Clinical oncology Flashcards

Question

Radiotherapy

Answer 1

Radium used until mid 1900s -cobalt and caesium units came into use Linear accelerators been used since late 1940s The use of ionising radiation to treat cancer

Answer 2

Energy of photos higher in therapeutic setting as opposed to diagnostic setting - diagnostic x-rays up to 150KV - therapeutic photons 80KV to 20MV

Answer 3

Ionising radiation interacts with water molecules --> free radicals Free radicals cause DNA damage Malignant and normal cells are damaged Normal cells can repair if tolerance not exceeded

Answer 4

``` Damage to normal cells -depend on area to be treated -divided into early or late effects Early (acute) -develop during or shortly after RT -very common -nearly always resolve Late (chronic) -develop months to years (>40yrs) after RT -very rare -irreversible and often severe ```

Answer 5

``` Radical - curative Palliative - to improve symptoms Adjuvant - alongside surgery Neoadjuvant - before surgery Alone - single modality Combined with chemo - can sensitise tissues to radiotherapy *Local treatment ```

Answer 6

Area being treated | Intention of treatment - curative vs palliative

Answer 7

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

Answer 8

``` Simple planning Simple localisation - X-ray Short course Less early side effects More late side effects ```

Answer 9

``` X-rays -superficial radiotherapy -megavoltage radiotherapy 6-20MV Electron treatment 6-20MeV Bracytherapy: insertion of isotopes into tumour ```

Answer 10

100KV photons Treats to depth of 6mm Good for superficial BCC and SCC

Answer 11

The linear accelerator

Answer 12

Less dose to underlying structures | Less toxicity?

Answer 13

Brain metastasis - <3 lesions of 3cm size Single treatment of high dose

Answer 14

``` Oral cavity -floor of mouth -anterior 2/3 tongue -alveolus -retromolar trigone -hard palate Nasopharynx Oropharynx Larynx -supraglottis/ glottis/ post cricoid Hypopharynx Sinuses ```

Answer 15

``` Squamous cell cancer 90% (arising from mucosa) Adenocarcinoma Small cell carcinoma Sarcoma Lymphoma Skin -SCC -BCC -malignant melanoma -merkel cell tumour ```

Answer 16

Males > females 2:1 Peak incidence 60-75 years Mortality: 3000 deaths/ year in England and Wales

Answer 17

DNA virus 72 L1 capsid proteins Orogenital transmission Cervical and oropharyngeal SCC type 16 most common

Answer 18

+ve in approx 25% Distinct disease entity -younger pts -40s to 50s Often not smokers or heavy alcohol drinkers Associated with orogenital and oroanal sex and > no. partners HPV related cancer (particularly H&N) definitely on the rise Improved response to chemoradiation -28% < risk of dying -49% < risk of local recurrence

Answer 19

``` Locally -soft tissues -cartilage -bone -nerves Lymph nodes -very common esp. nasopharynx and oropharynx Vascular -to lungs, bone and liver occurs late ```

Answer 20

``` Multidisciplinary approach Need to know -type of cancer -stage of cancer -fitness of pt -pt's wishes -functional outcomes for treatments/ side effects of treatments/ is it curative etc ```

Answer 21

Should happen in joint clinic - surgeon - oncologist - specialist nurse - plastic surgeon - speech and language therapist - dietician - (psycology input)

Answer 22

``` Clinical examination Blood tests Examination under anaesthesia Biopsy Imaging -of primary (MRI, CT scan) -potential sites of metastatic disease (FDG-PET scan, CT scan thorax/CXR) ```

Answer 23

Bone scan CT/ MRI scan of brain Angiograms etc

Answer 24

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

Answer 25

Surgery followed by Chemoradiotherapy Chemoradiotherapy alone Induction Chemotherapy followed by Chemoradiotherapy

Answer 26

Palliative Radiotherapy Palliative Chemotherapy Best supportive care

Answer 27

Radiotherapy Chemotherapy Targeted therapy -organ preservation: primary treatment -used alongside surgery to > chance of cure (adjuvant treatment) -often combined together: multimodality therapy

Answer 28

Critical structures close e.g. spinal cord, optic chiasm, eyes & brain Essential to keep pt v still & reproduce same position each day of treatment Pt often needs to be immobilised using head shell Pt then has CT scan in head shell CT is used to mark on: -areas to be treated -target volumes -organs at risk CT used to produce radiotherapy plan: radiotherapy prescription Verification process Pt then goes on to have their treatment Dose & number of treatments depends on site to be treated and treatment intent -may be daily treatments for up to 7 weeks if curative -may be single dose if palliative

Answer 29

Pt then goes to machine called simulator for verification Treatment check ‘Simulator’ is x-ray machine which can move in same way as treatment machine Simulates treatment X-rays taken by simulator to check treatment can be reproduced accurately Pt position verified

Answer 30

``` Xerostomia Altered/loss of taste Mucositis Loss of hair Fatigue Cough Soreness of skin -dry desquamation -moist desquamation ```

Answer 31

``` Xerostomia Altered taste Osteo-radionecrosis Alopecia Hypothyroidism Sub-cutaneous fibrosis Second malignancy Altered pigmentation ```

Answer 32

``` Xerostomia accelerates dental decay Osteo-radionecrosis of the mandible -associated with poor dental hygiene Pre-treatment dental assessment essential -for necessary treatment -education -on going care Some ps require dental clearance -issues with treatment start date ```

Answer 33

``` Developing Rapidly More accurate delivery Dose escalation Less toxicity Greater monitoring during treatment Progress -conformal 3D radiotherapy -IMRT -rotational treatment (Rapid Arc) -robotic mounted treatment machines (Cyberknife) ```

Answer 34

Concurrent Chemradiotherapy -Cisplatin every 3 weeks during Radiotherapy Induction Chemotherapy -Combination Cisplatin based chemotherapy prior to Radiotherapy for fit patients with bulky tumours -Docetaxel/ Cisplatin// 5FU (TPF) x3 every 3 weeks Palliative chemotherapy -Cisplatin and 5FU every 4 weeks

Answer 35

``` Alopecia Bone marrow toxicity -neutropenia -thrombocytopenia -anaemia Mucositis Diarrhoea Nausea/vomiting Peripheral Neuropathy Ototoxicity Altered taste ```

Answer 36

``` Infertility Early menopause Pulmonary fibrosis Renal impairment Cardiomyopathy Infertility Peripheral neuropathy Second malignancy ```

Answer 37

``` Diagnosis of oral cavity tumours Health promotion Dental assessment pre-treatment -RT, chemotherapy, bisphosphonates Pts receiving chemo may require dental work -abscess -beware neutropenia & thrombocytopenia -may need to ask oncologists opinion Post treatment follow up Screening for oral cancer Maxillo-facial surgeons Restorative dentists ```

Answer 38

Preferably all urgent dental work to be done before commencing chemo -above not practical for all as treatment needs to start asap to improve outcomes If already on chemo: -find out length of cycle -in 3 weekly cycle (most common) max risk of immuno-suppression between 7014 days -best to always check FBC prior to urgent dental tx to ensure not neutropenic or low platelets

Answer 39

``` General rule: avoid if not urgent In 3 weekly cycle, counts usually are recovering in 3rd week So just before next cycle is due Always check FBC prior Neutropenia is Neuts <1.0 Thrombocytopenia is platelets <100 RIsk of bleeding if platelets <20/ 30 ```

Answer 40

Usually on neutropenic sepsis protocol with IV antibiotics and other supportive measures Unlikely dental abscess is only source of infection If no other source identified and sepsis not improving with above measures -draining of abscess recommended -can have platelet transfusion if low with GCSF cover

Answer 41

Usually not immunosuppresed if on targeted treatments per se Risk of infection significant Check FBC prior to procedure and consider antibiotic cover Always check with relevant oncologist if treatment necessary

Answer 42

Now in use for most cancers in different settings PDL1 inhibitors - Pembrolizumab Immune checkpoint inhibitors - Nivolumab Can cause 'itis' of any organ that can be fatal Can also be effective in controlling cancers and in % of pts provide sustained benefit for many months/ years

Answer 43

Can be used in adjuvant or palliative setting Either to < risk of SREs or < symptoms from SREs Bisphosphonates RANK ligand inhibitors Radium 223

Answer 44

> bone resorption is hallmark - tumour cells release growth factors and cytokines - osteoclastic resorption stimulated (peptides e.g. TGF-beta released by bone resorption, tumour cell production of factors increased) * **

Answer 45

1/2 life of circulating bisphosphonate is short - around 0.5-2hrs in humans Approx 50% of circulating bisphosphonate taken up by skeleton Rate of uptake by bone very fast Bisphos can remain in bone from 1-10 years in humans Are liberated from skeleton during osteoclast resorption

Answer 46

Oral therapy - upper GI inflammation - diarrhoea and abdo pain

Answer 47

Mild to moderate flu-like symptoms occur after initial infusions -generally manageable with paracetamol (acetaminophren) Dose/ infusion rate-dependent effects on renal function -clinically relevant serum creatinine > are uncommon (<10%) and generally reversible ONJ is uncommon event that has been reported in pts with cancer receiving complex treatment reigmens, including IV bisphonates (primarily in pts with advanced malignancies and skeletal metastases)

Answer 48

<1% Probably related to potency and duration of treatment Probably more common with IV formulations About 1% per year of treatment on IV pamidronate/ zoledronic acid Largely preventable with good dental care

Answer 49

Spontaneous reports primarily in pts with advanced cancer and bone mets - freq. estimates vary but <1% - etiology and pathogenesis poorly understood

Answer 50

Consider dental exam with appropriate preventative dentistry before BP tx Avoid invasive dental procedures if possible during tx For pts requiring dental procedures, no data to suggest whether discontinuation of BPs < risk of ONJ

Answer 51

Reassess benefit/ risk of continued BP therapy Discuss options with pts Manage conservatively Note that healing of lesions has been reported in most cases

Answer 52

Pre-assessment prior to starting BPs or Denosumab mandatory Prevention vital While on BPs or Denosumab: -at onset of symptoms suspend Rx until dental assessment to exclude any suspicion of ONJ -if not ONJ, restart after 6 weeks of dental work -if ONJ, suspend or stop indefinitely (discuss risk/ benefit with pt)

Answer 53

Given SC, more convenient than IV Zoledronate No concerns about renal safety, so no renal monitoring required Fewer acute-phase reactions

Answer 54

Similar BUT Denosumab expensive

Answer 55

``` Back pain Arm and leg pain High cholesterol Muscle pain Bladder infection Hypocalcaemia - prescribe calcium and vit D ```