Case 17: cancer Flashcards
1
Q
Tumour grades
A
- Graded by degree of differentiation and growth rate with a scale 1-3.
- Grade 1: well differentiated, slow growing, resemble origin tissue. Better prognosis
- Grade 3: more aggressive, high mitotic rates, poorly differentiated. Worse prognosis
- Anaplastic: poorly differentiated, have few tissue specific features and don’t stain well
- Subjective assessment. Cancers have areas of different grades. Based on the highest grade present.
2
Q
Cytology
A
- Fine needle aspiration (FNA) of cell on a palpable mass: examine cells
- Fluid cytology: ascites, pleural fluid or CSF
- False negatives from sampling errors (especially Sputum), False positives from active infection or abscess formation
- Can examine cells from sputum, urine, cervix, pleural effusions and ascites
- If not sufficient for diagnosis will need biopsy
3
Q
Cytological features of cancer
A
- Increased rate of mitosis
- Altered polarity
- Tumour cell enlargement
- Increased nuclear to cytoplasmic ration
- Pleomorphism (variation in size and shape) of tumour cells and their nuclei
- Clumping of nuclear chromatin
- Distribution of chromatin along the nuclear membrane
- Enlarged nulcei
- Atypical or bizarre mitosis i.e. triporal
- Tumour giant cells with one or more nuclei
4
Q
Cytogenetic analysis
A
- Useful in: leukaemia, lymphoma and some sarcomas
- Shows Chromosomal changes which an be typical in some tumours
- FISH can be used in Ewing sarcoma and peripheral neuroectodermal tumours where there is a translocation between chromosomes 11 and 22. To find specific abnormalities in specific chromosomes
5
Q
Tumour staging
A
- How far the tumour has spread
- Based on: size of the tumour (T), presence of lymph nodes (N) and distant metastases (M)
- Different approaches: FIGO in ovarian cancer, Ann Arbor in lymphoma
6
Q
Cancer: performance status
A
- Assessment of functional capacity, ability to self care and mobility
- Correlates with prognosis and treatment tolerance. Most common scales used are ECOG and Karnofsky score. Range 0-4
- Performance status 3 or 4: don’t tolerate treatment and chemo can shorten lifespan
7
Q
ECOG performance status
A
- 0: fully active, able to carry out normal activities without restriction and analgesia
- 1: restricted in strenuous activity but ambulatory and able to carry out light work or pursue a sedentary occupation. Includes patients fully active with analgesia
- 2: ambulatory and capable of self care but unable to work. Up and about for >50% of waking hours
- 3: capable of limited self care. Confined to a bed or chair for >50% of waking hours
- 4: completely disabled. Unable to carry out any self care and permanently confined to a bed or chair.
8
Q
Cancer MDT
A
- Involves the physician, surgeons, radiologist, pathologist and specialist nurses
- Plan diagnosis and treatment
- May include additional support: physiotherapy, psychological support, symptom control, nutritional care or rehabilitation in the post op period
- Can run combined clinics i.e. triple assessment in breast cancer: improves communication between team members and reduces delays for the patient
- Discuss palliative cases
- Auditing and recruitment into clinical trials
9
Q
Systemic treatment intent
A
- Metastatic disease: indication for the majority of chemotherapy, for palliative use
- Adjuvant therapy: given after surgery to clear remaining microscopic cancer
- Primary therapy (neoadjuvant): given before cancer to reduce bulk
- Chemoprevention: prevent malignant transformation in high risk patient i.e. Tamoxifen in breast cancer
- When treating cancer you need to state whether the intent is curative or palliative
10
Q
Palliative chemotherapy
A
- For the majority of patients with widespread metastasis
- Aim is to improve symptoms and QOL
- Treatment should be well tolerated with few side effects
- Can have limited toxicity but shouldn’t effect performance status
- Can be used when patient has exhausted other treatment
- Main indication for chemotherapy
11
Q
Adjuvant chemotherapy
A
- Used after another another intervention i.e. surgery
- Aim is disease free and improve survival. Try to eradicate any remaining micro metastatic disease which remains
- Will accept greater toxicity
- Treatment has increased morbidity and mortality
- Chemo that has previously shown high response in palliative setting
- You measure response by assessing time to progression
12
Q
Neoadjuvant chemotherapy
A
- Chemotherapy is administered first before another procedure (surgery)
- Can result in a reduced requirement for surgery, increase the likelihood of successful debulking, reduce the duration of hospitalisation and improve patients health prior to surgery
- Help reduce the volume of disease to help make the second intervention possible. Cn reduce patients need for analgesia and mean they are discharged quicker.
- Most commonly used for an inoperable patient (technical or fitness factors), the volume of disease is too large or they don’t have the fitness for the anaesthetic
- Measure response by assessing size of tumour through imaging
- Can be used to determine adjuvant goals
13
Q
Chemoprevention
A
- Treatment used in at risk groups to prevent the development of cancer, helps improve survival
- Agents used are to modify risk and improve survival
- Only accept very low incidence of toxicity
- Many chemotherapy agents are themselves carcinogenic or can cause adverse side effects.
- Impact on overall survival needs careful evaluation
14
Q
Chemotherapy treatment approaches
A
- Chemo should start within 31 days of agreeing treatment with clinician and 62 days from the initial referral if 2ww
- Commonly: chemo is administered every 21-28 days which is one cycle
- A course of treatment is usually 6 cycles
- Results of different cycles are evaluated in clinical trials
15
Q
Chemo: low and high dose therapy
A
- Low dose: standard approach, most palliative chemo is given this way. May have cytotoxicity but only for a short time (few days).
- High-dose therapy: increased dose which kills more cells but results in more bone marrow toxicity. May have neutropenia for a few weeks (6-7). High risk of complications i.e. unusual infections. Use G-CSF. Allows more drug to be administered in the same schedule but the total dose can be less than intended due to limitations of non-haematological malignancy
16
Q
Chemo: dose dense therapy and alternating therapy
A
- Dose dense therapy: fractionating the intended dose of drug and administering each fraction more frequently (often weekly).
- Alternating therapy: involves giving different drugs in an alternating manner (1-2 weeks). Commonly used in Haematological malignancies, when cells might respond to different agents. Used to overcome drug resistance.
17
Q
Low dose chemo bone marrow recovery
A
G-CSF helps the bone marrow to recover. IM injection once a day up to 7 days The next cycle of chemo is started once the bone marrow function has recovered (neutrophils >1.0x109/L and platelets >100x109/L)
18
Q
High dose chemo bone marrow recovery
A
use GCSF to recover the bone marrow. Alternatively autologous stem cells are used from the patient from a previous chemo cycle and readministered to the patient as if they were having a blood transfusion. Repopulates the bone marrow quicker (16-21 days)
19
Q
Complications of chemo
A
- Low dose: bacterial infection
- High dose: unusual infections like fungi or protozoal
20
Q
Benefits of dose dense therapy
A
- Each individual dose produces less toxicity but the anticancer effect is related to the accumulative dose over time
- Such an approach can overcome drug resistance, produce a greater cell kill and in some cases produce a response with weekly administration when the 3-weekly schedule doesn’t work.
- May choose due to previous lack of response, low fitness or comorbid conditions
- Used commonly in breast and ovarian cancer
