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Oncology
Exam 4: Leukemias and Lung Cancer (Dr. Frei)
| Question | Answer |
|---|---|
| What are the different types of Leukemia? | ALL, AML, CLL, CML, |
| Which Leukemia type is mostly seen in pediatrics? | ALL |
| Most common type of leukemia in all patients? | CLL |
| What genotype would have unfavorable outcomes in leukemia? | t(9:22) |
| Risk factors for leukemia? | Chemical exposure, previous chemo, genetic disorders (down syndrome) |
| S/Sx of leukemia? | Symptoms of bone marrow suppression (fatigue, fever, bleeding/bruising) Bone pain/tenderness |
| What lab values would potentially indicate leukemia? | Increased or decreased WBC Increased LDH and uric acid Peripheral blast cells |
| What is immunophenotyping? | Used to determine the presence of cell markers and lineage (B cells vs T cells), helps determine prognosis |
| Which cell type is more common in leukemia? | B cell (CLL) |
| What would qualify as a very high risk acute leukemia patient? | Hypodiloidy (<45 chromosomes) t(9:22)-philidelphia chromosome (makes it tx resistant) t(4:11)- MLL fusion gene |
| How do we prevent meningeal disease in acute leukemia? | Using intrathecal chemo as a CNS prophylaxis, used during all 3 phases of treatment for leukemia |
| What are the 3 main phases of acute leukemia (ALL and AML) therapy? | Induction (4-6 weeks) Intensification and consolidation (20-30 weeks) Maintenance (2+ years) |
| What agents or regimens are used for induction in ALL ? | HyperCVAD HD (high dose) MTX/ARA-C |
| What agents are given in hyperCVAD? | Cyclophosphamide, vinicristine, doxirubicin, dexamethasone |
| What drugs are used in a MTX/ARA-C regimen? | High dose methotrexate and cytarabine |
| What regimen is used in Intensification and Consolidation for ALL? | HyperCVAD HD MTX/ARA-C *Aspariginase |
| What regimen(s) are used in Maintenance therapy in ALL? | POMP (purinethol (6-MP), Oncovin (vinacristine), Methotrexate, prednisone) |
| What is the goal of induction for leukemia? | Rapidly kill most tumor cells and obtain remission |
| What qualifies as remission in leukemia? | Less than 5% leukemic blasts in bone Normal blood cells Absence of tumor Absence of s/sx of leukemia |
| When is CNS prophylaxis given during chemo regimens? | Given every cycle |
| ADRs of methotrexate? | Mouth ulceration, end of white blood cells, tiredness, hepatotoxicity, oh fibrosis of the lung |
| What drugs are usually given IT for CNS prophylaxis in leukemia? | IT cytarabine and IT MTX |
| Can Vincristine be given IT? | NEVER, can cause death |
| Goal of intensification and consolidation? | Eradicate residual leukemia cells, using high doses of multi drug chemo. |
| What is the main regimen that will be used in intensification and consolidation for ALL? | HyperCVAD, MTX, and asparaginase (along with CNS prophylaxis) |
| What are our main concerns when giving asparaginase? | Hypersensitivity (pre-dose with steroids, benedryl, tylenol) Thombosis/bleeding Increase triglycerides Pancreatitis |
| When would we d/c asparaginase over ADRs? | If triglicerides > 1000, hold off Pancreatitis occurs, d/c therapy |
| What toxicities can be seen with asparaginase? | Hyperammonemia (asparaginase blues)- mental status changes Hyperglycemia Hepatotoxicity (watch bilirubin) |
| Goal of continuation/maintenance therapy in leukemia? | Prevent relapse of disease |
| Maintenance regimen for ALL? | POMP Purinethol (6-MP) Oncovin (Vincristine) MTX Prednisone |
| What type of supportive care would we give to a luekemia patient undergoing therapy? | Anti-infection prophylaxis (antibiotics/antifungals/antivirals) Growth factors (G-CSF) given during HyperCVAD and MTX-araC |
| What cell type difference is seen in chronic vs acute leukemia? | Acute: immature blast cells Chronic: mature cells |
| Which type of leukemia (chronic or acute) has better survival? | Chronic |
| Which Cell type is most commonly seen in CLL? | B cells (95%) |
| Risk factors for CLL? | Family history, age, sex, agent orange exposure, Monoclonal B-cell lymphocytosis |
| Symptoms of CLL? | Fatigue, fever, swollen lymph nodes, night sweats, weight loss, pain or fullness under ribs |
| What lab abnormalities would you expect in CLL? | elevated WBC and lymphocyte |
| What are B symptoms? | CLL symptoms, including fever, night sweats, and weight loss (10% in 6 months) |
| How do we diagnose CLL? | Blood flow Cytometry |
| Which gene mutation comes with a poor response to tx in CLL? | Deletion 17p/TP53 |
| When should we start tx for CLL? | Fevers for more than 2 weeks w/o infection, anemia or thrombocytopenia, splenomegaly, end-organ function, patient preference |
| When would you NOT treat for CLL? | Patient has significant co-morbidities |
| What are the 1st line options for CLL? | Venetoclax + Obintuzumab Venetoclax + acalabrutinib Zanabrutinib Acalabrutinib |
| Which drugs require the patient to avoid strong 3A4 inh or inducers? | The BTK inhibitors (like Zanubrutinib) and Venetoclax |
| Most common ADRs of Acalabrutinib? | Afib and headache |
| Most common ADRs of Zanubrutinib? | Infection |
| Which agents for CLL can cause Neutropenia and Hyperuricemia? | Obinutuzumab and Venetoclax |
| Can people with CLL get live vaccines? | NO |
| Which drug requires prophylaxis for TLS? | Venetoclax also Obinutuzumab (just for high risk patients) |
| What causes the myeloid cells to grow abnormally in CML? | BCR-ABL |
| How does the Philadelphia chromosome impact CML? | It increases production of BCR-ABL |
| Lab values seen in CML? | Increased WBCs, thrombocytopenia or high platelets, high basophils and eosinophils. Splenomegaly |
| Does CML increase infection risk? | No, unlike CLL |
| What is the Sokal risk score? | Used for CML, measures likelihood of achieving a complete cytogenetic response |
| What are considered low, high, and intermediate risk scores for Sokal? | Low: < 0.8 Intermediate: 0.8-1.2 High: >1.2 |
| What are the drug options we would use for a low risk Sokal score? | Imatinib* (only for low risk), Dasatinib, Nioltinib, Bosutinib, Asciminib |
| What are the drug options we would use for a intermediate risk Sokal score? | Bosutanib, Asciminib, nilotinib, dasatinib (BCR-ABL agents, except Imatinib) |
| What are the drug options we would use for a HIGH risk Sokal score? | *Ponatinib and Asciminib |
| MOA of Asciminib? | BCR-ABL TKI, targets CML cells with T315 mutation |
| When is Asciminib usually used/indicated? | For those with t315 positive mutation *can also be used after progression on 2 different TKI drugs |
| ADRs of Imatinib? | Nausea |
| Main ADRs of Dasatinib? | Fluid retention, pleural or pericardiac effusions |
| Main ADRs of Nilotinib? | QTc prolongation, metabolic syndrome |
| Main ADRs of Bosutinib? | Diarrhea |
| Which BCR-ABL meds cannot be taken with PPIs and delayed with H2 blockers? | Dasatinib, Nilotinib, and Bosutinib |
| Which BCR-ABL drug cannot be used with 2C9 substrates? | Asciminib |
| When can you safely stop TKI therapy in CML patients? | If they meet all of the criteria, inlcuding being an adult, with chornic phase CML, and had TKI therapy for 3+ years with BCR-ABL level measurements |
| Which BCR-ABL medication CANNOT be taken with food? | Asciminib |
| How do we know if acute leukemia is responding to therapy? | Complete response = <5% blasts in bone marrow, no abnormal blasts in blood, no s/sx, normal hematologic response |
| What do we do if there is a reccurance in ALL as far as induction? | May consider re-induction with inital regimen OR consider high dose chemo with SCT or blinatumomab |
| What lab value would indicate a patient has AML? | 20% blast in blood or higher |
| What is the induction therapy for AML? | 7 + 3 |
| What is 7 + 3? | Cytarabine for 1-7 days Anthracycline for 3 days |
| If the AML patient is FLT3 positive, and undergoing induction, what would you add? | Midostaurin |
| How early can we stop induction for AML? | At 14 days, IF they have no luekemic cells, start consolidation/post-remission phase If they SHOW leukemia, re-induction is needed |
| What is the standard regimen for AML consolidation (aka post-remission) therapy? | HiDAC (high dose cytarabine (Ara-C) for 4 cycles |
| If a AML patient opts for a transplant, do they still NEED to undergo consolidation therapy? | No, but they can if they want |
| If a AML patient opts for a transplant, do they get maintenance therapy? | NO |
| What is the standard maintenance therapy for AML? | Azacitadine |
| Toxicities of Cytarabine? | CNS toxicity and conjunctivitis |
| Anthracyclines toxicities? | Cardiotoxicity, mouth sores, extravasation risk |
| Toxicities of Midostaurin? | Pulmonary toxicity, anemia, QTc prolongation |
| Most common type of lung cancer? | Adenocarcinoma |
| Which lung cancer is the most aggressive? | Small cell lung cancer (SCLC), but it is highly sensitive to treatment |
| WHat is the main differnce between limited SCLC and extensive SCLC? | Extensive can NOT be treated with surgery |
| What is the recommended treatment for Limited SCLC? | Surgery and/or chemo + radiation |
| Once chemo is complete in SCLC, what is next? | Give consolidation therapy with durvalumab q28 days for 24 months |
| What is the preferred chemo regimen for limited SCLC? | Cisplatin + etoposide for 4 cycles |
| Can growth factors be used during radiation therapy? | NO |
| What is the differnce in treatment approaches for extensive vs limited SCLC? | Extensive: gets chemo with no radiation limited: chemo AND radiation |
| What is the regimen for extensive SCLC? | Carboplatin + etoposide + 1 checkpoint inhibitor (atezolizumab or durvalumab) |
| Which is more common non-SCLC or SCLC? | non small cell LC is more common than SCLC |
| Which drug is dosed based on AUC? | Carboplatin |
| For patients who have recurrent SCLC, what do we do? | If its been >6 months, use the original chemo regimen If its been 6 months or less, use one of the 4 drugs: Topotecan, Lurbinectedin, irinotecan, Tarlatamab-dlle |
| Which LC type is less sensitive to chemo and radiation? | Non-small cell |
| How do we decrease the risk of brain mets in patients with LC? | Radiation |
| How do we treat resectable lung cancer? | Test for PD-L1, EFGR mutations, ALK rearrangements, then perform surgery, then chemo |
| When would we give neoadjuvant chemo for resectable LC? | In stage 3 (and sometimes in stage 2) |
| What would be our regimen of choice for neoadjuvant treatment for resectable NSCLC (stage 2-3a)? | Checkpoint inhibitor (nivolumab, pembrolizumab, or durvalumab) + Platinum doublet (cisplatin + gemcitabine (or paclitaxel or pemetrexed) |
| Which chemo doublet can only be used in non-squamous resectable NSCLC? | Cisplatin + pemetrexed |
| Say a patient with resectable NSCLC has an ALK rearrangement, what should be added? | Alectinib x 2 years |
| Say a patient with resectable NSCLC has an EGFR exon 19 deletion or 21 mutation, what should be added? | Osimertinib x 3 years |
| Say a patient with resectable NSCLC has a PDL of 1+ without EFGR or ALK biomarkers, what should be added? | Atezolizumab x 1 year |
| Say a patient with resectable NSCLC has no EGFR or ALK markers AND PDL < 1, what should be added? | Pembrolizumab |
| What would be the regimen for UNresectable lung cancer (stage3b or beyond)? | Chemoradiation (cisplatin +pemetrexed or Paclitaxel + carboplatin, or cisplatin + etoposide) THEN consolidation therapy |
| What would be consolidation therapy for UNresectable lung cancer? | Osimertinib or Durvalumab |
| When would a patient be unfit for chemo? | Metastatic or advanced NSCLC, performance status 3-4, no benefit from cytotoxic treatment |
Created by:
cdaughtry