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Surgery > radiation oncology > Flashcards

radiation oncology Flashcards

1
Q

how many canadians will develop cancer

A

2 in 5

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2
Q

how many canadians will die of cancer

A

1 in 4

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3
Q

what are the 5 most common cancers

A 
lung
breast
colorectal
prostate
skin
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4
Q

what is a tumor/neoplasm

A

unregulated cell growth that is UNable to invade the basement membrane and travel to/metastasize to other structures

abnormal mass of tissue that results when cells divide more than they should or do not die when they should

may be benign or malignant

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5
Q

what is cancer

A

abnormal division with the ability to invade/metastasize

term used for diseases in which abnormal cells divide without control and are able to invade other tissues

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6
Q

what are the 4 hallmarks of cancer

A
  1. inappropriate cell proliferation
    - -increased cell production
    - -decreased cell death
  2. neoangiogenesis
  3. invasion and metastasis
  4. genomic instability (predisposition to mutation)
    - -receptors can change, they are error prone and in tumours can have trouble repairing properly
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7
Q

how does cancer spread

A
  1. direct invasion
  2. lymphatics
  3. hematogenous via the bloodstream
  4. transcoelomic (pleural, pericardial, peritoneal)
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8
Q

how is cancer staged

A

TNM

  1. Tumor–> size and/or extent of the primary tumor, correlates with direct invasion
  2. nodes–> whether there has been spread to nearby lymph nodes, correlates with lymphatic spread
  3. metastasis–> spread to other parts of body, correlates with hematogenous spread
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9
Q

why does staging matter

A

udnerstanding tumor spread can help us to

  1. conduct a proper history (about location, spread etc) and physical exam
  2. order the correct staging investigations
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10
Q

why do we stage cancers

A
  1. common language of communication for health care providers to describe the extent or severity of cancer
  2. guides treatment
  3. estimates prognosis
  4. allows us to compare results over time
  5. provides a clinical trial standardization
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11
Q

stage does stage 0 cancer indicate

A

carcinoma in situ

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12
Q

what does stage I, II, III cancer indicate

A

higher numbers indicate more extensive disease…
larger tumor…
extension into adjacent tissues…
spread to nearby lymph nodes

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13
Q

what does stage IV cancer indicate

A

metastasis to distant sites

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14
Q

what are the types of staging

A
  1. clinical staging
    - -physical exam
    - -imaging
    - -lab tests
  2. pathological testing
    - -pathology reports
    - -surgical reports
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15
Q

what does the “Stage” of a cancer indicate

A

tumor extent, node status, spread/severity

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16
Q

what is the “grade” of a cancer indicate

A

describes how normal/abnormal the cells look/appear in pathology and their level of differentiation compared to their precursors

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17
Q

what are the goals of cancer treatment

A
  1. radical
    - -curative intent
    - -complete ablation
  2. adjuvant
    - -curative-intent
    - -addresses microscopic disease
    - -reduces recurrence risk
  3. palliative
    reduce or prevetn sx
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18
Q

what types of things should you consider when designing cancer therapy

A

patient factors

tumor factors

treatment factors

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19
Q

examples of patient factors

A

performance status

what can the patient tolerate medically and surgically (can they life flat for radiation therapy)

co morbidities

past surgeries

patient preference

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20
Q

examples of tumor factors

A

type of cancer (histology, natural history, etc)

characteristics and extent of cancer (stage TNM, size, location, invasion etc)

symptoms

is complete resection/oblation possible

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21
Q

what are some treatment factors

A

availability and effectiveness of treatment

potential toxicity

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22
Q

what is the mainstay of radial therapy for solid cancers

A

surgery

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23
Q

what is the mainstay of radial therapy for hematollgic cancers

A

chemo

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24
Q

what are your cancer treatment options

A

surgery
radiation
chemo

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25
Q

how is radiation therapy used to manage cancer

A

it radical/curative therapy for some solid cancers (with or without chemo)

primarily used for HEENT cancers, lung cancers and skin cancers

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26
Q

how does radiation therapy work

A

it is high energy ionizing photons (“strong xrays”) that cause damage to cellular DNA

cancer cells have difficulty repairing cell damage compared to normal tissues

treatment is usually delivered in a series of small daily treatments called FRACTIONS

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27
Q

why do you give radiation in small doses/fractions

A

allows time for normal tissues to heal

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28
Q

how do you calculate total radiation dose

A

number of fractions x daily dose equals total dose

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29
Q

what are the 4 types of radiation therapy

A
  1. enteral beam radiation therapy (EBRT)–most common
  2. brachytherapy
  3. isotope therapy
  4. radio-immunotherapy
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30
Q

how does enteral beam radiation therapy (EBRT) work

A

radiation given from a source outside of the body (“that big spinny thang”)

most treatment is delivered by external beams which must go through normal tissue to reach the target cancer–> radiation side effects are dictated by the area the beams traverse

creates free radicals which attach to broken DNA so they cant be repaired

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31
Q

how does brachytherapy work

A

direct application of a radioactive source into/adjacent to the tumour

use in cervix, prostate, lung, esophagus

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32
Q

how does isotope therapy work

A

IV or oral ingestion of radioactive isotopes that concentrate in malignant tissue

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33
Q

do all tumours have the same radiosensitivity

A

no

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34
Q

which tumours are highly radiosensitive

A

lymphoma

leukemia

seminoma

35
Q

which tumours are medium radiosensitive

A

squamous cell cancers–

skin

oropharynx

bladder

cervix

36
Q

which tumors have low radiosensitivity

A

renal cancer

osteosarcoma

37
Q

what are acute side effects from radiation toxicity

A

those that occur within 6 months of treatment usually due to acute inflammatory reaction

i.e skin desquamation following chest wall irradiation, fatigue

38
Q

what are late side effects from radiation toxiciy

A

generally those occurring after 6 months, usually due to fibrosis of connective tissue and obliteration of small blood vessels

i.e changes in skin pigmentation, fibrosis and telangiectasia

39
Q

what is the framework for approaching cancer cases

A
  1. diagnosis
  2. staging and spread
  3. management reasoning
    - -patient, tumour, treatment factors
    - -radiation therapy side effects
40
Q

treatment for breast cancer

A

surgical treatment with partial or radical total mastectomy

followed by radiation therapy

post radiation therapy with tamoxifen if estrogen receptor positive

41
Q

treatment for non small cell carcinoma of the lung

A

surgical lobectomy

then radiation for spread to nodes with chemo

42
Q

treatment for prostate adenocarcinoma

A

surgical radical prostatectomy then radiotherapy with external beam or brachytherapy (especially if positive margins)

hormonal therapy with an LHRH antagonist to reduce testosterone

43
Q

acute side effects of pelvic radiation

A

bladder irradiation (frequenct, urgency, dysuria)

bowel irritation

ED

fatigue

44
Q

late side effects of pelvic radiation

A

chronic bowel or bladder changes

rectal bleeding

uretheral stricture

SBO

45
Q

acute side effects of thorax radiation

A

esophagitis

worsening SOB/cough

fatigue

46
Q

late side effects for thorax radiation

A

pneumonitis

esophageal stricture

rib damage

cardiac damage

2nd malignancy

47
Q

how can you best image the liver

A

well done by U/S

48
Q

what part of the body is particularly suscueptible to radiation

A

mucous membranes

49
Q

what is the key to cancer history and physical

A

pain, soreness, swelling etc

symptoms of mets–> local, lymphatic, hematogenous spread

50
Q

define radiation oncology emergency

A

medical condition arising from a reversible threat to organ function requiring radiation treatment within a few hours of diagnosis

51
Q

define spinal cord compression

A

compression of the dural sac and its contents (spinal cord, cauda equina or both) by an extradural tumour mass

52
Q

what is the minimum radiologic evidence for cord compression

A

indentation of the thecal/dural sac at the level of the clinical features

53
Q

what % of cancer patients have spinal mets

A

40%

54
Q

what % of patients with spinal mets develop symptomatic spinal cord compression

A

20%

55
Q

where do we most often see spinal mets

A

60% in thoracic spine because biggest

30% lumbosacral spine

10% cervical spine

56
Q

what is the pathophysiology of spinal cord compression

A

growth and expansion of the bone met into the epidural space or neural foramina extension by para-spinal mass–> causes destruction of vertebrae and collapse and displacement of bony fragments into the epidural space

damage mainly VASCULAR–> increased arteriole pressure, venous plexus compression, reduced capillary blood flow

leads to spinal cord edema

result is white matter ischemia and infarction and permanent cord damage

57
Q

what is the first symptoms of spinal cord compression in 90% of patients

A

back pain

pain is hallmark of spinal cord compression

58
Q

what is the most common symptom of spinal cord compression to cause people to seek medical attention

A

weakness

sphincter dysfunction of bladder and bowel can happen but almost always WITH the other sx

59
Q

describe the sensory symptoms of spinal cord compression

A

pain is most common, often preceeds other neuro deficits by months

often localized, most severe over the involved vertebrae (tightness sensation)

can be radicular around the trunk or down a limb

can have numbness, paresthesia

60
Q

motor symptoms of spinal cord compression

A

depends whether UMN or LMN lesion

above L1/L2 is spinal cord compression, below that it is cauda equina

61
Q

are the following present or absent in a UMN lesion?

  1. weakness
  2. atrophy
  3. fasciculations
  4. reflexes
  5. tone
A
  1. yes
  2. no
  3. no
  4. increased
  5. increased
62
Q

are the following present or absent in a LMN lesion?

  1. weakness
  2. atrophy
  3. fasciculations
  4. reflexes
  5. tone
A
  1. yes
  2. yes
  3. yes
  4. decreased
  5. decreased
63
Q

what investigations should you do for spinal cord compression

A

plain x rays

CT is reasonable to start

MRI–test of choice when suspicion is high –> myelography if MRI not available

consult rad onc/neurosurgery

64
Q

good spinal cord compression prognostic factors

A

ABLE TO WALK

tumor type responsive to chemo/radiation

gradual onset of symptoms with slow progression

good general health

vertebreal body intact

65
Q

poor spinal cord compression prognostic factors

A

unable to walk

tumor type resistant to chemo/radiation

acute onset with rapid progression

poor general health

vetebral body collapse

66
Q

treatment for spinal cord compression

A
  1. analgesics
  2. STEROIDS ARE FIRST LINE–> DECADRON
  3. surgery–> helps with tissue diagnosis//given prior to radiation to improve outcomes in certain patients//can help with vertebral body instability and other functional stability//wound healing and rehab post op may not be suitable for all patients
  4. radiotherapy–> offered to all patients who are NOT candidates for decompressive surgery upfront, if they are surgical candidates you give radiation afterwards // give 5-10 fractions directed to involved site//goals are to improve pain and improve/maintain ambulation
  5. chemotherapy–> may be useful in select cases of highly chemosensitive tumours but generally not first lime
67
Q

what is the first step in spinal cord compression treatment

A

steroids–> DECADRON

steroids help retain motor function

68
Q

who gets surgery for spinal cord compression

A

spinal instability

bony compression

patients with no/remote cancer diagnosis

neuro progression

69
Q

who gets radiotherapy for spinal cord compression

A

medically inoperable

ambulatory

diffuse disease

70
Q

what should be considered when deciding how to treat spinal cord compression

A

medical status

ambulatory status

structural factors

anticipated outcome

treatment goals

71
Q

what % of patients with lung cancer will develop superior vena cava obstruction

A

2-4% at some point–more commonly from small cell lung cancer than non small cell because of more rapid growth

72
Q

what causes superior vena cava obstruction in lung cancer?

A

invasion

external compression

internal blockage

can be due to…

  • -benign causes–> thrombus, aneurysm, goitre, etc
  • -malignant–> lung cancer (75%), lymphoma, germ cell tumour, thyroid cancer, mets
73
Q

what cancers are associated with superior vena cava obstruction

A

lung (75%)

lymphoma

germ cell tumour

thyroid cancer

mets

74
Q

symptoms of superior vena cava obstruction

A

3Ds

dyspnea/laboured breathing

distension (edema of face/arms, may have erythema)

dilated chest wall vessels

75
Q

investigations for superior vena cava obstruction

A

CXR

CT with contrast to see the SVC

76
Q

treatment for superior vena cava obstruction

A
  1. ABCs with supportive therapy
  2. steroids (dex)
  3. radiotherapy–best for non small cell lung cancer//wait for tissue confirmation unless patient is very unwell//takes DAYS TO WEEKS to work//relief of symptoms is the major effect in most cases
  4. chemo–> best for small cell lung cancer and lymphoma
  5. surgery–> endovascular stent for rapid relief
77
Q

what provides rapid relief from superior vena cava obstruction

A

endovascular stenting surgery

78
Q

what is the biggest problem with brain mets

A

increased ICP

79
Q

what are the 3 rad onc emergencies we could see

A

superior vena cava obstruction

brain mets

spinal cord compression

malignant hemorrhage

80
Q

how do brain mets present

A

widely variable

can be symptomatic

  • -headache
  • -cognitive impairment
  • -hemoparesis
  • -seizures
  • -change in vision or hearing
  • -LOC

or can be asymptomatic

81
Q

treatment for brain mets

A
  1. ABCs and supportive therapy
  2. medical management with steroids –> dex with or without antiepileptics
  3. surgery–> reduce mass effect, diagnosis, improve outcomes
  4. radiation–> goal is symptoms improvement but this can take time and can cause WORSENING EDEMA initially
82
Q

what causes malignant hemorrhage

A

due to disruption of friable vasculature associated with the tumour

most commonly in gyne/cervix, lung and head and neck cancers

83
Q

treatment of malignant hemorrhage

A
  1. ABCs and supportive management
  2. physical measures–> packing, cautery, surgery
  3. vascular embolization
  4. radiation–though results are not immediate–can take days to weeks to work

Surgery (20 decks)

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