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ONCOLOGY BOARD REVIEW

ONCOLOGY BOARD REVIEW . Most Common Solid Tumors. TNM. Breast Cancer Staging. Generally pathologic Staging, but clinical staging for neoadjuvant therapy. T4 are pts with “grave” prognostic signs (skin, chest wall, ulcer, inflammatory)

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ONCOLOGY BOARD REVIEW

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  1. ONCOLOGY BOARD REVIEW

  2. Most Common Solid Tumors TNM

  3. Breast Cancer Staging • Generally pathologic Staging, but clinical staging for neoadjuvant therapy. • T4 are pts with “grave” prognostic signs (skin, chest wall, ulcer, inflammatory) • N3 (supraclavicular nodes, Internal mammary nodes (Clinically staged)

  4. Most Common Solid Tumors TNM Surgeryor Surgery and XRT Yes

  5. Breast CancerAdjuvant Therapy • Additional Therapy after all gross disease is removed. • Options include Hormonal Therapy for ER positive disease, Chemotherapy for all patients (better for premenopausal), and Biologic therapy for 20-25% Her 2 overexpressors.

  6. Most Common Solid Tumors TNM Surgery Yes Yes

  7. Breast CancerSurveillance/Screening • Q year Mammogram starting age 40 saves lives • BSE/CBE does not save lives, but is done • Surveillance q year mammograms, bimanual exam (on tamoxifen) w/wo Ultrasound, baseline dexascan (AI), MUGA baseline then after anthracylcine rx, then after herceptin is complete

  8. Most Common Solid Tumors TNM Surgery Yes Yes Hormonal Chemo Biologic Rx

  9. Breast CancerSystemic Therapy • Therapy is based on Er status and Her 2 status. • Er positive get hormonal therapy Her 2 postive get Herceptin • Non organ threatening disease get either hormonal rx alone or Single Agent Rx in metastatic setting • AI only for postmenopausal

  10. Quiz 40 yo woman with breast ca 5 yrs ago rx with lumpectomy and xrt and 3 months of chemotherapy. ER/PR neg, Her 2 pos. and presents with skin nodules back pain and lung nodules on xray. Biopsy of skin adenocarcinoma. How to Rx.? A.)Hospice B.)Tamoxifen and AI C.) High dose CT bone marrow tx D.)Trastuzumab and Taxane E.) Ovarian ablation plus and AI

  11. Most Common Solid Tumors TNM Surgery Yes Yes Hormonal Chemo Biologic BRCA 1 BRCA 2 LCIS DCIS

  12. Breast Cancer Genetics • 5-10% of women have inherited form of Breast cancer (Ashkenazi Jewish women with 1%) • Three generation Pedigree • Penetrance is 40-80% • Most informative is one with known mutation and with breast cancer • BRCA1 associated with Ovarian, BRCA2 is found in male Breast CA • Consideration for prophylactic bilateral mastectomy and oophorectomy and Genetic counseling

  13. Quiz • 65 yo woman sp MRM for 1 cm breast ca with er and pr positive and negative for Her 2. SLN negative. What next? A.) xrt and tamoxifen B.) xrt and Anastrazole C.) Tamoxifen for 5 yrs D.) TAmoxifen and anastrazole for 5 yrs.

  14. Most Common Solid Tumors TNM Surgery Yes Yes Hormonal Chemo Biologic BRCA 1 BRCA 2 LCIS DCIS TNM Depth

  15. Colorectal CancerStaging • Depth of invasion with T3 invading muscularis propria (stage II) and T4 invading adjacent structures • N denotes nodes in pericolonic or rectal regions • Rectal staged the same but below peritoneal reflection

  16. Most Common Solid Tumors TNM Surgery Yes Yes Hormonal Chemo Biologic BRCA 1 BRCA 2 LCIS DCIS TNM Depth Surgery Yes

  17. Colorectal CancerAdjuvant Rx • Stage III colon (node positive) cancer OS benefit with 5FU based rx (oxaliplatin?) • Stage II and III Rectal cancer rx with Chemo and radiation therapy

  18. Most Common Solid Tumors TNM Surgery Yes Yes Hormonal Chemo Biologic BRCA 1 BRCA 2 LCIS DCIS TNM Depth Surgery Yes Yes

  19. Colorectal CaSurveillance/Screening • Vogelstein Model of progression of normal mucosa to cancer takes about 10 years • FOBT yearly saves lives, Colonoscopy every 10 years except for high risk groups. • Surveillance Colonoscopy one year after resection and then q 3-5 years • CEA done but not required and CT scan every year for first 3 to 5 years

  20. Most Common Solid Tumors TNM Surgery Yes Yes Hormonal Chemo Biologic BRCA 1 BRCA 2 LCIS DCIS TNM Depth Surgery Yes Yes Chemo Biologic

  21. Colorectal Cancer • Chemotherapy: 5 Fluorouracil {diarrhea, mucositis, myelosuppression (if bolus), Hand foot syndrome (if continuous infusion)}. Oxaliplatin (Neuropathy, cold induced Laryngospasm), Irinotecan (Pro-cholinergic side effects, diarrhea, myelosuppression) • Biologics: Role is metastatic disease. Avastin (Bleeding, HTN), Cetuximab (infusion related side effects)

  22. Most Common Solid Tumors TNM Surgery Yes Yes Hormonal Chemo Biologic BRCA 1 BRCA 2 LCIS DCIS TNM Depth Surgery Yes Yes Chemo Biologic FAP HNPCC

  23. Colorectal CancerGenetics • Incidence 148300 per year 56000 deaths • Familial Risk is 20% (>1 1st or 2nd degree) • 5-10% inherited in AD pattern • FAP and HNPCC (Age at onset HNPCC is 45 vs 63) • Proximal HNPCC and Distal FAP • Microsattelite instability (HNPCC MSH2 and MLH1) Very sensitive (negative test no need to do germ line assessment)

  24. MSI/HNPCC • 12 to 16% with MSI • Mutation in germ line is usually in non coding region, thus, elongation or contraction of DNA has little effect. • Detection shows homozygosity in germ line but multiple peaks in tumor • 70% proximal to splenic flexure • Endometrium, Ovary, Stomach, small bowel , pancreas hepatobiliary, brain,upper uroephtielial, sebaceous deonma sebaceou ca keratacanthoma (Torres Syndrome) • Adenoma to ca in 2-3 yrs (vs 8-10 yrs) • Surveillance age 20-25 with q 1 to 3 yrs colonoscopy, screen for Ovary and Endometrial

  25. Quiz • 58 yo postmenopausal woman on HRT for 4 yrs. Has father died of heart disease, mother died of breast cancer, sister with breast cancer. She had biopsy 2 years go showing atypical hyperplasia. She is considering chemoprevention but is concerned about heart disease. You recommend: • A.) HRT alone B.) HRT and Tamoxifen C.)DC HRT and start Tamoxifen D.) Change HRT to estrogen alone and add Tamoxifen

  26. FAP/APC • Cancer by age 40-50 • Screening at at 10-12, and yearly • Age 20 sutotal colectomy with annual fu of remaining rectum due to numerous polyps • Gastric, Duodenal, Periampullary CA, Desmoids (induced by surgery). • Less common are papillary thyroid, sarcoma, pancreatic ca, meulloblastomas • Penetrance is 100% except in 11307K mutation in Ashkenazi Jews (10-20%) • Celecoxib and Sulindac decrease number of polyps and delay surgery but still need screening

  27. Most Common Solid Tumors TNM Surgery Yes Yes Hormonal Chemo Biologic BRCA 1 BRCA 2 LCIS DCIS TNM Depth Surgery Yes Yes Chemo Biologic FAP HNPCC TNM Proximity

  28. Non Small Cell Lung CAStaging • T3 invasion into chest wall or less than 2 cm from carina • T4 invasion into major structures (SVC, Pericardium, Vertebral Body) or pleural effusion • N1 Hilar nodes, N2 Mediastinal nodes, N3 contralateral Mediastinal or Hilar or Supraclavicular • Stage III A is N2 disease, Stage IIIB T4 or N3

  29. Lung CancerStaging Study: Prospective of Dx Accuracy of Integrated PET-CT,CT,PET, and PET plus CT. METHODS: 50 pts with proven or suspected NSCLC and then histopathologic confirmation or one other radiologic modality Results: PET-CT better vs others above (P=.001,P<.001,P=.013). Nodal staging better with PET-CT vs PET (p=.013) Conclusions: Integrated PET-CT improves dx accuracy of staging in non-small cell lung ca. NEJM: 348:2500-2507,2003

  30. Most Common Solid Tumors TNM Surgery Yes Yes Hormonal Chemo Biologic BRCA 1 BRCA 2 LCIS DCIS TNM Depth Surgery Yes Yes Chemo Biologic FAP HNPCC TNM Proximity Surgery Yes

  31. Non Small Cell Lung CancerAdjuvant • Adjuvant systemic therapy indicated for NSCLC • Stage IB to III seem to benefit • Platinum based regimens are appropriate from NEJM: 352:2640-2642,2005

  32. Most Common Solid Tumors TNM Surgery Yes Yes Hormonal Chemo Biologic BRCA 1 BRCA 2 LCIS DCIS TNM Depth Surgery Yes Yes Chemo Biologic FAP HNPCC TNM Proximity Surgery Yes No Chemo Small Molecule

  33. Non Small Cell Lung CASystemic Rx • Chemotherapy: Cisplatin (Neuropathy, Nephropathy, Nausea/vomiting), Carboplatin (Myelosuppression and Thrombocytopenia), Taxol (Neuropathy, Allergic Rx), Gemzar (Myelosuppression), Taxotere (3rd Spacing), Navelbine (Myelosuppression) • Tarceva (EGFR TKI) Rash, Diarrhea

  34. Most Common Solid Tumors TNM Surgery Yes Yes Hormonal Chemo Biologic BRCA 1 BRCA 2 LCIS DCIS TNM Depth Surgery Yes Yes Chemo Biologic FAP HNPCC TNM Proximity Surgery Yes No Chemo Small Molecule Paraneoplastic

  35. Non Small Cell Lung CAParaneoplastic Syndromes • Squamous Cell CA : Hypercalcemia • Adenocarcinoma: Clubbing and Hypertrophic Osteoarthropathy

  36. Most Common Solid Tumors TNM Surgery Yes Yes Hormonal Chemo Biologic BRCA 1 BRCA 2 LCIS DCIS TNM Depth Surgery Yes Yes Chemo Biologic FAP HNPCC TNM Proximity Surgery Yes No Chemo Small Molecule Paraneoplastic Limited or Extensive Chemo or Chemo XRT NA No Chemo Paraneoplastic

  37. Small Cell Lung Cancer • Staging includes Bone scan and Brain scan if limited • Cisplatin and Etoposide (WBC and Platelets and AML) with xrt for LS and Chemo alone for ES • Eaton Lambert, SIADH, Perhipheral Neuropathy

  38. Quiz • 70 yo man with 80 pk yr tobacco presents with chronic cough and a 3 cm perihilar mass. CT scan shows two nodules in liver and PET shows no uptake in liver but uptake in mass. Bronch positive for cancer.What next? • A.) xrt B.)Chemotherapy C.) CT guided liver biopsy D) CEA E.) Surgery

  39. Quiz 68 yo man with 60 pk yr tobacco evaluated for hemoptysis. CXR shows right hilar mass and mediastinal widening. Bronch shows small cell. He has low sodium and SIADH. Rest of workup shows no disease. How do you rx? A.) Surgery followed by chemo B.) XRT followed by chemo C.) Chemotherapy alone D.)XRT and concurrent chemo E.) Chemo followed by xrt

  40. Most Common Solid Tumors TNM Surgery Yes Yes Hormonal Chemo Biologic BRCA 1 BRCA 2 LCIS DCIS TNM Depth Surgery Yes Yes Chemo Biologic FAP HNPCC TNM Proximity Surgery Yes No Chemo Small Molecule Paraneoplastic Limited or Extensive Chemo or Chemo XRT NA No Chemo Paraneoplastic TNM Clinical Surgery or XRT or Observation NA PSA? DRE? Hormonal Chemo chemoprev

  41. Prostate CancerTreatment N = 695 (FU was 8.2 years) Design: Randomized study of pts less than 75 with localized prostate cancer to radical prostatectomy or observation Pts: Median age 64, T1 and T2, GS 5-6 was 47% of population, GS 7 was 22%, GS 8-10 was 4-6%, Mean PSA 12-13. Results: RR 0.56 (CI .36-.88) for RP for death from cancer. OS was .74 (CI.56-.99) or 5% absolute at 10 years. Local progression 19-25% lower risk (RR.33) and Distant mets 8% (RR .60) Conclusion: RP decreases overall disease specific and overall mortality by a modest amount. Substantial benefit for distant mets and local tumor progression NEJM:352,1977-1984, 2005

  42. PROSTATE CANCERSCREENING N = 2950 Method: subgroup analysis of men who never had a PSA more than 4 ng/ml or abnormal DRE who had a final PSA determination and underwent biopsy after 7 years on study in PCPT randomizing 18,882 men to placebo or Finasteride 5mg. Results: 15% had prostate ca, 6.6% with psa 0.5, 10% w/PSA .5 to 1,17% w/PSA 1.1 to 2,23.9% w PSA 2.1-3, and 26.9 w/PSA 3.1-4.0. High grade cancer in 12.5% with PSA 0.5 and 25% PSA 3.1-4.0. Conclusions: Biopsy detected prostate cancer not rare among men with normal PSA (4 or less). High grade cancers also are detected. NEJM: 350: 2239-2246, 2004

  43. Prostate CancerPrevention with Proscar N= 18882 55 or older Methods: Normal DRE and PSA randomized to Finasteride 5 mg vs Placebo. Results: Finasteride decreased incidence of prostate ca from 24.4 to 18.4 percent (24.8% reduction CI 18.6 to 30.6) p<.001. High grade tumors higher in finasteride group 37 vs 22% (p<.001) Conclusions: Delays appearance of prostate ca but benefit may be nullified by risk of side effects and increased risk of high grade cancer. 349:215 - 224, 2003

  44. Quiz 45 yo presents with 2 cm palpable axillary node on right. Resection shows adenocarcinoma. CT and MRI show no other sites of disease. How do you manage? A.) Breast ca is most likely dx and rx as such B.) Lung ca is most likely and rx as such C.) All disease resected no more rx D.) Radiation therapy to axilla and breast is appropriate.

  45. Group IHormonally Related or Genetic Syndrome TNM Proximity Depth Surgery No No Hormonal Chemo BRCA1 TNM/FIGO Surgical Lap Surgery and Debulking Mostly NA Some Yes No Screen CA 125 for FU Chemo and IP Chemo BRCA1

  46. Group IIForegut, Smoking, or Environment related TNM Depth Surgery No No Chemo TNM Proximity Surgery No No Chemo Biologic? TNM Depth Surgery No? No Chemo Barrets? TNM Depth Surgery No? No Chemo Immuno Ureteral

  47. Group III Squamous Cell Rx with Chemo and XRT as Primary Rx TNM Depth Extent Surgery Or Chemo XRT No Yes Chemo HPV? TNM Size Chemo + XRT No No Chemo (MMC) HPV? TNM Depth, Size Chemo Biologic NPC/EBV EGFR MCA With XRT? Surgery Or XRT +- Chemo No? No

  48. Group IV Curable in Metastatic Setting NSGCT AFP HCG Seminoma HCG XRT Residual Masses IGCCC 3 stages Surgery plus XRT or Chemo NA? No Chemo

  49. Group VIncurable or Poor Systemic Rx Grade Surgery NA No Chemo AA and GBM Incurable, OLIGO chemo xrt Surgery Transplant? No AFP? US? Hep B TNM Size Extent Chemo TKI? TNM Depth Surgery No? No Chemo Biologic Sentinel nod Familial Synd TNM Extension Surgery No No Biologic TKI? Polycythemia TNM Grade Size Surgery Bone and Rhabdo only No Chemo X ray for Ewing And Osteosarc Cytogentic 11:22, X:18

  50. Long Term Complications of Chemotherapy Neuropathy Second Malignancies Pulmonary Toxicity Osteoporosis Fertility

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