Transcript Morrison - Oncology Board Review

Oncology Board Review
JENNY MORRISON 
AM REPORT
6/10/2009
Overview
 Cancer statistics
 Malignancies
 Breast Cancer
 Ovarian Cancer
 Prostate Cancer
 Testicular Cancer
 GI Malignancies
 Lung Cancer
 Bladder Cancer
 Head and Neck Cancer
 Random topics we missed on in service exam…
Estimated New Cases
MALE
1. Prostate
2. Lung
1. Breast
3. Colorectal
3. Colorectal
4. Bladder
4. Uterine
5. Melanoma
5. NHL
6. NHL
6. Melanoma
7. Kidney
7. Thyroid
8. Leukemia
8. Kidney
9. Head and Neck
9. Ovary
10. Pancreatic
10. Pancreatic
FEMALE
2. Lung
Cancer Facts and Figures 2009 from American Cancer Society
Estimated Deaths
MALE
FEMALE
1. Lung
1. Lung
2. Prostate
2. Breast
3. Colorectal
3. Colorectal
4. Pancreas
4. Pancreas
5. Leukemia
5. Ovarian
6. Liver
6. NHL
7. Esophageal
7. Leukemia
8. Bladder
8. Uterine
9. NHL
9. Liver
10. Kidney
10. Brain
Cancer Facts and Figures 2009 from American Cancer Society
Breast Cancer
 Most frequently diagnosed cancer in women.
 Ranks 2nd of cancer deaths in women.
 RF: Age, sex, genetics (BRCA1 and 2), personal or
family hx of breast CA, hx of XRT to chest, long
menstrual hx (early menarche, late menopause),
nulliparity, hormone therapy, 1st child after age 30,
exogenous estrogen use
Breast Cancer
 USPSTF recommends screening w/ mammography +/-
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CBE every 1-2 years starting at age 40.
 Evidence is strongest for women aged 50-69.
Over age 70, continue screening if life expectancy is at least
10 years.
For women 20-39, screen with CBE Q3yrs.
For those at increased risk (ex. family hx), consider
screening earlier (ex. 5-10 years younger than youngest
affected family member), consider alternative modalities
such as MRI or u/s.
Testing for BRCA1 and 2 should only be performed in those
with strong family hx of premenopausal breast cancer.
Breast Cancer
 Tamoxifen (a SERM) may be used to decrease risk
in those considered at high risk.
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Tamoxifen may increase risk for thrombosis and uterine
cancer.
Raloxifene may also decrease risk.
 Aromatase inhibitors (anastrozole, letrozole,
exemestane) may reduce risk even further (under
investigation).

AI’s are associated with increased risk of osteoporosis (as
well as menopausal sx).
Breast Cancer
 Recent declines in breast cancer mortality
attributed to earlier detection and improved
treatments.
 Mammography detects ~80-90% of breast cancers in
women without symptoms.
 If at high risk, MRI may be more sensitive in
detecting tumors.
 Sentinel LN bx may be used in early stage breast
cancer to detect spread to regional LN may prevent
unnecessary axillary LND.
Breast Cancer
 Primary therapy is surgical. Survival rates similar b/t lumpectomy +
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XRT and mastectomy are similar.
Adjuvant chemo is appropriate for pts at high risk for distant
recurrence but who do not have detectable metastases.
Endocrine therapy (ovarian ablation- surgical or w/ meds) may be
beneficial in ER+, PR+ tumors. Tamoxifen is used as adjuvant therapy
for 5 years after surgical treatment of ER+ tumors. AI’s are another
choice to use in lieu of or after Tamoxifen therapy.
Trastuzumab may be used in HER2 overexpressing tumors.
DCIS should be treated- lumpectomy + XRT or mastectomy followed by
Tamoxifen.
5 year survival (all stages combined) is 89%.
Ovarian Cancer
 S/sx: Abdominal swelling/ascites, bloating, pelvic or
abdominal pain, early satiety, urinary urgency or
frequency, bowel obstruction.
 RF: Age (peaks in late 70’s), nulliparity, HRT with
estrogen alone, family hx of breast/ovarian cancer,
genetics (BRCA1 or 2, possibly HNPCC).
 Pregnancy, long-term OCP use and possibly BTL and
TAH decrease risk.
 Serum CA-125 and u/s can detect early stage disease,
but given low prevalence, routine screening is not
performed in the general population.
Ovarian Cancer
 Ovarian cancer likes to spread within the abdominal
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cavity ( ascites, bowel obstruction). It rarely
metastasizes to liver, bone, lung, or brain.
Ovarian cancer is staged surgically.
Treat with surgery, chemo (platinum or taxanebased), and occasionally with XRT.
Only 19% are detected at localized stage (5 yr 92%).
Overall, 5 year survival 45%.
Uterine/Endometrial Cancer
 S/sx: abnormal uterine bleeding or spotting, dysuria,
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dyspareunia, pelvic pain.
RF: estrogen (especially when taken without progestin),
obesity, tamoxifen use (slight increase in risk), early
menarche, late menopause, nulliparity, hx of PCOS,
infertility, Lynch syndrome (HNPCC).
HRT (estrogen + progesterone) does not appear to
increase risk.
Pregnancy and OCP use are protective.
Typically diagnosed early during evaluation for
postmenopausal bleeding ( endometrial bx).
Treat w/ surgery, XRT, hormones, +/- chemo.
5 year survival is 83%.
Prostate Cancer
 Most common cancer diagnosis in men.
 2nd leading cause of cancer deaths in men.
 Incidence higher among African American men. Death
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rates are twice as high in AAM than Caucasians.
RF: age (>65), ethnicity, family hx.
Finasteride decreases risk for prostate CA in men >55.
S/sx: Weak or interrupted urinary flow, inability to urinate
or difficulty starting or stopping stream, urinary frequency,
nocturia, hematuria, dysuria, bony pain in hips, spine, ribs.
Most pts w/ prostate CA are asx at presentation with only
an elevated PSA.
Prostate Cancer
 There is insufficient data to recommend for or against
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screening men of average risk with age <75. They
recommend against screening if age ≥75. (USPSTF)
PSA and DRE should be offered annually to men of average
risk starting at age 50. (ACS)
For high risk individuals (African American men or strong
family hx), screening should begin at age 45. (ACS)
Clinical stage, Gleason score, and serum (pretreatment)
PSA are used to guide treatment.
Given slow progression of most prostate CA, comorbidities
and life expectancy should be considered in treatment
plans.
Prostate Cancer
 If decision is made to screen, screen with PSA +/- DRE every 2-4 years.
 If prostate exam is abnormal (nodules, induration, asymmetry), you
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should refer them to Urology.
If PSA is elevated, you should either repeat PSA several weeks later (esp
if borderline- PSA 3-7) or refer for transrectal ultrasound-guided
prostate biopsy.
Transient elevations in PSA can occur due to ejaculation, perineal
trauma, or prostatitis.
 Therefore, before retesting, pt needs to avoid ejaculation and bike
riding for 48 hrs prior, and prostatitis should be treated with
antibiotics.
Though PSA up to 4.0 is “normal,” some recommend following or
further w/u of level >3.0.
Stop screening if <10 yr life expectancy or age >75.
Prostate Cancer
 Radical prostatectomy, external beam radiation,
brachytherapy, cryotherapy, hormonal therapy are used in
treatment. For less aggressive tumors, some employ
“watchful waiting.”
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Radical prostatectomy improves survival over watchful waiting.
Pts who receive definitive local therapy have 30-40% recurrence
within 5 years (as detected by rising PSA).
Prostate Cancer
 Advanced/metastatic disease is usually treated w/ bilateral
orchiectomy or GnRH agonists +/- antiandrogen therapy.
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Antiandrogen therapy is typically used at onset of therapy with LHRH
analogs to avoid “flare”- as testosterone levels initially rise with onset of
therapy before falling. With this testosterone increase, sx from tumor
burden may worsen.
Side effects of therapy: osteoporosis, hot flashes, impotence, loss of
libido, gynecomastia.
GnRH/LHRH agonists
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Gosrelin Zoladex
Leuprolide Lupron
Antiandrogens
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Bicalutamide Casodex
Flutamide Eulexin
Prostate Cancer
 Hormone-refractory disease is defined as progression
despite having a castrate level (<50 ng/dl) of testosterone.
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Most patients will progress on androgen deprivation therapy after a
median of 18-24 months. Thereafter, the median survival is about
one year.
 Chemotherapy may improve survival w/ metastatic
androgen-independent prostate cancer, though
traditionally, prostate CA has been view as relatively
chemo-resistant.
 5 year survival for prostate cancer overall is 99%.
Testicular Cancer
 Most common solid malignancy affecting males 15-35.
 Germ cell tumors account for 95% of testicular cancers
broken down into pure seminomas and
nonseminomatous germ cell tumors (NSGCTs).
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NSGCT’s include embryonal carcinoma, teratoma,
choriocarcinoma, yolk-sac carcinoma.
 S/sx: nodule or painless swelling of one testicle, dull
ache or heavy sensation in lower abdomen, perianal area,
or scrotum.
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Acute pain in only 10%.
Metastatic disease s/sx in 10% (neck mass, cough or dyspnea,
anorexia, N/V, back pain, bone pain, CNS sx, LE swelling).
Gynecomastia and hyperthyroidism are endocrine
manifestations from hCG production.
Testicular Cancer
 Evaluation starts with bimanual exam of scrotum.
 DDx of testicular mass: testicular torsion, epididymitis,
epididymoorchitis, hydrocele, varicocele, hernia, hematoma,
spermatocele, syphilitic gumma, cancer.
 Ultrasonography is indicated with suspected tumor or
abnormality found on exam. Other radiographic studies may
also be indicated (CT A/P, CXR).
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U/S good at distinguishing intrinsic from extrinsic lesions.
 Measurement of serum tumor markers (AFP, β-hCG, LDH).
 Beta-hCG and/or AFP are elevated in 80-85% of men with NSGCT’s.
 Serum beta-hCG is elevated in fever than 20% of seminomas.
 AFP is not elevated in pure seminomas.
 Useful for subsequent follow-up of disease status after primary trx.
Testicular Cancer
 Prior to the 1970’s, death from testicular cancer
accounted for 11% of all cancer deaths in men 25-34.
It has now become one of the most curable of solid
neoplasms due to treatment advances.
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5-year survival rate is 95.5%.
 Management/treatment radical inguinal
orchiectomy +/- retroperitoneal LN dissection
 Initial therapy is based on histology (seminoma vs
NSGCT) and disease stage (TNM +tumor markers).
 Consider semen cryopreservation for future fertility.
Testicular Cancer
 Compared to NSGCT’s, pure seminomas are more likely to be
localized at presentation.
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80% seminomas present with stage I disease, 15% stage II
Seminomas rarely spread via bloodstream. Therefore, mets to liver,
lung, bone, brain are more likely to be NSGCT.
 Seminomas are exquisitely sensitive to RT, while NSGCT’s are
more radioresistant.
 AFP or beta-hCG are elevated in 85% of NSGCT’s.
 Treatment options include excision +/- watchful waiting,
radiation, chemo (platinum-based regimens).
 Follow tumor markers (if initially elevated), imaging.
Colorectal Cancer
 Ranks 3rd in cancer diagnoses and deaths for both men and
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women.
Incidence rates are decreasing over past 2 decades- likely
due to increased screening w/ polyp removal.
RF: age (>50), genetics (FAP, HNPCC), personal or family
hx, chronic IBD, obesity, inactivity, smoking, EtOH, redmeat rich diet, poor fruit/veggie intake.
NSAIDs/ASA, hormones (estrogen, progestin) may
decrease risk.
S/sx: none, rectal bleeding or blood in stool, change in
bowel habits- constipation or diarrhea, change in stool
caliber, lower abdominal cramping, weight loss, fatigue.
Colorectal Cancer
 At age 50, those at average risk should begin screening.
 If 1st deg relative w/ colon CA before age 60, start screening
at age 40 or 10 years younger than age that relative had
cancer.
 If 2 relatives w/ cancer at any age, start screening at 40 or
10 years younger than the youngest family member with
colon CA.
Colorectal Cancer
 Treatment: Surgery (resection of tumor, adjacent mesentary, regional
LN’s), chemo (5’FU-based) +/- XRT.
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For rectal CA, often use preoperative XRT (+/- chemo) to shrink tumor burden- goal for
sphincter preservation, followed by adjuvant chemo/XRT.
New targeted therapies include Bevacizumab (blocks blood vessels growth feeding tumor)
and Cetuximab and Panitumumab (block hormone pathways promoting cancer cell growth).
 Colon CA typically spreads to liver, though rectal CA may bypass liver
and spread to lungs via paravertebral venous and lymphatic channels.
 Surveillance: CEA Q3mos for 2 yrs, colonoscopy Q3-5yrs. CEA is
elevated in 2/3 recurrences, though measurement has not been shown
to improve survival.
 5 year survival 64% (all stages).
Gastric Cancer
 Incidence increases with increasing age, peaks in 60’s. Disease is
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typically advanced or metastatic at time of dx.
Antrum and lower ½ of stomach are most common sites. Increased
incidence recently in proximal gastric adenoCA’s and distal GE junction
adenoCA’s.
RF: smoking, H. pylori, chronic gastritis, pernicious anemia, family hx,
genetics (FAP, Lynch syndr), Menetrier’s disease, intestinal metaplasia,
diet low in fruits/veggies and high in smoked, salted, or preserved
foods.
S/sx: weight loss, abdominal pain, nausea, anorexia, dysphagia,
anemia, +hemoccult, abnl LFT’s.
Treatment is surgical, +/- adjuvant chemo/XRT.
Pancreatic Cancer
 Ranks 4th in cancer deaths (both men and women).
 RF: increasing age, smoking, family hx, and possibly
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obesity, chronic pancreatitis, diabetes, cirrhosis.
95% of tumors arise in the exocrine pancreas, 50% in the
head of the pancreas.
CA 19-9 is frequently elevated.
Typically develops without early sx, therefore, only ~7%
are diagnosed at an early stage.
S/sx: weight loss, abdominal pain, lumbar back pain,
anorexia, nausea, occasionally glucose intolerance,
jaundice, VTE.
Pancreatic Cancer
 Surgery, XRT/chemo are treatment options- used to
extend survival or palliate but rarely lead to cure
(unless disease is localized).
 Gemcitabine is often used for pts with metastatic
disease and good performance status.
 Overall 5 year survival 5%.
 Poor prognosis even for those with localized disease5 year survival 20%.
Lung Cancer
 Leads cancer deaths in men and women.
 14% lung cancers are small cell.
 S/sx: New/worsening cough, hemoptysis, chest pain,
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voice change, recurrent PNA or bronchitis, pleuritic CP.
Apical tumors may lead to Pancoast syndrome- shoulder
pain, lower brachial plexopathy, Horner’s syndrome.
RF: Smoking, occupational or environmental exposures
(smoke, asbestos, radiation), hx of TB
Efforts at early detection have not been shown to reduce
mortality.
There is an ongoing trial to assess whether screening
high risk individuals with CXR or CT may prevent lung
cancer deaths.
Lung Cancer
 PET scans routinely used in staging.
 NSCLC metastatic disease often precludes resection.
 Treatments include surgery, XRT, chemo, and targeted
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biologics (Bevacizumab, Erlotinib, Geftinib).
Studies have shown that survival with early stage NSCLC is
improved w/ chemo after surgery.
Small cell is presumed to be disseminated. Cure is rare.
Chemo +/- XRT is treatment of choice for small cell.
5 year survival rate is 15% for all stages combined (49% for
localized disease).
Lung Cancer
 Regarding management of hemoptysis in lung
cancer pt…
 Bronchogenic carcinoma is an infrequent cause of massive
bleeding but commonly causes nonmassive hemoptysis.
 Hemoptysis is common in pts with bronchial carcinoid
tumors.
 Only 3% of lung cancer pt had massive, terminal
hemoptysis and these pts typically had large, centrallylocated tumors, esp squamous cell carcinoma.
Lung Cancer
 Acute mgmt- airway protection, oxygenation, ventilation,
cardiovascular function. Reverse coagulation disorders.
C/s pulm, thoracic surgery, +/- VIR. Once stable, 
bronchoscopy.
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Place bleeding lung in dependent position.
May need to selectively intubate contralateral bronchus.
Bronchoscopy balloon tamponade, topical epi, vasopressin, or
thrombin, laser therapy or electrocautery.
VIR arterial embolization
Surgical contraindications include severe underlying pulmonary
disease, active TB, diffuse underlying lung disease (CF, multiple
AVM’s, multifocal bronchiectasis), diffuse alveolar hemorrhage
Bladder Cancer
 Incidence is ~4 times higher in men than in women
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and almost 2 times higher in Caucasians than AA.
S/sx: hematuria, increased urinary frequency.
RF: Smoking, exposure to dye, rubber, and leather
industries, arsenic exposure.
Dx by cystoscopy, examination of bladder washings.
Treatment is primarily surgical (+/- neoadjuvant
chemo, XRT), though intravesicular immunotherapy
or chemo may be used.
5 year survival is 80%.
Head and Neck Cancer
 Incidence is twice as high in men than in women.
 S/sx: Sore that bleeds easily and does not heal, lump
or thickening, ear pain, neck mass, hemoptysis, red
or white patch that persists. Later sx include trouble
chewing or swallowing, difficult/decreased mobility
of jaw or tongue.
 RF: Tobacco (smoked or chewed), EtOH.
 XRT and surgery, +/- chemo. Targeted therapy with
Cetuximab may be combined with XRT in initial
treatment or used alone in recurrences.
 5 year survival 59%.
Screening for 2◦ Cancers after HL Treatment
 After treatment of Hodgkin Lymphoma, there is an
increased risk of developing leukemia, NHL, or solid
tumors (lung, breast, bone, stomach, colon, thyroid,
melanoma).
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Risk for leukemia (typically AML) is related to use of alkylating
chemo agents whereas XRT (+/- chemo) is more-associated
with solid tumor development.
~1/2 to 2/3 of 2nd malignancies are solid tumors that arise
after ≥15 years of follow up.
Screening for 2◦ Cancers after HL Treatment
 Lung and breast cancers are most common solid 2nd
malignancies.
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Recommend annual chest imaging for those at increased risk
of lung CA (had chest XRT, treated with alkylating agent,
+smoker).
Annual mammogram or breast MRI- initiate 8-10 yrs post
therapy or age 40, whichever comes first if pt had chest or
axillary XRT. ACS recommends breast MRI + mammogram
for women who received XRT to chest b/t ages 10-30.
Paraneoplastic Erythrocytosis
 Which of the following tumors is associated
erythrocytosis?
Hepatocellular Carcinoma
 Renal Cell Carcinoma
 Hemangioblastoma
 Pheochromocytoma
 Uterine myomata
 All of the above
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Paraneoplastic Erythrocytosis
 Which of the following tumors is associated erythrocytosis?
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Hepatocellular Carcinoma
Renal Cell Carcinoma
Hemangioblastoma
Pheochromocytoma
Uterine myomata
All of the above
 Caused by overproduction of Epo.
 This is in contrast to polycythemia vera, which is characterized
by a low serum Epo level. (PV is due to an essential increase
in erythrocyte production by the bone marrow.)
References
 Collichio, F., et al. A Manual for Medical Residents and Trainees in Medical
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Oncology . 2003.
Fletcher, S. W. and J. G. Elmore. Mammographic Screening for Breast Cancer.
2003. NEJM. 348: 1672-80.
MKSAP 14: Hematology and Oncology. 2006. 56-85.
www.uptodate.com
www.cancer.org
 Cancer Facts & Figures 2009. (American Cancer Society)
www.cancer.gov
www.nccn.org
www.ahrq.gov (USPSTF)