OncologyOncology

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ScreeningScreening

Various Scenarios!Various Scenarios!

TestTest Starting AgeStarting Age FrequencyFrequency Ending ageEnding age

MammographyMammography 4040 yearlyyearly 7070

Pap SmearPap Smear 21 or age at 121 or age at 1stst sexual sexual intercourseintercourse

Yearly x 3yrs Yearly x 3yrs and then every and then every 3yrs3yrs

6565

ColonoscopyColonoscopy 5050 10 yrs10 yrs nonenone

Flex SigFlex Sig 5050 3-5 yrs3-5 yrs nonenone

FOBTFOBT 5050 YearlyYearly nonenone

General ScreeningGeneral Screening

Case StudyCase Study A 66 y/o woman comes to your office for A 66 y/o woman comes to your office for

regular check up. A colonoscopy done 7 regular check up. A colonoscopy done 7 yrs ago was normal. She has not yrs ago was normal. She has not undergone any other screening tests. Labs undergone any other screening tests. Labs revealed normal hemoglobin. Clinical revealed normal hemoglobin. Clinical examination revealed a 3cm mass in her examination revealed a 3cm mass in her breast which was ill defined. The most breast which was ill defined. The most appropriate test at this time is:appropriate test at this time is:

A) Mammogram BilateralA) Mammogram Bilateral B) Breast ultrasoundB) Breast ultrasound C) FOBTC) FOBT D) Pelvic ultrasoundD) Pelvic ultrasound E) Pap smearE) Pap smear

ColonoscopyColonoscopyEfficacyEfficacy Identifies up 95% of Colon cancerIdentifies up 95% of Colon cancer Efficacious and reduces mortality Efficacious and reduces mortality Preferred over other Colon Cancer screening Preferred over other Colon Cancer screening

modalities modalities

Comparision :Comparision : Fecal Occult Blood Testing (26% of Colon Cancer) Fecal Occult Blood Testing (26% of Colon Cancer) Digital Rectal Exam (5-10% of Colon Cancer) Digital Rectal Exam (5-10% of Colon Cancer) Flexible Sigmoidoscopy (50-60% of Colon Cancer) Flexible Sigmoidoscopy (50-60% of Colon Cancer) Colonoscopy (95% of Colon Cancer) Colonoscopy (95% of Colon Cancer) Barium Enema (32 to 53% of Colon Cancer)Barium Enema (32 to 53% of Colon Cancer)

ProtocolProtocol Colonoscopy may be preferred for all screening Colonoscopy may be preferred for all screening

Sigmoidoscopy misses 25% of lesions (proximal) Sigmoidoscopy misses 25% of lesions (proximal) Occult blood does not increase flex sig sensitivity Occult blood does not increase flex sig sensitivity

Colorectal CancerColorectal CancerRisk Factors for Colorectal CancerRisk Factors for Colorectal Cancer Age >50 years (accounts for 90% of Colon Cancer) Age >50 years (accounts for 90% of Colon Cancer) Past Medical History Past Medical History

Inflammatory Bowel Disease, Ulcerative ColitisInflammatory Bowel Disease, Ulcerative Colitis Adenomatous polyps >5mm (Confers RR of 2-3 times) Adenomatous polyps >5mm (Confers RR of 2-3 times) Hamartomatous polyposis syndromes Hamartomatous polyposis syndromes CholecystectomyCholecystectomy Pelvic irradiation Pelvic irradiation

Family HistoryFamily History First degree relative with Colon Cancer (RR=2-3x) First degree relative with Colon Cancer (RR=2-3x) Familial adenomatous polyposis Familial adenomatous polyposis Hereditary non-polyposis Colon Cancer Hereditary non-polyposis Colon Cancer

Lifestyle related risks Lifestyle related risks Tobacco abuse Tobacco abuse ObesityObesity

Dietary Risk Factors Dietary Risk Factors High Dietary Fat : Saturated fat , Polyunsaturated fat High Dietary Fat : Saturated fat , Polyunsaturated fat Red Meat: Pickled , Smoked , Barbeque Red Meat: Pickled , Smoked , Barbeque

Colorectal Cancer ScreeningColorectal Cancer ScreeningFirst classify the risk groups from the First classify the risk groups from the

question.question. Average Risk Average Risk Age 50 yrs and Older Age 50 yrs and Older Moderate Risk Moderate Risk Family hx of Family hx of

colorectal cancer, colon ca in other colorectal cancer, colon ca in other relatives, Single small adenomatous relatives, Single small adenomatous polyps, Large multiple adenomatous polyps, Large multiple adenomatous polyps, Colorectal ca pts f/u after polyps, Colorectal ca pts f/u after resection.resection.

High Risk High Risk FAP, HNPCC, IBD FAP, HNPCC, IBD ( Ulcerative Colitis) ( Ulcerative Colitis)

Colorectal Cancer ScreeningColorectal Cancer ScreeningAverage Risk: Age 50 years and Average Risk: Age 50 years and

olderolder Digital Rectal Examination and Digital Rectal Examination and Fecal Occult Blood yearly and Fecal Occult Blood yearly and Diagnostics Diagnostics

Endoscopy Endoscopy Flexible Sigmoidoscopy every 5 years or Flexible Sigmoidoscopy every 5 years or Colonoscopy every 10 years Colonoscopy every 10 years

Double contrast Barium Enema Double contrast Barium Enema Colonoscopy preferred for full colon evaluation Colonoscopy preferred for full colon evaluation Consider as adjunct to Flexible Sigmoidoscopy Consider as adjunct to Flexible Sigmoidoscopy

Colorectal Cancer Screening - Colorectal Cancer Screening - Moderate RiskModerate Risk

Family History of Colorectal Cancer Family History of Colorectal Cancer Defining criteria Defining criteria

First degree relative under age 60 years or First degree relative under age 60 years or Two First degree relatives with colon caTwo First degree relatives with colon ca

Screening protocol Screening protocol Start Start

Colonoscopy at age 40 years or Colonoscopy at age 40 years or Colonoscopy 10 years earlier than youngest case Colonoscopy 10 years earlier than youngest case

Repeat Colonoscopy every 5yrsRepeat Colonoscopy every 5yrs

Colorectal Cancer in other relatives Colorectal Cancer in other relatives As per Average Risk Recommendations As per Average Risk Recommendations ( start at age 50 years )( start at age 50 years )

Colorectal Cancer Screening - Colorectal Cancer Screening - Moderate RiskModerate Risk

POLYP ISSUES – POLYP ISSUES –

You did a screening colonoscopy and You did a screening colonoscopy and found a polyp. Sent it for biopsy. found a polyp. Sent it for biopsy. What next?? – how will screening What next?? – how will screening protocols change depending on type protocols change depending on type of polyp???of polyp???

Colorectal Cancer Screening - Colorectal Cancer Screening - Moderate RiskModerate Risk

If Single, Small Adenomatous Polyps If Single, Small Adenomatous Polyps (<1 cm) (<1 cm)

Repeat Colonoscopy Repeat Colonoscopy

Within Within 3 years3 years after initial polyp after initial polyp Diagnosis Diagnosis

If normal, as per Average Risk If normal, as per Average Risk Recommendations Recommendations

Colorectal Cancer Screening - Colorectal Cancer Screening - Moderate RiskModerate Risk

If Large or multiple adenomatous If Large or multiple adenomatous polyps (>1 cm) polyps (>1 cm)

Repeat Colonoscopy 3 years after initial Repeat Colonoscopy 3 years after initial polyp polyp

Repeat Colonoscopy every 5 yearsRepeat Colonoscopy every 5 years

Colorectal Cancer Screening - Colorectal Cancer Screening - Moderate RiskModerate Risk

If you resected a polyp and found cancer If you resected a polyp and found cancer that you believe is completely that you believe is completely removedremoved

Colonoscopy at Initial polyp diagnosis Colonoscopy at Initial polyp diagnosis Normal Colonoscopy protocol Normal Colonoscopy protocol

(assumes no recurrence) (assumes no recurrence) Repeat Colonoscopy in 1 year Repeat Colonoscopy in 1 year Repeat Colonoscopy in 3 years Repeat Colonoscopy in 3 years Repeat Colonoscopy every 5 yearsRepeat Colonoscopy every 5 years

Colorectal Cancer Screening - Colorectal Cancer Screening - High RiskHigh Risk

If Familial adenomatous polyposis Hx:If Familial adenomatous polyposis Hx: Early surveillance Early surveillance

Colonoscopy starting at PubertyColonoscopy starting at Puberty Counseling to consider genetic testing Counseling to consider genetic testing Genetic Testing positive or polyposis Genetic Testing positive or polyposis

confirmed confirmed Consider Total colectomy or Consider Total colectomy or Colonoscopy every 1-2 years Colonoscopy every 1-2 years

Colorectal Cancer Screening - Colorectal Cancer Screening - High RiskHigh Risk

Hereditary non-polyposis Colon Cancer Hereditary non-polyposis Colon Cancer Early surveillance Early surveillance

Colonoscopy starting at Age 21 years Colonoscopy starting at Age 21 years Counseling to consider genetic testing Counseling to consider genetic testing Genetic Testing positive or No genetic Genetic Testing positive or No genetic

testing testing Colonoscopy every 2 yrs until age 40 Colonoscopy every 2 yrs until age 40 Colonoscopy yearly after age 40 Colonoscopy yearly after age 40

Colorectal Cancer Screening - Colorectal Cancer Screening - High RiskHigh Risk

Inflammatory Bowel Disease Inflammatory Bowel Disease ( Ulcerative colitis)( Ulcerative colitis)

Initial Colonoscopy with biopsy for Initial Colonoscopy with biopsy for dysplasia dysplasia If Pancolitis ( entire colon) : 8 years after If Pancolitis ( entire colon) : 8 years after

the start or the start or If Left sided Colitis: 15 years after the If Left sided Colitis: 15 years after the

start start Repeat Colonoscopy every 1 year Repeat Colonoscopy every 1 year

TNM Staging System for Colon Cancer

StagePrimary Tumor (T)

Regional Lymph Node (N)

Remote Metastasis (M)

Stage 0Carcinoma in situ

N0 M0

Stage I

Tumor may invade submucosa (T1) or muscularis (T2).

N0 M0

Stage II

Tumor invades muscularis (T3) or perirectal tissues (T4).

N0 M0

Stage IIIA T1-4 N1 M0

Stage IIIB T1-4 N2-3 M0

Stage IV T1-4 N1-3 M1

Dukes Classification

Stage Characteristics

Dukes stage ACarcinoma in situ limited to mucosa or submucosa (T1, N0, M0)

Dukes stage BCancer that extends into the muscularis (B1), into or through the serosa (B2)

Dukes stage CCancer that extends to regional lymph nodes (T1-4, N1, M0)

Dukes stage DModified classification; cancer that has metastasized to distant sites (T1-4, N1-3, M1)

Colon Ca RxColon Ca RxTreatment of stage 0 (carcinoma in situ) may Treatment of stage 0 (carcinoma in situ) may

include the following types of surgeryinclude the following types of surgery Local excision or simple polypectomy. Local excision or simple polypectomy. Resection/anastomosis. This is done when the Resection/anastomosis. This is done when the

tumor is too large to remove by local excision. tumor is too large to remove by local excision. After polypectomy After polypectomy single specimen, single specimen,

completely removed with favorable histology completely removed with favorable histology and clear margins and clear margins Observe Observe

if fragmented tissue, unfavorable if fragmented tissue, unfavorable histology or margin cannot be assessed histology or margin cannot be assessed total colectomy with en bloc removal of lymph total colectomy with en bloc removal of lymph nodesnodes

Colon Ca RxColon Ca Rx Colon cancer, non metastatic: Surgical RxColon cancer, non metastatic: Surgical Rx Resectable, non obstructing Resectable, non obstructing colectomy with enbloc removal of colectomy with enbloc removal of

regional lymph nodesregional lymph nodes Resectable, Obstructing Resectable, Obstructing one stage colectomy with egional one stage colectomy with egional

lymphnode removal or resection with diversion or stent/ lymphnode removal or resection with diversion or stent/ diversion followed by colectomydiversion followed by colectomy

Locally unresectable Locally unresectable palliation therapy ( chemo) palliation therapy ( chemo)Adjuvant Chemo :No need for Stage O and Stage IAdjuvant Chemo :No need for Stage O and Stage I For Stage II, Stage III – adjuvant chemo rx with 5-For Stage II, Stage III – adjuvant chemo rx with 5-

FU/Leucovorin/ oxaliplatin is indicatedFU/Leucovorin/ oxaliplatin is indicated• Stage IV Stage IV depends on resectability of liver/ lung mets . If depends on resectability of liver/ lung mets . If

resectable mets resectable mets colectomy + adjuvant chemo + resection of colectomy + adjuvant chemo + resection of liver/lung mets or Neoadjuvant chemo( FOLFOX/ FOLFIRI) liver/lung mets or Neoadjuvant chemo( FOLFOX/ FOLFIRI) followed by colectomy and resection of hepatic mets.followed by colectomy and resection of hepatic mets.

Resectability criteria : Resectability criteria : Liver Complete resection must be feasible based on anatomic grounds and

the extent of disease, maintenance of adequate hepatic function is required.

There should be no unresectable extrahepatic sites of disease. Ablative techniques should be considered in conjunction with

resection in otherwise unresectable patients.

Colorectal CA - TreatmentColorectal CA - Treatment

Management: Non-resectable hepatic Management: Non-resectable hepatic metastasesmetastases

- Radiofrequency Ablation of mets + colectomy- Radiofrequency Ablation of mets + colectomyCourseCourse

Recurrence risk Recurrence risk Highest risk within first 5 years post-resection Highest risk within first 5 years post-resection

Protocol: Monitoring post-resectionProtocol: Monitoring post-resection Clinical examination with CEA-125 Clinical examination with CEA-125

Initially repeat every 3 months for 2 years Initially repeat every 3 months for 2 years Later repeat every 6 months for up to 5 yearsLater repeat every 6 months for up to 5 years Focus areas Focus areas

Ostomy problems or stool Incontinence Ostomy problems or stool Incontinence Radiation proctitis Radiation proctitis Bowel adhesions Bowel adhesions

Colonoscopy Colonoscopy Perform at one year and 3 years post-resection Perform at one year and 3 years post-resection Then, repeat every 5 years Then, repeat every 5 years

CEACEAIndicationsIndications Colon Cancer monitoring Colon Cancer monitoring Do not use to screen for Colon Cancer or other cancer Do not use to screen for Colon Cancer or other cancer InterpretationInterpretation Normal Normal Non-smokers: <2.5 mg/ml , Smokers: <5 ng/ml Non-smokers: <2.5 mg/ml , Smokers: <5 ng/ml Increased Increased

Benign disease unlikely if >10 ng/ml Benign disease unlikely if >10 ng/ml Distant metastasis most likely if >100 ng/ml Distant metastasis most likely if >100 ng/ml

EfficacyEfficacy Not specific - Seen in other adenocarcinomas Not specific - Seen in other adenocarcinomas Sensitivity varies by tumor stage and differentiation Sensitivity varies by tumor stage and differentiation

CEA not increased in poorly differentiated tumors CEA not increased in poorly differentiated tumors Increased in <25% of Duke A or B stage Colon Cancer, in 50% with Increased in <25% of Duke A or B stage Colon Cancer, in 50% with

Duke C , in 75% of Duke D stage Colon CancerDuke C , in 75% of Duke D stage Colon Cancer

Causes of increased CEACauses of increased CEA Benign causes : Tobacco abuse, Peptic Ulcer Disease, Inflammatory Bowel Benign causes : Tobacco abuse, Peptic Ulcer Disease, Inflammatory Bowel

Disease , Pancreatitis, Hypothyroidism, CirrhosisDisease , Pancreatitis, Hypothyroidism, Cirrhosis Malignant causes Malignant causes

Cancer – Colon, Breast, Stomach, Lung, Pancreas, Bladder, Cervix, Cancer – Colon, Breast, Stomach, Lung, Pancreas, Bladder, Cervix, Melanoma, LymphomaMelanoma, Lymphoma

Case StudyCase Study A 65 y-old male undergoes a screening A 65 y-old male undergoes a screening

colonoscopy which reveals a 2cm polyp. The colonoscopy which reveals a 2cm polyp. The histopathology reveals an adenomatous polyp histopathology reveals an adenomatous polyp with no atypical cells. The most appropriate with no atypical cells. The most appropriate follow up for this patient is : follow up for this patient is :

A) Colonoscopy at 10 yrsA) Colonoscopy at 10 yrs B) Colonoscopy at 5 yrs and then every 5 yrsB) Colonoscopy at 5 yrs and then every 5 yrs C) Colonoscopy at 3 yrs and then every 10 yrsC) Colonoscopy at 3 yrs and then every 10 yrs D) Colonscopy at 3 yrs and then every 5 yearsD) Colonscopy at 3 yrs and then every 5 years E) CEA every 3 monthsE) CEA every 3 months

Breast CABreast CA

Screening & TreatmentScreening & Treatment

Breast LumpBreast Lump

EvaluationEvaluation

Etiologies of Discrete Breast LumpsEtiologies of Discrete Breast Lumps Age under 20 years Age under 20 years

Fibroadenoma: 50% Fibroadenoma: 50% Benign Breast Mass: 50% Benign Breast Mass: 50%

Age 20 to 29 years Age 20 to 29 years Fibroadenoma: 35% Fibroadenoma: 35% Benign Breast Mass: 52% Benign Breast Mass: 52% Breast Cyt: 10% Breast Cyt: 10% Breast Cancer: 3% Breast Cancer: 3%

Age 30 to 39 years Age 30 to 39 years Fibroadenoma: 18% Fibroadenoma: 18% Benign Breast Mass: 62% Benign Breast Mass: 62% Breast Cyst: 10% Breast Cyst: 10% Breast Cancr: 10% Breast Cancr: 10%

Age 40 to 55 years Age 40 to 55 years Fibroadenoma: 9% Fibroadenoma: 9% Benign Breast Mass: 31% Benign Breast Mass: 31% Breast Cyst: 25% Breast Cyst: 25% Breast Canerr: 35% Breast Canerr: 35%

Age over 55 years Age over 55 years Benign Breast Mass: 13% Benign Breast Mass: 13% Breast Cyst: 2% Breast Cyst: 2% Breast Cancer: 85% Breast Cancer: 85%

Types of Breast Types of Breast MassesMasses

Breast Cyst Breast Cyst Fibroadenoma Fibroadenoma Fibrocystic Breast Fibrocystic Breast Breast Cancer Breast Cancer

Evaluating Breast LumpEvaluating Breast LumpClinical ExamClinical Exam If palpable lump If palpable lump proceed with aspiration/ if difficult to proceed with aspiration/ if difficult to

localize go for ultrasoundlocalize go for ultrasound If not palpable/ to evaluate possible concurrent, If not palpable/ to evaluate possible concurrent,

nonpalpable lesions nonpalpable lesions mammogram mammogram

DiagnosticsDiagnostics Breast Ultrasound Breast Ultrasound Mammogram in mass evaluation Mammogram in mass evaluation

Not used to evaluate palpable mass Not used to evaluate palpable mass Used to evaluate for other concurrent lesions Used to evaluate for other concurrent lesions Delay Mammogram 2 weeks after aspiration Delay Mammogram 2 weeks after aspiration

Aspiration may cause hematoma Aspiration may cause hematoma Wait time avoids false positives Wait time avoids false positives

Breast aspiration, fine needle aspirate or core biopsy Breast aspiration, fine needle aspirate or core biopsy Excisional breast biopsy Excisional breast biopsy

Evaluating Breast LumpEvaluating Breast LumpManagement: Protocol 1 based on Management: Protocol 1 based on

starting with ultrasoundstarting with ultrasound Start with breast ultrasound Start with breast ultrasound Ultrasound shows simple cyst Ultrasound shows simple cyst

Aspirate ( See Breast Cyst Aspiration )Aspirate ( See Breast Cyst Aspiration ) Repeat Clinical Breast Exam in 4-6 weeks Repeat Clinical Breast Exam in 4-6 weeks

Ultrasound shows complex cyst or solid Ultrasound shows complex cyst or solid lesion lesion Mammogram and Mammogram and Fine needle aspirate or core-needle biopsy Fine needle aspirate or core-needle biopsy

(See Breast Cyst Aspiration )(See Breast Cyst Aspiration ) Ultrasound does not reveal lesion Ultrasound does not reveal lesion

Mammogram and Mammogram and Fine needle aspirate or core-needle biopsy Fine needle aspirate or core-needle biopsy

Breast cyst aspirationBreast cyst aspiration InterpretationInterpretation No fluid (failed aspiration) No fluid (failed aspiration)

Consider breast ultrasound to better localize Consider breast ultrasound to better localize Refer solid lesions for breast biopsy Refer solid lesions for breast biopsy

Bloody Fluid Aspirate Bloody Fluid Aspirate Do NOT drain cyst (discontinue aspiration!) Do NOT drain cyst (discontinue aspiration!) Send fluid for Cytology Send fluid for Cytology Refer to Surgery for fine needle aspirate Refer to Surgery for fine needle aspirate

Non-bloody fluid aspirate Non-bloody fluid aspirate Drain cyst completely Drain cyst completely Discard aspirate fluid Discard aspirate fluid Reexamine after draining cyst Reexamine after draining cyst

Refer to surgery if mass still present Refer to surgery if mass still present Repeat Breast Exam in 4-6 weeks Repeat Breast Exam in 4-6 weeks

Evaluating Breast LumpEvaluating Breast LumpMangement: Protocol 2 based on starting with FNAMangement: Protocol 2 based on starting with FNA Start with fine-needle aspirate of breast mass Start with fine-needle aspirate of breast mass Breast mass is cystic Breast mass is cystic

No residual cyst after aspiration No residual cyst after aspiration Age over 40: Mammogram or core needle biopsy Age over 40: Mammogram or core needle biopsy Age under 40: Ultrasound or core needle biopsy Age under 40: Ultrasound or core needle biopsy

Residual cyst or bloody fluid aspirated Residual cyst or bloody fluid aspirated Repeat Clinical Breast Exam in 6 weeks Repeat Clinical Breast Exam in 6 weeks

Breast mass is solid Breast mass is solid FNA malignant: Treat FNA malignant: Treat FNA Suspicious: Core-needle or Excisional Biopsy FNA Suspicious: Core-needle or Excisional Biopsy FNA non-diagnostic FNA non-diagnostic

Age over 40: Mammogram or core needle biopsy Age over 40: Mammogram or core needle biopsy Age under 40: Ultrasound or core needle biopsy Age under 40: Ultrasound or core needle biopsy

FNA benign FNA benign Obtain Mammogram Obtain Mammogram If Mammogram positive If Mammogram positive

Ultrasound or Ultrasound or Core-needle biopsy Core-needle biopsy

If Mammogram negativeIf Mammogram negative Repeat Clinical Breast Exam in 6 weeks Repeat Clinical Breast Exam in 6 weeks

Evaluating Breast LumpEvaluating Breast LumpManagement: Protocol 3 Basic Approach Management: Protocol 3 Basic Approach

based on agebased on age Premenopausal asymmetrical palpable mass Premenopausal asymmetrical palpable mass

Reexamine during days 5-10 of Menstrual CycleReexamine during days 5-10 of Menstrual Cycle Mammogram if age over 30 years Mammogram if age over 30 years Breast Ultrasound if difficult localization Breast Ultrasound if difficult localization Attempt aspiration of breast lesion Attempt aspiration of breast lesion

See Breast Cyst AspirationSee Breast Cyst Aspiration Postmenopausal asymmetrical palpable Postmenopausal asymmetrical palpable

mass mass Have a high level of suspicion (High Risk) Have a high level of suspicion (High Risk) MammogramMammogram Attempt aspiration of breast lesion Attempt aspiration of breast lesion

See Breast Cyst AspirationSee Breast Cyst Aspiration

Risk Factors – Ca BreastRisk Factors – Ca Breast AgeAge Ethnicity/ Race : eg: Ashkenazi jews as they have increased Ethnicity/ Race : eg: Ashkenazi jews as they have increased

incidence of BRCA1/BRCA2 mutationsincidence of BRCA1/BRCA2 mutations Family Hx Family Hx should include 3 generations including should include 3 generations including

proband, offspring, paternal and maternal sidesproband, offspring, paternal and maternal sides Age at Menarche – early age increased riskAge at Menarche – early age increased risk Age at Menopuse – Late age Increased riskAge at Menopuse – Late age Increased risk Parity – Nulliparity is associated with increased ER+ breast Parity – Nulliparity is associated with increased ER+ breast

ca risk ca risk reduced number of ovulations in pregnancy may reduced number of ovulations in pregnancy may be responsible for this protective effect associated with be responsible for this protective effect associated with multiparitymultiparity

Age at first birth Age at first birth late age associated with increased risk late age associated with increased risk of ER, PR+ Breast cancerof ER, PR+ Breast cancer

ObesityObesity Prior thoracic RTPrior thoracic RT Known BRCA1/BRCA2, P53 Mutations, family hxKnown BRCA1/BRCA2, P53 Mutations, family hx Alcohol consumptionAlcohol consumption Current or prior Hormone Replacement TherapyCurrent or prior Hormone Replacement Therapy

ScreeningScreening

Risk Stratification : Risk Stratification : Normal Risk Normal Risk Increased Risk Increased Risk

* Prior Thoracic Radiotherapy ( Mantle * Prior Thoracic Radiotherapy ( Mantle radiation) eg: childhood survivors of radiation) eg: childhood survivors of hodgkins lymphomahodgkins lymphoma

* Strong family History or Genetic * Strong family History or Genetic PredispositionPredisposition

* LCIS/ Atypical hyperplasia* LCIS/ Atypical hyperplasia

* Prior history of breast cancer.* Prior history of breast cancer.

Screening – Normal Risk ptsScreening – Normal Risk pts

*Age >/= 20 but < 40 *Age >/= 20 but < 40 Counsel periodic breast self exam every Counsel periodic breast self exam every

month. Premenopausal women may find month. Premenopausal women may find BSE most informative when performed at BSE most informative when performed at the end of menses.the end of menses.

Clinical breast exam every 1-3 yearsClinical breast exam every 1-3 years*Age >/ = 40 years *Age >/ = 40 years Counsel on periodic self breast examCounsel on periodic self breast exam Annual clinical breast examAnnual clinical breast exam Mammogram every year.Mammogram every year.

Screening – Increased Risk ptsScreening – Increased Risk pts Annual clinical breast exam if age < 25yrs, if age Annual clinical breast exam if age < 25yrs, if age

25 yrs or more – consider it more frequently at 6-12 25 yrs or more – consider it more frequently at 6-12 mosmos

For pts with LCIS/ Atypical hyperplasia For pts with LCIS/ Atypical hyperplasia annual annual mammogram + consider breast ca reduction mammogram + consider breast ca reduction strategiesstrategies

Begin Mammogram at age 25 years for Hereditary Begin Mammogram at age 25 years for Hereditary Breast and Ovarian cancer pts Breast and Ovarian cancer pts

( eg: family member with a known BRCA1/ BRCA2 ( eg: family member with a known BRCA1/ BRCA2 mutation ) mutation ) also, consider risk reduction strategies also, consider risk reduction strategies

For pts with strong family history or other genetic For pts with strong family history or other genetic predispositions ( i.e; other than HBOC), Start annual predispositions ( i.e; other than HBOC), Start annual mammogram 5-10 yrs prior to youngest breast mammogram 5-10 yrs prior to youngest breast cancer case in the family cancer case in the family Also, consider risk Also, consider risk reduction strategiesreduction strategies

For pts with prior thoracic RT For pts with prior thoracic RT Begin annual Begin annual mammogram 8-10 yrs after RT or at age 40 years mammogram 8-10 yrs after RT or at age 40 years whichever is first!!whichever is first!!

HBOCHBOC Hereditary Breast and Ovarian Cancer – criteriaHereditary Breast and Ovarian Cancer – criteria Member of family with known BRCA1/BRCA2 mutationMember of family with known BRCA1/BRCA2 mutation Personal hx of breast cancer with either of the following : Personal hx of breast cancer with either of the following : *Diagnosed at or less than 40 yrs with/without family hx*Diagnosed at or less than 40 yrs with/without family hx *Diagnosed at any age with 2 or more close blood *Diagnosed at any age with 2 or more close blood

relatives with ovarian or breast cancers at any agerelatives with ovarian or breast cancers at any age * Close male blood relative with breast cancer* Close male blood relative with breast cancer * Personal hx of ovarian cancer* Personal hx of ovarian cancer * If pt is of certain ethnic descent associated with bad * If pt is of certain ethnic descent associated with bad

mutations mutations Ashkenazi Jews, Swedish, icelandic Ashkenazi Jews, Swedish, icelandic Personal hx of ovarian cancer with one or more of Personal hx of ovarian cancer with one or more of

following following * One or more close relatives with ovarian cancer* One or more close relatives with ovarian cancer * two or more close blood relatives with breast cancer* two or more close blood relatives with breast cancer * one or more close blood relatives with breast cancer * one or more close blood relatives with breast cancer

less than 50 yrs of ageless than 50 yrs of age * one or more close male blood relatives with breast ca* one or more close male blood relatives with breast ca * If Ashkenawzi jew * If Ashkenawzi jew no additional family hx required no additional family hx required

HBOC criteria met – what next? HBOC criteria met – what next? If BRCA1/BRCA2 status in the pt’s family is not If BRCA1/BRCA2 status in the pt’s family is not

known known test the affected family member at test the affected family member at highest likelihood of having the mutation. ( if more highest likelihood of having the mutation. ( if more than one affected than one affected younger age at onset, bilateral younger age at onset, bilateral breast ca, closest relative to proband, multiple breast ca, closest relative to proband, multiple breast primaries breast primaries are the things u can consider in are the things u can consider in judging the likelihood ) (If askenawji jew, consider judging the likelihood ) (If askenawji jew, consider testing 3 common mutations. If they are negative testing 3 common mutations. If they are negative you can go with full sequence testing. If the pt is you can go with full sequence testing. If the pt is not ashkenaji descent not ashkenaji descent proceed with full sequence proceed with full sequence testing). If family member is +ve for mutation, testing). If family member is +ve for mutation, proceed with HBOC management guidelinesproceed with HBOC management guidelines

If BRCA1/BRCA2 deleterious familial mutation is If BRCA1/BRCA2 deleterious familial mutation is known for that raceknown for that race test the pt for this specific test the pt for this specific familial mutation ( If the pt is Askenawzi jew, test familial mutation ( If the pt is Askenawzi jew, test for the three common mutations.) If mutations are for the three common mutations.) If mutations are +ve in the pt, proceed with HBOC management +ve in the pt, proceed with HBOC management guidelines.guidelines.

HBOC management guidelinesHBOC management guidelines Screening as Discussed earlierScreening as Discussed earlier Risk reduction strategies : Risk reduction strategies : counsel about option of risk reduction counsel about option of risk reduction

mastectomy if needed mastectomy if needed if the pt agrees proceed if the pt agrees proceed with b/l total mastectomy with reconstructionwith b/l total mastectomy with reconstruction

Counsel about the option of risk reducing salpingo-Counsel about the option of risk reducing salpingo-oophorectomy between ages 35 and 40 yrsoophorectomy between ages 35 and 40 yrs

For pts refusing risk reducing surgeries For pts refusing risk reducing surgeries continue continue follow ups with transvaginal ultrasound + CA-125 follow ups with transvaginal ultrasound + CA-125 every 6mos starting at age 35 yrs or 10yrs earlier every 6mos starting at age 35 yrs or 10yrs earlier than earliest age of 1than earliest age of 1stst diagnosis of ovarian cancer diagnosis of ovarian cancer in the family. in the family.

May consider non surgical options such as May consider non surgical options such as tamoxifen or raloxifene , data still neededtamoxifen or raloxifene , data still needed

Breast Ca - StagingBreast Ca - Staging Tis – DCIS, LCISTis – DCIS, LCIS T1 – Tumor less than or equal to 2 cmT1 – Tumor less than or equal to 2 cm T2 – Tumor greater than 2cm but < 5cmT2 – Tumor greater than 2cm but < 5cm T3 – Tumor>5cmT3 – Tumor>5cm T4 – Tumor of any size that has spread to T4 – Tumor of any size that has spread to

chestwall.chestwall. N0 – No lymphnodesN0 – No lymphnodes N1 – 1 to 3 LNsN1 – 1 to 3 LNs N2 – 4-9 LNsN2 – 4-9 LNs N3 – 10 or more LNsN3 – 10 or more LNs

Breast Ca - StagingBreast Ca - StagingOverall Stage T category N category M category

Stage 0 Tis N0 M0

Stage I T1 N0 M0

Stage IIAT0T1T2

N1N1N0

M0M0M0

Stage IIBT2T3

N1N0

M0M0

Stage IIIA

T0T1T2T3T3

N2N2N2N1N2

M0M0M0M0M0

Stage IIIB T4 Any N M0

Stage IIIC Any T N3 M0

Stage IV Any T Any N M1

Breast ca – Stage 0Breast ca – Stage 0 Lobular carcinoma in situ Lobular carcinoma in situ only surgical only surgical

procedure involved would be the biopsy. procedure involved would be the biopsy. Treatment : Careful follow up & observationTreatment : Careful follow up & observation Further screening as we already discussed for Further screening as we already discussed for

high risk groups i.e; clinical breat exam every high risk groups i.e; clinical breat exam every 6mos+ annual mammogram6mos+ annual mammogram

Consider Risk reduction strategies -> Consider Risk reduction strategies -> Tamoxifen/ raloxifene for full 5 years, can Tamoxifen/ raloxifene for full 5 years, can educe the risk of developing invasive breast educe the risk of developing invasive breast cancercancer

-> For pts with additional risk factors like -> For pts with additional risk factors like family hx, BRCA mutations , need to consider family hx, BRCA mutations , need to consider prophylactic b/l mastectomyprophylactic b/l mastectomy

Breast ca – Stage 0Breast ca – Stage 0 Ductal Carcinoma In Situ Ductal Carcinoma In Situ Options are a) Lumpectomy + radiationOptions are a) Lumpectomy + radiation b) Mastectomy b) Mastectomy Check for hormone receptors in the Check for hormone receptors in the

removed breast tissue. ER+ve tumors removed breast tissue. ER+ve tumors need 5 years of Tamoxifen/ Raloxifeneneed 5 years of Tamoxifen/ Raloxifene

Mastectomy provides almost certain cure Mastectomy provides almost certain cure from local recurrence. Pts with DCIS who from local recurrence. Pts with DCIS who undergo lumpectomy are not at a higher undergo lumpectomy are not at a higher risk of dying of breast ca as opposed to risk of dying of breast ca as opposed to mastectomy. However, they have a risk of mastectomy. However, they have a risk of local recurrence in the same breast!!local recurrence in the same breast!!

Breast Ca – Stage I, II, IIIABreast Ca – Stage I, II, IIIA Lumpectomy with surgical axillary Lumpectomy with surgical axillary

staging if pt desires breast staging if pt desires breast conservation. Follow with conservation. Follow with Radiotherapy. Check Hormonal status Radiotherapy. Check Hormonal status if ER, PR, Her2 if ER, PR, Her2 if ER +ve treat if ER +ve treat with tamoxifen 5 yearswith tamoxifen 5 years

If Her2 +ve, treat with trastuzumabIf Her2 +ve, treat with trastuzumab

Adjuvant chemotherapy with AC in Adjuvant chemotherapy with AC in case of hormone –ve tumorscase of hormone –ve tumors

* Total mastectomy with axillary node * Total mastectomy with axillary node staging is another optionstaging is another option

Absolute contraindications for Absolute contraindications for Lumpectomy requiring RTLumpectomy requiring RT

No radiation therapy is needed if tumor No radiation therapy is needed if tumor is less than 5cm, with good margins and is less than 5cm, with good margins and no spread to lymphnodesno spread to lymphnodes

In those requiring RT In those requiring RT Contraindications Contraindications for lumpectomy + RT are :for lumpectomy + RT are :

A)A) Prior RT to the breast or chest wallPrior RT to the breast or chest wall

B)B) RT during pregnancyRT during pregnancy

C)C) Diffuse suspicious or malignant Diffuse suspicious or malignant appearing microcalcificationsappearing microcalcifications

D)D) Positive pathological marginsPositive pathological margins

Treatment Stage IIIB/IVTreatment Stage IIIB/IV

Total mastectomy + RT to chestwall Total mastectomy + RT to chestwall + adjuvant chemo + hormonal + adjuvant chemo + hormonal therapy where indicatedtherapy where indicated

Paget’s diseasePaget’s disease Presentation : Eczema of areola, bleeding, Presentation : Eczema of areola, bleeding,

ulceration, itching of nipple – due to neoplastic ulceration, itching of nipple – due to neoplastic cells in the epidermis of nipple areolar complexcells in the epidermis of nipple areolar complex

Associated cancers : DCIS, Invasice cancerAssociated cancers : DCIS, Invasice cancer If Paget’s disease – first do clinical exam + biopsy If Paget’s disease – first do clinical exam + biopsy

of nipple-areolar complex of nipple-areolar complex if no other lesion if no other lesion palpable palpable MRI MRI

If any lesion on Clinical exam/ MRI If any lesion on Clinical exam/ MRI evaluate as evaluate as per guidelines of breast mass.per guidelines of breast mass.

If there is an associated cancer If there is an associated cancer options are total options are total mastectomy or breast conserving surgerymastectomy or breast conserving surgery

If there’s no associated cancer If there’s no associated cancer ( no palpable ( no palpable mass or imaging abnormality ) mass or imaging abnormality ) breast breast conserving surgery with removal of nipple-areolar conserving surgery with removal of nipple-areolar complex with –ve margin breast tissuecomplex with –ve margin breast tissue

Breast Cancer – Pregnancy Breast Cancer – Pregnancy Breast carcinoma is the most common malignancy associated with pregnancy.Breast carcinoma is the most common malignancy associated with pregnancy.

The incidence is low but increasing due to increasing number of late pregnancies. The incidence is low but increasing due to increasing number of late pregnancies.

Symptoms and signs of the disease may be overlooked, resulting in delays in treatment Symptoms and signs of the disease may be overlooked, resulting in delays in treatment and potentially compromising survival. For this reason, it is imperative that physicians and potentially compromising survival. For this reason, it is imperative that physicians perform careful clinical breast examinations in all pregnant patients-particularly early in perform careful clinical breast examinations in all pregnant patients-particularly early in gestation, before the breasts become difficult to examine. gestation, before the breasts become difficult to examine.

Upon finding any suspicious breast mass, an open biopsy without delay is indicated. Upon finding any suspicious breast mass, an open biopsy without delay is indicated.

Modified radical mastectomy may be safely performed and is the primary treatment of Modified radical mastectomy may be safely performed and is the primary treatment of choice when cancer is diagnosed during pregnancy.choice when cancer is diagnosed during pregnancy.

Chemotherapy can be given in late pregnancy, and radiotherapy is contraindicated. Chemotherapy can be given in late pregnancy, and radiotherapy is contraindicated.

In some cases, especially when disease presents early in gestation, an interruption of In some cases, especially when disease presents early in gestation, an interruption of the pregnancy may be warranted.the pregnancy may be warranted.

Breast cancer during pregnancy has a similar prognosis to that of breast cancer in Breast cancer during pregnancy has a similar prognosis to that of breast cancer in young, nonpregnant women; pregnancy itself does not appear to have an adverse young, nonpregnant women; pregnancy itself does not appear to have an adverse effect on the disease process. effect on the disease process.

There is no need for therapeutic abortion. Stage by stage, the prognosis of breast There is no need for therapeutic abortion. Stage by stage, the prognosis of breast carcinoma in pregnancy is similar to that of non-pregnant controls. With careful carcinoma in pregnancy is similar to that of non-pregnant controls. With careful counseling, further pregnancy can be planned after 2-3 years in selected cases.counseling, further pregnancy can be planned after 2-3 years in selected cases.

Case StudyCase Study1) A 35 y/o woman comes to you for a mass in her 1) A 35 y/o woman comes to you for a mass in her

left breast. Her last menstrual period was 8 left breast. Her last menstrual period was 8 weeks ago and a pregnancy test returned weeks ago and a pregnancy test returned positive. Further work up revealed ductal positive. Further work up revealed ductal carcinoma in situ. She requests if she can keep carcinoma in situ. She requests if she can keep the pregnancy and also does not ant to lose her the pregnancy and also does not ant to lose her breast. The appropriate response at this time: breast. The appropriate response at this time:

A)A) She may undergo lumpectomy with radiotherapy She may undergo lumpectomy with radiotherapy but needs to undergo therapeutic abortionbut needs to undergo therapeutic abortion

B)B) She can go for lumpectomy with radiation and She can go for lumpectomy with radiation and can keep the babycan keep the baby

C)C) We can postpone therapy untill the pregnancy is We can postpone therapy untill the pregnancy is completecomplete

D)D) We can just do lumpectomy for now and We can just do lumpectomy for now and postpone RT for the pregnancy to completepostpone RT for the pregnancy to complete

E)E) She must undergo radical mastectomy She must undergo radical mastectomy

Case StudyCase Study

1) A 35 year old woman comes to you 1) A 35 year old woman comes to you for regular physical exam. Her family for regular physical exam. Her family history reveals ovarian cancer in history reveals ovarian cancer in mother at 55 yrs and also breast mother at 55 yrs and also breast cancer in the sister at age of 25 yrs. cancer in the sister at age of 25 yrs. Your next step:Your next step:

A) Test mother for BRCA1/BRCA2A) Test mother for BRCA1/BRCA2 B) Test the patient for BRCA1/BRCA2B) Test the patient for BRCA1/BRCA2 C) Test the sister for BRCA1/ BRCA2C) Test the sister for BRCA1/ BRCA2

Prostate Ca Prostate Ca ControversiesControversies

PSA issuesPSA issues

Efficacy of PSAEfficacy of PSA USPSTF does not recommend screening : USPTF, ACP, AAFP USPSTF does not recommend screening : USPTF, ACP, AAFP

does not recommend. Where as NCCN, ACS, AUA advocate does not recommend. Where as NCCN, ACS, AUA advocate it it

Test SensitivityTest Sensitivity Overall: 79-82% Overall: 79-82% Cancers >1 cm: 90% Cancers >1 cm: 90% More sensitive than Rectal Exam (30% for 1 cm tumor) More sensitive than Rectal Exam (30% for 1 cm tumor) Much more sensitive than Acid Phosphatase Much more sensitive than Acid Phosphatase

Test Specificity = 59% Test Specificity = 59% High false positive rate High false positive rate Benign Prostatic Hyperplasia often increases PSA Benign Prostatic Hyperplasia often increases PSA

Positive Predictive Value (PPV) 32-40% Positive Predictive Value (PPV) 32-40% Much more cost-effective than Mammography Much more cost-effective than Mammography Outcomes uncertain despite effective screening Outcomes uncertain despite effective screening

Detection may not impact morbidity and mortality Detection may not impact morbidity and mortality

PSA issuesPSA issuesCauses of elevated PSACauses of elevated PSA Prostate Cancer Prostate Cancer Benign Prostatic Hyperplasia (BPH) Benign Prostatic Hyperplasia (BPH) Prostatitis Prostatitis Prostate inflammation, trauma, or Prostate inflammation, trauma, or

manipulation manipulation Prostatic infarction Prostatic infarction Recent sexual activity Recent sexual activity Urologic procedures Urologic procedures

Cystoscopy Cystoscopy Urinary Catheterization Urinary Catheterization

PSA IssuesPSA IssuesScreening (if performed) Screening (if performed)

Men without risk factors: Age over 50 years Men without risk factors: Age over 50 years Digital Rectal Exam yearly Digital Rectal Exam yearly Prostate Specific Antigen (PSA) yearly Prostate Specific Antigen (PSA) yearly

Men with risk factors: Age over 45 years Men with risk factors: Age over 45 years Indications Indications

African Americans African Americans Young first degree relative with Prostate Cancer Young first degree relative with Prostate Cancer

Digital Rectal Exam yearly Digital Rectal Exam yearly Prostate Specific Antigen (PSA) yearly Prostate Specific Antigen (PSA) yearly

Age over 70 to 75 years Age over 70 to 75 years Discontinue PSA screening Discontinue PSA screening

Screening interval Screening interval Screening every 4 years may be as effective as Screening every 4 years may be as effective as

annual annual

PSA issuesPSA issues Age specific Normal PSA valuesAge specific Normal PSA values Age 40 to 49 years 2.0 – 2.5Age 40 to 49 years 2.0 – 2.5

White: PSA <= 2.5 White: PSA <= 2.5 Black: PSA < 2.0 Black: PSA < 2.0 Asian: PSA < 2.0 Asian: PSA < 2.0

Age: 50 to 59 years 3.0 – 4.0Age: 50 to 59 years 3.0 – 4.0 White: PSA <= 3.5 White: PSA <= 3.5 Black: PSA < 4.0 Black: PSA < 4.0 Asian: PSA < 3.0 Asian: PSA < 3.0

Age 60 to 69 years 4.0 – 4.5Age 60 to 69 years 4.0 – 4.5 White: PSA <= 4.5 White: PSA <= 4.5 Black: PSA < 4.5 Black: PSA < 4.5 Asian: PSA < 4.0 Asian: PSA < 4.0

Age 70 to 79 years 5.0 – 6.5Age 70 to 79 years 5.0 – 6.5 White: PSA <= 6.5 White: PSA <= 6.5 Black: PSA <5.5 Black: PSA <5.5 Asian: PSA <5.0 Asian: PSA <5.0

PSA issuesPSA issuesMechanismMechanism Free PSA increases more in Benign Prostatic Free PSA increases more in Benign Prostatic

Hypertrophy Hypertrophy PSA associated with cancer is more protein bound PSA associated with cancer is more protein bound IndicationIndication Detection of Prostate Cancer when PSA 2.5 to 10 Detection of Prostate Cancer when PSA 2.5 to 10

ng/ml ng/ml EfficacyEfficacy Improved Specificity when combined with PSA Improved Specificity when combined with PSA InterpretationInterpretation Free PSA >27% with lower likelihood of Prostate Free PSA >27% with lower likelihood of Prostate

Cancer Cancer Values suggestive of Prostate Cancer Values suggestive of Prostate Cancer

Total PSA 3.0 to 4.0 with Free PSA <19% Total PSA 3.0 to 4.0 with Free PSA <19% Total PSA 4.0 to 10.0 with Free PSA <17 to 24% Total PSA 4.0 to 10.0 with Free PSA <17 to 24% PSA > 100ng/ml predicts bone mets in 75% casesPSA > 100ng/ml predicts bone mets in 75% cases

Staging Prostate CaStaging Prostate Ca Stage AStage A Stage A1: Single impalpable lesion (<5% of gland) Stage A1: Single impalpable lesion (<5% of gland) Stage A2: Impalpable microscopic lesion (>5% of gland) Stage A2: Impalpable microscopic lesion (>5% of gland) Stage BStage B Stage B1: Palpable Nodule in single lobe Stage B1: Palpable Nodule in single lobe Stage B2: Palpable Nodules Stage B2: Palpable Nodules Stage CStage C Stage C1: Localized disease extending beyond gland Stage C1: Localized disease extending beyond gland Stage C2: Localized disease includes seminal vesicles Stage C2: Localized disease includes seminal vesicles Stage DStage D Stage D1: Pelvic lymph node involvement Stage D1: Pelvic lymph node involvement Stage D2: Bone metastases or distant spread Stage D2: Bone metastases or distant spread

Case Study 1Case Study 1 A 65 y/o African American man is brought by his daughter A 65 y/o African American man is brought by his daughter

to you and requests a PSA test because there is a hx of to you and requests a PSA test because there is a hx of prostate ca in their family. You perform PSA and DRE. DRE prostate ca in their family. You perform PSA and DRE. DRE does not reveal any palpable mass. The lab test reveal : does not reveal any palpable mass. The lab test reveal : PSA : 8ng/ml, Free PSA: 1.5ng/ml. You reveal the results to PSA : 8ng/ml, Free PSA: 1.5ng/ml. You reveal the results to patient and his daughter. The daughter asks you if her patient and his daughter. The daughter asks you if her father has a cancer. Your best response is :father has a cancer. Your best response is :

A) The PSA level increases with age and your father’s is A) The PSA level increases with age and your father’s is age-appropriate rangeage-appropriate range

B) PSA level is very nonspecific and your father does not B) PSA level is very nonspecific and your father does not have a cancerhave a cancer

C) The fact that the free PSA is only 1.5ng/ml as opposed to C) The fact that the free PSA is only 1.5ng/ml as opposed to a bound of 6.5 indicates that your father most likely has a a bound of 6.5 indicates that your father most likely has a cancer etiology rather than benign causecancer etiology rather than benign cause

D) PSA will not help in diagnosing carcinoma prostateD) PSA will not help in diagnosing carcinoma prostate E) I did this test only because you requested for it, I don’t E) I did this test only because you requested for it, I don’t

think this results mean anything.think this results mean anything.

Case Study 2Case Study 2 A 55 y/o african american man with newly diagnosed Stage A 55 y/o african american man with newly diagnosed Stage

B prostate cancer undergoes radical prostatectomy and is B prostate cancer undergoes radical prostatectomy and is referred to you from surgical clinic for routine follow up. referred to you from surgical clinic for routine follow up. The patient requests how often he should follow up with The patient requests how often he should follow up with you and what tests he would need. Your best response is:you and what tests he would need. Your best response is:

A) You do not need any follow up because you had a local A) You do not need any follow up because you had a local cancer that was completely resectedcancer that was completely resected

B) PSA need to be tested every six months for 5 years and B) PSA need to be tested every six months for 5 years and thereafter, every yearthereafter, every year

C) Bone scan to evaluate metastasis is needed every yearC) Bone scan to evaluate metastasis is needed every year D) Digital Rectal Exam every year to look for local D) Digital Rectal Exam every year to look for local

recurrencerecurrence E) You need endocrine therapy before we proceed furtherE) You need endocrine therapy before we proceed further

Case Study 3Case Study 3 A 55 y/o african american man with A 55 y/o african american man with

newly diagnosed prostate cancer newly diagnosed prostate cancer undergoes radical prostatectomy and undergoes radical prostatectomy and undergoes a CT scan showing regional undergoes a CT scan showing regional pelvic lymphadenopathy. Biopsy of LNs pelvic lymphadenopathy. Biopsy of LNs revealed cancer in 2 of them. Your revealed cancer in 2 of them. Your next step: next step:

A) Endocrine therapy with lupronA) Endocrine therapy with lupron B) No further treatmentB) No further treatment C) RadiotherapyC) Radiotherapy D) Alpha receptor antagonistsD) Alpha receptor antagonists

Localized Prostate Cancer (Stages A to C) ManagementLocalized Prostate Cancer (Stages A to C) Management 1. Surgical Management 1. Surgical Management

Indications Indications Well-differentiated tumor Well-differentiated tumor Patient under age 65 years Patient under age 65 years

Better outcomes than with conservative therapy Better outcomes than with conservative therapy Procedures Procedures

Radical Prostatectomy Radical Prostatectomy Pelvic lymph node biopsy (Rule out Stage D) Pelvic lymph node biopsy (Rule out Stage D)

Indicated for Prostate Cancer Stage C Indicated for Prostate Cancer Stage C 2. Prostate Radiotherapy2. Prostate Radiotherapy

Procedures Procedures External Beam Prostate Radiotherapy External Beam Prostate Radiotherapy Prostate Seed Implant Radiotherapy (Brachytherapy) Prostate Seed Implant Radiotherapy (Brachytherapy) Consider Transurethral resection of prostate Consider Transurethral resection of prostate

Better quality of life than with prostatectomy Better quality of life than with prostatectomy 3. Conservative therapy (no curative treatment) 3. Conservative therapy (no curative treatment)

Indications (Curative treatment with risk > benefit) Indications (Curative treatment with risk > benefit) Well-differentiated tumor Well-differentiated tumor if life expectancy <10 years if life expectancy <10 years

Elderly patients with serious comorbities Elderly patients with serious comorbities Contraindications (Curative treatment preferred) Contraindications (Curative treatment preferred)

Poorly differentiated tumor Poorly differentiated tumor if life expectancy >10 years if life expectancy >10 years

Younger patients who are otherwise healthyYounger patients who are otherwise healthy

Stage DStage D Endocrine Therapy for Advanced Endocrine Therapy for Advanced

Prostate Cancer (Stage D)Prostate Cancer (Stage D) Bilateral Orchiectomy Bilateral Orchiectomy Diethylstilbesterol (DES) 1 to 3 mg qd Diethylstilbesterol (DES) 1 to 3 mg qd Leutonizing Hormone Releasing Hormone Leutonizing Hormone Releasing Hormone

Agonist (LHRH) Agonist (LHRH) Goserelin acetate (Zoladex) Goserelin acetate (Zoladex) Leuprolide acetate (Lupron) Leuprolide acetate (Lupron)

Antiandrogens Antiandrogens Flutamide Flutamide Bicalutamide Bicalutamide

Stage DStage D Palliative Care for Bone Metastases Palliative Care for Bone Metastases

(Spinal Metastasis)(Spinal Metastasis) Adequate Narcotic Analgesics Adequate Narcotic Analgesics Bisphosphonates (e.g. Fosamax) Bisphosphonates (e.g. Fosamax) Local radiation Local radiation Strontium 89 Chloride local therapy Strontium 89 Chloride local therapy Endocrine therapy as above ( Remember Endocrine therapy as above ( Remember

other spinal mets from other cas are rxed other spinal mets from other cas are rxed with RT)with RT)

Dexamethasone (Decadron) - ? Cord Dexamethasone (Decadron) - ? Cord compressioncompression Bolus: 16 mg IV Bolus: 16 mg IV First 3 days: 4 mg IV q6 hours First 3 days: 4 mg IV q6 hours Taper over 14 days Taper over 14 days MRI R/o cord compression.MRI R/o cord compression.

Post Prostate CA – Follow upPost Prostate CA – Follow upFollow-up Protocol: GeneralFollow-up Protocol: General Prostate Specific Antigen (PSA) as below Prostate Specific Antigen (PSA) as below Digital Rectal Exam yearly Digital Rectal Exam yearly Clinical examination every 6 months for 5 years Clinical examination every 6 months for 5 years Focus area on exam Focus area on exam

Bladder Cancer (new second tumor) Bladder Cancer (new second tumor) Erectile Dysfunction Erectile Dysfunction Stool or Urinary IncontinenceStool or Urinary Incontinence Radiation proctitis Radiation proctitis Major Depression Major Depression

Follow-up Protocol: Prostate Specific Antigen (PSA)Follow-up Protocol: Prostate Specific Antigen (PSA) Frequency of PSA Testing Frequency of PSA Testing

First year: PSA every 6 months for 5 years First year: PSA every 6 months for 5 years After fifth year: PSA every year After fifth year: PSA every year

PSA Levels after Radical Prostatectomy PSA Levels after Radical Prostatectomy PSA 0 within 3 months of Prostatectomy PSA 0 within 3 months of Prostatectomy PSA rise >2 mg/ml/year suggests high grade lesion PSA rise >2 mg/ml/year suggests high grade lesion

PSA Levels after Radiotherapy PSA Levels after Radiotherapy PSA falls gradually to under 1 ng/ml by 1 year PSA falls gradually to under 1 ng/ml by 1 year PSA remains under 1 ng/ml unless cancer recurrence PSA remains under 1 ng/ml unless cancer recurrence

LeukemiasLeukemias Consider age first Consider age first ALL - childrenALL - children AML – only promyelocytic important, AML – only promyelocytic important,

retinoic acidretinoic acid CML – ph+ , lap, imatinibCML – ph+ , lap, imatinib CLL – ElderlyCLL – Elderly D/W tumor lysis syndromeD/W tumor lysis syndrome

Lymphoma – Hodgkin’sLymphoma – Hodgkin’sEpidemiologyEpidemiology Second most common solid hematologic malignancy, Second most common solid hematologic malignancy, Most common is Non-Most common is Non-

Hodgkin's LymphomaHodgkin's LymphomaSymptomsSymptoms Painless lymph node enlargement , Pruritus, Abdominal Pain , Periodic Painless lymph node enlargement , Pruritus, Abdominal Pain , Periodic

fever , Cachexia fever , Cachexia SignsSigns LymphadenopathyLymphadenopathy

Firm, discrete, nontender nodes Firm, discrete, nontender nodes Nonsuppurative Nonsuppurative

HepatomegalyHepatomegaly Splenomegaly Splenomegaly Staging (Ann Arbor classification)Staging (Ann Arbor classification) Stage I Stage I Single Lymph Node or intralymphatic organ Single Lymph Node or intralymphatic organ Stage II Stage II Two or more lymph nodes on same side of diaphragm Two or more lymph nodes on same side of diaphragm Stage III Stage III Lymph nodes involve both sides diaphragm or Lymph nodes involve both sides diaphragm or

Localized spleen or extralymphatic involved Localized spleen or extralymphatic involved Stage IV Stage IV Diffuse or disseminated disease Diffuse or disseminated disease

Liver or Bone Marrow involvement Liver or Bone Marrow involvement Modifier Modifier A: Asymptomatic A: Asymptomatic

B: Fever, Night sweat, weight loss (>10% in 6 monthsB: Fever, Night sweat, weight loss (>10% in 6 months

Lymphoma – Hodgkin’sLymphoma – Hodgkin’sDiagnosis: Lymph node Excisional BiopsyDiagnosis: Lymph node Excisional Biopsy Reed-Sternberg Cells Reed-Sternberg Cells

Pathognomonic for Hodgkin's LymphomaPathognomonic for Hodgkin's Lymphoma Large binucleate cells with single distinct nucleoli Large binucleate cells with single distinct nucleoli Appearance: "Owl's Eye" Appearance: "Owl's Eye"

Pathology (Histologic Types)Pathology (Histologic Types) Nodular Sclerosis Nodular Sclerosis Most common type in North America, Most common type in North America,

Western Europe Western Europe Mixed cellularity Mixed cellularity Second most common histologic type in Second most common histologic type in

North America North America More frequent in poorer parts of world and in elderly More frequent in poorer parts of world and in elderly

Lymphocytic predominance Lymphocytic predominance Abundance of Reed- Abundance of Reed-Sternberg Cells Sternberg Cells Prognosis Favorable Prognosis Favorable

Lymphocyte depletion Lymphocyte depletion Paucity of cellular elements Paucity of cellular elements Rarest histologic type Rarest histologic type Associated features Associated features Advanced age , Systemic symptoms , Advanced age , Systemic symptoms ,

Retroperitoneal nodes and Extranodal involvement Retroperitoneal nodes and Extranodal involvement Worst prognosis Worst prognosis

Lymphoma – Hodgkin’sLymphoma – Hodgkin’sManagement: Localized disease - Stages I-IIIManagement: Localized disease - Stages I-III Combination Chemotherapy Combination Chemotherapy

Six cycles at 28 day intervals Six cycles at 28 day intervals Medications (ABVD Regimen) Medications (ABVD Regimen)

Adriamycin Adriamycin Bleomycin Bleomycin Vinblastine Vinblastine Dacarbazine Dacarbazine

Involved Region Radiation therapy Involved Region Radiation therapy ComplicationsComplications : Secondary tumors : Secondary tumors

Breast Cancer in women , Lung Cancer , Colorectal Breast Cancer in women , Lung Cancer , Colorectal Cancer , Bone Cancer , Thyroid Cancer Cancer , Bone Cancer , Thyroid Cancer

Other adverse effects : Hypothyroidism , Other adverse effects : Hypothyroidism , Premature Ovarian Failure , Cardiomyopathy due Premature Ovarian Failure , Cardiomyopathy due to Anthracycline , Osteoporosisto Anthracycline , Osteoporosis

NHLNHLSymptoms and Signs (differentiate from Symptoms and Signs (differentiate from

Hodgkin's)Hodgkin's) Presence of Lymphadenopathy draining Waldeyer's Presence of Lymphadenopathy draining Waldeyer's

ring ring Hodgkin's Lymphoma involves Supraclavicular nodes Hodgkin's Lymphoma involves Supraclavicular nodes

Epitrochlear lymph nodes Epitrochlear lymph nodes Mediastinal, abdominal and extranodal involvement Mediastinal, abdominal and extranodal involvement

Common at presentation Common at presentation Chest Pain (suggests lung involvement) Chest Pain (suggests lung involvement) Systemic symptoms more common in Hodgkin's Systemic symptoms more common in Hodgkin's Pathology (Lymph node histology)Pathology (Lymph node histology) Diffuse small cleaved cell Diffuse small cleaved cell Poorly differentiated LymphocyteS Poorly differentiated LymphocyteS ManagementManagement Combination Chemotherapy and Radiation Therapy Combination Chemotherapy and Radiation Therapy Monoclonal Antibody in certain cases Monoclonal Antibody in certain cases

Rituxan binds antigen on mature B Cells Rituxan binds antigen on mature B Cells

Testicular CancersTesticular Cancers Counsel young patients 20 – 40 to perform Counsel young patients 20 – 40 to perform

testicular self examinationtesticular self examination If pt reports/ clinician finds suspicious massIf pt reports/ clinician finds suspicious massDo beta hcg, afp, ultrasound if required, cxr is Do beta hcg, afp, ultrasound if required, cxr is

very important. very important. if suspicion strong do if suspicion strong do inguinal orchiectomyinguinal orchiectomy

+Seminoma +Seminoma normal AFP, Increased BHCG normal AFP, Increased BHCG Rx RT and follow up Rx RT and follow up

+ Teratmoa ( non seminomas ) + Teratmoa ( non seminomas ) elevated elevated AFP, Beta HCG AFP, Beta HCG initial surgery to be initial surgery to be followed by chemotherapy ( followed by chemotherapy ( etoposide/cisplatin) + retroperitoneal etoposide/cisplatin) + retroperitoneal lymphnode dissectionlymphnode dissection