Clinical Oncology II Flashcards
Types of head and neck cancers? Types of skin cancers?
Squamous Cell cancer 90% Adenocarcinoma Small cell carcinoma SCC Lymphoma
Skin:
- SS carcinoma
- BC carcinoma
- Malignant melanoma
- Merkel cell tumour
Demographics of head and neck cancer?
Males>females 2:1
Peak incidence 60-75yrs
Mortality - 3000 deaths/yr in England and Wales
HPV (Human papilloma virus) features?
DNA virus
72 L 1 capsid proteins
Orogenital transmission
Cervical and oropharyngeal SCC type 16 most common
HPV in head and neck cancer?
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
HPV positive cancer positives?
Improved response to chemoradiaton
HPV positive - 28% reduced risk of dying and 49% reduced risk of local recurrence
Patterns of spread of head and neck cancers?
Locally - soft tissues, cartilage, bone, nerves
Lymph nodes - very common esp nasopharynx and oropharynx
Vascular - to lungs, bone and liver (occurs late)
Head and neck cancer tx options?
Surgery RT Chemo Targeted therapies Laser therapy Best supportive care
What info is needed to treat a pt with cancer?
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
Who is involved in head and neck tx decision making?
Surgeon Oncologist Specialised nurse Plastic surgeon Speech and language therapies
What investigations are needed for cancer?
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
General management principles of 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 =surgery
General management principles of locally advanced disease?
Surgery followed by Chemoradiotherapy
Chemoradiotherapy alone
Induction Chemotherapy followed by Chemoradiotherapy
General management principles of metastatic disease?
Palliative Radiotherapy
Palliative Chemotherapy
Best supportive care
Name the types of non-surgical oncology for H&N cancer
RT
Chemo
Targeted therapy
Organ preservation - primary tx
Used alongside surgery to increase chance of cure - adjuvant tx
Often combined
What do side effects of RT depend on?
Area being treated
Divided into early and late effects
What can RT be combined with?
Chemotherapy
H&N RT? (this makes it difficult)
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
What is done after H&N RT?
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
How many RT txs for palliative and curable cancer?
Palliative = single Curative = up to 7 weeks
Side effects of RT?
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
Side effects of H&N RT?
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
Dental effects of RT?
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
Chemo in H&N cancer?
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
Side effects of chemotherapy?
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
What is radiotherapy?
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
How does RT work?
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
What may the intentions of RT be?
Radical - cure
Palliative - to improve symptoms
Adjuvant - alongside surgery
Neoadjuvant - before surgery
What does the dose of RT and number of treatments (fractions) depend on?
Area being treated
Intention of treatment - curative vs palliative
Principles of curative RT?
Complex planning Accurate localisation - CT Longer course of tx More early side effects Less late side effects
Principles of palliative RT?
Simple planning Simple localisation - xray Short course of tx Less early side effects More late side effects
RT treatment modalities?
Xrays
- Superficial RT, megavoltage RT
Electron Tx
Brachytherapy - insertion of isotopes into tumour
When is superficial RT used?
100KV photons
Treats to a depth of 6mm
Good for superficial BCC and SCC
Positive of CT planned RT?
Less dose to underlying structures
When is stereotactic radiosurgery used?
Brain metastasis - less than 3 lesions of 3cm size
Single high dose
Where can cancers be in the oral cavity?
Anterior 2/3 of tongue Floor of mouth Hard palate Alveolus Retromolar trigone
Ostoeradionecrosis of the jaw - what is it? Tx?
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
