Clinical Oncology II

Question 1

Types of head and neck cancers? Types of skin cancers?

Answer 1

Squamous Cell cancer 90%
Adenocarcinoma
Small cell carcinoma
SCC
Lymphoma

Skin:

• SS carcinoma
• BC carcinoma
• Malignant melanoma
• Merkel cell tumour

Question 2

Demographics of head and neck cancer?

Answer 2

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

Question 3

HPV (Human papilloma virus) features?

Answer 3

DNA virus
72 L 1 capsid proteins
Orogenital transmission
Cervical and oropharyngeal SCC type 16 most common

Question 4

HPV in head and neck cancer?

Answer 4

Positive in approx 25%
Distinct disease entity - younger pts, 40s to 50s
Often not smokers or heavy drinkers
Associated with orogenital and oroanal sex and increased no of partners
HPV related cancers is increasing

Question 5

HPV positive cancer positives?

Answer 5

Improved response to chemoradiaton

HPV positive - 28% reduced risk of dying and 49% reduced risk of local recurrence

Question 6

Patterns of spread of head and neck cancers?

Answer 6

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

Question 7

Head and neck cancer tx options?

Answer 7

Surgery
RT
Chemo
Targeted therapies
Laser therapy
Best supportive care

Question 8

What info is needed to treat a pt with cancer?

Answer 8

Type of cancer
Stage of cancer
Pt fitness
Pt wishes

TNM classification:
- Tumour, Nose, Metastases
Performance status of the pt - 0-4 and co-morbidities
Functional outcomes for tx/side effects of the txs/is it curative

Question 9

Who is involved in head and neck tx decision making?

Answer 9

Surgeon
Oncologist
Specialised nurse
Plastic surgeon
Speech and language therapies

Question 10

What investigations are needed for cancer?

Answer 10

Clinical exam
Blood tests
Exam under anaesthesia
Biopsy
Imaging - of primary (MIR, CT scan)
- Potential sites of metastatic disease: FDG-PET scan/ and SC scan thorax/CXR

Other:

• Bone scan
• CT/MRI of brain
• OPT
• Angiograms

Question 11

General management principles of early stage disease?

Answer 11

• 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 =surgery

Question 12

General management principles of locally advanced disease?

Answer 12

Surgery followed by Chemoradiotherapy
Chemoradiotherapy alone
Induction Chemotherapy followed by Chemoradiotherapy

Question 13

General management principles of metastatic disease?

Answer 13

Palliative Radiotherapy
Palliative Chemotherapy
Best supportive care

Question 14

Name the types of non-surgical oncology for H&N cancer

Answer 14

RT
Chemo
Targeted therapy

Organ preservation - primary tx
Used alongside surgery to increase chance of cure - adjuvant tx
Often combined

Question 15

What do side effects of RT depend on?

Answer 15

Area being treated

Divided into early and late effects

Question 16

What can RT be combined with?

Answer 16

Chemotherapy

Question 17

H&N RT? (this makes it difficult)

Answer 17

Critical structures close e.g. spinal cord, optic chiasm, eyes and brain
Keep pt skill and reproduce same position each day of tx
Pt can be immobilised using a head shell

Question 18

What is done after H&N RT?

Answer 18

CT scan in head shell
Marks areas to be treated and organs at risk
CT produces a RT plan

THEN pt goes into a machine called simulator for verification - tx check
X rays taken by simulator to check tx can be reproduced accurately

THEN pt has tx

Question 19

How many RT txs for palliative and curable cancer?

Answer 19

Palliative = single
Curative = up to 7 weeks

Question 20

Side effects of RT?

Answer 20

Early (acute):

• develop during or shortly after RT
• very common
• Nearly always resolve

Late (chronic):

• develop months to yrs after RT (>40yrs)
• very rate
• irreversible and often severe

Question 21

Side effects of H&N RT?

Answer 21

Early side-effects:
Xerostomia
Altered/loss of taste
Mucositis
Loss of hair
Fatigue
Cough 
Soreness of skin
- Dry desquamation
- Moist desquamation

Late side-effects:
Xerostomia
Altered taste
Osteo-radionecrosis
Alopecia
Hypothyroidism 
Sub-cutaneous fibrosis
Second malignancy
Altered pigmentation

Question 22

Dental effects of RT?

Answer 22

Xerostomia = accelerates caries
Osteo-radionecrosis of mandible
Pre tx dental assessment essential for necessary tx, education and ongoing care
Some pts require dental clearance - issues with tx start date

Question 23

Chemo in H&N cancer?

Answer 23

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

Question 24

Side effects of chemotherapy?

Answer 24

Early: 
Alopecia
Bone marrow toxicity
Neutropenia
Thrombocytopenia
Anaemia
Mucositis
Diarrhoea
Nausea/vomiting
Peripheral Neuropathy
Ototoxicity 
Altered taste

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

Question 25

What is radiotherapy?

Answer 25

The use of ionising radiation to treat cancer
Energy of photons is higher in a therapeutic setting as opposed to diagnostic setting
Diagnostic x-rays up to 150KV
Therapeutic photons 80KV-20MV

Question 26

How does RT work?

Answer 26

Ionising radiation interacts with water molecules, forming free radicals
Free radicals cause DNA damage
Malignant and normal cells are damaged
Damage to normal cells = side effects
Normal cells can repair if tolerance not exceeded

Question 27

What may the intentions of RT be?

Answer 27

Radical - cure
Palliative - to improve symptoms
Adjuvant - alongside surgery
Neoadjuvant - before surgery

Question 28

What does the dose of RT and number of treatments (fractions) depend on?

Answer 28

Area being treated

Intention of treatment - curative vs palliative

Question 29

Principles of curative RT?

Answer 29

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

Question 30

Principles of palliative RT?

Answer 30

Simple planning
Simple localisation - xray
Short course of tx
Less early side effects
More late side effects

Question 31

RT treatment modalities?

Answer 31

Xrays
- Superficial RT, megavoltage RT

Electron Tx

Brachytherapy - insertion of isotopes into tumour

Question 32

When is superficial RT used?

Answer 32

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

Question 33

Positive of CT planned RT?

Answer 33

Less dose to underlying structures

Question 34

When is stereotactic radiosurgery used?

Answer 34

Brain metastasis - less than 3 lesions of 3cm size

Single high dose

Question 35

Where can cancers be in the oral cavity?

Answer 35

Anterior 2/3 of tongue
Floor of mouth
Hard palate
Alveolus
Retromolar trigone

Question 36

Ostoeradionecrosis of the jaw - what is it? Tx?

Answer 36

Can happen anytime after RT, more common in later yrs
Worse if poor OH
Death of bone due to damaged BVs from RT

Tx

• Surgical debridement
• Pentoxyphylline
• Hyperbaric O2