Concise review on cancer must knows for the medical student who will be taking the Philippine Licensure Board Examination for Physicians

1. MEDICAL ONCOLOGY MUST KNOWS: INTERNS REVIEW COURSE
By Mary Ondinee Manalo Igot, MD, MSCM, FPCP, FPSO, FPSMO
Internal Medicine – Medical Oncology – Neuro Oncology
De La Salle - UMC / Asian Hospital & Medical Centre / The Medical City South Luzon
October 2018

2.  TOP 3 CANCERS in the PHILIPPINES:
 Lung Cancer
 Breast Cancer
 Colorectal Cancer

3. LUNG CANCER

4.  A 65-year old retired flight stewardess
with no vices came to your clinic
complaining of hemoptysis, cough and
weight loss. Physical examination was
largely unremarkable except for
decreased breath sounds on the right
upper lung field. You did a chest x-ray
and this revealed a mass in the right
upper lobe. A confirmatory CT scan
showed a solitary 4x4 cm mass in the
right upper lobe with no associated
lymphadenopathy or satellite nodules.
LAST YEAR’S
QUESTIONS:
LUNG
CANCER

5. LUNG CANCER
What should be done next?
 Core needle biopsy
 Bronchoscopy with bronchial
washing
 Transbronchial FNAB
 Excision biopsy

6. LUNG CANCER
What should be done next?
 Core needle biopsy
 a core is a tissue, it uses a big
bore needle
 Bronchoscopy with bronchial
washing
 washings will only give you cells
 Transbronchial FNAB
 fine needles are not used when
you penetrate a lot structures
 also does not give you the
architecture of the tissue
 Excision biopsy
 We do not do this for lung cancer
because it is INVASIVE
TIP: Most cancers will
require a tissue to
determine histology.
 Harrison’s page 511-512:
Given the greater emphasis
placed on molecular testing,
a CORE BIOPSY is preferred
to ensure adequate tissue
for analysis.

7. LUNG CANCER
What should be done next?
 Core needle biopsy
 Bronchoscopy with bronchial
washing
 Transbronchial FNAB
 Excision biopsy
CORE NEEDLE BIOPSY
TIP: Mode of biopsy
depends on the LOCATION
of the tumorCore needle
biopsy Bronchoscopy

8. LUNG CANCER
Histopathology yielded lung
cancer. What is her most
likely predisposing factor?
 Ionizing radiation
 Asbestos
 Tobacco smoke
 Radon

9. LUNG CANCER
Histopathology yielded lung
cancer. What is her most
likely predisposing factor?
 Ionizing radiation
 Asbestos
 Tobacco smoke
 Radon
Risk Factors (Harrison page 506):
 Tobacco (first hand or second hand /
environmental smoke)
 Occupational exposure (asbestos,
arsenic, bischloromethyl ether,
hexavalent chromium, mustard gas,
nickel and polycyclic aromatic
hydrocarbons)
 Ionizing radiation
 Low fruit and vegetable intake during
adulthood
 Radon
 Prior lung diseases (chronic bronchitis,
emphysema, TB)
 Inherited predisposition

10. LUNG CANCER
Before the late 1980s, flight
attendants were heavily
exposed to second hand
smoke
FAMRI: Flight Attendant
Medical Research Institute
 Flight attendants who
developed lung cancer and
those who experienced a lot
of other chronic lung
diseases filed a lawsuit
against the tobacco industry
 They won $300 million and
part of this was used to
create FAMRI

11. LUNG CANCER
Histopathology yielded lung
cancer. What is her most
likely predisposing factor?
 Ionizing radiation
 Asbestos
 Tobacco smoke
 Radon
Risk Factors (Harrison page 506):
 Tobacco (first hand or second hand /
environmental smoke)
 Occupational exposure (asbestos,
arsenic, bischloromethyl ether,
hexavalent chromium, mustard gas,
nickel and polycyclic aromatic
hydrocarbons)
 Ionizing radiation
 Low fruit and vegetable intake during
adulthood
 Radon
 Prior lung diseases (chronic bronchitis,
emphysema, TB)
 Inherited predisposition

12. LUNG CANCER
What is the most likely
histology based on her
exposure?
 Squamous cell carcinoma
 Adenocarcinoma
 Large cell carcinoma
 Bronchioalveolar carcinoma

13. LUNG CANCER
What is the most likely
histology based on her
exposure?
 Squamous cell carcinoma
 Adenocarcinoma
 Large cell carcinoma
 Bronchioalveolar carcinoma
Harrison’s page 507:
 All histologic types of lung
cancer can develop in
current and former smokers,
although squamous and
small cell carcinomas are
most commonly associated
with heavy tobacco use.

14. LUNG CANCER
What is the most likely histology based on her exposure?
 Squamous cell carcinoma
 Adenocarcinoma
 MOST COMMON HISTOLOGY for the following patients (MUST KNOW!!!) :
1. Never smokers / former light smokers
2. Women
3. Younger adults (<60 years)
 Large cell carcinoma
 DO NOT EVER CHOOSE THIS ANSWER because we rarely see this
 Bronchioalveolar carcinoma
 This subtype was dropped already by the World Health Organization so DO NOT
EVER CHOOSE THIS ANSWER

15. LUNG CANCER
The patient was lost to follow up
and then comes back after a few
weeks with Horner’s Syndrome.
Which are parts of the
syndrome?
 Mydriasis, ulnar nerve pain
 Enophthalmos, anhydrosis
 Ptosis, iris hypochromia
 Anisocoria, miosis
Horner’s Syndrome
(Harrison’s page 510):
 Enophthalmos
 Ptosis
 Miosis
 Anhydrosis

16. LUNG CANCER
If instead she presented
with a perihilar mass, what
is the most likely histology?
 Small cell carcinoma
 Bronchogenic carcinoma
 Adenocarcinoma
 Nonsmall cell carcinoma

17. LUNG CANCER
If instead she presented
with a perihilar mass, what
is the most likely histology?
 Small cell carcinoma
 Bronchogenic carcinoma
 Adenocarcinoma
 Nonsmall cell carcinoma
Harrison’s page 512:
 CENTRAL / PERIHILAR:
 Small cell carcinoma
 Squamous cell carcinoma
 PERIPHERAL:
 Adenocarcinoma
 Large cell carcinoma

18. OTHER MUST KNOWS FOR LUNG CANCER
 SSx: cough (75%), weight loss
(68%), dyspnea (60%), chest pain
(49%)
 Dx: Core needle biopsy
 Stage: Chest CT scan, abdominal CT
scan, bone scan, brain CT scan
(preferably MRI)
 If you will choose one best answer
and PET scan is an option, CHOOSE
PET SCAN
 Histology:
1. Nonsmall cell carcinoma (NSCLCA)
 adenocarcinoma, large cell
carcinoma, squamous
2. Small cell carcinoma SCLCA)
 Nonsmall Cell Carcinoma
 STAGING for NSCLCA (4 stages)
 Follows the TNM Staging
 Cell of origin: Type II epithelial
cell (alveolar epithelial cell)
 Tx: Surgery, Chemo, RT,
IMMUNOTHERAPY
 Small Cell Carcinoma
 STAGING for SCLCA (2 stages)
 Limited Stage: can be treated
in one radiation field
 Extensive Stage: cannot be
treated in one radiation field
 Cell of origin: Neuroendocrine
celles
 Tx: Chemo, RT (not surgery)

19. OTHER MUST KNOWS FOR LUNG CANCER
 Chemotherapy:
 Always PLATINUM-BASED
 Cisplatin
 Carboplatin
 All platinum-based
chemotherapy are
NEPHROTOXIC
 Syndromes:
1. Horner’s: enophthalmos,
ptosis, miosis, anhydrosis
2. Pancoast (aka superior
sulcus tumor): hits C8,T1,T2
 Shoulder pain that radiates in
the ulnar area
 Recall from Netter  Ulnar
nerve is C7, C8,T1)
3. SIADH: hyponatremia

20. OTHER MUST KNOWS FOR LUNG CANCER
 Screening: Low dose CT
scan
 NNTS (# needed to
screen) = 320
 You need to
screen 320 people
to prevent 1 lung
cancer death
 Who will I screen?
 >/= 60 yrs old
 >/= 30 pack years

23. BREAST CANCER

24. BREAST CANCER
 Risk Factors (Harrison’s p524):
1. Age at menarche
2. Age at first full term pregnancy
3. Age at menopause
4. Central obesity
5. Exposure to exogenous
hormones
6. Radiation
 Breast Self-Exam:
 Strongly encouraged
 Days 5-7 of the menstrual cycle
is the BEST TIME to examine in
premenopausal women
The longer you are exposed to
uninterrupted estrogen, the higher
risk for breast cancer.
 Genes involved:
1. BRCA1
2. BRCA2

25. BREAST CANCER
 Diagnosis:
 If suspicious
 CORE
NEEDLE
BIOPSY
(tissue
diagnosis)
 If not
suspicious 
may do an
FNAB

26. BREAST CANCER
 STAGING (MUST KNOW):
 How do you stage?
 Check for metastases to
most common sites
involved: liver, bone, lung
 Chest CT scan, Abdominal CT
scan, bone scan

27. BREAST CANCER
 STAGING (MUST KNOW):

28. BREAST CANCER
 STAGING (MUST KNOW):

29. BREAST CANCER
 SURVIVAL:

30. BREAST CANCER
 TREATMENT:
 SURGERY
 mastectomy = breast
conserving treatments
(lumpectomy) + radiation
 Sentinel lymph node biopsy
(SLNB): standard of care for
localized breast cancer with
clinically negative lymph nodes
 If negative, may not do
axillary dissection
 Not eligible for breast
conserving surgery:
1. Tumors >5 cm (or for smaller
tumors if the breast is small)
2. Tumors involving the nipple-
areola complex
3. Tumors with extensive
intraductal disease involving
multiple quadrants of the
breast
4. History of collagen-vascular
disease
5. Women who either do not
have the motivation for
breast conservation or do
not have convenient access
to radiation therapy

31. BREAST CANCER
 ADJUVANT (after surgery) TREATMENT:
 Chemotherapy:
 Most common are doxorubicin and taxanes (docetaxel, paclitaxel)
 Hormonal Therapy (for the ER/PR): depletes the body of estrogen
 Premenopausal: tamoxifen
 Postmenopausal: aromatase inhibitors (letrozole, anastrazole)
 Biologic Therapy (Her2neu):
 Trastuzumab (brand name: Herceptin)

32. BREAST CANCER
Side effects of tamoxifen
 Hot flushes, headache, dry
skin
 Osteoporosis
 Cataracts
 Hypercoagulability
 Endometrial thickening and
endometrial cancer
Side effects of doxorubicin
 Cardiotoxicity
 Cytopenias
 Hair loss
 Nausea and vomiting

33. BREAST CANCER
SCREENING
 Mammogram starting at age
40 years old, earlier if with a
family history of breast
cancer

34. COLORECTAL CANCER

35. COLORECTAL CANCER
 Precursor lesion:
 Adenomatous polyp
 Gene involved:
 APC gene
 Primary prevention:
 Aspirin and other NSAIDs by
inhibition of prostaglandin
synthesis
 Tumor marker:
 CEA (carcinoembryonic
antigen)
 A high preoperative CEA is
predictive of recurrence
 Risk Factors (Harrison’s page
538):
1. Diet: animal fat
2. Hereditary syndromes:
polyposis coli, MYH-assoc
polyposis, nonpolyposis
syndrome (Lynch syndrome)
3. Inflammatory bowel disease
4. Streptococcus bovis
bacteremia
5. ?Tobacco use
6. Insulin resistance

36. COLORECTAL CANCER
 SCREENING:
 STARTING AGE 50
 fecal occult blood
testing annually
coupled with flexible
sigmoidoscopy every 5
years
 colonoscopy every 10
years beginning at age
50 in asymptomatic
individuals with no
personal or family
history of polyps or
colorectal cancer

37. COLORECTAL CANCER
SIGNS AND SYMPTOMS depend on the location
 Fatigue, palpitations, angina,
hypochromic microcytic anemia
because of ulceration and insidious
blood loss
 Obstructive symptoms like
constipation or constipation
alternating with diarrhea
 Hematochezia, tenesmus,
constipation, back pain
Right / ascending colon:
Left / descending colon:
Rectosigmoid:

38. COLORECTAL CANCER
LIVER:
most
common
visceral site
of
metastases

39. COLORECTAL CANCER
COLON CANCER
TREATMENT
 Total removal of the tumor
plus at least 12 sampled
lymph nodes followed by…
 Adjuvant treatment with 5-
fluorouracil-based
chemotherapy regimen
RECTAL CANCER
TREATMENT
 Neoadjuvant radiation plus
chemotherapy with 5-
fluorouracil / capecitabine
followed by…
 Total mesorectal excision
(standard surgery for rectal
cancers)
 Adjuvant treatment with 5-
fluorouracil-based
chemotherapy regimen
BACKBONE CHEMOTHERAPY for COLORECTAL CANCERS: 5-Fluorouracil

40. LYMPHOMA

41. LYMPHOMA

42. LYMPHOMA
NON-HODGKINS
LYMPHOMA
 Precursor: B-cell
 Ann Arbor Staging
 Mass, palpable
lymphadenopathy, fever
 B symptoms
 Most common type is diffuse
large B cell
 Treatment is nonsurgical
 R-CHOP (Rituximab,
cyclophosphamide, doxorubicin,
vincristine, prednisone)
HODGKINS LYMPHOMA
 Precursor: T-cell
 Ann Arbor Staging
 Mass, palpable lymphadenopathy, fever
 B symptoms
 Pel-Ebstein fever: days to weeks of fever
followed by asymptomatic afebrile
periods
 Reed-Sternberg cells: large abnormal
lymphocytes with mutilobular or more
than one nucleus
 Treatment is nonsurgical
 ABVD (Doxorubicin, bleomycin,
vinblastine, dacarbazine)

43. Ann Arbor Staging

44. Other common cancer associations
LIVER CANCER
 Aflatoxin (molds)
 Hepatitis B and C
NASOPHARYNGEAL CANCER
 EBV
 Smoking
 Alcohol

45. Other common cancer associations
Diet and Obesity

46. 6 CANCERS THAT CAN BE
IDENTIFIED WITH SCREENING
1. Breast Cancer
2. Cervical Cancer
3. Colorectal Cancer
4. Lung Cancer
5. Prostate Cancer
6. Skin Cancer

47. BREAST CANCER SCREENING
 Self-examination for women
≥ 20 years old
 Annual breast examination
by a doctor starting 20 years
old
 Annual mammography for
women ≥ 40 years old

49. CERVICAL CANCER SCREENING
 PAP SMEAR
 ALL women once
sexually active yearly
 If not sexually active,
starting age 21 then
repeat every 3 years

50. COLON AND RECTAL CANCER
SCREENING
 COLONOSCOPY
 Starting age 45 years old
 If with family history:
 Age when relative was diagnosed
minus 10
 Example:
Relative diagnosed at 40 yrs old
40 yrs old – 10 = 30 yrs old to
start screening

51. LUNG CANCER SCREENING
 Low-dose CT scan
 Men and women 55-74
years old
 Smoking for 30 years or
more

52. PROSTATE CANCER SCREENING
 Men starting age 50 yrs
old
 Blood exam with
Prostate Specific
Antigen (PSA)
 Digital Rectal Exam
(DRE)

53. SKIN CANCER SCREENING
 Complete skin
examination by
an oncologist /
dermatologist
annually
 Self-examination
monthly

56. 0917-5581982 (SMS only)
marymanalo_md@yahoo.com
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