Solid Tumors.Onc.cont.

Antonio Rivas PA-c

Hepatocellular Carcinoma(HCC) Uncommon in the US More than 1 million cases/year around the world

Common causes chronic viral hepatitis B and C Cirrhosis

•Alcohol and Hemochromatosis

Hepatocellular Carcinoma(HCC) Alpha-feto-protein (commonly elevated even during early stages)

Treatment of early stage is surgery Cure rate >75 % for tumors <2cm Severe cirrhosis or small liver Ca may benefit from liver transplant

Not proven benefit from chemotherapy or radiation

Breast Cancer

Most common cancer in women Second leading cause of death in women after lung cancer, in the US

In 2005 - 213,000 women were Dx with invasive breast cancer

40,000 women died of Breast Ca Breast cancer in men is rare, but it happens

Breast Cancer

Risk factors Older age Family history Early menarche Late menopause First-term pregnancy after 25 years of age Nulliparity Prolonged Use of exogenous estrogen Postmenopausal obesity Exposure to ionizing radiation

Breast Cancer

Cancer - susceptibility genes BRCA1 and BRCA2 Present in Only 5-10% of patients with breast cancer

Pat. With Personal or family hx of male breast Ca

Family Hx of ovarian Ca Should be offered counseling / genetic testing

Breast Cancer

Yearly mammograms are recommended starting at age 40. A clinical breast exam should be part of a periodic

health exam, about every three years for women in their 20s and 30s, and every year for women 40 and older.

Women should know how their breasts normally feel and report any breast changes promptly to their health care providers. Breast self-exam is an option for women starting in their 20s.

Women at increased risk (e.g., family history, genetic tendency, past breast cancer) should talk with their doctors about the benefits and limitations of starting mammography screening earlier, having additional tests (i.e., breast ultrasound and MRI), or having more frequent exams.

Breast Cancer types

• Earliest form of the disease, ductal carcinoma in situ (DCIS), solely in the milk ducts.

The most common type of breast cancer, Invasive ductal carcinoma (IDC), develops from DCIS, spreads through the duct walls, and invades the breast tissue.

Invasive lobular carcinoma originates in the milk glands and accounts for 10-15% of invasive breast cancers

Less common Breast Cancer types Paget's disease of the nipple:

originates in the milk ducts and spreads to the skin of the nipple• Eczematoid dermatitis

Inflammatory: tends to spread quickly Erythema and edema of the overlying skin

• Underlying aggressive ductal carcinoma

Symptoms

Early symptoms: lump that feels different than the surrounding breast tissue

Lumps found in lymph nodes located in the armpits

Advanced changes: changes in breast size or shape, skin dimpling, nipple inversion, or spontaneous single-nipple discharge,ulceration

Symptoms

Symptoms of Inflammatory breast cancer include pain, swelling, warmth and redness throughout the breast, as well as an orange peel texture to the skin referred to as peau d'orange.

Paget's disease of the breast. eczematoid skin changes, redness , mild flaking of the nipple skin. As advances, symptoms may include tingling, itching, increased sensitivity, burning, and pain, discharge from the nipple. Approximately half of women diagnosed with Paget's also have a lump in the breast

Peau d’orange

Inflammatory Disease

Disproportionate breast size

Disproportionate breast size may occur as a result of: • Surgery and/or radiation • Breast feeding on one side only • Rapidly growing tumors

Breast puckering

Breast puckering secondary to a small, superficial cancer close to the skin, became apparent in this 65 year old woman on a visit to her doctor when she was asked to raise her arms during the clinical breast examination.

Dimpling

Dimpling may be associated with inflammatory cancer. It may also be seen after surgery

"accessory" breast tissue

Extra breast tissue or "accessory" breast tissue is not abnormal. It may be unsightly and some women consult with plastic surgeons if they feel awkward in tank tops or other sleeveless garments

Nipple Inversion

Nipple Inversion:This woman noted an inverted nipple since she was a teenager. This is longstanding and no further work-up is required.

Xeroradiograph that demonstrates a cancer behind the nipple pulling the nipple in. Xeroradiography has been replaced by mammography.

Inverted nipple (the discoloration is due to a needle biopsy

Nipple Discharge

Bloody discharge needs to be investigated. Please consult your physician

Ulceration of breast skin

This represents a breast cancer that has eroded the skin and caused a small ulcer.

Skin nodules

This represents a recurrence of breast cancer after a lumpectomy and radiation therapy. Breast cancer can recur after a lumpectomy or after a mastectomy.

Symptoms

More common sites of metastasis include bone, liver, lung and brain

Unexplained weight loss can occasionally herald an occult breast cancer, as can symptoms of fevers or chills.

Bone or joint pains can sometimes be manifestations of metastatic breast cancer, as can jaundice or neurological symptoms

Symptoms

Breast cancer diagnosed most often through screening mammogram

Fewer than 10% patients have metastasis at Dx

Staging

Requires removal of the primary tumor and ipsilateral axillary lymph node

If tumor more than 5cm with + lymph nodes include: chest radiograph CT of the abdomen

For smaller tumors, no need for above unless they have bone pain-sign of metastasis

Treatment

Small breast tumor- lumpectomy+radiation

Large tumor or two or more-mastectomy Women who had previous radiation-mastectomy

Chemotherapy may allow breast conservation

Preoperative hormone therapy in frail patients with hormone receptors pos.tumors

Treatment

Adjuvant therapy with chemo.and hormones improve relapse free and over all survival

Trastuzumab -monoclonal antibody Patients with metastasis:

Better prognosis in women with hormone responsive disease and lymph node metastasis only. No liver,bone or CNS

Treatment

Biphosphonates IV to alleviate pain from bone metastases and the risk of fractures

DCIS - lumpectomy, followed by radiation therapy or mastectomy

Tamoxifen: estrogen agonist

Genito-urinary cancers

Testicular cancer: 800-900 new cases each year in the US

Age 15-34 yo, most common 90% cure rates, 100% if it has not metastasize

Unusual lump in a testicle should be checked immediatelly

Testicular cancer

Recommended regular monthly testicular self examination

After a hot shower when the scrotum is looser

Feeling for pea-shaped lump Asymmetrical hardening of a testicle Feeling of numbness or pain Build up of fluid

Testicular cancer

Symptoms Loss of sexual activity Impotence Increase or decrease in testicle size in one side

Blood in semen Watery or clear semen

Testicular cancer

Dx Scrotal ultrasound CT scan Tumor markers: AFP,Beta HCG, LDH Inguinal orchiectomy Adjuvant therapy after surgery

Chemotherapy , radiation or surveillance

Germ cell tumor - most common

Prostate Cancer

No symptoms at early stage Dx by increased PSA during routine checkup

Symptoms when present similar to BPH Frequent urination, mainly at night Difficulty starting and maintaining steady stream

Blood in urine, and painful urination

Prostate Cancer

Decreased erection or painful ejaculation

Most common advanced symptom is bone pain(vertebrae , pelvis and ribs)

If spinal cord compression-leg weakness, urinary and fecal incontinence

Adenocarcinoma Risk factors:age, genetics, race,diet, life style

Prostate Cancer

Screening Digital rectal exam:feeling for irregularities or bumps

Prostate specific antigen (PSA) Elevated in BPH and Prostatitis, after ejaculation, catheterization

Only diagnostic test - Biopsy

Prostate Cancer

Treatment Early stage:prostatectomy,radiation therapy

Late stage:hormone therapy and/or radiation therapy

External beam radiation therapy and brachytherapy

Screening Guidelines for the Early Detection of Prostate Cancer, American Cancer Society

The prostate-specific antigen (PSA) test and the digital rectal examination (DRE) should be offered annually, beginning at age 50, to men who have a life expectancy of at least 10 years.

Men at high risk (African-American men and men with a strong family history of one or more first-degree relatives diagnosed with prostate cancer at an early age) should begin testing at age 45.

For men at average risk and high risk, information should be provided about what is known and what is uncertain about the benefits and limitations of early detection and treatment of prostate cancer so that they can make an informed decision about testing.

Bladder cancer

Less common in women than in men One fifth of the affected patients will dye

Most common risk factor is cigarette smoking

Other factors: exposure to chemicals, parasites and medications such as Cytoxan

Bladder cancer

Most common :transitional cell carcinoma

Most common presentation - gross hematuria

Bladder irritation or spasms When beyond the bladder : leg swelling, pelvic pain, compression nerves in the pelvic plexus

Bladder cancer

Tumors are divided into superficial, invasive and metastatic

Direct imaging and Biopsy to determine depth of invasion - prognosis - treatment

Cystoscopy the most important Dx tool to determine if wall of the bladder has been affected

CT and MRI for nodal involvement and Metastaisis

Bladder cancer

Treatment Superficial tumors

TURB transurethral resection of the bladder

Cytoscopy :every three months for monitoring and resections if required

Also use of immunomodulators instilled in the bladder:Interferon, mitoxantrone, every week for 6 weeks , then do cytoscopy

Bladder cancer

Tumors invading the muscle: If not through the bladder wall - radical cystectomy

A pouch is created from the small intestine to store and expel urine

Other approaches possible-with bladder preservation + chemotherapy

Invariably relapses