Radiation Therapy 3 Exam 1
Non melanoma tx side effects
Acute: Redness/moist Avoid trauma Cleansing Ointments Chronic: Telangietasia Hyperpigmentation Hair loss Necrosis
Tongue
Anterior 2/3 are included in oral cavity Base considered to be oropharynx T3 or T4 get RT as they are medically inoperable
Non-melanoma skin cancer
Any cancer that forms in basal, squamous, or Merkel cells of skin Ex basal cell carcinoma Squamous cell carcinoma Merkel cell carcinoma
BCC vs SCC
BCC has more varied appearance. Grows slower. Can be locally invasive SCC has less varied appearance Grows faster Some metastatic potential to lymph nodes
Non melanoma prognosis
Basal and squamous cell carcinomas have better than 95% cure rate if detected and treated early.
Types of skin cancer
Basal cell carcinoma Squamous cell carcinoma Malignant melanoma
Eyelid tumors
Basal cell carcinoma represents 90% of malignant eyelid tumors. Types: Nodular Ulcerative Pigmented Morpheaform Common on lower eyelid in fair skinned people
Why is skin cancer the most common cancer?
Because skin cancer is visible to the naked eye and symptoms are not required for diagnosis. Skin gets exposed to the most carcinogens
Seborrheic keratosis
Benign, often itchy growth that appears as a stuck on wart.
Determination of oral cancer
Biopsy Toluidine staining. Clinical appearance in retention of the dye Acetic acid - staining method
Squamous epithelium
Cancers of the head and neck begin here. Begins in oral cavity, salivary glands, paranasal sinuses and nasal cavities and pharynx
treatment options
Caught early, 98% survival rate. Most cutaneous melanomas are managed surgically. Rad therapy for post surgical use, medically inoperative patients and pts who refuse surgery. RT and chemo for palliation Radioresistant Immunotherapy targeted
Tongue cancer tx
Clinically presents with lesions on lateral borders near middle and posterior 1/3 section Lesions on tip are commonly early stage Lesions at base and posterior 1/3 are advanced and higher chance of nodal mets RT best choice for large T3 and T4 lesions to preserve speech and swallowing function Bilateral neck usually included in tx Usually ipsilateral until it reaches T3 and T4 level
Etiology of head and neck cancer
Closely related to use of tobacco and alcohol. Risks are about 35x for those who smoke and drink heavily than those who don't. Ultraviolet light (lip cancer) Occupational exposures (nickel refining, furniture and woodworking, steel and textile workers) Radiation exposure Viruses (epstein barr, herpes simplex 1, HPV)
Hypopharynx tx
Combined surgery and RT is curative Tumors of posterior pharyngeal wall are considered unresectable Common chemo Cisplatin 5-FU
Sublayers of epidermis
Come Let's Get Sun Burned Corneum Lucidum Granulosum Spinosum Basale
Topical 5-fluorouracil
Commonly used for tx of genital erythroplasia.
Actinic Keratosis
Crusty or scaly bump that forms on sun exposed skin. Common on bald heads. Most common precancer.
Non melanoma treatment
Curettage and electrodessication Scraping and burning Moh's surgery Cryosurgery using liquid nitrogen Laser surgery Chemotherapy (topical 5-FU)
Kaposi's Sarcoma Survival
Early epidemic outlook had less than 10% pts surviving 5 years after dx Now 5 year survival is about 72%
Layers of skin
Epidermis Dermis Hypodermis/subcutis
Characteristics of benign growth
Local spread Slow growing mitotic activity Encapsulated with clear borders Never metastasizes
Clinical presentation of oral cancer
Localized pain is considered a symptom of advanced disease. Non healing ulcers with little pain Leukoplakia Erythroplakia Dysplasia (abnormal cell growth) precancerous
Oral metastatic behavior
Lowest incidence of mets Bloodborne spread occurs in fewer than 20% of patients
Basal cell carcinoma
Makes up 80% of new cases. Best prognosis. Can come from epithelial, pigmentary or dermal tissue cells. Rarely metastasize to other parts of the body. Often looks like open sores, red patches, pink growths and shiny bumps or scars.
Lip cancer
Males 10x more likely to develop this due to occupation related sun exposure or greater tobacco and alcohol use Lower lip 12x more likely to be affected 95% ate melanomas Associated with smoking, alcohol, and immunosuppression
Lentigo maligna (Hutchinson's freckle)
Malignant freckle. Flat macule usually seen in elderly persons. Localized for up to 10-15 years Usually on face Rare 5%
Hypopharynx risk factors
Prolonged use of alcohol and tobacco Male older than 50 Plummer Vinson Syndrome (characterized by iron deficiency anemia) in pre menopausal women
integumentary system
Protects the body from chemicals, disease, UV light, and physical damage. Skin is 12% of your body weight and only a few mm thick
Nodular melanoma
Rapidly growing nodule or tumor. Cells invade dermis. 15% of melanomas 50+ Grows quickly
Merkel cell carcinoma
Rare aggressive cancer first described in 1972. Arise from stem cell in the epidermis (tactile or Merkel cells) High rates of recurrence after surgical excision Frequent involvement of regional lymph nodes and distant mets Also called trabecular carcinoma or neuroendocrine carcinoma
Hard palate
Rare for cancer. Mostly adenocarcinomas (SCC is rare) Surgery with post op RT for high risk Usually good local and regional control
Erythroplasia
Reddened patch with velvety surface on oral or genital mucosa that is considered to be a precancerous lesion. Early stages of SCC
Oral histopathology
SCC accounts for 90% to 95% (well to moderately well differentiated) Adenocarcinoma of salivary gland may be identified
Keratoacanthoma
Site of minor injury due to sun damage. Develops on hair bearing, sun exposed skin. Less serious form of SCC. May appear as pimple or boil with solid core of keratin. Grows rapidly. Surgical removal.
Non melanoma pattern of spread
Slow growing Direct extension Nodes and metastases
Non melanoma etiology
Sun exposure Genetics Radiation Chemical and physical agents esp in SCC through arsenic or fires Viruses: HPV which causes papilloma or warts Chronic irritations Previous cancer Age
Hypopharynx radiation tx borders
Superior - epiglottis Posterior - pharyngeal wall Anterior - larynx Inferior - cricoid cartilage/esophagus
Radiation Treatment borders
Superior - hard palate Anterior - lips Posterior - back 1/3 of tongue Inferior - floor of mouth
Treatment of Head and Neck Cancer
Surgery and Radiation therapy are the only curative txs for carcinomas arising in the head and neck. Chemotherapy alone is not curative.
Merkel cell treatment
Surgery fails locally in 75% of patients Half get distant mets Follow up RT is given 2cm margin and 50 Gy at low energy
Oral treatment
Surgery is the #1 choice Primary tumor resection Mandibular resection Maxillectomy Moh's microsurgery Neck dissection Pedicle or free flap reconstruction Dental extraction
Mycosis fungoides
Tumor of bloodborne "immigrant" cells. Present as skin macules and papules that progress to nodules and ulcerating large masses Lymphocytes become malignant and affect the skin Cutaneous T cell lymphoma
Kaposi's sarcoma
Tumor of dermal connective tissue. Prevalent in patients with AIDS. Immunosuppression facilitates proliferation of blood vessel forming cells in the dermis Associated with herpesvirus type 8. Patches of abnormal tissue growth under the skin. Affects elderly immunosuppressed adults.
Signs of skin cancer
Ulcer or nodule of irregular shale or indistinct margins. Friable, multicolored, bleeding.
Clark level of invasion
Ulceration consistently worsens prognosis across all tumor depths T changes with ulceration: a = no b= yes Presence or absence of positive lymph nodes beyond primary (yes or no)
SCC risks
Kidney transplant and rejection suppression drugs can add to the likeliness of SCC by 250x Lower lip and pipe smokers Ulcerated lip lesions are commonly SCC
Skin Cancer stats
1/5 americans will get skin cancer by the age of 70 More than 2 people die of the disease every hour
Non melanoma incidence
13 million new cases each year 80% BCC 20% SCC
Outcomes of Melanoma
5 year survival rate is 94% Regional and distant stage diseases are 68% and 18% respectively 78% of melanomas dxed at localized stage
Merkel cell survival rate
5 yr survival about 60% This is a rare cancer so it's hard to get accurate stats Survival rate is much higher if cancer is found earlier 1500 cases in US each year
Superficial spreading melanoma
70% of MMs diagnosed in this form Irregularly pigmented macules that enlarge Scalp and neck are worst sites
Pigmented lesions
Freckle Lentigo Nevus Malignant melanoma
Non melanoma radiation tx
Good cosmetic results 1-2 cm margin Beam: superficial 50-150 kV Orthovoltage 150-500 kV Electrons: bolus for surface dose of 95% Photons Brachytherapy using cesium 137, irridium 192
Tanning beds
If you have ever done this you are six times more likely to be dxed with melanoma. 97% of women in a study who had melanoma before 30 used this.
Advantage of RT over Surgery
In Head and neck cancers RT eliminates risk of post op complications. No tissues are removed so probability of functional or cosmetic defect is reduced Elective irradiation of lymph can be included with little added mobidity.
Advantage of Surgery over RT
In head and neck cancers surgery means a shorter tx time. Risk of radiation affects both latent and acute are avoided Radiation can be reserved for subsequent head and neck primary Early stage surgery
Oral cavity cancef
Includes lips Front 2/3 of tongue Gums Lining of cheeks and lips (buccal mucosa) Bottom floor of mouth under tongue Bony top of mouth (hard palate) Small area behind wisdom teeth (retromolar trigone)
squamous cell carcinoma (SCC)
Invasive malignant tumor of epithelium. Occurs most often in sun exposed skin Locally invasive, less than 2% metastasize Preceded by pre invasive stage known as actinic keratosis
Tumors of dermal connective tissue
May originate from fibroblasts, blood vessels and other structures. Mostly benign lesions or low grade malignant tumors. Curable by surgical excision.
Epidemic Kaposi's Sarcoma
Most cases in US have been dxed in men infected with HIV. Use of drug therapy called HAART reduces risk of this in pts with HIV
Dermatofibroma
Most common tumor of dermal connective tissue. Treated with surgery.
Nodular BCC
Most common. Classic basal cell carcinoma.
Radial growth
Most superficial spreading melanomas grow in this fashion with no tendency for dermal invasion.
Bucca mucosa
Mucous membranes that lines the inner surface of the cheeks and lips Most lesions on lateral walls Can tx with a single photon or electron beam to spare contralateral tissues (healthy structures)
Oral treatment chemo
Neoadjuvant Palliation Use Cisplatin and 5-FU
Use of RT in benign conditions
No other effective tx with acceptable side effects is available Lowest effective dose and tightest fields must be used Special care in pediatrics
types of basal cell carcinoma
Nodular Superficial Cystic
Vertical growth
Nodular melanomas grow in this fashion and invade the dermis. Extent of invasion is the most important prognostic sign.
Superficial BCC
Occurs most commonly in the trunk or distal extremities. Most common in HIV patients.
Acral lentiginous
On palms, plantar surfaces or underneath nails Rarest in white people. Most common in Japanese, African Americans and Native Americans Not related to sun exposure
Floor of Mouth
Optimal: primary surgery and adjuvant radiation Can spread to bone and tongue
recurrance risk
Oral cancer lesions usually recur within 2 years Rarely recur after 4 years
Melanoma
Originates in pigment producing melanocytes in basal layer of epidermis 50% originate from intact skin 50 % from freckles or pre existing nevi
Hypopharynx Survival
Poor prognosis compared to other H&N diseases. Due to late presentation and early nodal mets
Endemic Kaposi's Sarcoma
Predominantly males are affected. Mostly in equatorial Africa. Affects bone as well as skin. Treated with chemotherapy.
Supportive care
This is important in patients with substance abuse problems. Nutritional support, counseling, medications as appropriate.
Lip treatment
Treated with RT in same manner as skin cancer
Distant mets of head and neck
The lung is the most common site accounting for half of first recognized sites.
Urticaria pigmentosa
Tumor of bloodborne "immigrant" cells Characterized by dermal infiltrated of mast cells
Head and neck lymphatic spread
Usually ipsilateral 1/3 of bodies lymph nodes are in head and neck Exceptions (bilateral spread) Soft palate, tonsils, base of tongue, posterior pharyngeal wall and nasal pharynx
Mycosis fungoides treatment
Valchlor used for topical tx who have received prior skin directed therapy. Combination chemo only after no response or organ involvement
Cystic BCC
Very rare cystic lesion.
ABCD rule
When referring to melanoma Asymmetry Border irregularity (bleeding or crusting) Color Diameter alarm if above 6mm
Leukoplakia
White patches or spots (lesions) formed inside the mouth
Dermis
middle layer of skin. where most work is done. Most vascular layer
