Oncology step3


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Oncology step3

  1. 1. Oncology Archer Online Step III Rapid Review www.ccsworkshop.com All rights reserved
  2. 2. Screening Various Scenarios!
  3. 3. General Screening Test Starting Age Frequency Ending age Mammography 40 yearly 70 Pap Smear 21 or age at 1st sexual intercourse Yearly x 3yrs and 65 then every 3yrs Colonoscopy 50 10 yrs none Flex Sig 50 3-5 yrs none FOBT 50 Yearly none
  4. 4. Case Study       A 66 y/o woman comes to your office for regular check up. A colonoscopy done 7 yrs ago was normal. She has not undergone any other screening tests. Labs revealed normal hemoglobin. Clinical examination revealed a 3cm mass in her breast which was ill defined. The most appropriate test at this time is: A) Mammogram Bilateral B) Breast ultrasound C) FOBT D) Pelvic ultrasound E) Pap smear
  5. 5. Colonoscopy Efficacy  Identifies up 95% of Colon cancer  Efficacious and reduces mortality  Preferred over other Colon Cancer screening modalities Comparision :  Fecal Occult Blood Testing (26% of Colon Cancer)  Digital Rectal Exam (5-10% of Colon Cancer)  Flexible Sigmoidoscopy (50-60% of Colon Cancer)  Colonoscopy (95% of Colon Cancer)  Barium Enema (32 to 53% of Colon Cancer) Protocol  Colonoscopy may be preferred for all screening   Sigmoidoscopy misses 25% of lesions (proximal) Occult blood does not increase flex sig sensitivity
  6. 6. Colorectal Cancer Risk Factors for Colorectal Cancer  Age >50 years (accounts for 90% of Colon Cancer)  Past Medical History       Family History     First degree relative with Colon Cancer (RR=2-3x) Familial adenomatous polyposis Hereditary non-polyposis Colon Cancer Lifestyle related risks    Inflammatory Bowel Disease, Ulcerative Colitis Adenomatous polyps >5mm (Confers RR of 2-3 times) Hamartomatous polyposis syndromes Cholecystectomy Pelvic irradiation Tobacco abuse Obesity Dietary Risk Factors   High Dietary Fat : Saturated fat , Polyunsaturated fat Red Meat: Pickled , Smoked , Barbeque
  7. 7. Colorectal Cancer Screening First classify the risk groups from the question.  Average Risk  Age 50 yrs and Older  Moderate Risk  Family hx of colorectal cancer, colon ca in other relatives, Single small adenomatous polyps, Large multiple adenomatous polyps, Colorectal ca pts f/u after resection.  High Risk  FAP, HNPCC, IBD ( Ulcerative Colitis)
  8. 8. Colorectal Cancer Screening Average Risk: Age 50 years and older  Digital Rectal Examination and  Fecal Occult Blood yearly and  Diagnostics  Endoscopy Flexible Sigmoidoscopy every 5 years or  Colonoscopy every 10 years   Double contrast Barium Enema Colonoscopy preferred for full colon evaluation  Consider as adjunct to Flexible Sigmoidoscopy 
  9. 9. Colorectal Cancer Screening Moderate Risk Family History of Colorectal Cancer  Defining criteria   First degree relative under age 60 years or Two First degree relatives with colon ca Screening protocol   Start    Colonoscopy at age 40 years or Colonoscopy 10 years earlier than youngest case Repeat Colonoscopy every 5yrs Colorectal Cancer in other relatives  As per Average Risk Recommendations ( start at age 50 years )
  10. 10. Colorectal Cancer Screening Moderate Risk   POLYP ISSUES – You did a screening colonoscopy and found a polyp. Sent it for biopsy. What next?? – how will screening protocols change depending on type of polyp???
  11. 11. Colorectal Cancer Screening Moderate Risk If Single, Small Adenomatous Polyps (<1 cm)  Repeat Colonoscopy   Within 3 years after initial polyp Diagnosis If normal, as per Average Risk Recommendations
  12. 12. Colorectal Cancer Screening Moderate Risk If Large or multiple adenomatous polyps (>1 cm)  Repeat Colonoscopy 3 years after initial polyp  Repeat Colonoscopy every 5 years
  13. 13. Colorectal Cancer Screening Moderate Risk If you resected a polyp and found cancer that you believe is completely removed Colonoscopy at Initial polyp diagnosis  Normal Colonoscopy protocol (assumes no recurrence)    Repeat Colonoscopy in 1 year Repeat Colonoscopy in 3 years Repeat Colonoscopy every 5 years
  14. 14. Colorectal Cancer Screening High Risk If Familial adenomatous polyposis Hx:  Early surveillance    Colonoscopy starting at Puberty Counseling to consider genetic testing Genetic Testing positive or polyposis confirmed   Consider Total colectomy or Colonoscopy every 1-2 years
  15. 15. Colorectal Cancer Screening High Risk Hereditary non-polyposis Colon Cancer  Early surveillance    Colonoscopy starting at Age 21 years Counseling to consider genetic testing Genetic Testing positive or No genetic testing   Colonoscopy every 2 yrs until age 40 Colonoscopy yearly after age 40
  16. 16. Colorectal Cancer Screening High Risk Inflammatory Bowel Disease ( Ulcerative colitis)  Initial Colonoscopy with biopsy for dysplasia    If Pancolitis ( entire colon) : 8 years after the start or If Left sided Colitis: 15 years after the start Repeat Colonoscopy every 1 year
  17. 17. TNM Staging System for Colon Cancer Stage Regional Primary Tumor Lymph Node (T) (N) Remote Metastasis (M) Stage 0 Carcinoma in situ N0 M0 Stage I Tumor may invade submucosa N0 (T1) or muscularis (T2). 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
  18. 18. Dukes Classification Stage Characteristics Dukes stage A Carcinoma in situ limited to mucosa or submucosa (T1, N0, M0) Dukes stage B Cancer that extends into the muscularis (B1), into or through the serosa (B2) Dukes stage C Cancer that extends to regional lymph nodes (T1-4, N1, M0) Dukes stage D Modified classification; cancer that has metastasized to distant sites (T1-4, N1-3, M1)
  19. 19. Colon Ca Rx Treatment of stage 0 (carcinoma in situ) may include the following types of surgery  Local excision or simple polypectomy.  Resection/anastomosis. This is done when the tumor is too large to remove by local excision.  After polypectomy  single specimen, completely removed with favorable histology and clear margins  Observe  if fragmented tissue, unfavorable histology or margin cannot be assessed  total colectomy with en bloc removal of lymph nodes
  20. 20. Colon Ca Rx Colon cancer, non metastatic: Surgical Rx  Resectable, non obstructing  colectomy with enbloc removal of regional lymph nodes  Resectable, Obstructing  one stage colectomy with egional lymphnode removal or resection with diversion or stent/ diversion followed by colectomy  Locally unresectable  palliation therapy ( chemo) Adjuvant Chemo :No need for Stage O and Stage I  For Stage II, Stage III – adjuvant chemo rx with 5FU/Leucovorin/ oxaliplatin is indicated • Stage IV  depends on resectability of liver/ lung mets . If resectable mets  colectomy + adjuvant chemo + resection of liver/lung mets or Neoadjuvant chemo( FOLFOX/ FOLFIRI) followed by colectomy and resection of hepatic mets. 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.
  21. 21. Colorectal CA - Treatment Management: Non-resectable hepatic metastases - Radiofrequency Ablation of mets + colectomy Course   Recurrence risk  Highest risk within first 5 years post-resection Protocol: Monitoring post-resection  Clinical examination with CEA-125     Initially repeat every 3 months for 2 years Later repeat every 6 months for up to 5 years Focus areas  Ostomy problems or stool Incontinence  Radiation proctitis  Bowel adhesions Colonoscopy  Perform at one year and 3 years post-resection
  22. 22. CEA Indications  Colon Cancer monitoring  Do not use to screen for Colon Cancer or other cancer Interpretation  Normal  Non-smokers: <2.5 mg/ml , Smokers: <5 ng/ml  Increased  Benign disease unlikely if >10 ng/ml  Distant metastasis most likely if >100 ng/ml Efficacy  Not specific - Seen in other adenocarcinomas  Sensitivity varies by tumor stage and differentiation  CEA not increased in poorly differentiated tumors  Increased in <25% of Duke A or B stage Colon Cancer, in 50% with Duke C , in 75% of Duke D stage Colon Cancer Causes of increased CEA  Benign causes : Tobacco abuse, Peptic Ulcer Disease, Inflammatory Bowel Disease , Pancreatitis, Hypothyroidism, Cirrhosis  Malignant causes  Cancer – Colon, Breast, Stomach, Lung, Pancreas, Bladder, Cervix, Melanoma, Lymphoma
  23. 23. Case Study       A 65 y-old male undergoes a screening colonoscopy which reveals a 2cm polyp. The histopathology reveals an adenomatous polyp with no atypical cells. The most appropriate follow up for this patient is : A) Colonoscopy at 10 yrs B) Colonoscopy at 5 yrs and then every 5 yrs C) Colonoscopy at 3 yrs and then every 10 yrs D) Colonscopy at 3 yrs and then every 5 years E) CEA every 3 months
  24. 24. Breast CA Screening & Treatment
  25. 25. Breast Lump Evaluation
  26. 26. Etiologies of Discrete Breast Lumps      Age under 20 years  Fibroadenoma: 50%  Benign Breast Mass: 50% Age 20 to 29 years  Fibroadenoma: 35%  Benign Breast Mass: 52%  Breast Cyt: 10%  Breast Cancer: 3% Age 30 to 39 years  Fibroadenoma: 18%  Benign Breast Mass: 62%  Breast Cyst: 10%  Breast Cancr: 10% Age 40 to 55 years  Fibroadenoma: 9%  Benign Breast Mass: 31%  Breast Cyst: 25%  Breast Canerr: 35% Age over 55 years  Benign Breast Mass: 13%  Breast Cyst: 2%  Breast Cancer: 85%      Types of Breast Masses Breast Cyst Fibroadenoma Fibrocystic Breast Breast Cancer
  27. 27. Evaluating Breast Lump Clinical Exam  If palpable lump  proceed with aspiration/ if difficult to localize go for ultrasound  If not palpable/ to evaluate possible concurrent, nonpalpable lesions  mammogram Diagnostics  Breast Ultrasound  Mammogram in mass evaluation    Not used to evaluate palpable mass Used to evaluate for other concurrent lesions Delay Mammogram 2 weeks after aspiration     Aspiration may cause hematoma Wait time avoids false positives Breast aspiration, fine needle aspirate or core biopsy Excisional breast biopsy
  28. 28. Evaluating Breast Lump Management: Protocol 1 based on starting with ultrasound  Start with breast ultrasound  Ultrasound shows simple cyst    Ultrasound shows complex cyst or solid lesion    Aspirate ( See Breast Cyst Aspiration ) Repeat Clinical Breast Exam in 4-6 weeks Mammogram and Fine needle aspirate or core-needle biopsy (See Breast Cyst Aspiration ) Ultrasound does not reveal lesion   Mammogram and Fine needle aspirate or core-needle biopsy
  29. 29. Breast cyst aspiration   Interpretation No fluid (failed aspiration)    Bloody Fluid Aspirate     Consider breast ultrasound to better localize Refer solid lesions for breast biopsy Do NOT drain cyst (discontinue aspiration!) Send fluid for Cytology Refer to Surgery for fine needle aspirate Non-bloody fluid aspirate    Drain cyst completely Discard aspirate fluid Reexamine after draining cyst   Refer to surgery if mass still present Repeat Breast Exam in 4-6 weeks
  30. 30. Evaluating Breast Lump Mangement: Protocol 2 based on starting with FNA  Start with fine-needle aspirate of breast mass  Breast mass is cystic No residual cyst after aspiration    Age over 40: Mammogram or core needle biopsy Age under 40: Ultrasound or core needle biopsy Residual cyst or bloody fluid aspirated   Repeat Clinical Breast Exam in 6 weeks Breast mass is solid  FNA malignant: Treat FNA Suspicious: Core-needle or Excisional Biopsy FNA non-diagnostic      Age over 40: Mammogram or core needle biopsy Age under 40: Ultrasound or core needle biopsy FNA benign    Obtain Mammogram If Mammogram positive    Ultrasound or Core-needle biopsy If Mammogram negative  Repeat Clinical Breast Exam in 6 weeks
  31. 31. Evaluating Breast Lump Management: Protocol 3 Basic Approach based on age  Premenopausal asymmetrical palpable mass     Reexamine during days 5-10 of Menstrual Cycle Mammogram if age over 30 years Breast Ultrasound if difficult localization Attempt aspiration of breast lesion  See Breast Cyst Aspiration Postmenopausal asymmetrical palpable mass     Have a high level of suspicion (High Risk) Mammogram Attempt aspiration of breast lesion  See Breast Cyst Aspiration
  32. 32. Risk Factors – Ca Breast             Age Ethnicity/ Race : eg: Ashkenazi jews as they have increased incidence of BRCA1/BRCA2 mutations Family Hx  should include 3 generations including proband, offspring, paternal and maternal sides Age at Menarche – early age increased risk Age at Menopuse – Late age Increased risk Parity – Nulliparity is associated with increased ER+ breast ca risk  reduced number of ovulations in pregnancy may be responsible for this protective effect associated with multiparity Age at first birth  late age associated with increased risk of ER, PR+ Breast cancer Obesity Prior thoracic RT Known BRCA1/BRCA2, P53 Mutations, family hx Alcohol consumption Current or prior Hormone Replacement Therapy
  33. 33. Screening Risk Stratification :  Normal Risk  Increased Risk * Prior Thoracic Radiotherapy ( Mantle radiation) eg: childhood survivors of hodgkins lymphoma * Strong family History or Genetic Predisposition * LCIS/ Atypical hyperplasia * Prior history of breast cancer.
  34. 34. Screening – Normal Risk pts *Age >/= 20 but < 40  Counsel periodic breast self exam every month. Premenopausal women may find BSE most informative when performed at the end of menses.  Clinical breast exam every 1-3 years *Age >/ = 40 years  Counsel on periodic self breast exam  Annual clinical breast exam  Mammogram every year.
  35. 35. Screening – Increased Risk pts Annual clinical breast exam if age < 25yrs, if age 25 yrs or more – consider it more frequently at 6-12 mos  For pts with LCIS/ Atypical hyperplasia  annual mammogram + consider breast ca reduction strategies  Begin Mammogram at age 25 years for Hereditary Breast and Ovarian cancer pts ( eg: family member with a known BRCA1/ BRCA2 mutation )  also, consider risk reduction strategies  For pts with strong family history or other genetic predispositions ( i.e; other than HBOC), Start annual mammogram 5-10 yrs prior to youngest breast cancer case in the family  Also, consider risk reduction strategies  For pts with prior thoracic RT  Begin annual mammogram 8-10 yrs after RT or at age 40 years whichever is first!! 
  36. 36. HBOC Hereditary Breast and Ovarian Cancer – criteria Hereditary Breast and Ovarian Cancer – criteria  Member of family with known BRCA1/BRCA2 mutation  Personal hx of breast cancer with either of the following : *Diagnosed at or less than 40 yrs with/without family hx *Diagnosed at any age with 2 or more close blood relatives with ovarian or breast cancers at any age * Close male blood relative with breast cancer * Personal hx of ovarian cancer * If pt is of certain ethnic descent associated with bad mutations  Ashkenazi Jews, Swedish, icelandic  Personal hx of ovarian cancer with one or more of following * One or more close relatives with ovarian cancer * two or more close blood relatives with breast cancer * one or more close blood relatives with breast cancer less than 50 yrs of age * one or more close male blood relatives with breast ca * If Ashkenawzi jew  no additional family hx required 
  37. 37. HBOC criteria met – what next?   If BRCA1/BRCA2 status in the pt’s family is not known  test the affected family member at highest likelihood of having the mutation. ( if more than one affected  younger age at onset, bilateral breast ca, closest relative to proband, multiple breast primaries  are the things u can consider in judging the likelihood ) (If askenawji jew, consider testing 3 common mutations. If they are negative you can go with full sequence testing. If the pt is not ashkenaji descent  proceed with full sequence testing). If family member is +ve for mutation, proceed with HBOC management guidelines If BRCA1/BRCA2 deleterious familial mutation is known for that race test the pt for this specific familial mutation ( If the pt is Askenawzi jew, test for the three common mutations.) If mutations are +ve in the pt, proceed with HBOC management guidelines.
  38. 38. HBOC management guidelines Screening as Discussed earlier  Risk reduction strategies :  counsel about option of risk reduction mastectomy if needed  if the pt agrees proceed with b/l total mastectomy with reconstruction  Counsel about the option of risk reducing salpingooophorectomy between ages 35 and 40 yrs  For pts refusing risk reducing surgeries  continue follow ups with transvaginal ultrasound + CA-125 every 6mos starting at age 35 yrs or 10yrs earlier than earliest age of 1st diagnosis of ovarian cancer in the family.  May consider non surgical options such as tamoxifen or raloxifene , data still needed 
  39. 39. Breast Ca - Staging          Tis – DCIS, LCIS T1 – Tumor less than or equal to 2 cm T2 – Tumor greater than 2cm but < 5cm T3 – Tumor>5cm T4 – Tumor of any size that has spread to chestwall. N0 – No lymphnodes N1 – 1 to 3 LNs N2 – 4-9 LNs N3 – 10 or more LNs
  40. 40. Breast Ca - Staging Overall Stage T category N category M category Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage IIA T0 T1 T2 N1 N1 N0 M0 M0 M0 Stage IIB T2 T3 N1 N0 M0 M0 Stage IIIA T0 T1 T2 T3 T3 N2 N2 N2 N1 N2 M0 M0 M0 M0 M0 Stage IIIB T4 Any N M0 Stage IIIC Any T N3 M0 Stage IV Any T Any N M1
  41. 41. Breast ca – Stage 0 Lobular carcinoma in situ  only surgical procedure involved would be the biopsy.  Treatment : Careful follow up & observation  Further screening as we already discussed for high risk groups i.e; clinical breat exam every 6mos+ annual mammogram  Consider Risk reduction strategies -> Tamoxifen/ raloxifene for full 5 years, can educe the risk of developing invasive breast cancer -> For pts with additional risk factors like family hx, BRCA mutations , need to consider prophylactic b/l mastectomy 
  42. 42. Breast ca – Stage 0     Ductal Carcinoma In Situ  Options are a) Lumpectomy + radiation b) Mastectomy Check for hormone receptors in the removed breast tissue. ER+ve tumors need 5 years of Tamoxifen/ Raloxifene Mastectomy provides almost certain cure from local recurrence. Pts with DCIS who undergo lumpectomy are not at a higher risk of dying of breast ca as opposed to mastectomy. However, they have a risk of local recurrence in the same breast!!
  43. 43. Breast Ca – Stage I, II, IIIA Lumpectomy with surgical axillary staging if pt desires breast conservation. Follow with Radiotherapy. Check Hormonal status  if ER, PR, Her2  if ER +ve treat with tamoxifen 5 years  If Her2 +ve, treat with trastuzumab  Adjuvant chemotherapy with AC in case of hormone –ve tumors * Total mastectomy with axillary node staging is another option 
  44. 44. Absolute contraindications for Lumpectomy requiring RT   A) B) C) D) No radiation therapy is needed if tumor is less than 5cm, with good margins and no spread to lymphnodes In those requiring RT  Contraindications for lumpectomy + RT are : Prior RT to the breast or chest wall RT during pregnancy Diffuse suspicious or malignant appearing microcalcifications Positive pathological margins
  45. 45. Treatment Stage IIIB/IV  Total mastectomy + RT to chestwall + adjuvant chemo + hormonal therapy where indicated
  46. 46. Paget’s disease Presentation : Eczema of areola, bleeding, ulceration, itching of nipple – due to neoplastic cells in the epidermis of nipple areolar complex  Associated cancers : DCIS, Invasice cancer  If Paget’s disease – first do clinical exam + biopsy of nipple-areolar complex  if no other lesion palpable  MRI If any lesion on Clinical exam/ MRI  evaluate as per guidelines of breast mass. If there is an associated cancer  options are total mastectomy or breast conserving surgery If there’s no associated cancer  ( no palpable mass or imaging abnormality )  breast conserving surgery with removal of nipple-areolar complex with –ve margin breast tissue 
  47. 47.   Breast most common malignancy associated with pregnancy. Cancer – Pregnancy Breast carcinoma is the 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 and potentially compromising survival. For this reason, it is imperative that physicians perform careful clinical breast examinations in all pregnant patientsparticularly early in gestation, before the breasts become difficult to examine.  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 choice when cancer is diagnosed during pregnancy.     Chemotherapy can be given in late pregnancy, and radiotherapy is contraindicated. In some cases, especially when disease presents early in gestation, an interruption of the pregnancy may be warranted. 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 effect on the disease process. 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 counseling, further pregnancy can be planned after 2-3 years in selected cases.
  48. 48. Case Study 1) A 35 y/o woman comes to you for a mass in her left breast. Her last menstrual period was 8 weeks ago and a pregnancy test returned positive. Further work up revealed ductal carcinoma in situ. She requests if she can keep the pregnancy and also does not ant to lose her breast. The appropriate response at this time: A) She may undergo lumpectomy with radiotherapy but needs to undergo therapeutic abortion B) She can go for lumpectomy with radiation and can keep the baby C) We can postpone therapy untill the pregnancy is complete D) We can just do lumpectomy for now and postpone RT for the pregnancy to complete E) She must undergo radical mastectomy
  49. 49. Case Study     1) A 35 year old woman comes to you for regular physical exam. Her family history reveals ovarian cancer in mother at 55 yrs and also breast cancer in the sister at age of 25 yrs. Your next step: A) Test mother for BRCA1/BRCA2 B) Test the patient for BRCA1/BRCA2 C) Test the sister for BRCA1/ BRCA2
  50. 50. Prostate Ca Controversies
  51. 51. PSA issues Efficacy of PSA  USPSTF does not recommend screening : USPTF, ACP, AAFP does not recommend. Where as NCCN, ACS, AUA advocate it  Test Sensitivity      Test Specificity = 59%      Overall: 79-82% Cancers >1 cm: 90% More sensitive than Rectal Exam (30% for 1 cm tumor) Much more sensitive than Acid Phosphatase High false positive rate Benign Prostatic Hyperplasia often increases PSA Positive Predictive Value (PPV) 32-40% Much more cost-effective than Mammography Outcomes uncertain despite effective screening  Detection may not impact morbidity and mortality
  52. 52. PSA issues Causes of elevated PSA  Prostate Cancer  Benign Prostatic Hyperplasia (BPH)  Prostatitis  Prostate inflammation, trauma, or manipulation  Prostatic infarction  Recent sexual activity  Urologic procedures   Cystoscopy Urinary Catheterization
  53. 53. PSA Issues Screening (if performed) Men without risk factors: Age over 50 years Digital Rectal Exam yearly Prostate Specific Antigen (PSA) yearly   Men with risk factors: Age over 45 years Indications      African Americans Young first degree relative with Prostate Cancer Digital Rectal Exam yearly Prostate Specific Antigen (PSA) yearly Age over 70 to 75 years  Discontinue PSA screening Screening interval  Screening every 4 years may be as effective as annual
  54. 54. PSA issues   Age specific Normal PSA values Age 40 to 49 years 2.0 – 2.5     Age: 50 to 59 years 3.0 – 4.0     White: PSA <= 3.5 Black: PSA < 4.0 Asian: PSA < 3.0 Age 60 to 69 years 4.0 – 4.5     White: PSA <= 2.5 Black: PSA < 2.0 Asian: PSA < 2.0 White: PSA <= 4.5 Black: PSA < 4.5 Asian: PSA < 4.0 Age 70 to 79 years 5.0 – 6.5    White: PSA <= 6.5 Black: PSA <5.5 Asian: PSA <5.0
  55. 55. PSA issues Mechanism  Free PSA increases more in Benign Prostatic Hypertrophy  PSA associated with cancer is more protein bound Indication  Detection of Prostate Cancer when PSA 2.5 to 10 ng/ml Efficacy  Improved Specificity when combined with PSA Interpretation  Free PSA >27% with lower likelihood of Prostate Cancer  Values suggestive of Prostate Cancer Total PSA 3.0 to 4.0 with Free PSA <19%  Total PSA 4.0 to 10.0 with Free PSA <17 to 24% PSA > 100ng/ml predicts bone mets in 75% cases 
  56. 56. Staging Prostate Ca Stage A Stage A1: Single impalpable lesion (<5% of gland) Stage A2: Impalpable microscopic lesion (>5% of gland) Stage B  Stage B1: Palpable Nodule in single lobe  Stage B2: Palpable Nodules Stage C  Stage C1: Localized disease extending beyond gland  Stage C2: Localized disease includes seminal vesicles Stage D  Stage D1: Pelvic lymph node involvement  Stage D2: Bone metastases or distant spread 
  57. 57.       Case Study 1 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 prostate ca in their family. You perform PSA and DRE. DRE does not reveal any palpable mass. The lab test reveal : PSA : 8ng/ml, Free PSA: 1.5ng/ml. You reveal the results to patient and his daughter. The daughter asks you if her father has a cancer. Your best response is : A) The PSA level increases with age and your father’s is ageappropriate range B) PSA level is very nonspecific and your father does not have a cancer 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 cancer etiology rather than benign cause D) PSA will not help in diagnosing carcinoma prostate E) I did this test only because you requested for it, I don’t think this results mean anything.
  58. 58. Case Study 2       A 55 y/o african american man with newly diagnosed Stage B prostate cancer undergoes radical prostatectomy and is referred to you from surgical clinic for routine follow up. The patient requests how often he should follow up with you and what tests he would need. Your best response is: A) You do not need any follow up because you had a local cancer that was completely resected B) PSA need to be tested every six months for 5 years and thereafter, every year C) Bone scan to evaluate metastasis is needed every year D) Digital Rectal Exam every year to look for local recurrence E) You need endocrine therapy before we proceed further
  59. 59. Case Study 3      A 55 y/o african american man with newly diagnosed prostate cancer undergoes radical prostatectomy and undergoes a CT scan showing regional pelvic lymphadenopathy. Biopsy of LNs revealed cancer in 2 of them. Your next step: A) Endocrine therapy with lupron B) No further treatment C) Radiotherapy D) Alpha receptor antagonists
  60. 60. Localized Prostate Cancer (Stages A to C) Management  1. Surgical Management Indications    Well-differentiated tumor Patient under age 65 years  Better outcomes than with conservative therapy Procedures    Radical Prostatectomy Pelvic lymph node biopsy (Rule out Stage D)  Indicated for Prostate Cancer Stage C 2. Prostate Radiotherapy  Procedures     External Beam Prostate Radiotherapy Prostate Seed Implant Radiotherapy (Brachytherapy) Consider Transurethral resection of prostate Better quality of life than with prostatectomy  3. Conservative therapy (no curative treatment)  Indications (Curative treatment with risk > benefit)    Well-differentiated tumor if life expectancy <10 years  Elderly patients with serious comorbities Contraindications (Curative treatment preferred)    Poorly differentiated tumor if life expectancy >10 years  Younger patients who are otherwise healthy
  61. 61. Stage D     Endocrine Therapy for Advanced Prostate Cancer (Stage D) Bilateral Orchiectomy Diethylstilbesterol (DES) 1 to 3 mg qd Leutonizing Hormone Releasing Hormone Agonist (LHRH)    Goserelin acetate (Zoladex) Leuprolide acetate (Lupron) Antiandrogens   Flutamide Bicalutamide
  62. 62. Stage D        Palliative Care for Bone Metastases (Spinal Metastasis) Adequate Narcotic Analgesics Bisphosphonates (e.g. Fosamax) Local radiation Strontium 89 Chloride local therapy Endocrine therapy as above ( Remember other spinal mets from other cas are rxed with RT) Dexamethasone (Decadron) - ? Cord compression     Bolus: 16 mg IV First 3 days: 4 mg IV q6 hours Taper over 14 days MRI R/o cord compression.
  63. 63. Post Prostate CA – Follow up Follow-up Protocol: General  Prostate Specific Antigen (PSA) as below  Digital Rectal Exam yearly  Clinical examination every 6 months for 5 years  Focus area on exam  Bladder Cancer (new second tumor)  Erectile Dysfunction  Stool or Urinary Incontinence  Radiation proctitis  Major Depression Follow-up Protocol: Prostate Specific Antigen (PSA)  Frequency of PSA Testing  First year: PSA every 6 months for 5 years  After fifth year: PSA every year  PSA Levels after Radical Prostatectomy  PSA 0 within 3 months of Prostatectomy  PSA rise >2 mg/ml/year suggests high grade lesion  PSA Levels after Radiotherapy  PSA falls gradually to under 1 ng/ml by 1 year  PSA remains under 1 ng/ml unless cancer recurrence
  64. 64. Leukemias       Consider age first ALL - children AML – only promyelocytic important, retinoic acid CML – ph+ , lap, imatinib CLL – Elderly D/W tumor lysis syndrome
  65. 65. Lymphoma – Hodgkin’s Epidemiology  Second most common solid hematologic malignancy, Most common is Non-Hodgkin's Lymphoma Symptoms  Painless lymph node enlargement , Pruritus, Abdominal Pain , Periodic fever , Cachexia Signs  Lymphadenopathy  Firm, discrete, nontender nodes  Nonsuppurative  Hepatomegaly  Splenomegaly Staging (Ann Arbor classification)  Stage I Single Lymph Node or intralymphatic organ  Stage II  Two or more lymph nodes on same side of diaphragm  Stage III  Lymph nodes involve both sides diaphragm or  Localized spleen or extralymphatic involved  Stage IV  Diffuse or disseminated disease  Liver or Bone Marrow involvement  Modifier  A: Asymptomatic  B: Fever, Night sweat, weight loss (>10% in 6 months
  66. 66. Lymphoma – Hodgkin’s Diagnosis: Lymph node Excisional Biopsy  Reed-Sternberg Cells    Pathognomonic for Hodgkin's Lymphoma Large binucleate cells with single distinct nucleoli Appearance: "Owl's Eye" Pathology (Histologic Types)  Nodular Sclerosis  Most common type in North America, Western Europe  Mixed cellularity  Second most common histologic type in North America   Lymphocytic predominance  Abundance of Reed-Sternberg Cells   More frequent in poorer parts of world and in elderly Prognosis Favorable Lymphocyte depletion  Paucity of cellular elements    Rarest histologic type Associated features  Advanced age , Systemic symptoms , Retroperitoneal nodes and Extranodal involvement Worst prognosis
  67. 67. Lymphoma – Hodgkin’s Management: Localized disease - Stages I-III  Combination Chemotherapy   Six cycles at 28 day intervals Medications (ABVD Regimen)       Involved Region Radiation therapy Complications : Secondary tumors   Adriamycin Bleomycin Vinblastine Dacarbazine Breast Cancer in women , Lung Cancer , Colorectal Cancer , Bone Cancer , Thyroid Cancer Other adverse effects : Hypothyroidism , Premature Ovarian Failure , Cardiomyopathy due to Anthracycline , Osteoporosis
  68. 68. NHL Symptoms and Signs (differentiate from Hodgkin's)  Presence of Lymphadenopathy draining Waldeyer's ring    Hodgkin's Lymphoma involves Supraclavicular nodes Epitrochlear lymph nodes Mediastinal, abdominal and extranodal involvement  Common at presentation Chest Pain (suggests lung involvement)  Systemic symptoms more common in Hodgkin's Pathology (Lymph node histology)  Diffuse small cleaved cell  Poorly differentiated LymphocyteS Management  Combination Chemotherapy and Radiation Therapy  Monoclonal Antibody in certain cases   Rituxan binds antigen on mature B Cells
  69. 69. Testicular Cancers Counsel young patients 20 – 40 to perform testicular self examination  If pt reports/ clinician finds suspicious mass Do beta hcg, afp, ultrasound if required, cxr is very important.  if suspicion strong do inguinal orchiectomy +Seminoma  normal AFP, Increased BHCG  Rx RT and follow up + Teratmoa ( non seminomas )  elevated AFP, Beta HCG  initial surgery to be followed by chemotherapy ( etoposide/cisplatin) + retroperitoneal lymphnode dissection 