Clinical Oncology Flashcards by Naina K

Cancer

Group of diseases characterised by uncontrolled growth and spread of abnormal cells within a body

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Classification criteria

Type of cancer cell
Grade
TNM staging

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What are used to determine tx pathways

Prognostic markers

HER2 receptor in breast and gastric cancer

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Risk factors for cancer 
Colorectal 
Lung
Breast 
Skin 
Cervix 
Head and Neck

Dietary/genetic

Smoking

Obesity/genetic

Sun exposure

HPV

Smoking/alcohol/diet and nutrition/viruses/immunosuppression/radiotherapy exposure/premalignant oral conditions

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Tx options

Surgery
Radiotherapy - local
Chemotherapy
Hormonal therapy
Targeted therapies - specific target e.g receptor or growth factor 
Immunotherapy 
Laser therapy 
Cryotherapy
Best supportive care
Any combination

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Surgery aims and intentions

Side effects to consider?

Curative tx for many cancers

Side effects - fx, cosmetic, anaesthesia risks

Remove tumour with clear margins
May require adjuvant chemotherapy and radiotherapy

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Chemotherapy
Targets
Mechanism

Drugs which affect cell function
Used in combination to increase effect
Anti-cancer action in expense of side effects
Different mechanisms

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Chemotherapy adjuvant tx
For?
How?
Why?

What to consider ?

High risk post op patients
Combination of drugs
Given chemotherapy to reduce risk of recurrence
5-10% cured

Patient may not have disease therefore doesn’t need tx
May recur despite chemo

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Chemotherapy as palliative tx

Treatment to improve symptoms and maybe extend life
Single drug
Fewer side effects
Not usually offered until symptomatic 
Stop if increasing toxicity

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Chemotherapy side effects

General 
Skin 
Nerves 
Bone marrow 
Organs 
Lung toxicity and with what 
Cardiac toxicity and wth what

Nausea/vomiting/change in taste/bowel

Hair loss/rash/extravasation

Neuropathy/hearing loss
Infertility

Anaemia/thrombocytopenia/neutropenia

Renal/Liver dysfunction

Fibrosis/bleomycin

Cardiomyopathy/anthracyclines

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Immunosuppression

so?

Chemotherapy can lead to neutropenia by end of cycle

Incredibly susceptible to other disease

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Timing for dental work

When is max risk of IS in 3 week cycle

Ideally do it all before 
Platelets >100 
Neutrophils > 1
Platelets > 20/30
7-14 days through cycle 
Wait until end of cycle

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Dental abscess in immunocompromised patients

Check blood counts

Drainage is recommended

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Patients on targeted treatments

Usually not immunosuppressed if on targeted treatments
Risk of infection is high
Check FBC and consider Ab cover
Always check with oncologist

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Immunotherapy
Example?
Mechanism?
Can cause?

But also are ?

Very common now 
PDL1 inhibitors - PEMBROLIZUMAB e.g 
Trigger innate immune response 
Can cause organ inflammation 
Can also be effective in controlling cancers

Prednisalone to kerb inflammation

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Bone tx

Can be used when? and to do what?

What is an SRE?

Which meds are taken

Can be used in adjuvant or palliative setting
Reduce risk of SREs - skeletal related events
Bisphosphonates
Rank ligand inhibitors

Skeletal related events

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Cycle of bone destruction - mechanism

Tumour cells release GFs and cytokines
Osteoclast proliferation stimulated leading to resorption
Peptides released by bone resorption
Positive feedback leads to increased tumour factor production may encourage tumour activity
Tumour cells and other bone cells increase RANK ligand expression by osteoblasts
Increased osteoclast activity

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Bone tx

Can be used in adjuvant or palliative setting
Reduce risk of SREs - skeletal related events
Bisphosphonates
Rank ligand inhibitors - therefore reduce osteoclast activity

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Cycle of bone destruction

Tumour cells use bone cells to grown and lead to bone resorption
Peptides released by bone resorption
Osteoblasts and other bone cells increase RANK ligand expression

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Osteonecrosis of jaw

Related to?

More common in?

Potency and duration of tx
Rare

IV administration

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Radiotherapy

Energy of photons used?

Used as cancer tx
Photons accelerated toward targeted cells
Direct effect on DNA
Radiation reacts with water molecules –> free radicals
Free radicals cause DNA damage
Malignant and normal cells are damaged
Damage to normal cells manifests as side effects
Can repair if tolerant

20-80mV

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Radiotherapy is
Intention

Modalities

Local

radical/Curative/pallative/adjuvant/neoadjuvant
Dose depends on area being treated, intention of treatment

X-rays
Electron tx
Brachytherapy

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Superficial radiotherapy

Megavoltage radiotherapy

100kV photons
Treats to depth of 6mm
BCC and SCC

6-20 mV

Stereotactic radio surgery

Brain metastasis - <3 lesions of 3cm size

Single treatment of high dose

Types of Head and Neck cancer

Oral cavity - floor of mouth - anterior 2/3 of tongue - alveolus - retromolar trigone - hard palate ``` Nasopharynx Oropharynx Larynx Hypo pharynx Sinuses ```

Pathology of head and neck and in skin

``` Squamous cell cancer 90% Adenocarcinoma Small cell carcinoma Sarcoma Lymphoma ``` - SCC - BCC - Malignant melanoma - Merkel cell tumour

HPV

DNA virus Urogenital transmission Type 16 is most common Cervical and oropharyngeal is SCC type

HPV incidence

Positive in ~25% Distinct disease Younger patients and 40s-50s Not smokers or heavy alcohol drinkers

HPV tx

Chemoradiation

HPV patterns of spread

Locally - soft tissues, cartilage, bone, nerves Lymph nodes - naso and oropharynx Vascular - lungs, bone and liver

Management

Tx Decisions Investigations

Investigation needs

``` Clinical exam Blood tests Biopsy Bone scan CT/MRI OPT Angiograms ```

TNM classifications Performance status

Tumour/Node/Metastasis 0-4

Non surgical oncology treatments for H&N cancer

Radiotherapy/Chemotherapy/Targeted therapy Organ preservation Used alongside surgery to increase chance of cure Often combined together

General Management Principles

Early stage disease - Can be treated with either surgery or Radiotherapy - Choice of treatment largely depends upon functional outcome and patient choice - Surgery allows review of tumour, margins and lymph node status - Cancer involving cartilage or bone is best treated with surgery ``` Locally advanced Surgery followed by Chemoradiotherapy Chemoradiotherapy alone Induction Chemotherapy followed by Chemoradiotherapy Metastatic disease Palliative Radiotherapy Palliative Chemotherapy Best supportive care ```

44 y/o breast cancer already had chemotherapy cycle | Needs dental treatment what to do?

Return for treatment before 2nd cycle

66 y/o breast cancer - herceptin, zolendronate

Stop and restart after treatment

62 y/o needing dental treatment but is neutropenic

Check FBCs

``` Classification: type of cancer cell Glandular Skin/Mucosa Connective tissues Small cell Lymph node ```

``` Adenoma Squamous cell carcinoma Sarcoma Small cell carcinoma Lymphoma ```

Classification: Grade Measure of?

1-3 | Degree of differentiation

Classification: TNM staging | Stands for?

Tumour size N - spread to lymph nodes M - Spread to distal organs

Factors for improved survival and examples of that

Earlier diagnosis - increased awareness, screening programmes Improved treatment - surgery/radiotherapy and chemo/targeted txs and immunotherapy

Modern targeted agents and example

Tyrosine kinase inhibitors e.g sunitinib Monoclonal antibodies e.g cetuximab

Bone metastases are a mixture of Hallmark of it Key therapeutic target

Osteoblastic and osteolytic/clastic lesions Increased bone resorption Osteoclasts

SREs

Clinical consequences of bone metastases Spinal cord compression Bone surgery Radiotherapy to bone Pathological fracture Hypercalcaemia

Traditional tx of MBD Radiotherapy Endocrine Chemo Tumour targeted Orthopaedic intervention Analgesics Bone targeted

Palliate bone pain Anti-tumour Anti-tumour Anti-tumour Stabilise bone Pain management Inhibit bone cell fx

Bisphosphonate structure Most potent?

Phosphate group R chain Zoledronic acid

Effect of bisphosphonates

Decrease osteoclast activity Reduce peptide release Slow tumour growth Decreased bone resorption

Side effects of bisphosphonates

Osteonecrosis risk Upper GI inflammation Diarrhoea Temp fever and myalgia Mineral adverse events Calcium and vit D supplements required

Denosumab - mechanism What could it prevent

Rank L ligand inhibitor Binds to rank L - prevents activation of receptor on osteoclasts Inhibits osteoclast formation and maturation Bone resorption decreased Could prevent or delay SREs

Curative radiotherapy

``` Complex planning Accurate localisation - CT Longer course of treatment More early side effects Less late side effects ```

Palliative radiotherapy

``` Simple planning Simple localisaton – Xray Short course of treatment Less early side effects More late side effects ```

Radiotherapy Side effects May be given Early Late

Depend on area being treated Early or late effects Alone Combined with chemo Develop during or shortly after, resolve Develop months/years after Rare and irreversible

Side effects of H+N RT Early Late

Xerostomia/taste change/mucositis/loss of hair/fatigue/cough/sore skin i.e. desquamation Xerostomia/taste change/osteoradionecrosis /alopecia/hypothroidism

Dental context of effects of RT Xerostomia ORNJ Whats essential

Accelerated decay Poor dental hygiene Pre-treatment dental assessment/clearance

Chemo in H+N

Chemradiotherapy - cisplatin every 3 weeks Induction chemo - combined cisplatin before RT Palliative chemo - cisplatin and 5 fluorouracil