3 Solid Tumors2


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3 Solid Tumors2

  1. 1. Solid Tumors.Onc.cont. Antonio Rivas PA-c
  2. 2. Hepatocellular Carcinoma(HCC) <ul><li>Uncommon in the US </li></ul><ul><li>More than 1 million cases/year around the world </li></ul><ul><li>Common causes </li></ul><ul><ul><li>chronic viral hepatitis B and C </li></ul></ul><ul><ul><li>Cirrhosis </li></ul></ul><ul><ul><ul><li>Alcohol and Hemochromatosis </li></ul></ul></ul>
  3. 3. Hepatocellular Carcinoma(HCC) <ul><li>Alpha-feto-protein (commonly elevated even during early stages) </li></ul><ul><li>Treatment of early stage is surgery </li></ul><ul><li>Cure rate >75 % for tumors <2cm </li></ul><ul><li>Severe cirrhosis or small liver Ca may benefit from liver transplant </li></ul><ul><li>Not proven benefit from chemotherapy or radiation </li></ul>
  4. 4. Breast Cancer <ul><li>Most common cancer in women </li></ul><ul><li>Second leading cause of death in women after lung cancer, in the US </li></ul><ul><li>In 2005 - 213,000 women were Dx with invasive breast cancer </li></ul><ul><li>40,000 women died of Breast Ca </li></ul><ul><li>Breast cancer in men is rare, but it happens </li></ul>
  5. 5. Breast Cancer <ul><li>Risk factors </li></ul><ul><ul><li>Older age </li></ul></ul><ul><ul><li>Family history </li></ul></ul><ul><ul><li>Early menarche </li></ul></ul><ul><ul><li>Late menopause </li></ul></ul><ul><ul><li>First-term pregnancy after 25 years of age </li></ul></ul><ul><ul><li>Nulliparity </li></ul></ul><ul><ul><li>Prolonged Use of exogenous estrogen </li></ul></ul><ul><ul><li>Postmenopausal obesity </li></ul></ul><ul><ul><li>Exposure to ionizing radiation </li></ul></ul>
  6. 6. Breast Cancer <ul><li>Cancer - susceptibility genes </li></ul><ul><ul><li>BRCA1 and BRCA2 </li></ul></ul><ul><ul><li>Present in Only 5-10% of patients with breast cancer </li></ul></ul><ul><li>Pat. With </li></ul><ul><ul><li>Personal or family hx of male breast Ca </li></ul></ul><ul><ul><li>Family Hx of ovarian Ca </li></ul></ul><ul><ul><li>Should be offered counseling / genetic testing </li></ul></ul>
  7. 7. Breast Cancer <ul><li>Yearly mammograms are recommended starting at age 40 . </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  8. 8. Breast Cancer types <ul><li>• Earliest form of the disease, ductal carcinoma in situ (DCIS), solely in the milk ducts. </li></ul><ul><li>The most common type of breast cancer , Invasive ductal carcinoma (IDC), develops from DCIS, spreads through the duct walls, and invades the breast tissue. </li></ul><ul><li>Invasive lobular carcinoma originates in the milk glands and accounts for 10 - 15% of invasive breast cancers </li></ul>
  9. 9. Less common Breast Cancer types <ul><li>Paget's disease of the nipple: </li></ul><ul><ul><li>originates in the milk ducts and spreads to the skin of the nipple </li></ul></ul><ul><ul><ul><li>Eczematoid dermatitis </li></ul></ul></ul><ul><li>Inflammatory: </li></ul><ul><ul><li>tends to spread quickly </li></ul></ul><ul><ul><li>Erythema and edema of the overlying skin </li></ul></ul><ul><ul><ul><li>Underlying aggressive ductal carcinoma </li></ul></ul></ul>
  10. 10. Symptoms <ul><li>Early symptoms: </li></ul><ul><ul><li>lump that feels different than the surrounding breast tissue </li></ul></ul><ul><ul><li>Lumps found in lymph nodes located in the armpits </li></ul></ul><ul><li>Advanced changes: </li></ul><ul><ul><li>changes in breast size or shape, skin dimpling, nipple inversion, or spontaneous single-nipple discharge,ulceration </li></ul></ul>
  11. 11. Symptoms <ul><li>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 . </li></ul><ul><li>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 </li></ul>
  12. 12. Peau d’orange
  13. 13. Inflammatory Disease
  14. 14. Disproportionate breast size <ul><li>Disproportionate breast size may occur as a result of: </li></ul><ul><ul><li>Surgery and/or radiation </li></ul></ul><ul><ul><li>Breast feeding on one side only </li></ul></ul><ul><ul><li>Rapidly growing tumors </li></ul></ul>
  15. 15. Breast puckering <ul><li>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. </li></ul>
  16. 16. Dimpling <ul><li>Dimpling may be associated with inflammatory cancer. It may also be seen after surgery </li></ul>
  17. 17. &quot;accessory&quot; breast tissue <ul><li>Extra breast tissue or &quot;accessory&quot; 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 </li></ul>
  18. 18. Nipple Inversion <ul><li>Nipple Inversion: This woman noted an inverted nipple since she was a teenager. This is longstanding and no further work-up is required. </li></ul>
  19. 19. <ul><li>Xeroradiograph that demonstrates a cancer behind the nipple pulling the nipple in. Xeroradiography has been replaced by mammography. </li></ul><ul><li>Inverted nipple (the discoloration is due to a needle biopsy </li></ul>
  20. 20. Nipple Discharge <ul><li>Bloody discharge needs to be investigated. </li></ul><ul><li>Please consult your physician </li></ul>
  21. 21. Ulceration of breast skin <ul><li>This represents a breast cancer that has eroded the skin and caused a small ulcer. </li></ul>
  22. 22. Skin nodules <ul><li>This represents a recurrence of breast cancer after a lumpectomy and radiation therapy. Breast cancer can recur after a lumpectomy or after a mastectomy. </li></ul>
  23. 23. Symptoms <ul><li>More common sites of metastasis include bone, liver, lung and brain </li></ul><ul><li>Unexplained weight loss can occasionally herald an occult breast cancer, as can symptoms of fevers or chills. </li></ul><ul><li>Bone or joint pains can sometimes be manifestations of metastatic breast cancer, as can jaundice or neurological symptoms </li></ul>
  24. 24. Symptoms <ul><li>Breast cancer diagnosed most often through screening mammogram </li></ul><ul><li>Fewer than 10% patients have metastasis at Dx </li></ul>
  25. 25. Staging <ul><li>Requires removal of the primary tumor and ipsilateral axillary lymph node </li></ul><ul><li>If tumor more than 5cm with + lymph nodes include: </li></ul><ul><ul><li>chest radiograph </li></ul></ul><ul><ul><li>CT of the abdomen </li></ul></ul><ul><li>For smaller tumors, no need for above unless they have bone pain-sign of metastasis </li></ul>
  26. 26. Treatment <ul><li>Small breast tumor- lumpectomy+radiation </li></ul><ul><li>Large tumor or two or more-mastectomy </li></ul><ul><li>Women who had previous radiation-mastectomy </li></ul><ul><li>Chemotherapy may allow breast conservation </li></ul><ul><li>Preoperative hormone therapy in frail patients with hormone receptors pos.tumors </li></ul>
  27. 27. Treatment <ul><li>Adjuvant therapy with chemo.and hormones improve relapse free and over all survival </li></ul><ul><li>Trastuzumab -monoclonal antibody </li></ul><ul><li>Patients with metastasis: </li></ul><ul><ul><li>Better prognosis in women with hormone responsive disease and lymph node metastasis only. No liver,bone or CNS </li></ul></ul>
  28. 28. Treatment <ul><li>Biphosphonates IV to alleviate pain from bone metastases and the risk of fractures </li></ul><ul><li>DCIS - lumpectomy, followed by radiation therapy or mastectomy </li></ul><ul><li>Tamoxifen: estrogen agonist </li></ul>
  29. 29. Genito-urinary cancers <ul><li>Testicular cancer: </li></ul><ul><li>800-900 new cases each year in the US </li></ul><ul><li>Age 15-34 yo, most common </li></ul><ul><li>90% cure rates, 100% if it has not metastasize </li></ul><ul><li>Unusual lump in a testicle should be checked immediatelly </li></ul>
  30. 30. Testicular cancer <ul><li>Recommended regular monthly testicular self examination </li></ul><ul><li>After a hot shower when the scrotum is looser </li></ul><ul><li>Feeling for pea-shaped lump </li></ul><ul><li>Asymmetrical hardening of a testicle </li></ul><ul><li>Feeling of numbness or pain </li></ul><ul><li>Build up of fluid </li></ul>
  31. 31. Testicular cancer <ul><li>Symptoms </li></ul><ul><li>Loss of sexual activity </li></ul><ul><li>Impotence </li></ul><ul><li>Increase or decrease in testicle size in one side </li></ul><ul><li>Blood in semen </li></ul><ul><li>Watery or clear semen </li></ul>
  32. 32. Testicular cancer <ul><li>Dx </li></ul><ul><li>Scrotal ultrasound </li></ul><ul><li>CT scan </li></ul><ul><li>Tumor markers: AFP,Beta HCG, LDH </li></ul><ul><li>Inguinal orchiectomy </li></ul><ul><li>Adjuvant therapy after surgery </li></ul><ul><ul><li>Chemotherapy , radiation or surveillance </li></ul></ul><ul><li>Germ cell tumor - most common </li></ul>
  33. 33. Prostate Cancer <ul><li>No symptoms at early stage </li></ul><ul><li>Dx by increased PSA during routine checkup </li></ul><ul><li>Symptoms when present similar to BPH </li></ul><ul><li>Frequent urination, mainly at night </li></ul><ul><li>Difficulty starting and maintaining steady stream </li></ul><ul><li>Blood in urine, and painful urination </li></ul>
  34. 34. Prostate Cancer <ul><li>Decreased erection or painful ejaculation </li></ul><ul><li>Most common advanced symptom is bone pain(vertebrae , pelvis and ribs) </li></ul><ul><li>If spinal cord compression-leg weakness, urinary and fecal incontinence </li></ul><ul><li>Adenocarcinoma </li></ul><ul><li>Risk factors:age, genetics, race,diet, life style </li></ul>
  35. 35. Prostate Cancer <ul><li>Screening </li></ul><ul><li>Digital rectal exam:feeling for irregularities or bumps </li></ul><ul><li>Prostate specific antigen (PSA) </li></ul><ul><ul><li>Elevated in BPH and Prostatitis, after ejaculation, catheterization </li></ul></ul><ul><li>Only diagnostic test - Biopsy </li></ul>
  36. 36. Prostate Cancer <ul><li>Treatment </li></ul><ul><li>Early stage:prostatectomy,radiation therapy </li></ul><ul><li>Late stage:hormone therapy and/or radiation therapy </li></ul><ul><li>External beam radiation therapy and brachytherapy </li></ul>
  37. 37. Screening Guidelines for the Early Detection of Prostate Cancer, American Cancer Society <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  38. 38. Bladder cancer <ul><li>Less common in women than in men </li></ul><ul><li>One fifth of the affected patients will dye </li></ul><ul><li>Most common risk factor is cigarette smoking </li></ul><ul><li>Other factors: exposure to chemicals, parasites and medications such as Cytoxan </li></ul>
  39. 39. Bladder cancer <ul><li>Most common :transitional cell carcinoma </li></ul><ul><li>Most common presentation - gross hematuria </li></ul><ul><li>Bladder irritation or spasms </li></ul><ul><li>When beyond the bladder : leg swelling, pelvic pain, compression nerves in the pelvic plexus </li></ul>
  40. 40. Bladder cancer <ul><li>Tumors are divided into superficial, invasive and metastatic </li></ul><ul><li>Direct imaging and Biopsy to determine depth of invasion - prognosis - treatment </li></ul><ul><li>Cystoscopy the most important Dx tool to determine if wall of the bladder has been affected </li></ul><ul><li>CT and MRI for nodal involvement and Metastaisis </li></ul>
  41. 41. Bladder cancer <ul><li>Treatment </li></ul><ul><li>Superficial tumors </li></ul><ul><ul><li>TURB transurethral resection of the bladder </li></ul></ul><ul><ul><li>Cytoscopy :every three months for monitoring and resections if required </li></ul></ul><ul><ul><li>Also use of immunomodulators instilled in the bladder:Interferon, mitoxantrone, every week for 6 weeks , then do cytoscopy </li></ul></ul>
  42. 42. Bladder cancer <ul><li>Tumors invading the muscle: </li></ul><ul><li>If not through the bladder wall - radical cystectomy </li></ul><ul><li>A pouch is created from the small intestine to store and expel urine </li></ul><ul><li>Other approaches possible-with bladder preservation + chemotherapy </li></ul><ul><li>Invariably relapses </li></ul>