Oncology Exam Breakdown Quiz

Osteoporosis

• Bone strength depends on bone density and bone quality
• Bone density is how many bone cells per square millimeter
• Bone quality is the health of bone cells
• Bone mineral density is the mass of minerals per volume of bone
• Peak bone mass is achieved in the third decade of life
• If peak bone mass is low, osteoporosis and fractures are likely
• Mechanical stimuli are the only stimuli capable of inducing modelling in mature bone
• Estrogen deficiency is the most common cause of osteoporosis in women
• Clinical manifestations of osteoporosis:
  • Loss of height
  • Postural changes (kyphosis)
  • Back pain (low back and rhomboids)
  • Muscular pain
  • Trigger points
  • Fractures (compression fractures are the most common)
  • Functional impairment
  • Disability
  • Decreased quality of life

Paget Disease

• Increased bone resorption by osteoclasts and excessive and disorganized formation of new bone by osteoblasts
• Bone marrow gets replaced by vascular and fibrous tissue
• Enlarged bones are weak, leading to deformity, fracture, and arthritis/pain
• Cause is unknown
• Considered an osteoclastic disorder, but also involves osteoblasts
• Unrestrained proliferation of osteoclasts kickstarts the process
• Osteoblasts cannot keep up
• Initial resorption stage followed by abnormal regeneration
• New bone is coarse, irregularly thickened, rough, and pitted
• Clinical Manifestations:
  • Pain - headache, myalgias, arthritis, radiculopathy
  • Skeletal - bone pain and deformities (femur is the most commonly affected bone, kyphoscoliosis is the most common deformity)
  • Neurologic - nerve compression, impaired cognition
  • CV - increased cardiac output, heart failure
  • Fatigue, tinnitus, dizziness/vertigo

Hepatobiliary System - Anatomy

• Liver
  • Produces albumin and plasma proteins
  • Produces bile
  • Converts and excretes bilirubin
  • Produces clotting factors
  • Stores vitamins
• Gallbladder
  • Stores and concentrates bile
  • Expels bile into the duodenum when food is present
  • Bile alkalinizes intestinal contents and emulsifies, absorbs, and digests fat
  • Cholecystokinin causes the gallbladder to contract
• Pancreas
  • Exocrine secretion of digestive enzymes and pancreatic juices
  • Pancreatic juices are transported through the pancreatic duct to the duodenum
  • Secretion of glucagon and insulin by the islets of Langerhans

Hepatobiliary System - Aging

• Decreased response to drugs depending on liver function, affecting multiple systems
• Liver contains many immune cells and produces proteins associated with the acute inflammatory response
• Age-related cell changes impact immunity, often requiring drug dosage modification with age
• Liver volume decreases 20-40%, and blood flow decreases up to 35%
• Liver function tests (AST, ALT, ALP, GTP, and serum bilirubin) remain unchanged with age

Signs and Symptoms of Hepatic Disease

• GI symptoms (nausea, vomiting, anorexia, abdominal pain)
• Edema/Ascites
• Dark urine and light stools
• Skin changes
  • Jaundice (elevated bilirubin)
  • Bruising
  • Spider angiomas & palmar erythema (elevated estrogen)
• Neurologic involvement (from ammonia buildup)
  • Confusion
  • Sleep disturbances
  • Muscle tremors
  • Hyperreactive reflexes
  • Asterixis
• Musculoskeletal pain - midscapular pain, right shoulder/upper trap/subscap, thoracic
• Hepatic osteodystrophy - manifests as osteomalacia/osteoporosis

Jaundice

• Overproduction of bilirubin:
  • Reabsorption of hematoma
  • Blood transfusion
• Decreased uptake or conjugation in bilirubin metabolism
• Hepatocyte dysfunction
  • Hepatitis
  • Chronic hepatic disease
• Impaired bile flow
  • Cholethiasis
  • Primary sclerosing cholangitis
  • Pancreatic cancer
  • Pancreatitis
• If the underlying cause of jaundice is treated, it typically resolves in 4-6 weeks

Ascites

• Abnormal accumulation of fluid in the peritoneal cavity
• 85% of cases associated with decompensated liver cirrhosis
• Fluid accumulates due to portal hypertension
• Signs and Symptoms:
  • Clinically detectable once more than 500 mL has accumulated
  • Weight gain
  • Abdominal distention
  • Increased abdominal girth
  • Peripheral edema
  • Dyspnea when fluid displaces the diaphragm

Cirrhosis

• Chronic progressive inflammation of the liver
• #1 cause: viral hepatitis
• Cycles of inflammation, and healing with formation of fibrous bands of connective tissue
• Irreversible
• Clinical Manifestations:
  • Interference with liver functions (processing amino acids, carbs, lipids, and vitamins; metabolizing cholesterol, hormones, vitamins, meds, and toxins)
  • Treatment based on complications
  • Transplant is best for long-term survival

Portal Hypertension

• Portal: area where blood vessels enter the liver
• Venous blood from the stomach, large and small intestine, pancreas, and spleen is transported via portal vein to the liver
• Pressure increases when pressure in the portal vein is higher than pressure in the inferior vena cava
• Usually related to cirrhosis (structural changes and hyperdynamic vascular responses)
• Ultimately, blood backs up in the stomach, esophagus, umbilicus, and rectum
• Engorged vessels
• Varices
• Bleeding
• Clinical manifestatons:
  • Gastroesophageal varices (very serious and accounts for 1/3 of deaths related to cirrhosis and bleeding; endoscopy is needed for everyone with cirrhosis to screen, usually treated prophylactically with beta blockers)
  • Bleeding
• PT Implications:
  • Portal pressure is highest at night, after eating, and with coughing, sneezing, and exercise
  • Interventions should prioritize reducing abdominal pressure

Hepatitis

• Acute or chronic inflammation of the liver from a virus, a chemical, a drug reaction, or alcohol abuse
• Types:
  • Hepatitis A
    • Acute infection only
    • 25% of people do not progress to cirrhosis or cause cirrhosis prematurely
    • Does not progress to chronic disease
    • Transmission: fecal-oral; food and water
    • Symptoms - Malaise, Fatigue, Mild Fever, Nausea, Vomiting, Anorexia, RUQ discomfort, Diarrhea, Jaundice, Dark urine, Clay-colored stools
    • Treatment - Supportive care
    • Vaccine - Yes
  • Hepatitis B
    • 75-85% of acute infections become chronic
    • 10-20% progress to cirrhosis
    • Associated with liver cancer
    • Transmission - Parenteral, sexual contact, vertical, contact with blood or open sores
    • Symptoms - Malaise, Fatigue, Mild Fever, Nausea, Vomiting, Anorexia, RUQ discomfort, Diarrhea, Jaundice, Dark urine, Clay-colored stools
    • Treatment - Acute: supportive, Chronic: combination interferon and antivirals
    • Vaccine - Yes
  • Hepatitis C
    • Coinfection of HBV and HDV leads to more acute disease
    • 75-85% of acute infections become chronic
    • 10-20% progress to cirrhosis
    • Associated with liver cancer
    • Transmission - Parenteral, hemodialysis, vertical, blood before 1987, organs before 1992
    • Symptoms - Malaise, Fatigue, Mild Fever, Nausea, Vomiting, Anorexia, RUQ discomfort, Diarrhea, Jaundice, Dark urine, Clay-colored stools
    • Treatment - Acute: supportive, Chronic: interferon alfa2a or alfa2b
    • Vaccine - No
  • Hepatitis D
    • Can only get Hep D if already infected with Hep B
    • More acute disease
    • Transmission - Parenteral, sexual contact, perinatal
    • Symptoms - Malaise, Fatigue, Mild Fever, Nausea, Vomiting, Anorexia, RUQ discomfort, Diarrhea, Jaundice, Dark urine, Clay-colored stools
    • Treatment - None
    • Vaccine - No, but Hep B vaccine can prevent Hep D
  • Hepatitis E
    • Acute, self-limiting infection
    • Does not progress to chronic
    • High mortality in pregnant women
    • Transmission - Same as Hep A
    • Symptoms - Malaise, Fatigue, Mild Fever, Nausea, Vomiting, Anorexia, RUQ discomfort, Diarrhea, Jaundice, Dark urine, Clay-colored stools
    • Treatment - Preventive measures
    • Vaccine - Not in the US; vaccine approved in China in 2012

Oncology

• Risk Factors, Pathogenesis, and Clinical Manifestations
  • General and specific to lung, breast, and colorectal
• PT Implications for treatment
  • Impact of pain and metastases