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Utskriftsdato (22.7.2018)

Oral cancer

Squamous cell carcinoma is the major pathologisc type of oral cancer. Adenocarcinomas, sarcomas, and other tumor types also occur. 

The oral cavity is separated into the:

  • tongue, of which the mobile part is the anterior 2/3
  • gums of the upper and lower jaw
  • palate
  • cheek
  • oral vestibule
  • floor of the mouth

Treatment for oral cancer can greatly affect the patient`s speech and swallowing function. The extent of changes will depend on the location and stage of the tumor. In order to reduce the burdens this may cause, thorough information and follow-up is critical.(2).

Incidence

Oral cavity and pharynx cancer represents 2.9% of all new cancer cases in the United States and is most frequently diagnosed among people aged 55-64. Oral cancer is more common in men than women, among those with a history of tobacco or heavy alcohol use, and individuals infected with human papillomavirus (HPV).

In 2017, it is estimated to be 49,670 new cases of oral cavity and pharynx cancer (13).

 

Age-specific incidence of oral cancer, 2010–2014.

Source: National Cancer Institute. Bethesda, MD, USA

 

 

Incidence of Oral cavity and pharynx, 1975–2014.

Source: National Cancer Institute. Bethesda, MD, USA

Oral cancer made up 32% of the total number of head and neck cancers in Norway in 2005 (1). The incidence is higher in middle and southern Europe and parts of Asia.

The average age of newly diagnosed oral cancer is 64 years, and the disease affects more men than women (2).

Etiology of oral cancer

  • Tobacco and alcohol are the most significant etiological factors and most likely have synergistic effect (2).
  • Human papilloma virus (HPV) is associated with oropharyngeal cancer, but is very seldom implicated in cancer of the oral cavity (8).
  • Poor oral hygiene and dental status (8)

Chewing leaves from the betel plant is widely practiced in India and parts of Pakistan for its stimulating effect. The combination of chewing betel and tobacco has a potent carcinogenic effect and is the cause for the significant amount of oral cancer cases in parts of Asia.  

Use of snuff as a risk factor has not been adequately documented (8).

There is no well-defined hereditary risk for squamous epithelial carcinomas (9).

Histology of oral cancer

The most common malignant lesion in the mouth is squamous cell carcinoma (90%). This is often preceded by precursor lesions such as oral leukoplakia. When squamous cell cancer infiltrates deeper in the tissue it has a tendency to spread through lymph- and blood vessels.

There are other less common types of oral cancer such as: adenocarcinoma from minor salivary glands, lymphoma from tonsillar region and melanoma from melanin-producing cells of the oral mucosa.

In oral biopsies the pathologist must evaluate the squamous epithelium:

  • atypia and degree of atypia
  • carcinoma in situ
  • invasive carcinoma
  • depth of invasion

When resection of tumor is performed the pathologist should evaluate tumor type, size, depth of invasion, pattern of invasion, vessel invasion, perineural invasion and resection borders.

Metastatic patterns of oral cancer

Tumor often grows early into muscle, tendon, periosteum, and bone. Spreading is dictated by the anatomy, and each anatomical site has its own pattern of lymphatic spreading. Five to six percent of patients have lymphatic spread at the time of diagnosis (2).

Distant metastases rarely occur, but in such cases, the lungs are the most common location.

Staging of oral cancer

Oral cancer is separated into lateral tumors and midline tumors.

  • Lateral tumors – bucca, gingiva and retromolar space with a minimum of 1 cm distance to the midline without spreading to contralateral lymph nodes.
  • Midline tumors – tongue, floor of the mouth and hard palate. Tumors growing toward the midline have a tendency for bilateral lymph node spreading.

Epithelial tumors are classified according to the Union for International Cancer Control (UICC) (3,4).

T classification

The T classification represents the extent of the primary tumor.

  • T1 – small tumors ≤ 2 cm of greatest diameter
  • T2 – tumors 2–4 cm of greatest diameter

 

  • T3 – Tumors > 4 cm, < 6 cm
  • T4 – Advanced tumors with invasion of neigboring organs, muscle, bone, and skin (2).

 

N classification

The N classification represents spreading to regional cervical lymph nodes measured in greatest diameter.

  • N0 – no regional lymph node metastases
  • N1 – single ipsilateral lymph node metastasis ≤ 3 cm
  • N2
    • a – single ipsilateral lymph node metastasis > 3 cm ≤ 6 cm
    • b – multiple ipsilateral lymph node metastases ≤ 6 cm
    • c – bilateral or contralateral lymph node metastases ≤ 6 cm
  • N3 – lymph node metastases > 6 cm

M classification

The M classification represents distant metastases.

  • M0 – no distant metastases
  • M1 – distant metastases

 

Symptoms of oral cancer

Cancer of the mouth manifests as swelling.

Other symptoms are ulcers which do not heal, soreness and pain.

With advanced disease, eating difficulties and dysarthria are observed.

If teeth become loose without any dental cause, or an oral prosthesis no longer fits, the possibility for malignancy should be considered.

Exophytic-growing tongue cancer. Click to enlarge. Squamous epithelial carcinoma on the inside of the lower lip. Click to enlarge. Ulcerating cancer on the floor of the mouth. Click to enlarge.

 

 

 

 

Differential diagnoses of oral cancer

Example of leukoplakia on mucosa of inner cheek. Such lesions are removed since they are considered premalignant conditions. This particular lesion had an area with carcinoma in situ.
  • Stomatitis
  • Benign tumors/lesions
  • Cheek/toungue bite
  • Odontogenic lesions/tumors (cysts)
  • Leukoplakias
  • Glositis/gingivitis
  • Epulis - benign tumor in gums
  • Lichen planus - mucosal changes from skin disease
  • Torus palatinus - bone swelling in midline of palate

Prognosis of oral cancer

The prognosis depends on whether the cancer is localized, regional, or metastatic at the time of diagnosis. For oral cavity and pharynx cancer, 29.8% are diagnosed at the local stage and the 5-year survival for localized oral cavity and pharynx cancer is 83.7%. The overall 5-year survival rate for oral cavity and pharynx cancer patients during the period 2007-2013 was 64.5%.

The percent of cancer deaths is highest among people aged 55-64 and death rates are higher among males, particularly those of African American descent. Death rates have been stable over 2005-2014.

In 2014, there were an estimated 346,902 people living with oral cavity and pharynx cancer in the United States and in 2017 there are an estimated 9,700 people will die of this disease (13).

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References on oral cancer

  1. Cancer in Norway 2013, Cancer Registry of Norway, Institute of Population-based Research. Oslo, Norway
  2. Thawley SE, Panje WR, Batsakis JG, Lindberg WB. Comprehensive Management of Head and Neck Tumors. 2. opplag. W.B. Philadelphia: Saunders Company, 1999
  3. Sobin LH, Wittekind C, eds. TNM Classification of Malignant Tumours. 6th ed. New York: Wiley-Liss, 2002
  4. Wittekind C, Greene FL, Hutter RVP, Klimpfinger M, Sobin LH. TNM Atlas. 5. ed. Heidelberg: Springer, 2005
  5. Janfaza P, Nadol JB, Galla R, Fabien RL. Surgical anatomy of the head and neck. Lipincott, Williams & Wilkins, 2001
  6. Boysen M, Lövdal O, Tausjö J, Winther F. The value of follow-up in patients treated for squamous cell carcinoma of the head and neck. Eur J Cancer 1992; 28: 455-60
  7. Boysen M, Loven JØ. Second malignant neoplasms in patients with head and neck squamous cell carcinomas. Acta Oncol. 1993; 32: 283-288
  8. Pedersen E, Høgetveit AC, Andersen Å. Cancer of respiratory organs among workers at a nickel refinery in Norway. Int J Cancer 1973; 12 (1) :32-41
  9. Acheson ED, Cowdel RH, Hadfield E, Machbeth RG. Nasal cancer in woodworkers in the furniture industry. Br Med J 1968; 2 (5605): 587-96
  10. Boysen M, Due-Tønnesen BJ, Helseth E et al. Reseksjon av maligne svulster med relasjon til fremre skallegrop. Tidsskr nor Lægeforen 2001; 121: 1688-91
  11. Boysen M. Squamous cell carcinoma of the head and neck in the elderly. The open Otolaryngology Journal. In press. 2010.
  12. American Cancer Society's (ACS) publication, Cancer Facts & Figures 2016
  13. Howlader N, Noone AM, Krapcho M, Miller D, Bishop K, Kosary CL, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2014, National Cancer Institute. Bethesda, MD

Diagnostics of oral cancer

The patient's primary care doctor or dentist usually examines the patient first.

The clinical examinations should include:

  • thorough inspection of the mucosa of the mouth and pharynx
  • thorough palpation of the neck for enlarged lymph nodes
  • biopsy of suspect mucosal lesions

For suspected malignancy, the patient should be immediately referred to an otolaryngologist/clinic.

At Oslo University Hospital, the following examinations are performed according to the UICC certainty level C2 (4).

  • Clinical examination
  • Chest CT
  • CT/MRI of primary tumor area and neck. These examinations give objective measurements for primary tumor and metastases, and are necessary to determine the extent of surgery and modeling of the radiation field. 
  • Endoscopy and palpation evaluations under anesthesia (non-obligatory.
  • Fine needle cytology of regional nodes or tumor covered by mucosa, possibly with ultrasound.

Possible additional examinations:

  • Blood tests to evaluate T4, TSH, liver and kidney function
  • Chest CT in patients with suspected lung metastases/lung tumor
  • Broncho- or esophagoscopy for suspected lung metastases/lung tumor (not obligatory)
  • If needed, the patient is evaluated by a lung specialist, cardiologist or other specialists for operability.
  • Examination by an oral surgeon/maxillofacial surgeon
  • Orthopantogram

The staging form is completed and the patient is evaluated by an interdisciplinary team including a head/neck surgeon, oncologist, pathologist, radiologist, dentist, speech pathologist and cancer nurse.

Recurrence

Evaluation for recurrence is the same as for a primary tumor.

PROSEDYRER

Fine needle biopsy, non-aspiration technique

General

Fine needle biopsy is a simple and cost-effective method causing little discomfort for the patient.

It can be used for palpable tumors in patients with cancer or where possible spreading can be confirmed or excluded. It can also be used on patients without a previous cancer diagnosis, either to achieve a diagnosis or to determine further relevant examinations. This method gives the quickest result/diagnosis.

Indications

  • Fine needle biopsy is performed on palpable surface nodes

Goal

  • To obtain a specimen which provides a basis for making a diagnosis.

Equipment

  • 1 x 20 ml syringe filled with air
  • Cannulas, size depending on lesion
  • Colorless chlorhexidine, 1 mg/ml
  • Gloves
  • 3–4 slides
  • 3–4 cover glasses
  • RPMI-medium
  • Labels to mark slides and RPMI-glass
  • Staining solutions (haemacolor)
  • Water for rinsing
  • 6 tubs for staining/rinsing
  • Gauze pads
  • Bandage
  • Fan or hairdryer for drying specimens
  • Microscope, 10X or 20X objective
  • Examination table

Preparation

Explain to the patient precisely what will happen and why.

Implementation

The patient should sit or lie on the examination table - whatever gives the best result. 

  • Wash the area for puncture with colorless chlorhexidine 1 mg/ml.
  • Allow the skin to dry.
  • Palpate the node/tumor.
  • Find the best position for puncturing.
  • Fix the lymph node/tumor between your fingers.
  • Puncture quickly through the skin with the cannula.
  • Move the cannula back and forth into the node in different directions (approximately 2–3 movements/second).
  • When (after 3–4 seconds) the material is visible in the upper part of the cannula passage, the cannula is retrieved.
  • Put a pressure on the point of puncture if needed.
  • Connect the cannula to the syringe filled with air.
  • Carefully spray the specimen from the cannula onto the slide.
  • If the suspicion of lymphoma or tumor is difficult to confirm, repuncture and put some material in the RPMI medium from a new puncture (for flow cytometry/molecular examination etc. Which type of examination is determined after microscopic examination.)
  • Smear the specimen on the slide.
  • Dry the specimen under a fan or hairdryer.
  • Staining: fixation fluid with methanol + haemacolour + rinsing in water  
    • 5 dips in fixation fluid. Allow the solution to drip off on paper. 
    • 3 dips in staining solution 1.
    • 6 dips in staining solution 2. Allow the solution to drip off onto paper.
    • Rinse in two tubs with clean water.
  • Examine the specimen under the microscope with a 10X or 20X objective.

 

 

Observations

  • After the puncture, slight bleeding may occur.
  • Other complications are very rare.
Fine needle biopsy, non-aspiration techniqueFine needle biopsy, non-aspiration techniqueFine needle biopsy, non-aspiration techniqueFine needle biopsy, non-aspiration technique
Fine needle biopsy, non-aspiration techniqueFine needle biopsy, non-aspiration techniqueFine needle biopsy, non-aspiration technique

Positron Emission Tomography (PET)

General

Positron Emission Tomography (PET) is a nuclear medical examination method. PET is a well-documented, well-established and very useful tool in oncological imaging.

Indications

Oncological imaging for:

  • Staging the primary diagnosis and recurrence
  • Evaluating the effect of aggressive chemotherapy treatment
  • Evaluating the effect of completed treatment, including differentiating scar tissue from viable residue tissue
  • Suspicion of recurrence (for example, increased level of tumor marker in the blood)

Goal

  • To provide concrete diagnostic information that will provide a basis for the choice of the best possible treatment.

Definitions

PET has a very high sensitivity and can register absorption of radiopharmaceutical agents in extremely low concentrations. Since the central atoms in biochemical compounds (carbon, oxygen, nitrogen) all have positron-emitting isotopes that can be produced in small hospital cyclotrons, it is possible to mark a number of central molecules such as oxygen, water, amino acids, various metabolites, hormones, and neurotransmitters.

For clinical PET, dextrose is usually used where a hydroxide group is replaced by 18F (18-flourine), a compound that is called 18F-FDG (flourine-18 labeled deoxyglucose). 18F-FDG has a high affinity for cells with increased metabolism, for example cancer cells. The substance is transported into the cells and phosphorylates glucose to 18F-FDG-phosphate, but no further break-down occurs. Because cell membranes are impermeable to phosphorylated deoxyglucose, an intracellular accumulation of the substance occurs.

Limitations

  • Small tumors ( < 0,5 cm) and tumors with low to moderate absorption can escape detection.
  • Inflammatory conditions will produce increased absorption.
  • For patients with diabetes (especially those requiring insulin) and non-fasting patients, high muscular absorption will reduce the sensitivity for tumor detection.
  • Some tumor types have low FDG absorption (for example, prostate and bronchoalveolar carcinoma).

Sources of error

  • Infections and inflammatory conditions (including post-operative changes) will result in increased absorption.
  • Normally, the intestine can have a high absorption.
  • Myocardium often displays high absorption, also in fasting patients.
  • 18 F-FDG is excreted through the kidneys and FDG in the urinary tract can be misinterpreted.
  •  Absorption in brown fat tissue can be misinterpreted as a tumor if PET is not compared with CT. PET/CT combined in the same apparatus gives better specificity than PET alone.

Equipment

  • PET/CT-scanner  
  • Radio-pharmaceutical agent: 18F-FDG is formed by radiating a heavier natural variant of oxygen with protons. This occurs in a cyclotron. Fluorine-18 (18F) is produced at the hospital cyclotron located at Rikshospitalet .

Preparation

Patient preparation depends on the clinical diagnosis.

  • Fast for at least 6 hours before the examination in order to increase the absorption of 18F-FDG. But the patient should drink plenty (2-4 glasses per hour. Water, tea, or coffee without sugar or cream/milk added can be substituted for water.
  • Measurement of s-glucose is performed before injection of 18F-FDG.
  • After intravenous injection of 18F-FDG, it is very important that the patient lies relaxed in a quiet room without talking and avoiding all forms of stimuli, in order to avoid non-specific absorption of 18F-FDG in the muscles.
  • Tranquilizers and painkillers are often administered prior to the injection.
  • The patient should be warm and comfortable prior to the injection in order to prevent absorption in the brown fat, which may affect the interpretation.

There will be other precautions for neurological and cardiological diagnoses.

Implementation

  • The patient must lie completely still while the images are being taken.
  • A whole-body examination takes approximately 25 minutes.
  • For PET, tissue absorption is displayed by positron-emitting, radiopharmaceutical preparations.

Registration of emission

  • The positron is considered a positively charged electron.
  • When the positron leaves the radioactive core, it will travel up to a few millimeters before it collides and fuses with an electron and is transformed into energy; this is called annihilation.
  • The mass of the positron and the electron is transformed into energy in the form of two photons, each of 511 keV, which are emitted in diametrically opposing directions (180°).
  • A ring detector around the patient will catch the photons.
  • The two photons will encounter the ring detector at the same time (coincident detection), and because they have moved in exactly opposite directions, the detection will precisely localize the radiation focus (for example, a lymph node with tumor tissue).
  • A modern PET-camera with ring detector can map the entire body in 20 minutes.
  • The PET-scanners have integrated CT, so that the information from PET is accurately localized anatomically.

Examples of findings

  • Anal cancer: Anal tumor and metastasis in lymph node
  • Hodgkin's lymphoma (HL): HL with involvement of: soft tissue in the larynx , vertebra L4 ,  os pubis L  and femur
  • Cancer of the rectum: Adenocarsinom in rektosigmoideum liver metastases
  • Intracranial tumors: Astrocytoma grade II/III, left parietal lobe  high-grade glioblastoma, right frontal lobe 
  • Lung cancer: Lung tumor  lung cancer with lymph node spread
  • Sarcoma: Soft tissue sarcoma in the left thorax
  • Cancer in the esophagus: Tumor in the distal esophagus
  • Colon cancer: Metastasis-suspect lesion in adrenal gland

Follow-Up

  • At the end of the examination, the radioactivity is small, but the patient should keep a distance (about 3 meters) from children and pregnant ladies the day of the scan.
  • The result will normally be available the following day.
Postitron emission (PET) with <sup>18</sup>F-FDGPostitron emission (PET) with <sup>18</sup>F-FDGPostitron emission (PET) with <sup>18</sup>F-FDGPostitron emission (PET) with <sup>18</sup>F-FDG
Postitron emission (PET) with <sup>18</sup>F-FDGPositron emissions tomografi (PET) with <sup>18</sup>F-FDGPositron emission tomography (PET) with <sup>18</sup>F-FDGPositron emission tomography (PET) <sup>18</sup>F-FDG
Positron emission tomography (PET) with <sup>18</sup>F-FDGPositron emission tomography (PET) <sup>18</sup>F-FDGPositron emission tomography (PET) with <sup>18</sup>F-FDGPostitron emission (PET) with <sup>18</sup>F-FDG
Postitron emission (PET) with <sup>18</sup>F-FDGPostitron emission (PET) with <sup>18</sup>F-FDGPostitron emission (PET) with <sup>18</sup>F-FDGPostitron emission (PET) with <sup>18</sup>F-FDG
Positron emmissions tomography (PET) with<sup>18</sup>F-FDGPositron emission tomography (PET) with <sup>18</sup>F-FDGPositron emission tomografi (PET) with <sup>18</sup>F-FDG

Treatment of oral cancer

The goal of treatment is to establish locoregional control, prevent problems from local and regional tumor growth, as well as prevent recurrence.

Treatment is intended to maintain optimal conditions for function and anatomical appearance.

The available treatment modalities are mainly surgery and radiation therapy (5). Treatment often consists of a combination of these. 

Chemotherapy is used to a lesser degree, but regimens for concomitant radiation and chemotherapy are in development.

Age (>70 years) is not a contraindication for treatment, but the patient must be in good physical and mental condition (14).

Surgery of oral cancer

Small tumors (T1–2)

Small tumors are removed either by scalpel or CO2 laser. The specimen is then labeled thoroughly. Margins of resection are checked with frozen section to ensure complete removal of cancer.

For resection margins on the lower jaw, bone must not be exposed due to the danger of osteoradionecrosis (10). If the bone cannot be covered with primary sutures of the mucosa, a skin graft or nasolabial flap is often used for coverage. This is docked after 3-4 weeks. Indications for post-operative radiation therapy include close or positive resection margins, perineural invasion, lymphovascular invasion, lymph node metastases (usually more than 1), extracapsular spread, or sometimes T4 tumor.

Larger tumors

Status after reconstruction of the left part of the tongue and floor of the mouth with a pectoral myocutaneous flap. 

Skin/muscle flaps or free grafts allow for larger resections (5).

Excision of larger tumors often leads to a considerable defect in the mucosa and soft tissue and/or bone of the upper and lower jaw. Defects can be covered/replaced with a myocutaneous flap or skin flap. Free flaps are used increasingly to replace mucosa and bone grafts (fibula) for replacement of the lower jaw. 

Pectoral flap

Muscle covered by skin is dissected with a vessel pedicle from the thoracic wall. The skin muscle flap is then pulled up under the skin on the neck to the area requiring replacement of volume due to excision of soft tissue and skin coverage for replacement of mucosa.

Deltopectoral flap

Skin and subcutaneous tissue from the shoulder with a vessel pedicle is dissected and pulled up to the area to be covered.

Deltopectoral skin flap used to cover a defect on the skin of the neck. 

Surgery for tumors in the mouth is often combined with cervical lymphadenectomy. This is done therapeutically in cases of confirmed metastases, or prophylactic in cases where there is no suspected spreading to the cervical nodes, and to provide space for the skin/muscle flap.

PROSEDYRER

Hemiglossectomy

General

If tumor is located on the tongue, a tongue resection may be necessary. Depending on the size of the tumor, a partial resection or hemiglossectomy is performed. This means that parts or half of the tongue are resected.

If the mandible cannot be covered with primary sutures of mucosa, a nasolabial flap is used for coverage. This means that skin and subcutaneous tissue flap is dissected from underlying facial muscles (1). A hole is made in the cheek to the mouth and the skin flap is pulled through and sutured to the edges of the mucosa .

Indication

  • Tongue cancer

Goal

  • Curative resection

 

1. Reference: Rökenes HK, Bretteville G, Lövdal O, Boysen M. The nasolabial skinflap in intraoral reconstruction. ORL J Otorhinolaryngol Realt Spec 1991; 53 (6): 346-8

Equipment

  • Large basic tray (nr. 9)
  • Bent Colorado blades
  • Hook
  • Mouth block

Preparation

  • The surgery is performed under general anesthesia.
  • The patient lies in a supine position.

Implementation

  • With a diathermy needle, about a 1 cm margin is marked around the tumor.
  • Xylocain® with adrenaline is given.
  • The affected area of the tongue is resected and possibly some of the floor of the mouth. 
  • The resection border is inspected for remaining tumor tissue. 
  • If there are suspect areas, a frozen section is made.
  • If the mandible is exposed, it is covered. A nasolabial flap may be used.
  • The wound is usually left open for granulation. It may possibly be closed with widely spaced sutures.
  • The surgeon will attempt to preserve the lingual and hypoglossal nerves. 
  • Larger arteries are ligated. 
  • The specimen is oriented for a histological evaluation. 

Follow-up

A tube is inserted as needed.

If a nasolabial flap is made, the patient will have a feeding tube for a few weeks until the flap has healed to the edge of the mucosa and bone. The flap is then docked after about 3 weeks.

The patient will have a follow-up visit with the surgeon after a few weeks.

Hemiglossectomy

Mandibulectomy

General

If tumor grows near the lower jaw with threatening infiltrations, it may be necessary to remove parts of the mandible. It is very important that the remaining lower jaw is well covered with tissue after the surgery due to the possibility of osteoradionecrosis after radiation therapy.

If the mandible cannot be covered with primary sutures of mucosa, a nasolabial flap is often used for coverage.  This means that skin and subcutaneous tissue flap is dissected from underlying facial muscles (1). A hole is made in the cheek to the mouth and the skin flap is pulled through and sutured to the edges of the mucosa . A free flap can also be used from the underarm.

Indication

  • Primary tumor situated near the mandible.

Goal

  • Resection of tumor

 

1. Refererence: Rökenes HK, Bretteville G, Lövdal O, Boysen M. The nasolabial skinflap in intraoral reconstruction. ORL J Otorhinolaryngol Realt Spec 1991; 53 (6): 346-8

Equipment

  • SSO tray (teeth/jaw)

Preparation

  • The surgery is performed under general anesthesia.
  • The patient lies supine.
  • The surgical field is shaved if necessary.

Implementation

  • Xylocain® with adrenaline is given.
  • Decaying teeth are extracted.

Because of the risk for osteoradionecrosis, extraction of teeth should be avoided in patients who have received radiation therapy. Decaying teeth are therefore extracted in advance. This is often combined with the surgical procedure. 

  • An incision is made through the mucosa toward the alveolar process.
  • The anterior part of the cranial mandible is removed with an oscillating saw at the level of the roots of the teeth.
  • Tumor is resected with a 1 cm macroscopic margin.
  • The specimen is removed en bloc and marked.
  • The mandible is well covered, possibly with use of a skin graft, or nasolabial flap. 
  • The incision is sutured. 
  • A nasogastric tube is inserted to relieve the incision. 

Follow-up

The patient will have a feeding tube for the first few days after the surgery. The length of time for this varies from patient to patient.

Mandibulectomy

Mandibulectomy with fibula graft

General

In patients where tumor has infiltrated the lower jaw, parts of the jaw may need to be removed. In such cases, it may be necessary to reconstruct with vascularized bone. The fibula is well suited for this. Hip bone is another alternative used at other centers. Lower jaw injured by irradiation (osteoradionecrosis) may also require this type of surgery.  

Indications

  • Primary tumor has infiltrated the mandible.
  • Primary tumor originating in the mandible.
  • Osteoradionecrosis

The patient's general health status, vessel status, age, and other diseases may be contraindications for reconstruction.

Goal

  • Remove tumor without great consequences for eating, drinking, speech, and appearance.

Equipment

  • General surgery tray
  • Equipment for
    • orthopedics
    • osteosynthesis
  • Microinstruments

Preparation

  • Antibiotic prophylaxis
  • Steroids (Decadron®, Fortecortin®)
  • The surgery is performed under general anesthesia while the patient lies supine. 
  • Two surgical fields are prepared.

Implementation

Neck/jaw

The extent of the surgery depends on the disease. Sometimes half of the jaw must be removed. A cervical dissection is always performed on the same side, where a donor vessel is also found.

  • The lip is split in the midline and the skin is placed to the side.
  • The bite is immobilized intramaxillarily.
  • The skin of the cheek is resected.
  • The resection will depend on the extent of the tumor. Soft tissue content is resected and the mandible is resected with adequate margins.
  • Frozen sections are made from bone marrow, among others.

Leg

  • Surgical tourniquet to reduce bleeding
  • The incision is drawn lateral to the fibula.
  • Resect fibula with blood supply and any possibly overlying skin which is used for the covering in the mouth. The length of the fibula graft will depend on the defect in the mandible to be replaced. 

Reconstruction

Jaw surgeon

  • The free transplant from the fibula is adapted for the mandible.
  • The specimen is attached with plates on each side.

Hand surgeons

  • Microvascular anastomosis is performed to cervical vessels, usually the facial artery or superior thyroid artery. 
  • On the venous side, the facial vein or other branches is used.

ENT surgeons

  • The soft tissue over the graft is closed either primarily with mucosa or covered with full-thickness skin from the graft, or possibly with partial skin on muscle/soft tissues. 
  • The incision is closed.

Follow-up

  • The graft is monitored, possibly with a laser probe (doppler of vessels).
  • Steroids
  • Thrombosis prophylaxis
  • Antibiotic prophylaxis
  • The foot should be elevated for a couple of days.
  • The patient may drink water and other liquids from the first postoperative day. The patient should not chew.
  • Rehabilitation of teeth status is a significant part of treatment. Implants may be inserted around one year after hyperbaric oxygen treatment in Bergen. 

Frequent follow-up visits will take place during the first year at ENT- and oral surgeons. 

The patient will have follow-up for three years.

Mandibulectomy with fibula graft

Neck Lymphadenectomy

General

The neck is separated into 6 regions to better describe the areas involved with cancer which are to be operated.

Variations of a neck lymphadenectomy

  • Radical (classical) neck lymphadenectomy in which lymph nodes are resected in regions 1-5 including the internal jugular vein, nerve XI, and the sternocleidomastoid muscle.  
  • Modified neck lymphadenectomy preserves one or more of the non-lymphatic structures to be removed by a radical neck lymphadenectomy. 
  • Selective neck lymphadenectomy in which nodes are removed within one or more regions. 
  • Elective resections in the neck are equivalent to radiation therapy in terms of results (1).

If possible, resection of the primary tumor is performed during the same surgery as the lymphadenectomy. 

Indications

  • Suspected or confirmed lymph node metastasis in the neck.

Goal

  • Removal of confirmed cancer in neck lymph nodes.

 

1. Reference: Storaker KA. Kartlegging av skulderfunksjon etter lymfeknutedisseksjon. Oslo: Rikshospitalet Universitetsklinikk, 2002

Equipment

  • Universal set
  • Basic surgery tray

Preparation

  • The operation field is shaved.
  • The surgery will take place under general anesthesia.
  • The patient will lie supine.
  • The patient's head is turned to the side and a pillow is placed under the neck to extend the neck.
  • Tracheal tube is fixed in the corner of the mouth opposite to the side of surgery. 

Implementation

  • The incision is adapted for the metastatic pattern and localization of the primary tumor.
  • The skin flaps are elevated.
  • The sternocleidomastoid muscle and jugular veins are divided caudally (not in an elective resection).
  • Fat, lymph nodes, and muscle are resected with preservation of the vagus nerve. 
  • All lymph nodes of the applicable region are removed, in this case region 5.
  • Sternocleidomastoid muscle and jugular veins are divided cranially. 
  • The lymph nodes are mainly localized along the internal jugular vein.
  • In the front, the lymph nodes in regions IA and B are removed, and the submandibular gland is removed.  
  • The specimen is marked for multiple pathologic lymph nodes. 
  • Thorough hemostasis.
  • A drain is inserted.
  • The incision is closed.

Follow-up

Observe for:

  • hematoma
  • lymph leakage (left side)
  • infection
  • skin or muscle necrosis, especially if the neck is irradiated
  • nerve injury
    • The most common is injury of nerve XI
    • Shoulder syndrome (stiffness, reduced movement, pain)
    • Lymph edema and vein stenosis in the face and neck

The drain is removed when the fluid volume is less than 20 ml/24 hours.

Neck lymphadenectomy

Drug therapy of oral cancer

Standard treatment for head/neck cancer is surgery and radiation therapy. Chemotherapy was previously only used for recurring disease with a palliative intention. Because of poor results with standard treatment for locoregional advanced disease (stage III and IV), chemotherapy has been incorporated into the treatment strategy for primary tumor within the last two decades.

Chemotherapy has been given neoadjuvantly, concomitantly, and as adjuvant standard treatment. Of these strategies, concomitant therapy has given the greatest survival benefit in meta-analyses. Corresponding to this, it is now common to give weekly cisplatin with radiation therapy to patients younger than 70 years with ENT cancer stages III and IV.

One of the more significant breakthroughs in treatment is from a study by Bonner et al. using radiotheray plus cetuximab, concomitantly, for squamous-cell carcinoma of the head and neck. Cetuximab is a monoclonal antibody against epidermal growth factor receptor (EGFR). A high level of EGRF in tumor cells is associated with poor prognosis. In the study, radiotherapy plus cetuximab increased locoregional control and reduced mortality in locoregional advanced head and neck cancer compared to radiotherapy alone, without increasing toxicity. This applied primarily to hyperfractionated treatment of oropharyngeal cancer. It is unknown how effective this treatment is compared to radiochemotherapy with cisplatin, which is still considered the standard by many. It is, however, an alternative for patients in stage III or IV older than 70 years. 

Chemotherapy is still given for recurrence when surgery and radiation therapy are not possible. Depending on the medical condition of the patient, single- or multiple-drug regimens are given.

Vermorken et al. have reported that drug therapy with cetuximab was active and well tolerated in patients with recurrence and/or metastatic disease which had progressed on platinum therapy. The response rate was 46%, but it is worth noting that none of the patients reached complete response (complete response/partial response/stabile disease (0/13/33)).

 

 

 

 

PROSEDYRER

Sun Exposure under Drug Therapy

General

Correct information about the possibility of sunbathing may affect patients health and quality of life.

Precautions in connection with sunbathing should be followed under medical cancer treatment and for 2-3 weeks after end of treatment.

Drug cancer treatment includes chemotherapy, antibodies and other drugs used in cancer treatment.

Indication

Sun exposure in connection with drug cancer treatment.

Goal

Prevent sun damage of the skin during and after cancer drug treatment.

Definitions

Photosensitivity

Increased sensitivity to ultraviolet light have been associated with certain drugs used in cancer treatment. Photosensitivity reactions can be expressed in various ways. They can be phototoxic, which is by far the most common, or photoallergic (8,14). Druginduced photosensitivity is mainly caused by wavelengths in the UVA range, but UVB rays may also be involved (8).

Phototoxicity

A phototoxic reaction is reminiscent of a reinforced sunburn, with redness, edema, pain and increased sensitivity in sun-exposed areas of the skin. This is caused by a photochemical reaction of a photosensitive drug and irradiation of sunlight on the skin, which leads to skin cell death. In severe cases, blistering can occur (14). Symptoms may appear immediately or as a delayed inflammatory reaction (3). Higher doses of medication will give an increased risk of skin reaction (14). Healing of skin area will often lead to a hyperpigmentation that can last from weeks to months before they might disappear (8). Although the incidence of drug-induced photosensitivity is unknown, phototoxic reactions is possibly more common than is diagnosed or reported.

Photoallergy

An immunological reaction usually occurring 24-72 hours after sun exposure. The reaction degenerates as an itchy, eczema-like eruptions. In acute cases, one can see rash liquids. The prevalence of eczema is usually limited to sun-exposed skin, but can in severe cases spread to larger areas of the body. Unlike a phototoxic reaction, photoallergy is less dependent on the dose of the causative drug (8).

Photoinstability

Some drugs can be degraded when exposed to light. This can happen both before administration and when the drug is circulating in the body. This degradation can cause redness/rash and edema of the skin. This applies especially for dacarbazine (9). It is unknown whether the effect of the drug is affected and it is therefore recommended that one avoids direct sunlight as long as the drug is active in the body.

PPE ( palmoplantar erythrodysesthesia = Acral erythema )

PPE is also called hand-foot syndrom. The condition starts with altered skin sensation that develops into burning pain, swelling and redness of palm of the hands and soles of the feet. The symptoms can also occur in other parts of the body that is subjected to pressure, for example under tight clothing. In severe cases large blisters and ulceration can develop. The pain can be so severe that daily activities is limited.

PPE is often seen with liposomal doxorubicin (Caelyx®) and high dose cytarabine, but may in principle occur with any anthracyclines, taxanes and fluorouracil (5- FU® ) (9,14) .

Acne-like rash

Pimple-like eruptions in skin areas with a lot of sebaceous glands such as the face, scalp, chest and neck. In contrast to common acne, the liquid-filled blisters does not contain any bacteria (9,10,15).

Hyperpigmentation

Hyperpigmentation is a common side effect in patients receiving chemotherapy, especially alkylating drugs and antibiotics with cytostatic effect. The area that has increased pigmentation may be localized or diffusely distributed. It can occur in the skin, mucous membranes, hair and nails. Pigment changes can be normalized upon discontinuation of the drug, but it may also persist.

Fluorouracil is one of the most common drugs which can provide hyperpigmentation. Others are; metotrexate, busulfan, doxorubicin liposomal, Hydroksyurea®, procarbazine, bleomycin, cyclophosphamide, doxorubicin , ifosfamide, tegafur, mitoxantrone, daunorubicin, fluorouracil, cisplatin, carmustine, thiotepa, docetaxel, vinorelbine, vincristine, imatinib and combination regimens (14).

An increased pigmentation in sun-exposed areas with the use of methotrexate, fluorouracil and capecitabine is described (16,17,18). Beyond that there is little evidence in the literature  that hyperpigmentation aggravates by sun exposure.

Radiation Recall Dermatitis (RRD)/Photo Toxic recall reaction

Flares of an inflammatory skin reaction in an area of ​​previous radiation damaged skin resulting from sunburn or external radiation. RRD can occur from months to years after the initial radiation damage.

Drugs that can provide RRD are; bleomycin, capecitabine, cyclophosphamide, dactinomycin, cytarabine, daunorubicin, docetaxel, doxorubicin liposomal, doxorubicin, etoposide, fluorouracil, gemcitabine, Hydroksyurea® , idarubicin, lomustine, melphalan, methotrexate, paclitaxel, tamoxifen and vinblastine (14). EGFR inhibitors (cetuximab , gefitinib and erlotinib) may also cause other skin reactions that may be exacerbated by sun exposure (9,10,19).

Preparation

The patient is given written and verbal information by the medical responsible doctor and nurse at the start of the drug cancer treatment, and it is repeated as necessary.

Implementation

General Precautions

Prevention and protection:
  • Limit sun exposure during the first days after the cure.
  • Observe skin daily to detect any skin reactions early.
  • Avoid getting sunburned.
  • View extra care between 12.00-15.00 (2).
  • Wear protective clothing and headgear (2,3,4,5,6).
  • Wide-brimmed hats protect better than caps (2.4).
  • Please note that the window glass does not protect against UVA rays (7).
  • Use sunscreen; to protect against UVA and UVB rays, a minimum SPF 15 (3,4,6,8) is applied several times daily.
  • Use mild skin care products without perfumes.

In case of an eruption, sun exposure (including solarium) should be avoided until the skin is healed. Adverse skin reactions can be alleviated with moist and cooling compresses. Mild cortisone salves can also be highly effective. For very severe cases, systemic cortisone might be necessary (3,6,7,9).

When a photosensitive reaction occurs, it is important to consider what other medications the patient is receiving which can also trigger such reactions. For example, steroids, some antibiotics, diuretics and NSAIDs.

Medicaments that most commonly cause skin reactions

Medicament Common reactions Remedial action
Dakarbazin (DTIC)


Phototoxic/photoinstability
See general precautions
Redness in skin, tingling of the scalp and general unwellness
Avoid sunlight completely the day of the treatment (9)
Methotrexate
Phototoxic

See general precautions
Acne-like rash
Avoid direct sun exposure, heat and humidity (9,10). Avoid soap, alcohol based skin products (9). Use moisturizing products and oil bath (4,9,10).
Palmoplantar erythrodysesthesia = Acral erythema (PPE)

Preventive: Pyridoxin (vitamine B6) (2,6,9)

Avoid sunlight, heat, pressure against the skin and tight clothing can according to some studies have an effect (11,12,13). Use moisturizer.

Treatment/relief: Cortisone salves, cortisone tablets, cold compress, cold baths

(2, 9)

Fluorouracil (5-FU®)

 

Phototoxic See general precautions
Palmoplantar erythrodysesthesia = Acral erythema (PPE) Preventive: Pyridoxin (vitamin B6) (2,6,9)

Avoid sunlight, heat, pressure against the skin and tight clothing can according to some studies have an effect (11,12,13). Use moisturizer.

Treatment/relief: Cortisone salves, cortisone tablets, cold compress, cold baths   (2, 9)

Radiation recall
Treatment as with phototoxic

Kapecitabin (Xeloda®)

 

Phototoxic See general precautions
Palmoplantar erythrodysesthesia = Acral erythema (PPE)

Preventive: Pyridoxin (vitamin B6) (2, 6, 9). Preventive: Pyridoxin (vitamin B6) (2, 6, 9)

Avoidance of sunlight, heat, pressure against the skin and tight clothing can according to some studies have an effect (11,12,13). Use moisturizer.

Treatment/relief: Cortisone salves, cortisone tablets, cold compress, cold baths (2, 9)

Vinblastin

 

Phototoxic
See general precautions
Radiation recall Treatment as with phototoxic
Doxorubicin liposomal (Caelyx®)
Palmoplantar erythrodysesthesia = Acral erythema (PPE) Preventive: Pyridoxin (vitamin B6) (2, 6, 9)

Avoidance of sunlight, heat, pressure against the skin and tight clothing can according to some studies have an effect (11,12,13). Use moisturizer.

Treatment/relief: Cortisone salves, cortisone tablets, cold compress, cold baths (2, 9)

Tegafur

 

Phototoxic
See general precautions
Palmoplantar erythrodysesthesia = Acral erythema (PPE) Preventive: Pyridoxin (vitamin B6) (2, 6, 9)

Avoidance of sunlight, heat, pressure against the skin and tight clothing can according to some studies have an effect (11,12,13). Use moisturizer.

Treatment/relief: Cortisone salves, cortisone tablets, cold compress, cold baths    (2, 9)

EGFR-hemmere

(Cetuximab, panitumab, erlotinib, gefitinib, lapatinib, vandetanib)

Phototoxic
See general precautions
Acne-like rash
Avoid direct sun exposure, heat and humidity (9,10). Avoid soap, alcohol based skin products (9). Use moisturizing products and oil bath(4, 9, 10).

Beyond the medications listed in the table the literature gives som evidence that these substances may cause phototoxic skin reactions :

  • paclitaxel (Taxol®)
  • docetaxel (Taxotere®)
  • hydroxycarbamide ( Hydroksyurea® )
  • imatinib ( Glivec® ) and Dapson® and that paclitaxel can provide radiation recall .

References


  1. LOV-1999-07-02-63 Pasientrettighetsloven - pasrl. Lov om pasientrettigheter.
  2. Polovich M, White JM, Kelleher LO. Chemotherapy and biotherapy guidelines: recommendations for practice. Pittsburgh, PA: Oncology Nursing Society; 2005.
  3. González E, González S. Drug photosensitivity, idiopathic photodermatoses,and sunscreens. J Am Acad Dermatol 1996;35:871-85;quiz 886-7.
  4. Liffrig, JR. Phototrauma prevention. Wilderness Environ Med 2001;12:195-200.
  5. Tan E. Skin toxicity of chemotherapy drugs [created 2007, last updated  2010 Mar 5]. Hentet 1. desember 2010 fra: http://dermnetnz.org/reactions/chemotherapy-toxicity.html
  6. Gould JW, Mercurio MG, Elmets CA. Cutaneous photosensitivity diseases induced by exogenous agents. J Am Acad Dermatol 1995;33:551-73.
  7. Payne, AS & Bernandin, RM. Sunburn [topic last updated 2010 Oct 06]. I: BMJ Best Practice. Hentet 23. november 2010 fra http://bestpractice.bmj.com
  8. Zhang AY, Elmets CA. Drug-induced photosensitivity [updated 2010 Jan 15]. Hentet 1. desember 2010 fra: http://emedicine.medscape.com/article/1049648-overview
  9. Ulrich J, Hartmann JT, Dörr W, Ugurel S. Skin toxicity of anti-cancer therapy. J Dtsch Dermatol Ges 2008;6:959-77.
  10. Agero AL, Dusza SW, Benvenuto-Andrade C, Busam KJ, Myskowski P, Halpern AC.Dermatologic side effects associated with the epidermal growth factor receptor inhibitors. J Am Acad Dermatol 2006;55:657-70
  11. Alley E, Green R, Schuchter L. Cutaneous toxicities of cancer therapy. Curr Opin Oncol 2002;14:212-6.
  12. Mangili G, Petrone M, Gentile C, De Marzi P, Viganò R, Rabaiotti E. Prevention strategies in palmar-plantar erythrodysesthesia onset: the role of regional cooling. Gynecol Oncol 2008;108:332-5.
  13. Tanyi JL, Smith JA, Ramos L, Parker CL, Munsell MF, Wolf JK. Predisposingrisk factors for palmar-plantar erythrodysesthesia when using liposomal doxorubicin to treat recurrent ovarian cancer. Gynecol Oncol 2009;114:219-24.
  14. Payne AS, Savarese DMF. Cutaneous complications of conventional chemotherapy agents. I: UpToDate [version 18.2 2010]. Hentet 1. desember 2010 fra: http://www.uptodate.com
  15. Heidary N, Naik H, Burgin S. Chemotherapeutic agents and the skin: an update. J Am Acad Dermatol 2008;58:545-70.
  16. RELIS Sør. Hyperpigmentering av cytostatika og forverring av sollys. I: RELIS database 2010, Spm.nr 4736. Hentet 1. desember fra: http://relis.arnett.no/Utredning_Ekstern.aspx?Relis=2&S=4736
  17. Hendrix JD Jr, Greer KE. Cutaneous hyperpigmentation caused by systemic drugs. Int J Dermatol 1992;31:458-66.
  18. Schmid-Wendtner MH, Wendtner CM, Volkenandt M, Heinemann V. Clinical picture: leopard-like vitiligo with capecitabine. Lancet 2001;358(9293):1575.
  19. Segaert S, Tabernero J, Chosidow O, Dirschka T, Elsner J, Mancini L, et al. The management of skin reactions in cancer patients receiving epidermal growth factor receptor targeted therapies. J Dtsch Dermatol Ges 2005;3:599-606.

Preparation of Chemotherapy, Spills, and Cleaning a LAF Bench

General

Preparation of chemotherapy outside of a pharmacy

At Oslo University Hospital, the pharmacy primarily prepares chemotherapy for each patient. If it is necessary to dilute/mix the medicine at the department, then this should occur in a designated room with a LAF bench (laminar airflow bench). Many chemotherapy drugs are carcinogenic and teratogenic, and it is extremely important for health personnel to follow directions for preparation of of these medications. At Oslo University Hospital, all chemotherapy should be prepared and administered by a nurse who has completed a cytostatic treatment course at Oslo University Hospital, or by nurses who are certified cancer nurses from Oslo University College.

Pregnant women and employees under physician orders not to temporarily or permanently work with chemotherapy drugs, should not handle or be exposed to these chemicals. Nursing mothers may handle chemotherapy drugs as long as they follow the general guidelines for chemotherapy handling. For each work place, there should be written guidelines for handling of chemotherapy drugs and for first aid for spills and maintenance of fume hoods etc..

Designated room with LAF-bench to dilute/mix chemotherapy

  • The ventilation should be separate from the main ventilation and fumes should be vented to the outside and if necessary, filtered.
  • The room should be well illuminated for visual control of the fluid.
  • The LAF bench should be a workbench having sterile, filtered air from the ceiling with defined speed and an approved fume hood. The bench should be routinely tested and approved.

Goal

  • To protect nurses and surroundings from exposure to cytotoxic chemicals and to preserve the sterility of the drug.

Handling of chemotherapy spills

Chemotherapy drugs are a heterogeneous group of drugs in which many are known mutagens, teratogens and/or carcinogens. Allergic reactions have also been reported. Studies show that there is a health risk during exposure of chemotherapy drugs and there are guidelines for minimizing exposure of health personnel to these chemicals. Workers in daily contact with these drugs will be more at risk due to the increasing use of chemotherapy. Chemotherapy spills refers to spills during preparation and leakage from infusion bags.

Goal

  • To ensure that spills of chemotherapy drugs or waste materials that contain these chemicals are handled in a safe way to protect health and safety.

Cleaning of LAF-bench

The Norwegian Work Authority recommends that each workplace should have written guidelines for handling chemotherapy drugs, first aid for spills, and maintenance of fume hoods etc. A LAF-bench (laminar airflow bench) is a bench protecting workers from the drug being prepared and also protects from microbiological organisms. Those who carry out cleaning should have training and knowledge of the risk for exposure to chemotherapy drugs.

Goal

  • Maintain a clean LAF bench
  • Avoid contamination and preserve the sterility of the drug 
  • Protect people and surroundings from exposure

Source

Applicable directives and guidelines (www.lovdata.no)

  • Warn against exposure to chemicals at the workplace (Kjemikalieforskriften §24), mandated by The Norwegian Labour Inspection Agency from 5 May 2001, last edition from 26 April 2005.
  • Guidance for chemical directives attachment VII Cytostatica from September 2003 (www.arbeidstilsynet.no).

Equipment

  Preparation of chemotherapy in a hospital

  • 2 pairs of gloves: vinyl gloves inside and sterile, powder-free latex gloves outside
  • Protective coat with long arms/plastic apron
  • Arm protectors
  • LAF bench
  • Dilution fluid
  • Syringes and cannulas
  • Sterile compresses
  • Disposable cloths
  • 70% ethanol
  • Absorbent benchcoat with plastic underside for the work bench
  • If a LAF bench is not used, use a protective mask with aerosol filter and protective goggles.

Handling of chemotherapy spills

Spill kit includes:

  • 2 pairs of nitrile gloves, long
  • 2 pairs of latex gloves, long
  • 2 pairs of shoe covers
  • Plastic coat\apron
  • 1 mask
  • 2 diapers
  • 1 bed absorbent bed sheet
  • 2 plastic bags with zippers (30 x 40 cm)
  • 4 thin, white plastic bags (60 x 90 cm)
  • Absorbant material   
  • 8 disposable wash cloths

Washing of LAF-bench

  • Plastic apron
  • Arm protectors
  • Gloves: either double vinyl gloves or special gloves
  • Disposable cloths
  • 70% ethanol
  • Bucket and soapy water
  • Waste container with plastic bag for chemotherapy waste (biohazardous waste)

 

 

Preparation

Preparation of chemotherapy outside of the pharmacy

For preparation of chemotherapy drugs, use gloves and a protective lab coat with long arms or tight-fitting cuffs.   Use two pairs of gloves where the inner pair is vinyl or other latex-free material. The outer glove should be sterile and of latex or other material which is impenetrable.  The gloves are recommended to be changed every half hour for preparation of chemotherapy drugs, and right away with spills.

  • Start the LAF-bench a minimum of 30 minutes before use.
  • Wash hands
  • Put on the inner gloves
  • Disinfect the work surface with 70% ethanol
  • Cover the work surface with a benchcoat. This should not cover the vent; otherwise, the bench will not function properly.
  • Read the dilution directions and find the necessary equipment and medications as described.
  • Choice of dilution system/fluids
    • A transfer cannula should be used in preference to a syringe where possible to maintain a closed system as much as possible.
    • If a syringe is used: use a syringe with Luer lock connection. These have a better connection between the syringe and the cannula.
  • Check the expiration on the drug packaging and infusion fluid.
  • Check that the drug in liquid form does not contain particles or visible solids.
  • Check that the packaging does not have any cracks or leakages.
  • Perform necessary calculations, date, and sign the work form.
  • Obtain another nurse to double check: right patient, work form, drug, dosage, fluid type and volume, as well as calculations.  All checks should be against the original ordination. The person doing the check should sign and date it.
  • Set out necessary equipment on the LAF-bench or where the work will take place. The equipment should be placed in the corner within the ventilation of the LAF-bench.  Remove the outer packaging of the sterile gloves and lay the gloves on the bench.
  • Put on the protective clothing (coat/apron and arm protectors)
  • Put on the sterile gloves in the bench
  • Disinfect the rubber membrane on the infusion bag and hood windows as well as the ampules.
  • Make sure the protective glass on the LAF-bench is pulled down to the correct work level as recommended by the manufacturer of the bench.

Handling of chemotherapy spills

All, except the workers who clean the spill, should leave the room.  Preferably, two people should help each other to remove the spill.  This way, one can ensure that proper precautions are taken.

At Oslo University Hospital, a packet is available from the pharmacy for chemotherapy spills.

Washing of LAF-bench

  • The LAF-bench should be operating under cleaning.
  • The sash should be down, as under normal working conditions.
  • Use a plastic apron, arm protectors, and gloves.

 

 

Implementation

Preparation of chemotherapy drugs outside of a pharmacy

Aseptic procedure

  •   To avoid turbulence of the sterile, laminar air stream:
    • Work at least 15 cm inside the perforation with steady movements
    • Avoid hands or other objects from coming between the airflow and the medicine.
  • Make only one medicine at a time.
  • A full syringe or finished bag should be labeled for the next preparation.  The label should be labeled with the patients name, birthdate, drug and dosage, preparation date, expiration, and the name of the person who prepared and checked the medicine.
  • Avoid spills and aerosol formation
    • Use a dry, sterile compress around neck of the ampule when it is broken.
    • When the cannula is removed from the syringe, hold a sterile compress around the barrel neck to catch any spills.
    • Hold the syringe/ampule such that the opening is directed away from the face.
    • For solid substances, solvent should be added along the glass wall to avoid whirling of particles.
    • With positive/negative pressure in the hood glass: apply a filter cannula first to reduce pressure.
    • With use of adapter: place adapter first in the infusion bag and connect to the hood glass with medicine.
    • When the air is removed from the syringe, place the cannula cap on the cannula again while the syringe is held vertically with the cannula upright. A sterile compress should be held around the opening between the cannula and the syringe to collect spillage.
    • Clean up spills at once
  • After each addition, the contents of the infusion container should be mixed well by inverting and repeating 5-6 times.
  • Infusion fluid which has been added to should be marked satisfactorily.
  • The finished solution should be scrutinized for solid or foreign particles. All solid should be dissolved.
  • If visible changes occur under the mixing procedure, the physician should be contacted and the fluid should not be used. Store the infusion fluid and packaging of the added drug and contact the pharmacy (chemist) for further clarification.
  • All used equipment should be rolled up in the benchcoat (alternatively, all used equipment can be placed in a plastic bag which can be tied or closed with zipper) and disposed of in box with plastic bag for chemotherapy waste/biohazardous waste.
  • LAF-bench should be stopped at least 30 minutes after use.

Multiple additions

  • Addition of multiple drugs for chemotherapy solutions should be avoided. If it is still appropriate, there should be clear documentation of the mixture.
  • Different chemotherapies can mix if their mixing properties are documented (and checked with pharmacist).

Handling of chemotherapy spills

  • Use two pairs of disposable latex\nitrile gloves, plastic coat, mask, shoe covers (used with floor spills) and protective goggles.
  • Lay the smallest diaper in the middle of the spilled fluid. Then, place the absorbent bed sheet over the diaper and the rest of the fluid. Use more diapers and absorbent material if necessary.
  • Dispose of used diapers, absorbent material, bed sheets, and gloves is appropriate waste container, which can be closed.
  • Use new gloves and wash thereafter with soapy water and disposable wash cloths a minimum of three times. Use a new cloth before each wash. Used cloths should not be put back in the wash solution.  Used cloths and gloves should be disposed in the appropriate waste containers (in plastic bags which can be closed).
  • The plastic bags with used equipment should be disposed of in the appropriate containers which are properly labeled.

Washing of LAF-bench

  • Other than a cannula bucket, nothing should be stored in the bench after the last preparation.
  • Washing with 70% ethanol is sufficient if there are no visible spills.
  • For visible spills, wash the bench with soapy water and spray afterwards with 70% ethanol (see procedure under). Soapy water is the most effective for removing chemotherapy spills.

Routine washing

  • Washing should be done every 1-4 weeks depending on frequency of use.
  • Spills and dust pose risks for washing.
  • It is important that any remaining solution of chemotherapy is not spread under washing.
  • Use disposable cloths.
  • To avoid contamination of washing water, the washing hand should not be dipped in the water.
  • Wash with slow movements and use a new cloth as needed.
  • Cloths that have been in contact with the bench should not be put back in the washing water and should be discarded in proper waste container.
  • Wash first the walls from top to bottom with soapy water (the cleanest to the most contaminated) – place the cloth on a squeegee for hard-to-reach areas.
  • The filter in the ceiling of the bench should not be washed.
  • Wash the work surface in the bench – wash from back to forward (from the cleanest to the most contaminated).
  • Raise the work surface.
  • Wash the work surface on the underside, especially the closest, perforated part.
  • Then wash the underside bottom of the work surface.
  • Wash thereafter all surfaces (not the ceiling) with 70% ethanol.
  • Remove protective clothing.
  • Discard all protective clothing for one-time use and washcloths in the appropriate waste container.
  • Wash hands.
  • Replace the cannula bucket.
  • There should be a record for bench washing; the employee who washes should sign and date the record.

Follow-up

Aerosol formation with spraying or squirting can occur:
  • when a syringe is used and cannula is retracted for transfer
  • when an ampule is broken
  • when air is removed to measure volume
  • with a leak in a syringe or IV catheter
  • with waste handling

First aid if contact with chemotherapy drugs

  • Skin: Rinse well with water for 15 minutes. Wash contacted area with regular soap.
  • Eyes: Rinse well with water, or use spray bottle with NaCl 9 mg/ml (at least 20-30 minutes of continual rinsing).
  • Contact a doctor.

Radiation therapy of oral cancer

Second to surgery, radiation therapy is the most important mode of treatment for this cancer type.

Even if the patient is successfully operated, radiation therapy will be necessary in most cases postoperatively. This is because there is often microscopic disease remaining where the tumor was localized even when margins are considered free. There may also be microscopic disease in lymph nodes which drain from the original location of the tumor. The likelihood of this depends on the site of the primary tumor and stage/depth of infiltration.

In the head/neck region, there are many structures sensitive to radiation. These should be protected from radiation as much as possible. This is difficult in practice, and a small dose of radiation must be accepted for certain structures. It is therefore important to know the level of tolerance, which depends on fractionation (how the total dose is divided into small, daily fractions). This has long been based on empirical data, but over the last two decades has also been based on mathematical models.

Side effects must be expected. Curing the disease may be at high cost of quality of life, even if no maltreatment has taken place. It is therefore not correct to use the expression radiation damage in this context.

High-energy electromagnetic radiation is used, and sometimes, high-energy electrons. This is generated with a linear accelerator, a machine that accelerates electrons to the speed of light with subsequent braking. This will develop electromagnetic radiation - "bremsstrahlung".

Radiation therapy with today's technology occurs with millimeter precision. Two circumstances are therefore very important:

  • Knowing the disease site and extent.
  • The patient must lie in the same position for each treatment and not move during irradiation.

One of the characteristics of cancer is local spread, that is, when a tumor infiltrates its surroundings. This is not always as easy to identify with today's diagnostic methods. Optimal evaluation of the tumor often requires CT and MRI examinations and in some cases PET. Still, one must still operate with multiple safety margins to compensate for uncertainty of disease extension and daily variation in positioning.

In order for the patient to lie still during radiation therapy, customized masks are made for the head/neck. This is known as immobilization. Thereafter, a CT examination is performed while wearing the mask. On the CT images, the tumor and organs at risk are labeled. After this, irradiation is planned by a radiation oncologist and physicist. When this is completed, the patient is ready for simulation, which is modeling and drawing of the field of radiation. When this is done, treatment can start. The entire process takes about 1-2 weeks.

PROSEDYRER

Brachytherapy for oral cancer

General

Brachytherapy is a form of radiation therapy where one or more radioactive sources (iridium) are inserted close to or into the tumor .

Benefits compared to external radiation treatment

  • Problem with positioning of patient and organ movement is eliminated.
  • Allows increased dose to the target volume and thereby possible increase in curative potential.
  • Shorter treatment time
  • Saves normal tissue structures.

Disadvantages of brachytherapy

  • Invasive procedure with the need for anesthesia

To ensure the irradiation of possible microscopic cancer outside the tumor, brachytherapy is always given in combination with conformal (organ configured) external radiation therapy.

Indication

  • Boost treatment for cancer on the floor of the mouth, tongue/root of the tongue.

Goal

  • Eliminate tumor
  • Eliminate residual tumor if treatment is given postoperatively.

Definitions

Brachytherapy is differentiated by the rate of irradiation dose delivered to the tumor known as high-dose rate (HDR) and low-dose rate (LDR) brachytherapy. Theoretically, there is a great difference between these two methods. Most of our knowledge is centered around LDR brachytherapy. It has been problematic to convert this knowledge to HDR brachytherapy. For this conversion, mathematical models have been developed, which still are not adequately tested for head/neck cancer. The indications for HDR brachytherapy are therefore fewer than for LDR brachytherapy. 

Low-dose rate brachytherapy (LDR)

This is done by inserting radioactive rods/threads surgically into the patient. The rods remain for extended time intervals.

High-dose rate brachytherapy (HDR)

This is perfomed by moving a point-shaped radiation source through previously inserted plastic catheters (remote afterloading). The treatment is fractionated (one or two per day). Remote afterloading was introduced to reduce radiation exposure to technicians.

Preparation

The patient is evaluated preoperatively by an internist and anesthesiologist.

Insertion of plastic catheter .

While the patient is under general anesthesia, four parallel equidistant guide-needles are inserted centrally in the area at risk in the created rectangle.

The guide-needles are then replaced by plastic catheters for after loading. The closed ends of the plastic catheters are inserted close to the surface of the tongue. Under the chin, plastic tubes are attached with "snaps".

CT is taken with 1 mm thick slices. The target volume is drawn which is mostly in the volume within the limits of the catheters. 

A physicist will then prepare the dosage plan .

Implementation

A dosage of 2.5 Gy x 6 is given in 2 fractions daily. The total dose will vary from patient to patient.

After the last treatment, the tubes will be devided on the outside of the skin and removed from the tongue from inside the mouth.

Follow-up

The side effects will peak from 7-14 days after the last treatment.

Side effects may be as intense as for external radiation therapy, but are less extensive since the radiation field is smaller. 

BrachytherapyBrachytherapyBrachytherapy

Primary radiation therapy for the oral cavity

General

Radiation therapy is targeted towards the primary tumor. Regional lymph nodes are also irradiated for regional metastases.

Depending on the localization of the primary tumor and/or T stage, regional lymph nodes are irradiated due to high probability of microscopic disease.

This therapy is foremost given to patients with inoperable tumors, or preoperatively to render tumor more accessible for surgery.

The target volume is adapted individually.

Indication

  • Oral cancer

Goal

  • Eliminate tumor
  • Reduce tumor volume
  • Remove or limit extent of regional metastases

Definitions

Target volume

 

 

Definitions of target volumes according to ICRU (International Commission on Radiation Units and Measurements)
CTV (Clinical Target Volume) Tissue volume that contains a GTV and/or subclinical microscopic malignant disease, which has to be eliminated.
ITV (Internal Target Volume) Volume encompassing the CTV and IM. (ITV = CTV + IM)
PTV (Planning Target Volume) Geometrical concept. Defined to select appropriate beam sizes and beam arrangements, taking into consideration the net effect of all the possible geometrical variations and inaccuracies in order to ensure that the prescribed dose is actually absorbed in the CTV. Its size and shape depend on the CTV but also on the treatment technique used, to compensate for the effects of organ and patient movement, and inaccuracies in beam and patient setup.
OAR (Organ at Risk) Normal tissues whose radiation sensitivity may significantly influence treatment planning and/or prescribed dose.
PRV (Planning Organ at Risk Volume) Includes margin around the OAR to compensate for changes in shape and internal movement and for set-up variation.
TV (Treated Volume) Volume enclosed by an isodose surface.
IV (Irradiated Volume) The volume that receives a dose that is significant in relation to normal tissue tolerance.
CI (Conformity Index) Relationship between TV and PTV (TV/PTV).

 

Lateral tumors

Lateral tumors are located on the cheek, gum, and retromolar space with 1 cm distance to the midline without spreading to contralateral lymph nodes. In these cases, a treatment technique can be utilized to reduce the dose absorbed by healthy tissue of the oral cavity and neck. Tongue cancer and tumors growing into tongue muscle should always, regardless of localization, be treated as a midline tumor.

Midline tumors

Midline tumors are located on the tongue, floor of the mouth, and hard palate.

These tumors and tumors reaching these regions that originate in the cheek and gum have a tendency to metastasize bilaterally. Malignant cells can spread with lymph drainage from the anterior tongue directly to midjugular and supraclavicular lymph nodes.

Preparation

Before the first session of radiation treatment, a customized plastic mask is made for the head/neck of the patient to immobilize the area to be treated.

This is followed by a CT examination while in the mask to mark tumor tissue and organs at risk.

In the head/neck region, there are many organs at risk with limited tolerance for radiation such as the:

  • spinal cord
  • parotid gland
  • optic tracts
  • brain stem
  • internal ear

A uniform dose distribution over the target volume is ideal with complete avoidance of critical organs. In practice, however, this is impossible to achieve. There will always be a compromise between what is possible and desired.

Preparation for simulation which involves modeling and drawing of radiation fields takes about one week. When this is completed, the patient is ready to start radiation treatment.

Naxogin®

Naxogin® is a drug that mimics the effect of oxygen.

Cells are three times more radiosensitive in the presence of oxygen (oxygen effect). Because of inadequate blood supply, squamous epithelial carcinomas over a few millimeters lack oxygen. A result of this is that cells in certain areas can survive radiation therapy and be a source for persistent disease or recurrence.

Radiation therapy is therefore more effective on tumor with adequate oxygen supply. Naxogin is now routinely used for radiotherapy of laryngeal cancer in Denmark and Norway.

The emetic effect of the drug, however, is a disadvantage.

Implementation

Dose and fractionation

Patients are treated with photons, but sometimes in combination with electrons . The dose rate should be between 0.5 and 5 Gy per minute. A homogeneous dose should always be striven for, possibly with use of a compensation dose.

It is important to maintain the planned treatment schedule.

Standard treatment

All fields are treated at each fractionation.

  • 46 Gy to union of all ITV (=CTV)

  • 70 Gy to union of all GTV (concomitant boost, 6 fx/week)
  • 6 fractionations per week  
  • 1 fraction daily, Monday-Friday
  • The 6th fractionation is given additionally on one of the week's first 5 days, but always with a 6 hour interval. 

Unforeseeable interruptions

Not more than one extra fractionation per week is the goal, and missed sessions should be given within one week. This is done by giving an extra fractionation on the weekend, or the same day as the planned fractionation with ≥ 6 hours interval.

Follow-up

The patient will have regular follow-up with the radiation therapy department.

Side effects of radiation therapy:

Acute

  • Mucositis
  • Salivary gland dysfunction
  • Dry mouth due to reduced saliva secretion
  • Taste disturbances
  • Pain
  • Thick mucous
  • Fungal infection

It is very important to have good follow-up of the mouth and nutritional status.

Late

  • Salivary gland dysfunction
  • Dry mouth
  • Taste disturbances
  • Tooth decay
  • Periodontal disease
  • Osteoradionecrosis
  • Trismus
Primary radiation therapy for oral cavity.Primary radiation therapy for oral cavity.Primary radiation therapy for oral cavity.Radiation therapy for oral cavity.
Primary radiation therapy for oral cavity.Primary radiation therapy for oral cavity.Primary radiation therapy for oral cavity.Postoperative radiation therapy
Postoperative radiation therapy

Postoperative radiation therapy for the mouth

General

The risk for recurrence after surgery alone varies according to localization.

Radiation therapy targets the area of the tumor because there is often microscopic residual disease despite "free" resection margins evaluated by light microscopy. In addition, regional lymph nodes are irradiated either for manifest regional metastases or because of the primary tumor's localization, and/or the T stage suggests high probability for microscopic disease in regional lymph nodes.

The interval between surgery and radiation therapy should be as short as possible, preferably 3-4 weeks (<5 weeks).

The target volume and dose are adapted for each patient.

Indication

  • Oral cancer

Goal

  • Postoperative radiation therapy is intended to remove microscopic residual disease and prevent and/or eradicate spreading to cervical lymph nodes.

Definitions

Target volume

 

Definitions of target volumes according to ICRU (International Commission on Radiation Units and Measurements)
CTV (Clinical Target Volume) Tissue volume that contains a GTV and/or subclinical microscopic malignant disease, which has to be eliminated.
ITV (Internal Target Volume) Volume encompassing the CTV and IM. (ITV = CTV + IM)
PTV (Planning Target Volume) Geometrical concept. Defined to select appropriate beam sizes and beam arrangements, taking into consideration the net effect of all the possible geometrical variations and inaccuracies in order to ensure that the prescribed dose is actually absorbed in the CTV. Its size and shape depend on the CTV but also on the treatment technique used, to compensate for the effects of organ and patient movement, and inaccuracies in beam and patient setup.
OAR (Organ at Risk) Normal tissues whose radiation sensitivity may significantly influence treatment planning and/or prescribed dose.
PRV (Planning Organ at Risk Volume) Includes margin around the OAR to compensate for changes in shape and internal movement and for set-up variation.  
TV (Treated Volume) Volume enclosed by an isodose surface.
IV (Irradiated Volume) The volume that receives a dose that is significant in relation to normal tissue tolerance.
CI (Conformity Index) Relationship between TV and PTV (TV/PTV).

Lateral tumors

Lateral tumors are located on the cheek, gum, and retromolar space with 1 cm distance to the midline without spreading to contralateral lymph nodes. In these cases, a treatment technique can be utilized to reduce the dose absorbed by healthy tissue of the oral cavity and neck. Tongue cancer and tumors growing into tongue muscle should always, regardless of localization, be treated as a midline tumor. 

Midline tumors

Midline tumors are located on the tongue, floor of the mouth, and hard palate.

These tumors and tumors reaching these regions that originate in the cheek and gum have a tendency to metastasize bilaterally. Malignant cells can spread with lymph drainage from the anterior tongue directly to midjugular and supraclavicular lymph nodes.

Preparation

Before the first session of radiation treatment, a customized plastic mask is made for the head/neck of the patient to immobilize the area to be treated.

This is followed by a CT examination while in the mask to mark tumor tissue and organs at risk.

In the head/neck region, there are many organs at risk with limited tolerance for radiation such as the:

  • spinal cord
  • parotid gland
  • optic tracts
  • brain stem
  • internal ear

A uniform dose distribution over the target volume is ideal with complete avoidance of critical organs. In practice, however, this is impossible to achieve. There will always be a compromise between what is possible and desired.

Preparation for simulation which involves modeling and drawing of radiation fields takes about one week. When this is completed, the patient is ready to start radiation treatment.

Implementation

Dose and fractionation

Patients are treated with photons . The dose rate should be between 0.5 and 5 Gy per minute. A homogeneous dose should always be striven for, possibly with use of a compensation dose.

It is important to maintain the planned treatment schedule.

Standard treatment

All fields are treated at each fractionation.

  • Radically operated (R0) will have 50 Gy (T1-2) or 60 Gy (T3-4)
  • Non-radically operated (R1/R2) and levels with extracapsular growth will have 66 Gy
  • Elective lymph nodes will have 46-50 Gy
  • 5 fractionations per week
  • 1 fractionation daily, Monday-Friday.

The interval between surgery and radiation therapy should be as short as possible, preferably 3-4 weeks (<5 weeks).

Postoperative irradiation to at least 60 Gy after a neck lymphadenectomy done if there is:

  • extranodal growth in one or more lymph nodes
  • tumor infiltration in lymph nodes at multiple levels
  • tumor tissue in soft tissue/skin
  • involved resection margins/residual tumor
  • mid-linear primary tumors (contralateral neck field)

Some of the above mentioned factors may require local boosts to higher doses.

Unforeseeable interruptions

Not more than one extra fractionation per week is the goal, and missed sessions should be given within one week. This is done by giving an extra fractionation on the weekend, or the same day as the planned fractionation with ≥ 6 hours interval.

Follow-up

The patient will have regular follow-up with the radiation therapy department.

Side effects of radiation therapy:

Acute

  • Mucositis
  • Salivary gland dysfunction
  • Dry mouth due to reduced saliva secretion
  • Taste disturbances
  • Pain
  • Thick spit
  • Fungal infection

It is very important to have good follow-up of the mouth and nutritional status.

Late

  • Salivary gland dysfunction
  • Dry mouth
  • Taste disturbances
  • Tooth decay
  • Periodontal disease
  • Osteoradionecrosis
  • Trismus
Postoperative radiation therapy for oral cavityPostoperative radiation therapy for oral cavityPostoperative radiation therapyPostoperative radiation therapy

Palliative radiation therapy for the head/neck region

General

Patients with advanced cancer and short expected survival time may benefit from both symptom-relief and prevention by radiation therapy. In some cases, radiation treatment may also extend survival. 

Normal tissue has a greater ability to repair itself between fractionations compared to tumor tissue. Radiation therapy is therefore given with one or few fractions with good effect and little side effects. In this way, a high total dose is given to the tumor tissue but injury to healthy tissue is still limited. 

It is very important that acute side effects are minor and of short duration.

Palliative radiation therapy is used both for primary tumors, local recurrence, and metastases.

Indications

  • Incurable cancer in the head/neck region.
  • Clear association between metastasis(es) and symptom(s). 

Goal 

  • Relieve symptoms
  • Prevent symptoms

Definitions

Target volume

 

Definitions of target volumes according to ICRU (International Commission on Radiation Units and Measurements)
CTV (Clinical Target Volume) Tissue volume that contains a GTV and/or subclinical microscopic malignant disease, which has to be eliminated.
ITV (Internal Target Volume) Volume encompassing the CTV and IM. (ITV = CTV + IM)
PTV (Planning Target Volume) Geometrical concept. Defined to select appropriate beam sizes and beam arrangements, taking into consideration the net effect of all the possible geometrical variations and inaccuracies in order to ensure that the prescribed dose is actually absorbed in the CTV. Its size and shape depend on the CTV but also on the treatment technique used, to compensate for the effects of organ and patient movement, and inaccuracies in beam and patient setup.
OAR (Organ at Risk) Normal tissues whose radiation sensitivity may significantly influence treatment planning and/or prescribed dose.
PRV (Planning Organ at Risk Volume) Includes margin around the OAR to compensate for changes in shape and internal movement and for set-up variation.
TV (Treated Volume) Volume enclosed by an isodose surface.
IV (Irradiated Volume) The volume that receives a dose that is significant in relation to normal tissue tolerance.
CI (Conformity Index) Relationship between TV and PTV (TV/PTV).

 

Preparation

Locoregional radiation therapy

The irradiated volume should be limited to the absolute minimum. This requires CT dose planning for treatment.

Before the first treatment session, a customized plastic mask is made for the patient to immobilize the head/neck area.

A CT examination is then performed while the patient is wearing the mask to label tumor tissue and organs at risk.

In the head/neck region, there are many organs at risk with limited tolerance for radiation, such as the:  

  • spinal cord
  • brain stem
  • parotid gland 
  • optic chiasm
  • internal ears
  • optic nerves
  • lenses
  • eyes 

A uniform dose distribution over the target volume is ideal with complete avoidance of critical organs. In practice, however, this is impossible to achieve. There will always be a compromise between what is possible and desired.

Preparation for simulation which involves modeling and drawing of radiation fields takes about one week. When this is completed, the patient is ready to start radiation treatment.

 

Implementation

Fractionation and total dose will depend on whether the patient has received radiation therapy in the same area previously.

If the problem is locoregional, for example a recurrence, the first attempt will be 20 fractions of 1.5 Gy, 10 fractions per week.

If the tumor responds and the patient tolerates treatment, an additional series with the same fractionation can be attempted after 14 days.

Metastases causing symptoms outside the head/neck region, such as painful bone metastases, can be treated with higher fractions, possibly 10 fractions of 3 Gy.  

Follow-up

Most side effects occurring during treament are due to normal organs included in the radiation field. The dose levels used for pure symptom relief are, however, held low to minimize the risk for acute side effects. 

The total dose is at a level to minimize the risk for late effects.

Good follow-up is important to achieve adequate relief of symptoms and usually takes placed with the patient's local hospital or primary care doctor. 

Palliative radiation therapy for the head/neck region.Palliative radiation therapy for the head/neck region.Palliative radiation therapyPalliative radiation therapy

Complication treatment of oral cancer

Surgery, systemic treatment, and radiation therapy cause side effect to varying degrees.

It is usually necessary to provide supportive care in order for the patient to complete and achieve the full effect of planned treatment.

Supportive care can also be given to reduce the side effects and to improve the patient's quality of life during and after treatment.

PROSEDYRER

Nutritional status and radiation therapy

General

Many head/neck patients are at risk for developing malnutrition, which is associated with increased morbidity and illness. Malnutrition is more difficult to treat than to prevent.

Monitoring nutritional status is an important part of treatment. The goal is to identify malnutrition as early as possible in order to initiate measures quickly. 

Radiation therapy is often intensive and causes side effects such as dry mouth, pain, mucositis, and taste disturbance. 

Indication

  • Radiation therapy to the head/neck region.

Goal

  • Maintain nutritional status in the period of acute side effects caused by radiation therapy.

Background

Weight loss is one of the most important signs of change in nutritional status. A weight loss of more than 10% over the past 6 months or more than 5% over the last 3 months is a significant and serious weight loss. If the weight loss occurs in combination with low BMI (body mass index) (< 20 kg/m2 for adults) and/or a food intake of less than 60% of the calculated requirement over the past 10 days, the patient will be malnourished or be at nutritional risk.

Calculation of nutrition and fluid requirements

  • Ambulatory patients: 30-35 kcal/kg/day
  • Bed-ridden patients: 25-30 kcal/kg/day
  • Elderly above 70 years: Recommended amount is reduced by 10%
  • Fluid requirement: 30-35 ml/kg/day  

Actions include offerring the patient a diet that is appropriate for their symptoms and nutritional status. The patient should be offered nutritionally-rich food, snacks, nutritional beverages, tube feeding, and intravenous nutrition.  

Small, frequent meals

Patients must often have food of softer consistency and milder in taste. This requires the food to be as rich in nutrition as possible. These patients will need 6-8 small meals per day to meet their energy need.

Enrichment of food and beverages

The most effective way to enrich food and drink is to use ordinary foods such as cream, oil, butter, sour cream, mayonaise, etc. 

Enrichment of food and drink is done to increase the energy content of the meal without increasing the volume. This is done for patients who eat too little and therefore need energy-rich food. 

Enrichment powders

  • are not supplemented with vitamins, minerals, or trace elements
  • are supplemented usually with only fat, carbohydrates, or protein (sometimes a combination of fat and carbohydrates). 

Some powders are nutritionally complete, that is, a given amount includes everything the body needs of energy and vitamins and minerals. There are also powders neutral in taste which do not affect the taste or consistency of food. 

Nutrional beverages

Nutritional beverages may be used as a meal in itself or between meals. Nutritional drinks can be a more valuable snack than "normal" food, because it is often easier for the patient to drink than to eat. It has been shown that if nutritional drinks are introduced as snacks, it does not affect the energy intake during the main meals.

There are a number of ready-made nutritional drinks on the market. Some of the products are of nutritionally complete. They contain carbohydrates, protein and fat and are supplemented with all the necessary vitamins, minerals and trace minerals and possibly fiber. Some of these products can be used as the sole source of nutrition. The energy content varies from 85-200 kcal/100 ml and some products have a high protein content.

The products are also adapted for age, and the dose is determined individually by a clinical dietician/doctor.

Many patients prefer homemade nutritional drinks based on full fat milk, cream, ice cream, fruit and possibly flavor supplements. These are free of additives and have a fresher taste. The energy and protein content is close to the commercial products and at the same time they are more sensibly priced.

Tube feeding

Tube feeding is preferable to total parenteral nutrition (TPN) when the digestive system is working. Nutrition supply to the intestine is more physiological. It protects against bacterial growth, maintains the intestine's mucous membrane structure and function, and promotes motility. Tube feeding involves less risk of metabolic complications.

Tube feeding is used in the event of

  • insufficient food intake (less than 60% of energy requirements) over the past 5-7 days despite oral intake
  • weight loss >2 % over the past week, >5 % over the past month or >10 % over the past 6 months
  • danger of weight loss due to planned treatment
  • low albumin values (under 35 g/l, lower limit for normal area)
  • stenosis with feeding obstacles in pharynx/gullet

Tube feeding must not be used for the following conditions.

  • Paralysis or ileus of the alimentary tract
  • Short bowel syndrome
  • Serious diarrhea
  • Serious acute pancreatitis
  • Obstruction of the intestine
  • Serious fluid problems

Tube feeding solutions

The tube feeding solution must be nutritionally complete because they are used as the sole source of nourishment. The most frequently used are standard (1 kcal/ml), or energy-rich (1.5 kcal/ml) solutions with or without fiber. There are also tube feeding solutions adapted for patients with digestion and absorption problems, patients with diabetes or lactose allergy, and intensive care and cancer patients.

Parenteral ernæring

Parenteral nutrition should only be used if food by mouth or tube feeding cannot be maintained. Parenteral nutrition can also be used as a supplement to tube feeding or ordinary food if the patient's nutrional needs are not met by this alone.

Precautions must be taken for the following conditions:

  • Renal failure
  • Heart failure
  • Lung failure
  • Large fluid or electrolyte loss
  • Diabetes mellitus
  • Liver failure 

Preparation

Subjective Global Assessment (SGA)

Subjective Global Assessment (SGA) is a scheme for classifying the patient's nutritional status.

Based on information about weight, food intake, symptoms and physical function, the patient is classifed as well-nourished, somewhat undernourished, or seriously malnourished. This categorization as shown to correlate well with more objective goals for nutritional status as well as morbidity, death, and quality of life. 

Other tables that are frequently used are Malnutrition Universal Screening Tool (MUST), Mini Nutritional Assessment (MNA) and Nutrition Risk Score (NRS). In principle, these schemes are prepared in the same way as SGA, but they are not validated for patients with cancer.

Actions include offerring the patient a diet that is appropriate for their symptoms and nutritional status. The patient should be offered nutritionally-rich food, snacks, nutritional beverages, tube feeding, and intravenous nutrition.

Tube feeding

The end of the tube is often inserted into the stomach. In the event of poor gastric function, total gastrectomy or pancreatic resection, the feeding tube should be inserted in the duodenum or jejunum. The position of the feeding tube is vital for the choice of tube feeding solution and mode of administration.

The most common method is to insert the tube nasogastrically, but it can also be done through the abdominal wall (PEG).

Parenteral ernæring

Peripheral veins can be used for short-term parenteral nutrition. In this case, a large vein on the forearm is used and a small needle. Nutrition is then given as more diluted solutions.

Central veins must be used for TPN with high osmolality.

Implementation

All patients are weighed regularly (1–2 times each week). This is a prerequisite to being able to register changes in the nutritional status.

Tube feeding

Tube feeding is given continuously with a low drop rate or by interval/bolus administration (individually adapted meals with high drop rate).

When the patient's energy and fluid requirements are fulfilled, it will be decided whether the patient will be given bolus or continuous supply at night, in order to increase mobilization during the day. However, this requires that the patient does not have diarrhea, nausea or other complaints associated with the supply of nutrition.

For a running feeding tube:

  • Every 4-8 hours, it should be aspirated in order to monitor the gastric emptying. This applies especially to immobile and weak patients.
  • Weekly or more often, the nutrition program/fluid balance, evaluation, edema control, blood tests (albumin, K, Mg, P, blood glucose) should be monitored weekly or more often.
  • Every 6 weeks, the tube should be changed. Alternate nostrils avoid irritation in the nose through prolonged feeding.  
 

If it is not possible to administer drugs orally, it can be done via a tube. It is recommended to use drugs available in fluid form. Tablets can also be crushed and dissolved in water or gluocose water.

Experience shows that the use of infusion pumps causes fewer side effects and ensures correct volume and rate.

Bolus supply

Initiation of tube feeding with bolus supply is only recommended

  • if the patient been taking any food until the last 24 hours
  • if the patient is taking some food and requires tube feeding for additional nourishment

It is recommended to use pumps for bolus supply for the first 1–2 days.

Continuous supply

If the patient cannot tolerate bolus supply (vomiting, abdominal discomfort, nausea, diarrhea), reverting to continuous supply should be considered.

Tube feeding should always be administered continuously to very malnourished patients or if the tube end is located distally to the pylorus.

Parenteral ernæring

If the patient has a satisfactory nourishment status, begin with 100% of the requirement. If the patient is seriously malnourished and at risk for refeeding syndrome, renourishment should start slowly (10 kcal/kg/day), thereafter increasing slowly to 100% over 4-7 days. 

The patient must be monitored closely in relation to

  • electrolytes (potassium, phosphate and magnesium).
  • infusion rate.
  • twenty-four hour urine sample and fluid balance should be calculated daily.
  • glucose in the blood and urine, and electrolyte in the blood should be examined daily at the start.
  • liver tests, kidney function tests and triglycerides should be taken examined at least once every week.

For TPN treatment longer than 1 month, vitamins and trace elements should be examined.

Follow-up

The patient's nutrition status should be monitored at follow-up visits after the end of treatment.

Oral Hygiene Associated with Radiation Therapy

General

Radiation treatment to the head/neck region causes bothersome side effects to the mouth. Proper care and hygiene of the mouth are therefore very important for the patient to be able to complete radiation treatment without unnecessary side effects.

Indication

  • Radiation therapy toward the head/neck region.

Goal

  • Prevent side effects from treatment
  • Relieve side effects from treatment
  • Maintain healthy status of teeth and oral mucosa 
  • Promote well-being

Background

Radiation treatment to the head/neck region is detrimental to the mucous membranes of the mouth, teeth, jawbone, salivary glands, temporomandibular joint, masticatory muscles depending on radiation dose and location, and may cause acute and chronic side effects.

Mucositis is one of the most common acute side effects from radiation to the head/neck. It is defined as an inflammation-like process in the oral mucous membrane caused by ionizing radiation. Ninety to 100% of patients treated with radiation to this region develop mucositis. The extent varies with radiation field and dose. Mucositis increases the risk of serious infections including sepsis.  

Other acute side effects:

  • Infection
  • Salivary gland dysfunction
  • Dry mouth due to reduced saliva secretion
  • Taste dysfunction
  • Bleeding
  • Pain
  • Viscous mucous 

Pain in the mouth can reduce the patient's quality of life by reducing food intake, causing dysphagia, and hoarseness. The acute side effects last for up to 4-6 weeks after end of radiation therapy. 

Chronic side effects:

  • Salivary gland dysfunction
  • Dry mouth
  • Taste dysfunction
  • Cavities in the teeth
  • Periodontal disease
  • Osteo(radio)necrosis
  • Reduced mouth opening (trismus)

Optimal dental and oral hygiene without damage to the teeth, jaw, mucous membranes, and salivary glands, prevents and reduces severity of side effects and complications.

Preparation

Patients to be treated with radiation toward the head/neck region should have the following assessed and/or treated before treatment starts.

  • Cavities in the teeth (number/severity)
  • Teeth which require endodontal therapy 
  • Periodontal disease
  • Periapical infection and other pathology in the jaw
  • Disease status related to wisdom teeth (pericoronitis)
  • Number of teeth which should be extracted 
  • Oral hygiene (instruction and follow-up)
  • Salivary gland dysfunction (information/measures)
  • Mucous membrane symptoms
  • Edges of teeth or fillings that may cause trauma to the mucosa
  • Temporomandibular dysfunction, measure of mouth opening

At least two week interval is necessary between tooth extraction and start of radiation treatment.

Implementation

Measures to reduce side effects in the mouth from radiation therapy

Fluoride is effective for fighting cavities and can be ingested by chewable tablets, gum, or mouthwash. For patients suffering from dry mouth, a mouthwash is the most gentle mode. Fluoride should be taken in the morning and evening.  

If the patient has a sore and dry mouth, a toothpaste with a mild soap or a sodium lauryl sulphate-free toothpaste should be used. Dental floss and/or an interdental brush should be used daily.

The mouth should be rinsed with lukewarm 9% NaCl  after each meal, preferably more frequently. Mouthwash such as Corsodyl® should only be used for short periods to optimize the oral hygiene, diluted 50% with water. If toothbrushing and rinsing is to painful, the teeth may be cleaned with Q-tips soaked in Corsodyl®.

Due to the high risk of cavities in the teeth, sugar intake should be reduced.

For dry mouth, it helps to drink copious amounts of fluids. If necessary, artificial saliva and moisturizing gels can be used. It may also help to chew gum to stimulate saliva secretion. Sugar-free chewing gum is recommended. 

Oral hygiene for patients with sore mucous membranes

  • Use lip balm/cream. 
  • The patient is offered a pain medication 30 minutes before oral cleaning. The mucosa can also be numbed with viscous Xylocain® or Andolex® mouthwash.

If the oral cleaning will take place in the patient's bed, the patient should lie with their head to the side to avoid fluid draining down their throat.

  • Hold the pus basin under the mouth through the entire cleaning. 
  • For ulcers and crusts in the mouth, wash the patient's mouth with a swab dipped in 3% hydrogen peroxide (1 tbs to 1/2 glass water). This will loosen crusts and remove mucous.
  • Start by washing the tip of the tongue and work further dorsally on the upper and lower surface of the tongue and finish with the inside of the cheeks. Brush the teeth with a soft toothbrush and use a mild toothpaste.

In cases of suspicion of an infection, examine for bacteria, fungi, or a virus.

  • Use tooth floss or an interdental brush between the teeth.
  • Frequent change of toothbrush.
  • After cleaning the mouth, lubricate the patient's mucosa.
  • Finally, the lips should be lubricated with lip balm/cream.

Oral cleaning should take place at least 2 times per day.

Oral hygiene for patients with dentures

Before cleaning the mouth, the dentures are removed to clean with a toothbrush or nailbrush. Dish soap or toothpaste can be used. For tartar, dentures can soak in 7% vinegar overnight. Coregas® dissolvable tablets can be used to prevent tartar.

When the mouth is dry, dentures may loosen. It may be necessary to use an adhesive. The adhesive should be removed daily before a new layer is applied.  

The mucosa will be thinner as a result of radiation treatment. Dentures or sharp edges may therefore more easily give rise to blisters. Some patients may find it difficult to wear dentures.

Blisters from dentures increase the risk for developing osteoradionecrosis. In these cases, the patient should not wear dentures.

If the denture does not fit properly, adjustments should be postponed until the condition of the mouth has normalized. This usually takes 4-6 weeks after the last radiation treatment.  

Follow-Up

Observations

  • Formation of ulcers and possible sign of infection in the mouth
  • Pain
  • Mouth opening should be measured regularly after radiation treatment if temporomandibular joint and jaw muscles were included in the radiation field. Jaw exercises should be implemented to keep adequate mouth opening.
Oral hygieneOral hygieneOral hygiene

Smoking cessation in connection with cancer treatment

General

In patients treated with surgery, radiation and/or chemotherapy, the treatment efficacy may be affected by smoking. Smoking has an impact on both metabolism and pharmacokinetics.

Smoking may inhibit wound healing after surgery and increase the probability of surgical site infections. Because smokers generally have more mucus in the airways and are less able to remove it, they also may have a increased risk of serious lung complications during anesthesia. However, it is disputed whether or not it is beneficial to quit smoking directly prior to surgery and this should be considered in each case individually. (28,30-33). Smokers are more prone to stagnation of bronchial secretion than non-smokers and rapid postoperative extubation is important. 

Patients who continue smoking during radiation therapy have a lower risk of complete respons, development of secondary cancer, increased toxicity and several other side effects compared to non-smokers and smokers that quit before treatment. Continued smoking during radiation therapy is also associated with oral mucositis, impaired ability to taste, dry mouth, reduced voice quality, weight loss, cachexia, fatigue, pneumonia, bone-and soft tissue necrosis.

Tobacco may have an effect the metabolism and the mechanisms of chemotherapy and in this way may make the treatment less effective. Smokers undergoing chemotherapy may also experience a weakened immune system, increased rates of infection, exacerbation of common side effects, weight loss, cachexia, fatigue and cardiac or pulmonary toxicity. Some findings suggest that it may also apply to monoclonal antibodies.

Cancer patients who quit smoking before chemo- and radiation therapy get a total symptom burden equal to that of non-smokers, but those who continue to smoke state a higher symptom burden. Targeted measures in smoking cessation may increase quality of life and lead to less treatment interruptions.

A lot of patients wonder if there is any point to quit smoking after receiving a cancer diagnosis. tudies show that continued smoking is associated with increased treatment-related toxicity, increased risk of second primary cancers, reduced quality of life, reduced treatment effect and reduced survival in patients with cancer. This applies to both cancer diagnoses where smoking is a known causal factor, as with lung- and head and neck cancers and in cases where smoking has no known correlation with the diagnosis. Studies conducted on smoking and cancer diagnoses such as breast cancer, prostate cancer, colorectal cancer, esophageal cancer, cervical and ovarian cancer as well as leukemia and lymphoma cancers show that to continuation of smoking after a proven cancer diagnosis is associated with increased risk of mortality.

Studies support that quitting smoking improves cancer, and emphasizing the potential importance of targeted smoking cessation in cancerpatients during and after treatment. The link between tobacco and impact on cancer and cancer treatment is a complex matter.

Regarding the significance of the various components much is still unkown. When it comes to tobacco use in cancer treatment research is primarily done on the link between cigarette smoking and efficacy of cancer treatment. Nevertheless, it cannot be excluded that using other smokeless tobacco products such as snuff and chewing tobacco, may also impact the cancer treatment. According to international guidelines all tobacco use should be stopped during cancer treatment.


Benefits of smoking cessation and risks of continued smoking in patients with cancer
Quitting smoking results in the following benefits: Continued smoking results in a risk of :
  • improved treatment results.
  • less side effects
  • fewer infections
  • improved respiration and circulation
  • increased survival
  • reduced efficacy of treatment.
  • postoperative complications and longer recovery.
  • cardiovascular and respiratory complications.
  • recurrence of cancer, and secondary cancer.
  • shortened life expectancy.

 

Indication

Weaning of nicotine in connection to cancer treatment. 

Goal

Healthcare providers should convey evidence-based information to patients about how smoking affects cancer treatment, the risk of side effects and prognosis and also provide guidance and relevant treatment for smoking cessation.

Preparation

Patients require clear, formalized and fact-based guidance and continuous follow-up. Many patients want encouragement for smoking cessation early in the disease. Being hospitalized is a good opportunity because patients have access to support and help to reduce nicotine withdrawal symptoms and discomfort.

A patient recently diagnosed with cancer is often motivated to quit smoking and also receptive to conversations about how to do this. Motivation or willingness to quit often changes during the treatment, and use of tobacco and motivation should therefore be discussed at every consultation.

Clarifying the patient´s smoking habit is important. The time of day the patient lights their first cigarette says something about the degree of addiction. Making the patient aware of the situations in which he or she smokes most; at work, at home or in social settings, can help break unwanted patterns of behavior.

Implementation

The best and most direct approach to motivate the patient is telling that tobacco use will decrease the effectiveness of treatment and the most important thing the patient can do himself is to stop using tobacco.

  • Speak directly to the patient about how tobacco use may decrease the effectiveness of treatment.
  • Discuss smoking cessation with the patient at each visit.
  • Clarify any misunderstandings about the risks of tobacco use. Point out the importance of quitting.

Sometimes there may be misunderstandings about what kind of health risk smoking during and after cancer treatment may entail.

Advice to those who are not ready for smoking cessation
The smokers statement The response of health care professionals
Justifications
The damage from smoking is already done.
Some damage is done, but continued smoking will still damage your health and reduce the effects of treatment. Quitting smoking is more important now than ever.
This response tells the patient that it is not too late to quit smoking, and the effect of treatment will be positive.

I have reduced smoking.
That is great, and now you need to focus on quitting completely. What do you think keeps you from quitting altogether?
This response tells the patient the importance of quitting completely, as the benefits of quitting at baseline are documented.
This is not a good time to quit smoking.
The benefits of quitting are greatest now, before treatment begins. What is needed to make you feel ready to quit smoking?
 
This response make the patient aware of the fact that quitting smoking optimizes the cancer treatment.

Health professionals must assist the patient identifying realistic expectations and goals for smoking cessation. For some, it may feel easier to scale down the number of cigarettes than to quit completely. The patient should know that every puff affects their health, and that the total health benefits can only be achieved through smoking cessation. For patients unable to stop completely, a gradual reduction may be a step in the right direction.

The probability of success for smoking cessation significantly increases for those who receive professional help in combination with nicotine replacement therapy (NRT) or non-nicotine based products. For the best possible effect of NRT the patient needs professional guidance to find the right product and dosage. For some patients combining two products or receiving a higher dosage than recommended will give the best effect. Sometimes the product must be replaced during the treatment.

Treatment with nicotine replacement therapy

Topical products are patches (Nicorette®, Nicotinell®), chewing gum (Nicorette®, Nicotinell®), lozenges (Nicorette®, Nicotinell®), inhalator (Nicorette®) or a combination of these. These products contain nicotine and therefore reduce the withdrawal symptoms experienced after smoking cessation.

  • Patch: Nicorette® 5 mg,10 mg and 15 mg/16 hours up to 6 months or Nicotinell® 7 mg,14 mg og 21 mg/24 hours up to 3 months.
  • Chewing gum: Nicorette®/Nicotinell® 2 mg and 4 mg, 8-12 pcs/day up to 12 months.
  • Lozenges: Nicorette® 2 mg and 4 mg, typically 8-12 pcs/day, maximum respectively 15 pcs/day up to 9 months or Nicotinell® 1 mg and 2 mg, typically 8-12 pcs/day, maximum is respectively
    25 and 15 pcs/day up to 12 months.
  • Inhalator: Nicorette® 10 mg/dosage container, 4-12 pcs/day up to 6 months.

Combination therapy means combining patches with chewing gum, lozenges or an inhalator.

  • Nicorette® patch15 mg/16h and Nicorette chewing gum 2 mg. 5-6 chewing gums daily. Maximum 24 pcs/day
  • Nicorette® patch 15 mg/16h and Nicorette® inhalator 10 mg: 4-5 dosage-container daily. Maximum 8 pcs/day

Nicotine replacement therapy increases the chance of smoking cessation by 50 to 70% after six months. Two products used in combination increase the chance of smoking cessation compared to the use of only one product.

Side effects

  • Headache, dizziness, nausea, flatulence and hiccup.
  • Irritation in the mouth and esophagus using chewing gum/ lozenges/inhalator
  • Skin irritations while using patches.

Precautions

  • Precaution in acute cardiovascular disease, peripheral arterial disease, cerebrovascular disease, hyperthyroidism, diabetes mellitus, kidney- and liver failure and peptic ulcers.
  • Should not be used during pregnancy, unless the potential benefit outweighs the potential risk.
  • The products should not be used during breastfeeding.

Treatment with non-nicotine medications

Bupropion (Zyban®) is a selective reuptake inhibitor of dopamine and norepinephrine. The mechanism behind why the ability to refrain from smoking increases by using bupropin is unknown. A should be set for smoking cessation for the second week of treatment.

Bupropion increases the chance of smoking cessation after 6 months by nearly 70%.

Side effects

  • Dry mouth, nausea, insomnia, hypersensitivity reactions and seizures (convulsions)

Precautions

  • Contraindicated in people with disease that can cause convulsions,  people with substance abuse or other circumstances lowering the seizure threshold.
  • Depression, which in rare cases includes suicidal thoughts and – behavior including  suicide attempt.
  • Safety and efficacy have not been established for people under 18 years.
  • Should not be used during pregnancy.

Varenicline (Champix®) is a partial agonist by a subtype of nicotinic receptors. It has both agonistic activity with lower intrinsic efficacy than nicotine and antagonistic activity in the presence of nicotine.

A date for smoking cessation should be set. Treatment should start 1-2 weeks, or up to 35 days, before that date. The starting dose is 0,5 mg one time daily on days 1-3, then 0,5 mg two times daily on days 4-7, then 1 mg two times daily on day 8 and until the end of treatment. The treatment should last for 12 weeks.

Side effects

  • Nausea, sleep disturbances, headache, constipation, flatulence and vomiting

Precations

  • Links have been reported between the use of varenicline and an increased risk of cardiovascular events, suicidal thoughts, depression and aggressive and erratic behavior
  • Safety and efficacy have not been established for people under 18 years of age
  • Should not be used during pregnancy

Follow-up

If the patient experiences a relapse, it is important to inform them that this is completely normal, and encourage them to continue. If the most common measures do not work,
consideration should be given both to increase the NRP and to provide closer follow-up by health care providers.

Guidance in smoking cessation is described in the literature as brief and clear advice and then further follow-up with a telephone helpline offering treatment for addiction and behavior change/issues. It is not necessary for the patient to have decided to quit smoking in order to be referred to a quitline. If the patient agrees to receive a call from quitline, he or she will be followed up by a supervisor. Supervisors are bound by confidentiality, are up-to-date professionally and offer free follow-up counseling calls for up to a year.

References

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Treatment of Nausea Induced by Chemotherapy

General

The majorities of chemotherapy drugs are emetic to varying degrees and may cause nausea and vomiting. Today, there are efficient antiemetic drugs that can significantly reduce the side effects.

Other factors that can aggravate or prolong the presence of nausea and vomiting are: pain, anxiety, electrolyte disturbances, constipation, dyspepsia, and ulcers.

There is a distinction between acute nausea, which occurs within the first 24 hours, and late nausea, which occurs later than 24 hours after the treatment.

Acute nausea can be effectively treated with 5HT3-antagonists (ondansetron, tropisetron, palonosetron), and possibly combined with steroids. Dopamine antagonists (metoklopramid, metopimazine) also have some effect on acute nausea. If this treatment is not effective, it may be improved with aprepitant.

If standard prophylaxis and treatment of nausea is not satisfactory, other nausea regimens should be tried.

Indication

  • Nausea induced by chemotherapy drugs.

Goal

  • Prevention and treatment of nausea and vomiting.

Definitions

Chemotherapies according to emetic potential

High emetogenicity   

Group 1

Moderate emetogenicity   

 Group 2

Low/minimal emetogenicity

Group 3

All cisplatin-containing regimens (CiFu, GemCis, BEP, TIP, VIP, PV, AP, EDP, DHAP, ECX, weekly dose cisplatin, and others) BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosfamide, vincristine, prokarbazine, prednisolone)
Doxorubicin/epirubicine weekly dose
Doxorubicin/ifosfamide Bendamustine
Docetaxel
FEC-60 og FEC-100
(fluorouracil, epirubicin, cyklophosfamide)
Carboplatin
ENAP (etoposide, mitoxsantrone, cytarabine, prednisolone)
ABVD (doxorubicin, bleomycin, vinblastine, dakarbazine Carboplatin/pemetrexed
FLv (fluorouracil)
FOLFIRINOX
Carboplatin/vinorelbine
FuMi (fluorouracil, mitomycin)

CHOP (cyclophosfamide, doxorubicin, vincristine, prednisolone)
Gemcitabine

CHOEP (cyclophosfamide, doxorubicin, vincristine, etoposide, prednisolone)
Methotrexate weekly dose
   Dakarbazine
Navelbine
      ECO/ACO (epirubicin/doxorubicin, cyclophosfamide, vincristine)
Paclitaxel
       EOX (epirubicin, oxaliplatin, capecitabine)
Pemetrexed
      EPOCH-F (etoposide, prednisolone, vincristine, cyclofosfamide, doxorubicin, fludarabine)

    EPOCH-F (etoposide, prednisolone, vincristine, cyclophosfamide, doxorubicin, fludarabine)
 
    FLIRI (fluorouracil, irinotecan)
 
    FLOX (fluorouracil, oxaliplatin)    
   Gemcitabine/carboplatin      
   HD-Cytarabine
   
    HD-Methotrexate    
  IGEV (ifosfamide, gemcitabine, vinorelbine)
  
   IME (ifosfamide, methotreksate, etoposide)  
   Irinotecan  
   Streptozocin  
   Vorphase (cyclophosfamide)
 

References

  1. Lehne G, Melien Ø, Bjordal K, Aas N, Mella O. Kvalme og oppkast ved cytostatikabehandling i: Dahl O, Christoffersen T, Kvaløy S, Baksaas. Cytostatic Medication cancer treatment. 7. edition. Oslo. Department of Pharmacotherapeutics and The Norwegian Cancer Society, 2009, p 119-130.

Preparation

Nausea regimens are selected according to the emetogenicity of the relevant drugs.

  • Inform about the risk for and treatment of nausea. 
  • In the event of anxiety or conditional nausea, give tranquilizers if necessary.

Implementation

  • Start with an optimal antiemetic regimen starting with the first cycle of chemotherapy in order to counteract the amplification of the nausea that often occurs with a new treatment.
  • Start the oral antiemetic regimen 1-2 hours before chemotherapy and approx. 15-30 minutes before an intravenous injection.
  • If the patient is already nauseous, the medication should be administered parenterally or rectally.

Antiemetic regimens

Mildly emetic chemotherapy

  • Metoclopramide 10 mg is given intravenously before treatment with cytostatic agents.
  • Metoclopramide 10 mg is given orally uptil 3 times.

Moderately emetic chemotherapy

Ondansetron 8 mg orally 2 x daily. In the event of nausea before treatment, give ondansetron intravenously. If this has little effect, try ondansetron 8 mg x 3 or change to a 5HT3-antagonist, for example, tropisetron 5 mg orally/intravenously or palonosetron 250 µg intravenously.

Highly emetic chemotherapy, or if other treatment does not help

For highly emetic chemotherapy drugs, or if other treatment is not adequate, a 5HT3-antagonist can be given orally or intravenously. It should be combined with dexamethasone 8-16 mg intravenously ½-1 hour before treatment, and further, 8 mg x 2 intravenously or orally on the first day.

In addition, dopamine antagonists may be given, for example, metoclopramide 10 mg x 3.

In some cases, traditional nausea treatment is not sufficient. In this case, the patient can be treated with aprepitant. Aprepitant is used for highly emetic regimens and for patients where the usual antiemetic treatment has failed during moderate emetogenic treatment. Aprepitant is given orally 1 hour before chemotherapy and is combined with dexamethasone and 5HT3-antagonists:  125 mg capsules orally on day 1, then 80 mg orally on days 2-5, depending on the duration of the treatment. Aprepitant can enhance the effect of taxane and etoposide, as well as vinorelbine, and can reduce the effect of warfarin.

The regimen is repeated daily if highly emetic treatment is given over a number of days.

Delayed nausea

Aprepitant in combination with dexamethasone and 5HT3-antagonists is preferable if there is a high risk of delayed nausea and vomiting. This is offered especially to patients who have previously experienced delayed nausea.

Conditional nausea

In the event of conditional nausea, diazepam or other tranquilizers may be considered. Diversion or desensitization can be tried in more serious cases.

Follow-up

Ondansetron can have a constipating effect. Use of a laxative for several days should be considered.

Transfusions

General

Transfusions of blood components are often necessary for the patient to complete the planned cancer treatment.

Blood transfusions are appropriate for low hemoglobin (Hb) and thrombocyte transfusions for low thrombocytes (trc) which also poses a risk for serious bleeding.

Normal values

  • Hemoglobin 13.4–17 g/dl
  • Platelets 145–348 109/l

Indications

Blood transfusion

Assessment for a blood transfusion based on:

  • Hb/hct
  • symptoms/sign/function level
  • underlying disease (heart/lung, serious infection)
  • expected development of anemia (marrow function, current bleeding)
  • acute blood loss > 15% of total blood volume
  • Hb < 8.0 g/dl and symptom causing chronic anemia
  • Hb < 8.0 g/dl and reduced bone marrow production without sign of regeneration
  • Hb < 8.0 g/dl in perioperative period
  • Hb < 7.0 g/dl in patients without symptoms of other disease
  • Hb < 10.0 and receiving radiation therapy

Platelet transfusion

The patient is assessed for thrombocyte transfusion based on:

  • clinical status (bleeding, bleeding tendency, or fever/infection)
  • ongoing bleeding and thrombocytopenia < 50x19/l
  • degree of thrombocytopenia and cause of thrombocytopenia (reduced production or increased consumption)

Prophylactic platelet transfusion

  • For values < 10x109/l secondary to previous chemotherapy
  • Before invasive procedures
  • For spinal puncture and installation of central vein catheter, thrombocytes should be 30x109/l and 
  • Puncture biopsies (liver/kidney/tumor) > 40x109/l
  • For major surgeries, thrombocytes should be > 50x109/l. After surgery, thrombocytes should be monitored and transfusion repeated, if necessary.

Remember clinical evaluations: possible bleeding, other risk factors for bleeding, diagnosis, treatment, prognosis.

Goal

  • Complete the planned treatment
  • Ensure hemostasis 
  • Ensure adequate oxygen transport to peripheral tissue.
  • Maintain intravascular fluid volume for adequate circulations of vital organs

Definitions

Blood

For a blood transfusion for anemia, SAGMAN erythrocytes are used. One unit is obtained from 450 ml blood. Most of the plasma is removed and replaced with 100 ml SAGMAN solution (Saltwater-Adenine-Glucose-Mannitol). Hematocrit is about 0.60%.

Platelets

One unit contains 240-300 x 109 platelets and is prepared from blood donors with type O and A. In acute situations, the receiver's blood group is of minor importance.
Two kinds of platelet products are available:
  • Apheresis platelets produced from thrombophereses from one donor
  • Buffcoat platelets produced from buffy coat from 4 donors

All cellular blood products should be leukocyte filtered. Leukocyte filtration is done to remove antigen-presenting and virus-bearing cells. 99.99% of leukocytes in the unit are removed.

Radiation

Blood and thrombocytes are irradiated to a minimum of 25 Gy in the blood bank to eliminate T-lymphocytes.

This is done for:

  • Bone marrow transplant or stem cell transplant (1 month before or 3 months after HMAS until 1 year after allogeneic stem cell transplant)
  • For use of HLA-compatible platelet concentrations
  • For all transfusions from relatives
  • For use of fresh blood
  • For use of fludarabine

Preparation

Blood tests

Before the first blood transfusion, the following blood tests are performed:
  • Virus antigens
    • HCV
    • HBV
    • HIV
Every three days, and as needed, pre-transfusion tests are taken.

Compatibility

Erythrocyte concentration—Rh(D) negative products can usually be given to everyone while Rh(D) positive can only be given to Rh(D) positive receivers.

Thrombocyte concentration—Rh(D) negative girls and women in fertile ages who obtain Rh(D) positive thrombocyte products should be given a prophylaxis for Rh immunization. Boys/men and women who are over the fertile age may obtain thrombocytes regardless of Rh(D) type.

Implementation

Blood components should never be given together with other medications.
  • Premedication if the patient has reacted to previous transfusions.
  • Secure venous access
  • The blood product is checked to ensure the correct unit is given to the correct patient.
  • Use blood set with filter
  • Give SAGMAN over 1 hour and thrombocytes 20-30 minutes per unit.
  • Rinse the set with NaCl 9 mg/ml at the end of the infusion
  • Store the blood product bag for one day before discarding

Observations

The patient should be observed during the transfusion with emphasis on reactions. Most serious transfusion reactions occur within the first 20 minutes.

Symptoms of transfusion reaction:
  • chills
  • fever
  • feeling of heat in the face
  • breathing difficulty
  • itching
  • nervousness
  • fall in blood pressure
  • shock
Suspect/manifest blood transfusion reaction:
  • Stop transfusion immediately
  • Start treatment if necessary (intravenous fluid, adrenalin, steroids, oxygen, respirator)
  • Check blood bag and compatibility form. The residue should be sent to the blood bank.

Follow-up

Hemoglobin and thrombocytes are checked.

If poor effect of platelet transfusion, platelet value should be checked after approximately one hour. The value should have increased by approximately 30x109/l or more after a standard dose.

If the increase is drastically less, the cause may be:
  • Abnormally high consumption. This is an indication for more frequent transfusions.
  • Antigens against HLA or platelet-specific antigens. The patient must be examined in cooperation with the blood bank to find compatible donors.

Febrile Neutropenia

General

Febrile neutropenia occurs in compromised immune systems due to a low number of leukocytes, especially granulocytes. Patients with a declining number of granulocytes after chemotherapy, can during bacterial sepsis, quickly develop extensive neutropenia and become critically ill. Febrile neutropenia can be a life-threatening condition.

A patient with neutropenia and simultaneous fever or clinical suspicion of systemic infection should be treated as quickly as possible with broad spectrum antibiotics including gram-negative and gram-positive coverage as soon as the required microbiological samples are taken.

The clinical situation is most critical in patients who have not yet started antibiotic treatment. When broad-spectrum antibiotic treatment is started, monitoring the fever may be permitted.

Fever is often the only symptom. Some have septicemia without fever. One should therefore also be aware of other symptoms such as lethargia, diarrhea, or visible sign of infection. The local clinical symptoms and signs (redness, pain, temperature increase, swelling (boil), and reduced organ function) are most often very much reduced or completely absent during neutropenia.

Indications

  • A patient with neutropenia and simultaneously fever or clinical suspicion of systemic infection

Goals

  • Avoid septicemia.
  • The patient is able follow the planned scheme of treatment.

Definitions

Fever is defined as:

  • a single (rectal) temperature ≥ 38.5 °C or
  • temperature ≥ 38 °C for more than 2 hours or
  • temperature ≥ 38 °C measured three times during 24 hours

There is a known increase of infections when neutrophil < 1.0 x 109/l.  The infection risk increases with degree and duration of neutropenia. The neutropenia is considered severe when granulocytes are ≤ 0.5 x 109/l.

Preparation

The following diagnostic tests should be performed:

  • Adequate microbiologic tests: blood culture x 2-3, throat/nasopharynx, urine, catheter opening any surgical incisions. All blood cultures should be taken simultaneously to avoid losing valuable time.
  • Blood culture and other microbiological samples should be taken before antibiotic treatment is started
  • Blood tests with differential count of leukocytes, thrombocytes, Hb, CRP, SR, creatinine
  • X-ray of chest

Information

Before initiation of chemotherapy, the patient should be extensively informed, both verbally and in writing, of febrile neutropenia and  its consequences.

A patient who can develop febrile neutropenia should obtain a written statement of the condition to present to other treatment providers.

Use of an isolated or private room

Patients with neutrophil granulocytes ≤ 0.3 x 109/l should have a private room if possible. Guidelines for protective isolation should be followed. Thorough washing of hands is especially important.

 

Implementation

  • Treatment is started as soon as possible.  Treatment may be postponed a maximum of 30 minutes to complete microbiological testing.
  • Start septicemia treatment for fever if neutropenia is expected, regardless of granulocyte value.

Antibiotic regimen

  • Benzylpenicillin sodium 5 mg IE x 4 tobramycin or gentamicin 5-10 mg/kg x1
  • Tazocin® 4 g x 3
  • Cefotaxime® 1 g x 4 if aminoglycoside should be avoided
  • Ceftazidim® 1 g x 4  with suspicion of pseudomonas infection
  • Meronem ® 0.5 g x 4 usually 2nd or 3rd choice

When using aminoglycoside, the first dose should be high. Keep in mind the following:

  • age
  • sex
  • kidney function
  • fat index   

Otherwise, the dose should be decided from concentration of aminoglycoside determined after the second day and thereafter monitored 2x per week. 

Serum concentration of tobramycin and gentamycin

For single dose in 24 hours

  • Trough concentration (0-test = 24 hour test) < 0.5 mg/l
  • Top concentration (30 minute after infusion is completed) > 12 mg/l

For multiple doses in 24 hours

  • Trough concentration < 2 mg/l, top concentration (30 minutes after the infusion is completed) preferably > 8-10 mg/l 
  • Avoid aminoglycoside :
    • If kidney function is reduced. Avoid aminoglycoside if cisplatin is used. If cisplatin has been previously used, many patients will have subclinically reduced kidney function. If necessary, use aminoglycoside for a short period and monitor kidney function closely.
    • If carboplatin is used, determine glomerulus filtration rate (GFR) for each new treatment. Penicillin/aminoglycoside can be used if GFR is stable (has not declined more than 15% if initial value is in the normal range)
    • With sarcoma: Protocols with very high doses methotrexate and ifosfamid (> 5 g/m2) should be used in sarcoma treatment. It is not abnormal for these patients to have an increase in creatinine.
    • with massive ascites
    • with suspicion of or documented myeloma kidney (myelomatosis)
    • If aminoglycoside has been used in the past two weeks
  • Suspicion of staphylococcus aureus as a cause of infection (relatively rare)
    • Give penicillinase-stable penicillin, cloxacillin, or dicloxacillin, possibly clindamycin instead of ordinary penicillin. Yellow staphylococci are also killed by cefotaxime and by merop
  • Gram-positive cocci in multiple blood cultures and if the patient has clinical signs of infection
    • Use vancomycin 500 mg x 4 until resistance determination is available
  • Poor patient condition and suspicion of gram-negative septicaemia
    • Use “double gram-negative” with for example ceftazidim or tobramycin
    • Other preparations with good effects against most gram-negative bacteria are meropenem and ciprofloxacin
  • Suspicion of anaerobic infection
    • Use an anaerobic drug: Metronidazol 500 mg x 3, clindamycin 600 mg x 4, piperacillin/tazobactam 2g x 4 or meronem 500 mg x 4.  This especially applies if there is suspicion of anaerobic infection under the diaphragm such as gallbladder, intestines, perforation, abscess.
    • penicillin is often adequate for anaerobic infections above the diaphragm.

With continuing clinical signs of infection, adjust the antibiotic treatment according to resistance determination in blood culture. Maintain gram-negative coverage.

Systemic fungal treatment

By persistent fever after multiple days with broad spectrum antibiotic treatment, one should consider empirical treatment of possible candida-sepsis, for example with fluconazole 600 mg the first 24 hours, and thereafter 400 mg x 1.

If candida is documented without adequate response to fluconazole, a fungicide drug should be used, for example amphotericin B.

If suspected infection with Aspergillus apply voriconazole, amphotericin B or caspofungin.

Follow-up

Observe for symptoms of a new infection.

Bone Marrow Stimulation with G-CSF

General

Bone marrow stimulation with G-CSF (Neupogen®, Granocyte®) is only recommended for febrile neutropenia which does not respond to antibiotic treatment, severe neutropenia (granulocytes < 0.5 x 109 /L for more than 1 week), and in cases where it is necessary to administer curative treatment with sufficient dosage intensity.

Indications 

  • To maintain dosage intensity for curative treatment; when a reduction in dosage will significantly reduce the chance of cure.
  • As prophylaxis for treatments associated with a high risk for febrile neutropenia (> 40 %)
  • Febrile neutropenia that does not respond quickly to antibiotic treatment
  • Long-lasting neutropenia

Goal

  • Maintain treatment intensity

Preparation

The patient should be adequately informed about the treatment.

Implementation

  • The dosage of Neupogen® is 5 µg/kg daily. The treatment is initiated, at the earliest, 48 hours after the treatment is completed. The treatment continues for 10 days.
  • The dosage of Neulasta® is 6 mg subcutaneously administered 24 hours after chemotherapy is completed. The neutrophil cells are counted on day 15.
  • The subsequent course is started on day 21, if the neutrophil count is 0.5 or higher, and the patient has not had febrile neutropenia.
  • It is important not to postpone the treatment if the neutrophil count is 0.5 or higher. The neutrophil count will compulsory decline after ending Neupogen® stimulation. Low values at the start of treatment should not be alarming if the values during hospitalization have been high enough to avoid febrile neutropenia.
  • Stimulation late in the cycle should only be performed for long-lasting, severe neutropenia. At least 48 hours should pass after completed stimulation treatment before the next chemotherapy course  is started. In these cases, it is always important to check that the doses are correct and to recalculate GFR etc. Continuation of chemotherapy will either require a drastic dosage reduction or secondary prophylaxis with G-CSF.

 

Follow-up Care

It is of utmost importance that the patient is informed of the risk of infections associated with a low neutrophil count.

Patients at risk for developing  very low values, must be  informed to take their temperature if they feel unwell or  febrile. In case of  a temperature above 38 °C they should contact their doctor immediately.

Movement and strict bed rest for threatening spinal cord lesion

General

Approximately 5% of the patients with advanced malignancies develop symptoms of threatening spinal cord lesion. The condition is most frequently in patients with cancer originating from lungs, prostate or breast, but is also seen in other types of cancer where bone metastases may occur.

Symptoms

  • Pain in the back, possibly in the neck
  • Changes in existing pain (increased intensity, changed character, radiance of pain)
  • Pain that worsens with exertion (for example cough, sneeze or going to the toilet)
  • Walking difficulties and inability to control the extremities
  • Paralysis of the legs and-/or arms
  • Loss of sensation
  • Urinary problems and/or defecation problems

The stability in columna

  • Ambulatory patients without neurological deficits do not need strict bed rest.
  • For other patients, it may be appropriate to have strict bed rest until the stability of columna is assessed. The need of strict bed rest is assessed by a physician based on the risk of increased neurological deficits and the degree of pain. When columna is considered stable enough (usually clarified 2 to 4 days after the initiation of radiotherapy), gradually mobilization until pain threshold should quickly get started. Increasing pain or neurological deficits should be observed during mobilization.
  • For strict bed rest, the head end of the bed can be elevated up to 30 ° C.
  • If flat bed rest causes increased pain, the head end of the bed should be raised until pain reduction.

Indication

  • Threatening spinal cord lesion caused by tumor/metastases.

Goal

  • Limit spinal cord damage so that  functions may be maintained.

Preparation

The patient and their family should receive proper information and guidance regarding to disease, treatment and restrictions. For advanced disease, small chance of getting better and short life expectancy, quality of life rather than strict restrictions should be emphasized.

The patient should, if he/she wishes, be involved in decisions regarding to treatment and further training.

Implementation

Use of cervical collar and corset

  • Lack of documentation of the effect of using cervical collar and corset, require the patient's wishes to be taken into account in assessing whether this should be used.
  • Cervical collar may be relevant for spinal cord lesions in the cervical level of the spinal cord. Some patients find this pain relieving. A neurologist/neurosurgeon will decide whether there is a need for cervical collar.
  • A corset are generally not used preoperatively, but if prescribed by a surgeon, it may be used postoperatively.
  • The corset must be adjusted by a prosthetist or physiotherapist.
  • The corset is put on in either supine position, sitting position or in standing position, initially by competent personnel. The patient is instructed to put on the corset unassisted.

Bed rest and positioning

  • The patient should be referred for physical therapy at an early stage. To avoid accumulation of mucus in the lungs, the physiotherapist should give instructions in appropriate breathing exercises, consider use of mini-pep and need for chest physiotherapy.
  • Patients who need strict bed rest must have electrically controlled bed with a pressure relieving mattress.

Movement in bed

  • The patients must be instructed in how to move to lateral position in bed using logrolling. Logrolling involves moving to lateral position without rotation or flexion/extension in columna. The healthcare staff are performing the movement to lateral position by rolling the patient while their hands are securely placed over the patient's hips and back/shoulder.
  • If the patient has mobility in the legs, he/she may, using bent knees and hips and feet down in the mattress as well as arms straight up in the air as levers, roll over to lateral position.
  • When the patient needs to be moved higher up in bed, the bed should be tilted a bit backward, the patient is lifted calmly with the sheet close to the body by means of the draw sheet and two persons.
  • Slingbar is not recommended for cervical or thoracic lesions.

Activity during bed rest

  • By instructions from a physiotherapist, nurses can assist the patient to do appropriate activity and exercises. Passive exercises when paresis or paralysis is present, otherwise active exercises.
  • Activity that causes pain must be interrupted.
  • Individually customized movements of upper and lower extremities, passive or active, are carried out in a supine position with a low strain on columna.
  • A footboard made of compact foam at the end of the bed is an aid to prevent the patient from sliding down in the bed and provides a resistant surface against which the patient can push for a good venous-/muscle pump.
  • Strength training of arms by static resistance to the mattress and without movement of the columna, is recommended. Light hand weights for arm exercises are only considered when the affection is in the lumbar level.
  • The need for contracture prophylaxis is considered, and if there is a drop foot a footboard should be customized.
  • Instructions in self-training will be given, preferably also as a written program as well.

Thrombosis prophylaxis

  • Bedridden patients should have compression stockings in thigh/- possibly knee length, unless contraindicated.
  • Patients at high risk of venous thrombosis should also have subcutaneous thrombosis prophylaxis with low molecular weight heparin.
  • The duration of thrombosis prophylactic treatment is considered individually based on current risk factors, general health condition and mobilization of the patient.

Pressure relief and prevention of pressure ulcers

  • Patients who must have strict bed rest is particularly prone to pressure ulcers.
  • Prevention of pressure ulcers must be followed in relation to risk assessment, assessment of the patient's skin, skin care, nutrition, pressure relieving underlay, change of position in bed/chair and mobilization.
  • For patients with/having strict bed rest, change of positions in bed must be in accordance with the restrictions.

Bladder function

  • An assessment of  the bladder function is done at arrival. An accuracate anamnesis is obtained: Last urination, episodes of incontinence, frequency, painful urination and abdominal pain.
  • Evaluate the  bladder function at least once a day for any changes.
  • If incontinence, insert a permanent catheter.
  • If it turns out to be permanent muscle tone, evaluate eventually intermittent catheterization or insertion of suprapubis catheter.
  • Bedpan/urinal bottle should be easily accessible at strict bed rest. When using bed pan, loggrolling is required.

Gastrointestinal function

  • An assessment of  the gastrointestinal function is done at arrival.
  • An accuracate anamnesis is obtained: Last bowel movements, frequency, consistency, nausea/vomiting, abdominal pain and previous ailments.
  • Evaluate the gastrointestinal function evaluated at least once a day.

Pain relief

  • Spinal cord compression can cause severe pain that may be difficult to treat. If so, contact the pain -/palliative team.

Mobilization

  • The patient and the healthcare staff collaborate to find the right level of activity.
  • Go gradually from an increased angle on the bed`s back rest to sitting position, to sitting position on the bedside and then to standing position. The back rest is gradually raised to about 45 ° and the bed´s leg-rest is angled and the patient can try this sitting position, further to 60 °. By worsening of pain and/or neurological outcomes, the patient is returned to the previous position for reconsideration. If the increase of the back-rest is unproblematic, the patient can further be mobilized to the bedside.
  • The first time the patient is moved to sitting position on the bedside, this is preferably done by a physiotherapist together with a nurse by rolling over to lateral position (logrolling). The patient sits up assisted by two persons, one at the upper body and one supporting the legs over the edge of the bed.
  • When affection in the cervical region only, the patient can be mobilized up to a sitting position by raising the head of the bed and bring the legs over the bedside. The patient is allowed to sit for a little while, blood pressure and pain are evaluated.
  • Exercises to increase circulation and good breathing exercises are recommended. Balance in a sitting position is considered.
  • When the patient is moved to standing position, custom walking aids must be used (pulpit walker or forearm walker). To ensure safe mobilization the first time, assistance of two persons are recommanded.
  • For lasting paresis, a high-back reclining wheelchair with leg rests should be customized.
  • The need of other aids, like transfer slide board, drop foot brace, grasping forceps and similar equipment, should be considered.
  • Instruction in self-training should be given, preferably after a written program in standing exercise and walking exercice with support.
  • Gradually, the patient can sit  for short periods of time, using a good armchair with a high seat and good backrest.

Follow-up Care

  • Patients with a long life expectancy should be considered for further training at a suitable institution.
  • Patients with a short expected life expectancy are usually not recommended for stay at rehabilitation institutions.

The website www.physiotherapyexercises.com is recommended for obtaining exercises.

Follow-up care after treatment of oral cancer

Follow-up is crucial for diagnosing and treating recurrence and any possible secondary malignant tumors early (7). It also provides the opportunity for determining side effects of treatment as well as to provide psychosocial support. Patients should be monitored for 5 years. Only 15% of recurrences appear later than 3 years after treatment is over (6).

Number of consultations per year:

  • 1st year: 3–4 visits
  • 2nd year: 2–3 visits
  • 3rd year: 2–3 visits
  • 4th-5th year: 1–2 visits

Follow-up in the first year should take place at the treating hospital and later with the referring physician/clinic.

Each follow-up visit should include a complete physical examination with relevant endoscopic examinations as well as ultrasound of the neck. An X-ray of the neck may be necessary.

In cases where the thyroid gland is irradiated, T4 and TSH should be measured once a year.

Effects of treatment

Treatment causes varying degrees of side effects. Most side effects will disappear after treatment is over.

Patients who have undergone radiation therapy may have chronic side effects in the form of:

  • salivary gland dysfunction
  • dry mouth
  • taste disturbances
  • tooth decay
  • periodontal disease
  • osteoradionecrosis
  • trismus

PROSEDYRER

Fatigue before, during, and after Cancer Treatment

General

There are many reasons why cancer patients feel fatigued. In many patients, the causes are synergistic. Cancer patients are often very sick during treatment periods and may experience extreme fatigue during intensive chemotherapy. It is also very important to be aware that fatigue is a symptom of many other medical conditions, both physical and psychological, which also affects cancer patients. Some known causes of fatigue associated with cancer and cancer treatment are: 

  • Cancer itself
  • An operation
  • Current or recently concluded chemotherapy
  • Current or recently finished radiation therapy
  • Severe anemia
  • Other symptoms such as pain and nausea 
  • Fever or infection
  • Too little fluid or food intake
  • Reduced lung function
  • Changes in sleep
  • Worries, anxiety, stress, or depression

For some of these conditions, such as infections, there is medical treatment available. Fatigue that occurs after an operation or during chemotherapy and radiation therapy will, for most, gradually disappear when strength is regained. If a patient was feeling healthy after treatment and all of the sudden experiences fatigue, they should contact their doctor. If a patient feels fatigue and at the same time feels stressed, worried, or down, they may be reluctant to speak to their doctor or health personnel about it. It is still recommended to talk about these problems. Talking about it may be therapeutic, and provides room for discussing measures with a qualified person with experience with patients that have the same problems. For cured patients experiencing chronic fatigue, it may be difficult to pinpoint a specific cause. Many of these patients experience improvement by changing their lifestyle to a lower tempo than before the diagnosis.

Definition

Everyone knows what it feels like to be tired, fatigued, or lethargic when sick. This feeling is the most common side effect of cancer and cancer treatment. A symptom is a condition or state that something is not right in the body. Other frequent symptoms associated with cancer and cancer treatment are reduced appetite and nausea. Most patients who experience fatigue associated with cancer say that the feeling does not improve with rest, and many describe a lack of energy or exhaustion.  

If fatigue arises during chemotherapy or radiation therapy, most patients experience that it will gradually go away when treatment is over and their strength is regained. This type of fatigue is considered acute. Improvement may take time depending on the intensity of treatment. Some patients experience that fatigue lasts for months, or even years. This is considered chronic fatigue. The ability to carry out daily activities, a lack of humor, health-related worries, a reduced capacity to carry out work functions, or less energy for family, can also accompany chronic fatigue. Most patients will find it difficult to be told by their doctor that they are considered healthy, while their friends and family expect them to be normal again, despite having a lack of energy and ability to perform activities they want to.  

For many, feeling fatigued is often accompanied by having difficulty concentrating, poor memory, and an increased need for sleep. Most patients will need more sleep than before they became sick. For many, sleep is not restful, and it may take time to "get going" in the morning. Many also experience that they quickly become drained of strength if they exert themselves, and that it takes a long time before regaining strength after exertion. Exertion in this context can mean both physically and mentally such as working on a task that requires concentration.

Preparation

Fatigue can occur in all phases of cancer illness. Some patients feel it before the diagnosis, and almost all patients experience fatigue during radiation therapy or chemotherapy. A minority of patients experience long term fatigue after cancer treatment is over and the disease is cured. Patients who cannot be cured will almost always feel tired, worn-out, and exhausted. The degree of fatigue in these patients varies depending on the cancer type, spreading, and other symptoms of the disease.

The patient should be given necessary information on both causes of fatigue and measures he/she can take.

Implementation

General measures that can reduce feeling tired and fatigued

Following suggestions are meant as general advice that may not necessarily apply to everyone in all situations. This advice is based on results from studies, experiences from cancer patients, and recommendations from experts. Each patient should assess what works for them. It is recommended to express concerns and seek advice for what measures you can take and what you should avoid.

General advice
  • Try to live as "normal" as possible.
  • Try to plan your day to include time to rest.
  • Take many small breaks during the day instead of a few long ones.
  • Rest after strenuous activity.
  • Plan your daily activities and do those that are most important for you.
  • Set realistic goals for yourself and try to be happy with those you accomplish.
  • Try to recognize activities that make you especially tired/fatigued and limit them, or spread them out over longer intervals. 
  • Try to accept that you do not have the energy to do the things you could previously.
  • Assess what is important for you to do yourself and what you can allow others to do.
  • Assume you will be tired after something strenuous even if you experience the activity as positive.

Physical activity and exercise

Exercise and physical activity that is appropriate for you will reduce the feeling of fatigue. Regular exercise is the most effective measure against chronic fatigue in cancer patients. Nevertheless, both too much and too little exercise can worsen fatigue, therefore, it is important to find a level (frequency and intensity) that suits you. You should never exercise so intensely that you must stop a session or exercise period because you are exhausted. Remember that daily form varies for everyone and adjust your exercise routine accordingly. Make long-term goals (months) and gradually increase activity, and carefully for a period. 

  • Activities such as walking, biking, swimming, dance, and aerobics are recommended.
  • Light exercise periods at regular intervals are better than intense, sporadic periods.
  • Always start with a slow tempo and increase gradually before finishing with a slow tempo again.
  • Always sit down and rest after exercise but try not to lay down and sleep.
  • Physical therapists and sport pedagogs can provide advice on exercises that are right for you. The principles are the same for all exercise, but it should be adjusted for your energy level.  

Sleep

Many cancer patients with chronic fatigue have sleep pattern disturbances. It is important to maintain a normal rhythm even if you feel like sleeping during the day.

  • Try to wake up at the same time every day and keep a regular bedtime.
  • Avoid too much activity right before bedtime.
  • Try not to sleep during the day because this will disturb your biological rhythm.
  • But, a short afternoon nap may be energizing!
  • Rest during the day by relaxing in a good chair, but try not to fall asleep.
  • Speak to your doctor about lasting sleep disturbances.

Nutrition

Having a reduced appetite or intake of food can also result in a lack of strength and energy. We recommend eating healthy food regularly, and to follow the national guidelines on nutrition. Special diets or supplements do not improve fatigue unless there is a deficiency.

Work situation

Some patients do not have the strength to continue working, or they must reduce their hours because of chronic fatigue. Consulting with a social worker may be beneficial for guidance regarding your work situation, your welfare rights, and financial situation. 

Some adjustments that you and your employer can make:

  • Discuss the possibility for more simple or easier tasks, especially if you have a physically demanding profession.
  • Assess the possibility of reducing your hours.
  • Remember to take regular breaks also at work, if possible.
  • Assess the possibility of flexi-time to work during the hours you have energy, as well as the possibility of working from home.

Care for children

Caring for children or adolescents may be very difficult when you are fatigued or lack energy and strength. There are, however, some measures you can take:

  • Explain to your children that you are tired and are not able to do as much as you used to.
  • Discuss what the children can help you with and allow them to take part in household chores.
  • Try to establish permanent household chores for all family members.
  • Try to do activities that suit you that do not require too much energy, and can be performed without too much exertion. 
  • Ask and accept help from others for driving to and from activities, school, etc. if this relieves you.

Drug therapy

In Norway, there is currently no specific drug therapy for chronic fatigue associated with cancer. If the fatigue is due to specific conditions, this is of course treated with medication, if possible. Sometimes, such treatments improve the fatigue, but other times they do not. Examples of treatment that often reduce fatigue are treatment for infections and depression. 

Treatment with medications that stimulate production of red blood cells is not recommended for cancer patients due the the danger of serious side effects.

Follow-up

Information about fatigue

Healthcare workers in cancer care will often have knowledge about fatigue and cancer. Most general care physicians have general experience with fatigue but meet relatively few cancer patients. There is a lot of information available on the internet of varying quality. Below is a list of web adresses and some literature. Be aware that you may find opposing advice because knowledge on treatment especially, is limited.

Some articles/books:

  • Armes J., m.fl. (2004). Fatigue in cancer. Oxford University Press.
  • Berger A.M., m.fl. (2009). NCCN Clinical Practice Guidelines in Oncology. Cancer-Related Fatigue. www.nccn.org
  • Patarca-Montero R. (2004). Handbook of cancer-related fatigue. Haworth Medical Press

Lymphedema

General

According to etiology, there are two general classifications of lymphedema primary and secondary lymphedema. Primary lymphedema is caused by deficient or faulty development of the lymph system. Secondary lymphedema occur as a complication from trauma or diseases which damage the lymphatic vessels or lymph nodes. The primary cause of lymphedema in the western world, is impaired or disrupted flow of lymph fluid caused by cancer or cancer treatment (secondary lymphedema).

Lymphedema occurs when the transport capacity of the lymph system is reduced significantly.
The swelling is caused by an accumulation of fluid (rich in protein) in the tissue, due to reduced drainage of lymph fluid (1,2). The swelling is often chronic. A lymphedema can lead to pain/discomfort and changes in the soft tissues in the affected area (fibrosis) (3,4). Lymphedema occurs most often during the first 2-3 years after cancer treatment (5 6). Without treatment, lymphedema can lead to progressive swelling.

In some cancer treatment the lymph nodes and fatty tissue are removed, most often in the axilla, pelvis and the groin. This treatment causes damage to the lymphatic wessels and reduces the number of lymph nodes. The subsequent reduced capacity for drainage of lymph fluid in the arm and leg may result in lymphedema.

Radiation therapy may cause tissue scarring and fibrosis. The combination of surgery and radiation therapy to the axilla additionally increases the risk of developing lymphedema.

Cancer related lymphedema can also occur due to metastasis in areas where blocking the central lymph vessels in advanced disease.

Factors which may increase the risk for developing lymphedema are:

  • obesity
  • infection in the area where lymphedema occurs
  • overheating/sunburn
  • trauma of the arm/leg on the operated side

Indications for treatment

Lymphedema in the arm/hand, breast, leg, groin, face and neck after treatment of:

  • breast cancer where axillary dissection is performed
  • gynecologic cancer where the lymph nodes in the pelvis or the groin are removed
  • melanoma where the lymph nodes in the axilla or the groin are removed
  • lymphoma and cancer of the head and neck region where lymph nodes in the neck region are removed
  • prostate cancer where the lymph nodes in the pelvis or the groin are removed
  • sarcoma where lymph nodes are removed

Without treatment the lymphedema can increase in size. This may cause skin changes (fibrosis), increased swelling and therefore more discomfort in the area (3).

Contraindications

Absolute
  • acute infections, local or general (erysipelas)
  • arterial insufficiency with risk of necrosis
  • thrombosis and embolism
Relative

Untreated cancer disease, heart failure, or kidney failure

Goal

  • reduce lymphedema
  • relieve tormenting side effects
  • improve function 
  • prevent complications such as skin changes and inflammation in the area (erysipelas)

References

1. Rockson SG. Diagnosis and management of lymphatic vascular disease. J Am Coll Cardiol 2008;52:799-806.
2. Lawenda BD, Mondry TE, Johnstone PAS. Lymphedema: (Review) A primer on the identification and management of a chronic condition in oncologic treatment. CA Cancer J Clin 2009;59:8-24.
3. Mortimer PC. The patophysiology of lymphedema. Cancer 1998;83(12 Suppl American): 2798-802.
4. Erickson VS, Pearson ML, Ganz PA, Adams J, Kahn KL. Review: Arm edema in breast cancer patients. J Natl Cancer Inst 2001;93:96-111.
5. Nesvold IL, Dahl AA, Løkkevik E, Mengshoel AM, Fosså SD. Arm and shoulder morbidity in breast cancer patients after breast-conserving therapy versus mastectomy. Acta Oncol 2008;47:835-842.
6. Norman SA, Russel Locario A, Potashnik SL, et al (2009) Lymphedema in breast cancer survivors: incidence, degree, time course, treatment, and symptoms. J Clin Oncol 2009;27:390-397.
7. Johansen J, Overgaard J, Blichert Toft M, Overgaard M. Treatment morbidity associated with the management of the axilla in breast-conserving therapy. Acta Oncol 2000;39:349-54

Definitions

Complete psysical therapy treatment of lymphedema

Consists of manual lymph drainage, compression therapy, skin care and instruction in exercises and self-treatment (1). The treatment is performed by physical therapists with special expertise.
The treatment may be extensive at the start. In cases of severe swelling one usually start with manual lymph drainage followed by bandaging of the arm/leg (1).

Manual Lymph Drainage

This is a kind of massage which requires guided training to perform optimally. The goal is to encourage the drainage of lymph fluid and thereby reduce the swelling of the tissue (2). It is quite different from other kinds of massage applied within physiotherapy. The anatomical conditions of the lymph system is the basis for manual lymph drainage. These are: the course of the large lymph veins, the borders of different lymphatic functional regions (watershed), natural anastomoses crossing these lines, and the lack of valves in the lymphatic vessels .

Bandaging

Bandaging is used mostly at the start of a treatment to reduce swelling. When the swelling is reduced a compression stocking is adjusted.

Compression stocking

Clinical experience and research show that compression is the most important treatment. (3;4) Accordingly it is of great importance to adjust a compression stocking for the arm or leg. If there is swelling of the hand, a compression glove might help.
A compression stocking is used to increase tissue tension. The pressure from the stocking increases absorption of tissue fluid. The stocking provides a graded pressure highest distally and lowest proximally. To adjust the stocking, the circumference of the arm or leg is measured at several defined points. There are several compression classes, but the most commonly used are class 1 and 2. The stocking should provide a constant pressure without causing discomfort. It may take some time to get used to the compression stocking. Some choose to use the stocking occasionally, while others wear it daily.
A facemask at night is recommended to treat lymphedema in the neck and face region (5). Patiens with lymphedema in the groin can be helped by using a bike pant or a panty. Bandaging, tubigrip or bike pants may benefit if there is swelling of the penis and scrotum .

Intermittent pressure massage with pulsation

Treatment is carried out with an electronically powered apparatus which blows air in a double-walled cuff. The cuff, covering the whole arm or leg, has multiple channels and creates a peristaltic pressure wave in proximal direction. The treatment encourages the lymph drainage and thereby reduces the swelling (4).

References

1. The diagnosis and treatment of peripheral lymphedema. Consensus document of the International Society of Lymphology Executive Committee. Lymphology 2003;36:84-91.
2. McNeely ML, Peddle CJ, Yurick JL, Dayes IS, Mackey JR. Conservative and dietary interventions for cancer-related lymphedema: A systematic review and meta-analysis. Cancer 2010.
3. Badger C, Preston N, Seers K, Mortimer P. Physical therapies for reducing and controlling lymphedema of the limbs. Cochrane Database Syst Rev 2004;CD003141.
4. Johansson K, Albertsson M, Ingvar C, Ekdahl C. Effects of compression bandaging with or without manual lymph draining treatment in patients with postoperative arm lymphedema. Lymphology 1999;32:103-110.
5. Deng J, Ridner SH, Murphy BA. Lymphedema in patients with head and neck cancer. 2011;38:1-10.

                                                                          

Preparation

Main points of information

Information should be given to patients who have received surgery only or combined with radiotherapy with increased risk of getting lymphedema. The patient usually gets information about lymphedema after the surgery. Sufficient information and guidance is important and crucial for both avoiding getting lymphedema and being able to identify lymphedema at the very beginning.

  • The function and purpose of the lymphatic system
  • Causes of lymphedema
  • Symptoms of lymphedema
  • Different treatment options
  • Precaution
  • Complications/side effects caused by the disease and treatment
  • The importance of maintaining mobility in the arm or leg

Symptoms of lymphedema

  • A feeling of uncomfortable change
  • A feeling of heaviness
  • Bursting pain
  • Changes of consistency (visible or palpable) in the soft tissues
  • Suspicion of increased circumference
  • Swelling may disappear overnight, but usually returns during daytime
  • Some have swelling sporadically

The dominating symptom is lasting swelling in the involved area. Other symptoms will to a large extent depend on the amount, duration, and localization of the edema.

Moderate swelling after cancer surgery, can be a reaction which often spontaneously disappears.

Diagnostics

Lymphedema is usually measured using a clinical method. There are multiple methods to measure the extent of lymphedema. The gold standard is the water displacement method, which measures and compares the volumes of both arms/legs. But a method of comparing volume by using several circumferential measurements of the arms/legs is often used in research and sometimes in the clinical setting. The most widely used method is measurement of circumference at multiple anatomic points on the arm/leg with comparison with the contralateral arm/leg. A difference in circumference of ≥2cm is often defined as lymphedema. Stemmer sign is also used.

Implementation

With development of lymphedema, it is important to take precautionary measures as soon as possible. Treatment with compression is the component which seems to be most effective in reducing the swelling. Manual lymph drainage is often used in combination with bandaging in the first 1-2 weeks of the treatment. This complete decongestive therapy is a composite treatment including multiple techniques which are performed by a specially trained physical therapist.

The intensive phase

  • Compression treatment – possibly with bandaging and thereafter adjustment of an elastic stocking
  • Manual lymph drainage
  • Circulation and drainage inducing exercises
  • Skin care

During the intensive phase, the patient is usually treated 5 days a week with continuously bandaging until the desired volume reduction is achieved. This usually takes one to two weeks.

Bandaging

After stimulating the lymphatic flow by manual lymph drainage, a compression stocking is used or the whole arm is bandaged for one to two weeks. The bandages should be worn as long as they are not too uncomfortable. Correct bandaging with short, elastic bandages provide the tissue with high pressure under activity and low pressure while resting.

  • An ointment with a low pH (5.5) should be applied to the skin.
  • A light tube gauze should be worn.
  • The padding is then applied.
  • The bandaging starts distally to the lymphedema.
  • The bandages are laid evenly, circularly, and in multiple layers.
  • The pressure should decrease gradually from distal to proximal.
  • The pressure is regulated partially with the bandaging technique and mainly by the number of layers of bandages.

Compression stocking

  • The stocking may be removed at night.
  • At night an ointment is preferably applied to the skin.
  • With incipient  lymph edema, wear the stocking during activity.
  • In moderate and extensive lymph edema, the stocking is usually worn all day.
  • The stocking should be washed at least every third day.

A poorly customized stocking may create faulty compression. The most frequent error is that the compression stocking is used after it has lost its elasticity (worn out) and therefore has less effect.

Manual Lymph Drainage

The massage strokes should be performed in the direction of the lymphatic drainage with light pressure and with slow motions. The treatment should not be painful.

Manual lymph drainage has four main movements: standing circles, pumping grip, turning grip, and corkscrew grip.

Pressure massage with pulsator

Pulsation is never a first choice for treatment of lymphedema, but could be a measure over time when monitoring has shown that the treatment is effective. At the start, the patient should be informed about possibly complications. Sometimes, an increase in edema is seen proximal to the cuff. Further pulsation treatment should then be postponed until manual lymph drainage and exercises have improved the condition. If the pressure is too high, the lymphatic vessels may be damaged and the amount of interstitial fluid may increase.
The pressure should be moderate and the patient should experience the treatment as comfortable. It is not the amount of pressure that is important, but uniform rhythmic pressure wave. Tuning of rate and pressure are adjusted for each patient.
Usually, the treatment should last for twenty minutes at the start increasing gradually to thirty to forty minutes. Can be used daily or when needed. Pulsation treatment may also be performed by the patient at home.

Skin Care

Regardless of whether the patient has lymphedema or not, it is important to hinder the occurrence of scratches, sores, and unnecessary skin irritation. Use of gloves is appropriate in some situations. The patient should also be cautious of overheating and sunburn. The main goal of skin care is to prevent infections, because this can trigger an eruption of lymph edema.

Regular use of bandages and compression stockings dries out the skin. Use of skin care products and cleansers with a low pH (5.5) are recommended. Good skin care keeps the skin soft and supple and maintains the skins natural ability to fight infection.

Disinfecting ointment and adhesive tape should be used in the event of an ulcer or scratch or if there is danger of infection.

Maintenance phase

  • Use of elastic stocking and/or glove as needed
  • Skin care
  • Regular exercises to facilitate the muscle-joint pump
  • Possible intermittent pressure massage with pulsator

The patient obtains some treatment during the maintenance phase and may have treatment by a physical therapist if necessary. In the short term, the treatment is almost always satisfactory. In the long run, the result depends on the patient practicing the measures recommended. The pulsator may usually be borrowed from a health care center.

Exercises to improve mobility and lymph flow of the shoulder/arm

Dynamic exercises with a relaxation phase are optimal. "Throwing" movements may feel uncomfortable. Many experience that it is better to walk with poles, but it is important to maintain a loose grip of the pole.

Correctly adjusted movement exercises:

  • induce circulation without straining the reduced lymphatic system
  • provide adequate joint movements
  • stimulate dynamic change between tension and relaxation, preferably in conjunction with respiration

Movement therapy in a heated pool may be favorable for some lymphedema patients. Water pressure stimulates lymphatic drainage and simultaneously activates circulation and movement.

 

Follow-Up

If necessary, the patient may obtain a referral for physical therapy in their home area for further follow-up. Follow-up and guidance by a physical therapist with the necessary skills is important. Some with serious lymphedema will need frequent treatment for the rest of their life. But others will be able to manage the treatment themselves by adhering to the guidelines that they have learned. Compression with stockings and skincare are often sufficient treatment. So many patients do not need physical therapy as treatment, but rather information and functional guidance.

Moderate physical activity improves joint movement, circulation, and well-being, as well as stimulation of lymph drainage. Blood pressure should not be measured and vaccinations should not be given in the treated arm. Gloves are recommended for gardening.

Complications

Fibrosis of the dermis and epidermis with affects some persons with lymphedema. The skin loses its elasticity and is more easily traumatized than normal skin.

The immune system is weakened in the edematous area. This may be for multiple reasons, among others, weakened transport of dendritic cells, lymphocytes, and proteins. If the area’s regional lymph nodes are removed, this will also weaken the local immune system.

In some edema patients, especially secondary lymphedema, a distinctive reaction (erysipelas) may occur in the skin of the affected area. This will usually start acutely with a strong feeling of malaise with high fever, hyperemia with flushing, and increased swelling of the skin. The area of skin involvement is often limited. The symptoms are usually improved after four to six days but it is not uncommon for the edema to deteriorate. The condition should be treated with antibiotics (penicilin) as quickly as possible.

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Lymph edema in the arm.Lymph edema in the arm.