Principles of Oncology- part 2 Flashcards by Johannah Crumpton

Conversely, when the clinical goal is palliation, careful attention to minimizing the _____ becomes a significant goal

toxicity of potentially toxic treatments

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What are the 4 types of cancer treatments. Most cancer treatments are _____

Surgery
Radiation therapy
Chemotherapy
Biologic therapy

Some combination of the above treatments

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Surgery and radiation therapy are considered ____ treatments

local

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Chemotherapy and biologic therapy are usually _____ treatments.

systemic

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_____ is the most effective means of treating cancer

surgery

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Name some reasons surgery is used

Cancer prevention (prophylactic mastectomy/colectomy)
Diagnosis
Staging
Treatment (for both localized and metastatic disease)
Palliation

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____ of cancer patients cured by surgery

40%

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Even if the surgery is not curable, name some benefits of surgery

Local control of tumor

Preservation of organ function

Debulking for subsequent treatments

Palliative/Supportive care
-Placement of lines
-Control of effusions and ascites
-Removal of adhesions/strictures
-Reconstructive surgery

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What is the main goal of radiation therapy?

deprive cancer cells of their cell division potential

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** Radiation causes breaks in DNA that prevent replication and generates _____ from cell water that damages cell membranes, proteins, and organelles

hydroxyl radicals

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Cancer cells are not as ??? repairing the damage caused by radiation resulting in differential ____ killing

efficient as normal cells in

cancer cell

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Name some factors that influence the development of systemic effects

volume of tissue irradiated

dose fractionation

radiation fields

individual susceptibility

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____, ____ and _____ are features that make a particular cell more sensitive or more resistant to the biologic effects of radiation

total absorbed dose

number of fractions (delivering radiation in repeated doses to maximize exposure during cell division)

time of treatment

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Type of radiation: ______ with focused beams of radiation generated at a distance and aimed at the tumor within the patient

teletherapy

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Type of radiation: ______ with radionuclides targeted in some fashion to a site of tumor……radioactive iodine for thyroid cancer

systemic therapy

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Type of radiation: ______ with encapsulated/sealed sources of radiation implanted directly into or adjacent to tumor tissues

brachytherapy

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What type of radiation is the most common? With ____ or _____ photons

teletherapy

x-ray or gamma ray photons

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What is a common way to treat prostate cancer? What type of radiation?

brachytherapy

insert radioactive encapsulated rods into the prostate

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Radiation therapy is used in a curative manner in what types of cancer?

Breast cancer, Hodgkin’s disease, head and neck cancer, prostate cancer, and gynecologic cancers.

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Radiation therapy is used in a palliative manner for ???

Relief of bone pain from metastatic disease, control of brain metastases, reversal of spinal cord compression and superior vena caval obstruction, shrinkage of painful masses, and opening of threatened airways.

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What are some systemic toxic effects associated with radiation therapy?

fatigue, anorexia, nausea, and vomiting,

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______ include mucositis, skin erythema (ulceration in severe cases), and bone marrow toxicity.

acute toxicities associated with radiation

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Radiation carcinogenesis with secondary malignancy; pericarditis; myocardial infarction; thyroid failure; cataracts; lung fibrosis; arteritis; spinal cord transection are all examples of _____

chronic toxicities associated with radiation

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______ use of extreme cold to sterilize lesions in certain sites

cyrosurgery

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_______ focused microwave radiation to induce thermal injury within a volume of tissue

radiofrequency ablation

_________ Infusion of chemotherapeutic agents directly into the target area via vascular catheters aka target vascular supply of the tumor

chemoembolization

Name the 4 broad categories of chemotherapy

Conventional cytotoxic chemotherapy agents Targeted agents Hormonal therapies Biologic therapies

Types of chemo: ______ mainly target DNA structure or segregation of DNA as chromosomes in mitosis

Conventional cytotoxic chemotherapy agents

Types of chemo _____-: designed and developed to interact with a defined molecular target important in either maintaining the malignant state or selectively expressed by the tumor cells.

targeted agents

types of chemo: ______ work on the biochemical pathways underlying estrogen and androgen function

hormonal therapies

types of chemotherapy: ______ Have a particular target or may have the capacity to regulate growth of tumor cells or induce a host immune response to kill tumor cells.

biologic therapies

The usefulness of a drug is determined by ?????

therapeutic effect vs toxic effect to the host

The _____ is the degree of separation between toxic and therapeutic doses.

therapeutic index

Unfortunately chemotherapy agents have a _____ therapeutic index

narrow

Chemotherapy can either ______ or _______

They can induce cancer cell death They can induce cancer cell differentiation or dormancy with loss of tumor cell replicative potential and reacquisition of phenotypic properties resembling normal cells.

Name the 2 antimetabolites

Methotrexate 5-fluorouracil (5-FU)

**_______ MOA causes DNA damage indirectly, through misincorporation into DNA, abnormal timing or progression through DNA synthesis, or altered function of pyrimidine and purine biosynthetic enzymes

Antimetabolites: Methotrexate, 5-fluorouracil (5-FU)

**antimetabolites: ______ prevents thymidine formation (required for DNA replication)

5-fluorouracil

**antimetabolites:_______ competes and counteracts folic acid, causing folic acid deficiency in cancer cell and cell death

methotrexate

**What are the toxic manifestations of antimetabolites?

stomatitis, diarrhea, and myelosuppression

**Name the mitotic spindle inhibitors. What the toxic manifestations?

Vincristine, Vinblastine Paclitaxel alopecia, neuropathy (especially in the hands and feet), and myelosuppression.

What are the Alkylating Agents?

Cyclophosphamide Chlorambucil Cisplatin

**______ MOA break down, either spontaneously or after normal organ or tumor cell metabolism, to reactive intermediates that covalently modify bases in DNA

Alkylating Agents

**What the toxic effects of Cisplatin?

neuro-toxicity (stocking-glove), hearing loss, renal failure

What is stocking glove neurotoxicity?

distal to proximal neuropathy in the hands

**_______ Produced by bacteria that in nature appear to provide a chemical defense against other hostile microorganisms. As a class they bind to DNA directly and can frequently undergo electron transfer reactions to generate free radicals in close proximity to DNA, leading to DNA damage in the form of single-strand breaks or cross-links.

Antitumor antibiotics Doxorubicin (Anthracyclines)

**What is the toxic effect of Doxorubicin (Anthracyclines)?

cardiotoxicity, arrthrymias and heart failure

Which chemotherapy agent is nicknamed "the red devil"? Why?

Doxorubicin (Anthracyclines) because it is physically a red liquid and causes cardiotoxicity

**_____ MOA inhibits DNA synthesis by forming a complex with topoisomerase II and DNA, causing breaks in DNA, which prevents the mitotic phase of cell division, causing cell death

Topoisomerase inhibitor Etoposide

** What is the toxic effect of Etoposide?

transient side effects but may lead to *secondary leukemia* with high doses

**How do you treat neutropenia caused by bone marrow suppression? When does it have the greater effect?

Filgrastim: colony stimulating factors Stimulate the production of neutrophils, monocytes, and eosinophils. peaks levels of neutrophils in 24 hours

bleeding gums, blistering, burning, coldness, discoloration of the skin, feeling of pressure, hives, infection, inflammation, itching, lumps, numbness, pain, rash, redness, scarring, soreness, stinging, swelling, tenderness, tingling, ulceration, or warmth at the injection site. Are all SE of _______.

Filgrastim, pegfilgrastim and sargramostim

**What is the treatment for anemia caused by bone marrow toxicity?

Transfusion; Epogen (erythropoiesis-stimulating agent)

**What is the treatment for thrombocytopenia caused by bone marrow toxicity?

monitoring should be getting blood work every week

**_____ is the MC SE of chemotherapy. What is the treatment?

Nausea Ondansetron (anti-emetic)

_______ is oral soreness and ulcerations (along with the severe diarrhea). What is the treatment?

Mucositis “Magic” Mouthwash diphenhydramine, lidocaine, Maalox

Drugs most commonly associated with causing mucositis in the mouth and the gastrointestinal tract are ????? name 3

cytarabine 5-FU methotrexate

_____ is a common chemo toxicity and is especially with tx with 5FU infusions. What is the treatment?

diarrhea 1st- Loperamide (antimotility drug) (Imodium) 2nd- Octerotide (somatostatin analogue) or opiate-based preparations if no response to Loperamide

______ manifests as painful palms or soles accompanied by erythema, progressing to blistering desquamation and ulceration in its worst forms. What is the treatment for the blank and broad category?

Acral erythema Broad category: Skin toxicity Supportive care; cold packs; sun protection

What is the treatment for chemo associated alopecia?

Psychological support - “chemo caps” - reduce scalp temp - very controversial

_____ refers to the disorders that accompany benign or malignant tumors but are not directly related to mass effect or invasion.

Paraneoplastic syndromes

Neoplastic cells can produce a variety of products that stimulate ????? responses. 5 organ systems

hormonal, hematologic, dermatologic, renal and neurologic

paraneoplastic syndromes usually manifest as _____, _____, ____ or _______

Endocrine Metabolic Hematologic Neuromuscular

Why are the paraneoplastic syndromes clinically important?

1. can provide early clue of cancer 2. the toxic effect of the syndrome may be a more urgent threat to the pt's life 3. treatment of the cancer should result in a resolution of the paraneoplastic syndrome

Name some common endocrine paraneoplastic syndromes?

hypercalcemia hypoglycemia gonadotropin secretion cushing's syndrome SIADH

Name some common hematologic paraneoplastic syndromes?

coagulopathy erythroyctosis- points to kidney or liver cancer

Name some common neurologic paraneoplastic syndromes? What type of cancer are they related to ?

Lambert-Eaton syndrome Subacute cerebellar syndrome Small Cell Lung Cancer (SCLC)

**neurologic paraneoplastic syndromes that is characterized by muscle weakness of the limbs

Lambert-Eaton syndrome

**neurologic paraneoplastic syndromes that is characterized by dizziness, nausea, vertigo, tremor, and sometimes dysphagia and blurry vision

Subacute cerebellar syndrome

Name some common dermatologic paraneoplastic syndromes?

Dermatomyositis Acanthosis Nigricans

**dermatologic paraneoplastic syndromes that is characterized a system disorder causing inflammation of the muscles and skin, as well as joints, lungs, esophagus and heart. What cancers does it point to?

Dermatomyositis SCLC, NSCLC

**dermatologic paraneoplastic syndromes that is characterized thickening of mucous membranes/skin and it presents with brownish discoloration. What cancers does it point to?

Acanthosis Nigricans GI adenocarcinomas Side note: Can occur with diabetes/obesity, typically in fold of neck, under breast

What is a neutropenic fever defined as?

recurrent temperatures above 38’C or a single temperature above 38.3’C in the presence of neutropenia neutrophil count (ANC) less than 500 cells/mL

neutropenic fever is commonly the result of _______, not ______

chemotherapy NOT the underlying cancer

vague and mild initially, but may rapidly progress to sepsis and death Symptoms also vary based on site of infection and source of infection Infectious agents may be viral, fungal or bacterial What am I?

neutropenic fever

**T/F: All immunocompromised pts should have a rectal exam as part of their PE work up

FALSE!! It is an ABSOLUTE CI to perform a rectal exam on an immunocompromised pt!!

What should be part of a dx workup with a pt who is suspected of having neutropenic fever?

cultures (skin, blood, urine, sputum and stool) CXR CBC with diff, CMP, coag panel and UA

**What is the empiric treatment for a neutropenic fever? When should treatment be started?

Ceftazidime, Cefipime or Imipenem for antipseudomonal coverage Aminoglycoside to cover gram – bacteria Vancomycin to cover MRSA All three! start AFTER the culture is taken!!

Back pain at the level of the tumor mass, which may be aggravated by lying down, weight bearing, sneezing, or coughing Mix of nerve root and spinal cord symptoms What am I? What is the dx tool of choice?

spinal cord compression MRI

What is the usually worsening of symptoms that is common to see with a spinal cord compression?

LE weakness hyperreflexia motor/sensory loss loss of reflexes loss of bowel/bladder paraplegia

What is the treatment for spinal cord compression?

High dose IV corticosteroids Surgical decompression Radiation

What are the 3 mechanisms that can cause hypercalcemia

Systemic effects of tumor-released proteins Direct osteolysis of bone by tumor Increased absorption of calcium due to increased active metabolite of Vitamin D

What is the MC cause of hypercalcemia?

a parathyroid hormone-related peptide secreted by the cancer cells

If hypercalcemia due to cancer is present, what does this indicate?

marker of advanced cancer median survival range of 1-3 months

What are the top 3 cancers associated with hypercalcemia?

myeloma, breast carcinoma, and non-small cell lung carcinoma (NSCLC)

polydipsia, polyuria, generalized weakness, lethargy, anorexia, N/V, constipation, abdominal pain, AMS and psychosis What am I? What is the treatment?

hypercalcemia Hydration and forced diuresis and bisphosphonates

zoledronic acid or pamidronate IV are in the drug class ______. When are they commonly used?

Bisphosphonates treatment of hypercalcemia

What is second line treatment for hypercalcemia? If that still doesnt work, use ______

2nd- Calcitonin alternative: Hemodialysis-> will be the definitive treatment

Hypercalcemia labs will show elevated _____ and ______

Total serum calcium level ionized calcium levels

What will the EKG show a pt with hypercalcemia?

may show shortened QT, ST depression and AV blocks

______ is a clinical syndrome that occurs 1-3 days following radiochemotherapy of most commonly hematologic malignancies. Especially _____

Tumor Lysis Syndrome Especially Burkitt lymphoma

_____ is a massive release of cellular material including nucleic acids, proteins, phosphorus, and potassium. If both the metabolism and excretion of these breakdown products are impaired, hyperuricemia, hyperphosphatemia, and hyperkalemia will develop abruptly.

Tumor Lysis Syndrome

What is the pt at a huge risk for following Tumor Lysis Syndrome? Why?

Acute kidney injury may then develop from the crystallization and deposition of uric acid and calcium phosphate within the renal tubules further exacerbating the hyperphosphatemia and hyperkalemia.

**In Tumor Lysis Syndrome, combination of hyperkalemia and hypocalcemia, development of _____ may occur

fatal cardiac arrhythmias

**Patient may present with lethargy, N/V, cloudy urine, and neuromuscular irritability, muscular spasm, seizure and altered mentation associated with hypocalcemia. What am I? What is the treatment?

Tumor Lysis Syndrome includes IV hydration and correction of electrolyte abnormalities May require emergency hemodialysis

**What does the EKG show in a pt with tumor lysis syndrome?

may show peaked T waves of hyperkalemia, as well as arrhythmias

**____ and _____ most commonly caused by lung and breast cancers

Pleural and pericardial effusions

**_____ associated with ovarian, colorectal, stomach, and pancreatic cancers.

Malignant ascites

**fatigue, chest heaviness, dyspnea, palpitations, cough and syncope Tachycardia, narrowed pulse pressure, hypotension, distended neck veins, muffled heart sounds, and pulsus paradoxus What am I? What is the dx tool of choice? What is the treatment of choice?

Pericardial Effusion / Cardiac Tamponade Transthoracic echocardiogram echo-guided percutaneous pericardiocentesis under local anesthesia

What other dx tools can you use to dx Pericardial Effusion/Cardiac Tamponade?

Chest x-ray may demonstrate an enlarged cardiac silhouette and pleural effusion EKG may show sinus tachycardia, low QRS voltage and electrical alternans **Transthoracic echocardiogram is diagnostic tool of choice

_____ is caused by malignancies such as compression of the vessel wall by right upper lobe tumors or thymoma and/or mediastinal lymphadenopathy

Superior Vena Cava Syndrome

What is the MC malignancy that causes SVCS?

bronchogenic carcinoma

gradual onset of dyspnea, chest pain, cough and, facial and arm swelling; cerebral edema is rare Distended neck, arm and chest veins, nonpitting edema of the neck, arm swelling, tongue and facial swelling and cyanosis What am I? What is the dx tool of choice? What is the treatment?

SVC syndrome Chest CT with contrast is diagnostic test of choice **steroids **Intravascular stenting chemotherapy radiation

What is Virchow's triad?

Vessel wall injury stasis hypercoagulability

hx of dyspnea, fever, cough, DOE, pleuritic chest pain, leg pain or swelling, and rarely hemoptysis include low-grade fever, tachypnea, tachycardia, pleural rub and unilateral lower extremity swelling What am I? What is the dx tool of choice? What is the treatment?

DVT/PE Chest CT with contrast or V/Q scan IV heparin or lovenox immediately then follow up with DOAC

When is thrombolytic therapy necessary?

When the patient is tanking and their life in crisis aka when systolic is below 90