PRINCIPLES OF ONCOLOGY An outline

Dr. V N Bhattathiri MD PhD Professor of Radiology Academy of Medical Sciences Pariyaram Medical College PO Kannur-670503

Pathologic Classification of diseases

Congenital Traumatic Inflammatory

Specific Non-specific

Degenerative Neoplastic

Cancer

Neoplastic condition Abnormal proliferation of cells

Arise from a single clone Ability to invade and metastasize

Self origin: from bodys own cells

Exception:

Aim of treatment

Curative Cure: Disease free life expectancy equal to normal population Usually intense Symptom control Usually less intense

Factors affecting decision

Tumour
Site & Histology

Solid Hematogenous Localised Metastatic

Extent

Host
Performance status Age, organ function

Treatment Modalities

Surgery Radiotherapy Chemotherapy Biological therapy Hyperthermia

Surgery

Solid tumours Principle: Remove macroscopic as well as microscopic (ie potentially involved) tumour
Limited by site and extent of tumour Repair at time of surgery Curative; Emergency

Surgery

Main curative role in

Adenocarcinomas Breast; Stomach, Colorectal, Ovarian, Uterus Salivary gland, Thyroid Squamous cell carcinomas
Head and neck; Uterine cervix; Skin, Lung Oesophagus

Sarcomas CNS Tumours

Radiotherapy

Use of ionising radiation

Produce ions/free radicals which damage DNA/kinetic structures

Leads to death by apoptosis/mitotic catastrophe

Radiotherapy

Radiation
Electromagnetic: X-rays or -rays

Only differ in source

Particulate: Electrons, Neutrons, Alpharays, etc

Source
Machines: Linear accelerators, cyclotrons Radioactive isotopes: Cobalt, Iridium, Cesium, etc.

Factors affecting RT results

Tumour
Site: Critical organs: Eye, Spinal cord Growth rate: Potential doubling time

Size: number of cells; growth rate; blood

supply Histology: intrinsic radiosensitivity

Factors affecting RT results

Host
Age Performance status Other diseases Anemia

Factors affecting RT results

Treatment factors
Fraction size Interruptions

Dose
Radiation used Planning

Radiotherapy

Delivered by
Teletherapy Brachytherapy Internal therapy

Radiotherapy

Teletherapy
Source kept at a distance from body Irradiates all tissues between skin and tumour Use multiple fields

Radiotherapy

Brachytherapy
Radioactive Source kept close to or inside body Intracavitary, intraluminal, interstitial, etc High tumour dose, low normal tissue dose

Radiotherapy

Internal therapy
Injected or ingested unsealed radionuclides Radioiodine : Thyroid; Strontium: Bone mets

Radiotherapy

Curative
Head and neck cancers Uterine cervix Lymphomas

Adjuvant
To surgery: Breast, brain, sarcomas, etc

Symptomatic
Bone mets, lung,

Chemotherapy

DNA damagers:
Alkylating agents, Bleomycin

Antimetabolites:
Methotrexate, 5FU, 6MP

Mitotic spindle inhibitors:

Vinca alkaloids, Taxanes,

Topoisomerase inhibitors:
Etoposide, Adriamycin, Actinomycin-D

Tyrosine kinase inhibitor: Imatinib

Biological therapy

Interferons
Antiproliferative, Differentiating; Alter cell

surface antigens; Immunostimulation

Interleukins
Immune stimulator, induce cytokines (TNF,

lymphotoxin, etc.)

Biological therapy

Hormonal agents
Estrogens, Antioestrogens, Progesterones,

Antiandrogens, Hormone replacement

Differentiating agents
ATRA & Arsenic trioxide-APL;

13cisRetinoicacid-Mycosis fungoides

Biological therapy

Monoclonal antibodies
Anti-CD20 (Rituximab): Low grade NHL Anti-HER2/neu (Trastuzumab): Breast

Angiogenesis inhibitors
Thalidomide-Myeloma

Gene therapy

Suicide gene
HSV-TK, cytosine deaminase Brain trs, mesothelioma Use retro and adenoviruses

Tr suppressor gene
P53, BRCA1, retinoblastoma, p16 Lung, colon, ovarian Use retro and adenoviruses

Hyperthermia
Temperatures of 42-450 C Perfusion: local, body cavities Microwave Radiofrequency With chemotherapy, radiotherapy, immunotherapy

Other techniques

Photodynamic therapy
Laser surgery Cryosurgery

Combined modalities

Needed in most of the cancers

Increase cure Decrease morbidity

Team management

Cancer best managed as a team

Before any treatment is offered Consisting of Surgeon, Radiotherapist, Medical Oncologist, Rehabilitation specialist, etc.