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DEN303 - IHD > Clinical Oncology > Flashcards

Clinical Oncology Flashcards

1
Q

Cancer

A

Group of diseases characterised by uncontrolled growth and spread of abnormal cells within a body

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2
Q

Classification criteria

A

Type of cancer cell
Grade
TNM staging

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3
Q

What are used to determine tx pathways

A

Prognostic markers

HER2 receptor in breast and gastric cancer

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4
Q 
Risk factors for cancer 
Colorectal 
Lung
Breast 
Skin 
Cervix 
Head and Neck
A

Dietary/genetic

Smoking

Obesity/genetic

Sun exposure

HPV

Smoking/alcohol/diet and nutrition/viruses/immunosuppression/radiotherapy exposure/premalignant oral conditions

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5
Q

Tx options

A 
Surgery
Radiotherapy - local
Chemotherapy
Hormonal therapy
Targeted therapies - specific target e.g receptor or growth factor 
Immunotherapy 
Laser therapy 
Cryotherapy
Best supportive care
Any combination
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6
Q

Surgery aims and intentions

Side effects to consider?

A

Curative tx for many cancers

Side effects - fx, cosmetic, anaesthesia risks

Remove tumour with clear margins
May require adjuvant chemotherapy and radiotherapy

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7
Q

Chemotherapy
Targets
Mechanism

A

Drugs which affect cell function
Used in combination to increase effect
Anti-cancer action in expense of side effects
Different mechanisms

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8
Q

Chemotherapy adjuvant tx
For?
How?
Why?

What to consider ?

A

High risk post op patients
Combination of drugs
Given chemotherapy to reduce risk of recurrence
5-10% cured

Patient may not have disease therefore doesn’t need tx
May recur despite chemo

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9
Q

Chemotherapy as palliative tx

A 
Treatment to improve symptoms and maybe extend life
Single drug
Fewer side effects
Not usually offered until symptomatic 
Stop if increasing toxicity
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10
Q

Chemotherapy side effects

General 
Skin 
Nerves 
Bone marrow 
Organs 
Lung toxicity and with what 
Cardiac toxicity and wth what
A

Nausea/vomiting/change in taste/bowel

Hair loss/rash/extravasation

Neuropathy/hearing loss
Infertility

Anaemia/thrombocytopenia/neutropenia

Renal/Liver dysfunction

Fibrosis/bleomycin

Cardiomyopathy/anthracyclines

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11
Q

Immunosuppression

so?

A

Chemotherapy can lead to neutropenia by end of cycle

Incredibly susceptible to other disease

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12
Q

Timing for dental work

When is max risk of IS in 3 week cycle

A 
Ideally do it all before 
Platelets >100 
Neutrophils > 1
Platelets > 20/30
7-14 days through cycle 
Wait until end of cycle
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13
Q

Dental abscess in immunocompromised patients

A

Check blood counts

Drainage is recommended

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14
Q

Patients on targeted treatments

A

Usually not immunosuppressed if on targeted treatments
Risk of infection is high
Check FBC and consider Ab cover
Always check with oncologist

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15
Q

Immunotherapy
Example?
Mechanism?
Can cause?

But also are ?

A 
Very common now 
PDL1 inhibitors - PEMBROLIZUMAB e.g 
Trigger innate immune response 
Can cause organ inflammation 
Can also be effective in controlling cancers

Prednisalone to kerb inflammation

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16
Q

Bone tx

Can be used when? and to do what?

What is an SRE?

Which meds are taken

A

Can be used in adjuvant or palliative setting
Reduce risk of SREs - skeletal related events
Bisphosphonates
Rank ligand inhibitors

Skeletal related events

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17
Q

Cycle of bone destruction - mechanism

A

Tumour cells release GFs and cytokines
Osteoclast proliferation stimulated leading to resorption
Peptides released by bone resorption
Positive feedback leads to increased tumour factor production may encourage tumour activity
Tumour cells and other bone cells increase RANK ligand expression by osteoblasts
Increased osteoclast activity

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18
Q

Bone tx

A

Can be used in adjuvant or palliative setting
Reduce risk of SREs - skeletal related events
Bisphosphonates
Rank ligand inhibitors - therefore reduce osteoclast activity

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19
Q

Cycle of bone destruction

A

Tumour cells use bone cells to grown and lead to bone resorption
Peptides released by bone resorption
Osteoblasts and other bone cells increase RANK ligand expression

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20
Q

Osteonecrosis of jaw

Related to?

More common in?

A

Potency and duration of tx
Rare

IV administration

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21
Q

Radiotherapy

Energy of photons used?

A

Used as cancer tx
Photons accelerated toward targeted cells
Direct effect on DNA
Radiation reacts with water molecules –> free radicals
Free radicals cause DNA damage
Malignant and normal cells are damaged
Damage to normal cells manifests as side effects
Can repair if tolerant

20-80mV

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22
Q

Radiotherapy is
Intention

Modalities

A

Local

radical/Curative/pallative/adjuvant/neoadjuvant
Dose depends on area being treated, intention of treatment

X-rays
Electron tx
Brachytherapy

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23
Q

Superficial radiotherapy

Megavoltage radiotherapy

A

100kV photons
Treats to depth of 6mm
BCC and SCC

6-20 mV

24
Q

Stereotactic radio surgery

A

Brain metastasis - <3 lesions of 3cm size

Single treatment of high dose

25
Q

Types of Head and Neck cancer

A

Oral cavity

  • floor of mouth
  • anterior 2/3 of tongue
  • alveolus
  • retromolar trigone
  • hard palate
Nasopharynx
Oropharynx
Larynx 
Hypo pharynx 
Sinuses
26
Q

Pathology of head and neck

and in skin

A 
Squamous cell cancer 90% 
Adenocarcinoma
Small cell carcinoma
Sarcoma 
Lymphoma
  • SCC
  • BCC
  • Malignant melanoma
  • Merkel cell tumour
27
Q

HPV

A

DNA virus
Urogenital transmission
Type 16 is most common
Cervical and oropharyngeal is SCC type

28
Q

HPV incidence

A

Positive in ~25%
Distinct disease
Younger patients and 40s-50s
Not smokers or heavy alcohol drinkers

29
Q

HPV tx

A

Chemoradiation

30
Q

HPV patterns of spread

A

Locally - soft tissues, cartilage, bone, nerves

Lymph nodes - naso and oropharynx

Vascular - lungs, bone and liver

31
Q

Management

A

Tx
Decisions
Investigations

32
Q

Investigation needs

A 
Clinical exam 
Blood tests 
Biopsy 
Bone scan
CT/MRI 
OPT 
Angiograms
33
Q

TNM classifications

Performance status

A

Tumour/Node/Metastasis

0-4

34
Q

Non surgical oncology treatments for H&N cancer

A

Radiotherapy/Chemotherapy/Targeted therapy
Organ preservation
Used alongside surgery to increase chance of cure
Often combined together

35
Q

General Management Principles

A

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 is best treated with surgery
Locally advanced 
Surgery followed by Chemoradiotherapy
Chemoradiotherapy alone
Induction Chemotherapy followed by Chemoradiotherapy
Metastatic disease
Palliative Radiotherapy
Palliative Chemotherapy
Best supportive care
36
Q

44 y/o breast cancer already had chemotherapy cycle

Needs dental treatment what to do?

A

Return for treatment before 2nd cycle

37
Q

66 y/o breast cancer - herceptin, zolendronate

A

Stop and restart after treatment

38
Q

62 y/o needing dental treatment but is neutropenic

A

Check FBCs

39
Q 
Classification: type of cancer cell 
Glandular 
Skin/Mucosa
Connective tissues
Small cell 
Lymph node
A 
Adenoma
Squamous cell carcinoma 
Sarcoma
Small cell carcinoma 
Lymphoma
40
Q

Classification: Grade

Measure of?

A

1-3

Degree of differentiation

41
Q

Classification: TNM staging

Stands for?

A

Tumour size
N - spread to lymph nodes
M - Spread to distal organs

42
Q

Factors for improved survival and examples of that

A

Earlier diagnosis - increased awareness, screening programmes
Improved treatment - surgery/radiotherapy and chemo/targeted txs and immunotherapy

43
Q

Modern targeted agents and example

A

Tyrosine kinase inhibitors e.g sunitinib

Monoclonal antibodies e.g cetuximab

44
Q

Bone metastases are a mixture of

Hallmark of it

Key therapeutic target

A

Osteoblastic and osteolytic/clastic lesions

Increased bone resorption

Osteoclasts

45
Q

SREs

A

Clinical consequences of bone metastases
Spinal cord compression
Bone surgery
Radiotherapy to bone Pathological fracture
Hypercalcaemia

46
Q

Traditional tx of MBD
Radiotherapy

Endocrine

Chemo

Tumour targeted

Orthopaedic intervention

Analgesics

Bone targeted

A

Palliate bone pain

Anti-tumour

Anti-tumour

Anti-tumour

Stabilise bone

Pain management

Inhibit bone cell fx

47
Q

Bisphosphonate structure

Most potent?

A

Phosphate group
R chain

Zoledronic acid

48
Q

Effect of bisphosphonates

A

Decrease osteoclast activity
Reduce peptide release
Slow tumour growth
Decreased bone resorption

49
Q

Side effects of bisphosphonates

A

Osteonecrosis risk
Upper GI inflammation
Diarrhoea

Temp fever and myalgia
Mineral adverse events
Calcium and vit D supplements required

50
Q

Denosumab - mechanism

What could it prevent

A

Rank L ligand inhibitor
Binds to rank L - prevents activation of receptor on osteoclasts
Inhibits osteoclast formation and maturation
Bone resorption decreased

Could prevent or delay SREs

51
Q

Curative radiotherapy

A 
Complex planning
Accurate localisation - CT
Longer course of treatment
More early side effects
Less late side effects
52
Q

Palliative radiotherapy

A 
Simple planning
Simple localisaton – Xray
Short course of treatment
Less early side effects
More late side effects
53
Q

Radiotherapy

Side effects

May be given

Early

Late

A

Depend on area being treated
Early or late effects

Alone
Combined with chemo

Develop during or shortly after, resolve

Develop months/years after
Rare and irreversible

54
Q

Side effects of H+N RT

Early

Late

A

Xerostomia/taste change/mucositis/loss of hair/fatigue/cough/sore skin i.e. desquamation

Xerostomia/taste change/osteoradionecrosis /alopecia/hypothroidism

55
Q

Dental context of effects of RT

Xerostomia

ORNJ

Whats essential

A

Accelerated decay
Poor dental hygiene

Pre-treatment dental assessment/clearance

56
Q

Chemo in H+N

A

Chemradiotherapy - cisplatin every 3 weeks
Induction chemo
- combined cisplatin before RT
Palliative chemo - cisplatin and 5 fluorouracil

DEN303 - IHD (58 decks)

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