The document discusses the management of cancer of unknown primary presenting as neck lymph node metastases, including definitions, epidemiology, diagnostic evaluation, and treatment approaches such as chemotherapy, radiation therapy, and surgery. Identification of the primary site can help guide more targeted treatment but often remains challenging given the metastatic presentation; combined modality therapy is generally recommended.
Metastasis of Neck Node with Unknown Primary Himanshu Soni
carcinoma of unknown Primary accounts for 5%-10% of all tumours. 3–5% of head and neck cancers presented as cervical squamous cell carcinomas of unknown primary
Metastasis of Neck Node with Unknown Primary Himanshu Soni
carcinoma of unknown Primary accounts for 5%-10% of all tumours. 3–5% of head and neck cancers presented as cervical squamous cell carcinomas of unknown primary
Target Audience: Oncology fellows and Oncologists
Carcinoma of unknown primary is a challenging scenario often encountered in Oncology practice. This slide presentation discusses favorable and unfavorable presentations of CUP and it's management
HEAD AND NECK OCCULT PRIMARY CANCERS. SAM & RICH.pptxRitchieShija
Carcinoma of unknown primary is a diagnosis given when doctors aren't able to locate where a cancer began.
Most often, cancer is diagnosed when doctors discover the spot where the cancer began (primary tumor). If the cancer has spread (metastasized), those sites might be discovered, too.
In carcinoma of unknown primary, also known as occult primary cancer, doctors find the cancer cells that spread in the body, but they can't find the primary tumor.
In carcinoma of unknown primary, also known as occult primary cancer, doctors find the cancer cells that spread in the body, but they can't find the primary tumor. Doctors consider the location of the primary tumor when choosing the most appropriate treatments.So if carcinoma of unknown primary is found, doctors work to try to identify the primary tumor site. Your doctor might consider your risk factors, symptoms, and results from exams, imaging tests and pathology tests when trying to determine where your cancer began.
Target Audience: Oncology fellows and Oncologists
Carcinoma of unknown primary is a challenging scenario often encountered in Oncology practice. This slide presentation discusses favorable and unfavorable presentations of CUP and it's management
HEAD AND NECK OCCULT PRIMARY CANCERS. SAM & RICH.pptxRitchieShija
Carcinoma of unknown primary is a diagnosis given when doctors aren't able to locate where a cancer began.
Most often, cancer is diagnosed when doctors discover the spot where the cancer began (primary tumor). If the cancer has spread (metastasized), those sites might be discovered, too.
In carcinoma of unknown primary, also known as occult primary cancer, doctors find the cancer cells that spread in the body, but they can't find the primary tumor.
In carcinoma of unknown primary, also known as occult primary cancer, doctors find the cancer cells that spread in the body, but they can't find the primary tumor. Doctors consider the location of the primary tumor when choosing the most appropriate treatments.So if carcinoma of unknown primary is found, doctors work to try to identify the primary tumor site. Your doctor might consider your risk factors, symptoms, and results from exams, imaging tests and pathology tests when trying to determine where your cancer began.
This is a Central presentation, presented at National Institute of Cancer Research & Hospital(NICRH), Mohakhali, Dhaka, Bangladesh on Metastatic neck node of unknown primary.
Biopsy proven cancer of the neck, which even after a complete clinical & radiological workup (that includes physical examination, CT scan, esophgeoscopy, laryngoscopy, bronchoscopy & multiple survillence biopsies) reveals or yields no primary demonstrable lesion.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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3. Definition
Occult primary tumours or CUPs are histologically
proven metastatic tumors whose primary site cannot
be identified during standard pre-treatment
evaluation.
CUP’s (Neck) : Metastatic disease in the lymph
nodes of the neck WITHOUT any evidence of
primary tumour.
Remains a Multidisciplinary challenge.
Lack of prospective randomized studies.
4. Epidemiology
accounts 2% to 9% of all H&N tumours.
1.5-5% accuracy of the diagnostic workup. [Strogen P
et. al 2013]
Primary site is found in <30% of cases.
Q: Why CUP’s is a Diagnostic Challenge?
Unusual Presentation.
Delaying Treatments.
Therapeutic Errors.
CUP’s is a diagnosis of Exclusion.
5. Epidemiology
men = women
average age at diagnosis 60-75 years.
10 most frequently diagnosed tumours in developed
countries.
On the global scale, the CUP is ranked as 6th to 8th most
common cancer. (NCCN 2020)
SKIMS Data : Approx. 350 patients of CUP’s are registered
per annum (2015-2020) constituting 10% of all tumors.
6. Mechanism
I. The primary cancer may have shed metastases and then
undergone spontaneous regression.
II. The primary tumor may be too small to be detected, even at
autopsy.
III. The site of origin may be obscured by the extensiveness of
metastases or by the atypical pattern of dissemination.
IV. Primary acquires a metastatic phenotype soon after
transformation and remains small.
clonal proliferation
invasion and intravasation
widespread dissemination via
circulation
extravasation
8. Head & Neck CUP’s
Most encountered site of primary origin is oropharynx.
CUP of the oropharynx is known for metastasis to levels II or III, in
certain cases to levels IV as well.
Squamous cell carcinoma (55-90%) > undifferentiated
carcinoma > adenocarcinoma
Risk factors :
smoking, alcohol, poor oral hygiene
HPV & EBV (90%).
90% correlation between HPV & squamous cell CUP (Fu TS. J Otolaryngol.2016)
GERD, Malnutrition, Plummer-Vinson Sx.
9. ClinicalPresentation
Painless neck mass in an adult >40 years.
[94% Cl./P (Grau et.al. 2005)]
Symptoms Possible Primary Tumor
Otalgia Oral cavity/Pharynx/Larynx/Ear
Dysphagia/Odynophagia Pharynx/oesophagus
Hoarsness Larynx
Trismus, Speech alteration Oral cavity/oropharynx
Nasal congestion, Epistaxis Sino-nasal
Aspiration Orophaynx/Larynx
10.
11. Nodal group Primary tumor sites
Level IA (submental) Anterior oral cavity, lower lip
Level IB (submandibular) Oral cavity, anterior nasal cavity,
submandibular gland, midfacial face
skin
Level II (upper jugular) Oropharynx, oral cavity, nasopharynx,
nasal cavity, larynx, hypopharynx
Level III (mid jugular) Oropharynx, oral cavity, nasopharynx,
larynx, hypopharynx
Level IV (lower jugular) Oropharynx, larynx, hypopharynx, upper
esophagus, thyroid
Level V (posterior triangle) Nasopharynx, posterior scalp skin,
thyroid
Level VI (anterior compartment) Thyroid, larynx, hypopharynx, upper
esophagus
Supraclavicular Non-head and neck, thyroid
Retropharyngeal Nasopharynx, posterior pharynx
Parotid Lateral/upper facial and scalp skin,
parotid gland
12. Complete History
Physical Examination
Skin Examination
[Head to Toe]
Sub-mucosal lesions are not usually
evident on inspection
Palpation
Cranial Nerve Examination
Diagnostic Work-up
13. Further Evaluation
BLI
Panendoscopy-tonsillectomy-Biopsy [preferably
after imaging]
Narrow Band Imaging
FNA of node [First Step], image guided.
Trucut Biopsy [95% yield reported Novoa et. al
2012]
Molecular studies.
HPV DNA or RNA
In situ Hybridization (ISH) for EBV-encoded RNA or
PCR for EBV-genomic DNA.
CT/MRI [First Imaging Choice]
PET/CT
14. Narrow band Imaging
Advanced endoscopic imaging techniques (AEITs)
Based on the penetration properties of light.
Shorter wavelengths penetrate only superficially
into the mucosa, whereas longer wavelengths can
penetrate more deeply.
NBI utilizes red-green-and-blue filters to modify WL
endoscopy (WLE): the blue light filter (400–430 nm)
highlights the capillaries in the superficial mucosa
through mean peak absorption of hemoglobin (415
nm), while the green light filter (525–555 nm)
penetrates deeper into the mucosa.
This results in greater clarity of mucosal surface
structures due to the increased contrast between
mucosa and superficial vessels, which appear
brown/black.
15. Detection of lesions in the digestive tract.
Distinction between benign and malignant
lesions
Targeting biopsies
Prediction of the risk of invasive cancer
Delimitation of resection margins
Identification of residual neoplasia in a scar
16.
17. PerformingaBiopsy
• Patients with metastases to neck lymph nodes only :
• Suspicious cervical nodes should not undergo
excisional biopsy until a complete diagnostic
evaluation of the head and neck has been performed.
• About 35% of these patients have potentially curable
cancers of the upper aerodigestive tract.
• However, supraclavicular lymph nodes may be
directly excised for histologic examination.
18. IHC
• improves diagnosis, determine lineage, determine tissue
of origin.
• Tumor biomarkers that can help with treatment
decisions: EGFR, BRAF, HER2, RAS, BCL2, c-kit, p53.
• BCL2 & p53 are over expressed in 40% and 26%-53% of
occult primary respectively.
Nowadays but not recommended by NCCN for CUPs
• Gene expression profiling assays are developed to
identify the tissue of origin in pt’s of occult primary.
• Mutational testing with Next generation sequencing
have gained interest.
22. • Identification of primary 24-73%.
• Modification of treatment plans 20-60%.
• Good candidates for PET/CT
• CUP Patients with cervical adenopathy.
• Patients with single metastatic focus–prior to definitive
loco regional therapy.
• Additional sites of metastases.
• Post RT neck evaluation.
• Largely necrotic nodes : -ve on PET
Caution : False Positives
Lympho-epithelial tissue of Waldeyer’s ring.
Salivary glands : physiological uptake.
RoleofPET-CT
24. Management
Combined-modality therapy (surgery and radiation
therapy) is better than either modality alone
Neck dissection is indicated if:
Goss disease is left behind after excisional biopsy
Single LN > 6 cm
E C E+
In squamous cell carcinoma, unilateral tonsillectomy
ipsilateral to the presenting neck mass is indicated
In unresectable squamous cell head and neck cancers
chemotherapy with cisplatin/5- fluorouracil–based and
cetuximab-based regimens has been given
Identification of the primary site help reduce morbidity by
limiting the field of radiation and would improve surveillance.
31. RegionalLymphNodes
N
category
ClinicalN criteria(cN) Pathological N criteria(pN)
Nx Regional lymph nodes cannot be
assessed
Regional
as
lymph nodes cannot be
N0 No regional
metastasis
lymph node No regional lymph node metastasis
N1 Metastasis in a single ipsilateral
lymph node, 3 cm or smaller in
greatest dimension and ENE (-)
Metastasis in a single ipsilateral lymph
node, 3 cm or smaller in greatest
dimension and ENE (-)
N2a Metastasis in a single ipsilateral
lymph node, larger than 3 cm but not
larger than 6 cm in greatest
dimension and ENE (-)
Metastasis in a single ipsilateral lymph
node, larger than 3 cm but not larger than
6 cm in greatest dimension and ENE (-)
OR
Metastasis in a single ipsilateral or
contralateral node, 3 cm or smaller in
greatest dimension and ENE (+)
AJCCCancerStaging Manual, 8th ed.
32. N
category
Clinical N criteria(cN) Pathological N criteria(pN)
N2b Metastasis in multiple ipsilateral
lymph nodes, none more than 6
cm in greatest dimension and ENE
(-)
Metastasis in multiple ipsilateral lymph
nodes, none more than 6 cm in greatest
dimension and ENE (-)
N2c Metastasis in bilateral or
contralateral lymph nodes, none
more than 6 cm in greatest
dimension and ENE (-)
Metastasis in bilateral or contralateral
lymph nodes, none more than 6 cm in
greatest dimension and ENE (-)
N3a Metastasis in a lymph node, larger
than 6 cm in greatest dimension
and ENE (-)
Metastasis in a lymph node, larger than
6 cm in greatest dimension and ENE (-)
N3b Metastasis in any lymph node(s)
with clinically overt ENE (+)
Metastasis in any lymph node(s) with
clinically overt ENE (+)
OR
Metastasis in single ipsilateral node,
larger than 3 cm in greatest
dimension and ENE (+)
33. PET Scan based Response
Assessment
N1, N2a Disease N2b, N2c, N3 Disease
Upfront Surgery
alone?
Initial RT f/b Salvage
Surgery
Surgery f/b PORT
[A loco-regional failure rate of 13-
32% for patients treated with
surgery alone versus 0-18% with
surgery + PORT]
N2b : Primary chemo-
radiotherapy.
N2c/N3 : Induction
chemotherapy.
37. • Choiceof the regimenshould bebasedonthe histologictype
of cancer.
1. Paclitaxel and Carboplatin:
based on the relatively
Choice for first-line therapy,
large experience with this
Combination.
• Addition of a third drug (either Etoposide or Gemcitabine) to
a taxane and platinum regimen may improve efficacy
2. Second line therapy - Single agent Gemcitabine (1000
mg/m2 weekly three of four weeks) has modest
activity.
39. Neuroendocrine Tumors
Neuroendocrine CUPs
are uncommon
clinical behaviour is dependent on the tumour grade
and level of differentiation
represent a favourable prognostic subset of CUPs
responsive to combination chemotherapy,
making long-term survival a possibility in some
patients
40. Clinical Scenario
Young lady XYZ
32 years of age
No underlying co
morbidities
Married with 2 kids
Hailing from J&K
Presented with right
submandibular neck
swelling * 3 months.
Evaluated for same at
periphery.
USG Neck : Right Lv. Ib-II
(+)
FNA : Inconclusive
Q. What you will do next?
41. Unfortunately she was operated at periphery
Submandibular gland excision with LN
Dissection..
Post-op HPR : DLBCL
Without complete
evaluation they operated
the patient, thought there
was no need for surgery if
they would have
considered excision biopsy
rather than surgery.
Same is true with CUP’s
do proper evaluation and
you will reach the