oncology board review. most common solid tumors typestagingprimary rxadjuvant rxsurveillance/...

ONCOLOGY BOARD REVIEW

Most Common Solid TumorsType Staging Primary Rx Adjuvant Rx Surveillance/

ScreeningSystemic Rx Misc

Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate

TNM

Breast Cancer Staging

• Generally pathologic Staging, but clinical staging for neoadjuvant therapy.

• T4 are pts with “grave” prognostic signs (skin, chest wall, ulcer, inflammatory)

• N3 (supraclavicular nodes, Internal mammary nodes (Clinically staged)



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate

TNMSurgery or

Surgery and XRT

Yes

Breast CancerAdjuvant Therapy

• Additional Therapy after all gross disease is removed.

• Options include Hormonal Therapy for ER positive disease, Chemotherapy for all patients (better for premenopausal), and Biologic therapy for 20-25% Her 2 overexpressors.



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate

TNM Surgery Yes Yes

Breast CancerSurveillance/Screening

• Q year Mammogram starting age 40 saves lives

• BSE/CBE does not save lives, but is done

• Surveillance q year mammograms, bimanual exam (on tamoxifen) w/wo Ultrasound, baseline dexascan (AI), MUGA baseline then after anthracylcine rx, then after herceptin is complete



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate

TNM Surgery Yes YesHormonal

ChemoBiologic Rx

Breast CancerSystemic Therapy

• Therapy is based on Er status and Her 2 status.

• Er positive get hormonal therapy Her 2 postive get Herceptin

• Non organ threatening disease get either hormonal rx alone or Single Agent Rx in metastatic setting

• AI only for postmenopausal

Quiz 40 yo woman with breast ca 5 yrs ago rx with

lumpectomy and xrt and 3 months of chemotherapy. ER/PR neg, Her 2 pos. and presents with skin nodules back pain and lung nodules on xray. Biopsy of skin adenocarcinoma. How to Rx.?

A.)Hospice B.)Tamoxifen and AI C.) High dose

CT bone marrow tx D.)Trastuzumab and Taxane E.) Ovarian ablation plus and AI



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate


ChemoBiologic

BRCA 1BRCA 2

LCISDCIS

Breast Cancer Genetics• 5-10% of women have inherited form of Breast

cancer (Ashkenazi Jewish women with 1%)• Three generation Pedigree• Penetrance is 40-80%• Most informative is one with known mutation and

with breast cancer• BRCA1 associated with Ovarian, BRCA2 is

found in male Breast CA• Consideration for prophylactic bilateral

mastectomy and oophorectomy and Genetic counseling

Quiz

• 65 yo woman sp MRM for 1 cm breast ca with er and pr positive and negative for Her 2. SLN negative. What next?

A.) xrt and tamoxifen

B.) xrt and Anastrazole

C.) Tamoxifen for 5 yrs

D.) TAmoxifen and anastrazole for 5 yrs.



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate


ChemoBiologic

BRCA 1BRCA 2

LCISDCIS

TNMDepth

Colorectal CancerStaging

• Depth of invasion with T3 invading muscularis propria (stage II) and T4 invading adjacent structures

• N denotes nodes in pericolonic or rectal regions

• Rectal staged the same but below peritoneal reflection



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate


ChemoBiologic

BRCA 1BRCA 2

LCISDCIS

TNMDepth

Surgery Yes

Colorectal CancerAdjuvant Rx

• Stage III colon (node positive) cancer OS benefit with 5FU based rx (oxaliplatin?)

• Stage II and III Rectal cancer rx with Chemo and radiation therapy



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate


ChemoBiologic

BRCA 1BRCA 2

LCISDCIS

TNMDepth

Surgery Yes Yes

Colorectal CaSurveillance/Screening

• Vogelstein Model of progression of normal mucosa to cancer takes about 10 years

• FOBT yearly saves lives, Colonoscopy every 10 years except for high risk groups.

• Surveillance Colonoscopy one year after resection and then q 3-5 years

• CEA done but not required and CT scan every year for first 3 to 5 years



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate


ChemoBiologic

BRCA 1BRCA 2

LCISDCIS

TNMDepth

Surgery Yes YesChemoBiologic

Colorectal Cancer

• Chemotherapy: 5 Fluorouracil {diarrhea, mucositis, myelosuppression (if bolus), Hand foot syndrome (if continuous infusion)}. Oxaliplatin (Neuropathy, cold induced Laryngospasm), Irinotecan (Pro-cholinergic side effects, diarrhea, myelosuppression)

• Biologics: Role is metastatic disease. Avastin (Bleeding, HTN), Cetuximab (infusion related side effects)



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate


ChemoBiologic

BRCA 1BRCA 2

LCISDCIS

TNMDepth


FAPHNPCC

Colorectal CancerGenetics

• Incidence 148300 per year 56000 deaths• Familial Risk is 20% (>1 1st or 2nd degree)• 5-10% inherited in AD pattern• FAP and HNPCC (Age at onset HNPCC is

45 vs 63)• Proximal HNPCC and Distal FAP• Microsattelite instability (HNPCC MSH2

and MLH1) Very sensitive (negative test no need to do germ line assessment)

MSI/HNPCC

• 12 to 16% with MSI• Mutation in germ line is usually in non coding region,

thus, elongation or contraction of DNA has little effect.• Detection shows homozygosity in germ line but multiple

peaks in tumor• 70% proximal to splenic flexure• Endometrium, Ovary, Stomach, small bowel , pancreas

hepatobiliary, brain,upper uroephtielial, sebaceous deonma sebaceou ca keratacanthoma (Torres Syndrome)

• Adenoma to ca in 2-3 yrs (vs 8-10 yrs)• Surveillance age 20-25 with q 1 to 3 yrs colonoscopy,

screen for Ovary and Endometrial

Quiz

• 58 yo postmenopausal woman on HRT for 4 yrs. Has father died of heart disease, mother died of breast cancer, sister with breast cancer. She had biopsy 2 years go showing atypical hyperplasia. She is considering chemoprevention but is concerned about heart disease. You recommend:

• A.) HRT alone B.) HRT and Tamoxifen C.)DC HRT and start Tamoxifen D.) Change HRT to estrogen alone and add Tamoxifen

FAP/APC

• Cancer by age 40-50• Screening at at 10-12, and yearly• Age 20 sutotal colectomy with annual fu of remaining

rectum due to numerous polyps• Gastric, Duodenal, Periampullary CA, Desmoids

(induced by surgery).• Less common are papillary thyroid, sarcoma, pancreatic

ca, meulloblastomas• Penetrance is 100% except in 11307K mutation in

Ashkenazi Jews (10-20%)• Celecoxib and Sulindac decrease number of polyps and

delay surgery but still need screening



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate


ChemoBiologic

BRCA 1BRCA 2

LCISDCIS

TNMDepth


FAPHNPCC

TNMProximity

Non Small Cell Lung CAStaging

• T3 invasion into chest wall or less than 2 cm from carina

• T4 invasion into major structures (SVC, Pericardium, Vertebral Body) or pleural effusion

• N1 Hilar nodes, N2 Mediastinal nodes, N3 contralateral Mediastinal or Hilar or Supraclavicular

• Stage III A is N2 disease, Stage IIIB T4 or N3

NEJM: 348:2500-2507,2003

Lung CancerStaging

Study: Prospective of Dx Accuracy of Integrated PET-CT,CT,PET, and PET plus CT.

METHODS: 50 pts with proven or suspected NSCLC and then histopathologic confirmation or one other radiologic modality

Results: PET-CT better vs others above (P=.001,P<.001,P=.013). Nodal staging better with PET-CT vs PET (p=.013)

Conclusions: Integrated PET-CT improves dx accuracy of staging in non-small cell lung ca.



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate


ChemoBiologic

BRCA 1BRCA 2

LCISDCIS

TNMDepth


FAPHNPCC

TNMProximity

Surgery Yes

from NEJM: 352:2640-2642,2005

Non Small Cell Lung CancerAdjuvant

• Adjuvant systemic therapy indicated for NSCLC

• Stage IB to III seem to benefit

• Platinum based regimens are appropriate

Study N Rx Results P level Other

IALT 1867 CDDP vs Obs

44.5 vs 40.4 OS at 5 yrs

P<.03 FU 56 mo

St. I,II,III

JBR 10 482 CDDP + Navelbine vs obs

69 vs 54% at 5 yrs

P=.04 HR = .69

FU 5.1 yrs St. IB,II (no benefit in stage I)

CALGB 9633

344 Carbo taxol

71% vs 59% at 4 years

P=.018 St IB

ANITA 840 CDDP + Navlebine

51 vs 43% 5 yr OS

P= .013 FU 70 mo.St I,II,III

(no benefit in stage I



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate


ChemoBiologic

BRCA 1BRCA 2

LCISDCIS

TNMDepth


FAPHNPCC

TNMProximity

Surgery Yes No ChemoSmall Molecule

Non Small Cell Lung CASystemic Rx

• Chemotherapy: Cisplatin (Neuropathy, Nephropathy, Nausea/vomiting), Carboplatin (Myelosuppression and Thrombocytopenia), Taxol (Neuropathy, Allergic Rx), Gemzar (Myelosuppression), Taxotere (3rd Spacing), Navelbine (Myelosuppression)

• Tarceva (EGFR TKI) Rash, Diarrhea



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate


ChemoBiologic

BRCA 1BRCA 2

LCISDCIS

TNMDepth


FAPHNPCC

TNMProximity


Paraneoplastic

Non Small Cell Lung CAParaneoplastic Syndromes

• Squamous Cell CA : Hypercalcemia

• Adenocarcinoma: Clubbing and Hypertrophic Osteoarthropathy



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate


ChemoBiologic

BRCA 1BRCA 2

LCISDCIS

TNMDepth


FAPHNPCC

TNMProximity


Paraneoplastic

Limited orExtensive

Chemo or Chemo XRT NA No Chemo Paraneoplastic

Small Cell Lung Cancer• Staging includes Bone scan and Brain

scan if limited

• Cisplatin and Etoposide (WBC and Platelets and AML) with xrt for LS and Chemo alone for ES

• Eaton Lambert, SIADH, Perhipheral Neuropathy

Quiz

• 70 yo man with 80 pk yr tobacco presents with chronic cough and a 3 cm perihilar mass. CT scan shows two nodules in liver and PET shows no uptake in liver but uptake in mass. Bronch positive for cancer.What next?

• A.) xrt B.)Chemotherapy C.) CT guided liver biopsy D) CEA E.) Surgery

Quiz

68 yo man with 60 pk yr tobacco evaluated for hemoptysis. CXR shows right hilar mass and mediastinal widening. Bronch shows small cell. He has low sodium and SIADH. Rest of workup shows no disease. How do you rx?

A.) Surgery followed by chemo B.) XRT followed by chemo C.) Chemotherapy alone D.)XRT and concurrent chemo E.) Chemo followed by xrt



Breast

Colorectal

Lung (NSCL)

Lung (SCLC)

Prostate


ChemoBiologic

BRCA 1BRCA 2

LCISDCIS

TNMDepth


FAPHNPCC

TNMProximity


Paraneoplastic

Limited orExtensive

Chemo or Chemo XRT NA No Chemo Paraneoplastic

TNMClinical

Surgery orXRT or

ObservationNA

PSA?DRE?

HormonalChemo

chemoprev

NEJM:352,1977-1984, 2005

Prostate CancerTreatment

N = 695 (FU was 8.2 years)

Design: Randomized study of pts less than 75 with localized prostate cancer to radical prostatectomy or observation

Pts: Median age 64, T1 and T2, GS 5-6 was 47% of population, GS 7 was 22%, GS 8-10 was 4-6%, Mean PSA 12-13.

Results: RR 0.56 (CI .36-.88) for RP for death from cancer. OS was .74 (CI.56-.99) or 5% absolute at 10 years. Local progression 19-25% lower risk (RR.33) and Distant mets 8% (RR .60)

Conclusion: RP decreases overall disease specific and overall mortality by a modest amount. Substantial benefit for distant mets and local tumor progression

NEJM: 350: 2239-2246, 2004

PROSTATE CANCERSCREENING

N = 2950Method: subgroup analysis of men who never had a PSA

more than 4 ng/ml or abnormal DRE who had a final PSA determination and underwent biopsy after 7 years on study in PCPT randomizing 18,882 men to placebo or Finasteride 5mg.

Results: 15% had prostate ca, 6.6% with psa 0.5, 10% w/PSA .5 to 1,17% w/PSA 1.1 to 2,23.9% w PSA 2.1-3, and 26.9 w/PSA 3.1-4.0. High grade cancer in 12.5% with PSA 0.5 and 25% PSA 3.1-4.0.

Conclusions: Biopsy detected prostate cancer not rare among men with normal PSA (4 or less). High grade cancers also are detected.

349:215 - 224, 2003

Prostate CancerPrevention with Proscar

N= 18882 55 or olderMethods: Normal DRE and PSA randomized to

Finasteride 5 mg vs Placebo.Results: Finasteride decreased incidence of

prostate ca from 24.4 to 18.4 percent (24.8% reduction CI 18.6 to 30.6) p<.001. High grade tumors higher in finasteride group 37 vs 22% (p<.001)

Conclusions: Delays appearance of prostate ca but benefit may be nullified by risk of side effects and increased risk of high grade cancer.

Quiz

45 yo presents with 2 cm palpable axillary node on right. Resection shows adenocarcinoma. CT and MRI show no other sites of disease. How do you manage?

A.) Breast ca is most likely dx and rx as such B.) Lung ca is most likely and rx as such C.) All disease resected no more rx D.) Radiation therapy to axilla and breast is appropriate.

Group IHormonally Related or Genetic

SyndromeType Staging Primary

RxAdjuvant Rx

Screeining

Systemic Rx

Misc

Breast TNM Surgery Yes Yes Chemo, Hormonal, Bioloigic

LCIS, DCIS, Genetic Syndromes

Endometrial

Ovarian

Colorectal TNM Surgery Yes Yes Chemo, Biologic

Genetic Syndromes

Prostate TNM Surg, XRT, or Obs

NA PSA?

DRE?

Hormonal, Chemo

Chemoprev

TNMProximity

DepthSurgery No No Hormonal

Chemo BRCA1

TNM/FIGOSurgical Lap

Surgery and Debulking

Mostly NASome Yes

No ScreenCA 125 for FU

Chemo andIP Chemo BRCA1

Group IIForegut, Smoking, or Environment related

Type Staging Primary Rx

Adjuvant Rx

Screening Systemic Rx

Misc

Lung TNM

Proximity

Surgery Yes No Chemo Paraneoplastic

Gastric

Pancreatic

Esophogus

Bladder

TNMDepth

Surgery No No Chemo

TNMProximity

Surgery No No ChemoBiologic?

TNMDepth

Surgery No? No Chemo Barrets?

TNMDepth

Surgery No? NoChemoImmuno

Ureteral

Group III Squamous Cell Rx with Chemo and XRT as Primary Rx


Adjuvant Rx


Misc

Cervical

Anal

Head and Neck

TNMDepth Extent

SurgeryOr Chemo

XRTNo Yes Chemo HPV?

TNMSize

Chemo+ XRT No No

Chemo(MMC)

HPV?

TNMDepth,Size

SurgeryOr

XRT +-Chemo

No? NoChemoBiologic

NPC/EBVEGFR MCAWith XRT?

Group IV Curable in Metastatic Setting


Adjuvant Rx


Misc

Germ Cell IGCCC3 stages

Surgery plus XRT or Chemo NA? No Chemo

NSGCT AFP HCGSeminoma HCG

XRTResidual Masses

Group VIncurable or Poor Systemic Rx


Adjuvant Rx

Screeining

Systemic Rx

Misc

Brain

Hepatic

Melanoma

Renal Cell

Adult Sarcoma

Grade Surgery NA No ChemoAA and GBM

Incurable,OLIGO chemo

xrt

TNMSize

Extent

TNMGrade

SizeSurgery

Bone and Rhabdo

onlyNo Chemo

X ray for EwingAnd Osteosarc

Cytogentic11:22, X:18

TNMExtension

Surgery No NoBiologic

TKI?Polycythemia

TNMDepth

Surgery No? NoChemoBiologic

Sentinel nodFamilial Synd

SurgeryTransplant? No

AFP?US?

ChemoTKI?

Hep B

Long Term Complications of Chemotherapy

Neuropathy

Second Malignancies

Pulmonary Toxicity

Osteoporosis

Fertility

Long Term Complications Radiation Therapy

Second Malignancies

Proctitis

Endocrine

Xerostomia

Quiz

68 yo woman with hx of lumpectomy and breast xrt and tamoxifen for er pos 1 cm breast cancer node negative develops lump on chest wall. Biopsy shows fibrosarcoma. What is relationship between this and her treatment?

A.) Related to original CA B.) Related to xrt C.) Related to tamoxifen D.) Not related to original cancer or treatment

Long Term ComplicationsHormonal Therapy

Second Malignancies

Osteoporosis

Long Term ComplicationsSurgery

Breast : Lymphedema, Neuropathy

Gastrectomy: Nutritional Deficiency

APR: Long term ostomy issues

Prostatectomy: Urinary Incontinence, Impotence

RPLND: Retrograde ejaculation

NEJM: 352:2714-2720,2005

Lung Cancer Screening

• No randomized studies showing survival benefit• ELCAP study of 1000 pts over 60 with 10 pack

yrs found 233 non calcified nodules by CT and 68 by CXR (alone?) and 27 of CT scan detected were malignant and 7 by CXR were malignant. Stage I in 23 of CT pts and 4 of CXR pts.Thus dx early disease

• Ongoing randomized studies by NCI and European studies are pending.

• Length time bias (biology), Lead time bias (measurement), Unnecessary procedures

oncology board review. most common solid tumors typestagingprimary rxadjuvant rxsurveillance/...

Documents

hormonal therapy

hormonal rx

er positive disease

breast cancerbrca1

neoadjuvant therapy

biologic therapy

anthracylcine rx

skin nodules