Oncology Oncology Elisa A. Mancuso RNC-NIC, MS, Elisa A. Mancuso RNC-NIC, MS, FNS FNS Professor of Nursing Professor of Nursing
Feb 09, 2016
OncologyOncologyElisa A. Mancuso RNC-NIC, MS, Elisa A. Mancuso RNC-NIC, MS,
FNSFNSProfessor of NursingProfessor of Nursing
White Blood Cells(Leukocytes)
White Blood Cells (WBC) • Formed in bone marrow and
lymphatic tissue• Destroy foreign cells via
– phagocytosis and antibody production
Granulocytes• Phagocytic cells
– produced in the bone marrow
Neutrophils• fight bacteria
Eosinophils• fight parasites • responds to allergens • influences the inflammatory process
Basophils• contain histamine• activate the inflammatory
response
Granulocytes
AgranulocytesParticipate in inflammatory and immune
reactions
Monocytes (macrophages)• First line of defense in inflammatory
process• Phagocytize large cells & necrotic tissue • Important for chronic infections
Lymphocytes• Blast cells in bone marrow, spleen, thymus
and other lymph glands and tissue• Responsible for immune protection
T Lymphocytes• T-cells
– Made in thymus – Cell mediated immunity (RT an antigen)
• B cells – Humoral immunity
• “memory” cells that produce antibodies to specific antigens
• Natural killer cells– kill certain type of tumor cells and viruses
Acute Lymphocytic Leukemia (ALL)
Cancer is the 2nd cause of death <15 years• Leukemia
– malignant disease of bone marrow and lymph system• ALL
– most common form of childhood cancer– Peak onset 3-5 years of age– 80% of cases of acute leukemia in childhood– Etiology;
•Genetic abnormalities – Philadelphia chromosome (↓ prognosis)– Trisomy 21 = 20 x ↑ Risk
•Chernoble - Nuclear Radiation exposure• Alkylating agents or certain chemical
agents • Virus trigger of oncogene
ALL Pathophysiology• Abnormal, poorly differentiated blast cells
– DNA mutation of an immature white blood cell – Causes the cell to multiply uncontrollably – Infiltrate bone marrow & ↑ vascular RE organs
• Hepatomegaly• Splenomegaly • Lymphadenopathy
• Malignant blast cells replace the functioning WBC’s in bone marrow causing: Anemia (↓↓ RBCs) Neutropenia (↓↓ WBCs) Thrombocytopenia (↓↓ Plts)
Signs and symptoms1st sign: Infections that linger > 2 weeks
(↓WBC)• Fever• Chills• Anorexia• Weight loss (↑ metabolic demands of CA
cells)• Bone & joint pain (Marrow expansion)• Abdominal pain (Hepatosplenomegaly)• Pallor, fatigue, lethargy (↓ RBCs) • Ecchymosis, petechiae, GI bleeding (↓ Plts)• CNS = ↑ICP ( HA, Vomiting & Irritability)
– Late stage RT– Brain protected by blood barrier.
ALL Diagnosis • Bone Marrow Aspiration @ iliac spine• >25% blast cells = + diagnosis• Lumbar puncture (LP)
– √ any CNS involvement• PET, CT & MRI ScansGood Prognosis- Poor Prognosis• WBC <10,000/mm3 WBC >50,000/mm3 • Age 1-10 Age <1 or >10• Female Male • Early + response Poor treatment
response • No CNS involvement CNS involvement
Chemotherapy MedsCorticosteroids• Anti-inflammatory• ↓ and kill lymphoblastic cells (↓ WBC)
Prednisone - 40 mg/m2 PO QDDexamethasone – 2.5 -10mg/m2/day IM/IV
÷ q6-8HSide Effects:
– Hyperglycemia – Na & Fluid retention = wt gain, puffy moon face– Peptic ulcers, mood changes– Delayed growth pattern
Chemotherapy Meds Enzymes• ↓ levels of amino acid (asparagine) →• ↓↓ tumor growth
L-Asparaginase (Elspar) 10,000 u/m2/day IM 2x/week
• Side Effects:– Allergic rxn = chills, fever & rash– Jaundice √ LFTs– Respiratory distress & ↓ BP– N & V, DM
Chemotherapy Meds Plant Alkaloids• Anti-neoplastic = Inhibits cell division
Vincristine (Oncovin) 1.5 mg/m2 IV• Side Effects
– Peripheral neuropathy• severe constipation• ↓ bowel innervation
– Stomatitis, N & V,– Anemia – Thrombocytopenia
Chemotherapy MedsAlkylating Agents• Interferes with cell growth
Cyclophosphamide (cytoxan, CTX) 60-250 mg/m2/day
Ifosfamide (Ifos) 1.2gm/m2/dayCisplatin (Platinol) 30-70 mg/m2/day• Side Effects
– Alopecia– Pulmonary fibrosis – Hemorrhagic cystitis
• (caused by chemical irritation of drugs)– Leukopenia– Anorexia, N & V
Chemotherapy Meds Antibiotics• Documented bacterial infections
Actinomycin D (dactinomysin, ACT-D) 2.5 mg/m2/wk
Bleomycin (Blenoxane) 10-20 U/m2/wkDoxorubicin (Adriamycin) 20mg/m2/wk
Side Effects – Cardiotoxic! – Red urine (Not hematuria) – Alopecia– N & V and stomatitis
CNS ProphylacticAntimetabolites• Inhibits folic acid reductase = inhibits DNA
synthesis and cellular replication. Inhibits replication of neoplastic cells
Methotrexate (MTX, Amethopterin) 20mg/m2/week PO IV or Intrathecal
Mercaptopurine (6-MP) 75mg/m2/day IVCytarabine (Ara-C, Cytosar-U) 100-200mg/m2/day
IV5-Fluorouracil (5-FU) 7-12mg/kg IV
• Side Effects – Leukopenia, chills/fever, vomiting– Red rash, Alopecia– ↓ Folic Acid metabolism– Hyperurecemia
Other AgentsAllopurinol (zyloprim) • Inhibits production of uric acid. • CA cell destruction = ↑ uric acid levels
– accumulates in tubules → renal calculi• Side Effects
– ↑ SGOT & SGPT = hepatotoxicity– Blocks metabolism of 6-MP = 6-MP
toxicity•Need 1/3 -1/4 normal dose of 6-MP
Other Agents
Mesna (mesnex)• Ifosamide detoxifying agent. • Binds to toxic metabolites. • Prevents hemorrhagic cystitis • Use with alkylating agents
– Cytoxan, Ifos, Platinol
Radiation• Prophylactic in high risk patients• Minimize CNS involvement • Side Effects after 7-10 days
– GI•dysphagia, stomatitis, N & V, diarrhea
– Skin•Erythema, desquamination, alopecia
– Myleosuppression ↓ RBCs ↓ WBCs↓ Plts•Fatigue, Infection, Bruising/Bleeding
– Pneumonitis• ↑ RR ↑HR Dyspnea & dry cough
TransfusionsUsed to correct specific deficiencies• PRBC
– Epoetin (Epogen)/Procrit – ↑ RBC in 2-6 weeks
• Platelets• Granulocyte Colony Stimulating Factors-
GCSF– Filgrastin (Neupogen) – ↑Neutrophils (ANC) – Stimulate dev of new white blood cells 10-14
days– SE: Bone pain, fever, malaise & HA
• Whole blood transfusions– Rarely used since ↑ risk of fluid overload
Bone Marrow Transplant
• Replaces pt own bone marrow.– Need 500 cc -1 Liter– Takes 1-3 weeks for marrow to self
produce• Autologous
– uses own bone marrow if in remission • Allogenic (Donor)
– √ Compatible = match 6 HLA antigens– Prevent Graft vs. Host Disease (GVHD)
Bone Marrow Transplant
• 1st give ↑↑ dose chemo and radiation (total body)– Rids body of CA cells – Suppresses immune system to prevent
rejection• Strict reverse isolation• Neutropenic Precautions
– No fresh flowers, fruit, veggies– Monitor visitors √ immunization status
• Monitor s/s of infection– √ Temp, CBC, Activity– √ Absolute Neutrophil Count (ANC) <500 – ↑ risk for overwhelming infection– ANC = WBC times the % of neutrophils
Nursing Interventions
Prevent Infections• Live vaccines are contraindicated.
– No MMR or Varicella• Inactivated vaccines
– Wait @ least 6 months after chemo for appropriate immune response
• ↑↑ predisposition to resistant organisms
• Broad spectrum prophylactic antibiotics
Nursing Interventions
Nutrition • ↑↑ Hydration ↑ Protein ↑Caloric
Intake• Bland , easily digestible diet• Encourage nutritious foods
– Allow pt to choose– ↑ Pt participation with meal
planning• No acidic juices or spicy foods
Nursing Interventions
Mouth Care• Frequent cleansing
– Magic Mouthwash (Malox/Benadryl/HO)
• Cotton swabs not toothbrush for ↓ Plts
• Stomatitis– Chloroseptic spray– Viscous Lidocaine
Nursing Interventions
Skin Care• High risk for rectal ulcers from
diarrhea• Keep area clean and dry & OTA• Turn & Position• Sheepskin or Air mattress• √ SE from meds & radiation
– ↑risk for skin breakdown & irritation
Nursing Interventions
Nausea and Vomiting• Small frequent feeding• ↑ PO intake via ices, jello, favorite
fluids• √ weight √ I and O’sAntiemetics• Ondanesetron (Zofran) [Aloxy]
– Blocks 5-HT3 site in brain• Dronabinol (Marinol)
– THC synthetic active component of marijuana
Nursing Interventions
Peripheral Neuropathy• ↓ bowel innervation → constipation• Foot drop, tremors, jaw pain• Weakness & numbness of
extremities Maintain safe environment• Assist with ambulation• Sneakers, hand rails & walkers
Nursing Interventions
Alopecia• Prepare child & family ( temp
condition)• Allow kids to cut their own hair!• Obtain wig before hair is lost• Scarfs or hats
• Re-growth 3-6months – Darker, thicker & curlier
Nursing Interventions
Hemorrhagic Cystitis• Chemical irritation to the
bladder• ↑ Fluid intake (1.5 x daily
amount)• ↑ Voiding frequencyMedication• Mesna
– ↓ Urotoxicity of Ifos & Cisplatin
Nursing Interventions
Pain relief• Evaluate non-verbal and verbal cues• Note cultural differences & accommodate needs
• Position– H2O beds, bean bag chairs, stuffed animals
• Change environment– ↓ Sensory stimulation (lights, noise, activity)
• Relaxation techniques– Massages, rocking, guided imagery,
distraction, – Humor!
Pain Meds• Give ATC to maintain steady state
– Give meds before pain is severe– Adhere to scheduled med time– Kids have ↑ BMR
•Need more frequent dosing not ↑ dose• Tylenol [10-15 mg/kg/dose q 4-6 H]
– Maximum 90 mg/kg/dose (hepatotoxic)• Tylenol with codeine [Codeine 0.5 -1 mg/kg/dose]
– Tylenol No. 1 (Codeine 7.5 mg & Acetaminophen 300 mg)– Tylenol No. 2 (Codeine 15 mg & Acetaminophen 300mg)
• Percocet [oxycodone 0.1 mg/kg/dose]– [Oxycodone 5 mg & Acetaminophen 325 mg]
• Tylox – [Oxycodone 5 mg & Acetaminophen 500 mg]
• Vicodin – [Hydrocodon 5mg & Acetaminophen 500
mg]
Pain MedsNSAIDS• Ibuprophen (Motrin) 40 mg/kg/day
• SE: Skin rash, abdominal cramps, N, dizziness
Opioids • Hydromorphone (Dilaudid) 0.4 -1mg/kg q 4-6 H
• Quick onset of action 15 minutes• Shorter duration than MSO4• ↑ potency 1 mg Dilaudid = 4 mg MSO4
• Morphine SO4 (Roxanol) 0.025 -2.6 mg/kg/H• SE: Sedation, ↓ RR ↓BP Constipation
Flushed face• Methadone (Dolophine) 0.2 mg/kg q 6-8 H
• Long ½ life 24 -36 H• SE: Confusion, Sedation, ↓BP Constipation
Nursing Interventions
Emotional support• Guidance with honest answers• Education
– Serious signs & symptoms, adverse drug effects
– When to seek medical attention• Establish good plan for FU care• Encourage verbalizations or fears/
concerns• Reassure pt will be comfortable
Neuroblastoma• Most common solid malignant tumor in
kids• ↑ risk < 2 years old.• 75% before child is 5 years old.• Tumors begin as embryonic cells
– Develop into the adrenal medulla and sympathetic nervous system (ganglia).
• Majority a non-familial, sporadic pattern• Silent Tumor
– 70% Dx after metastasis – Poor Prognosis
Clinical Manifestations
• Primary sites:– Abdomen & Pelvis, Chest, Head &
Neck• Retroperitoneal region (65%)
– Adrenal medulla - ↑↑ E/NE release• ↑ HR ↑ BP ↑ Bounding Pulses +3, diaphoresis
– Abdominal mass-bloating/constipation•Anorexia
– Kidney compression•Polyuria → Polydipsia
– Spinal chord compression• Pain & Paresthesia
Clinical Manifestations
• Mediastinum (15%) – Compresses trachea & bronchi
•Tracheal deviation•Persistent cough, Dyspnea & SOB•Stridor & Chest pain
– Lymphadenopathy •Cervical, supraclavicular & groin
– Neck/facial edema– ↑ ↑ HA in AM & ↑ ↑ HC – Supraorbital ecchymosis (Raccoon
eyes)– Infection
Clinical Manifestations
• Systemic– Weight loss
•RT Anorexia RT ↓↓ Bowel function– Irritability– Fatigue– Myoclonus ataxia syndrome– Anemia– Febrile, ↑ HR ↑ BP– Changes in urination, bowel
elimination
Diagnosis
• CT: Chest, Abdomen & Pelvis• Bone Scan IVP Abdominal
Sonogram• Bone Marrow aspiration and biopsy• CBC: √Anemia √Thrombocytopenia • 24 H urine collection of VMA
Vanillylmandelic Acid = ↑ DA & NE
Treatment• Surgery if tumor is localized• Radiation
– ↓ size of tumor a & p surgery
• Chemotherapy – Diffuse & advanced disease– Cytoxin, Vincristine & Cisplatin– 3F8 immunotherapy
Wilm’s Tumor (Nephroblastoma)
• Common type of abdominal tumor– ↑ Incidence with Hypospadias & Cryptorchidism
• 80% diagnosed at <5years – ↑ risk @ 3 years
• 90% survival rate– ↑ Cure rate with early diagnosis
• Encapsulated Tumor – Arises from renal parenchyma– Rapidly growing tumor
• Favors left kidney and usually unilateral• 10% of cases have both kidneys involved
Clinical signs• Non-tender mid-line abdominal
mass• Flank pain• ↑↑ BP
– RT kidney & adrenal compression & Renin
• Anemia RT Hematuria• Rare Mets → Lung & Bone
Diagnosis ASAP!• Abdomen & Chest
– CT scan, X-Ray & Ultrasound• IVP • Renal function tests• CBC with differential• Bone scan
Therapy• 1st Place sign on wall:
– DO NOT PALPATE ABDOMEN!• Radiation and chemo a & p
surgery• Surgery
– Radical Nephrectomy – whole kidney and adrenal– Large Y autopsy-like incision:
•Examine entire abdominal cavity
Nursing Interventions
• Prepare family for scar • Prepare for chemo and radiation• Abdominal surgical care• I&O’s• Monitor bleeding• No contact sports • Watch for any kidney infections
or • ⇊ function
Osteogenic SarcomaOsteosarcoma
• Arises from bone forming osteoblasts and bone digesting osteoclasts
• Most common bone tumor in children – 10 – 15 years, can go up to 25 years
• Femur, tibia or shoulder near growth plate– ↑ Frequency during growth spurt
Signs and Symptoms• Gradual onset
Insidious, intermittent local joint pain
• Palpable mass – (Bone Biopsy)• Pain more intense with activity • Limp & change in gait, ↓ ROM• High serum alkaline PO4, and LDH• Pathological fractures
– Starburst formation on x-ray
Therapy• R/O Metastasis
– Bone Scan, CT, MRI & Lung Scan• Surgery
– Amputation 3” proximal to tumor or joint
– Limb salvage• Chemotherapy
– ↑ Methotrexate, Adriamycin,– Cisplatin, Ifos
Pre-op• Exercise to strengthen upper arms• Prepare patient for extensive PT• Emotional support
– allow pt to grieve for limb loss – Focus on what the pt can do
• Support Group: – ACS-Osteo Support Group;
Camping & youth directed activities
– www.candlelighters.org
Post-op• √ signs of hemorrhage q1H x 24 then
q4H• Tourniquet at bedside (arterial bleed)• Venous oozing reinforce dressing• Pressure dressing
– Mold and shape for prosthesis• Phantom limb pain
– Stimulation of nerve endings– Burning, aching, tingling & cramping. – It is real! – Pain meds & Elavil
Post-op• Position
– 1st 24 H - Elevate stump with pillow
– >24 H No pillow below knee– Position prone to prevent hip
flexion– No external rotation or abduction
• Place prosthesis immediately after surgery. – Fosters early function and
adjustment
Ewing’s Sarcoma• 2nd most common malignant bone tumor• Highly invasive into bone marrow. • Infiltrates soft tissue around the bone
– Pain with soft tissue mass• Sites:
– Femur, tibia, fibula, ulnar, ribs and vertebrae
• 5 – 25 years of age (peaks @ age 10-20)• Prognosis depends on degree of
infiltration
Therapy• Chemotherapy
– Shrinks tumor & control mets– VAC – Vincristine, Actinomycin &
Cytoxan• Intensive Total Body Radiation
– (6-8 weeks)
• No Surgery – tumor is too invasive
Nursing Interventions
• Anticipatory guidance RT Therapy SE
• Radiation burns– Erythema, blisters, pain– Hyperpigmentation
• Loose clothing, protective cream, • Protect against sunlight• Avoid sudden changes in temp
– No ice/heat packs
Non-Hodgkin’s Lymphoma
• Malignancy of lymphatic system– Proliferation of T or B lymphocytes– Lymphoblastic Lymphoma 30%
• 75% Medialstinal mass, Pleural effusion Lymphadenopathy
– Large B Cell Lymphoma 20%•Lymphadenopathy & Invades other tissues•Associated with Epstein Barr virus
– Small,non-cleaved type 50% •Burkitts Lymphoma-90% (intrabdominal
mass)• Generalized and very aggressive• ↑ Incidence with age• Males 2x > females• ↑ Incidence with AIDS
Sign and Symptoms• Acute onset & progression
– Pain & swelling in chest or abdomen – Lymphadenopathy in neck, underarm or
groin• Fever, malaise & Night Sweats• Mediastinal mass = SOB ↑ RR ↑
Cough• CNS = HA & vomiting (no nausea)• Superior Vena Cava Syndrome (SVCS)
– Obstruction of SVC •Edema of face, neck & trunk
• Bone Marrow Infiltration– Petechia, Bruising, Bleeding & Bone Pain
Diagnosis• Biopsy from tumor site• Staging (I – IV)
– Bone marrow & Lumbar puncture– CT: Chest, Abdomen & Pelvis– PET Scans (total body) ↑ activity & uptake– Gallium Scans- Cardiac
• Tumor Lysis Syndrome (WBC > 50,000)– Release of purines from destroyed
lymphoblasts– ↑ Uric acid levels →Renal Failure– Therapy
• IV NaHCO3 keep urine pH > 7-8•Allopurinol (Zyloprim) ↑ uric acid
secretion
Treatment• Chemotherapy
– Multi Agent aggressive R-CHOP protocol
– R= Retuxin (monoclonal AB therapy)– CHOP
•Cytoxin, Adriamycin, Oncovin (Vincristin) & Prednisone
• Radiation – 20 - 40 treatments @ tumor site
Nursing Interventions
• Chemotherapy & Radiation SE– Aranesp, Procrit, PRBC Transfusions– Neupogen & Neutropenic
Precautions• No fresh fruit or Vegetables• ↓ Exposure to infections
• Immunizations – Flu, PPCV, Gamma Globulins,
Acyclovir– Leuprolide (Lupron) suppress
ovaries