Cancer Incidence and Diagnosis

Dr. Reham AbdulmonemA. Consultant Radiation Oncology

KFMC, PSHOC

Lecturer Radiation Oncology

NCI, Cairo University

Radiotherapy Applications

RAD 462

Course Description

This course is designed to provide the student with clinical aspects of radiation oncology as well as techniques used for simulation and treatment delivery.

Site specific topics will include brain, head & neck, lung, breast, pelvis and lymphoma.

Educational Goals

By the end of this course you will be able to:

Discuss the patient’s progress from the first indication of serious illness, to diagnostic and surgical work-up, to referral, treatment and follow-up in the radiation oncology department.

Discuss the factors influencing the choice of management tools of cancer patient.

Educational Goals (cont.,)

Explain principles and applications of radiotherapy in the treatment of tumors of the following anatomical system/sites: CNS, head and neck, breast, lung, bladder, rectum, and lymphoid tissue.

Describe patient care during RT and the side effects of RT on different body organs and tissues.

Educational Goals (cont.,)

Identify simple simulation and localization procedures.

Identify simple treatment procedures.

Describe the steps and materials involved with formation of shielding blocks.

Apply principles of radiation protection.

Demonstrate professionalism through personal appearance and behavior.

Evaluation

Your course grade will be based on the following:

1 Two mid term exam (W6-W11)

40

2 Lab assignment* 15

3 Course project 5

4 Final Exam 40

Total 100* Visits to Radiation Oncology

Department

References

•Water and Miller’s: Textbook of

Radiotherapy.

•Gunilla C. Bentel: Radiation Therapy

Planning:

•Faiz M. Khan: Treatment Planning in

Radiation Oncology.

USA Mortality at 2006

1. Heart Diseases 685,089 28.0

2. Cancer 556,902 22.7

3. Cerebrovascular diseases 157,689 6.4

4. Chronic lower respiratory diseases 126,382 5.2

5. Accidents (Unintentional injuries) 109,277 4.5

6. Diabetes mellitus 74,219 3.0

7. Influenza and pneumonia 65,163 2.7

8. Alzheimer disease 63,457 2.6

9. Nephritis 42,453 1.7

10. Septicemia 34,069 1.4

Rank Cause of DeathNo. of deaths

% of all deaths

Change in the US Death Rates* by Cause, 1950 & 2003

1950

2003

21.9

180.7

48.1

586.8

193.9

53.3

190.1

231.6

0

100

200

300

400

500

600

Rate Per 100,000

Heart Disease Cerebro-vascular Pneumonia-influenza Cancer

2006 Estimated US Cancer Deaths*

ONS=Other nervous system.Source: American Cancer Society, 2006.

Men291,270

Women273,560

26% Lung & bronchus

15% Breast

10% Colon & rectum

6% Pancreas

6% Ovary

4% Leukemia

3% Non-Hodgkin lymphoma

3% Uterine corpus

2% Multiple myeloma

2% Brain/ONS

23% All other sites

Lung & bronchus 31%

Colon & rectum 10%

Prostate 9%

Pancreas 6%

Leukemia 4%

Liver & intrahepatic 4%bile duct

Esophagus 4%

Non-Hodgkin 3% lymphoma

Urinary bladder 3%

Kidney 3%

All other sites 23%

Cancer Death Rates*, for Men, US,1930-2002

0

20

40

60

80

100

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

Lung

Colon & rectum

Stomach

Rate Per 100,000

Prostate

Pancreas

LiverLeukemia

Cancer Death Rates*, for Women, US,1930-2002

0

20

40

60

80

100

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

Lung

Colon & rectum

Uterus

Stomach

Breast

Ovary

Pancreas

Rate Per 100,000

2006 Estimated US Cancer Cases*

Men720,280

Women679,510

31% Breast

12% Lung & bronchus

11% Colon & rectum

6% Uterine corpus

4% Non-Hodgkin lymphoma

4% Melanoma of skin

3% Thyroid

3% Ovary

2% Urinary bladder

2% Pancreas

22% All Other Sites

Prostate 33%

Lung & bronchus 13%

Colon & rectum 10%

Urinary bladder 6%

Melanoma of skin 5%

Non-Hodgkin4% lymphoma

Kidney 3%

Oral cavity 3%

Leukemia 3%

Pancreas 2%

All Other Sites 18%

* For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2000 to 2002.

Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan

Lifetime Probability of Developing Cancer, by Site, Men, 2000-2002*

† All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary bladder .

Site Risk

All sites† 1 in 2

Prostate 1 in 6

Lung and bronchus 1 in 13

Colon and rectum 1 in 17

Urinary bladder‡ 1 in 28

Non-Hodgkin lymphoma 1 in 46

Melanoma 1 in 52

Kidney 1 in 64

Leukemia 1 in 67

Oral Cavity 1 in 73

Stomach 1 in 82

‡ Includes invasive and in situ cancer cases

Lifetime Probability of Developing Cancer, by Site, Women, US, 2000-2002*

Site Risk

All sites† 1 in 3

Breast 1 in 8

Lung & bronchus 1 in 17

Colon & rectum 1 in 18

Uterine corpus 1 in 38

Non-Hodgkin lymphoma 1 in 55

Ovary 1 in 68

Melanoma 1 in 77

Pancreas 1 in 79

Urinary bladder‡ 1 in 88

Uterine cervix 1 in 135

Five-year Relative Survival (%)* during Three Time Periods By Cancer Site

 

 

 

Site 1974-1976 1983-1985 1995-2001All sites 50 53 65

Breast (female) 75 78 88

Colon 50 58 64

Leukemia 34 41 48

Lung and bronchus 12 14 15

Melanoma 80 85 92

Non-Hodgkin lymphoma 47 54 60

Ovary 37 41 45

Pancreas 3 3 5

Prostate 67 75 100

Rectum 49 55 65

Urinary bladder 73 78 82

†

Cancer Incidence Rates* in Children 0-14 Years, by Site, 1998-2002

Site Male Female Total

All sites 15.6 14.3 15.0

Leukemia 4.9 4.2 4.6

Acute Lymphocytic 3.9 3.4 3.6

Brain/ONS 3.6 3.3 3.5

Soft tissue 1.1 0.9 1.0

Non-Hodgkin lymphoma 1.2 0.6 1.0

Kidney and renal pelvis 0.8 1.0 0.9

Bone and Joint 0.6 0.6 0.6

Hodgkin lymphoma 0.6 0.5 0.5

Cancer Death Rates* in Children 0-14 Years, by Site, US, 1998-2002

Site Male Female Total

All sites 2.7 2.3 2.5

Leukemia 0.8 0.7 0.8

Acute Lymphocytic 0.4 0.3 0.4

Brain/ONS 0.8 0.7 0.7

Non-Hodgkin lymphoma 0.1 0.1 0.1

Soft tissue 0.1 0.1 0.1

Bone and Joint 0.1 0.1 0.1

Kidney and Renal pelvis 0.1 0.1 0.1

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

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.

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

Screening should begin approximately three years after a women begins having vaginal intercourse, but no later than 21 years of age.

Screening should be done every year with regular Pap tests or every two years using liquid-based tests.

At or after age 30, women who have had three normal test results in a row may get screened every 2-3 years. However, doctors may suggest a woman get screened more frequently if she has certain risk factors, such as HIV infection or a weakened immune system.

Women 70 and older who have had three or more consecutive Pap tests in the last ten years may choose to stop cervical cancer screening.

Screening after a total hysterectomy (with removal of the cervix) is not necessary unless the surgery was done as a treatment for cervical cancer.

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

Beginning at age 50, men and women should follow one of the following examination schedules:

A fecal occult blood test (FOBT) every year

A flexible sigmoidoscopy (FSIG) every five years

Annual fecal occult blood test and flexible sigmoidoscopy every five years

A double-contrast barium enema every five years

A colonoscopy every ten years

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.

Diagnosis

Clinical Presentations

Warning

Signs of

Cancer

Diagnostic Workup

Purpose:Purpose:

Confirm diagnosis

Determine the disease stage,

Information required for treatment decision.

Methods:Methods:

History,

Examination: General and Local

Investigations: Laboratory, Medical Imaging, Endoscopies, and Pathological.

Biopsy

Importance:Importance:Confirm diagnosis (the single most).

Histopathologic type:• Cararcinoma, sarcoma, lymphoma,. .

etc.

Grading of cancer:• Degree of malignancy (grade 1-4),

• Therapeutic and prognostic implications

Types:Types:Needle, incisional or excisional.

Medical ImagingPurpose:Purpose:

–Determine the extent of local disease,

–Involvement of regional nodes, and

–Presence or absence of distant metastases.

Include:Include:

–Chest x-ray film,Chest x-ray film,

–Mammogram, Mammogram,

–Radionuclide scan,Radionuclide scan,

–Ultrasonography,Ultrasonography,

–Computed Tomography,Computed Tomography,

–Magnetic Resonance Imaging,Magnetic Resonance Imaging,

–Positron Emission Tomography.Positron Emission Tomography.

Staging Classification

Characteristics of workable Characteristics of workable classification:classification:

Useful in making therapy decision,

Prognostic implication,

Help in evaluating treatment results,

Ease with exchange of information.

Tumor-node-metastasis (TNM) Tumor-node-metastasis (TNM) system.system.

T: primary tumor extension,

N: lymphatic involvement,

M: distant metsatsis.

Diagnosis

History

Physical Examination

Pathology

Genetics

Tumor Markers

Radiological imaging

Blood work

History of present illness

Past Hx (Past Cancer,Sx,CTx,Rx)

Family history

Gynacological history

Social history

Cancer Symptoms

CNS HA,Motor & Sensor dysfunction,Seizure,cognitive dysfunction,Ataxia,gait

Breast Lump, Nipple discharge, Axillary lump

Lung Chest pain, cough, Haemoptysis, SOB

Colorectal Pain, constipation, Diarrhea, Bleeding

Gastric Pain, Haematemesis, Vomitting

Esophagus Dysphagia, odynophagai, cough

cervix Vaginal bleeding, pain,

Nasopharynx Hearing loss, Neck mass, nasal obstruction, Epistaxis

larynx Hoarseness, Sore throat, Otalgia, pain,SOB ,

Bladder Haematuria, dysuria, Urgency

Lymphoma Lump, fatigue, Itching (B symptoms, Fever, Weight loss, sweating)

General ( weight , vital sign , appearance , skin, sign of anaemia )

Lymphatic system

Breast

Respiratory system

CVS

GYN system

RECTAL

CNS

Head & Neck

CBC

Ca , Mg , Ph , .. ) ) Eletrolyte

RFT

LFT

Hormones

Virology Titer

Tumor Marker

Primary Tumor Other Tumors Benign conditions

AFP HCCa and nonseminomatous germ cell tumors

Gastric, biliary, and pancreatic Cirrhosis, Viral hepatitis , pregnancy

B-2 microglobulin Multiple myeloma Other B Cell neoplasms, lung, hepatoma, breast

Ankylosing spondylitis, Reiters syndromeCA125 ovarian Endometrial, Fallopian tube,

breast, lung, esophageal, gastric, hepatic, pancreatic

Menstruation, pregnancy, fibroid, ovarian cysts, cirrhosis, ascites, endometriosis

CA15-3 Breast Ovary, lung, prostate Benign breast or ovarian disease, endometriosis, hepatitis, pregnancy , lactation

CA19-9 Pancreatic, biliary tract Colon, esophageal, hepatic Pancreatitis, biliary disease, cirrhosis

CA27.29 Breast Colon, gastric, hepatic, lung, pancreatic, ovarian, prostate

Breast, liver, kidney disorders, ovarian cysts

Calcitonin Medullary

Thyroid

Metastatic breast, lung, pancreas, hepatoma, renal cell, carcinoid

Zollinger-Ellision syndrome, pernicious anemia,chronic renal, pregnancy

Prostatic acid phosphatase

prostate Testicular, leukemia, non-hodgkin’s lymphoma

Paget’s disease , osteoporosis, cirrhosis, pulmonary, embolism, hyperparathyroidism

PSA prostate none Prostatitis, BPH, prostate trauma, after ejaculation

Thyroglobulin Differentiated thyroid cancer (not medullary )

Hyperthyroidism, subacute thyroiditis, benign adenoma

Chromosomal changes Human cancer

Deletion (1), Gene amplification Neuroblastoma

Translocation (1-8) , (8-22) Burkitt’s lymphoma

Deletion (5) Acute nonlymphocytic Leukemia

Deletion (11) Sarcoma

Translocation (8-14) B-Cell Lymphoma

Translocation (3-8) Parotid Cancer

Translocation (6-14) Carcinoma

Gene amplification Breast Cancer

a = anterior cerebral artery m = middle cerebral artery fh = frontal horn - lateral ventricleph = posterior horn - lateral ventriclecc = corpus callosum

1 = prostate 2 = rectum 3 = obturator internus 4 = ischium5 = body of pubis6.= pubic symphysis7 = femoral artery8 = femoral vein

6 cm right posterior parietal lesion

Irregular margins, infiltrating tumour

Rim-enhancing, central necrosis

Mass effect / edema

Beware corpus callosum involvement

42

81 yo female with headache, confusion, ? History of fever

referred for radiation without biopsy

labelled WBC scan +

diagnosis = abscess

resected/drained - well 2 years later

43