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All you need to know about Chemotherapy.

All you need to know about Chemotherapy. Lynne Cormode. What is Chemotherapy?. Systemic treatment against malignant cells to try and prevent growth, invasion, metastasis and eventual death of patients.

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All you need to know about Chemotherapy.

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  1. All you need to know about Chemotherapy. Lynne Cormode

  2. What is Chemotherapy? • Systemic treatment against malignant cells to try and prevent growth, invasion, metastasis and eventual death of patients. • Initially discovered after WW1 when soldiers exposed to nitrogen mustard were observed to have had a improvement in solid tumour size.

  3. Adjuvant To reduce cancer recurrence Neo-Adjuvant To down stage tumour prior to surgery or radical treatment Palliative To reduce cancer load thereby improving symptoms and prognosis Radical Curative treatment Concomitant Combined modality treatment (Chemo/radiotherapy) Regime Single / Combination Drugs Cycle Varies from weekly to 12 weekly Dose Body surface area i.e. mg/m2 (Dubois + Dubois) Renal excretion i.e. AUC (Area under the curve) Chemotherapy Intent / Terms

  4. Oral Intravenous Bolus / Infusional Central / Peripheral Locally Intratheccal Intraperitoneal / Intravesical Topical Intra-arterial (limb perfusion) Subcutaneous or Intramuscular Classic chemotherapy Immunotherapy Biological / Molecular targeted therapy Chemotherapy Forms / Types

  5. Modes of Action - General Inhibition of cell multiplication via • Macromolecular synthesis and function i.e. DNA / RNA / Proteins • Cytoplasmic signalling • Cell membrane receptor synthesis, expression and function • Cellular environment

  6. Interphase G1 (presysnthesis gap) S (synthesis of DNA) G2 (postsynthesis gap) Mitosis M (cell division) Prophase Sister chromatids condense Mitotic spindle assembles Nuclear envelope breaks down Metaphase Microtubles align chromosomes Centromeres halfway between spindle poles Anaphase Separation of sister chromatids at centromere moving towards poles Cytokinesis (cell division) starts Telophase Nuclear membranes reforms Chromosomes become extended Cytokinesis completes The Cell Cycle

  7. Traditional Chemotherapy Classes ANTIMETABOLITES TAXANES PODOFYLOTOXINS ANTIMICROTUBULE AGENTS ANTITUMOUR ANTIBIOTICS ANTRACYCLINES CHEMOTHERAPY VINCA ALKALOIDS CAMPTOTHECINES ALKYLATING AGENTS NITROSOUREAS PLATINUM DRUGS

  8. Antimetabolites nucleoside analogues / antagonists FOLIC ACID Methotrexate inhibitsDHFR PURINES Guanine Adenine PYRIMIDINES Cytosine Thymine Uracil TETRAHYDROFOLIC ACID 5FU Capecitabine Cytarabine Mercaptopurine Azathioprine Fludarabine inhibit Thymidylate synthase NUCLEOTIDES DNA REPLICATION

  9. Antitumour Antibiotics • Topoisomerases are essential enzymes that maintain the topology of DNA. Inhibtion interferes with both transcription and replication of DNA by upsetting proper DNA supercoiling. • Cell cycle specfic – G1 and S phase • Type I topoisomerase inhibitors, Camptothecins (Irinotecan, Topotecan) • Type II topoisomerase inhibitors, Epipodopyllinotoxins (Etoposide); Antracyclines (Doxorubicin, Daunorubicin) – also induce O2 free radicals that break DNA strands inhibiting replication • Others include Actinomycin D, Mitomycin C, Bleomycin

  10. Antimicrotubule Agents • Prevent microtubule function therefore preventing the separation of chromatids. • Cell cycle dependant – M (anaphase) • Taxanes (Paclitaxel; Docetaxel) – causes hyperstabilisation of microtubules • Vinca Alkaloids (Vincristine, Vinblastine, Vinorelbine) – inhibits the assembly of tubulin into microtubules

  11. Alkylating agents • Ability to alkylate many nucleophilic function groups causing the formation of covalent bonds (cross linking of DNA) • Non cell cycle specific • Platinum drugs (Oxaliplatin, Cisplatin, Carboplatin) – renally excreted • Nitroureas (Carmustine, Lomustine, Semustine) – highly lipid soluble i.e. cross BBB • Others Cyclophosphamide, Dacarbazine, Procarbazine, Melphalan, Busulphan, Chlorambucil.

  12. Hormones / Cytokines • Prednisolone / Dexamethasone • Tamoxifen • Aromatase Inhibitors (Letrozole, Anastrozole) • Gonadotropin releasing hormone agonists (Zoladex) • Interferon alpha

  13. Monoclonal Antibodies • Designed to target highly expressed tumour specific antigens thereby increasing the immune response to the tumour cell. • Rituximab (CD20) • Cetuximab (Epidermal Growth Factor Receptor 1) • Transtuzumab (Human Epidermal growth factor Receptor 2) • Bevacizumab (Vascular Endothelial Growth Factor) • Tyrosine Kinase Inhibitors • Imatinib (Philadelphia chromosome, Bcr-Abl TKI) • Erlotinib (EGFR inhibitor) • Sunitinib (multiple receptor inhibitors inc VEGFR, PDGFR)

  14. Bone Marrow Suppression Neutropenia Anaemia Thrombocytopenia GI Nausea / Vomiting Mucositis Reproductive Skin / Hair Palmar plantar erythodysthesia Sun sensitivity Extravasation Rashes Alopecia (scalp cooling) Nephrotoxicity Hepatic toxicity Chemotherapy Toxicities 1

  15. Neurotoxicity Peripheral neuropathy Ototoxicity Constipation Cardiac toxicity Coronary vasospasm Reduced LVEF Bladder toxicity Haemorrhagic cystitis Chemotherapy Toxicities 2

  16. Ward admissions Neutropenic sepsis Symptomatic myelosupression Dehydration Cardiac events Extravasations Anaphylactoid reactions Chemotherapy spillage policy Practical Issues

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