Chemotherapy and Radiotherapy - PowerPoint Presentation

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Chemotherapy and Radiotherapy

Dr. Sura FindaklyMBChB,DGO,CABOG

Learning objectives:

1.Describe the clinical uses and evaluation parameters of chemotherapy. 2.Name the types of chemotherapeutic agents.3.Identify side effects chemotherapy and its uses in different gynecological malignancies.4.Recognize types of radiotherapy. 5.List side effects of radiotherapy and reproduce its uses in different gynecological malignancies.

principle of chemotherapy

attain maximal therapeutic cytotoxic effects upon cancer cells without extreme toxicity to normal tissues.

Clinical uses of chemotherapy

1-Primary Therapy. first-line treatment.2-Adjuvant Therapy. undergone primary surgical staging and cytoreduction but are known to be at high risk for the presence of micrometastases

, and recurrence, or have persistent disease at the end of primary surgery.

3-Neoadjuvant Therapy.

before

cytoreductive

surgery.

4-Salvage Therapy.

recurrent disease after first-line chemotherapy.

Evaluation parameters defined by (WHO)

1-Complete Response. Disappearance of all evidence of disease for at least 1 month.2-Partial Response. The reduction of each measurable lesion by at least 50% for at least 1 month 3-Stable Disease. Maintenance for each lesion of criteria less than those required for either a partial response or increasing disease.4-progressive Disease. Increase of a lesion by at least 25% or the appearance of a new lesion within 1 month.

Chemotherapeutic Agents

*Alkylating agents are cell cycle nonspecific. prevents DNA duplication. eg Cyclophosphamide *Antimetabolites are similar in chemical structure to metabolites required by both normal and tumorous cells for cell division to occur.eg

methotrexate

.

*

Vinca

alkaloids

They bind to tubules, interfere with spindle formation. arrest of metaphase and inhibits mitosis.eg

Vincrestine

,

vinblastine

*

Antitumor antibiotics

have many different modes of action, including increasing cell membrane permeability, inhibiting DNA and RNA synthesis, and blocking DNA replication.

Common Side Effects of Chemotherapy

1-Local and dermal: alopecia (reversible) and photosensitivity, phlebitis, tissue necrosis. 2-Myelosuppression. (Neutropenia , Anemia, Thrombocytopenia)3-Infections. the severity and duration of the neutropenia and

integrity

of mucous membranes and skin.

Fever

in a

neutropenic

patient is sufficient evidence of occult infection

4-Cardiac Side Effects

Daunorubicin

and doxorubicin

irreversible

cardiomyopathies

: CHF, pleural effusions, heart dilation, and venous congestion.

Paclitaxel

(

Taxol

)

may cause asymptomatic and transient and atypical chest pain during infusion. resolve with slowing of infusion.

5-

Pulmonary

Side Effects

Bleomycin

sulfate may cause significant pulmonary fibrosis, lung examination , Pulmonary function tests baseline pulmonary capacity before the first dose, repeated as needed

Common Side Effects of Chemotherapy

6-Hepatic. Transient elevations in LFT7.GastrointestinalStomatitis and mucositis …antimetabolites, methotrexate and paclitaxel.

Nausea and vomiting.

Diarrhea…

nephrotoxicity

or electrolyte disturbances.

8-Acute allergic reactions

etoposide.Bleomycin

can cause anaphylaxis, skin reactions, fever, chills, and pulmonary fibrosis.

9.Genitourinary

Hemorrhagic cystitis

cyclophosphamide

Nephrotoxicity

cisplatin

. Irreversible renal damage

10.Neurotoxicity

.

vinca

alkaloids

peripheral, central, and visceral neuropathies.

Tinnitus or high-frequency hearing loss ..

cisplatin

Chemotherapy in Gynecologic Cancers

1-Ovarian Cancer after initial surgery. platinum (cisplatin , carboplatin) and paclitaxel in epithelial ovarian cancer. malignant germ cells: bleomycin, etoposide, and cisplatin (BEP)

2-Endometrial Cancer

advanced or recurrent metastatic

doxorubicin, platinum, and

paclitaxel

.

3-Cervical Cancer

chemoradiation

cisplatin

or a combination of

cisplatin

and 5-FU

R adiotherapy

kills cells by the use of ionizing radiation:• X -rays• g amma-rays• β -particles.can lead to breakage of DNA directly or indirectly via production of free radicals with curative and palliative intent

Delivery of radiotherapy

Radiation may be given by external beam therapy and/or brachytherapy.1. External beam therapy:• radiation is distant from the patient2. Brachytherapy:• placement of radioactive source directly within or around the tumour site (e.g. intravaginal/ intrauterine

brachytherapy

for cervical cancer)

•

advantage

—higher radiation dose to the

tumour

, lower exposure to normal tissue.

• Side effects may be reduced by giving radiotherapy in divided doses so that normal tissues can recover.

3. Interstitial implants are another form of

brachytherapy

. Various sources of radiation may be configured as radioactive wires or seeds and placed directly within tissues. Hollow guide needles are to a target tumor volume. After the position of the guide needles is confirmed

radiologically

, they can be threaded with the radioactive sources and the hollow guides removed.

Toxicity of radiotherapy

. The severity of normal tissue reaction to radiation depends on: total dose, dose fraction, treatment volume, and radiation energy.1-Skin Toxicity. erythema, desquamation, and pruritus2-Hematologic Toxicity. The volume of marrow irradiated and the total radiation dose determine the severity of myelosuppression3-Gastrointestinal Toxicity

Acute

Complications. Nausea, vomiting, and diarrhea commonly occur 2 to 6 hours after abdominal or pelvic irradiation.

Long

-term Complications. Chronic diarrhea, obstruction (bowel adhesions), and fistula formation <1% of cases

4-Genitourinary Toxicity

Cystitis:

pain, urgency,

hematuria

, and urinary frequency.

Vesicovaginal

fistulas and

ureteral

strictures

Vulvovaginitis

:

erythema

, inflammation, mucosal atrophy, inelasticity, and vaginal ulcer. Adhesions and

stenosis

of the vagina ….Rx vaginal dilation

1-Cervical Cancer

Radiation therapy with curative intent uses both external-beam and intracavitary radiation. Palliative radiation for advanced cervical cancer may use either modality for control of bleeding, management of disease in the pelvis, and relief of pain.The goal of external irradiation in cervical cancer is to sterilize metastatic disease to pelvic lymph nodes and the parametria

and/or to decrease the size of the cervix

to allow optimal placement of

intracavitary

radioactive sources.

Definitive radiation therapy is an acceptable alternative to radical surgery for women with

early stage disease

(stages IA, IB1, and

nonbulky

IIA). concurrent

cisplatin

-based chemotherapy

The treatment volume for women undergoing adjuvant external radiation therapy usually involves the

whole

pelvis, with larger fields for patients with higher stage disease.

Patients with known or suspected metastatic disease to

periaortic

lymph nodes may be considered for

extended field

irradiation

2- Endometrial Cancer

after surgical staging : estimated risk recurrenceadnexal or pelvic metastases, involvement of lymphovascular space, grade 2 disease with invasion > 50% into the

myometrium

, or

grade 3 disease with any amount of

myometrial

invasion

:

high risk of recurrence

adjuvant radiation therapy

.

For high-risk disease confined to the uterus,

whole-pelvic therapy or vaginal

brachytherapy

may

be used.

For high-risk disease outside of the uterus but confined to the pelvis,

whole-pelvis radiation with or without vaginal

brachytherapy

should

be employed.

Women with more

extensive

disease undergo

extended-field radiation or whole-abdomen radiation.

Primary radiation therapy may be employed in women who are considered to be at high surgical risk, such as the elderly and those with significant comorbidities.

Ovarian &Vaginal Cancer

3-Ovarian Cancer: Radiotherapy controversial4-Vaginal CancerRadiotherapy : primary treatment for vaginal cancer. squamous cell carcinoma: whole-pelvic radiation therapy followed by intracavitary or interstitial brachytherapy. lesions involving the lower third of the vagina should have the inguinal and femoral lymph nodes included in the external-beam treatment field.

Extended field radiation to include

periaortic

lymph nodes may be needed if imaging studies reveal

bulky pelvic or

periaortic

disease.

5-Vulvar Cancer

squamous cell in origin. the mainstay of treatment of stages I and II vulvar cancer is surgical, radical vulvectomy plus inguinal and pelvic lymphadenectomy. Adjuvant radiation therapy benefits patients with close or positive surgical margins, as well as patients with positive inguinal lymph nodes.In patients with vulvar squamous

cancer

(stage III or IV)

chemoradiation

may reduce the need for more radical surgery; primary pelvic

exenteration

.

SUMMARY:

Knowing chemotherapy and radiotherapy types, side effects and its uses in different gynecological malignancies is important to prevent and treatcomplications of their use.

THANK YOU