Cancer / Cancer and Immunocompromised Flashcards
When to consult oncologist when seeing a pt who is undergoing cancer tx:
every pt, every time
What is important for px of pts with cancer:
HPV status
TNM system:
T - tumor size, N - cervical LD metastases, m - distant metasases
T1:
less than or equal to 2cm –> up to diameter of a nickel
T2:
greater than 2cm, less than or equal to 4cm
T3:
greater than 4cm
T4:
greater than 4cm with invasion of adjacent structures
N:
cervical LD metastases “regional)
N0
no node
N1:
single ipsilateral node less than or equal to 3cm “small”
N2a:
single ipsilateral node, larger than 3cm, less than or equal to 6cm
2b:
multiple ispisliateral nodes, larger than 3cm, less than or equal to 6cm
N2c:
bilateral or contralateral nodes less than or equal to 6cm
N3a:
ipsilateral node greater than 6cm
N3b:
bilateral nodes greater than 6cm
N2 a-b N3 a-b:
progrtssively bigger and /or contralateral
M0:
no known metastases:
M1:
metastases
Staging is from:
1-4
Stage 1:
T1N0Mo
Stage 2:
T2N0M0
Stage 3:
T3N0M0 or T1,2, or 3N1M0, any lymph node metastases is at least Stage 3
Any lymph node metastases is at least Stage:
3
Stage 4:
T4 and NM0, any TN2 or N3M0, ant T or NM1
New cases of cancer in US for oc and pharynx:
48,330
Deaths due to cancer in the oc and pharynx per year:
9,570
5 yr relative survival rate f cancer of the oral cavity or pharynx:
64% (2009-2013)
% of oral and pharyngeal cancer cases that are localized:
30%
% of oral and pharyngeal cancers that are regional:
47%
% of oral and pharyngeal cancers that are distant:
18%
% of oral and pharyngeal cancers that are at an unknown stage:
5%
5yr relative survival rate of localized oral and pharyngeal cancer:
83.3%
5yr relative survival rate of regional oral and pharyngeal cancer:
63.3%
5yr relative survival rate of distant oral and pharyngeal cancer:
38%
5yr relative survival rate of oral and pharyngeal cancer that is at an unknown stage:
47.2%
Risk factors for oral and pharyngeal cancer:
tobacco, alcohol, combined, HPV, Betel-quid chewing, any immunocompromised condition, history of radiation therapy, history of cancer
Risk of smokers in relation o non”
10 times greater risk, dose related
What are most oral cancers attributable to?
smoking
Risk of oral cancer for those who drink 3-4 drinks per day in relation to those who don’t:
2 times
Is the risk of oral cancer from drinking alcohol dose dependant?
yes
The risk of oral cancer for those who both smoke and drink heavily is how many times greater than that for ppl who never smoke or drink?
35 times
Oral infection w HPV 16 confers about a___ -fold increase in risk relative to individuals without oral HPV 16 infection:
15 fold
Relative risk of oral cavity cancer s greater for which, betel quid chewing alone or gutka?
gutka, oral pharyngeal cancer
These can lead to immunocompromised conditions:
steroids, transplants, immune modulation medications
Reasons why pts may have had radiation therapy in the in the past:
acne, benign conditions, previous cancers
Why a history of cancer may be a risk factor for oral cancer:
filed cancerization, genetic predisposisiton
Colors of suspicious lesions:
red, white, red and white, blue, brown, mixed
Surface descriptors of suspicious lesions:
ulcerated, exophytic, macules, papules
Consistency descriptors for suspicious lesions:
soft, firm, hard
Longest duration to watch a suspicious lesion:
2wk BIOPSY!!
Initial tx for suspicious lesion:
remove potential source of irritation
What does the accuracy of biopsy results depend upon?
skill of the practitioner and pathologist, site selected
TF? If biopsy results com back negative, you don’t’ need to continue to monitor the lesion
F. must continue, take photos, repeat biopsy by linical appearance
Types of dysplasia:
mile, moderate, severe
TF? Dysplasia can become into cancer.
T, if the pt lives long enough
Purpose of pretreatment for dyplasia (?):
reduce morbidity during and after tx, treat any potential source of o=infection, id potential problems for closer follow-up
How to pretreat for patients with dysplasia:
remove teeth with poor prognosis, severe perio, unrestorable caries, large pa lesions, optimally 21 d prior to radiation
How many days prior to radiation should pre-treatment in the dental office be done?
21 d
Surgical pretreatment concerns of pts w dysplasia:
sufficient teeth for the pt to continue to function, which teeth are vital to help retain post-op function?
Radiation concerns of pretreatment for dysplasia (OLD SCHOOL):
which teeth will be in the port, can the teeth in the port remain for the lifetime of the pt, are any teeth in danger of requiring emergency care during radiation?
Radiation concerns of pretreatment for dysplasia (NEW SCHOOL):
Intensity modulated radiaiton therapy, no longer as clear cut what the dose is to a give tooth, however new computer modeling programs can help
Pretreatment concerns for pts who will undergo chemo
Are any teeth abscesseed or at risk of local infection during chemo?., is there a risk of septicemia from any current oral conditions
OH counseling to give as pretreatment for pts about to get treated for cancer:
nutrition and diet, complications of therapy, prevention via freq recalls, F therapy (every day/ varnish?), chlorhexidine rinses
Fluoride to Rx for pts about to get treated for cancer:
neutral sodum fluoride, neutral pH is less irritating
Directions to give for pts that are Rx’ed F for pretretment for cancer tx:
Brush for 5m, expectorate, DO NOT RINSE, EAT OR DRINK FOR 30m
What to treat before radiation or chemo?
mucositis, fungal infection, bacterial infection, viral infection, oral pain
Mucositis, how to treat in pts with cancer who are getting tx:
basic oral care, , use oral mouthwashes not containing alcohol wo intense flavor, no superiority of one mouthwash over saline or bicarbonate rinses, oral prostheses should be kept clean w an antimicrobial solution and their use should be discouraged during night time and in presence of overt oral mucositis
Post-surgical tx:
rehabilitation potential (implant, prosthesis), hypomobility concerns
Post-radiation therapy:
salivary gland dysfunction, hypomobility concerns, less potential with IMRT, but not absent!, osteoraidonecrosis ptential
Salivary gland dysfunction can lead to:
dysphagia, dental caries potential
Post-radiation tx:
recall every 3mo, Rx F therapy, chlorhexidine possible, osteoradionecrosis potential
Hyperbaric oxygen concerns of osteoradionecrosis:
cost, time, access to chambers, risk/benefit
Indications for hyperbaric oxygen:
prevention of osteoradionecrosis
Osteoradionecrosis i more likely to occur in man or max?
man, does >6000 cGy
Osteoradionecrosis is likely in these sites:
ites of extraction of teeth in previously irradiated site
How many exposures and at how much oxygen is hyperbaric oxygen tx:
30 preop exposures at .4 absolute oxygen for 90m each time, followed by 10 additional exposures post-op
Tx concerns of osteoradionecrosis:
soft tissue breakdown that heals spontaneously, reports of poor long-term resolution (healing s/p HBO w recurrence of osteoradionecrosis within 2y), cost/ benefit ratio unknown, availability of chambers
Medical risks of tx w HBO:
if residual tumor cells are present, risk of seizures (oxygen toxicity), barotrauma, middle ear injuries, temporary myopia
Drugs used for bisphosphonate IV therapy:
zoledronic (Zometa), pamidronate (Aredia)
How to dec risk once bisphosphonate therapy is started:
no known way
Risk of ON after oral bisphosphonates after IV:
1-10%
Risk of ON after ofal bisphosphonates:
0.001-0.01%
TF? There is an increased risk of ON if taking oral bisphosphonates for longer than 3y.
T? not sure
How to prevent occurence?
no way
Is the absolute risk of ON from oral bisphosphonates therapy low or high?
low
TF? Morbidity and mortality of hip fracture is significant in relation to MRONH.
T
What are IV bisphosphonates used for?
metastatic bone disease
Result of stopping IV bisphosphonates:
may limit quality of remaining life by increasing pain and tumor size
TF? Surgery is the best option after diagnosis of ON:
F. Surgery may exacerbate ON
TF? Debridement is the best option after diagnosis of ON:
F/ all areas of the jaw are at risk, debridement may only increase the area exposed
Consequence of bone marrow suppression by chemotherapy:
thrombocytopenia
How often to take PrEP:
daily
Trade name for PrEP:
truvada
Truvada is a combo of these 2 meds:
tenofovir and emtricitabine
HIV- CDC Stage 1:
Early HIV infection: acute phase of HIB infection and recent HIV infection
acute phase HIV infection:
immediately after HIV infection and before seroconversion
Recent infection:
within first 6mo of HIV infection
Initial testing for HIV:
CD-4 count; plasma HIV-1 RNA levels; resistance assays
HIV, clinical latency:
With ART can live decades; wo ART avg period 10 yr
Goals in tx for HIV pts:
CD-4 count >500 (continue in CDC Stage 1), plasma HIV-1 RNA levels < 200
CDC Stage 2:
CD-4 count bw 200-499
CDC Stage 3:
CD-4 plus HIV+, HIV+ and pulm TB, recurrent pneumonia, invasive cervical carcinoma, Karposi’s sarcoma, P. carinii pneumonia, opportunistic infections, Wasting syndrome, CNS syndrome
PEP must start within:
72h, continue for 4wk, 3+ drugs
ART sf:
Antiretroviral therapy
Concerns regarding tx with ART for HIV:
Cost (AIDS Drug Assistance Programs), drug toxicities, non-sdherence, potential eariier development of resistnace
Oral signs of the immunocompromised:
candidiasis, viral associated: Hairy leukoplakia, Cancers: Karposi’s sarcoma, Non-Hodgkins lymphoma, PDD
Tx for oral candidiasis;
antifungals - topical or systemic
Topical rinse used for candidiasis:
nystatin, clotrimazole
Systemic pill for candidiasis:
Fluconazole (Diflucan)
Disadv to Nystatin and clotrimazole:
sugar containing, may have resistance, prosthesis concerns
Disadv to systemic antifungal:
arrhythmias, hepatotoxicity
Oral signs of the immunocompromised:
salivary gland enlargement, xerostomia
Tx for the immunocompromised with xerostomia:
biotene products, artificial saliva
Drug tx for xerostomia in immunocompromised pt:
Salagen (pilocarpine), Evoxav (cevimeline)
Other oral manifestations of immunocomp=romisd pts:
bac infections, NUG, biral infections: Herpes complex, HPV, Herpes zoster, CMV
TF? All organ transplants require immunosuppression.
F. not if identical
What is req for dental “clearance”
FMS, exam, follow-up
What happens immediately after Bm transplant?
severe immunosuppression initially
Long term result of organ transplant;
raft vs. host disease
% of pts that are long term survivors of allogenic stem cell transplants that graft vs. host disease occurs in:
25-40%
Oral signs of graft vs. host disease:
erythema, lichenoid lesions, pain
How much more of an increase risk of developing oral cancer is there for pts with graft vs host disease?
10 fold
% of incidence of malignant tumors after 10y:
15-20%
Up to ___% increased risk after 20yr:
40%
