OncologyOncologyOncologyOncology

Elisa A. Mancuso RNC-NIC, MS, Elisa A. Mancuso RNC-NIC, MS, FNSFNS

Professor 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

Agranulocytes

Participate 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 Meds

Corticosteroids• 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 Meds

Alkylating 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