Radiation Therapy 3 Exam 1

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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


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