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29 Cards in this Set
- Front
- Back
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What is the role of surgery in the prevention, diagnosis and treatment of cancer?
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Prevention
• Underlying conditions or congenital or genetic traits are associated with an extremely high incidence of subsequent cancer Diagnosis • Acquisition of tissue for exact histologic diagnosis Treatment • Can be a simple, safe method to cure pts when the tumour is confined to the anatomic site of origin |
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What are the different types of surgical treatment?
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Definite
• In some cases, surgery which encompasses a sufficient margin of normal tissue is sufficient local therapy Reduce residual disease • Cytoreductive surgery - surgical resection of bulk disease may lead to improvements in ability to control residual gross disease that hasn't been resected Metastatic disease for cure • Pts with a single site of metastatic disease that can be resected without major morbidity should undergo resection of that cancer Oncologic emergencies • Treatment of haemorrhage, perforation, drainage of abscesse, impending destruction of vital organs Palliation • Required for relief of pain or functional abnormalities Reconstruction & rehabilitation • Reconstructing anatomic defects can improve function & cosmetic appearance |
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How is radiation used in the treatment of cancer, and how is it delivered?
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• Deliver a precisely measured dose of radiation to a specific tumour volume with minimal injury to the structure & function of adjacent tissue
• Generally localised Tx either used alone or in conjunction with others e.g. surgery & chemo • Some organs particularly vulnerable to radiation damage (e.g. lungs, spinal cord, eyes) Delivery: • Linear accelerators used to treat deep seated tumours • Brachytherapy places radiation source in a sealed unit, in close proximity to the tumour |
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What toxicity effects are associated with the use of radiation in the treatment of cancer?
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Acute radiation effects
• Occurs largely in renewing tissues (e.g. skni, SI, bladder & vagina mucosa) • Dependent on duration Late radiation effects • The dose-limiting factor • Necrosis, fibrosis, fistula formation, nonhealing ulceration, damage to specific organs • Depends on total dose & size of radiation rather than duration |
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Discuss the benefits of combination chemotherapy vs single-agent chemotherapy.
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Standard single drugs at clinically tolerable doses have been unable to cure cancer.
Combination chemo: • Provides maximal kill within range of toxicity tolerated • Broader range of interaction b/w drugs & tumour cells with different genetic abnormalities in a heterogenous tumor population • May prevent or slow down drug resistance |
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How should and shouldn't the dose of chemotherapy be calculated?
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• BSA calculated dose not accurate (do not use as sole parameter)
• Do not use extremes of BSA to calculate dose • Adjust dose based on appropriate tests of drug elimination • Check for other meds that may alter drug elimination • Check other factors that affect normal tissue sensitivity • Know that this dose will be incorrect in up to 40% of the time - ~10% will be overdosed • Measure a biological endpoint (e.g. myelosuppression) to check affect of administered dose |
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What is the effect of chemotherapy on neutrophil count and how can we manage this?
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• Decreases neutrophil count
• Mortality from infection increases greatly when the absolute neutrophil count is low • Reduce this risk by giving colony stimulating factors |
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What is the effect of chemotherapy on platelet count and how can we manage this?
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• Platelet count drops (slower than with neutrophils)
• Prophylactic transfusion of platelets |
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What is mucositis and how is it managed in chemotherapy?
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• Erythema, inflammation, ulceration, haemorrhage & pain of soft palate, buccal mucosa, tongue, floor of mouth
• Onset parallels neutrophil count • One of the most debilitating SEs of chemotherapy Management: • Mouth care • Cryotherapy • Antibiotic pastille or paste • Benzydamine, chlorhexidine or cocaine mouthwash • Clarithromycin, GM-CSF, povidone iodine rinse, sucralfate • Opioids for pain |
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What is Palifermin?
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• Developed for prevention & management of severe oral mucositis
• Enhances proliferation of epithelial cells & increases tissue thickness of tongue, buccal mucosa & GIT and upregulates cytoprotective mechanisms • Helps protect epithelial cells lining mouth & gut from damage caused by SE's of chemo & radiation Tx • Approved for use in pts with haematological malignancies receiving very high doses of chemo • Injected before & after transplantation • Not PBS listed and very expensive so you have to be abit selective |
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What are some side/toxic effects of chemotherapy?
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• Neutropenia
• Thrombocytopenia • Mucositis • Alopecia • Infertility • Nausea & vomiting |
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How is chemotherapy induced nausea & vomiting managed (acute, delayed, anticiatory)?
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Acute:
• 3 drug regimen • 5-HT3 antagonist, dexamethasone + aprepitant given before chemo Delayed: • Metoclopramide • +/- Dexamethasone Anticipatory: • Lorazepam SL |
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What is Palonosetron?
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• 5-HT3 receptor antagonist
• Long half life & receptor binding • Approved for prevention of chemotherapy induced N+V • Superiority over ondansetron • Superior for delayed N+V • Not on PBS yet.. • Injectable form |
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What is Aprepitant?
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• Substance P/NK1 receptor antagonist
• Used in treatment of chemotherapy induced N+V • Given an hour before chemo, and for 2 days after |
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What is EGFR inhibitor associated rash and how is it managed?
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• EGFR expressed by normal keratinocytes & skin fibroblasts
• EGFR inhibition in basal epidermal keratinocytes & outer root sheath of hair follicle leads to growth arrest & inflammation • Described as "acniform" • Starts in first 2 weeks, max intensity after 2-3 weeks Management: • Continuation of Tx primary goal • Patient education • Rash often improves spontaneously w/out intervention • No evidence based guidelines • Approaches incl. antibiotics, antifungals, steroids, tretinoin • Dose reductions only when absolutely necessary (may reduce Tx effectiveness) |
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What SE's can you get with the use of Sunitinib?
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Skin discolouration
• Assoc. with yellow discolouration of urine secondary to excretion of drug & metabolites • Occurs after one week of therapy • Reversible with discontinuation of therapy Hair depigmentation: • Reversible after discontinuation Hypothyroidism • Can present as fatigue |
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What SE's can you get with Sunitinib and Sorafenib?
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Subungual splinter haemorrhages:
• Looks like red/black wood splinters under nails • Painless • More common on fingernails than toes Hand-foot skin reactions: • Paresthesia, tingling, burning or painful sensations • Development of cutaneous lesions • Hyperkeratosis • 1/3 have SMx that impact on walking capacity • Preventative measures (avoid tight shoes, wear soft shoes, emollient creams, shock absorbers, pedicure and/or lotions for hyperkeratosis, topical steroids) |
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What is a SE that can be seen with any EGFR inhibitor?
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Paronychial inflammation (nail changes)
• Erythema first, then lesions • Can be very painful • Pathogenesis unknown • Affects fingers or toes • Antibiotics often warranted • Sometimes resolves spontaneously • Disappears within days of discontinuation of EGFR inhibitor |
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What is the role of thalidomide in oncology and what are some side effects?
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Immunomodulatory agent with anti-angiogenesis properties
• S100 approval for refractory or relapsed multiple myeloma in pts who have failed at least one other treatment Side effects • Somnolence (take at night) • Teratogenic • Peripheral neuropathy (reversible if stopped in early stages) • Increased risk of DVT |
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What and when is Bortezomib used, and what are some of the AE's?
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• Reversible inhibitor of 26S proteasome
• Used in multiple myeloma • Use after thalidomide has not worked or pt unable to tolerate Side effects: • Peripheral neuropathy • Thrombocytopenia • Diarrhoea (common, use loperamide) • Hypotension • Acute liver failure |
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What is rituximab and what are some of its serious adverse effects?
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Monoclonal antibody which binds specifically to CD20 antigen on normal & malignant B lymphocytes.
• CD20 expressed by >90% of B-cell non-Hodgkin's lymphoma • No CD20 on human stem cells, progenitor cells or plasma cells Serious AE's: • Hepatotoxicity • Fluid retention syndrome • Neutropenia • Thrombocytopenia • Severe infusion reactions (may be fatal) |
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What are the signs and symptoms of a severe infusion reaction with ritixumab, and what is the management?
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(first infusion event)
Signs & symptoms: • Hypotension, angioedema, hypoxia, bronchospasm Most severe: • Pulmonary infiltrates • Acute respiratory distress syndrome • Myocardial infection • Ventricular fibrillation • Cardiogenic shock Management: • Interrupt rituximab infusion • Supportive care (e.g. IV fluids, vasoopressors, O2, bronchodilators) • Infusion may be resumed upon SMx resolution with 50% rate reduction |
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What are the eligibility requirements for rapid administration of rituximab?
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• Pts who have not had a grade 3 reaction to their 1st or subsequent rituximab infusions
• Prescriber endorsed medication chart with "over 2 hrs" • Pts must receive the following premedications 30 mins prior to infusion: - Corticosteroid - Oral paracetamol - Antihistamine Exclusion criteria: • Pts with CLL & those with persisting circulating malignant cells • Pts who have had a severe first dose reaction |
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What are the symptoms in spinal cord compression (oncologic emergency) and what is the treatment?
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The compression of the spinal cord by metastatic or locally advanced cancer.
• Pain accompanies in most cases • Weakness develops gradually in association w/ progressive balance disturbance & numbness • Complete loss of motor & sensory function below the affected level can occur abruptly as vascular insufficiency progresses to ischaemia Treatment: • Corticosteroids (except in those with early cord compression & no motor or sensory dysfunction) • All pts should be considered for primary radiotherapy • Surgery • Radiotherapy should follow surgical resection if site hsa not previously been irradiated |
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What are the symptoms of hypercalcaemia (metabolic oncologic emergency) and what is the treatment?
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Pts present with wide variety of symptoms affecting multiple organ systems.
Treatment is to decrease serum calcium by: • Increasing urinary Ca excretion - Increase fluids - Tx with antiresorptive drugs • Decreasing bone resorption by inhibition of osteoclast function - Bisphosphonates - Calcitonin - Phosphates - Corticosteroids (acutely inhibit osteoclast-mediated bone resorption) |
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What are the signs and symptoms of hyperuricaemia (metabolic oncologic emergency) and what is the treatment?
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Results from breakdown of nucleic acids from within cells. Uric acid combines & forms crystals which precipitate within collecting ducts of renal tubules - obstrutive uropathy/ARF
Treatment: • Hydration • Alkalinisation • Prevent uric acid crystallisation • Breakdown formed uric acid crystals Allopurinol • Xanthine oxidase inhibitor • Inhibits synthesis of uric acid from xanthine & hypoxanthine (which are more soluble than uric acid) |
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What is tumour lysis syndrome (a metabolic oncologic emergency) and how do you prevent it?
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Rapid release of intracellular contents into bloodstream which then increase to life-threatening concentrations.
Characterised by hyperuricaemia, hyperkalemia, hyperphosphatemia & hypocalcaemia. • Lethal cardiac arrhthmias are most serious consequence of hyperkalemia Prevention: • IV hydration should start 24-48 hrs before administration of chemo • Tx with allopurinol should be undertaken along with other measures to minimise hyperuricaemia |
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What urological oncologic emergencies can occur?
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Cystitis due to:
• Chemotherapy • Radiation • Thrombocytopenia w/ subsequent bleeding • Myelosuppresion w/ assoc. infection Bladder haemorrhage: • Related to thrombocytopenia Urinary obstruction: • Can lead to accumulation of water, urea, electrolytes as well as loss of renal concentrating ability • Immediately after release of obstruction, brisk diuresis, hypovolemia & shock can occur • Pts with severe fluid & electrolyte disturbances may require dialysis |
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What happens in superior vena cava obstruction (an oncologic emergency) and what is the treatment?
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• SVC is responsible for flow of blood from upper body to heart
• Obstruction leads to congestion of blood above blockage • Untreated can lead to death (pulmonary, cardiac & cerebral oedema) Most often caused by lung cancer and sometimes by lymphoma and other cancers. SMx: • Dyspnoea • Vein distention • Facial, arm oedema • Cough • Chest pain • Dysphagia Treatment: • Chemotherapy • Radiotherapy • Surgery • Anticoagulation & thrombolysis if indicated • Oxygen • Elevate bedhead • Diuretics for oedema • Steroids reduce cerebral oedema |
