Solid tumors

Antonio Rivas PA-CFebruary 2009

Case # 1 56 yo real state broker

76 pack-year hx of tobacco use (2 packs per day since age 16)

Nl chest x-ray 8 months ago

HPI Hemoptysis x 10 days(blood tinged sputum)

Chronic cough Denies :

weight loss Chest pain Bone pain DOE

PE Lungs CTA Bil.

No organomegaly No abn.neurologic findings

No clubbing Laboratory Studies

NL liver function tests (?)

Ca.11.1 mg/dl (?) Albumin 3.9 gm/dl(wnl) CBC- WNL

Chest Xray New 2x3cm R hilar mass

Diagnostic tests? Bronchoscopic biopsy of a lung mass

Biopsy of a supraclavicular lymph node for histologic study and staging

Central location of the lesion Offer information about histological type

Either Squamous(NSCLC) or SCLC Biopsy needed for confirmation

High Calcium level associated with Squamous cell carcinoma

Staging TNM T2 Nx Mx

Tumor 3cm in greatest dimension Nodal status unk. Unk. Metastases

CT scan needed for staging, nodules and metastases evaluation

Lung Cancer

One of the most malignant disease in the US

More than 163,000 death occurs each year

Tobacco smoke accounts for >90 % of all lung cancers

Metabolite of cigarette smoking binds and alter suppressor gene TP53

Lung cancer Small cell lung cancer SCLC

•(15 %)of all lung cancer Non-small cell lung cancer NSCLC

•Squamous cell carcinomas(25-30 %)•Adenocarcinomas (40 %)•Large cell tumors (10-15 %)

The category of the cancer determines the treatment options

Small cell lung Cancer

Aggressive course: grows rapidly and spreads to lymph nodes, bone, brain, adrenal glands, and the liver.

Highly associated with tobacco smoking. Less than 5% incidence in non-smokers

Paraneoplastic syndromes Associated to SIADH, and Cushing’s Syndrome

Often, large mediastinal mass centrally located tumor in the mediastinum

Non-Small Cell Lung Cancer

Squamous cell carcinoma: highly associated with tobacco smoking develops in the central region of the lungs,

assoc.paraneoplastic-hypercalcemia Adenocarcinoma:

outer region of the lungs, most common lung cancer, the most often Dx in non smokers

Large cell tumors: the least common, Histologic features of neuro-endocrine tumors

Factors that influence risk of developing lung cancer include:

Family History of Lung Cancer Smoking Radon Asbestos Chronic Lung Diseases

Case # 1

CT of the liver showed no mets. Alk.p.WNL - no bone mets. If AP abn- do bone scan If Neurology consultation PE is WNL CT scan of the head defered

T2 N0 M0

Family History of Lung Cancer

inherit defective genes that lead to the development of a familial form of a particular cancer type

For example, certain genes influence a person's ability to metabolize some of the carcinogenic chemicals in cigarette smoke.

An individual with inherited suceptibility that chooses to smoke may be at an increased the risk of developing lung cancer compared to other smokers.

Family History of Lung Cancer Risk is higher if an immediate family member has been diagnosed with lung cancer. The more closely related an individual is to someone with lung cancer, the more likely they are to share the genes that increased the risk of the affected individual. Risk also increases with the number of relatives affected

Smoking Smoking is, by far, the leading risk factor for lung cancer.

• In 2004, the United States Surgeon General released a report addressing the harmful effects of smoking on health (The Health Consequences of Smoking: A Report of the Surgeon General)

Included in the report was the following "The evidence is sufficient to infer a causal relationship between smoking and lung cancer.

Smoking

There are more than 60 molecules in cigarette smoke that are thought to be carcinogenic in humans

Two carcinogens highly associated with lung cancer are benzo[a]pyrene and N-nitrosamine NNK. These molecules bind to DNA and proteins, forming adducts.

The presence of adducts increases the chance of DNA mutation and interferes with the proper function of proteins

Second-Hand Smoke

second-hand smoke also greatly increases risk of lung cancer. In 2006, the Surgeon General released a report addressing the harmful effects of second-hand smoke on health

According to the report, second-hand smoke contains over 50 cancer-causing chemicals and can lead to many health problems, including lung cancer. The effects of second-hand smoke are especially harmful to the developing lungs of infants and children

Other risk factors for lung cancer

Radon is a naturally occuring, colorless, oderless gas, possibly contributing to 10% of all lung cancer cases

Asbestos a naturally occurring mineral frequently used in commercial construction throughout the 1950's and 1960's. The long, thin fibers of asbestos are fragile and have a tendency to break down into dust particles Asbestos particles are easily inhaled into the lungs, where they cause damage to lung tissue that can lead to lung cancer

Other risk factors for lung cancer Chronic lung diseases such as asbestosis (scarring of lung tissue caused by asbestos), asthma, chronic bronchitis, emphysema, pneumonia, and tuberculosis have been suggested to increase risk of lung cancer. All of these diseases damage lung tissue and can result in scar tissue on the lungs.

Symptoms

no symptoms associated with early stage lung cancer

symptoms associated with advanced stage lung cancer Persistent cough Sputum streaked with blood Chest pain Voice change Recurrent pneumonia or bronchitis

Detection

At the time diagnosed, majority of lung cancers have progressed to an advanced state. Lung cancer screening is not currently routine practice

sometimes caught in its early stages by tests that are performed for other reasons

most common methods of lung cancer detection include chest x-ray, chest CT scan, bronchoscopy ,and sputum cytology

Pathology Report

suspicion that a patient may have lung cancer, a sample of tissue (biopsy)is taken

Staging of non-small cell lung cancer (NSCLC) follows the TNM criteria.

Because small cell lung cancer (SCLC) is often diagnosed at a more advanced state, the T/N/M system is not used

Veterans Administration Lung Study Group System small cell lung cancer (SCLC) usually staged using the Veterans Administration Lung Study Group System

2-stage system based on location of the cancer Limited-stage: The cancer is located in only one lung and lymph nodes on the same side of the body

Extensive-stage: The cancer has spread to the other lung and/or other regions of the body

Case # 1 Treatment Stage II NSCLC Surgical excision Lobectomy or Pneumonectomy If ABG, EKG, Past Med.Hx WNL showing no excess risk for major surgery

Surgeon consult Mediastinoscopy : nodes biopsied on both sides

If neg.upper lobectomy through lateral thoracotomy

Pathologic follow up

Treatment NSCLC

Complete removal of the tumor offers better chance of survival• Assessment of resectability• Anatomic loc.tumor• Patients medical condition• Pulmonary reserve

Stage I and II - surgical treatment Stage III - neoadjuvant therapy, then resection

80 % not resectable- stage IIIA and IIIB chemotherapy and radiation

Stage IIIB and IV- chemo.improved survival in 8-11months

Treatment SCLC

Combination therapy, best option Limited stage : 4-6 cycles chemotherapy as long as they respond to therapy

Concomitant radiation provides longer survival

40% has brain metastasis and prophylactic cranial radiation should be considered

Head and Neck cancers

Most are squamous cell carcinomas Larynx, oral cavity, oropharynx and sinuses

Risk factors: tobacco, alcohol, poor oral hygiene

Nasopharyngeal Ca. associated with EBV infection

High risk for lung and esophageal cancer

Head and Neck Ca.

Prognosis associated to: Tumor burden Thickness of the tumor Presence or absence of regional lymph node involvement

Cure rate with small tumors 75-95%

Continued used of tobacco after Dx associated with poor prognosis

Symptoms

Depending on location Pain with swallowing Change in voice Mass under the tongue Red or white patches in the mouth Oral bleeding, ill fitting dentures

Recurrent or not resolving sinusitis

Diagnosis of Head and Neck Cancers

Required confirmation with Biopsy MRI and CT head and neck

to determine extent of the tumor Endoscopy to examine the whole aerodigestive tract

Small tumors with no lymph node involvement, treated With radiation or surgery

Locally advanced disease : surgery, radiation and chemotherapy

Most recurrence 2-3 years after therapy

GI Cancers

Among the most common tumors Improved survival and quality of life for patients with colorectal cancer

Cancer of the esophagus, pancreas, liver and stomach less common

Esophageal cancer

Two types: Squamous cell - most common in cervical and thoracic esophagus

Adenocarcinoma - lower esophagus, related to Barret’s esophagus

More common in African-Americans Smoking Achalasia Caustic injury Alcohol

Symptoms, Dx and TTo

Dysphagia - solid food is “stuck”,main symptom, chest pain

Progressive regurgitation-afraid to eat -weight loss

Upper GI series-Biopsy Endoscopic US for staging CT and PET for metastasis to the liver and chest (most common)

Tto. For Esophageal Cancer Surgery more common If surgery not possible radiation and chemotherapy

For metastasis: systemic chemotherapy

For severe dysphagia endoscopic placement of a metal or plastic stent

Gastric Cancer

Higher in poor countries with increased used of smoked meat high in nitrates

Assoc.to Pernicious anemia Achlorhydria Gastric ulcers Prior gastric surgery H . pylori infections

Gastric Cancer

Symptoms Abdominal pain Early satiety Anemia Hematemesis Weakness Weight loss

Gastric Cancer

Frequently involving local lymph nodes at the time of DX

PE: gastric mass Umbilical node (Sister Mary Joseph’s nodes)

Left supraclavicular node (Virchow’s node)

Adenocarcinoma

Gastric cancer

Incidence has decreased in US , except for Gastroesophageal junction cancers

Biopsy - Adenocarcinoma Local or spread to gastric lining (linitis plastica)

CT scan and upper endoscopy for staging and to look for metastasis to the liver

Gastric Cancer

Treatment Most often surgery If tumor and involved lymph nodes removed 20-60% 5 year survival rate

Most common site of metastasis and recurrence : the liver

Chemotherapy and radiation also improves survival

Colorectal cancer (CRC) 3rd most common cancer in both sexes

Rare before age 40 yo Most arise from polyps Risk factors:

Inflammatory bowel disease (IBD)•Ulcerative colitis

Personal hx of adenomas family Hx of CRC, 1st and 2nd degree relative

Other risk factors Sedentary life Obesity Diet rich in red meats Cigarette smoking Alcohol use

Colorectal Cancer

Patients with known mutations or family Hx or a disease related with Colon cancer, begin Colonoscopy early

Familial adenomatous polyposis start in teenage years

10 years before the age of the age of DX of the youngest family member with colon cancer

Colorectal Cancer symptoms

Right sided lesions: Asymptomatic Anemia

•Occult bleeding Left sided lesions:

Signs of abdominal obstruction•Abdominal pain, distention, cramping•Constipation /Diarrhea•Nausea / Vomiting

Bowel perforation / peritonitis

Colon Cancer Dx

1st choice Colonoscopy- in symptomatic patient (visualize/biopsy)

2nd choice Double contrast barium enema

• Apple core lesion

Preoperative CT abd. / pelvis

• Metastases first to liver

Staging Stages

Pathology

Duke’s

TNM Numerical

------

TisNoMo 0 Ca in situ

A T1NoMo I Limited to mucosa/submucosa

B1 T2NoMo I Into muscularis mucosae

B2 T3NoMo II Into serosa

C TxN1Mo III Involve regional lymph nodes

D TxNxM1 IV Distant mets(liver and lungs)

Colon Cancer Staging and Tx Early stages-surgery (Dx and curative)

Duke’s and TNM after surgery Curative Surgery:

• Removal involved bowel section• Disease free margin at both ends• Removal of affected Lymph Nodes • Temporary colostomy

Extensive Permanent colostomy

Treatment colorectal cont. Adjuvant chemotherapy warranted in Duke’s stage C and some B

•5-fluoruracil + leucovorin

Metastatic ds•Chemo – improves survival

Radiation •for rectal cancer or tumors arising <25 cm from anal verge

Colorectal screening 2008

following examination schedules after age 50 yo

A flexible sigmoidoscopy (FSIG) every five years A colonoscopy every ten years A double-contrast barium enema every five years A Computerized Tomographic (CT) colonography

every five years A guaiac-based fecal occult blood test (FOBT) or

a fecal immunochemical test (FIT) every year A stool DNA test (interval uncertain)

Tests that detect adenomatous polyps and cancer Tests that primarily detect cancer

Tumor Marker CEA –

Elevated 1/3 of the pat.early on ds. Present in 90% of metastatic Ds. Not useful screening Good to detect recurrence after resection

Most recurrences within 4years after surgery

Better prognosis for stage I tumors

Anal Carcinoma

Increased frequency HPV and HIV

Rectal bleeding and fullness Chemotherapy and radiation for localized lesions

Abdomino-perineal resection for failure to chemo.

Pancreatic Cancer

Strong association with smoking Adenocarcinoma-high mortality Islet cell carcinoma-less common Most common symptom: rapid weight loss and abdominal pain

Pain in periumbilical area piercing to the back

Recent onset of diabetes

Pancreatic Cancer

Palpable gallbladder•(Courvoisier’s sign)

Jaundice (blockage distal bile duct)

Migrating thrombophlebitis (trousseau’s sign) - paraneoplastic complication

Tumor marker CA-19-9 only elevated in 75 % or less of the patients

Pancreatic Cancer

Treatment Pancreaticoduodenectomy (Whipple’s procedure) surgery

High mortality rate