Heme Onc Combined
What is the definition of a fever?
(1) One temperature of 38.3C or greater OR (2) Temp of 28 C for sustained for at least 1 hour
Myelodysplastic syndrome: (A) Is caused by an abnormal population of dysplastic plasma cells (B) Typically presents with microcytic anemia (C) Can progress into acute leukemia in select patients (D) Can be diagnosed by looking at the peripheral smear (E) Commonly presents in the fifth decade of life
(C) Can progress into acute leukemia in select patients
von Willebrand disease type I: (A) Is an autosomal recessive bleeding disorder (B) Has a predilection to affect males (C) Causes a prolonged prothrombin time/international ratio (PT/INR) (D) Can be treated with vasopressin (DDAVP) for bleeding (E) Is often followed by measuring factor VII levels
(D) Can be treated with vasopressin (DDAVP) for bleeding
What is acupuncture best known for treating?
*Acute and chronic pain control* N/V Fatigue Diarrhea/constipation
What are some inherited thrombotic disorders?
*Factor V Leiden* *PT 20210A (gene mutation)* Protein C deficiency Protein S deficiency AT-III deficiency Dysfibrinogenemia
What are some clinical symptoms of MDS?
*Infection* Ecchymoses Fatigue Pallor Ecchymoses/petechiae Abnormal bleeding
How do you dx and evaluate NHL?
*Lymph node biopsy* BM biopsy CBC, ESR Chem panel, uric acid LDH (poor prognostic feature) Beta2 Microglobulin Serum protein electrophoresis CXR (mediastinal mass) CT C/A/P PET/CT scan Lumbar puncture for undifferentiated lymphoma
How do you dx Hodgkin's Disease?
*Lymph node excisional biopsy* PE, CBC, ESR, chem panel, CT C/A/P, BM bx, PET scan
How is hereditary spherocytosis diagnosed?
*Osmotic fragility test* and exam of peripheral smear.
What is the role of surgery in metastatic disease?
- Primary tumor is controlled/can be controlled - Metastasis is single or multiple which are *localized* - Evidence that there will be clinical benefits - Tumor doubling time is sufficiently long - No significant co-morbid factor Complete resection of distant mets improves 5 year survival rates
What are the components of the history of the development of CIM?
- immigrants bring old world healing - advances in aseptic techniques and introduction of abx changed approach to therapeutics - information age/mass transport - consumer demand
What are some characteristics of Follicular lymphoma?
- usually widespread at presentation - often asymptomatic - not curable (some exceptions) - cell of origin: germinal center B-cell - High M and M - watch and wait if asymptomatic
What are the stages of the Zubrod Scale?
0 - Normal activity 1 - Symptomatic and ambulatory; cares for self 2 - Ambulatory > 50% of time; occasional assistance 3 - Ambulatory </= 50% of time; nursing care needed 4 - Bedridden
What are the stages of CLL?
0 - lymphocytosis (> 15,000) I - lymphocytosis, adenopathy II - Lymphocytosis, hepatosplenomegaly III - Lymphocytosis, anemia (Hgb < 11) IV - lymphocytosis, thrombocytopenia (plt < 100,000)
What is the normal range for reticulocytes?
0.5 - 1.5%
What does 1 Gray of radiation provide in terms of energy
1 Joule/ Kilogram of tissue
What are some causes of aplastic anemia?
1) Acquired: - irradiation, drugs and chemicals, viruses (parvovirus), immune diseases 2) Inherited - Fanconi's anemia 3) Idiopathic
What are 5 clinical risk factors in NHL?
1) Age >/= 60 2) Serum LDH elevated 3) Poor performance status 4) Ann Arbor Stage III or IV 5) > 1 extranodal site Pts assigned 1 point for each factor. Grouped by type of NHL: 0,1: low risk, 80% complete response 2: low-intermediate risk 3: high-intermediate risk 4,5: high risk, lower response rate, poor survival
What are some other emergency conditions that can be caused by CA?
1) Airway obstruction 2) Acute-malignancy-associated cardiac tamponade 3) Hyperviscosity syndrome
What is the #1 and #2 Dx in hospice utilization?
1) Alzheimer's disease 2) CHF
How can you assess for non physical causes of pain?
1) Ask about and listen non-judgmentally for clues about the presence of: psychological, social and spiritual issues 2) Nonjudgmental listening, emotional support and education can alleviate mild nonphysical pain 3) Moderate to severe non-physical pain requires more patient interventions including medications and the involvement of counselors, social workers or chaplains.
What are the signs and symptoms of anemia (in order of appearance)?
1) Asymptomatic - develops slowly or is chronic and stable 2) *SOB or DOE* 3) Weakness/fatigue 4) Dizziness/lightheadedness 5) Tinnitus or pounding/whooshing in ears 6) Pallor
What are some causes of a high MCV (megaloblastic anemia)?
1) B12 deficiency 2) Folate deficiency 3) Drugs: chemo, phenytoin 4) Hemolytic anemias: high retic count b/c retics are larger than normal RBCs
How are chronic myeloproliferative disorders classified?
1) Based on lineage of predominant proliferation 2) Level of marrow fibrosis 3) Clinical and lab data
How do you treat Acquired Thrombotic Thrombocytopenic Purpura?
1) Begin daily plasma exchange as soon as possible (within 4 to 8 hours of presentation) in patients with microangiopathic hemolytic anemia (ie, anemia with schistocytes on peripheral smear) and thrombocytopenia, and no other identifiable clinical cause. 2) Immunosuppressant therapy with corticosteroids 3) Start low-dose aspirin once the platelet count is over 50 x 10⁹/L, stopping when recovery from the episode has been achieved (usually 1-2 months after presentation) 4) Administer low-molecular-weight heparin when platelet count is over 50 x 10⁹/L until acute episode has resolved 5) Folic acid supplementation 6) Additional support is provided as needed, including anticonvulsants for seizures, antihypertensives for hypertension, and packed RBCs if needed for severe anemia
What are the causes of Fe def anemia?
1) Blood loss (most common cause in adults) 2) Inadequate absorption 3) Dietary deficiency (most common cause in children)
In what cases can XRT help with palliation?
1) Bone pain can be incapacitating, to the point of excruciating. - XRT diminishes or eradicates pain in 70% of cases - prevent pathological fx - stabilize a pinning or joint replacement 2) Brain mets can incapacitate the pt depending on location - reduce intracranial pressure - diminish symptoms - improve QOL
What are two common validated screening tools for substance use disorder?
1) CAGE-AID 2) Opioid Risk Tool (ORT)
What are some imaging studies you can use to dx SVC syndrome and what will you find?
1) CXR: mediastinal widening and/or pleural effusion 2) CT chest with IV contrast: masses and collateral vessels 3) *Superior Vena Cavogram*: gold standard 4) Biopsy
What are the main types of cancers?
1) Carcinoma 2) Sarcoma 3) Leukemia 4) Lymphoma and multiple myeloma 5) CNS cancers
What are treatment options for CLL?
1) Chemotherapy - frequently given in combinations - bendamustine, chlorambucil, fludarabine, cyclophosphamide 2) Monoclonal antibody - Anti CD20, obinutuzumab, alemtuzumab (anti CD52) 3) Corticosteroids for autoimmune complications 4) Splenectomy
Which clonal abnormalities can develop into AML?
1) Chronic Myeloid Leukemia 2) Polycythaemia rubra vera 3) Myelofibrosis
What are the three phases of CML?
1) Chronic phase - < 10% myeloblasts in BM - lasts 3-5 years (lengthening chronic phase with improved therapy) 2) Accelerated phase - 10 - 20% myeloblasts in BM - transitional phase < 1 year 3) Blasts crisis! (acute leukemia) - > 20% myeloblasts in BM - 3-6 mos survival
What are three causes of intravascular hemolytic anemia?
1) DIC 2) TTP 3) G6PD (rare, inherited)
What are some potential cellular targets for cancer therapy?
1) DNA direct damage (traditional chemo) 2) Binding to membrane antigens 3) DNA/RNA transcription block or interference 4) DNA replication/repair systems 5) Intracellular regulatory or housekeeping systems 6) Extracellular portion of transmembrane receptors 7) Extracellular ligands 8) Modulation of intracellular pathways that signal the nucleus
What are the two main causes of MDS?
1) De Novo: environmental exposure - benzene - cigarette smoking - viruses: Fanconi's anemia 2) Therapy related: - alkylating agent chemo - radiation
What are some causes of secondary erythrocytosis due to increased EPO level or response?
1) EPO producing tumors: hepatoma, uterine leiomyoma, cerebellar hemangioblastoma, ovarian carcinoma, pheochromocytoma 2) Renal diseases: RCC, kidney cysts, hydronephrosis, renal transplant 3) Androgen abuse: adrenocortical hypersecretion, exogenous androgens
What are the four ways in which normal cells acquire cancer-causing mutations?
1) Environmental insults 2) Spontaneous errors 3) Inherited from parents 4) Carried into cells via viruses
What are the 6 hallmarks of CA?
1) Evading apoptosis 2) Self-sufficiency in growth signals 3) Insensitivity to anti-growth signals 4) Sustained angiogenesis 5) Limitless replicative potential 6) Tissue invasion and metastasis
What are the three main classifications of Heavy Chain Diseases?
1) Gamma Heavy Chain 2) Alpha Heavy Chain 3) Mu Heavy Chain
What is the theory behind BM or Peripheral Blood Stem Cell Transplantation?
1) Giving higher doses of chemo will yield better chance of killing all tumor cells 2) High-dose chemo will also ablate the BM leaving pt at high risk 3) Remove/store some BM or PBSC before chemo- give back after chemo 4) Usually performed as outpatient procedure
What are the two diagnostic groups for MDS?
1) Good group - refractory anemia - refractory anemia with ringed sideroblasts - 5q syndrome 2) Bad group - refractory anemia with excess blasts - refractory cytopenia with multilineage dysplasia
What are some common side effects of cancer therapy?
1) Hematological toxicity: anemia, neutropenia 2) Pain 3) Neurological toxicity: peripheral neuropathy, cognitive impairment 4) Psychological toxicity: emotional distress
How can you distinguish TTP from HUS?
1) Hemolytic uremic syndrome tends to affect children and adolescents, whereas thrombotic thrombocytopenic purpura tends to manifest in adults 2) Hemolytic uremic syndrome typically follows Escherichia coli gastroenteritis 3) Renal dysfunction tends to predominate and neurologic deficits are less common in hemolytic uremic syndrome, whereas 65% of patients with thrombotic thrombocytopenic purpura present with neurologic deficits, and renal dysfunction is less common
What are the disorders that cause thrombocytopenia due to destruction of plts?
1) ITP 2) Drug reaction 3) HIT 4) DIC and TTP
What are the etiologies of folate deficiency?
1) Inadequate intake - malnourishment - alcoholism - drug addiction - elderly - inadequate food prep 2) Increased requirements - pregnancy - acute or chronic hemolysis - exfoliative dermatitis - malabsorption
What are three main types of NHLs?
1) Indolent Lymphomas (B, T or NK cell) 2) Aggressive Lymphomas (B or T cell) 3) Highly Aggressive Lymphomas (B or T cell)
How is APL treated?
1) Initial therapy (4-6 weeks - Tretinoin + Arsenic 2) Postremission therapy (Consolidation 4-6 mos) - Chemo - Autologous/allogeneic Stem cell transplant 3) Supportive Care - growth factors - transfusions
How is AML treated?
1) Initial therapy (induction 4-6 weeks) - Anthracycline + Cytarabine 2) Post remission therapy (Consolidation 4-6 mos) - Chemo - autologous/allogeneic stem cell transplant 3) Supportive Care - growth factors - transfusions
What are the options for routes of administration for chemo?
1) Intravenous Push or Intravenous Piggyback - infusaport/mediport - Hickman catheter (Central venous catheter) - PICC line 2) Oral 3) Intrathecal: Ommaya reservoir 4) Regional - intra-arterial
What are the different grades of NHL?
1) Low grade (indolent, slow growing) - smaller, more mature cells, follicular pattern 2) Intermediate grade (aggressive) - mix of small to large cells, diffuse pattern 3) High grade (highly aggressive) - very immature cells, very mitotically active, diffuse pattern
What are the goals of XRT treatment planning?
1) Maximize the dose to the tumor volume 2) Minimize the dose to the surrounding normal tissue
What are four systems that can be emergently affected by oncologic problems?
1) Neurological 2) Cardiopulmonary 3) Hematological 4) Metabolic
What are some consequences of chronic myeloproliferative disorders?
1) Overproduction of all cell lines, with usually one line in particular. 2) Fibrosis is a secondary event 3) Acute Myeloid Leukemia
What are the possible etiologies of hypercalcemia in CA?
1) PTH-related protein secretion (humoral hypercalcemia of malignancy) - Breast CA, ovarian carcinomas, NHL, leukemia 2) Increase osteoclast activity - osteolytic mets from breast CA, MM 3) Increased 1,25 OH D production - Hodgkin lymphoma, some NHL, ovarian dysgerminomas 4) Ectopic PTH secretion - ovarian carcinoma, lung carcinoma, pancreatic malignancy
What are the various etiologies of B12 deficiency anemia?
1) Pernicious anemia (autoimmune systemic disorder) 2) Pregnancy 3) Dietary insufficiency (vegan) 4) Malabsorption (celiac) 5) Gastrectomy or intestinal bypass for obesity 6) Atrophic gatritis 7) Tapeworm 8) Pancreatic insufficiency
How can you dx TTP?
1) Petechiae, purpura, and/or ecchymoses 2) Thrombocytopenia (platelet count below 50 x 10⁹/L or 50% decrease from previous count) 3) Schistocytes on peripheral blood smear 4) Signs of hemolysis (eg, jaundice, high I-lactate dehydrogenase, elevated bilirubin, decreased haptoglobin)
How do you treat Waldenstrom Macroglobulinemia?
1) Plasmapheresis: control hyperviscosity symptoms 2) Chemotherapy: fludarabine, cladribine, velcade, rituximab (anti CD 20), ibrutinib 3) Autologous stem cell transplant (younger pts with more aggressive disease)
What are some causes of thrombocytopenia due to decreased production?
1) Post-viral (parvo, Hep B/C, EBV, varicella, measles, mumps, rubella, MMR vaccine, CMV, toxo, influenza) 2) Sepsis (DIC) 3) Aplastic anemia (pancytopenia) 4) Direct toxicity to BM (XRT, chemo, alcohol) 5) Marrow infiltration (lymphoma, myelofibrosis, mets, tB) 6) Meds with toxic effect (non immune-mediated: TMS) 7) Malignancies 8) B12 or folate def 9) Congenital (Fanconi)
What are the different types of Immune Thrombocytopenic Purpura (ITP)?
1) Primary: Acquired immune autodestruction of plts 2) Secondary: Associated with another condition: HIV, HepC, SLE, CLL 3) Drug-induced immune thrombocytopenia: drug-dependent platelet antibodies that cause platelet destruction (acetaminophen, quinine, quinidine, ibuprofen, Trimethoprim-sulfamethoxazole, valproic acid, vanco, beta lactams, etc)
What are the benefits of fractionated treatments?
1) Reduces acute effects on normal tissues 2) Tumor cells and normal cells both sustain damage, but normal cells repair and repopulate between fractions.
What does the response of tumor to XRT depend on?
1) Response to the particular histology of radiation 2) Oxygenation of tumor (blood flow) 3) Size of tumor
What are the methods used in radiation treatment planning?
1) Rx planning CT: 2) Collimators: creates edge of the beam, customized to each patient. 3) Dosimetry: via computer planning, determination of dose to - tumor or tumor bed - critical adjacent organs at risk Multiple fields centered on the tumor or multiple arcs with fulcrum at tumor
Serious Illness Conversation Guide components
1) Set up the convo 2) Assess illness understanding and information preferences 3) Share prognosis: take info to pt preference, allow silence 4) Explore key topics: goals, fears and worries, sources of strength, critical abilities, tradeoffs, family 5) Close the conversation 6) Document your conversation
What are two types of nociceptive pain?
1) Somatic: innervates skin, bone, muscle, precise often sharp, aching or throbbing 2) Visceral: mediated by autonomic nervous system, GI tract structure, hollow organs
What 5 organs tend to be at risk during stereotactic body radiation therapy?
1) Spinal cord 2) Great vessels 3) Duodenum 4) Kidney 5) Liver
What are some situations in which XRT can help in emergencies?
1) Spinal cord compression: back pain radiating around to front bilaterally with band-like pain. Later - loss of motor function, loss of continence, loss of sensation. - XRT can prevent these deficits from becoming permanent 2) Superior Vena Cava Syndrome: tumor or mets presses on SVC, backing up blood flow - puffiness or neck and pulmonary congestion. if SCC of lung, often treated with chemo
What are some catastrophic side effects of XRT?
1) Transverse myelitis - loss of neurologic function at site of overdose to spinal cord and all points distal Paraplegia or quadriplegia 2) Blindness from excess dose to retinas or optic chiasm 3) Radiation pneumonitis: SOB, non-productive cough > pulmonary cripple 4) Sudden death: fatal pericarditis 5) Kidney failure - dialysis, transplant or death
What are four reasons why anemia develops?
1) Underproduction (hypoproliferative marrow) 2) Increased destruction (less than normal 120 day life span): sickle cell, DIC, thalassemia, autoimmune, TTP 3) Blood loss: surgery, trauma 4) Combo of underproduction and shortened life span: chronic inflammatory disease
What is the process of hemostasis?
1) Vascular injury (collagen exposure) 2) Plt adhesion and activation 3) Plt aggregation (primary hemostatic plug) 4) Fibrin formation via cascade (secondary hemostasis) 5) Clot retraction (thrombasthenin) 6) Fibrinolysis and healing
What are some indications for using a PCA?
1. Cannot use oral route 2. For perioperative pain management 3. For rapid titration/dose finding 4. For rapid control of severe incident pain
What is the conventional fractionation scheme (treatment schedule)?
1.8 - 2 Gy/Fxn once/day @ 5 days/week
What is the time to maximal concentration of an IV med?
10 mins
What is the platelet nadir in HIT?
15K - 150 K
In which year was the Philadelphia chromosome identified?
1960
In which year was the Tp53 gene (most commonly mutated gene in human cancer, a tumor suppressor gene, protein product P53) used to help control cell proliferation to suppress tumor growth?
1979
When did the FDA approve rituximab (monoclonal antibody)?
1997
When did the FDA approve Gardasil?
2006
When was the first human cancer treatment vaccine created?
2010
How long does one cycle of chemotherapy typically last?
21 - 28 days
What is the time to maximal concentration of a SC or IM med?
30 mins
According to the MD Anderson study of pts with gyno or breast CA, what % of patients used pharmacologic CAM therapies?
48%
What is a haplo-identical BM or PBSC transplant?
50% match Usually from parent or child
What is haplo-identical BM or PBSC transplant?
50% match, usually from parent or child
According to the MD Anderson study of pts with gyno or breast CA, what % of patients told their physician about using CAM therapy?
54%
What is the skin CA fractionation scheme (treatment schedule)?
6 Gy/Fxn once/week x 6 weeks 3 Gy/Fxn once/day x 16 Rx days @ 5 days/week 2 Gy/Fxn once/day x 30 Rx days @ 5 days/week
What is the time to maximal concentration of a PO med?
60 mins
What % of patients do not tell their doctors that they use CIM?
60%
What are some characteristics of Monoclonal Gammopathy of Undetermined Significance (MGUS)?
< 10% BM plasma cells < 3 g/dL of M components Minimal urinary Bence Jones protein No anemia, renal failure, lytic bone lesions or hypercalcemia
What are some poor indicators in ALL?
>/= 50,000 WBC < 1 or >/= 10 years of age Male T cell and mixed blasts Hypoploidy Trisomy 5 t(1;19) E2A/PBX1 Mixed lineage leukemia T(9;22) Ph BM blast count during induction: Mild reduction at day 7
Sub-staging in NHL
A = Absence of B symptoms B = Presence of B symptoms (fever, night sweats, wt loss > 10%) C = Extralymphatic involvement
What is mindfulness meditation?
A Buddhist concept taking a non-judgemental look at thoughts and images in order to release them.
After treatment with iron, what response should you expect?
A brisk reticulocyte response (1-2 weeks) 2 g increase in Hgb in 3 weeks
What is transcendental meditation?
A concentrative meditation using a mantra created by Maharishi Mahesh Yogi
What is the definition of CA-related fatigue?
A distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to CA or CA treatment that is not proportional to recent activity and interferes with usual functioning. Most patients will experience
What is opioid tolerance?
A long-term adaptation to opioid exposure that causes one or more opioid effects to diminish over time at any given dose. Tolerance typically develops rapidly to sedation and nausea (hours to days)
What is the RBC Distribution Width (RDW)?
A measure of the amount of variability in size of RBC. The higher the number, the greater the variability or heterogeneity of RBC size.
What is Reiki?
A meditative state in which a Reiki energy is transferred from a universal force through a practitioner into a client to facilitate healing.
What is biofeedback?
A modality where the practitioner learns to control and change bodily functions such as heart rate, muscle tension, and pain reduction by visualization/meditation while attached to a feedback system.
What is the NCCN definition of distress in CA?
A multi-factorial unpleasant emotional experience of a psychological, social and/or spiritual nature that may interfere with the ability to cope effectively with CA, it's physical symptoms and treatment. Extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis.
What is Thrombotic Thrombocytopenic Purpura (TTP)?
A rare, life-threatening thrombotic microangiopathy characterized by thrombocytopenia, microvasculature occlusion, and hemolysis.
Which oncological condition is present in nearly every case of acute promyelocytic leukemia? A. Acute disseminated intravascular coagulation B. Spinal cord compression C. Hypercalcemia D. Superior vena cava syndrome E. Airway obstruction
A. Acute disseminated intravascular coagulation
In which of the following diseases are petechiae typically found on physical examination? A. Aplastic anemia B. Meningococcemia C. Endocarditis D. Rocky Mountain spotted fever E. Polycythemia rubra vera
A. Aplastic anemia B. Meningococcemia C. Endocarditis D. Rocky Mountain spotted fever
Which of the following laboratory values would be expected in a patient who has hemolysis? A. Decreased serum haptoglobin B. Increased serum lactate dehydrogenase C. Increased reticulocyte percentage D. Decreased serum gamma-glutamyl transpeptidase E. Decreased serum ferritin
A. Decreased serum haptoglobin B. Increased serum lactate dehydrogenase C. Increased reticulocyte percentage
Presence of which of the following differentiates intravascular hemolysis from extravascular hemolysis? A. Hemosiderinuria B. Elevation of serum indirect bilirubin C. Absent serum haptoglobin D. Hypersegmented neutrophils on peripheral smear examination E. Nucleated red blood cells on peripheral smear examination
A. Hemosiderinuria
Which of the following are risk factors for substance use disorder based on medical and social history? A. History of drug and/or alcohol use B. Current opioid therapy C. Current drug and/or alcohol use D. Family history of substance use disorders
A. History of drug and/or alcohol use C. Current drug and/or alcohol use D. Family history of substance use disorders
A 60 year-old female with a PMHx of hypertension, hyperlipidemia, and 80 pack-year smoking history. Patient complaining of facial swelling, which is made worse by leaning forward, worsening and bilateral arm swelling for the past 10 days. Patient has also had a chronic non-productive, non-bloody cough for 1 year. Patient also notes dyspnea of exertion, worsened over the past month. Based on the history, which is the most likely diagnosis? A. Lung cancer, complicated by superior vena cava syndrome B. Acute lymphoblastic leukemia, complicated by tumor lysis syndrome C. Pancreatic cancer, complicated by bowel obstruction D. Multiple myeloma, complicated by spinal cord compression E. Breast cancer, complicated by cardiac tamponade
A. Lung cancer, complicated by superior vena cava syndrome
Which patients should be asked about substance use history? A. Patients currently on opioid therapy B. Opioid-naïve patients for whom they are considering opioid therapy
A. Patients currently on opioid therapy B. Opioid-naïve patients for whom they are considering opioid therapy
Which of the following is a cause of vitamin B12 deficiency? A. Pernicious anemia B. Strict vegan diet C. Crohn's disease D. Hypertriglyceridemia E. Sulfonylurea medication
A. Pernicious anemia B. Strict vegan diet C. Crohn's disease
Which of the following serum laboratory values is typically elevated in the tumor lysis syndrome? A. Potassium B. Sodium C. Uric acid D. Norepinephrine E. 5-Hydroxyindoleacetic acid
A. Potassium C. Uric acid
AML, ALL, CML or CLL? Childhood Pre-B cell Leukocytosis or pancytopenia Treat with combo chemo
ALL
What accounts for 25% of childhood cancers?
ALL
Hematopoietic cell lines
ALL: Lymphoid progenitor CLL: Naive B-lymphocytes Lymphomas: Germinal center B lymphocyte or T lymphocytes MM: Plasma cells AML: Myeloid progenitor
AML, ALL, CML or CLL? Auer rods Adults ~60 Leukocytosis or pancytopenia Treat with chemo or transplant
AML
Which leukemia accounts for 85% of the acute leukemias in adults?
AML
What other leukemia can you see the Philadelphia chromosome?
AML (small %)
Which leukemias is leukostasis most commonly seen?
AML ALL CML in blast crisis
How can you tell AML from ALL in the cytochemistry?
AML: Positivity with Sudan black and Myeloperoxidase (MPO)
What is the definition of neutropenia?
ANC < 1.5 Mild: 1.0 - 1.5 Moderate: 0.5 - 1.0 Severe: 0 - 0.5
What are some common associations with DIC?
APL Sepsis Trauma Obstetric complications Intravascular hemolysis
According to the WHO 3-step ladder, 1 or mild pain should be treated with what...
ASA Acetaminophen NSAIDs +/- adjuvants
How do you treat symptoms of Essential Thrombocythemia?
ASA Some are resistant and need cytoreductive therapy
What is Bernard Soulier Disease?
Abnormal GP1b-IX complex - receptor for vWF - adhesion/plt activation @ high shear stress - testeed by ability to aggregate plt in presence of ristocetin
What happens in vWF disease?
Abnormal synthesis of vWF causes decreased plt adhesion and decreased serum levels of factor VIII
Characteristics of AML
Accumulation of immature blast cells Avg age of dx: 60 years Increases rapidly with age Male > Female Abrupt, dramatic onset - serious infections, abnormal bleeding Hyperplasia of BM and spleen
According to the WHO 3-step ladder, 2 or moderate pain should be treated with ..
Acetaminophen/Codeine Acetaminophen/hydrocodone Acetaminophen/oxycodone Acetaminophen/dihydrocodeine Tramadol +/- Adjuvants
Which is more common: acquired aplastic anemia or idiopathic aplastic anemia?
Acquired (80%)
What are some alternative therapies for pain?
Acupuncture Aromatherapy - peppermint, lavender, cypress Homeopathy Massage/reflexology Yoga Meditation/visual imagery Nutrition - anti-inflammatory diet
What are some alternative treatments for HA?
Acupuncture Aromatherapy Homeopathy Massage/reflexology Chiropractic Yoga Meditation/guided imagery Nutrition - avoid trigger foods
What are some alternative treatments for immune suppression?
Acupuncture Aromatherapy Homeopathy Massage/reflexology Yoga Meditation/guided imagery Nutrition - mushrooms, juices, berries Supplements - ginseng, mushrooms, astragalus
What are some alternative treatments for insomnia?
Acupuncture Aromatherapy Homeopathy Massage/reflexology Yoga Meditation/visual imagery Nutrition - avoid caffeine, alcohol Supplements - L-tryptophan, melatonin, valerian
What are some alternative therapies for N/V?
Acupuncture Aromatherapy Homeopathy Massage/reflexology Yoga Meditation/visual imagery Nutrition - fresh/dried ginger, congee, roasted pumpkin Supplements - ginger
What are alternative treatments for xerostomia/mucositis?
Acupuncture Homeopathy Massage/reflexology Meditation/visual imagery Nutrition - honey, garlic, green tea Supplements - glutamine
Which malignancy is DIC most commonly associated with?
Acute Promyelocytic Leukemia (APL)
What are signs/symptoms of GvH disease?
Acute disease is characterized by maculopapular rash, jaundice, and diarrhea Chronic disease affects multiple organs and is characterized by involvement of skin, eyes, mouth, lungs, genitalia, gastrointestinal tract, and musculoskeletal system
What are adverse effects of monoclonal antibodies?
Acute infusional hypersensitivity reactions (rigors, fevers)
What are the therapeutic effects of ginseng?
Adaptogen: increases resilience and resistance to stress enabling the body to avoid reaching collapse Tonic Stimulant Hypoglycemic
How do you convert a short to a long acting drug?
Add all short acting doses in a 24 hour period Divide by 2 for the long acting dosage Oral to IV route 3:1 ratio
What does one Cycle of chemotherapy consist of?
Administration of cytotoxic agents + Subsequent drop in peripheral blood counts to the nadir + Recovery of blood counts to level at which next cycle can safely be given
How do you treat neutropenic fever?
Admit to hospital *Broad spectrum Abx should be started within an hour of fever* - Piperacillin-tazobactam or cefepime - Vanco can be added if concerned for gram + Consider IV hydration Neutropenic precautions Consider growth factor support, if warranted Acetaminophen for antipyresis
What is the daily requirement for folic acid?
Adult: 50 - 100 mcg/day Child: 50 mcg/day Pregnant/lactating: 300 - 400 mcg/day
Who gets Alpha Thalassemia?
African Americans and Asian origin
What are the demographics in G6PD?
African or Mediterranean heritage Predominantly males due to X linked transmission.
Approximately 70% of cancer survivors have comorbid conditions associated with....
Age-related Cancer-related Treatment sequelae
What are some examples of cardiopulmonary emergencies brought on by oncologic problems?
Airway obstruction Cardiac Tamponade SVC syndrome
What are some oncological emergencies that need to be treated within minutes?
Airway obstruction Neutropenic fever Cardiac tamponade Cord compression CNS mets with symptoms
Who should be screened for substance use disorder?
Al pain patient populations - prior to initiation of opioid therapy - when at risk behaviors occur - ongoing, at random but regular intervals
What are the classifications of CCNSAs?
Alkylating agents Antitumor antibiotics Hormonal therapies Nitrosoureas
How are aggressive, high grade NHL patients treated?
Allogeneic transplant
How is Hairy Cell Leukemia treated?
Alpha interferon Pentostatin *Cladribine*
Definition of anemia
An absolute decrease in the number of red blood cells as measured by: - Hgb < 12 - Hct - RBC # A lack of RBC sufficient to cause a functional impairment in a person's lifestyle
What is doxorubicin?
An anthracycline that can cause damage to heart muscle
What is the WHO definition of palliative care?
An approach that improves the *quality of life of patients and their families* facing the problems associated with life-threatening illness, through the *prevention and relief of suffering* by means of early ID and *impeccable assessment* and treatment of pain and other problems, *physical, psychosocial and spiritual.*
How does Medicare define hospice care?
An approach to caring for the terminally ill individual that provides palliative care. A program where patients with incurable diseases are symptomatically treated while encouraged to live until they die.
What was the first aromatase inhibitor and when was it created?
Anastrozole 1996
How do you dx myelofibrosis?
Anemia High WBC at presentation Later leukopenia and thrombocytopenia Leukoerythroblastic blood film Teardrop red cells BM aspiration failed due to fibrosis Trephine biopsy (fibrotic hypercellular marrow) JAK2+ in 50%
What are some lab findings in ALL?
Anemia Thrombocytopenia Leukopenia/leukocytosis BM infiltration malignant lymphoblasts High uric acid LDH
What are some lab findings in AML?
Anemia (Hgb < 11) Thrombocytopenia (plt < 100,000) Neutropenia (ANC < 1000) Blasts in peripheral blood > 20% blasts in BM Auer rod High uric acid/LDH DIC or Tumor lysis syndrome
What are some lab findings in MM?
Anemia (rouleaux formation) Hypercalcemia (due to bone lysis) Proteinuria (Overflow) Elevated ESR Renal failure (hypercalcemia and/or light chains) Immunoelectrophoresis reveals monoclonal protein Bence Jones Proteins in urine (free light chains > 300 mg/24 hours) Amyloidosis
What are some lab findings in Waldenstrom Macroglobulinemia?
Anemia - rouleaux formation Abnormal plasmacytoid lymphocytes BM plasmacytic lymphocyte infiltration Monoclonal IgM spike on SPEP in beta or gamma globulin region Positive Coombs
What are some causes of a normochromic, normocytic anemia?
Anemia of chronic disease (most common) Multiple Myeloma Leukemia Acute bleeding
What is one of the earliest symptoms of malignancy?
Anorexia
What is an allogeneic BM or PBSC transplant?
Another person's BM or PBSCs (HLA matched)
What is an allogeneic BM or PBSC transplant?
Another person's HLA matched BM or PBSCs
What are some increased new CA risks due to chemotherapy?
Anthracycline-related leukemia
How do you monitor LMWH?
Anti-factor Xa assay
What are the benefits of Ginkgo Biloba?
Anti-inflammatory Vasodilator Relaxant Digestive bitter Uterine stimulant Can increase bleeding risk
How do you treat venous thromboembolism?
Anticoagulant therapy Fibrinolytic therapy IVC interrupting (filter)
What are Cell Cycle Specific Agents?
Antimetabolites Plant alkaloids Miscellaneous agents Schedule dependent Greatest tumor kill when given in divided but frequent doses OR Continuous infusion w/short cycle time
What are the therapeutic benefits of garlic?
Antimicrobial Diaphoretic Hypocholesterolemic Stimulates gallbladder Hypotensive Antispasmodic
What are some etiologies of acquired hypercoagulable states?
Antiphospholipid antibody syndrome Malignancy Pregnancy Therapy-related Nephrotic syndrome and loss of Protein C Inflammation and factor VII level and CRP Stasis PNH and myeloproliferative syndromes
What are some causes of acquired hypercoagulable states?
Antiphospholipid antibody syndromes Malignancy Pregnancy Therapy-related Nephrotic syndrome and loss of protein C Inflammation and factor VIII level adn CRP Stasis Paroxysmal Nocturnal Hemoglobinuria and myeloproliferative syndromes
What is the definition of a long-term effect of cancer treatment?
Any side effect or complication of treatment for which a person with CA must compensate - persistent effects - begin during treatment and may continue beyond the end of treatment
What is the definition of a Cancer Survivor?
Anyone who has been diagnosed with CA from the time of dx through the balance of his or her life.
What is the direct thrombin inhibitor used to treat HIT?
Argatroban
When should discharge planning begin?
As soon as they are getting admitted. Begin long before patient enters hospital.
What are symptoms of CML?
Asymptomatic Fatigue Malaise Night sweats Weight loss Early satiety LUQ tenderness Less common: infections, thrombosis, bleeding, CVA, MI
What are some symptoms of CLL?
Asymptomatic Fatigue, fever, chills, night sweats, enlarged lymph nodes, weight loss, recurring infections, bleeding, SOB
What are some unique features of the atypical promyelocytes seen in APL (M3)?
Atypical promyelocytes in the bone marrow and peripheral blood. - large (usually >20 microns in diameter) myeloid precursors with variable morphology. - high nucleus to cytoplasmic ratio, fine chromatin, and prominent nucleoli. - violet granules in the cytoplasm with either a dense or coarse pattern, often obscuring the nucleus. - larger and typically have creased, folded, bilobed, kidney-shaped, or dumb-bell shaped nuclei
What are some different types of extravascular hemolysis?
Autoimmune (AIHA) - Coombs test positive ABO incompatibility: neonate or transfusion Hereditary spherocytosis (rare)
What are some complications of CLL?
Autoimmune hemolytic anemia Thrombocytopenia Pure Red Cell Aplasia Hypogammaglobulinemia
How are relapsed NHL patients treated?
Autologous stem cell Tx
How do you treat MM?
Autologous stem cell transplant (pts < 70 yrs) Allogeneic SCT (potentially curable but high mortality rate) High dose corticosteroids Chemo - Kyprolis (carfilzomib) - Bortezomib Radiation Bisphosphonates
When do you not see little letters before TNM?
Autopsy
How is vWF disease inherited?
Autosomal Dominant
How is Sickle Cell anemia inherited?
Autosomal recessive Two normal alpha chains with mutations in the Beta chains. Sub of valine for glutamic acid
Most NHL are of ______ lymphocyte lineage
B cell
A 20-year-old healthy male was treated 4 days ago for an MRSA skin infection with Bactrim. The infection is improving but he is increasingly weak and his sclera have turned yellow. Today his hemoglobin is 11 g/dL (13.5 to 18 g/dL) and his MCV is 85 (80 to 100 fL); the corrected reticulocyte count is elevated. What is the best test for the most likely diagnosis? A. Homocysteine level B. Heinz body stain C. Hemoglobin electrophoresis D Erythropoietin level E Iron studies
B. Heinz body stain Pt needs workup for G6PD.
Presence of which of the following would be expected on examination of a peripheral blood smear in a patient who has pernicious anemia? A. Microcytosis B. Hypersegmented neutrophils C. Target red blood cells D. Blast cells E. Increased number of platelets
B. Hypersegmented neutrophils
In which of the following diseases is thrombocytopenia caused by autoimmune antibody destruction of platelets? A. Rocky Mountain spotted fever B. Idiopathic thrombocytopenic purpura C. Heparin-related thrombocytopenia D. Parvovirus infection E. Splenomegaly caused by portal hypertension
B. Idiopathic thrombocytopenic purpura C. Heparin-related thrombocytopenia
What is the most common cause of epidural spinal cord compression? A. Epidural abscess B. Metastatic tumors C. Meningiomas D. Hematomas E. Radiation myelopathy
B. Metastatic tumors
A patient is receiving immediate release morphine tablets. She asks you how often she can take the morphine for pain. Your best response would be to say, as often as: A. every ½ hour B. every 2 hours C. every 4 hours D. every 6 hours
B. every 2 hours
Pain that is described as dull, achy and is well localized, is most likely: A. neuropathic pain B. somatic pain C. vascular pain D. visceral pain
B. somatic pain
Crohn's disease can cause low (pick a vitamin)?
B12
What are some tests to do in megaloblastic anemia?
B12 and folate levels Look at smear for large RBCs and *hypersegmented polys* Schilling test (rarely done now) Anti-parietal cell antibodies Anti-intrinsic factor antibodies Coombs test (looking for autoimmune process) MMA (B12 def) and homocysteine levels (folate + B12 def) [both elevated]
What gene is follicular lymphoma associated with?
BCL-2 gene rearrangement t(14;18)
Which tissues are more affected by cytotoxic therapy?
BM Hair follicles/skin Organs of reproductive system Mucosal cells of GI tract
What is the BM transplantation process?
BM donor harvested pelvic bones in OR
What is the process of a BM or PBSC transplantation?
BM donor harvested pelvic bones in OR PBSC harvested as outpatient by apheresis (CD-34 + cells) after priming with chemo andor hematopoietic growth factors (G-CSF)
What happens in aplastic anemia?
BM failure with peripheral blood pancytopenia. Normal BM cells are replaced by fat/abnormal cells.
More conditions associated with DIC
Bacterial Viral (CMV, varicella, hepatitis) Fungal Intravascular hemolysis Acute liver disease Tissue injury Eclampsia Missed abortion Placental abruption Amniotic fluid emboli
What are the components of primary palliative care skill set?
Basic management of pain and symptoms Basic management of depression and anxiety Basic discussions about: - prognosis - goals of treatment - suffering - code status
How can you prevent anticipatory N/V in the CA pt?
Benzos
What is the onset of timing for HIT?
Between days 5 and 10 after heparin initiation. Rapid onset if previously exposed to heparin.
How does Heparin work?
Binds to AT III - inactivates factors IIa, Xa, IXa, XIa, XIIa - binds to plts and inhibits function
What are some side effects of heparin?
Bleeding Osteoporosis Thrombocytopenia Urticaria, papules, necrosis Hypoaldosteronism, hyperkalemia
Plt < 50,000 symptoms?
Bleeding with trauma
What are some clinical manifestations of DIC?
Bleeding, especially oozing, from sites of trauma, catheters and drains - epistaxis, hemoptysis, melena Petechiae and ecchymosis Thromboembolism - venous and/or arterial - most commonly in small-medium sized vessels - may be pulm embolism, MI, CVA
What are some clinical findings in MM?
Bone pain (back/chest) Osteoporosis (femoral neck) Lytic lesions (skull) Pathologic fx (femoral neck) Recurrent infections (PNA, pyelo) Spinal cord compression Hyperviscosity syndrome Pallor Soft tissue masses (plasmacytomas) Neuropathy
What are the therapeutic effects of CoQ10?
Boosts immune system Helps body fight certain infections and types of CA
What is integrative oncology?
Both a science and a philosophy that focuses on the complexity of health of cancer patients and proposes a multitude of approaches to accompany to conventional therapies to facilitate health.
What are some behaviors typical of substance use disorder?
Bought pain meds from a street dealer. Stole money to obtain drugs Tried to get opioids from more than one source Performed sex for drugs Seen two doctors at once for opioids without them knowing it Stole drugs from others Rx forgery
What are some examples of organs at high risk of malignancy even where a precancerous lesion has not been ID'd, where surgery will be helpful.
Breast and ovary in deleterious BRCA mutations Colon, stomach, uterus, urologic tract in HNPCC (Lynch)
What is Fractionation?
By dividing up the dose of radiation into a number of fractions, sublethal damage repair of normal cells is perpetuated, while CA cells continue to die. This favors preservation of normal cells, while killing CA cells.
Which metabolic abnormality does rasburicase treat in tumor lysis syndrome? A. Hypocalcemia B. Hyperphosphatemia C. Hyperuricemia D. Hyperkalemia E. Acute Kidney Injury
C. Hyperuricemia
The single best way to diagnose Substance Use Disorder when prescribing opioid analgesics, is to watch for: A. Evidence of pain relief following administration of a placebo B. Evidence of a withdrawal reaction if opioids are suddenly discontinued C. Incidents where continued use of opioids leads to adverse health or social consequences
C. Incidents where continued use of opioids leads to adverse health or social consequences
Which one of the following drugs is the most appropriate to use as prophylaxis for opioid-induced constipation? A. Bisacodyl suppository (Dulcolax) B. Docusate (Colace) C. Polyethylene Glycol (Miralax) D. Psyllium (Metamucil)
C. Polyethylene Glycol (Miralax)
A 72 year-old female with a PMHx of acute myeloid leukemia is admitted to the hospital for initiation of chemotherapy. Two weeks after completion of chemotherapy when she is neutropenic, she develops a new fever. All review of systems is negative. Vitals are 38.9C, 101HR, 122/78BP, 16RR, 99% room air. Physical exam otherwise unremarkable. How quickly should empiric antibiotics be started for this patient? A. Whenever B. Within 5 minutes C. Within 1 hour D. Within 12 hours E. Within 1 day
C. Within 1 hour
What are two very helpful markers in B cell lymphoma?
CD 19 CD 20
AML, ALL, CML or CLL? Adults (65 y) Most prevalent RAI Stage 0 - IV Lymphocytosis Smudge cell
CLL
What is the most prevalent leukemia?
CLL (25% of leukemias)
AML, ALL, CML or CLL? Mean age ~42 Philadelphia chromosome Chronic-accelerated-blast phases Treat with Gleevec
CML
What are signs and symptoms of cardiac tamponade?
CP, presyncope, dyspnea Beck's triad: low arterial blood pressure (narrow pulse pressure), dilated neck veins (increased JVP), muffled heart sounds Pericardial rub, sinus tachy, tachypnea, pulsus paradoxus.
What other study can be used to help dx cord compression?
CT Myleography - requires lumbar/cervical puncture to dx leptomeningeal disease - can sometimes visualize abnormalities not seen in MRI, esp laterally located lesions - can be used when MRI not possible
What does the mnemonic CRAB stand for in multiple myeloma?
Calcium (high) Renal disorder Anemia Bone lytic lesions
What conditions could be helped by palliative radiation?
Cancer patient with mets disease to bone or brain with pain/confusion Pt may experience worsening of pain s/p radiation tx for up to a week after, due to increased edema. May use steroids.
What are some common interventional therapies for pain?
Celiac plexus/splanchnic nerve block Superior hypogastric plexus/ganglion impair block Intercostal blocks Kyphoplasty and vertebroplasty Lumbar sympathetic block Myofascial injection Epidural infusions/bolus
How can chemotherapy be used as a radiation therapy sensitizer?
Certain drugs will increase sensitivity of tumor tissue to effects of RT. - Cis-platinum - given during RT treatments for head and neck CA - 5-FU given during RT for GI CA
What are some treatment options for CML?
Chemotherapy - Gleevec - Interferon alfa - hydroxyurea Allogeneic SC transplant - best results with pts < 40 years and within 1 year of dx
What are some causes of N/V in the CA patient?
Chemotherapy/biotherapy Tumor obstruction, constipation, increased ICP, brain mets, vestibular dysfunction Hypercalcemia, hypokalemia, elevated blood glucose, uremia, elevated Cr Opioids, Abx Psychological: anxiety, fear
Who should you use caution in when doing acupuncture or acupressure?
Children Immediately after eating Senility Blood clotting disorders
What is the most frequently used alternative health care profession in the US?
Chiropractic
What are the nutrition guidelines for CA survivors (AICR guidelines)?
Choose predominantly plant-based diets rich in a variety of fruits and veggies. If eaten at all, limit intake of red meats to less than 3 oz daily. Limit consumption of fatty foods, particularly those of animal origin. Limit EtOH to less than two drinks/day for men and less than one drink a day for women. Do not eat charred food. Consume the following only occasionally: - meat and fish grilled in direct flame - cured and smoked meats Avoid being overweight and limit weight gain in adulthood Take an hour's brisk walk or similar exercise daily.
How do you decide which biopsy technique to use?
Choose the least invasive method that will yield the effect you desire.
Which type of clonal abnormality overproduces granulocyte precursors?
Chronic Myeloid Leukemia
What happens in Hairy Cell Leukemia?
Chronic disease of lymphoproliferation - B lymphocytes that infiltrate BM and spleen/liver - B cells are characterized by cytoplasmic protrusions
What conditions lead to anemia of chronic disease?
Chronic infections and/or HIV Cancer Autoimmune disorders Chronic renal failure
What is the tyrosine kinase inhibitor, Gleevec, used to treat?
Chronic myeloid leukemia
What are the main treatments for sickle cell disease?
Chronic transfusions with iron chelation Exchange transfusions Hydration Good nutrition and folic acid supplementation Get vaccines Pain meds Abx for infections
What does cTNM mean?
Clinical stage/pretreatment stage based on PE, imaging, endoscopy, biopsy, surgical exploration
How is DIC diagnosed?
Clinically and by lab findings
What are Chronic Myeloproliferative Disorders?
Clonal diseases originating in pluripotential hematopoietic stem cells. - increased and abnormal hematopoiesis - produces a group of interrelated syndromes - Classified by predominant phenotypic expression of the myeloproliferative clone
What is polycythemia vera?
Clonal stem cell disorder characterized by increased red cell production.
What are some ways to manage cough at the end of life?
Codeine Morphine
What kind of pain is typically seen in CA patients and pts with multiple co-morbidities?
Combined or mixed pain
What is the definition of integrative medicine?
Combines treatments from conventional medicine with non-mainstream modalities for which there is some quality of evidence of safety and effectiveness.
What is the definition of "Palliation" in CA?
Comfort when cure/control impossible. Reduction of side effects/symptoms, including pain.
What is the MOA of antimetabolites?
Compete with or substitute for normal metabolites in DNA and or metabolic pathways Results in interference with DNA/RNA synthesis
What is considered a good response to treatment in CML?
Complete hematologic response: WBC < 10,000, normal morphology, normal Hgb/Plt Cytogeneic repsonse: absence of Ph and + metaphases on BM 6 mos post rx
How can you differentiate pain from substance use disorder?
Complete two assessments: 1. Pain assessment 2. Substance use disorder assessment
What are some causes of plt aggregation abnormalities?
Congenital Drugs (NSAIDs) Alcohol Uremia Hyperglobulinemia (monoclonal gammopathies) Fibrin/fibrinogen split products Thrombocythemia
How do you identify amyloidosis in a biopsy?
Congo Red Stain Interstitial Amyloid deposits
What are some adverse effects of opioids?
Constipation Nausea Sedation and confusion Respiratory depression Pruritus
What are some common adverse effects of opioids?
Constipation Nausea Sedation or drowsiness Confusion or hallucinations Dry mouth, sweating, urinary retention, pruritus, urticaria, seizures, SIADH, hypogonadism, myoclonus.
What are some examples of neurological emergencies brought on by oncologic problems?
Cord compression CNS mets Carcinomatous meningitis Hyperviscosity Leukostasis TTP
What is the diagnostic approach to treating hypercalcemia in CA?
Correct calcium lab result according to albumin level - Serum Ca + 0.8 x (4-albumin) Helpful if unsure of the cause of hypercalcemia If known malignancy, can start treatment
What does "carcinoma" mean?
Crab-leg tumor
What is the MOA of Alkylating Agents?
Cross-linking of DNA strands Single and double strand DNA breaks Both of above result in lethal damage to DNA
How is intermediate grade NHL treated?
Curative intent - localized disease (short course of chemo + radiation_ - R-CHOP
How do you treat Hodgkin's disease?
Curative intent 1) Low risk (stage IA/IIA) - radiation - limited chemo 2) Medium-high risk (Stage IIIB and IV) - combo chemo: ABVD, *brentuximab* 3) Relapsed patients - high dose chemo + autologous stem cell tx
What is the physiologic mechanism of anemia of chronic disease?
Cytokines and RES cells: - dysregulation of iron homeostasis - impaired proliferation of erythroid progenitor cells - blunted erythropoietin response - RBC membrane damage
A cancer patient with bone metastases has well controlled pain on long acting opioid. Over two weeks the pain worsens in the same location, with the same quality. Increasing pain in a cancer patient most likely represents: A depression B. psychological dependence C. opioid tolerance D. worsening metastatic cancer
D. worsening metastatic cancer
How do you treat vWF disease?
DDAVP (deamino-8-arginine vasopressin) - increases vWF levels by stimulating secretion from endothelium - not generally used in type 2 Humate-P (VWF/FVIII replacement therapy)
ITP, TTP, or DIC? Caused by thrombin excess Ill-appearing Schistocytes Increased PT, PTT, D-dimer Decreased fibrinogen
DIC
TTP, DIC, or HIT? Caused by sepsis, burns or trauma Abnormal PT/PTT Bleeding and clotting Treat with FFP, cryoprecipitate or platelets
DIC
Schistocytes
DIC TTP [intravascular hemolysis]
What is folic acid essential for in the body?
DNA synthesis and RBC maturation
What is the possible pathophysiology of CA-related fatigue?
Deconditioning Cachexia Mood disorders Inflammation/cytokines Drugs CA-related symptoms Anemia Tumor byproducts Infection Dehydration Bio Immunotherapy/chemo/XRT Renal/hepatic/heart disease
What are some pathological causes of fatigue?
Deconditioning Cachexia Mood disorders Inflammation/cytokines Drugs Cancer related symptoms Anemia Tumor byproducts Infection Dehydration Bio Immunotherapy/chemo/radiation Renal/hepatic/heart disease
What is wasting syndrome?
Decreased lean tissue Decreased performance status Altered or futile REE Decreased appetite
Lab findings in B12 deficiency
Decreased serum B12 level Increased MCV Macroovalocyte RBC Hypersegmented neutrophils +/- pancytopenia Anti-intrinsic factor or anti-parietal cell Ab Increased homocysteine Increased MMA level Increased serum LDH Modest increase in indirect bilirubin BM erythroid hyperplasia with large RBC precursors and asynchronous maturation
What are some causes of secondary erythrocytosis (class 1)?
Decreased tissue oxygenation: - chronic lung diseases - cyanotic congenital heart diseases - high-altitude erythrocytosis (Monge disease) - hypoventilation syndromes (sleep apnea) - hemoglobin-oxygen dissociation abnormalities (hemoglobinopathies associated with high oxygen affinity; carboxyhemoglobin in smokers polycythemia)
Punch biopsy
Deep sample of skin 1/4"; epidermis, dermis and upper SQ. Close with sutures.
How is NHL treated?
Depends on type/stage/status of patient
What is the role of surgery in CA treatment?
Desire for adequate margin of resection. Prevention of tumor spillage Minimal manipulation Reconstruction
What is the MOA of Antitumor Antibiotics?
Developed from strain of Streptomyces Too cytotoxic to use as antibacterials Act by causing breaks and cross-linking of DNA and free radical formation
What medication will provide short term relief of brain mets?
Dexamethasone
How do you manage anorexia?
Dexamethasone Megestrol acetate THC Androgens
How do you treat anemia of chronic disease?
Diagnose and treat the underlying disease. EPO or DarbEPO can be useful and effective
What are the side effects of XRT on the pelvis?
Diarrhea Dysuria Lowered blood counts
What are some common early/intermediate complications (adverse effects) of radiation treatment?
Diarrhea, N/V, proctitis, fatigue, alopecia, sexual dysfunction, edema, urinary/bladder changes, pneumonitis, oral mucositis, esophagitis, dysphagia, xerostomia, skin changes
What is the #1 used approach in CIM?
Dietary supplements
What is the key symptom of delirium?
Difficulty focusing or paying attention
What is the most common type of aggressive lymphoma?
Diffuse large B-cell lymphoma
What happens in plasma cell dyscrasias?
Disproportionate proliferation of one clone. Increased serum level of secreted molecular product (monoclonal Ig protein - M proteins) Decreased serum levels of Ig other than monoclonal Ig
What is the MOA of Cell-Cycle Non-Specific Agents?
Dose Dependent Exert effect in all phases of cell cycle, including G0 resting phase. Drug incorporated into cell, kills when cell attempts to divide Given intermittently to allow patient recovery from dose-limiting toxicities
How do you avoid catastrophic side effects of XRT?
Dose to organ at risk % volume of organ at risk exposed to critical high dose
What are some etiologies of AML?
Down's syndrome, Bloom's Fanconi's anemia Viral (HLTV-1) Radiation Chemical/occupational exposures (chemo, benzene) Majority of cases cause is unknown
What are examples of Antitumor Antibiotics?
Doxorubicin Daunorubicin Mitoxantrone
What are some factors that affect warfarin?
Drug interactions > 100 Hereditary resistance and hypersensitivity Altered liver fxn Hypermetabolic state Comorbid conditions (infection, malnutrition)
What is the cause of alpha thalassemia?
Due to gene deletions - inherit 2 alpha chain genes from each parent - alpha chain genes found on chromosome 16
Why may chemo cycles occasionally be prolonged?
Due to prolonged nadir phase or delayed recovery of blood counts
What are the top 3 gram (-) bacterium in neutropenic fever?
E. coli Pseudomonas Klebsiella
What are examples of endoscope directed biopsy?
EGD Colonoscopy Bronchoscopy ERCP
How do you evaluate cardiac tamponade?
EKG CXR Echocardiogram CT chest
What is ECOG Performance scale?
Eastern Cooperative Oncology Group Grades 0 [fully active] - 5 [dead] on how active and how can self-care.
What are some causes of SIADH in the CA patient?
Ectopic ADH production - small cell lung CA CNS disturbances - stroke, hemorrhage, infection, trauma, psychosis Medication adverse effects - high dose IV cyclophosphamide, melphalan, vincristine, vinblastine, vinorelbine, cisplatin, ifosfamide, methotrexate, opiates, high dose imatinib, steroids
What are some lab findings in CML?
Elevated WBC (12 - 200,000) - mature cells dominate - circulating blasts < 5% Basophilia and Eosinophilia Elevated plt Increased marrow cellularity, normal blasts In accelerated disease: anemia, increased blasts in BM, decreased plt
Palliative care is a whole patient assessment. What does that entail?
Emotional Social Spiritual Physical
What are some alternative routes to administering pain meds?
Enteral feeding tubes Transmucosal: sublingual, rectal Transdermal: topical Parenteral SQ Intraspinal
Which clonal abnormality overproduces megakaryocytes?
Essential thrombocytosis
What is a syngeneic BM or PBSC transplant?
Exact match from identical twin
What is syngeneic BM or PBSC transplant?
Exact match from identical twin
What is the definition of "Control" in CA?
Extension of life when cure unrealistic; prevent growth w/o complete elimination of disease
What is the FAB classification of Burkitt Leukemia/Lymphoma?
FAB L3
(T/F) Individual opioids are identical to one another.
FALSE They have different potency, half life and risks.
What are some examples of image-directed biopsy?
FNA or cutting needle Ultrasound, CT or MRI
What do Nurse Navigators do?
Facilitates scheduling Coordinates services Fosters communication b/t team members Problem solves Finds potential clinical studies
Most common inherited thrombosis disorder?
Factor V Leiden
Which factor stabilizes the fibrin clot?
Factor XIII [lysine residues]
Which clotting factors require vitamin K for synthesis?
Factors II, VII, IX, X Protein C and S
What are some clinical manifestations of Waldenstrom Macroglobulinemia?
Fatigue, epistaxis, retinal hemorrhages, dizziness, confusion, CHF, mucosal/GI bleed, nausea, vertigo Hyperviscosity syndrome (80% of IgM is intravascular) Cryoglobulinemia/cold agglutination syndrome Acrocyanosis, Raynaud's phenomenon, vascular symptoms, hemolytic anemia Peripheral neuropathy
What are some sudden onset symptoms in ALL?
Fatigue, pallor, fever, malaise, bone pain, bleeding, bruising, HA, CN palsies
What are some symptoms of AML?
Fatigue, weakness, SOB, anorexia, weight loss, fever/infection, bleeding/easy bruising Less common: bone pain, nonspecific cough, HA, diaphoresis
What are some important general side effects of XRT?
Fatigue: but not impairment of consciousness Lowered blood counts: large field irradiation Skin reaction: sunburn like > blistering > chafing > pain
Ulcerative Colitis can cause ______ deficiency.
Fe
What is the most common anemia in the USA?
Fe def anemia
What are the demographics of Essential Thrombocytosis?
Female > Male Median age 60 20% of patients < 40 1/3 asymptomatic 2/3 have vasomotor or thrombohemorrhagic complications
Which opioids are lipophilic?
Fentanyl Methadone
What are some physical findings in pts with AML?
Fever Hepatosplenomegaly Lymphadenopathy Sternal tenderness Evidence of infection and hemorrhage
Which herbs have anticoagulant effects?
Feverfew Garlic Ginger Ginkgo Dong guai
What was the former goal of radiation and cancer therapy?
First try must be the best try
What does "sarcoma" mean?
Fleshy tumor
What are some examples of antimetabolites?
Folic acid analogues (methotrexate) Pyrimidine analogues (5-FU [inhibits thymidine], Ara-C [cytosine] Purine analogues (fludarabine [adenosine], 6-TG (guanine))
What is the most common type of "indolent" lymphoma?
Follicular lymphoma
What is the definition of "Adjuvant therapy" in CA?
Follows primary treatment modality
What are acupuncture and acupressure?
Forms of TCM that simulate specific points on the body known as acupoints in order to reduce tension, help the body relax deeply, and strengthen resistance to disease. Relax muscle fibers, resulting in increased blood flow and release of toxins.
What is Step 2 in the pain assessment?
Functional Assessment
What is the FAST Scale for Dementia?
Functional Assessment Scale for Dementia Rates from 1 - 7 1 = no difficulty either subjectively or objectively 7 = Limited to approx </= 6 intelligible different words, limited speech ability, ambulatory ability is lost, cannot sit up without assistance, loss of ability to smile, loss of ability to hold up head independently
Heinz bodies Bite cells
G6PD deficiency
What are some roles of surgery in alleviating treatment-related complications?
GI or GU strictures Fistulae Tissue necrosis (bone or skin) Proctitis and cystitis Radiation induced secondary malignancies
What are the different grades of tumors?
GX - Grade cannot be assessed G1 - Well differentiated (resembles parent cell) G2 - Moderately differentiated G3 - Poorly differentiated (bears little resemblance to parent cell) G4 - Undifferentiated (impossible to tell which cell is parent)
What kinds of medications do you use to manage neuropathic pain?
Gabapentin Pregabalin TCAs: amitriptyline, nortriptyline Opioids
What are some clinical manifestations of ischemic (early) DIC?
Gangrene Delirium/coma Oliguria/azotemia Dyspnea/hypoxia GI ulcers/infarcts Adrenal infarcs
Who performed the first Pap smear in 1928?
George Papanicolaou
Which herbs can interact with warfarin?
Ginger Garlic Turmeric
What are some clinical findings in AML?
Gingival hyperplasia Leukemia Cutis (skin infiltration with AML)
Which herb inhibits CYP3A4?
Ginkgo
How do you treat fluid overload in TLS?
Give loop diuretics If unresponsive, perform dialyssi
Which CA needs such a high dose of radiation to cure that it would be toxic and it's not given?
Glioblastoma multiforme
What is Glucose 6 Phosphate Dehydrogenase deficiency?
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an inherited disorder caused by a genetic defect in the (RBC) enzyme G6PD, which generates NADPH and protects RBCs from oxidative injury.
What are some ways to manage excessive oropharyngeal secretions (death rattle) at the end of life?
Glycopyrrolate IV or SQ 0.2 mg every 4 hours PRN, not to exceed 4 doses per day. Don't use anticholinergic agents.
How are toxicities graded?
Grade 1: numbness, dysesthesia or paresthesia, tingling, painless swelling or erythema and/or discomfort of hands or feet not disrupting normal activities Grade 2: Painful erythema and swelling of hands or feet and/or discomfort affecting ADLs Grade 3: Moist desquamation, ulcerations, blistering or severe pain of hands or feet, or severe discomfort preventing work or performance of ADLs
What is the risk in allogeneic BM or PBSC transplants?
Graft vs. Host Disease - hepatic - pulmonary - cardiac - skin and mucous membrane abnormalities
What are the toxicities and risks of Bm or PBSC transplants?
Graft vs. Host disease - hepatic - pulmonary - cardiac - skin and mucous membrane abnormalities
What is Graft vs. Host disease?
Graft-versus-host disease is a major complication of allogeneic hematopoietic stem cell transplant that occurs when donor immune cells from the graft become sensitized to and attack the host tissues
AMl is characterized by an abnormal increase in what types of cells circulating in the blood?
Granulocytes Myelocytes Myeloblasts
What are some vasomotor symptoms in essential thrombocythemia?
HA, lightheadedness, syncope Atypical CP Acral parasthesia Visual disturbances *Livedo reticularis* Erythromelalgia: burning pain of hands or feet with erythema and warmth
TTP, DIC or HIT? Abnormal PTT Autoimmune clotting disorder
HIT
What does the Hgb fractions look like in sickle cell trait?
Hb S/A = 40/60
What does the Hgb fractions look like in sickle cell disease?
Hb S/A: 100/0 Hb F: 2-25%
Which sites are sensitive to radiation therapy?
Head and neck CA (early) Breast CA Hodgkin's Disease; Non-Hodgkin's lymphomas Skin CA (Basal cell and squamous cell) Rectal CA Gyn CA Seminoma Soft tissue sarcomas
What does anemia with a high corrected retic count imply?
Healthy marrow production and therefore, a peripheral process. Hemorrhage GI bleed Hemolysis
What are some examples of late effects of CA therapy?
Heart failure Osteoporosis Distress Second malignancies Peripheral neuropathy Bowel obstruction
What are some risk factors for TLS?
Hematologic malignancies, esp Burkitt's lymphoma and acute leukemias with elevated WBC counts Cytotoxic agents High tumor proliferation rate Large tumor burden or bulky disease Chemosensitivity Kidney disease
In which situations is the TNM staging not used?
Hematologic malignancies: lymphomas, leukemias, MM (systemic diseases) Pediatric tumors Colon CA may use Dukes System, but TNM provides more detail/greater precision SCLC and NSCLC now use TNM
What are some head CT signs/symptoms of DIC?
Hematoma Subarachnoid hemorrhage Intraventricular hemorrhage
What are two causes of relative erythrocytosis (pseudopolycythaemia)?
Hemoconcentration Spurious polycythemia
What are some lab findings in G6PD deficiency?
Hemoglobinuria Heinz bodies in RBC Bite cells on blood smear
In Hgb electrophoresis, what types of Hgb will be elevated in Beta thalassemia?
Hgb A2 and F
What kinds of Hgb do people with Sickle Cell anemia have?
Hgb S and Hgb F
How do you dx Thalassemia?
Hgb electrophoresis
How do you dx sickle cell disease?
Hgb electrophoresis
Anemias with a high degree of cell turnover (hemolytic processes) have a __________ (high/low) RDW.
High
TIBC in Fe deficiency: High, low or normal?
High
How do you treat Primary Amyloidosis?
High dose chemo and autologous stem cell transplant
What are some factors that would prevent a patient from getting home hospice, requiring inpatient?
High flow oxygen Intractable symptoms Complicated wound care Multiple IV meds
How can you present acute N/V in the cancer pt?
High risk: 5HT3 antagonist (Zofran), NK-1 antagonist (Emend) and corticosteroid prior to chemo (Decadron). May add lorazepam. Low risk: Corticosteroid, 5HT3 antagonist or metoclopramide. Possible NK-1 antagonist.
What are some advantages to the conformational technique?
Higher dose to tumor volumes: ex. Prostate CA Lower dose to surrounding normal tissues: ex. Abdomen Improved QOL: pts with brain mets Treatments to areas impossible up till now: ex. Nasal cavity Often shorter times to patients --> shorter length of stay
What are the direct thrombin inhibitors?
Hirudin Bivalirudin (angiomax) Argatroban
What is the workup for acquired hypercoagulability?
History and physical - review of meds CBC and review of blood film Baseline PT and aPTT Malignancy screening appropriate for age
Which two types of CA or particularly sensitive to radiation therapy?
Hodgkin's Disease Seminoma
Where is most hospice care delivered?
Home hospice (41%) In-patient hospice (22%)
Hospice or Palliative care? Limited life expectancy of 6 months of less certified by 2 MDs with certification periods of 90-90-60 days.
Hospice
Are there co-pays for hospice or palliative care?
Hospice: No co-pays Palliative care: Co-pays may apply
What is the SPIKES protocol?
How to break bad news: *S*etting up the interview Assessing the patient's *P*erception: establish what the patient knows. Assess ability to comprehend new bad news. Be mindful of risk for suicide. Obtaining the patient's *I*nvitation: how much do they want to know? Giving *K*nowledge and information to the patient: confirm facts, encourage them to make a list of concerns for upcoming appts Addressing the patient's *E*motions with *E*mpathetic responses: allow the pt to verbalize fears, anger, dismay, depression *S*trategy and *S*ummary: make a plan
How do you treat tumor lysis syndrome?
Hydration Allopurinol
How do you treat a sickle cell crisis?
Hydration Oxygen Analgesics
How do you treat thrombocythemia?
Hydroxyurea Anagrelide IFN alpha Low dose ASA BMT
What are the findings of the BM aspirate and trephine in AML?
Hypercellular > 20% blast cells Presence of Auer rods
What is the name of M3 AML?
Hypergranular Promyelocytic Leukemia (PML)
JAK2 Mutation
Hypersensitive and persistent signaling, proliferative disorder Mutation is always on - constantly making red cells and plts
What is the prognosis for the various stages of Hodgkins' Disease?
IA/IIA - radiation rx: 90% 10 year survival IIIB/IV - 50-60% 5 year survival
How do you treat folate deficiency?
ID and treat cause Folic acid supplementation with 1 mg PO QD Prophylactic supplementation - females trying to get pregnant - pregnant females - lactating mothers - people with chronic hemolysis - people with hyperhomocystemia and risk for ASCVD
What is the name of the first oral targeted therapy for adult patients with relapsed/refractory AML and and IDH2 mutation?
IDHIFA
Which stages of CLL are treated?
II - IV Only treat stage I if lymph nodes are large and annoying
ITP, TTP or DIC? Caused by antiplatelet antibodies Not ill Normal appearing RBCs
ITP
How do you treat leukostasis?
IV hydration Cytoreduction (hydroxyurea, initiation of chemo, and leukapheresis) - hold RBC transfusion
How do you treat hyperkalemia in TLS?
If K < 6, increase IV fluids If K > 6, perform EKG immediately - if no acute changes, may use loop diuretics, lactulose or sodium polystyrene (Kayexalate) for excretion - if acute changes, give calcium gluconate, insulin, albuterol, and/or sodium bicarb along with loop diuretics, lactulose, or sodium polystyrene. Repeat labs 1-2 hours after dosing. If unresponsive, perform dialysis
When do you get a lymph node biopsy in CLL?
If despite treatment, lymph node enlargement persists --> Richter's transformation (aggressive lymphoma in pts with CLL)
When should a constipated CA patient call the office?
If they have not had a BM in 3 days.
What is portal imaging?
Image of the actual treatment beam taken on a regular basis to check field placement. Patients can gain or lose a lot of weight during treatment, which will change set-up and distort beam.
How do you manage emergent SVC syndrome?
Immediate treatment with endovenous stent placement and radiation therapy
What is required to identify the heavy and light chain class of protein?
Immunofixation or immunoelectrophoresis
How do you treat Hypocellular MDS?
Immunosuppressive drugs
What does anemia with a low or normal corrected retic count in the face of anemia imply?
Impaired marrow Chronic Kidney disease B12 or Fe def
Side effects of CA treatment may be exacerbated if patient has....
Impaired renal/hepatic functions Comorbid conditions Protein-calorie malnutrition < 1 year old or elderly > 85 Tissues with high growth factors
When should long acting opioids be used?
In patients who are already on a stable dose of short acting opioid and have established tolerance to the sedating and respiratory depressant effects of opioids.
What is DIC?
Inappropriate coagulation leading to rapid consumption of coagulation factors with outpaces production, leading to severe bleeding diathesis
How do you treat hypocalcemia in TLS?
Increase IV fluid If corrected calcium > 7.5, treat hyperphosphatemia If corrected calcium < 7.5, may give calcium gluconate repletion If unresponsive, perform dialysis
How do you treat AKI in TLS?
Increase IV fluid May give loop diuretics to facilitate renal excretion If unresponsive, perform dialysis
How do you treat hyperuricemia in TLS?
Increase IV fluid and give allopurinol as prophylaxis If still elevated, give *rasburicase* If unresponsive, perform dialyssi
How do you treat hyperphosphatemia in TLS?
Increase IV fluid and give phosphate binders If unresponsive, preform dialysis
What are some lab findings in PV?
Increased Hgb/Hct Increased WBC Increased PLT Basophilia (in all MPDs) Increased uric acid and B12 Increased leukocyte ALP score Low EPO Positive JAK2 V617F
What are some non-opioid adjuvant pain medication indications?
Increased ICP, nerve compression: corticosteroids Neuropathies: TCAs, anticonvulsants Bone pain, soft tissue pain: NSAIDs Bone pain: Bisphosphonates
What are demographics of Multiple Myeloma (MM)?
Increased incidence with age Median age at dx: 68 years Males > Females
What is some demographic info on CML?
Increased incidence with age Peak 30 - 50 years, avg age 42 Male > female 50% diagnosed incidentally
What are the demographics of CLL?
Increased incidence with age, 65 years average age Males > females Whites > Blacks
What is SIADH?
Increased plasma concentrations of ADH leading to increased water retention resulting in hyponatremia.
Intravascular and extravascular hemolysis have these in common:
Increased retic count (increased MCV) Increased LDH (cell destruction) Increased Indirect bilirubin Low serum haptoglobin Nucleated RBCs (not always)
How is hyperviscosity syndrome diagnosed?
Increased serum viscosity levels; however serum viscosity measurements do not always correspond with clinical findings Increased monoclonal IgM protein levels Clinical findings with known dx that is associated with hyperviscosity
erythromelalgia in PV
Increased skin temp Burning sensation Redness
The number of cancer survivors in the US is (increasing, decreasing, staying the same)
Increasing
What are some long term complications of treatment of Hodgkin's Disease?
Infertility - Males > females Secondary malignancy - skin, AML, lung, MDS, NHL, thyroid, breast Cardiac disease
What are some examples of long-term effects of CA therapy?
Infertility Memory loss Fatigue Weight issues Peripheral neuropathy Sexuality issues
What are some common late complications (adverse effects) of radiation treatment?
Infertility, joint problems, lymphedema, secondary malignancies, cognitive (memory loss, personality changes, incontinence, difficulty concentrating)
What is involved in pre-op evaluation?
Informed consent Surgical risk calculation ASA Physical status classifications Mallampati score Assess risk-benefit ratio and ID correct underlying, relevant health problems
How do you treat TTP?
Infusion of FFP Plasma exchange Steroids RBC if needed Plts only if absolutely necessary Rituxan
What does Jakafi do?
Inhibits JAK1 and JAK2 signaling. Use in PV who are intolerant of hydroxyurea or inadequate response. Myelofibrosis
How can myelofibrosis present?
Insidious onset in older people - asymptomatic - severe fatigue Massive splenomegaly Hepatomegaly Hypermetabolic symptoms - loss of weight, fever, night sweats Bleeding problems Bone pain Gout
What is brachytherapy used for?
Internal radiation therapy: for deep tumors - cervix and post-hysterectomy uterus
What is Tai Chi?
Internal strengthening Chinese martial art practiced for self-defense and health benefits. Slow repetitive routines generated gently and measurably increases and opens the internal circulation to relieve the effects of stress.
What is the MOA of plant-derived mitotic inhibitors?
Interruption of mitosis at metaphase by interference with chromosome movement during mitosis (microtubule inhibition)
What is the most common cause of microcytic, hypochromic anemia?
Iron deficiency anemia
What does the Iron, Transferrin, Transferrin saturation, ferritin, and cytokine levels look like in anemia of chronic disease?
Iron: Reduced Transferrin: reduced to normal Transferrin saturation: Reduced Ferritin: Normal to increased Cytokine levels: increased
How do you manage Severely symptomatic moderate or severe (> 14) hypercalcemia in the CA patient?
Isotonic IV volume expansion (NS) for goal urine output of 100 - 150 ml/hour Calcitonin with repeat Ca level in 8 hours to check for response Bisphosphonates Dialysis if needed
What can TTP result from?
It can result from inactivation of ADAMTS13 (von Willebrand factor-cleaving protease) by autoantibodies, from hereditary deficiency of ADAMTS13 activity due to hereditary mutation, or as episodes secondary to a variety of conditions (Pregnancy, Cancer, Autoimmune disease, Pancreatitis, Hematopoietic stem cell transplant, Surgery, Heavy alcohol intake)
What does staging do for CA and when do you do it?
It determines the extent of the disease. You stage at the time of dx. - Defines prognosis. - Guides selection of primary and adjuvant therapy - Assists in evaluating result of tx and clinical trials - Facilitates exchange and comparison of info among treatment centers - Contributes to continuing investigation of cancers
What are signs/symptoms of thalassemia major?
Jaundice Hepatosplenomegaly Growth and sexual retardation Cardiac failure can occur due to severe anemia and/or iron overload
How do you treat increased LDH in TLS?
Just continue to monitor
What labs do you need to monitor closely in tumor lysis syndrome?
K, Phos, Ca, uric acid, Cr, LDH Also urine output
What are the three different FAB classifications of ALL?
L1 - most common in children L2 - most common in adults L3 - uncommon, aggressive, poor prognosis
How is lymphovascular invasion assessed?
LV1 or LV space 1
How is clinical TLS defined?
Laboratory TLS plus a major clinical sign or symptoms, such as seizure, cardiac arrhythmia, markedly increased Cr or death
What are some lab findings in Hodgkin's Disease?
Leukocytosis Elevated ESR Eosinophilia Reed Sternberg Cell Advanced disease: thrombocytopenia, leukopenia
What are some typical lab findings in AML?
Leukocytosis or leukopenia Blastemia Auer rods in M2, M3 and M4 Thrombocytopenia Anemia > 20% blasts in BM
What are some precancerous lesions that are helped by surgery?
Leukoplakia of tongue Thyroid gland in MENS 2 HGSIL of cervix
What is Qi Gong?
Life Energy Cultivation Practice of aligning breath, movement and awareness fo rhealing.
What does ayurveda focus on?
Life energies and not symptoms - performed through the use of exercise, yoga, meditation and mineral supplements
What happens in extravascular hemolytic anemia?
Loss of RBC membrane due to antibody binding and removal in the spleen causes many *spherocytes* on peripheral blood smear.
MCV in Fe deficiency: high or low?
Low
MCV in thalassemia: high or low?
Low
What is the drug of choice for delirium?
Low dose haloperidol If no response in 24-48 hours, can use other sedating neuroleptics: - olanzapine - chlorpromazine
What are some causes of SVC syndrome?
Lung CA (esp small cell( NHL Thymoma Other CA Thrombosis Fibrosing mediastinitis and fungal infection Postradiation fibrosis
Which CAs is acute malignancy-associated cardiac tamponade most associated with?
Lung and breast CA
What may you find on PE in a pt with NHL?
Lymphadenopathy Extranodal sites (skin, GI tract)
What are some physical findings in CLL?
Lymphadenopathy Hepatosplenomegaly Signs of infection
What are some physical exam findings in Waldenstrom Macroglobulinemia?
Lymphadenopathy/hepatosplenomegaly Retinal vein engorgement Purpura
What are some early lab findings in CLL?
Lymphocytosis (> 5000) - smudge cells - 70-80% of circulating cells, mature appearing Leukocytosis (> 20,000) Variable lymphocyte BM infiltration
What are the M stages?
M0 - No distant mets M1 - distant mets
What is the gold standard imaging study to dx cord compression?
MRI
How is indolent NHL treated?
Maintenance intent - if not bulky, not symptomatic, no initial therapy may be needed - local irradiation for localized disease - chlorambucil, cyclophosphamide, vincristine, prednisone, fludarabine, rituxan, bendamustine, ibrutnib
What is the demographic that gets aplastic anemia?
Males = females Asians > Americans/Europeans Bimodal distribution: 15 - 30 and > 60 years
What are the demographics of Hairy Cell Leukemia?
Males > 40 years old
What are some common conditions associated with DIC?
Malignancy Post-cardiac arrest Acute MI Prosthetic devices Hypothermia/hyperthermia ARDS PE Severe acidosis Severe anoxia Collagen vascular diseaes Anaphylaxis
What is Waldenstrom Macroglobulinemia?
Malignancy of plasmacytoid lymphocytes that secrete *large quantities of IgM* Median age is 64 (develops insidiously in 60s and 70s) Shares features with low grade lymphoma and myeloma
What are some causes of Vitamin K deficiency?
Malnutrition Biliary obstruction Malabsorption Antibiotic therapy
What are the components of the Specialty Palliative Care skillset?
Management of refractory pain or other symptoms Management of more complex depression, anxiety, grief and existential distress Assistance with conflict resolution regarding goals or methods of treatment - within families - between staff and families - among treatment teams Assistance in addressing cases of near futility
What is characteristic of intravascular hemolysis?
Many schistocytes on smear.
Who discovered radium and polonium?
Marie and Pierre Curie
What is leukostasis?
Markedly elevated blast cell count that creates white cell plugs and leads to symptoms of tissue ischemia. - PE, CVA, MI, renal infarct, priapism, bowel infarct, acute limb ischemia Associated with TLS and DIC
What is Tumor Lysis Syndrome?
Massive tumor cell destruction resulting in the release of intracellular components into the cardiovascular system - K, Phos, nucleic acids
What are the goals in radiation treatment planning?
Maximize dose absorbed by the tumor while minimizing dose delivered to normal tissue (sublethal damage repair).
What is MCHC?
Mean corpuscular Hgb concentration Concentration of Hgb in average RBC
What is MCH?
Mean corpuscular hemoglobin Hgb content in average RBC
What is Step 3 in the pain assessment?
Medication reconciliation
What does astragalus interact with?
Medications that suppress the immune system (cyclophosphamide) May affect blood sugar and blood pressure levels.
What are some alternative treatments for Diarrhea?
Meditation Acupuncture Massage/reflexology Homeopathy Nutrition - coconut water, prebiotics
Who is affected by Beta Thalassemia?
Mediterranean and Greek origin
What are adverse effects of epidermal growth factor receptor inhibitors?
Moderate to severe skin reactions with dryness, desquamation, erythema
What is the most common plasma cell dyscrasia?
Monoclonal Gammopathy of undetermined significance
What does abciximab (ReoPro) do?
Monoclonal antibody against GPIIb/IIIa Binds to GPIIb/IIIa platelet binding sites, increases bleeding time and blocks plt aggregation
What are the demographics of NHL?
More frequent in elderly Males > Females Immunodeficiency states are predisposed - HIV, organ transplant, inherited immune deficiencies, RA Environmental factors: infectious agents, chemical exposure, medical Rx - HTLV-1, EBV, HIV, Hep C, H.Pylori (MALT), HHV-8
According to the WHO 3-step ladder, how do you treat 3-severe pain?
Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone +/- adjuvants
Which opioids are hydrophilic?
Morphine Oxycodone Hydromorphone
What are some things you can do to help relieve dyspnea at the end of life?
Morphine Oxygen adjust to achieve satisfactory O2 sats and subjective relief of dyspnea Psychosocial support, relaxation, and breathing training Facial cooling with fan, keeping windows open for ventilation Keeping ambient room temp low, humidifying air and keeping HOB elevated
What is the TNM Staging system?
Most clinically useful system for staging: T - classifies CA by size and depth of invasion of primary tumor N - involvement of regional lymph nodes; size and location important M - Presence or absence of distant mets
What is the presentation of aplastic anemia?
Mucosal and skin bleeding Bruising Anemia Weakness Fatigue DOE Pallor Infection
What are the components of a Cancer Center?
Multidisciplinary teams Complementary therapies Financial assistance counselors Personalized medicine Survivorship medical services
Waldenstrom's or Multiple Myeloma? Lytic lesions and hypercalemia
Multiple Myeloma
Waldenstrom's or Multiple Myeloma? Renal excretion of protein
Multiple Myeloma
BM or PBSC transplants have proven value in these conditions....
Multiple Myeloma High risk leukemias and lymphomas
Rouleaux formation
Multiple Myeloma Waldenstrom's Macroglobulinemia
BM or PBSC transplants have proven value in ....
Multiple myeloma High-risk leukemias and lymphomas
What are some non-pharmacological ways to prevent N/V?
Music therapy Moderate aerobic exercise Acupressure wristbands Acupuncture Behavioral: self hypnosis, biofeedback, guided imagery, cognitive distraction, systemic desensitization
What is the cause of Beta Thalassemia?
Mutations or loss of beta chain gene on chromosome 11 Heterozygous: thalassemia trait (minor) Homozygous: both genes mutated (Cooley's anemia)
What is another cause of a macrocytic anemia?
Myelodysplastic syndrome
Teardrop RBCs
Myelofibrosis
What are some adverse effects of chemotherapy?
Myelosuppression GI and mucosal side effects Alopecia Fatigue Cardiac/hepatic/renal/neural/cutaneous/ocular toxicities Pancreatitis Sexual/reproductive dysfunction Secondary malignancies
What are the different N stages?
N0 - No regional lymph node mets N1, N2, N3 - Increased number or extent of lymph node involvement NX - Lymph nodes cannot be assessed
Are serious or advanced illness related to age or circumstance or birth?
NO
Are there petechiae in HIT?
NO
Is it normal when platelet count falls by half, but is still in the "normal" range?
NO
Is platelet activation affected in Hemophilia A, Hemophilia B and vWF disease?
NO
Can you use fentanyl in the opioid naive?
NO It's VERY STRONG and is 80 - 100x more potent than morphine
Should methadone be used in the opioid naive?
NO! It's long acting and accumulates over time - also significantly more potent on a per mg basis than morphine with long-term use.
When CA pts get endocrine toxicity--> early menopause, do you rx hormone therapy?
NO. It's often contraindicated.
Should you give iron for pts with Thalassemia trait, alpha and beta?
NOOOO Only give if deficiency
In 1937, legislation was signed by FDR establishing what..
National Cancer Institiute
Which is usually worse for chemo/radiation patients - nausea or vomiting?
Nausea
What are the benefits of Valerian?
Nervine Hypnotic Antispasmodic Carminative Hypotensive Emmenagogue (stimulates menstrual flow)
What are symptoms of hyperviscosity syndrome?
Neurological: change in vision, HA, vertigo, nystagmus, tinnitus, deafness, diplopia, ataxia, confusion, dementia, change in consciousness, stroke, coma Heart failure
What kind of pain? Burning, tingling, shooting, stabbing, electrical
Neuropathic pain
What is the adverse effect of angiogenesis inhibitors?
Neuropathy
What are some hematological emergencies that can be brought on by oncologic problems?
Neutropenic fever, DIC, TTP, Hyperviscosity, severe thrombocytopenia, sickle cell crises, hypercoagulation
What is the nadir phase?
Neutrophil response to chemotherapy, infection, inability of the body to respond to infection. The lowest point that an individual's blood cell count will reach during chemotherapy.
What are examples of Alkylating Agents?
Nitrogen mustard Cyclophosphamide
Is there an antidote for bivalirudin or argatroban?
No
Is thrombolytic therapy indicated in venous thrombosis?
No Its useful in PE or large thrombosis
How do you treat MGUS?
No therapy required, just monitor for progression
Is there a treatment for G6PD deficiency?
No, just avoid triggers for the symptoms.
Is any treatment needed in Thalassemia minor?
No. It's also the most common form.
Is Tis (carcinoma in situ) cancer?
No. It hasn't broken through the basement membrane.
Which lymphoma is more common: Hodgkin's or Non-Hodgkins?
Non-Hodgkins
In 1944, nitrogen mustard was used to treat a patient with _______ and brief remission was achieved.
Non-Hodgkins Lymphoma
How do you manage Mild (< 12) or chronic moderate hypercalcemia (12 - 14) in the CA patient?
Non-emergent treatment with calcium restriction and adequate hydration.
The Joint Commission Revision 2015 Pain management standards were revised to include....
Nonpharmacologic strategies: physical modalities (acupuncture, chiropractic, osteopathic manipulative treatment, massage therapy and physical therapy), relation therapy and CBT.
Iron in thalassemia: High, low or normal?
Normal
RDW in thalassemia: High, low or normal?
Normal
What is considered complete remission in AML?
Normal peripheral blood with resolution of cytopenias Normal BM with no excess blasts (< 5% blasts) Normal clinical status
RBC # in thalassemia?
Normal to high
What are the lab findings in sickle cell disease?
Normocytic/macrocytic anemia Sickle cells Increased retic count NRBC Howell Jolly Bodies Target Cells Increased LDH Increased indirect bili +/- increased platelets WBC
What are some cytology findings in CML?
Nucleated RBCs Increased Basophils and Monocytes
How can you treat hematological toxicity?
Nutrition Avoidance of germs/infections Avoidance of medications that lower blood counts CSFs
What is "Myeloablation"?
Obliteration of BM in prep of stem cell/bone marrow transplant.
What are some indications for treatment of CLL?
Observe until necessary Hyperleukocytosis/rapidly rising lymphocytosis Disease related symptoms BM involvement with anemia/thrombocytopenia Symptomatic lymphadenopathy/splenomegaly Autoimmune hemolytic anemia or thrombocytopenia
How do you manage N/V at the end of life?
Octreotide 100-200 ug SQ 3x/day Dexamethasone 4-8 mg orally or IV every day IF c/b gastroparesis: metoclopramide 10-20mg orally or IV q4-6 hours
Who tends to get MDS?
Older patients > 70 years
What happens in tumor lysis syndrome?
Oncologic emergency that is caused by massive tumor cell lysis with the release of large amounts of potassium, phosphate, and nucleic acids into the systemic circulation. Catabolism of the nucleic acids to uric acid leads to hyperuricemia, and the marked increase in uric acid excretion can result in the precipitation of uric acid in the renal tubules and can also induce renal vasoconstriction, impaired autoregulation, decreased renal blood flow, and inflammation, resulting in acute kidney injury. Hyperphosphatemia with calcium phosphate deposition in the renal tubules can also cause acute kidney injury.
What is an autologous BM or PBSC transplant?
One's own BM or PBSCs
What is an autologous BM or peripheral blood stem cell transplant?
One's own BM or PBSCs
What % of CAM info to patients came from MDs?
Only 13%
What are some factors that can contribute to delirium/agitation?
Opioid-induced toxicity Brain tumor/mets CA treatments Psychotropic drugs Metabolic factors (hypercalcemia, renal failure) Sepsis
What is the time to peak analgesic effect for oral, IV and SQ administration of opioids?
Oral: 60 mins IV: 10 mins SQ: 30 mins
What is a hallmark symptom of hyperviscosity syndrome in Waldenstrom's Macroglobulinemia?
Oronasal bleeding with dilated and tortuous retinal veins (sausage link appearance)
What are some triggers for G6PD?
Oxidative drugs: ciprofloxacin, phenacetin, sulfonamides, dapsone, chloroquine, nitrofurantoin, *fava beans.* Bacterial or viral infection
What is the PBSC transplantation process?
PBSC harvested as outpatient by apheresis (CD-34 positive cells) after priming with chemo and/or hematopoietic growth factors (G-CSF)
What is included in the Pain assessment (part 1)?
PQRSTU Precipitating and Palliating Quality Region and radiation Severity Temporal U You
What are indications for use of opioids?
Pain is... ...of moderate to severe intensity ... adversely affects patient's function ... and has not responded to appropriate non-opioid therapies
What are the most common causes of constipation in the CA pt?
Pain medications: Opioids Low fluid intake
What are some prevalent symptoms in advanced illness?
Pain, breathlessness, fatigue or lack of energy, anorexia, N/V constipation, anxiety or nervousness, depression or sadness, dry mouth, sleep disturbance
What are some complications that can develop as CLL progresses?
Pain, paralysis from enlarged lymph nodes causing pressure Infection
What happens in a sickle cell crisis?
Painful Small vessel occulsion
What are signs/symptoms of NHL?
Painless lymphadenopathy Fever Drenching night sweats Weight loss
What are some signs and symptoms of Hodgkin's Disease?
Painless lymphadenopathy - spreads to other LNs - supradiaphragmatic (90%) - cervical (60-80%) - mediastinal: cough, wheeze, dyspnea - extranodal presentation (liver, lung, BM) Hepatosplenomegaly B symptoms Malaise Pruritis
What are some lab findings in iron deficiency anemia?
Pale, washed out RBCs with poikilocytosis Fe low, ferritin low, TIBC high Decreased RBC count Microcytic, hypochromic (low MCV, low MCH)
What is now the goal in radiation and CA therapy?
Palliative care morphing into supportive care. People living longer with mets disease - better QOL - more time to enjoy loved ones and be productive - retreatment
What is the clinical presentation of B12 deficiency?
Pallor Icterus Neurologic: - peripheral neuropathy (stocking glove) - paresthesias - decreased vibratory/positional sense - Ataxia - Confusion and dementia Fetal loss and infertility Glossitis Anorexia Diarrhea
Vasculitis - palpable or nonpalpable?
Palpable
How do you treat B12 deficiency?
Parenteral B12 (IM) 1 mg weekly x 4, then monthly and follow Hgb and B12 levels *Lifelong* treatment for pernicious anemia
What does pTNM mean?
Pathologic stage determined by pathology results/surgery
What is the Center for Medicare/Medicaid Services definition of Palliative Care?
Patient and family-oriented care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social and spiritual needs and to facilitate patient autonomy, access to information and choice.
What is substance use disorder?
Patterns of symptoms resulting from the use of a substance that the individual continues to take, despite experiencing problems as a result. Maladaptive behavior with continued use despite harm and loss of control - compulsive use - loss of control over drugs - loss of interest in pleasurable activities - continued use of drugs in spite of harm
Who linked chimney soot to squamous cell carcinoma in 1775?
Percivall Pott
What tools guide prognosis?
Performance status: tools ECOG, Karnofsky Weight loss > 6% body weight Anorexia Pathology of tumor Co-morbidities: 5 main organs and body systems to take into account
What are the lab findings in aplastic anemia?
Peripheral blood - pancytopenia - no retics - RBC morphology normal - MCV normal or increased - Plt normal size - no immature cells seen BM - hypocellular - relative increase in plasma cells and lymphocytes - scant normal hematopoietic progenitor cells - no abnormal cells
How can you make the dx of CLL?
Peripheral blood smear and flow cytometry Protein electrophoresis
What are some lab findings in NHL?
Peripheral blood smear usually normal Late presentation: leukemic phase LN bx - characteristic cells/markers BM - paratrabecular lymphoid aggregates CSF - meningeal involvement, malignant cells CXR - mediastinal mass (lymphoblastic) LDH elevated - prognostic marker
What are some hemorrhagic findings in DIC?
Petechiae Ecchymosis Oozing ICH Hematuria Hemorrhagic lung Massive GI hemorrhage
Clinical features of ITP
Petechiae, purpura, mucosal bleeding No constitutional symptoms of splenomegaly Normal other blood counts and coag parameters No schistocytes
What is the characteristic chromosomal abnormality in CML?
Philadelphia chromosome t(9;22) Abnormal chromosome is 22 with fusion oncogene bcr-abl - protein acts as on switch for cell proliferation
How do you treat PV?
Phlebotomy: 1 unit (reduce Hct to 45%) Myelosuppressive agents - Hydroxyurea - Alkylating agents such as busulfan Interferon alpha
How do you treat chemobrain or chemofog?
Physical activity Brain exercises Medications are being tested (ritalin, focalin)
What is Physical Dependence?
Physiologic adaptation with withdrawal symptoms.
What are some ways to manage xerostomia at end of life?
Pilocarpine (Salagen) 5-10 mg orally 3x/day (don't exceed 30 mg/day) Mouth care: antimicrobial mouthwashes, saliva substitutes, oral rehydration, mouth swabs, sugarless gum, lip balm, humidifier.
What are some laboratory tests to evaluate bleeding disorders (or before surgery)?
Platelet count Platelet aggregation test PT aPTT Thrombin time DRVVT [lupus anticoagulant screen]
What are the emergency treatment options for ITP?
Platelet transfusion + high dose steroids Platelet transfusion + continuous IVIG Antifibrinolytics Emergent splenectomy
What is the definition of thrombocytopenia?
Plt < 150,000
Which clonal abnormality overproduces red cell precursors?
Polycythaemia rubra vera
Which disease? Increased numbers of RBC and total blood volume JAK2 mutation Hyperviscosity Can convert to CML/AML or myelofibrosis
Polycythemia vera
What are two causes of primary erythrocytosis?
Polycythemia vera Familial erythrocytosis
What are the indications for use of eptifibatide or tirofiban?
Post angioplasty Unstable angina AMI without ST elevation
What is vcTNM or vpTNM?
Post therapy or post adjuvant therapy
Which cell-line type of ALL is most common?
Pre-B ALL (L1, L2) - 75%
What is a residual tumor?
Presence of residual tumor after treatment - surgery or neoadjuvant therapy. Denoted by symbol R - not included in TNM staging R0 = no residual tumor R1 = microscopic residual tumor R2 = macroscopic RX = presence cannot be detected
What are meant by surgical margins?
Presence or absence of disease at margin of resection. May be predictor of risk of recurrence. Negative = tumor not present at surgical margin. Microscopic positive margin Macroscopic positive margin Margin not assessed
What are Myelodysplastic Syndromes?
Present with some evidence of BM failure and dysplasia of one or more of the myeloid lineages: - < 20% blasts in the blood or marrow
What is "Chemoprevention" in CA?
Prevent CA in high risk patients
What are the risks and benefits to an IVC filter?
Prevent recurrent PE in short term Increase risk of recurrent DVT in long term
When autopsying victims of mustard gas poisoning, what did they find?
Profound lymphoid and myeloid suppression
What are the lab findings in DIC?
Prolonged PT Prolonged aPTT Thrombocytopenia Hypofibrinogenemia Increased D-dimer Microangiopathic hemolytic anemia
What is the definition of "Cure" in CA?
Prolonged absence of detectable disease Not always achievable
What are the lab findings in uncomplicated thalassemia minor?
Prominent microcytosis Only slightly lowered or normal Hgb and Hct Relatively high RBC count Normal RDW *Target cells* on peripheral blood smear
What are the benefits of Reiki?
Promotes relaxation Eases pain Reduces anxiety and stress Assists the body in cleansing toxins and balances the flow of subtle energy
How do you manage airway obstruction in CA?
Protect airway. Steroids if edema is present. Dx after pt is stable (may require bronchoscopy) May need stenting or laser curettage for airway protection. Treat underlying cause (chemo, radiation, and/or surgery)
When do you initiate treatment in MM?
Protein level > 5g/dL or bone lesions
What does the grade of the tumor mean?
Qualitative assessment of the degree of differentiation of the tumor. Reflects the extent to which a tumor resembles the normal tissue at that site. Higher grade = more aggressive
What does histopathologic type mean?
Qualitative assessment; tumor is categorized according to the normal tissue or cell type it most closely resembles (hepatocellular, osteosarcoma, squamous cell carcinoma)
What is a basic principle in radiation side effects?
Radiation side effects stem from the part of the body being treated.
How do you treat non-emergent SVC syndrome?
Radiation with chemo Surgery with preoperative chemo Consider percutaneous stent placement, if severely symptomatic Supportive care Anticoagulation, if thrombus is cause
What happens in Heavy Chain Diseases?
Rare lymphoplasmacytic malignancy Overproduction of monoclonal Ig heavy chains (defective/incomplete monoclonal Ig produced) Clinical picture more like lymphoma
Plt <100,000 symptoms?
Rarely causes spontaneous bleed
What are some factors that increase the likelihood of infection in a neutropenic patient?
Rate of WBC count declining Duration of neutropenia Immune system status Alterations in physical defense barriers, such as mucositis or burns Exposure to infectious environments
What is the Karnofsky Scale?
Rates ambulation and self-care status of patients from 10 (moribund) to 100 (Normal, no evidence of disease)
What is the Karnofsky Score?
Rates patient on how well can ambulate, activity and evidence of disease, self-care, intake and level of consciousness. 0 [death] - 100% [Full, normal]
What is immunotherapy?
Recognition of the cancer cells as non-self instead of self. Immune cells kill CA directly, and others help activate specific immune cells to kill CA cells.
Which herbs have phytoestrogen effects?
Red clover Dong guai Licorice
What is pathognomonic for Hodgkin's Disease?
Reed-Sternberg cell
What is the role of surgery in palliative care?
Relieve symptoms when patients are beyond cure or when non-surgical measures are not feasible, not effective or not expedient. Pt should be better at completion of procedure Pain control Relief of GI, airway or other obstruction Stop hemorrhage Relief of renal failure Alleviate rectal or urinary incontinence
How is hyperviscosity syndrome treated?
Relieve symptoms with prompt plasmapheresis Treat underlying disease Rituximab +/- chemotherapy in WM depending on severity
How do you treat aplastic anemia?
Remove suspected cause Supportive care - transfusions, abx Immunosuppressive therapy Allogeneic hematopoietic stem cell transplant
What happens in an open excisional biopsy?
Removes entire tumor and some surrounding tissue. Most invasive. Sutures/skin graft may be required.
Shave biopsy
Removes epidermis and small portion of dermis. Surgical razor. Relatively pain free. No sutures. Do not use for suspected melanoma (cannot detect depth of lesion)
What happens in an open incisional biopsy?
Removes portion of tumor: +/- sutures
What are some roles of surgery in rehabilitation?
Restoration of form Restoration of function Care of ostomies Psych treatment and support Maintenance and improvement of QOL
What is rTNM?
Retreatment or recurrence
What is it called when follicular lymphoma transforms into an aggressive lymphoma?
Ricter's transformation
What is a new therapy for Hodgkin's Disease?
Rituximab/Opdivo - immune therapy that enhances T cells to fight lung CA and Hodgkin's
What are two thrombopoiesis-stimulating drugs?
Romiplostim (Nplate) Eltrombopag (Promacta)
Who demonstrated the link between inflammation and CA (leukemia defined as excess WBCs)?
Rudolph Virchow
What are the side effects of XRT on the lung?
SOB Non-productive cough
What are some oncological emergencies that need to be treated within days?
SVC syndrome Hypercalcemia CNS mets without edema INR 5 - 9
Who first used radiation therapy to cure cancer in 1903?
SW Goldberg E London
What are the symptoms/signs of Fe def anemia?
Same as for anemia in general PLUS Pica Atrophic glossitis Cheilitis Brittle nails with spooning
What are some increased new cancer risks due to radiation?
Sarcoma, lung CA, other CA depending on exposed tissue
How do you treat Fe def anemia?
Search for and correct underlying cause. Oral iron - ferrous sulfate 325 mg 1-3x/day Parenteral iron if oral cannot be used - caution: IV forms can cause allergic rxns and anaphylaxis
What is the most common cause of DIC?
Sepsis
What does a "Regimen" of chemotherapy consist of?
Series of cycles of a given combo of cytotoxic agents. Can be assigned an acronym based on the initials of the drugs (MOPP, CHOP) Usually 4 - 8 cycles in a given regimen.
What are two tools for enhanced communication?
Serious Illness Guide SPIKES Protocol
When should you consider hospitalization of a sickle cell patient?
Severe long episode of pain Tachycardia Hypoxia Low Hgb and Hct Increased WBC Temp > 101 Hypotension New infiltrates on CXR
What happens in Thalassemia major?
Severe microcytic anemia with repeated RBC transfusions c/b iron overload in heart and liver.
What do symptoms and signs of anemia depend on?
Severity of anemia Abruptness of onset Ability of the body to compensate Age/comorbidities
What is the best assessment of dyspnea?
Shortness of breath Anxiety often associated [patient complaints, not PO2]
What is involved in informed consent?
Should start long before OR - with 1st visit Excellent documentation Pt gives valid consent Discuss common/uncommon risks Relate info in meaningful way/put in perspective
In 1947, who discovered antimetabolites?
Sidney Farber
Who should get a thrombophilia (inherited hypercoagulable state) workup?
Single episode of idiopathic venous thromboembolism and one or more of the following: - (+) FHx - Young age (< 50) - thrombosis at unusual site - massive thrombosis Recurrent episodes of venous thromboembolism
What are the benefits of Chamomile?
Skin conditions Mouth ulcers caused by chemo or radiation Relief of digestive problems Antispasmodic Anti-inflammatory Anti-septic Mild bitter actions
What is calendula used for?
Skin healing Antibiotic Immune system booster Causes sleepiness and drowsiness Don't take with sedatives
What happens in CLL?
Slow progressive lymphocyte accumulation. Production and accumulation of functionally inactive but long-lived mature-appearing lymphocytes - incompetent cells, poorly respond to antigens - 95% B cell neoplasm - Lymph node enlargement is noticeable throughout the body - increased incidence of infection
What are some dietary interventions for N/V in CA pts?
Small frequent meals Medicate prior to meals Avoid fatty, spicy, highly salted foods with strong odors Eat cold/room temp foods Cook meals b/t chemo regimens when not nauseated and freeze later for use or have someone else cook Avoid favorite foods on day of chemo and while N/V persists Eat foods/drinks containing ginger
What kind of pain? Easy to describe, well localized, bone and skin.
Somatic pain
What is the best long term treatment for hereditary spherocytosis?
Splenectomy - can result in high risk of infections Folic acid supplementation
What are some physical exam findings in PV?
Splenomegaly Hepatomegaly HTN Fundoscopic exam: vessels may be engorged, tortuous, irregular in diameter; veins may be dark purple Facial plethora
What are some physical findings in ALL?
Splenomegaly Hepatomegaly Lymphadenopathy Mediastinal mass Renal insufficiency (risk for tumor lysis syndrome)
What are the symptoms of Hairy Cell Leukemia caused by?
Splenomegaly Pancytopenia Infection Vasculitis
What are some physical findings of CML?
Splenomegaly (mild-mod) Hepatomegaly (mild) Lymphadenopathy (late) Myeloid sarcomas (late)
Plt < 10,000 symptoms?
Spontaneous, CNS bleeding
Which herbs induce CYP3A4?
St. John's wort Echinacea Grape seed Kava Garlic Ginseng Valerian
What are the different stage groupings for cancer prognosis?
Stage 0 = CiS Stage 1 = Tumors confined to primary site Stage 2 + 3 = Increasing local and regional nodal involvement Stage 4 = Distant mets disease
When recommending to increase fiber in the constipated patient, how should they progress?
Start adding 3-4g/day and increase to adding 6-10g/day
What are the treatment options for ALL?
Started ASAP 1) Induction phase (1-4 weeks) - aggressive combo chemo - daunorubicin, vincristine, prednisone, asparaginase - allopurinol to prevent tumor lysis syndrome 2) Consolidation phase - high dose systemic rx - CNS prophylaxis: methotrexate, cytarbine, radiation 3) Maintenance phase - continue rx 1-2 years Bone marrow transplant in high risk patients Cure rate much higher for children
What are some examples of drugs that can cause physical dependence?
Steroids Caffeine Alcohol Opioids B-blockers
What are some signs/symptoms of emergent SVC syndrome?
Stridor due to central airway obstruction or laryngeal edema OR coma from cerebral edema
What are the differences in the treatment schedules for subclinical, microscopic (+ margins) and gross (1 cm) Squamous Cell Carcinoma?
Subclinical disease: 50 Gy / 25 Fxn 5 weeks Microscopic Disease (+ margins) 60 Gy/30 Fxn 6 weeks Gross Disease (1 cm): 70 Gy/35 fxn 7 weeks
How does radiation help treat CA?
Sublethal Damage Repair CA cells lack the capacity for repair after radiation than normal cells have. It takes about 4 hours for normal cells to repair radiation damage.
What are the side effects of XRT on the breast?
Sunburn-like reaction in skin folds
What is electron beam radiation therapy used for?
Superficial tumors
Treatment for DIC?
Supportive
Treatment for TTP?
Supportive Plasma exchange Steroids
Treatment for ITP?
Supportive Steroids IVIG Splenectomy
How do you treat cardiac tamponade?
Symptomatic treatment with catheter pericardiocentesis or surgical drainage - send cytology labs on fluid Need close monitoring with telemetry in ICU or step down unit
What is vWF and what does it do?
Synthesized in endothelium and megakaryocytes. Forms large multimers. Carrier of factor VIII Anchors plts to subendothelium Bridge b/t plts
What is the MOA of eptifibatide?
Synthetic GPIIb/IIIa inhibitor - competes with fibrinogen binding on plt
What is primary amyloidosis?
Systemic illness characterized by deposition of *Ig light chain* in organs/tissues Results in symptoms caused by organ dysfunction - CHF, bleeding diathesis, nephrotic syndrome, peripheral neuropathy
What are the different T stages?
T0 - No evidence of tumor Tis - Carcinoma in situ T1, T2, T3, T4 - increased size and/or local extension Tx - primary tumor cannot be assessed
(T/F) According to the WHO, health is a state of complete physical, mental and social well being and not merely the absence of disease and infirmity.
TRUE
(T/F) Clinicians should screen for pain at each encounter with a patient.
TRUE
(T/F) Folate is destroyed with prolonged cooking.
TRUE
(T/F) MD Anderson study finds Qi Gong improves QOL for breast CA patients undergoing radiation therapy.
TRUE
(T/F) Palliative care is billed as any other specialty.
TRUE
(T/F) Patient outcomes directly relate to surgeon's experience and past patient volume.
TRUE
(T/F) Traditional Chinese Medicine has been found to reduce chemotherapy induced side effects.
TRUE
(T/F) Using fish oil with medications that slow clotting may cause bleeding.
TRUE
(T/F) Yoga may help with fatigue-related symptoms in breast cancer survivors.
TRUE
(T/F) You should avoid rectal exams on pts with neutropenia and thrombocytopenia.
TRUE
(T/F) If left untreated, the 1-week mortality rate of leukostasis is 20-40%.
TRUE Empiric treatment is initiated when WBC count > 100,000 and symptoms of ischemia
CoQ10 has been shown to protect the heart when pts are given anticancer drug doxorubicin (T/F)
TRUE In study animals
(T/F) 85-90% of epidural spinal cord compression is due to metastatic tumors.
TRUE Most common underlying malignancies: lung CA, breast CA, MM
(T/F) Any general surgeon can call themselves a surgical oncologist.
TRUE So know who you are referring to. You want to refer to someone who did a fellowship approved by the Society of Surgical Oncology.
Dx? Low PLT Intravascular hemolysis RBC fragmentation High LDH
TTP
ITP, TTP or DIC? Caused by endothelial defect Ill-appearing Schistocytes Maybe slight incr in PT, PTT, D-dimer
TTP
TTP, DIC or HIT? Cause: ADAMTS 13 and big vWF PT/PTT normal Fever Bleeding and clotting Treat with plasma exchange
TTP
What are some presenting signs of anemia?
Tachycardia Tachypnea Jaundice (hemolysis) Peripheral neuropathy (pernicious anemia) Splenomegaly (hemolytic, chronic leukemia, liver disease) Pallor of nail beds and conjunctiva
How is M protein detected?
Tall symmetric spike on electrophoresis of serum/urine
What are examples of hormonal and anti-hormonal agents?
Tamoxifen - estrogen receptor (+) breast CA LHRH Agonists and anti-estrogens - metastatic prostate CA
What is an increased new cancer risk due to hormonal therapy?
Tamoxifen-related endometrial CA
What are some lab findings in Thalassemia?
Target cells on peripheral smear Hgb A2 elevated Iron normal, ferritin normal, RBC count normal to elevated
Target cell
Thalassemia
Remember that nutritional status should be optimized *prior* to surgery.
That's forgotten often, so don't forget.
In a 28 day cycle, the 29th day is considered....
The first day of cycle 2
What is respite care?
The provision of care of a community patient in the setting of a hospital nursing home or inpatient hospice to provide caregivers with a break for up to 5 days.
What is a "proposed" definition of medical-legal suffering?
The stripping of personhood by the inability to resolve legal problems created or aggravated by advanced or disabling illness.
What is the definition of complementary medicine?
The use of other modalities together with conventional medicine, such as acupuncture in addition to conventional care for pain control.
What is alternative medicine?
The use of these non-mainstream modalities in place of conventional medicine.
What the symptoms of polycythemia vera?
There are common to all erythrocytosis - HA, decreased mental acuity, weakness Specific to PV: - pruritus after bathing - erythromelalgia - hypermetabolic symptoms - thrombosis - hemorrhage
How do you manage/treat spinal cord compression?
Time is spine. Pain management (opiates), bedrest, anticoagulation if applicable, aggressive bowel regimen. Corticosteroids Surgery if stable - spinal decompression and spine stabilization - vertebroplasty adn kyphoplasty External beam radiation therapy
What is treatment for thalassemia major?
Transfusions Iron chelation with deferoxamine to treat or prevent iron overload (hemosiderosis)
How do you manage SIADH?
Treat the underlying cause (d/c medication if possible) Fluid restriction IV NS IV hypertonic 3% saline if severe or resistant to other treatment Salt tabs with or without loop diuretics Vasopressin receptor antagonists if applicable - tolvaptan, mozavaptan, satavaptan, lixivaptan and IV conivaptan *very rapid correction of hypernatremia can lead to neurological damage*
How do you manage DIC?
Treat the underlying disease - abx for sepsis - chemo for malignancy - delivery for obstetric complications Supportive measures - keep plt > 50,000 with plt transfusions - treat hypofibrinogenemia and prolonged PT/PTT with FFP or CP - no need for antifibrinolytic agents - anticoagulation may be used for thromboembolism if plt are > 50,000
What is Herceptin used for?
Treatment of women with breast CA in which HER2 is overexpressed.
What are some oncological emergencies that need to be treated within hours?
Tumor lysis syndrome DIC Leukostasis TTP Severe thrombocytopenia Sickle cell complications INR > 9
What are some metabolic emergencies that can be brought on by oncologic problems?
Tumor lysis syndrome Hypercalcemia
Which types of tumors are CCNSAs most effective for?
Tumors with slowly dividing cells
What is the work-up for neutropenic fever?
Two sets of blood cultures, drawn prior to initiation of abx - need at least one set peripherally CBC, chemistry, LFTs, lactate Urinalysis and urine culture CXR Stool studies (c. diff) if indicated Nasal swab if indicated
What kinds of medications do you use to manage nociceptive pain?
Tylenol, NSAIDs Opioids: morphine, oxycodone, dilaudid, fentanyl, methadone Steroids
What are the classifications of vWF disease?
Type 1 - decreased (partial quant def) Type 2 - abnormal (qual def) Type 3 - absent
What is the workup for SIADH?
Typically euvolemic hyponatremia with high urine osmolality Sodium levels Serum osmolality levels Urine sodium levels ADH levels Basic metabolic panel
What is the mechanism of anemia of chronic disease?
Underproduction by marrow and shortened RBC lifespan.
What is the cause of CML?
Unknown Radiation exposure?
What is the etiology of ALL?
Unknown, but associated with: - EBV in infancy (L3/Burkitt's) - increased risk in Down Syndrome - radiation exposure (T cell ALL) - industrial, chemical, smoking exposure (adult)
Increased levels of ________ and _____ can lead to acute kidney injury through crystal formation at the renal tubules in TLS.
Uric acid Phosphorus
Laboratory TLS is two more more of the following lab abnormalities (25% increase/decrease or more from baseline)
Uric acid > 8 mg/dl Potassium > 6 mEq/dl Phosphorus > 4.5 mg/dl Calcium < 7 mg/dL
If a patient is at risk for Lynch their urologic tract should be screened how..
Urine microscopy
How do you correct the reticulocyte count for low Hgb levels?
Use corrected reticulocyte count: Corrected Retic Count = Retic % X (Patient's Hgb/Normal Hgb[14])
What is the definition of "Neoadjuvant therapy" in CA?
Use of chemotherapy prior to surgery or another modality
What is targeted (biologic) therapy?
Use of medications designed to target aberrant molecular pathways in a subset of patients with a given cancer type. These meds are a prime example of "rational drug design" based on knowledge of disease pathophysiology.
Features of Diffuse large B cell lymphoma..
Usually asymptomatic Extranodal involvement is common Cell or origin: germinal center b-cell Treatment should be offered Curable in ~40%
What are some clinical manifestations of sickle cell disease?
Vaso Occlusive crisis - back, rib, limb pain - bone infarcts - acute chest syndrome - stroke - avascular necrosis - cutaneous ulcers - spleen infarct Aplastic crisis Growth and development delays Bony abnormalities Priapism Renal tubular defects Pulm HTN Retinopathy Infections Gallstones
What are some manifestations of the hypercoagulable state of essential thrombocythemia?
Venous and arterial thrombotic events Distal vessel thromboses Strokes Coronary artery occlusions Budd-Chiari syndrome (hepatic vein thrombosis) or skin necrosis Vasomotor symptoms: HA, dizziness, paresthesias, *acrocyanosis*
Retic count in Sickle cell anemia - High, low or normal?
Very high unless marrow is dysfunctional
What are some examples of plant-derived mitotic inhibitors?
Vincristine Vinblastine Etoposide Paclitaxel, docetaxel
Which chemotherapies are derived from herbs?
Vincristine Vinblastine Taxol
What kind of pain? Difficult to describe, poorly localized, vague, diffuse, deeper.
Visceral pain
What are the components of Magic Mouthwash for oral mucositis?
Viscous lidocaine 2% + Benadryl + Nystatin
Howell-Jolly Bodies
Vitamin B12 deficiency s/p Splenectomy Sickle Cell Anemia
What are some favorable indicators in ALL?
WBC < 50,000 Age 1- 10 Female B-cell blast Hyperploidy, trisomy 4,10,17, t(12;21), (TEL/AML1) BM blast count during induction: major reduction at day 7
How do you distinguish essential thrombocytosis from other diseases?
WBC and RBC not markedly elevated No teardrops or nucleated RBCs Normo/hypercellular marrow *Megakaryocytes increased* No fibrosis
Which conditions may cause hyperviscosity syndrome?
Waldenstrom macroglobulinemia Multiple myeloma Polycythemia vera Myeloid/monocytic leukemias Sickle cell disease
Waldenstrom's or Multiple Myeloma? Hepatosplenomegaly
Waldenstrom's
Waldenstrom's or Multiple Myeloma? IgM spike
Waldenstrom's
Waldenstrom's or Multiple Myeloma? Lymphadenopathy
Waldenstrom's
What is the definition of conventional medicine?
Western or allopathic medicine Medicine practiced by physicians and other healthcare professionals.
When is palliative care delivered?
When needed, throughout a person's life, from the time of dx onward.
Demographics of Hodgkin's Disease
Whites > Blacks Male > Female Bimodal peak incidence in 20s and > 50 years Risk factors - EBV infection
What is involved in discharge planning?
Who does pt live with/support system? Post-op care - home care - d/c to rehab Health insurance Someone to drive to post-op visits Nutrition and diet Medications - rec with in-patient meds - pain meds
Who performed the first X ray in 1895?
Wilhelm Roentgen
Who performed the first radical mastectomy to treat breast CA in 1882?
William Halstead
How can you manage the adverse effects of opioids?
With the exception of constipation, most side effects can be managed by rotating to another opioid or adding an adjuvant analgesic.
What has a WORSE prognosis - CML with the Philadelphia chromosome or without?
Without
ITP is more common in....
Women Peak incidence at 60+ but can occur at any age 40% have associated disorder (HIV, HepC, collagen vascular disease)
Can Substance Use Disorder occur with or without Physical Dependence?
YES
Is AML potentially curable?
Yes
Can myelofibrosis transform into AML?
Yes - 10 - 20% of cases
Can unmanaged pain lead to nervous system damage and potentially permanent damage and amplify pain?
Yes!
Can it be normal to have platelets lower than the "normal" range?
Yes, 2.5% of the population does.
What are some alternative treatments for constipation?
Yoga Aromatherapy Acupuncture Massage/reflexology Homeopathy Nutrition - fiber, flax, hydration
Which is prolonged in Hemophilia A, Hemophilia B and vWF disease: PT or aPTT?
aPTT
In TLS, decreased levels of _________ can lead to seizures and cardiac arrhythmias.
calcium
When a patient is on these meds, they shouldn't take fish oil....
clopidogrel dalteparin dipyridamole enoxaparin heparin ticlopidine warfarin
Which patients tend to have poorer survival/treatment results in Hodgkin's Disease?
elderly, bulky disease, lymphocyte depletion, mixed cellularity
In TLS, increased levels of ___________ can lead to cardiac arrhythmias and death.
potassium
Aromatherapy can be particularly beneficial during and after ___________
stem cell transplant
In chiropractic, the belief that adjusting the spinal joints and resolving ________ restores normal nerve function and optimal health.
subluxation
What is the translocation involved that causes APL?
t(15;17)
MD Anderson study suggests that acupuncture given alongside radiation may help reduce....
xerostomia
