First Quarter 2008 - Issues in Hematology - ION Solutions

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nurse’s forumoncologistics volume 7, issue 1 - spring 2008 48excessive sweating or night sweats, anorexia, fever,or unexplained fatigue. 2 Enlarged lymph nodes can befound upon physical examination or on radiology fi lms,such as chest x-rays or CT scans. Diagnosis is made byobtaining a tissue biopsy of an involved organ or lymphnode. A complete blood count, lactic dehydrogenase level,electrolytes, liver function tests, and renal function tests arealso done as part of the routine workup for Diffuse largeB-cell lymphoma. Further workup may include a positronemission tomography test to evaluate if metastatic diseaseis present. 3Diffuse large B-cell lymphoma is staged by utilizingCotswold’s classifi cation system. Stage one diseaseinvolves a single lymph node or structure; stage twodisease involves two or more lymph nodes on the sameside of the diaphragm; stage three disease involves two ormore lymph nodes on both sides of the diaphragm; andstage four disease involves one or more extranodal sites. 4Treatment options are based on staging of the disease,and for all intensive purposes, the goal of inductionchemotherapy for Diffuse large B-cell lymphoma iscurative. Treatment for localized (stage I or II) diseaseis based on the size or bulkiness of the tumor. Tumorsthat are “non-bulky” and less than 10 cm can be treatedwith three cycles of Rituxan ® (rituximab), Cytoxan ®(cyclophosphamide), Oncovin ® (vincristine), Adriamycin ®(doxorubicin), prednisone, and radiation therapy. Tumorsthat are greater than or equal to 10 cm or “bulky”should be treated with six to eight cycles of rituximab,cyclophosphamide, vincristine, doxorubicin, prednisone,and radiation therapy. Tumors that are “advanced” (stage IIIor IV) should be treated the same as bulky tumors. Clinicaltrials are also an option for those with advanced disease aswell as autologous stem cell transplants. 5Adverse effects from the chemotherapy agents usedto treat Diffuse large B-cell lymphoma include: nausea,vomiting, diarrhea, constipation, oral mucositis, anorexia,cytopenias, oral candidiasis, cystitis, pain, peripheralneuropathy, alopecia, depression, and tumor lysis syndrome.Of the adverse effects, tumor lysis syndrome is knownas one of the “oncologic emergencies” as it can be lifethreatening. It is a complication that follows chemotherapyfor lympho-proliferative disorders. There is a spontaneousor chemotherapy-induced mass destruction of tumorcells. Cell lysis releases intracellular contents into thebloodstream and can cause fatal arrhythmias if notcorrected. Nucleic acids are also released into thebloodstream and further broken down into uric acid.Renal insuffi ciency can result in the inability of the kidneysto excrete uric acid, which can lead to acute renal failure. 6Tumor lysis syndrome is characterized by hyperuricemia,hyperkalemia, hypocalcemia, hyperphosphatemia, lacticacidosis, and renal failure. 7What role do oncology nurses, who work in outpatientinfusion clinics, play in patients receiving chemotherapyfor Diffuse large B-cell lymphoma? Oncology nurses haveto fi rst be aware of those patients at risk for tumor lysis.Tumor lysis syndrome commonly occurs in tumors that arehighly responsive to chemotherapy such as lymphomas.The risk for tumor lysis is also greater in those patientswith extreme leukocytosis, bulky tumors, elevated LDH,pre-existing renal insuffi ciency, and hyperuricemia priorto initiation of chemotherapy. 8 The oncology nurseshould be assessing all patients with risk factors prior tothem receiving chemotherapy. The patient’s laboratorydata should be reviewed and renal function should beassessed. Any abnormal laboratory results, as well asabnormal fi ndings on a physical exam, should be reportedimmediately to the physician or mid-level provider (NP orCNS). Management of tumor lysis syndrome involves goodhydration with diuresis, alkalinization of urine with sodiumbicarbonate, use of Allopurinol or Rasburicase for reductionof uric acid, dietary restriction of phosphorus or phosphatebinders, and Kaexylate for hyperkalemia. Allopurinolshould be given at a dose of 300 mg by mouth twicedaily and should begin at least two days prior to startingchemotherapy. Rasburicase is given intravenously, its effectpeaks within hours of infusing and it removes existing uricacid from the body. It is given at 0.05mg/kg up to 0.2mg/kg. The disadvantage of Rasburicase is that it should begiven for three to fi ve days in order to control tumor lysis.Table 1 by Cairo and Bishop shows laboratory valuesconsistent with tumor lysis syndrome. They also gradedtumor lysis syndrome on a scale of one to fi ve. Grade I
oncologistics nurse’s forumTable 1Parameters:1234Cairo and Bishop reported a classification for grading the acute tumor lysis syndrome (TLS).This was based on the model of Hande and Garrow.laboratory evidence of TLSserum creatininecardiac arrhythmiasseizuresLaboratory evidence of TLS:1234elevation serum uric acid (≥ 8 mg/dL OR 25% increase from baseline)elevation of serum potassium (≥ 6 mmol/L OR 25% increase from baseline)elevation of serum phosphorus (≥ 6.5 mg/dL OR 25% increase from baseline)decrease in serum calcium (≤ 7 mg/dL OR 25% decrease from baseline)criteria are: laboratory values consistent with tumor lysis,creatinine 1.5 x the upper limit of normal, minimal cardiacarrhythmias, and no seizure activity. Grade II has laboratoryevidence of tumor lysis, creatinine 1.5 to 3.0 x the upperlimit of normal, mild cardiac arrhythmias, and one seizureor seizures controlled by medications. Grade III haslaboratory evidence of tumor lysis, creatinine 3.0 to 6.0 xthe upper limits of normal, symptomatic cardiac arrhythmias,and seizures with impaired consciousness. Grade IV haslaboratory evidence of tumor lysis, creatinine greater thansix times the upper limit of normal, life threatening cardiacarrhythmias, and status epilepticus. Grade V has laboratoryevidence of tumor lysis followed by death from tumorlysis syndrome. 9Tumor lysis syndrome is an oncologic emergencythat can be fatal. Management of tumor lysis syndromestarts with assessment of those patients at risk prior toinitiating chemotherapy. Oncology nurses are the vital linkbetween the patient and the physician. Appropriate patientassessment can catch signs of tumor lysis syndrome inthe outpatient clinic and hopefully prevent the patient fromhaving to be hospitalized for more aggressive managementof symptoms. ❚Tamika M. Turner M.S.N., N.P.-C., O.C.N.,is an oncology nurse practitioner at American HealthNetwork Hematology Oncology in Indianapolis, IN.References:1. Roemer, J. (1999). An end to outpatient chemotherapy?Medicare takes aim at reimbursement. Journal of theNational Cancer Institute, 91(17), 1444-1445.2. Howard, S.C. and Pui, C. (2006). Commentary on matoet al.: A predictive model for the detection of tumor lysissyndrome during AML induction therapy. Leukemia andLymphoma, 47, 877-883.3. Long, J.M. (2007). Treatment approaches and nursingapplications for Non-Hodgkin lymphoma. Clinical Journalof Oncology Nursing, supplement to 11(1), 13-21.4. Casciato, D.A. (2004). Manual of clinical oncology. 5th ed.,Philadelphia: Lippincott Williams and Wilkins.5. www.nccn.org6. Cope, D. (2004). Tumor lysis syndrome. Clinical Journal ofOncology Nursing, 8(4), 415-416.7. Mourad, Y.A., Shamseddine, A., and Taher, A. (2003). Acutetumor lysis syndrome in large B-cell Non-Hodgkin lymphomainduced by steroids and anti-CD20. The HematologyJournal, 4, 222-224.8. Abubakar, S., Khan, A., and Malik, I. (1994).Dexamethasone-induced tumor lysis syndrome in high gradeNon-Hodgkin lymphoma. Southern Medical Journal, 87(3),409-411.9. Cairo, M.S. and Bishop, M. (2004). Tumor lysis syndrome:New therapeutic strategies and classifi cation. British Journalof Haematology, 127, 3-11.oncologistics 49
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