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ONCOLOGY - PHARMACOLOGY - ANAESTHETICS > Clinical Oncology I & II > Flashcards

Clinical Oncology I & II Flashcards

1
Q

What type of cancel cell is:

  • Glandular
  • Skin/Mucosa
  • Connective tissues
  • Small cell
  • Lymph node
A
  • Glandular = ADENOCARCINOMA
  • Skin/Mucosa = SQUAMOUS CELL CARCINOMA
  • Connective tissues = SARCOMA
  • Small cell = SMALL CELL CARCINOMA
  • Lymph node = LYMPHOMA
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2
Q

What is the TNM staging of cancers

A

T = Size of tumour

N = Spread to lymph nodes

M = Spread to distal organs

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3
Q

How is surgery used to treat cancer

A

• Aims to remove tumour with clear margins before spread

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4
Q

How is Chemotherapy used to treat caner

A
  • Drugs which inhibits DNA from replicating - cell death. Drugs often used in combination to increase effect
  • Can also affect own cells
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5
Q

What are the side effects of Chemotherapy

A
  • Fatigue
  • Hair loss
  • Infection
  • Anaemia
  • Neutropenia
  • Nausea & Vomiting
  • Appetite changes
  • Constipation
  • Neuropathy
  • Rash
  • Hearing loss
  • Fibrosis (lung toxicity)
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6
Q

What are the different mechanisms of action of Chemotherapy

A

• PLATINUM
(cisplatin)
- causes cross linking of DNA, inhibiting DNA repair/synthesis

• TAXANES
(Docetaxel, Paclitaxel)
- disruption of microtubule function which are essential for division

• ANTI-METABOLITES
(5fluorouracil/methotrexate)
- impair DNA replication

• ALKYLATING AGENTS
(Dacarbazine/Temozolamide)
- binds to DNA covalently via their alkyl group

• ANTHRACYCLINES
(Doxorubicin/Epirubicin)

  • Inhibits DNA synthesis.
  • Topoisomerase-II toxin
  • Generates ROS leading to DNA damage
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7
Q

When are patients the most immunosuppressed from when they start chemotherapy and why is this relevant

A
  • Suppressions will fall slowly and then after around 7 days substantially falls for 5 days. It can then rise after a fortnight
  • This is important when planning procedures for the patient due to the risk of infection
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8
Q

What is the general rule for dental treatments while on Chemotherapy

A

• Preferably all urgent work done before starting chemotherapy

• If already on Chemo:
- Find out length of cycle (3 weekly/2 weekly/weekly/daily tablets etc.)

  • In a 3 week cycle - max risk of immunosuppression is between 7-14 days
  • Best to check FBC prior to urgent dental treatments to ensure not neutropenic (< 1.0) or low platelets (< 100)
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9
Q

Describe the ‘Vicious’ cycle of bone destruction in cancer

A
  • Tumour cells release growth factors & cytokines (IL-6,8. PGE2. TNFalpha. CSF-1)
  • This stimulates osteoclastic resorption
  • Peptides (i.e. TGFbeta) are released by bone resorption
  • Tumour cell production of factors increase with resorption = tumour cell proliferation and even more bone resorption
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10
Q

How are RANK ligands involved in this vicious cycle

A
  • Tumour cells produce factors that stimulate osteoblasts to secrete RANK
  • Osteoblasts increase expression of RANK
  • Overexpression of RANK ligand drives increased formation, function and survival of osteoclasts, leading to excessive bone resorption
  • Bone resorption releases GFs from the bone matrix that increase tumour activity
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11
Q

How do we treat metastatic bone disease

A

• Radiotherapy:
- palliate bone pain

• Endocrine tmt / Chemo / Tumour target therapies:
- Anti-tumour

• Analgesics:
- pain management

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12
Q

What are the three main drugs for Bone targeted treatments

A

• BISPHOSPHONATES:

  • clodronate
  • zoledronic acid (more potent than clodronate)

• RANK ligand inhibitor:
- Denosumab

• Radiopharmaceuticals:

  • Radium-223
  • Strontium-89
  • Samarium-152
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13
Q

What are the effects of bisphosphonates on vicious cycle of bone destruction

A

• Decreases activity of osteoclasts:
- Reduction in the release of peptides

  • Slows tumour cell growth
  • Reduced production of PTHrP and other factors
  • Decrease in bone resorption
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14
Q

What are the Pharmokinetic properties of bisphosphonates

A
  • Half life is short (0.5-2 hours)
  • Approx 50% of circulating bisphos is taken up by the skeleton
  • Bisphos can remain in bone from 1-10 years in humans
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15
Q

What are the side effects of Bisphosphonates

A

• Oral therapy:

  • Upper GI inflammation
  • Diarrhoea and abdominal pain

• Intravenous therapy:
- Temporary fever and myalgia

  • Electrolyte & mineral adverse events (severe hypocalcaeima incidence < 1%. Calcium & VitD supplements in all patients
  • Renal toxicity rare at approved dose and schedule
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16
Q

What can happen to the jaw with Bisphosphonates (very rare)

A

• OsteoNecrosis of the jaw:
- Related to potency and duration of the treatment

  • More common in IV
  • 1% per year of treatment on IV pamidronate/zoledronic acid
  • Largely preventable with good dental care
17
Q

How does Denosumab break the vicious cycle of bone destruction in cancer

A
  • Denosumab precisely binds to RANK ligand, preventing activation of the RANK receptor on osteoclasts
  • Because of this binding to RANK, denosumab inhibits osteoclast formation, function and survival
18
Q

What is Radiotherapy

A
  • The use of ionising radiation to treat cancer
  • Energy of photons (x-rays) is higher in a therapeutic setting as opposed to diagnostic setting:

Diagnostic x-rays: up tp 150KV

Therapeutic photons: 80KV-20MV

19
Q

How does Radiotherapy work?

A
  • Ionising radiation interacts with water molecules making free radicals (ROS which damages DNA)
  • Malignant & Normal cells are damaged
  • Normal cells can repair if tolerance not exceeded
20
Q

What are the different intentions of cancer treatment (NARP)

A

Neoadjuvant - before surgery

Adjuvant - After surgery

Radical - curative

Palliative - to improve symptoms

21
Q

Difference between Curative & Palliative treatment

A

CURATIVE:

  • complex planning
  • accurate localisation using CT
  • longer course
  • More early side effects but less late

PALLIATIVE:

  • simple planning
  • simple localisation
  • short course of treatment
  • less early side effects
  • more late side effects
22
Q

What are the different Radiotherapy treatment modalities

A

• X-RAYS:
- Superficial (100KV photons, 6mm depth - good for skin cancer)

  • Megavoltage

• ELECTRON TREATMENT

• BRACHYTHERAPY:
- insertion of isotopes into tumour

23
Q

What is Stereotactic radio surgery

A

For brain metastasis:
< 3 lesions of 3cm size

Single treatment of high dose

24
Q

How can Head & Neck cancers spread

A

• LOCALLY:

  • soft tissues
  • cartilage
  • bone
  • nerves

• LYMPH NODES:
- very common esp. nasa/oro - pharynx

• VASCULAR:
- to lungs, bone and liver

25
Q

How is the decision made about treatment for an individual patient and their cancer

A

• Multidisciplinary approach:

  • type of cancer (905 of H&N cancers are SSC’s arising from the mucosa
  • stage of the cancer (TNM)
  • fitness of the patient
    (performance score 0-4)
  • the patients wishes

• Should happen in a joint clinic:

  • surgeon
  • oncologist
  • specialist nurse
  • plastic surgeon
  • speech & language therapist
  • dietician
26
Q

What investigations are needed when deciding on treatment

A 
• Clinical examination
• Blood tests
• Examination under anaesthesia
• Biopsy
• Imaging:
- MRI
- CT scan

• Potential sites of metastatic disease:
- CT scan thorax

27
Q

What are the non-surgical treatments for H&N cancer

A
  • Radiotherapy
  • Chemotherapy
  • Targeted therapy
  • ORGAN PRESERVATION
  • USED ALONGSIDE SURGERY TO INCREASE CHANCE OF CURE
  • OFTEN COMBINED TOGETHER
28
Q

What is important when the patient is undergoing H&N radiotherapy

A
  • Critical structures are close (spinal cord, optic chiasm, eyes, brain)
  • Essential to keep pt. very still & reproduce same position each day of treatment
  • Patient often needs to be immobilised using a head shell to keep them still

CT is used mark areas to be treated and organs at risk

The CT is used to produce a radiotherapy plan

Patient then enters simulator to verify the treatment (simulates treatment).
After this - the pt. is upgraded to cone beam CT scans

29
Q

What are the side effects of H&N radiotherapy

A

EARLY:

  • xerostomia
  • altered taste
  • mucositis
  • loss of hair
  • fatigue
  • cough
  • soreness of skin
30
Q

What are the late side effects of H&N radiotherapy

A

LATE:

  • xerostomia
  • altered taste
  • osteo-radionecrosis
  • alopecia
  • hypothyroidism
  • second malignancy
  • altered pigmentation
  • sub-cutaneous fibrosis
31
Q

Chemotherapy in H&N cancer

A

• Concurrent chemoradiotherapy:
- cisplatin every 3 weeks during RT

• Induction chemotherapy
- combination cisplatin based chemo prior to radiotherapy for fit patients with bulky tumours

• Palliative chemo:
- Cisplatin and 5FU every 4 weeks

32
Q

The role of dentists in H&N cancer

A
  • Prevention (smoking)
  • General dental hygiene
  • Dental assessment prior to radiotherapy
  • Screening (for oral cancer)
  • Management of ONJ and ORN
  • Restorations

ONCOLOGY - PHARMACOLOGY - ANAESTHETICS (1 decks)

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