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Oncology
Dead Man’s party
Biology of abnormal cells
Cancer grading and stages
Cancer statistics
Chemotherapeutic agents
Radiation treatments
Bone Marrow and Stem Cell
transplants
Onco-gene therapy
Oncology Objectives
• 1. Identify the different phases of cancer cell
replication.
• 2. Compare the features of a benign versus
malignant tumor
• 3. Recognize the TNM stage and grading
system of cancer tumors.
• 4. Discuss the role of oncogenes and
suppressor genes in cancer development.
• 5. Identify behaviors with corresponding
primary and secondary nursing prevention
for risks of cancer development
• 6. Recognize the different classes of
chemotherapies.
• 7. Create appropriate nursing interventions
for a case study of a patient with cancer.
Oncology Objectives
• 8. Identify appropriate testing for cancer
patients.
• 9. Recognize signs and symptoms of
chemotherapy side effects.
• 10. Recognize signs and symptoms of radiation
therapy.
• 11. Prioritize nursing interventions for a patient
with neutropenia.
• 12. Prioritize nursing interventions for a patient
with thrombocytopenia.
• 13. Prioritize nursing interventions for a patient
receiving bone marrow or stem cell
transplant.
Oncology Objectives
• 14. List 4 risk factors for the development of
leukemia.
• 15.Compare Leukemia and Lymphoma
pathophysiology, etiology and clinical
manifestations.
Cellular Review
• Evolve 3D Cellular Differentiation
on web site
Oncology
• Biology of abnormal cancer cells
• They have continuous or inappropriate,
usually faster growth or larger growth
patterns
• They have no specific morphology and
often do not resemble their parent cells
= anaplastic
• They do not respond to signals for
apoptosis = programmed cell death
Oncology
• Biology of abnormal cancer cells
• Have a large nuclear – cytoplasmic
ratio; the nucleus may occupy most of
the cell area
• They lose some or all of their normal
cell functions
• They do not make fibronectin, and
thus cannot connect easily and break
off easily
Oncology
• Biology of abnormal cancer cells
• They are able to migrate throughout the
body = metastasis
• They invade other tissues and types of
cells.
• They are not controlled by contact
• They have more or less chromosomes
than the parent cells = aneuploid
or a mutation of the genes
Oncology
• Cancer development
• Initiation – there are many
theories as to when the genes in
the cells are damaged, maybe in
utero, from physical or chemical
exposure, latent oncogenes,
viruses, or a lack of suppressor
genes from our parents, and at
this point the cell is not dividing.
Oncology
• Skin cells
Oncology
• Cancer development
• Promotion - the stage when the
abnormal cell starts to divide, may
be stimulated by environmental
changes, hormones, drugs, or
irritants
Oncology
• Cancer development
• Progression – the phase when
the abnormal cells have continued
to grow into a Primary tumor, may
produce angiogenesis factors
which supply blood and vascular
nourishment to the tumor. The
tumor may have subcolonies of
cells with different genes and
features
Oncology
• Cancer development
• Metastasis
the movement of cancer cells into
other organs of the body, thus
creating new tumor sites.
Oncology
• Cancer grading and staging
• Cancer is graded upon the resemblance to
normal cells = G
(The higher the number, the worse the grade of
cancer) i.e. G1, G2, G3, G4
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Staging is based upon
the presence of a primary tumor = T
involvement in lymph nodes = N
and appearance of metastasis = M
Numbers of the stage range from
x = none to 3 or 4 for each letter
Oncology
• Is this a high grade or low grade
cancer?
• Case study
Julie has a breast lump in her right
breast, and has also found one in her
right armpit. Biopsy and lumpectomy
were performed. The tumor was
graded G3, T2, N2, M1.
Is this a high grade or low
grade cancer?
1. High
2. Low
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Oncology
• Julie opted to have a lymphectomy
of her right arm lymph nodes, and
started radiation treatment right
away. Her doctor also suggested
that she start Adriamycin IV
chemotherapy to get any cells that
the radiation might miss.
Oncology
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Cancer Risks
#1 = advancing age
#2 = smoking tobacco
Hormones – Prempro caused a
substantial increase in breast cancer on
the HERS trial
• Genetic inheritance of oncogenes and
autoimmune diseases
• Environmental exposure
• Excessive intake of dietary fats
Oncology
• Cancer risks
• High alcohol consumption
• Low dietary vegetables and fiber
(sources of antioxidants)
• Previous Viral infections:
Hepatitis B or C
Herpes viruses
Papilloma viruses (HPV)
Retrovirus HTLV –I
Oncology
• Types of cancer cells are named for
their site of origin:
• Adenocarcinoma
• Carcinoma in situ (CIS)
• Squamous
• Basal cell
• Astrocytomas
• Melanomas
• Sarcomas
• Lymphomas
Oncology
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Symptoms of Cancer
Cachexia – weight loss,unexplained
Anorexia
Anemia
Impaired immune response
Pain – when the cancer is large enough
to compress nerves or organs
• Lymphadema – when the tumor blocks
lymph or circulatory flow
• Motor or sensory deficits
Oncology
• The 60 year old client with small cell lung cancer
is concerned that his grown children also might
develop the disease. What is the nurses best
response?
– A. “This disease is a random event
and there is no way to prevent it.”
– B. “Because this disease is inherited as a
dominant trait, your children have a 50% risk
for developing it.”
– C. “Cigarette smoking is the main cause of this
disease, and helping your children not to
smoke will decrease their risk.”
– D. “ Lung cancer can be avoided by decreasing
dietary intake of fats and increasing the
amount of regular aerobic exercise.”
Oncology
• Cancer statistics
• The top four cancers found in the
United States are:
• Lung
• Breast
C
• Prostate
• Colorectal
Oncology
• Cancer statistics
• Prostate cancer is the most
common site of cancer and the 2nd
most common cause of cancer
death in the United States
• The first cause of death in males is
Lung Cancer
Oncology
Oncology
• Cancer statistics
• Lung cancer has annual
new cases (incidence)
of 173,770 people
per year: 93,110 males and
80,660 females
• Annual mortality: 160,440 per
year consisting of 92,000 males
and
68,510 females
Oncology
• Cancer statistics
• 28% of all cancer deaths are due to
lung cancer
• This is the leading cause of cancer
death in both men and women
• There are more deaths from lung
cancer than prostate, breast, and
colorectal cancers combined
Oncology
• Cancer statistics
• Risks for lung cancer:
• Smoking (75-80% of cases)
• Occupational exposure
• Nutrition/Diet
• Genetic factors
Oncology
• Cancer statistics
• Prostate cancer is number two cause of
cancer in men
• Breast Cancer is number two cause of
cancer in women
• Most common non-malignant or nonfatal cancer is non-melanoma type skin
cancers
Oncology
• The client says that she has heard that the
origin of most cancers is “genetic”. What is
the nurse’s best response?
– A. “The development of most cancers is
predetermined and not affected by
environmental factors.”
– B. “Cancers arise in cells that have been
damaged,which may be in the genes”.
– C. “ The majority of cancers are inherited”
– D. “Cancer is more common among males than
females.”
Oncology
• Lab tests for cancer
• Ultrasounds to determine size
• CT scan with contrast– the golden
standard
• Genetic markers – BRCA 1 and BRCA 2
• Tumor markers:
CEA – general carcinogenic antigen
PSA – prostate antigen
CA-125 – ovarian
CA-25,27 – breast
HER 2 NEU – breast tissue needed
Oncology
• Lab tests for cancer
• Liver function tests
• CBC with diff
• Renal function tests
• PET scan – looks for metastasis
using a radioactive glucose
solution
• PT, PTT, Fibrinogen, Fibrin levels
Oncology
• Lab tests for cancer
• Pathology slide of tumor:
(Should be kept for a period of years)
• Determines type of tumor
• Source of tumor
• Aggression of tumor – whether fast
growing, differentiated, or nondifferentiated
• Used to determine tumor growth
factors and susceptibility to certain
chemotherapies
Oncology
• Chemotherapy
• Prevention chemotherapy – for
high risk patients, precancerous
lesions, or history of cancer
• Antioxidants, vitamins
• Aldara cream 3x weekly for
precancerous skin lesions
• Aspirin
• Protease inhibitors
Oncology
• Chemotherapy
- typically
started after surgical dissection of
tumor, unless the tumor is nonoperative
• Usually given by a long term venous
access device, i.e. PICC line, implanted
ports, or direct catheratization to the
tumor.
• Chemotherapy is usually potent and
horribly scarring on normal veins
Oncology
• Chemotherapy
• Biochemotherapy – used as in-patient
or outpatient settings for cancer, MS, and
viral treatments:
Alpha interferon – (IFN)- Alpha 2a,
Roferon, Intron-Aused for leukemias, AIDS, Hep-C
Beta interferon – Beta 1b
– used for renal carcinoma,
melanoma, AIDS, MS, Hepatitis A, B
Oncology
• Chemotherapy/Biochemotherapy
• Interleukin I (IL-1)
• Interleukin 2 (IL-2), Proleukin–
stimulates growth of T-cells and NK
cytotoxic cells
• – used investigationally for melanoma
in Stage II to Stage IV cases on a
monthly basis with a 80% nonrecurrence rate
Oncology
• Chemotherapy/Biochemotherapy
• Tumor necrosis factor (TNF) –
selectively targets abnormal cells, in
nature is produced by NK cells
Oncology
• Chemotherapy/Biochemotherapy
• Vaccines
HPV vaccine for cervical cancer
Melanoma vaccine - for stage II only
at this time, or malignant melanoma
Oncology
• Chemotherapy/Biochemotherapy
Monoclonal antibodies – used for
treatment of cancer, rheumatoid
arthritis, transplants, and other
autoimmune diseases. Can be used to
stimulate immune response or suppress
it.
Rituximab – Treatment of CD20 –
positive non-Hodgkins B-cell lymphoma
Gentuzumab – treatment of CD33
positive AML in first relapse in patients
who are not candidates for reg. chemo.
Oncology
• Chemotherapy/Biochemotherapy
Monoclonal antibodies
• Adalimumab – Humira
–new treatment for severe rheumatoid
arthritis, given s.q every other week
• Alemtuzumab – Campath
- treatment of B-cell lymphoma who
have failed traditional chemotherapy
with fludarabine
• Basilixamab – Simulect
- immunosuppressive monoclonal
antibody for renal transplants
Oncology
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Chemotherapy – Alkylating agents
Bisulfan
oral
Carboplatin (CBDCA)
IV
Chlorambucil (leukeran) oral
Cisplatin
IV
Cyclophosphamide(Cytoxan) IV or PO
Melphalan (Alkeran)
oral
Ifosfamide
IV
Thiotepa
IV or PO
Oncology
• Chemotherapy/ Antibiotics
given IV as chemotherapy
• Adriamycin (Doxirubicin)
• Bleomycin
• Dactinomycin
• Daunorubicin (actinomycin D)
• Idarubicin (idomycin)
• Mitomycin C
• Mithramycin
Oncology
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Chemotherapy – anti-metabolites
Cytorubine (Cytosar)
IV
Floxuridine (FUDR)
IA or SQ
Flourourcil (5FU)
IV
Fludara
IV
Hydroxyurea
PO or IV
Methotrexate
IV or IM
6MP
PO
IRESSA
PO
Xeloda
PO
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Oncology
Chemotherapy- Hormones
Progestins – uterine cancer
Estrogens
Testosterone - myelodysplasias
Anti-hormones – block hormonal
activity in hormone sensitive cancers:
Leupron
Eulexin
Tamoxifen/Nolvadex
Arimedex/Arista
Oncology
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Chemotherapy – Plant alkaloids
Vinblastine (Velban)
IV
Vincristine (Oncovin)
IV
Vindesine
IV
Eldisine
IV
• The first doses of this are usually given
in a hospital setting, are vesicants, and
neurotoxic. Nurses must wear
protective gear!
Which of the following are appropriate
protective gear for the nurse when hanging
chemotherapy?
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1. Splash goggles
2. Latex gloves
3. Rubber gloves
4. Paper gown
5. Special
biohazard bags
for disposal
6. Lead apron
Oncology
• Chemotherapy –Antimitotics
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Dacarbazine (DTIC – Dome)
Leukovorin
Paclitaxol (Taxol)
Topotecan
Gemzar
Docetaxol
Camptothecan (CPT-11)
Taxotere (Ormaplatin)
IV
PO or IV
IV
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IV
IV
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Oncology
Side effects of Chemotherapy
Alopecia
Fatigue
Anemia
Leukopenia
Thrombocytopenia
Always – Nausea,Vomiting, Diarrhea
Neurotoxicity & neuropathies
Capillary leakage
Headaches
Fluid and electrolyte imbalances
Oncology
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Side effects of Chemotherapy
Anorexia – change in taste buds
Back aches
Joint aches
Blood clots
Oral mucositis – (reduced significantly
by L-glutamine amino acids orally)
Supra opportunistic infections
Septic DIC
Tumor lysis syndrome
Edema or pulmonary edema
Oncology
• Chemotherapy Nursing Interventions
• Evaluate and assess sites of chronic
chemotherapy, ports, veins, skin area
• Accurate I & O’s
• Monitor for fluid overload or dehydration
• Monitor lab electrolytes before and after
infusion
• Monitor BUN and Creatinine
• Monitor CBC with differential during the
time of Nadir
• Monitor PT, PTT
Oncology
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Cancer Nursing Interventions
Nutritional assessment and weights
Dentition – oral checks
Monitor for signs of suprainfection, low
grade temperatures, rash, etc…
• Vital signs before, during, and after
treatments
• Assess bowel status
• Assess pain level
Oncology
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Cancer Nursing Interventions
Educate patients and family members:
side effects of treatments, meds
care of port and IV sites
oral hygiene
symptoms to report, i.e. shortness of
breath or signs of infection
• Increase fluid intake, suck on hard candies
to reduce chemotherapy metallic tastes
Oncology
• Nursing Diagnoses
• Disturbance in self esteem, body image
• Altered nutrition, less than body
requirements
• Risk for fluid volume excess or deficit
• Impaired skin integrity
• Pain, chronic
• Decreased cardiac output
• Self-care deficit
• Sexual dysfunction
Oncology
• Nursing Diagnoses
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Alteration in tissue perfusion
Knowledge deficit
Risk for injury
Impaired physical mobility
Sensory perception alterations
Alterations in bowel patterns
Alterations in mucous membranes
Anxiety and Fear
Oncology
• Nursing Diagnoses
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Depression
Grief
Respiratory compromise
Ineffective coping
Spiritual distress
Impaired social interactions
Sleep pattern disturbance
Altered family roles
Oncology
• Pharmacological interventions
• Megace, Marinol – for appetite
stimulation
• Premedications for nausea, vomiting,
edema, headaches: usually on the
protocol for chemo
Antiemetics;
Zofran – 24 hour control
Tigan, Kytril, ativan, anzamet,
Compazine, benadryl, reglan
Corticosteroids
Oncology
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Pharmacological interventions
Analgesics
IV electrolytes and fluid replacement
Stool softeners to counteract
constipation from opioids
GSF for WBC’s
Epogen/Procrit for anemia
Leukine/Prokine for leukopenia
Neupogen for neutrophilia
Neumega for thrombocytopenia
Diuretics for edema
Oncology
• Non-Pharmacological interventions
– Massage
– Reflexology
– Accupuncture
– Musical therapy
– Prayer
– Meditation
– Diversional acitivities
– Dietary counselling
Oncology
• Radiation therapy
• All types of cells are injured or
destroyed by concentrated
radiation. Rapidly dividing cells
are the most sensitive.
Oncology
• Radiation therapy
• Types :
Gamma knife
Local beam treatment
Local seeding
ARC – stereotactic
Radioimmunotherapy
Fractionation
Total body irradiation
Particle beam therapy, i.e.
proton or neutron therapy
Oncology
• Radiation therapy side effects
• Side effects depend on the amount
and area being irradiated
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Fatigue
Nausea and vomiting
Mild anemia
Leukopenia
Diarrhea
Pain
Oncology
• Radiation therapy side effects:
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Erythema/burns
Fatigue
Pneumonitis
Esophagitis
Dysphasia
• (Please educate your patients on
these as doctors are notoriously
bad at pre-educating their patients).
What side effects of radiation therapy would you
expect to see in a 48-year-old woman with breast
cancer?
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1. Debilitating
fatigue
2. Mucositis
3. hair loss
4. nausea and
vomiting
What are some of the educational
issues for patients receiving radiation
treatment
1. Burns
2. Anemia
3. Skin care
4. Diet
5. All of the above
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Oncology
• Nursing interventions for radiation
TX
• Assess incidence and severity of side
effects
• Maximize radiation protection, all
wastes will be radioactive if isotopes are
injected
• Shielding for staff
Oncology
• Malignant Lymphomas – 2 types
• Hodgkin's Lymphoma – most common
cancer in 10 to 20 year olds (young
adults). Associated with an inflammatory
process related to +EBV/mono infection.
• Diagnosis: Classic Reed-Steinberg cell
with two mirrored nuclei, CT scan
• Symptoms: Extreme fatigue, enlarged
lymph nodes that are painless. May
progress to weight loss fevers, night
sweats
Oncology
• Malignant Lymphomas – 2 types
• Hodgkin's Lymphoma
• Treatment – combined radiation
and chemotherapy, stem cell
transplants if resistant type or
recurring
• 85% curable
• (90% in some institutions)
Oncology
• Malignant Lymphomas – 2 types
• Non-Hodgkins Lymphoma – 3 times
more common than Hodgkin’s
lymphoma, can either be T-cell
lymphomas, or B-cell lymphomas
• Can be low grade or high grade disease.
B-cell lymphomas = 50% and usually
are more aggressive tumors. Since they
grow faster, they are also more sensitive
to radiation and chemotherapy
Oncology
• Malignant Lymphomas – 2 types
• Non-Hodgkins Lymphoma
• Diagnosis: bone marrow biopsy, CT
scan, lymphoma panel with CD markers
• Symptoms- adenopathy, spleenomegaly
with vague abdominal pain, back pain,
and since immunity B or T-cell function is
affected- the patient is more prone to
infections. Subcutaneous T-cell
lymphoma is a classic discoid rash on the
upper body and trunk that does not
respond to steroids or creams.
• NHL can progress rapidly to leukemia if
untreated.
Oncology
• Malignant Lymphomas – 2 types
• Non-Hodgkins Lymphoma
• Treatments: Monoclonal
antibodies, chemotherapy with
Fludara/Fludarabine, radiation
therapy, and bone marrow implants
Oncology
• Leukemia– hematopoeitic cancer
of the stem cells. These stem cells
proliferate into non-functional
immature white cells.
• More children get leukemia than
any other type of cancer and it is
the #1 cause of death in children.
• Anyone can get leukemia at any
age.
Oncology
• Leukemia -4 types
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Acute lymphoblastic leukemia (ALL)
Acute myelogenous leukemia (AML)
Chronic Lymphocytic leukemia (CLL)
Chronic myelogenous leukemia (CML)
Anagram – ALL AniMals are CLearLy
CaMeLs
Oncology
• Leukemia –ALL suspected cause is a
T-cell virus (HTLV-1) – 85% is seen in
children, 25% in adults 30-to-40 y.o.
• Diagnosis: peripheral blood smear
after abnormally high white count, bone
marrow biopsy shows lymphoblasts
>50%m may have decrease in
platelets. Lumbar puncture to
determine CSF involvement
Oncology
• Leukemia –ALL
• Symptoms – fatigue, anorexia,
malaise, weight loss, bleeding,
infections, headaches, adenopathy,
spleenomegaly, gingival hypertrophy,
hepatomegaly, bone or joint pain
• Treatment: complete response is a
bone marrow aspirate with < 5%
blasts. Chemotherapy – vincristine,
prednisone, danorubicin, methotrexate,
• Maintenance therapy – 6 weeks of
• 6-mercaptopurine and methotrexate
low dose therapy
Oncology
• Leukemia – AML – more common in
patient’s with chromosomal genetic
disorders, exposure to benzene or
radiation. Use of alkylating agents for
breast, ovarian, or myeloma are
associated with a later malignancy of
this type.
• Symptoms- are like ALL with the
additions of anemia, thrombocytopenia,
visual disturbances, epistaxis
(nosebleeds), headache with vomiting,
dysphagia, papilladema, menorrhagia
(lots more bleeding problems)
Oncology
• Leukemia – AML
• Diagnosis: peripheral blood
smear shows Auer bodies (rods),
platelets less than 20,000/mm3,
bone marrow biopsy
• Prognosis – poor prognosis if
patient has already received
radiation or chemotherapy, or has
a WBC >100,000
Oncology
• Leukemia – AML
• Treatment: Cytaribine
chemotherapy in combination
therapy with Danorubicin or
doxirubicin, works 65% of the
time.
• Bone marrow transplant or stem
cell transplant.
Oncology
• Leukemia – CLL – staged 0-5
• chronic diseases have more mature
cells, majority of CLL is B-cell
proliferation – 95%. Only 5% are Tcells, more common in people with
autoimmune diseases, i.e. SJogren’s,
SLE, hemolytic anemia
• Symptoms: skin and respiratory
infections, fatigue, thrombocytopenia,
anemia, spleenomegaly
Oncology
• Leukemia – CLL
• Diagnosis- peripheral blood
smear, bone marrow biopsy
• Treatments: Gleevac – drug of
choice; chemotherapy in
combinations, spleenectomy,
radiation therapy to spleen, bone
marrow transplant, stem cell
transplants
Oncology
• Leukemia – CML (last is the CaMeL)
- More common after radiation exposure,
benzene exposure, less common than the
other types of leukemia, and occurs most
often between 50-60 y.o.
• Diagnosis: hallmark is the presence of
the Philadelphia Chromosome,
Chromosome #22 is missing part of the
long arm which is translocated to
Chromosome #9. This is present in 95%
of those patients with CML.
• WBC >100,000 with proliferation of all
types of mature and immature white cells.
• Bone marrow biopsy
Oncology
Leukemia – CML
• Symptoms: same as other leukemias
with chronic fever, sternal tenderness
and dyspnea – usually due to severe
anemias
• Treatments: chemotherapy with
Bisulfan and hydroxurea, other
combination chemos,
• Interferon alpha 2b to suppress the
expression of the Philadelphia
chromosome.
• Bone marrow transplant or stem cells
Oncology
• Bone marrow and stem cell implants
New treatments for:
Acute myelogenous leukemias (AML)
Acute lymphoblastic leukemias (ALL)
Myelodysplasia syndromes (MDS)
Chronic myelogenous leukemias that do not
respond to chemotherapy (CML)
Blast crisis
Pediatric acute leukemias
Non-Hodgkins lymphoma
Large B-Cell lymphoma
Multiple myelomas
Bone marrow and stem cell
implants
Oncology
• Bone marrow and stem cell
implants
• Procedure= multiple punctures
• Marrow acquisition from donor or
when patient is in remission, or stem
cells from umbilical blood of a
matching sibling or family member
• Marrow is filtered to purge tumor
cells, fat and bone particles, then place
in a blood bag for cryopreservation.
Oncology
• Bone marrow and stem cell
implants
Preparing Recipient:
• Marrow recipient is given high dose
chemotherapy alone or in combination
with radiation to suppress immune
system, open spaces in the marrow,
and kill remaining cancer cells.
• Bone marrow is thawed and infused
through a central venous catheter
Oncology
• Bone marrow and stem cell
implants
Preparing Recipient:
• Stem cells are infused after thawing
• Post-procedure:
• Patient is supported through the period
of aplasia, 10 to 30 days, while in
reverse isolation and on graft
immunosuppressants,
• Observed for signs of Graft-versushost disease and/or infection
Oncology
• The waves of the future:
• Stem Cell Research
• Oncogene therapy – now that cancer
cells are being genetically tagged, we
can tell which growth factors are
present, and which enzymes turn off
the gene. Soon all gene markers will
have a pill that matches the enzyme,
i.e. IRESSA is a tyramine kinase
inhibitor, and stops the tumors growth
that use tyramine kinase
Oncology
• Stem Cell Induction – there are new
drugs out for stem cell induction to
immunosuppress the patient, even in
deadly cancers, i.e. Multiple
Myeloma. Recently, the combination
of lenalidomide(Revalamid),
bortezomib (Velcade) and
dexamethasone produced a
98% response rate in patients
Oncology
• The waves of the future:
• Cancer vaccines
• Oncology is the science of cancer
and treatment of all cancer
patients. It is one of the most
demanding and rewarding fields in
medicine.
• The future is open for a cure.
Oncology