1. Oncology
Archer Online Step III Rapid
Review
www.ccsworkshop.com
All rights reserved

2. Screening
Various Scenarios!

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. Case Study

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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. 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. Colorectal Cancer
Risk Factors for Colorectal Cancer
 Age >50 years (accounts for 90% of Colon Cancer)
 Past Medical History

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Family History

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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. 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. 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. 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. 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. 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. 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. 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. Colorectal Cancer Screening High Risk
If Familial adenomatous polyposis Hx:
 Early surveillance


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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. 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. 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. 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. 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. 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. 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. 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



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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. 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. Case Study
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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. Breast CA
Screening & Treatment

25. Breast Lump
Evaluation

26. Etiologies of Discrete Breast Lumps



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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%
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Types of Breast
Masses
Breast Cyst
Fibroadenoma
Fibrocystic Breast
Breast Cancer

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


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Not used to evaluate palpable mass
Used to evaluate for other concurrent lesions
Delay Mammogram 2 weeks after aspiration
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Aspiration may cause hematoma
Wait time avoids false positives
Breast aspiration, fine needle aspirate or core biopsy
Excisional breast biopsy

28. Evaluating Breast Lump
Management: Protocol 1 based on starting
with ultrasound
 Start with breast ultrasound
 Ultrasound shows simple cyst


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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. Breast cyst aspiration
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Interpretation
No fluid (failed aspiration)

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Bloody Fluid Aspirate

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

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


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Drain cyst completely
Discard aspirate fluid
Reexamine after draining cyst

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Refer to surgery if mass still present
Repeat Breast Exam in 4-6 weeks

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


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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




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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. 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. Risk Factors – Ca Breast

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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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Treatment Stage IIIB/IV

Total mastectomy + RT to chestwall +
adjuvant chemo + hormonal therapy
where indicated

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. 

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. 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. 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. Prostate Ca
Controversies

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. 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. 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. 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. 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. 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. 





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. 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. 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. 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. 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. 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. 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. Leukemias






Consider age first
ALL - children
AML – only promyelocytic important,
retinoic acid
CML – ph+ , lap, imatinib
CLL – Elderly
D/W tumor lysis syndrome

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. 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. 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. 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. 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
