Oncology 2 Section 5 Final

etiologic factors for leukemia

• previous radiation exposure

• Down syndrome

• alkylating agents

• genetic - chromosome #22

• chemicals - Benzene

number of lobes in each breast

15-20

risk factors for breast cancer

• gender- most significant

• estrogen

• age

• longer fertility period - early menarche and/or late menopause

• socioeconomic status

• dietary fat

• obesity

  • apple shaped body > pear shaped body

• no children or first child after age 35

• family history

• BRCA-1 or 2

• Caucasian women

• moderate consumption of alcohol

• history of benign breast disease

• ionizing radiation

• previous history of cancer

• hormone replacement therapy (HRT)

• hypercalcemia

• smoking longer than 20 years

• oral contraceptives?

pathology of breast cancer

• infiltrating ductal carcinoma

  • most common

  • “cancer of the breast”

  • tends to spread to axillary nodes

• intraductal carcinoma

  • palpable lump, discharge from nipple (Paget’s disease), or abnormal mammogram showing clustered macrocalcifications

• lobular carcinoma

  • occurs most often in younger premenopausal women

• inflammatory carcinoma

  • poor prognosis

  • rapid growth and metastasis

  • considered automatic stage T4

  • treated with surgery, RTT, and chemo

• male breast cancer

  • about 1% of all breast cancers

  • worse prognosis than for women

ER/PR status effect on breast cancer

positive = better prognosis and response to hormonal therapy (Tamoxifen)

staging for CLL

• RAI staging system

• stage 0: lymphocytosis only

• stage 1: + lymph node enlargement

• stage 2: + splenic involvement

• stage 3: + anemia

• stage 4: + thrombocytopenia

muscles that are contiguous or in close proximity to breast

• pectoralis major/minor

• serratus anterior

• latissimus dorsi

percentage of women affected by breast cancer

1 in 8

reservoir via a burr hole leading to the third ventricle by which methotrexate can be introduced directly into the CNS

Ommaya

appearance of cells in acute vs chronic leukemia

acute leukemias tend to have larger, stickie cells

presentation of breast cancer

• painless lump on breast - most common

• nonlactational discharge from breast - 2nd most common

• enlarged axillary node - occasionally the first symptom

• nipple retraction/tenderness

• Paget’s disease

• hypercalcemia

most common location of the breast where cancers arise

upper outer quadrant, left breast

treatment techniques for breast surgery

• radical mastectomy

  • introduced by William Halsted

  • removal of breast and all underlying muscle including pectoralis major/minor and axillary nodes

• modified radical mastectomy AKA total mastectomy

  • removes all breast tissue and some or all axillary nodes

  • preserves as much muscle as possible

• lumpectomy AKA tylectomy, wide excision, partial excision

  • removal of lump and axillary nodes

mammography guidelines for women

• 35-40: baseline

• 40s: every other year

• 50s: every year

diagnostic procedures for breast cancer

• mammography

• MRI

• ultrasound

only type of leukemia that is still considered incurable

chronic lymphocytic lymphoma (CLL)

lymph node groups involved in breast cancer

• axillary

  • most important

  • 10-38 in each axilla

  • 70% of drainage from breast

• supraclavicular

• internal mammary chain (IMC)

  • 8 nodes on average w/ 4 on each side of sternum

lesions of medial and central breast area more frequently spread to what lymph node group

internal mammary chain (IMC)

flow cytometry results associated with poorer prognosis of breast cancers

• aneuploid tumors

• S-phase

estrogen receptors are found more commonly in what women

post-menopausal

prognostic factors for breast cancer

• most important: number of positive axillary lymph nodes

  • >10 is poor prognosis

• involvement of IMC and/or supraclavicular nodes = poor prognosis

breast cancer histology associated with symptom “Peau d’ Orange”

inflammatory carcinoma

chemotherapy agents commonly used for breast cancer

• adriamycin AKA doxorubicin

• cyclophosphamide AKA Cytoxan

• 5FU

  • methotrexate

• megace

anti-estrogen traditionally used by patients that are positive for hormone receptors

Tamoxifen

contraindications for breast conservation treatment techniques

• unfavorable breast size to tumor (large tumor in small breast)

• extremely large or pendulous breasts

• pregnancy

• advanced disease

best energy range for breast treatment

4-8 MV

leukemia that typically presents with acute sickness, fever, anemia, etc.

acute myelogenous leukemia

leukemia in which patients undergo a “blast crisis” and almost always die unless given a BMT

chronic myelogenous leukemia (CML)

person who developed staging system for CLL

Rai

flash required on tangential fields for breast treatment

1-2 cm

dose for breast treatment

entire breast: 45-50 Gy

chestwall of post-mastectomy patient: 45-60 Gy

total w/ boost: 60-66 Gy

possible effects of irradiation to the breast

• acute

  • erythema

  • fatigue

• late

  • skin fibrosis

  • hyperpigmentation

  • edema (in ipsilateral arm)

  • pneumonitis - if over 25 Gy to any portion of lung

  • cardiac effects

  • brachial plexopaty

  • osteoradionecrosis

overall 5 year survival rate for breast cancer

80-90%

chromosome #22

AKA Philadelphia chromosome, lost in detecting CML

median survival per stage for CLL

• stage 0: 11+ years

• stage 1: 8 years

• stage 2: 4 years

• stage 3: 2 years

• stage 4: 1 year

leukemia that is most common in children and referred to as “childhood”

acute lymphocytic leukemia (ALL)

leukemia that sometimes “hides” in sanctuary sites

acute lymphocytic leukemia (ALL)

Down’s syndrome is an etiological factor for which type of leukemia

acute myelogenous leukemia (AML)

nodes radiation with posterior axillary boost (PAB) field

level 3 axillary nodes

determining optimal incline angle when using a breast board for positioning

slope of chest

best technique when treating supraclavicular field along with opposing tangents

half-field technique

reason for limiting amount of lung tissue in tangential breast fields to 2 cm

to decrease risk of lung fibrosis

staging for breast cancer

• American Joint Committee on Cancer (AJCC) based on TNM system

• TIS: Paget’s disease of the nipple, lobular carcinoma in situ, and intraductal carcinoma in situ

• T1: tumor 2 cm or less

  • T1a: no fixation to underlying fascia

  • T1b: fixation to underlying fascia

• T2: tumor greater than 2 cm but less than 5 cm

• T3: tumor greater than 5 cm

• T4: tumor of any size with direct extension to the chest wall or skin

sentinel lymph node biopsy involves

injection of blue dye and radioactive Technetium-99m (Tc99m)

leukemia causes impairment of the body’s normal production of

red blood cells

factors that lead to failure in bone marrow transplants

• recurrent disease

• autologous donor

• graft vs host disease

types of bone marrow transplants

autologous: using own bone marrow

allogeneic: using someone else’s bone marrow

leukemia that always involves lymphocytosis

chronic lymphocytic leukemia (CLL)

leukemia with worst prognosis

chronic myelogenous leukemia (CML)

dosimeter used to check midline doses and placed at specific areas such as patient’s ankles, knees, and thighs when treating TBI

thermoluminscent dosimeters (TLDs)

needed for definitive diagnosis for ALL

bone marrow aspiration biopsy

“generic” cell that has a lot of growth potential

stem cell

non-malignant disease resulting when a BMT patient’s body rejects the new bone marrow or immunity cells as being “foreign”

graft vs host disease (GVHD)

functional unit of the breast

lobule

treatment fields associated with breast treatment

• parallel opposed tangents

• supraclavicular

• posterior axillary boost

• internal mammary chain

“sanctuary sites” of leukemia

• brain

• cerebrospinal fluid (CSF)

• testes

borders of breast tangential fields

• medial: around mid-line, line from the SSN to xiphoid

• superior: at least 2 cm superior/cephalad to the mass and as far as possible without including the arm

• inferior: 1-2 cm inferior/caudal to inframammary fold

• lateral: CR around mid-axillary line

• anterior: 1 cm flash

pathology of breast cancer for which induction chemotherapy is given as an initial treatment

inflammatory carcinoma

German physician who coined “leukemia”

Rudolph Virchow

person who developed radical mastectomy

William Halsted