Med - Basic Onco Chemo

BASIC ONCOLOGY
Jhade Lotus Peneyra MD FPCP FPSMO

PRINCIPLES OF CANCER
DIAGNOSIS
 APPROACH TO THE PATIENT WITH
CANCER
1. Clinical history and physical examination
2. Diagnosis
3. Staging workups
4. Treatment plan

DIAGNOSIS
 CLINICAL HISTORY
 First and foremost will lead to possible
diagnosis of cancer
• Duration of symptoms
• Underlying comorbidities
• Exposure to carcinogens
• Familial cancer predisposition
• Review of systems revealing presence of metastases

DIAGNOSIS
 SYMPTOMS: CAUTION US
• Change in bowel or bladder habits
• A sore that does not heal
• Unusual bleeding or discharge
• Thickening or lump in breast or elsewhere
• Indigestion or difficulty in swallowing
• Obvious change in wart or mole
• Nagging cough or hoarseness
• Unexplained anemia
• Sudden unexplained weight loss

DIAGNOSIS
 SIGNS:
• MASS EFFECTS
• Tumor ablates or crowds normal structures
• Cause pain, obstruction, bleeding

DIAGNOSIS
 SIGNS & SYMPTOMS:
• REMOTE EFFECTS (PARANEOPLASTIC
SYNDROMES)
• Related to abnormal secretion of certain peptides
• Exert biologic actions at local or distant sites
• Can elicit hormonal, hematologic, dermatologic,
neurologic symprtoms

DIAGNOSIS
 SIGNS & SYMPTOMS:
• REMOTE EFFECTS (PARANEOPLASTIC
SYNDROMES)
• Cushing’s syndrome (ectopic ACTH) SCLCA
• Sensory / motor neuropathy SCLCA
• Acanthosis nigricans GI cancers
• Weight loss, fever, anorexia
• Rheumatoid arthritis lymphomas

DIAGNOSIS
 SYMPTOMS:
• PSYCHOSOCIAL EFFECTS
• Loss of control
• Acceptance of personal finitude
• Fear of pain and mutilation
• Separation and loneliness

DIAGNOSIS
 DIAGNOSIS
 BIOPSY
• Surgical biopsy or invasive tissue biopsy is the
single most important procedure in the diagnosis
of cancer

DIAGNOSIS
 DIAGNOSIS
 BIOPSY
• Depend on the adequate tissue obtained to permit careful
evaluation of the tumor histology
• Varies with the type of cancer, anatomical location and
medical condition of the patient
• Fineneedle aspiration biopsy
• Excision biopsy
• Incision biopsy
• Cytology from body fluids or exfoliated from organs

DIAGNOSIS
 DIAGNOSIS
 BIOPSY
• Specimens can be amplified by:
• Immunohistochemistry
• Molecular markers
• Molecular genetics

DIAGNOSIS
 DIAGNOSIS
 BIOPSY
• Histologic / Cytologic features of cancer:
• Invasiveness
• Destruction of normal tissues
• Atypical tissue structure
• Pleomorphism
• High mitotic rate
• Aneuploidy

DIAGNOSIS
 DIAGNOSIS
 BIOPSY
• HISTOPATHOLOGY RESULT
• Anatomic origin
• Tissue of origin
• Grade (degree of malignancy) and differentiation (extent of
resemblance to normal tissue)

DIAGNOSIS
 DIAGNOSIS
 NONINVASIVE TESTS:
• Oncologic imaging and endoscopy
• Plain radiography excellent sensitivity and specificity in
soft tissues/ bones
• Contrast GI studies cancer screening for highrisk grps
• Ultrasound scanning abdominal screening

DIAGNOSIS
 DIAGNOSIS
 NONINVASIVE TESTS:
• CT scanning procedure of choice for screening mass lesions
• MRI scanning elimination of bone artifacts
• PET scanning scan for tumor metabolism
• Monoclonal antibody imaging specific labeling of antigens &
antibodies

DIAGNOSIS
 DIAGNOSIS
 NONINVASIVE TESTS
• Bronchoscopy
• Mediastinoscopy
• Gastroscopy
• Colonoscopy

DIAGNOSIS
 DIAGNOSIS
 TUMOR MARKERS
• Macromolecules formed in or on tumor cells or via induction of
other cells
• Present in the blood or other body fluids
• Correlate with the presence and growth of malignant tumors in
the patient
• More useful for monitoring patient response and detecting
recurrence
• Determined before initiating treatment then q 3mos x 2yrs then q
612mos thereafter

DIAGNOSIS
Tumor markers Cancer Benign
HORMONES
HCG Gestational trophoblastic disease, Pregnancy
gonadal germ cell tumor
Medullary cancer of the thyroid
Calcitonin
Pheochromocytoma
Catecholamines
ONCOFETAL
ONCOGENES
Alphafetoprotein HCC, gonadal germ cell tumors Cirrhosis, hepatitis
Carcinoembryonic Antigen AdenoCA of colon, pancreas, Pancreatitis, hepatitis,

lung, breast, ovary inflammatory bowel
disease, smoking

DIAGNOSIS
Tumor markers Cancer Benign
ENZYMES
Prostatic acid phosphatase Prostate CA Prostatitis, prostatic hypertrophy
Neuronspecific enolase SCLCA, Neuroblastoma
LDH Lymphoma, Ewing’s sarcoma Hepatitis, hemolytic anemia, many
others
TUMOR ASST’D PROTEINS
PSA Prostate CA Prostatitis, prostatic hypertrophy
Monoclonal Ig Myeloma Infection,MGUS

CA125 Ovarian CA, some lymphoma Menstruation, peritonitis,
pregnancy
CA 199 Colon, pancreatic, breast CA Pancreatitis, ulcerative colitis
CD30 Hodgkin’s dse, anaplastic large cell lymphoma
Hairy cell leukemia, adult T cell
CD25 leukemia/lymphoma

DIAGNOSIS
 STAGING WORKUPS
 STAGE OF THE TUMOR
• Extent of the tumor at the time of diagnosis
• Combined clinical and pathological process
• Clinical staging (PE, imaging studies)
• Pathologic staging (surgical information, histologic
information)

DIAGNOSIS
 STAGING WORKUPS
• To make treatment decisions, define objective of
therapy and determine prognosis
• To measure and follow the results of therapy
• To standardize the description of extent of disease in
order to accurately compare results of investigational
or standard therapy

DIAGNOSIS
 STAGING WORKUPS
• TNM staging by American Joint Committee on Cancer
• T primary tumor characteristics (location,size, tissue
involvement)
• N locoregional LN involvement w/ tumor
• M presence or absence of metastasis and location

DIAGNOSIS
 STAGING WORKUPS
• TNM staging by American Joint Committee on Cancer
• Once TNM score is defined, stage is assigned (I IV)
• Tumor burden increases and curability decreases with increasing
stage
• Other systems : Ann Arbor staging, Dukes classification, FIGO
staging, Veterans administration lung cancer study grp

DIAGNOSIS

DIAGNOSIS
 STAGING WORKUPS
• Physiologic reserve of the patient
• How likely the patient would cope with cancer
complications and treatment side effects
• Karnofsky perfomance index, ECOG / WHO PS scale

DIAGNOSIS
 STAGING WORKUPS
 ECOG / WHO PS
0 Normal
1 Symptomatic but ambulatory
2 Disabling symptoms, < 50% bedridden
3 Severely disabled, >50% bedridden, able to
stand up
4 Very sick, 100% bedridden
5 Dead

DIAGNOSIS
 STAGING WORKUPS
• Biologic features of the tumor
• Expression of particular oncogenes, drugresistance genes
• Presence of cytogenetic abnormalities
• Proliferation related markers (PCNA)

DIAGNOSIS
 STAGING WORKUPS
• Recommended staging workups:
• Predilection of tumor for spread to adjacent or distant
organs

DIAGNOSIS
 TREATMENT PLAN
 Extent of the disease
 Prognosis
 Patient’s wishes
 Cooperation among various specialties

DIAGNOSIS
 TREATMENT PLAN
 The finality of treatment of a cancer patient
demands that only those who are capable and
properly trained undertake therapy
 Emergence of subspecialties in all major
oncology disciplines

MANAGEMENT
 Topic objective:
 To discuss the basic principles of cancer
management with emphasis on
chemotherapy

MANAGEMENT
 FIRST PRINCIPLE:
 Be certain that the diagnosis is correct
 Many diseases may mimic malignancy

MANAGEMENT
 SECOND PRINCIPLE:
 Primum succerrere (first hasten to help)
 Cure or control the disease or to palliate the
symptoms of the patient
 Minimal functional or structural impairment

MANAGEMENT
 How radical should the treatment be?
 Aggressiveness of the cancer
 Morbidity & mortality of the treatment
 Cure rate of the treatment

MANAGEMENT
 Why choose such treatment?
 What is the goal of treatment?
 Do benefits outweigh risks in achieving these
goals?
 Is difference between potential benefit and
harm worth the cost?

MANAGEMENT
 OUTCOMES OF CANCER TREATMENT
 Survival rates
• Most important outcome
• DFS improvement required for adjuvant treatment
• Treatment may be advised if it can improve QOL

MANAGEMENT
 Tumor responses
• Complete response important outcome if it
predicts survival
• Progressive disease change the therapy or stop
the treatment

MANAGEMENT
 Patient outcomes
• Quality of life and survival are more important
• Benefits should be balanced against risks and
costs

MANAGEMENT
 2 MAJOR MODALITIES OF CANCER
TREATMENT:
 Locoregional treatment
 Systemic treatment

MANAGEMENT
 LOCOREGIONAL TREATMENT
 Surgical Oncology
• Main treatment modality for early stage tumors
• Biopsy for diagnosis
• Surgical resection when appropriate with attention to other
needs of other consultants
• Adequate staging
• Consulation with med / rad onco for adjuvant therapy
• Surgical resection for cure, control or palliation
• Appropriate ffup of patient

MANAGEMENT
 LOCOREGIONAL TREATMENT
 Radiation oncology
• RT involves radiation inactivation of cancer cells
• Can be given as external beam or brachytherapy or
radioimmunotherapy
• Tumors and body tissues differ in their radiosensitivity and
radioresistance

MANAGEMENT
 SYSTEMIC TREATMENT
 CHEMOTHERAPY:
• Refers to the use of drugs in the treatment of any disease
• With systemic effect on the patient
• Cytotoxic conventional chemotherapy
• Hormonal therapy
• Molecularly targeted therapies
• Biologic therapy

Tumors Responsive to
Chemotherapy
Curable:
 ALL, NHL, Wilm’s tumor, Ewing’s sarcoma,
retinoblastoma, rhabdomyosarcoma Child
 Hodgkin’s disease; some aggressive
lymphomas
 Testicular carcinoma
 Choriocarcinoma
 Ovarian carcinoma
 Acute Leukemia Adult

Chemotherapy
Improved Survival:
• Neuroblastoma, child
• Aggressive nonHodgkin’s lymphoma
• Small cell lung cancer
• Breast carcinoma
• Osteogenic sarcoma

Chemotherapy
Occasional Response:
• Soft tissue sarcoma
• Brain cancer
• NSCLC
• H & N carcinoma
• Urinary bladder transitional cell carcinoma
• Malignant melanoma

Chemotherapy
Palliation:
 NonHodgkin’s lymphoma
(low & intermediate type)
 Chronic leukemia
 Multiple myeloma
 Prostatic carcinoma
 Endocrine malignancy

Tumors Not Responsive to
Chemotherapy
Ineffective:
• Malignant melanoma
• Pancreatic carcinoma
• Renal cell carcinoma

MANAGEMENT
 Tumor response assessment (RECIST
criteria)
 COMPLETE RESPONSE
• Complete disappearance of all clinical signs of
the disease

MANAGEMENT
criteria)
 PARTIAL RESPONSE
• Decrease in tumor size by >= 50%
• Control of the disease is the endpoint

MANAGEMENT
criteria)
 STABLE DISEASE
• Decrease in tumor size by < 50% of >=25%
• Palliation is the endpoint
• 6 months or more is favorable

MANAGEMENT
criteria)
 PROGRESSIVE DISEASE
• Increase in tumor size => 25%
• Ineffective treatment

MANAGEMENT
 CHEMOTHERAPY CLASSIFICATION AS TO GOAL IN
COMBINATION WITH OTHER TREATMENT MODALITY
• PRIMARY CHEMOTHERAPY
• Main modality of treatment
• Aggressive tumors w/ high probability of systemic
involvement

MANAGEMENT
• ADJUVANT CHEMOTHERAPY
• Given after a locoregional therapy
• Control micrometastatic disease
• Prolong DFS, OS

MANAGEMENT
• NEOADJUVANT CHEMOTHERAPY
• Given before a definitive locoregional therapy
• Decrease tumor size, better locoregional
control, controlling micrometastasis
• Prolonging DFS, OS

MANAGEMENT
• CONCURRENT CHEMORADIOTHERAPY
• Simultaneous use of chemo and RT in the
management of cancer

MANAGEMENT
 CHEMOTHERAPY CLASSIFICATION AS TO GOAL OF THE
TREATMENT
• CURE
• CONTROL
• PALLIATION

MANAGEMENT
 CONTRAINDICATIONS TO CHEMOTHERAPY
• Infection
• Previous chemo given < 2 weeks prior
• Leukopenia
• Thrombocytopenia
• Severely debilitated patients
• Pregnancy, 1st trimester
• Major surgery < 2wks prior
• Poor patient ffup
• Psychological problem

• Terminal illness
MANAGEMENT
 PHARMACOLOGIC ASPECTS OF CANCER CHEMOTHERAPY
• Absorption
• Determines the route of administration
• Rate of absorption affects the concentration achieved
(duration and intensity of exposure of cancer cells to the
drug)
• Pharmacokinetics ( alterations with time of conc’n after
drug administration) determine the appropriate dose and
interval between dosing

MANAGEMENT
• Distribution
• Concentration and effectiveness of the drugs can be
enhanced by local or regional administration
• Choice of an agent according to its time distribution is
important
• Nitrosureas for CNS tumors

MANAGEMENT
• Biotransformation
• Activation of cyclophosphamide by hepatic mixedfunction
oxidase system
• Phosphorylation of 5FU
• Decreasing 6mercaptopurine dose if with allopurinol (6MP
more toxic if xanthine oxidase is inhibited by allopurinol)

MANAGEMENT
• Excretion
• Important determinants of toxicity and need for drug dose
alteration
• Rely on the function of excretory organ

MANAGEMENT
 MECHANISMS OF DRUG ACTION
• SELECTION OF AGENTS
• Depend on the pharmacodynamics of the anticancer agent
• Choice against a tumor can be a result of empiric clinical trials
• Most cytotoxic agents act on macromolecular synthesis or
function
• Production or function of DNA, RNA, proteins
• With overlaps in their MOAs
• Can be grouped into several classes

AIM OF COMBINATION
THERAPY
INCREASED EFFICACY
ACTIVITY SAFETY
Different mechanisms of action Compatible side effects

Different mechanisms of resistance

MANAGEMENT
• DESIGNS OF COMBINATIONS
• Concurrent or simultaneous use of multiple
agents are more likely to cause cell death
• Damaging several different biochemical sites,
minimize the proliferation of resistant cells,
minimizing toxicity to normal tissues

MANAGEMENT
• DESIGNS OF COMBINATIONS
• Use only drugs that show activity against the tumor type
• Select drugs w/c differ in MOAs
• Select drugs w/c differ in the site of their major toxicities
• Use optimal doses and timing for each drug

MANAGEMENT
• SYNERGY AND ANTAGONISM OF DRUGS
• Biochemical modulation = 2 or more drugs interact to enhance
their effects or decrease them
• Synergistic inhibition of metabolic pathways
• Synergistic inhibition of macromolecule synthesis, repair or
processing
• Synergistic enhancement of cellular toxicity
• Cell cycle synchronization

MANAGEMENT
• HOST SELECTIVE RESCUE
• Leucovorin rescue from high dose methotrexate
• Diethyldithiocarbamate and thiourea from cisplatin

MANAGEMENT
 BASIC CONCEPTS OF CHEMOTHERAPY
• Purpose of treating cancer with chemotherapy is to
prevent cancer cells from multiplying, invading,
metastasizing and ultimately killing the hosts

MANAGEMENT
• General mechanisms
• Fractional cell kill hypothesis
• A proportion of the cells die with a given treatment
• Repeated doses of chemotherapy must be used to
continue to reduce the cell number
• 3 log kill, 1 log regrowth principle

MANAGEMENT

MANAGEMENT

MANAGEMENT
• Skipper and Scable principles:
• The growth characteristics of the cancer cell
predominantly determines its responsiveness to
chemotherapy

MANAGEMENT
• Growth fractions and doubling times of primary tumors
may differ from micrometastasis, hence, responsiveness
to chemotherapy may differ
• The response rate of the primary tumor in the plateau
phase need not reflect the response of the micromets in
exponential growth

MANAGEMENT
• The micromets may differ from and may respond
differently to cyclical chemotherapy
• Ablation of primary tumor may alter the growth
characteristics of residual micromets (decrease doubling
time, increase growth fraction, improved cell cycle
synchronization) enhancing sensitivity to chemotherapy

MANAGEMENT
• CELL DEATH
• Necrosis physical damage with cell swelling and membrane
disruption

MANAGEMENT
• CELL DEATH
• Apoptosis programmed cell death
• cell dies after a defined stimuli
• chromatin condensation, cell shrinkage,
phagocytosis by surrounding stromal cells w/out inflammation
• regulated by signal transduction systems or in
response to specific cell surface receptors that mediate death
signals

MANAGEMENT
 RESISTANCE TO ANTINEOPLASTIC AGENTS
• Natural resistance
• Initial unresponsiveness of the tumor to a given drug
• Acquired resistance
• Unresponsiveness to chemotherapy agents that emerge
after an initial successful treatment

MANAGEMENT
• Cell kinetics and resistance
• Most tumors are in the plateau phase making cells
insensitive to antimetabolites and relatively
unresponsive to others
• GOLDIE COLDMAN HYPOTHESIS: As tumor cell
population increases, resistant phenotypic variants
also expand due to spontaneous mutations

MANAGEMENT
• Cell kinetics and resistance
• Reduce tumor bulk
• Combine drugs to affect G0 cells
• Schedule drugs to prevent phase escape

MANAGEMENT
• Biochemical causes
• Inability of the tumor to convert a drug to its active form
• Ability of the tumor to inactivate the drug
• Substrates are present that bypass a lethal blockade
• MDR (multidrug resistance): Enhanced energydependent drug efflux
mechanism that results in lower intracellular drug concentrations
• p170 P glycoprotein; mdr gene product

MANAGEMENT
• Combination chemotherapy
• Biologic response modifiers (calcium channel blockers,
antiarrhythmics)
• Use a second agent to rescue normal cells if using high dose
chemo agents
• Follow marrowlethal dose of chemo with autologous BMT
• Combine highdose chemo with blood cell GF

MANAGEMENT
• Pharmacologic causes:
• Poor absorption
• Increased excretion
• Drug interactions
• True resistance poor transport of agents to certain
tissues and tumor cells

MANAGEMENT
• Nonselectivity & resistance
• Some mechanisms are still poorly understood

MANAGEMENT
 CYTOTOXIC AGENTS
• Generally effective against rapidly multiplying cells
• Primarily on cell multiplication and tumor growth

CHEMOTHERAPY DISRUPTS
THE CELL CYCLE
What is
wrong with
this picture?

MANAGEMENT
MECHANISM OF ACTIVITY:
 Phase NonSpecific
• Cycle nonspecific (G0 or outside the cell cycle)
• BCNU
• Cycle specific
• cisplatin, cyclophosphamide, doxorubicin
 Phase Specific
• Cycle specific
• FU, methotrexate, bleomycin, vincristine, paclitaxel

SITES OF ACTION OF CYTOTOXIC AGENTS
Antibiotics
Antimetabolites
S
(2-6h)
G2
(2-32h) 
M 
(0.5-2h)

Alkylating agents
G1
(2-∞
 

MANAGEMENT
• Phase nonspecific drugs
• Cycle nonspecific drugs effective even if cells are in G0 or
outside the cell cycle
Alkylating agents Nitrogen mustard Carmustine (BCNU)
Nitrosurea Lomustine (CCNU)

MANAGEMENT
• Phase nonspecific drugs
• Cycle specific drugs broadspectrum agent capable of affecting
any cell as long as it is within the cycle regardless of what phase
Alkylating agents Nitrogen mustard Cyclophosphamide
Melphalan
Triazine Dacarbazine
Metal salt Cisplatin, carboplatin
Natural product Antibiotic Dactinomycin, Doxorubicin,

MANAGEMENT
• Phase specific drugs
• Effective in certain phases of the cell cycle
Gap 1 Natural product Enzymes Asparaginase

Hormone Corticosteroid Prednisone
S Antimetabolite Pyrimidine AraC, 5FU

Antimetabolite Folinic Acid MTX
Gap 2 Natural product Antibiotic
Bleomycin

MANAGEMENT
• Phase specific drugs
• Effective in certain phases of the cell cycle
Gap 2 Natural product Topoisomerase 2 inh Etoposide

Natural product Microtubule poly Paclitaxel
merization/stabilization
Mitosis Natural product Mitotic inhibition Vinblastine

Vincristine
Vindesine

Phase specific drugs
Implications
 Limitation to singleexposure cell
kill
 Increasing cell kill by prolonged
exposure
 Recruitment

Alkylating Agents
Alkylating agents transfer parts of their molecules to
the DNA, thus causing single and double strand
breaks; Platinum compounds form stable complexes
with DNA, resulting in similar effects

Alkylating Agents
Cyclophosphamide
Ifosfamide
Melphalan or Busulfan

Platinum Compounds
 Cisplatin
(DDP = DiaminoDichloroPlatinum); forms stable complexes with
DNA; severe nephrotoxicity (hyperhydration necessary!),
irreversible ototoxicity; extremely emetogenic
 Carboplatin
less nephro and ototoxicity compared to cisplatin, but more
pronounced myelosuppression; dose usually adjusted to renal
clearance (AUC / Area under curve dosage)
 Oxaliplatin
(DACH = DiAminoCycloHexan); dose limiting: diarrhea,
mucositis and peripheral polyneuropathia; side effects strongly
influenced by chronobiological effects

"Antibiotics"/Anthracyclines
Cytotoxic Antibiotics (especially Anthracyclines)

intercalate DNA, inhibiting despiralization during
mitosis and transcription

Anthracyclines
 Doxorubicin
cardiotoxic after repeated cycles, therefore
cumulative dose of 550 mg/m2 should not be
exceeded
 Epirubicin
less cardiotoxic than Adriamycin, therefore used also
in high dose protocols
 Mitoxantrone
less cardiotoxic than Adriamycin

Topo I/II Inhibitors
Topoisomerase - Inhibitors prevent re-assembling of
DNA strands after despiralization

Topoisomerase Inhibitors
Topotecan
 derived from a chinese tree (Camptotheca accuminata); interacts
with DNArepair by Topoisomerase I inhibition; penetrates the
blood brain barrier
Irinotecan (CPT11)
 derived from a chinese tree (Camptotheca accuminata); interacts
with DNArepair by Topoisomerase I inhibition; delayed diarrheas
(= problematic esp. in ambulant setting)
Etoposide (VP16)
 derived from the mandrake plant; blocks Topoisomerase II,
resulting in DNA strand breaks; broad range of activity

Antimetabolites
Antimetabolites interact with DNA - Synthesis; some of
them are incorporated into DNA instead of physiological
purines and pyrimidines, some block synthesis enzymes

Antimetabolites
Methotrexate
 inhibits foline synthesis; application of antidote
(folinic acid, e.g. Leucovorin) allows application of
extremely high dosages
Fluorouracil (5FU)
 is only moderately myelosuppressive, but causes
severe stomatitis / mucositis
Gemcitabine
 subjectively tolerated quite well, thus used in a
variety of palliative treatments

Mitosis Inhibitors
Vinca-Alkaloids and Taxanes inhibit mitosis by damage
of mitotic spindle and cytoscelet´s structure.
Vinca - Alkaloids (i.e. Vinblastin, Vincristin, Vindesin,
Vinorelbin) are only moderately myelosuppressive

VincaAlkaloids
Vincristine
 derived from vinca rosea; inhibits tubulin polymerisation; high peripheral
neurotoxicity, but very low myelosuppression
Vinblastine
 reduced neurotoxicity, but increased bone marrow toxicity compared to
Vincristine
Vindesine
 reduced neurotoxicity, but increased bone marrow toxicity compared to
Vincristine
Vinorelbine
 only very rarely inducing peripheral neurotoxicity

Taxanes
 Paclitaxel
 Taxane derived from yewtree; destroys cell structure and
inhibits mitosis by tubulin polymerisation; severe allergic
reactions (premedication!); peripheral neurotoxicity; given as 3
hour or 24hour infusion; new trend: weekly application
 Docetaxel
 derived from yewtree; destroys cell structure and inhibits
mitosis by tubulinpolymerisation; allergic reactions
(premedication!); low peripheral neurotoxicity

Direct DNAinteracting Agents
 Alkylators  Antibiotics
 Cyclophosphamide  Bleomycin
 Ifosfamide  Etoposide
 Dacarbazine  Irinotecan
 Temozolomide  Doxorubicin
 Cisplatin  Epirubicin
 Carboplatin
 Oxaliplatin

Indirect DNAinteracting Agents
 Antimetabolites  Antimitotic
 Hydroxyurea  Vincristine
 Methotrexate  Vinorelbine
 5fluorouracil  Paclitaxel
 Capecitabine  Docetaxel
 AraC
 Gemcitabine
 Fludarabine

Important Combinations
Breast Ca CMF Cyclophosphamide - Methotrexate - 5FU
FEC 5FU - Epirubicin - Cyclophosphamide
Lung Ca GC Gemcitabine - Carboplatin

PC Paclitaxel -Cisplatin
Lymphomas CHOP Cyclophosphamide - Adriamycin -

Vincristine - Prednisone
Ovarian Ca PT Cis-/Carboplatinum - Taxol
Seminoma PEB Cisplatinum - Etoposide - Bleomycin

MANAGEMENT
 HORMONAL THERAPY
• The steroid hormone receptorrelated molecules are
targeted
• When bound to their cognate ligands, these
receptors can alter gene transcription and induce
apoptosis
• Glucocorticosteroids
• Tamoxifen
• Megestrol acetate
• Leuprolide and goserelin
• Flutamide and bicalutamide
• Anastrazole and letrozole
• Exemestane

MANAGEMENT
 HORMONAL TREATMENT
• Additive hormonal therapy addition of hormonal agents in a
chemo regimen (steroids, estrogen, progesterone, adrogens)
• Ablative hormonal therapy use of antihormones to treat
hormone sensitive cancers (tamoxifen, flutamide,
gonadotropin analogue, oopherectomy, orchiectomy)

MANAGEMENT
 MOLECULARLY TARGETED THERAPIES
• Targets are products of oncogenes/tumor suppressor genes,
regulators of cell death pathways, mediators of cellular immortality,
molecules responsible for microenvironmental molding
• Basis for discovery is the a priori importance of the target in the
biology of tumor
• Imatinib mesylate against bcrabl kinase in CML, kit kinase in GISTs

MANAGEMENT
 BIOLOGIC THERAPIES
• Manipulate the hosttumor interaction in favor of the host
• Antibodies
• After lessons were learned, humanized antibodies were
developed
• Rituximab and Trastuzumab (alone or in combination w/ chemo)
• Ibritumomab tiuxetan as radioconjugates against lymphoma

MANAGEMENT
• Cytokines
• Interferon alpha effects on the tumor are doserelated
• IFN is most effective at its MTD
• Can induce partial responses in follicular lymphoma, melanoma
• Adjuvant use has uncertain effects on OS

MANAGEMENT
• Cytokines
• Interleukin2 exert its efforts indirectly through augmentation
of immune system
• Promote the growth and activity of T cells and natural killer
cells
• High dose used in metastatic melanoma and renal cell
carcinoma

MANAGEMENT

MANAGEMENT

SIDE EFFECTS OF
CHEMOTHERAPY
Mucositis Alopecia
Nausea/vomiting Pulmonary fibrosis
Cardiotoxicity
Diarrhea
Cystitis Local reaction
Sterility Renal failure

Myalgia
Myelosuppression
Neuropathy
Phlebitis

MANAGEMENT
 ACUTE COMPLICATIONS:
Myelosuppression
• Maximal neutropenia: 614 days after
conventional doses of anthracyclines, antifolates,
antimetabolites,
• Neutropenia : 6 wks after dosing of nitrosureas,
DTIC, procarbazine
• Febrile neutropenia (if < 500µL, increase
mortality)

Neutropenia
Neutro-
phils/µl
Nadir
3-7 10-14 21-28

Time [days]

MANAGEMENT
Nausea & vomiting
• Agents may vary in intensity
• Highly emetogenic : cisplatin, DTIC
• Moderately emetogenic: doxorubicin,
cyclophosphamide
• Low emetogenesis: MTX, 5FU

MANAGEMENT
Alopecia
• Agents vary in capacity
• Anthracyclines, alkylating agents, topoisomerase
inhibitors cause near total alopecia

MANAGEMENT
Gonadal dysfunction and pregnancy
• Cessation of ovulation and azoospermia from
alkylating agents and topoisomerase poisons
• Varies with age and sex

QUESTIONS?

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BASIC ONCOLOGY

Carcinoembryonic Antigen AdenoCA of colon, pancreas, Pancreatitis, hepatitis,

Monoclonal Ig Myeloma Infection,MGUS

Different mechanisms of action Compatible side effects

Gap 1 Natural product Enzymes Asparaginase

S Antimetabolite Pyrimidine AraC, 5FU

Gap 2 Natural product Topoisomerase 2 inh Etoposide

Mitosis Natural product Mitotic inhibition Vinblastine

Cytotoxic Antibiotics (especially Anthracyclines)

Lung Ca GC Gemcitabine - Carboplatin

Lymphomas CHOP Cyclophosphamide - Adriamycin -

Ovarian Ca PT Cis-/Carboplatinum - Taxol

Seminoma PEB Cisplatinum - Etoposide - Bleomycin

Nausea/vomiting Pulmonary fibrosis

Sterility Renal failure

3-7 10-14 21-28

You might also like

Med - Basic Onco Chemo

Uploaded by

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Original Description:

Copyright

Available Formats

Share this document

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Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

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Med - Basic Onco Chemo

Uploaded by

Copyright:

Available Formats

BASIC ONCOLOGY

Carcinoembryonic Antigen AdenoCA of colon, pancreas, Pancreatitis, hepatitis,

Monoclonal Ig Myeloma Infection,MGUS

Different mechanisms of action Compatible side effects

Gap 1 Natural product Enzymes Asparaginase

S Antimetabolite Pyrimidine Ara­C, 5FU

Gap 2 Natural product Topoisomerase 2 inh Etoposide

Mitosis Natural product Mitotic inhibition Vinblastine

Cytotoxic Antibiotics (especially Anthracyclines)

Lung Ca GC Gemcitabine - Carboplatin

Lymphomas CHOP Cyclophosphamide - Adriamycin -

Ovarian Ca PT Cis-/Carboplatinum - Taxol

Seminoma PEB Cisplatinum - Etoposide - Bleomycin

Nausea/vomiting Pulmonary fibrosis

Sterility Renal failure

3-7 10-14 21-28

You might also like

S Antimetabolite Pyrimidine AraC, 5FU