Clinical Oncology I Flashcards
(40 cards)
Dentists involvement in oncology?
Diagnose oral cavity tumours
Health promotion
Dental assessment pre-tx:
- RT, chemo, bisphosphonates, denosumab
Pt receiving cancer tx may require dental work:
- Extractions - when is best time to do tx
- Dental abscesses on chemo
- Immunocompromised pt
- Dental problems 2ndry to cancer tx - bronj
- Dentures/prostheses post cancer tx
Case 1
Come back before 2nd cycle of chemo for the procedures
Case 2: Acute dental pain
Zoledronate = bisphosphonate
Check it’s not osteo-necrosis
Likely diagnosis = BRONJ
Case 3: Colon cancer
Dental abscess
Low neutrophil count (as below 1)
On chemo
Neutropenic sepsis
Case 4: Smoked recently diagnosed with T4N2b base of tongue squamous cell cancer
Comes to you for dental assessment prior to RT planning
Cancer is curative with RT
Do not start dental tx during RT:
- Radionecrosis
- Xerostomia
Case 5: Tonsil cancer invading soft palate
Pt refuses dental tx
Treated her cancer without dental tx
Define cancer
Group of diseases characterised by uncontrolled growth and spread of abnormal cells within a body
How to classify cancer?
Type of cancer:
- Glandular = adenocarcinoma
- Skin/mucosa = squamous cell carcinoma
- CT = sarcoma
- Small cell = small cell carcinoma
- Lymph nodes = lymphoma
Grade - degree of differentiation usually G1-3
TNM staging:
T = size of tumour
N = Spread to lymph nodes
M = spread to distal organs
What prognostic markers are used to determine tx pathways?
Oestrogen receptor (ER) in Breast cancer HER2 receptor in Breast cancer BRAF mutation in melanoma HPV association in head and neck cancer EGFR expresson in lung cancer PSA level in Prostate cancer
Incidence of oral cavity cancer
Is increasing
Risk factors for cancer?
Lung - smoking Breast - genetic, obesity Skin - Sun exposure Cervix - Human papilloma virus Head and neck: - Smoking - Alcohol - Diet and nutrition - Viruses - HPV, EBV - Immunosuppression - Premalignant oral conditions (leukoplakia, lichen sclerosis) - Radiotherapy exposure
How to improve cancer survival?
Earlier diagnosis - increased pt awareness - screening programmes: colorectal, breast, prostate, ovary, cervix Improved tx: - surgery - RT - Chemo
Tx options for cancer?
Surgery RT Chemo Hormonal therapy Targeted therapies Immunotherapies Laser therapy Cryotherapy Best supportive care Any combo of these
Surgery features?
Can be curative tx
Usually need to be fit for GA
Side effects - functional, cosmetic, risk of anaesthetic
Aim to remove tumour with clear margins
May require further tx on review of histology - adjuvant chemo/hormones, adjuvant RT
Chemo features?
Drugs which affect cell function Drugs often used in combo to increase effect Different mechanisms: - Platinum - Taxanes - Anti-metabolites (methotrexate) - Alkylating agents - Antracyclines
Chemo adjuvant tx features?
High risk post op pts
Often a combo of drugs - more side effects
Given chemo to reduce risk of recurrence:
- Pt may not have disease and not need it
- Pt may get recurrence despite chemo
- But a proportion will be cured bcos of it (5-10%, tx carries risks, need to assess and discuss with pt, risks vs benefits)
Chemo palliative tx features?
Tx to improve symptoms and maybe extend life
Often single drug - fewer side effects, lower intensity of tx
Not usually offered until symptomatic
Stop early if not working or increasing toxicity
Chemo side effects?
General: - Nausea and vomiting - Fatigue - Change in taste - Bowel disturbance Skin: - Rash - Hairloss
Nerves:
- Neuropathy
- Hearing loss
Infertility
Bone marrow: - Anaemia - Neutropenia - Thrombocytopenia Renal and liver dysfunction Allergic rxn Lung toxicity - fibrosis Cardiac toxicity - cardiomyopathy
Give examples of modern targeted agents?
Tyrosine kinase inhibitors
Oral
Vemurafenib - BRAF mutation in melanoma
Gefitinib - EGFR mutation in Lung Cancer
Imatinib - c-Kit CML/GIST
Sunitinib - PDGF/VEGF in Renal/Sarcoma/
Monoclonal antiobodies
IV infusion
Trastuzumab - HER2 receptor in breast cancer
Cetuximab - EGFR receptor Colorectal/Head and Neck
Bevacuizumab - VEGF receptor Colorectal/Breast/Gynae
General rule for dental txs while on chemotherapy?
Avoid if not urgent
Urgent work completed before chemo
Do tx just before next cycle
If already on chemo:
- Find out length of cycle - 3 weekly/weekly/daily tablets
- In a 3 weekly cycle (most common) - max risk of immunosuppression is between 7-14 days
- Check FBC prior to urgent dental tx to ensure not neutropenic or low platelets
- Neutropenia neuts less than 1
- Thrombocytopenia - platelets less than 100
- Risk of bleeding if platelets less than 20/30
Why may an abscess be in an immunocompromised pt?
Can be source of infec for neutropenic sepsis - IV antibiotics and supportive measures provided
If no other source of infec or sepsis not improving = drainage of abscess and platelet transfusion if low with GCSF cover
Immunotherapy features?
PDL1 inhibitors - pembrolizumab
Immune checkpoints inhibitors - Nivolumab
Can cause an ‘itis’ in any organ (hepatitis, thyroiditis) that can be fatal
Can be effective in controlling cancers
Can provide a sustained benefit for months/yrs
When are bone txs used in cancer? Examples?
Used in adjuvant or palliative setting Either to reduce risk of SREs or decrease symptoms from SREs Bisphosphonates RANK ligand inhibitors Radium 223
What are bone metastases often a mixture of?
Osteoblastic and osteoclastic lesions
