyperphosphatemia, secondary hypocalcemia, renal failure
- Typically during first several days of chemotherapy but can occur spontaneously prior to chemotherapy
71
Complications of tumor lysis syndrome
-rapidly progressing renal failure, seizure and cardiac dysrhythmia leading to death
72
Tumor lysis syndrome is most common in...
- high grade, high bulk lymphomas
- acute leukemias
- low to intermediate grade heme malig such as myeloma, CLL, etc..
- Solid Tumor patients with high bulk disease
73
what causes hyperkalemia in TLS
-release of intracellular potassium from tumor and can also be exacerbated by AKI
74
what causes hyperuricemia in TLS
-released from tumor, exacerbated by AKI and contributes to AKI crystal obstructive nephropathy
75
What causes hyperphosphatemia in TLS
Tumor cells contain up to 4X the inorganic phos than normal cells and this is released with cell death, again exacerbated by AKI, and contributes to AKI when Calcium and phosphate combine forming Ca/phos crystals and an obstructive nephropathy
76
What causes hypocalcemia in TLS
-secondary to increased phosphate binding, exacerbated by AKI and contributes to direct tubular injury.
77
Signs of hyperkalemia
```
Muscle cramps
Paresthesias
ECG changes
Bradycardia
Dysrhythmias
Cardiac arrest
```
78
signs of hyperphosphatemia
Nausea/Vomiting/Diarrhea
Lethargy
Seizure
AKI
79
signs of hypocalcemia
```
Muscle cramps
Tetany
Hypotension
Dysrhythmia
AKI
```
80
signs of hyperuricemia
AKI
81
TX of hyperkalemia
1. avoid potassium supplementation
2. NS infusion
3. cardiac monitoring
4. Stabilize heart
- calcium gluconate
5. Shift potassium
- sodium bicarbonate
- insulin/D50
- albuterol
6. Remove potassium
- sodium polystyrene resin (kayexalate)
- dialysis
82
TX for HYPERURICEMIA
- allopurinol
- rasburicase
- NS infusion
- dialysis
83
TX for HYPERPHOSPHATEMIA
- avoid phos and calcium supplementation
- NS infusion
- phosphate binder *ONLY OF EATING(sevelamer; aluminum hydroxide, calcium acetate)
- dialysis
84
TX for Hypocalcemia
- if asymptomatic, no intervention
| - if symptomatic, calcium gluconate
85
if you give rasburicase...
walk labs down on ice for 48 hours
86
Hypercalcemia of malignancy (HCM)
- HCM is a complex metabolic disorder occurring in approx. 25% of cancer patients
- Most common in (breast, lung, squamous, myeloma)
87
mild HCM level
-10.5-11.9mg/dL
88
moderate HCM level
12-13.9
89
severe HCM level
>24
90
how is calcium homeostasis maintained normally
- intestinal absorption, bone resorption and renal excretion.
* In certain cancers this homeostasis can get out of whack due to renal dysfunction or hormonal dysregulation.
91
Acronym for HCM
Stones, Groans, Bones, and Moans
- stones: ca stones =renal dys and gum up of the kidneys = renal failure
- Groans: abdominal pain, anorexia, ulcers
- Bones: Fractures
- Moans: neuro symptoms: Drowsiness, lethargy, weakness, depression, confusion, delirium
92
other renal symptoms of HCM
Polyuria, polydipsia, e-lyte wasting, dehydration, nephrolithiasis (kidney stones), renal insufficiency
93
other GI symptoms of HCM
Anorexia, N/V, constipation, abdominal pain, ulcers, pancreatitis
94
other cardiovascular symptoms of HCM
ECG changes (prolonged PR/QRS, shortened QT/ST, bradycardia, arrhythmia)
95
other MSK symptoms of HCM
Muscle weakness, fatigue, reduced muscle tone, bone pain
96
Interventions for mild HCM
- Close monitoring
- Oral hydration
- Ambulation
- Limit nephrotoxins
- Limit drugs that inc. Calcium
- Treat underlying malignancy
* Treat as “severe” if symptomatic
97
interventions for moderate HCM
- Hospitalization often required
| * Typically treat as “severe”
98
interventions for severe HCM
- Hospitalization required
- Baseline ECG and Telemetry
- Close electrolyte monitoring
- IV Fluids
- Diuresis
- Administration of Calcitonin +/- Bisphosphonates and Steroids
- May need emergent Dialysis
- TREAT DISEASE
99
Superior Vena cava obstruction syndrome
- Compression or invasion of the SVC by tumor, thrombosis or infection causing obstruction of blood flow to the heart from the head, neck, arms and upper thorax
* 80% caused by cancer (Lung cancers, lymphoma, thyroid, head and neck cancer, other metastases)
100
early signs of Superior Vena cava obstruction syndrome
- Edema of face, neck, arms, thorax
- Dilated veins (spider veins)
- Facial plethora: red and ruddy
- Horner syndrome: spider veins from pressure on the cervical nerves
101
late signs of Superior Vena cava obstruction syndrome
-Cyanosis
-Absent peripheral pulses
CHF, decreased BP, syncope
-Chest pain/SOB/resp. distress
-Hoarseness, stridor
-Mental status changes, seizure, coma
102
DX of Superior Vena cava obstruction syndrome
- CT
- Tissue Biopsy
- Radiation +/- Chemotherapy
103
tx of Superior Vena cava obstruction syndrome
- Steroids
- Surgery/Vascular stenting
- Thrombolysis/anticoagulation
- Frequent VS, Tele Monitoring
104
Malignant spinal cord compression
- Occurs when malignant disease or pathologic vertebral fracture compresses spinal cord or cauda equina
- Second most common neurologic complication in cancer
- May cause devastating neurologic disability and death
* New pain is the most common presenting symptom
-commonly caused by: head and neck cancer affecting the cervical spine and prostate, bladder, colon, renals affecting lower spine or breast and lung affecting thoracic
105
cervical injury
-Occipital headache and neck stiffness
| Radicular pain in neck, shoulder, arm
106
thoracic injury
Localized and/or radicular pain in chest and back
107
lumbosacral injury
Localized and/or radicular pain in groin or sciatic distribution in legs, pain with straight leg raise
108
Cauda equina
Cauda equina
| Localized, radicular or referred pain in back and legs(s)
109
acute management of malignant spinal cord compression
- Diagnostic Imaging Evaluation (MRI entire spine)
- Neurosurgical and Rad Onc consultation
- Dexamethasone
- Radiation
- Surgery (laminectomy, vertebral resection, kypho/vertebroplasty)
- Chemotherapy
110
malignant pleural effusion
-Malignancy associated collection of fluid in the pleural space
-Life threatening emergency affecting respiratory function through restriction of lung expansion, decreased lung volume and altered gas exchange
-Most commonly in lung, breast, lymphoma
Associated with advanced disease and poor outcomes
111
subjective signs of malignant pleural effusion
```
Dyspnea
Dry cough
Pleuritic chest pain
Orthopnea/PND
Hemoptysis, tracheal deviation
Anxiety/fear of suffocation
Fever
Malaise
Weight loss
```
112
objective signs of malignant pleural effusion
```
Tachypnea
Dullness to percussion
Decreased/absent lung sounds
Tracheal deviation (away)
Egophony, tactile fremitus
Bronchial breath sounds
Friction rub
diaphragmatic excursion
Cyanosis, accessory muscle use
```
113
dx of malignant pleural effusion
- CXR-lateral and decubitus
- CT-detect smaller effusions; differential diagnoses
- Thoracentesis
114
TX of malignant pleural effusion
- Treat underlying cause of effusion: Chemo, XRT, antibx, diuresis, steroids, NSAIDs
- Therapeutic thoracentesis
- Chest tube drainage
- Pleurodesis/talc
- Pleuroperitoneal shunt
- Pleurex catheter
- Pleurectomy and pleural abrasion
115
hypersensitivity reaction
- Reaction of variable severity occurring in response to the administration of chemotherapy, biotherapy or supportive care therapies in cancer treatment
- Can be allergic (immunogenic) or nonallergic (nonimmunogenic)
- Hypersensitivity reactions, despite the cause, are treated similarly
116
Grade one hypersensitivity reaction
urticaria, pruritis, rash, mild upper resp. symptoms
117
grade two hypersensitivity reaction
1+ wheezing, N/V, SOB
118
grade 3 hypersensitivity reaction
grade 1/2+ serious cardiopulmonary or neurologic compromise
119
hypersensitivity reaction Prevention
1. pre-medication
- H1/H2
- Acetaminophen
- Corticosteroids
120
Hypersensitivity reaction tx Cutaneous/Mild reaction
slow or stop infusion
H1/H2 blockers; +/- corticosteroids
Demerol/dilaudid for rigors
121
Hypersensitivity reaction tx Anaphylactoid reactions
```
STOP infusion
Epinephrine
Corticosteroids
H1/H2 Blockers
Resuscitation (O2, fluids, nebs, intubation, pressors, etc.)
```
122
extravasation
- Infiltration of a vesicant agent into surrounding tissue with potential to cause tissue destruction, nerve and tendon damage and functional impairment
- Vesicants classified as DNA binding (worse) or Non-DNA binding
- Vesicant extravasation is an emergency requiring immediate intervention and specialty consultation
123
acute management of extravasation
- Stop the infusion (including chemotherapy and any other fluids)
- Do NOT remove the catheter/needle (disconnect IV tubing, but leave IV catheter/needle)
- Aspirate fluid (attempt to aspirate any fluid from the subcutaneous tissue through the IV catheter/needle)
- Do NOT flush the IV line/catheter
- If indicated, Sodium thiosulfate is the only antidote
- Elevate and immobilize the affected extremity (for 24-48 hrs.)
- Monitor the site closely (outline the extravasation area)
- Consultation/evaluation by plastic surgery team
124
Disseminated intravascular coagulation
- Hematologic oncologic emergency that develops secondary to an underlying pathologic condition
- Coagulation disorder characterized by widespread intravascular thrombosis causing tissue ischemia and organ dysfunction (clotting and bleeding at the same time)
- depletion of coagulant factors and platelets contributing to hemorrhage
125
common causes of DIC
sepsis, trauma, obstetric conditions and malignancy
126
how DIC works
- result of the destruction of leukemic blast cells that release procoagulant substances from the leukemia cells causing systematic activation of coagulation
- can cause microvascular clots and, in pts whose platelets are already low due to the pathophysiology of the disease as we already discussed, increased platelet consumption, which can lead to bleeding
- need to transfuse products so that the patient can keep up with her consumption demands until we can treat the underlying leukemia
127
DIC manifestations
- Thrombosis is most common in solid tumors
- Bleeding occurs more often in Heme Malignancy
- Oozing from multiple sites, ecchymosis, petechiae, uncontrolled hemorrhage
- Microvascular thrombosis with hypoperfusion, ischemia, necrosis, organ failure
- Mental status changes, irritability, confusion
- Cardiopulm decompensation, shock, MODS, death
128
general management of DIC
- Treat underlying cause of DIC (cancer, infection, trauma)
- Monitor DIC panel every 6-12hrs (cbc, dimer, fib, INR, PTT)
- Heparin anticoagulation if thrombosis predominates or for VTE prophylaxis if not contraindicated
- Blood product replacement
129
management of DIC if plt are <10-20 or <30 if heme malignancy and <50 if active bleeding
1 unit of plt
130
management of DIC if INR is >2
2 u FFP
131
management of DIC if fibrinogen is <100
2 u FFP or CRYO
132
management of DIC if HGB is <8
1-2 u PRBC's
133
iMMUNO COMPROMISED FEVER most common causes
- gram negative or positive bacteria
- yeast/fungal organisms
- viral
134
fever is...
- FEVER is a sign of INFECTION
- FEVER is a sign of SEPSIS
- FEVER may be the ONLY sign of INFECTION and impending SEPSIS
- SEPSIS may progress to SHOCK and DEATH
135
Immuno-compromised Fever: Timeliness of interventions makes a difference
```
reduces morbidity
reduces mortality
reduces hospital LOS
reduces ICU interventions
reduces healthcare cost
```
136
management of Immunocompromised fever
1. Vital signs
- Volume resuscitation
- Oxygen support
2. Labs
- CBCd, CMP, PT/INR, fibrinogen, lactate
3. Cultures
- Blood (line/peripheral), urine, sputum, wound/lesions, abscess, etc.
4. ANTIBIOTICS
* DO NOT DELAY antibiotics for labs, diagnostic testing or any cultures OTHER THAN blood cultures
5. Diagnostic testing
- CXR, CT, US, Bronchoscopy, etc.
137
normal WBC
4,500 to 11,000
138
normal HGB
For men, 13 to 16
| for women, 11 to 15
139
normal Hct
For men, 38 to 48 percent. For women, 35 to 44 percent
140
normal plt
150,000 to 450,000
141
normal sodium
135 and 145
142
normal K+
3.6 to 5.2
143
normal BUN
6 to 24
144
normal Creatinine
around 1 or less
