Transcript ONCOLOGY BOARD REVIEW

Calvin Thigpen, M.D.
July 18, 2014
Study 5 things in oncology, they
should be:
Breast Cancer
2. Lung Cancer
3. Colon Cancer
4. Prostate Cancer
5. Complications (of these diseases and
their therapy)
1.
Pay close attention to:
1.
2.
3.
4.
Interventions that lead to a cure
Emergent situations
Inherited conditions
Atypical approaches to cancer care
These are the kinds of things practicing
general internists need to know.
It will DEFINITELY
be on the exam.



Risk factors
Locoregional disease therapy
Hormone/endocrine therapy



Indications
Side effects
Recurrent disease
Exactly when to start, or how
often to get, mammograms
 Specific combinations of
chemotherapy








Age and family history
Menopausal status
Exposure to estrogen
Hormone receptor status
Previous cancer therapy
Site of metastasis
Drugs
A nulliparous 29-year-old Ashkenazi Jewish woman has a palpable left breast mass
present for 6 months. Her mother was adopted; her father is 72 years old and has a
history of prostate cancer. Her paternal aunt was diagnosed with ovarian cancer at age
48 years. Another paternal aunt was diagnosed with breast cancer at age 49 years. Her
paternal grandmother died of complications from breast cancer at age 60 years.
On exam, there is a 4-cm mass in the left breast affixed to the chest wall and a 1-cm,
freely movable left axillary lymph node. Biopsy reveals moderately differentiated ER+,
PR+, H2N- invasive ductal carcinoma. CT and bone scan show no metastatic disease.
She will receive preoperative chemotherapy followed by surgery.
Which of the following will be most helpful in determining the best surgical
approach?
A. Counseling and genetic testing
B. Genomic profile assay
C. PET scan
D. Tumor marker testing
For women who have breast cancer
and are at high risk for BRCA1 or
BRCA2 mutations, genetic testing and
counseling may inform surgical
options.




2 1st degree relatives
with breast cancer (one
at <50 years of age)
3 or more 1st or 2nd
degree relatives with
breast cancer
regardless of age;
Both breast and
ovarian cancer among
1st and 2nd degree
relatives;
1st degree relative with
bilateral breast cancer;



2 or more 1st or 2nd
degree relatives with
ovarian cancer
regardless of age;
1st or 2nd degree
relative with both
breast and ovarian
cancer at any age; or
Breast cancer in a male
relative.


The history suggests genetic cancer
Test results either:
Establish the diagnosis
 Influence the management of family
members at risk


Test those already with cancer if at
all possible
A 65-year-old woman is evaluated for a 2-cm right breast mass
discovered on routine mammography.
Vital signs and physical exam are unremarkable, and there is no
palpable breast mass or lymphadenopathy.
Ultrasound-guided needle biopsy reveals a well-differentiated, ER+,
PR+, H2N- invasive ductal carcinoma.
Which of the following is the most appropriate next step in
management?
A. Right breast lumpectomy
B. Right breast lumpectomy, sentinel lymph node biopsy, and radiation
C. Right breast mastectomy
D. Right breast mastectomy, sentinel lymph node biopsy, and radiation
Breast conservation therapy, which
consists of excision of the primary
tumor and radiation therapy, is
equivalent to mastectomy in long-term
survival.



All breast cancer patients need surgery
at some point.
Breast-conserving therapy is equivalent
to mastectomy.
Sentinel lymph node biopsy:



For clinically lymph node negative disease
Fewer side effects (far less lymphedema)
Adjuvant radiation reduces local
recurrence.

ER+/PR+

Premenopausal
 Tamoxifen for 5 years
 If tumor large, chemotherapy + Tamoxifen

Postmenopausal
 Aromatase inhibitor (anastrazole, letrozole,
exemestane) for 5 years
 +/- Tamoxifen for 5 years prior to AI
 If tumor large, chemotherapy + AI

H2N+

One year of Trastuzumab
Premenopausal
Primary prevention
Postmenopausal
Tamoxifen
Tamoxifen, OR
Raloxifene, OR
Aromatase Inhibitor
Small tumor (≤ 1
cm)
Tamoxifen x 5 yrs
Tamoxifen x 5 yrs followed
by AI x 5 yrs, OR
AI x 5 yrs
Big tumor and/or
+LN
Tamoxifen x 5 yrs, PLUS
chemotherapy
Tamoxifen x 5 yrs followed
by AI x 5 yrs, OR AI x 5
yrs
(both + chemotherapy)
Tamoxifen +/chemotherapy
AI +/- chemotherapy
Tamoxifen +
chemotherapy
AI + chemotherapy
Adjuvant therapy
Metastatic therapy
Non-visceral
disease
Visceral disease
For those with the two most
important prognostic factors:
 Positive
lymph nodes
 Larger tumors (>1 cm)

Endocrine therapy + chemotherapy

Endocrine therapy
 Premenopausal – Tamoxifen
 Postmenopausal – Aromatase inhibitor

Chemotherapy
 Sequential single agents equivalent to combination
 Anthracyclines, Taxanes, Methotrexate, Cytoxan, 5-FU

H2N
 Trastuzumab
 In combination with chemotherapy or not

Zoledronic acid or denosumab for bony disease
A 45-year-old woman undergoes evaluation after a recent
diagnosis of stage II ER+, PR+, H2N- breast cancer. She is
premenopausal. She was treated with modified radical
mastectomy and just completed adjuvant chemotherapy. She
had a DVT associated with oral contraceptive pill use 20 years
ago. She is a nonsmoker and is very physically active.
Physical exam and labs are unremarkable.
Which of the following is the most appropriate next step in
management?
A. Adjuvant aromatase inhibitor therapy
B. Adjuvant trastuzumab therapy
C. Baseline imaging with whole-body CT scan or PET scan
D. Ovarian ablation
Tamoxifen can increase the risk for
thromboembolic complications.
A 60-year-old woman is evaluated for 6 weeks of worsening left hip and right
arm pain. She had stage III ER+, PR+, HER2- breast cancer diagnosed 5
years ago and treated with modified radical mastectomy, chemotherapy, and
radiation. She declined adjuvant hormonal therapy.
Physical exam reveals tenderness over the left sacroiliac joint and the right
humerus.
Bone scan shows uptake in the bilateral femurs, lumbar spine, and right
humerus consistent with metastases. CT shows no abnormalities in the lungs
or liver, but bony lesions are evident and are consistent with the bone scan
findings. No pathologic fractures are present.
Which of the following is the most appropriate intervention?
A. Aromatase inhibitor
B. Bone biopsy
C. Chemotherapy
D. Radiation therapy
E. Trastuzumab therapy
A lesion due to a first recurrence of
breast cancer should be biopsied to
confirm malignancy and hormone
receptor and HER2 status, which then
guides treatment.

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

Originally, the only FDA approved drug for
primary breast cancer prevention (5 years)
Used in adjuvant treatment for ER+ tumors
to reduce the risk of recurrence (5 years)
Used in treatment of ER+ metastatic breast
cancer
Side effects:



Thromboembolism
Endometrial cancer
Serotonin syndrome (when given with SSRIs)




Anastrazole, letrozole, exemestane
Adjuvant therapy for postmenopausal
women with ER+ tumors to prevent
recurrence
Therapy for postmenopausal women with
metastatic ER+ tumors
Side effects:



Hot flashes
Arthralgias
Osteoporosis
Doxorubicin, epirubicin,
daunorubicin
 Reduce dose for hepatic
dysfunction
 Cardiac toxicity

Determined by cumulative dose of drug
 Cardiomyopathy largely irreversible,
difficult to treat



For women with Her-2-neu + tumors
To be given for 52 weeks as adjuvant therapy
Reduces recurrence by 50%
 Reduces mortality by up to 30%



Given in metastatic disease
MAJOR side effect – can induce heart failure
Especially when given with an anthracycline (so
don’t do it)
 Monitor LV EF before, during, and after treatment

A 45-year-old woman is evaluated for severe hot flushes that significantly limit
her quality of life as well as vaginal dryness that is controlled with local
lubricants. She had stage II ER+, PR+, HER2- invasive breast cancer
diagnosed 1 year ago and treated with lumpectomy, chemotherapy, and
radiation therapy. She has not had a menstrual cycle since her 4th cycle of
chemotherapy. She began taking tamoxifen 3 months ago after completing
radiation therapy. Nonpharmacologic interventions for hot flushes have
brought no improvement.
Physical exam is normal other than evidence of surgery on the left breast and
radiation changes on her skin.
Which of the following is the most appropriate therapy for this patient?
A. Fluoxetine
B. Low-dose estrogen-progesterone
C. Red clover
D. Venlafaxine
Selective serotonin reuptake inhibitors
that are potent CYP2D6 inhibitors
(such as fluoxetine and paroxetine)
should be avoided in patients with
menopausal symptoms caused by
tamoxifen.
A 65-year-old woman is evaluated during a routine examination. She
is asymptomatic. She had stage I ER-, PR-, HER2- breast cancer
diagnosed 3 years ago treated with modified radical mastectomy
followed by chemotherapy with docetaxel and cyclophosphamide.
On physical exam, the left chest wall is well healed with no nodularity.
No right breast masses, axillary lymphadenopathy, or supraclavicular
lymphadenopathy are present.
The patient will undergo periodic mammography and routine health
maintenance.
Which of the following would be the most appropriate additional
evaluation in this patient?
A. Bone scan yearly
B. CT scan yearly
C. PET scan yearly
D. Tumor marker measurement, complete blood count, and
comprehensive metabolic panel yearly
E. No additional studies
The use of screening blood tests
(including tumor markers) and imaging
is not recommended for routine breast
cancer follow-up in an otherwise
asymptomatic patient with no specific
findings on clinical examination.
The most common
and the biggest
killer


Knowing when to search for it – smoker
with symptoms
Non-small cell
Early stage therapy – surgery or radiation
 Metastatic therapy – platinum-based
chemotherapy
 Isolated recurrent therapy – resection, then
chemotherapy


Small cell
Limited stage therapy – concurrent
chemoradiation, then prophylactic brain
irradiation
 Extended stage therapy – platinum-based
chemotherapy




Specifics of staging in non small cell
Use of gamma knife radiation in
brain metastases
Specific combinations of
chemotherapy

Non small cell

Early stage – I or II
 Tumor confined to one lobe
 No mediastinal nodes

Advanced stage – III
 Another nodule in the same lung
 Mediastinal nodes

Metastatic disease
 Nodule in opposite lung
 Pleural effusion
 Disease in other organs

Small cell

Limited stage
 Disease confined to one hemithorax or radiation
port
 Includes mediastinal and ipsilateral supraclavicular
nodes

Extensive stage
 Any spread outside of the above
 1/3 of the time, this is in the brain

Non-small cell
Slower growing
 Not very chemo- or radiosensitive
 Resect disease confined to one lobe and
nodes on one side


Small cell
Faster growing
 Very chemo- and radiosensitive
 Surgery only accidentally


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



Hypercalcemia – PTHrP – squamous cell
Hyponatremia – ectopic ADH – small cell
Cushing’s syndrome – from ectopic
ACTH – small cell
Hypertrophic pulmonary osteoarthropathy
Lambert-Eaton Syndrome
Cerebellar degeneration
More serious than the common cold
A 56-year-old woman is evaluated for a persistent cough of 2.5
months' duration. She also notes a 10-lb weight loss. The patient has
no history of pulmonary disease and has never smoked cigarettes.
Physical exam is unremarkable.
Right hilar and subcarinal lymphadenopathy, as well as several
hepatic hypodensities consistent with metastatic disease, are
identified on CT of the chest and abdomen. MRI brain is normal. Bone
scan notes uptake in several ribs. Lung biopsy demonstrates
adenocarcinoma.
Which of the following is the most appropriate next step in the
evaluation of this patient?
A. CT-guided biopsy of the liver
B. Epidermal growth factor receptor mutation tumor analysis
C. Mediastinoscopy with biopsy
D. Serum chromogranin measurement
Patients with epidermal growth factor
receptor (EGFR) gene tumor mutations—
most commonly women with
adenocarcinoma who are never smokers or
have a very limited smoking history and
women of East Asian descent—often
benefit dramatically from therapy targeting
this receptor.

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Patients with no evidence of nodal disease,
or with nodal disease only in the ipsilateral
lung (and hilum) on PET, PET/CT, or
medastinoscopy
Patients with a single lesion recurrence in
the liver or brain
Patients with cord compression
Patients with a good performance status
Remember this is in nonsmall cell only!
Anyone with positive
lymph nodes or
metastatic disease

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

Any patient who was a candidate for
surgery, but for their functional status
Patients with localized pain from
their tumor
Patients with brain metastases
Patients with cord compression
where surgery was not performed
A 52-year-old man is evaluated for a 5-week history of hemoptysis, a 6-month
history of cough, and a 10-lb weight loss. He has a 60-pack-year smoking
history.
On physical exam, he has expiratory wheezing localized to the left upper
pulmonary lobe.
CT of the thorax and abdomen reveals a 7-cm pulmonary mass in the left
upper lobe and small mediastinal lymph node enlargement. Biopsy of the lung
lesion shows squamous cell carcinoma. A PET/CT shows extensive uptake in
the mass but a low level of uptake in the mediastinal nodes. An MRI brain is
normal. Mediastinoscopy and lymph node sampling reveal no evidence of
cancer. Stage II disease is confirmed.
Which of the following is the most appropriate treatment of this patient?
A. Combination radiation and chemotherapy
B. Surgical resection
C. Surgical resection followed by chemotherapy
D. Systemic chemotherapy
Stage II non-small cell lung cancer is
potentially curable with surgical
resection and adjuvant postoperative
chemotherapy to reduce the
recurrence risk.
A 54-year-old woman is evaluated for shortness of breath of 3 months'
duration and a 10-lb weight loss. She has a 35-pack-year smoking history.
On physical exam, O2 sat is 92% on room air. The patient has clubbing of the
fingertips. The lung fields are clear on the left, with diminished breath sounds
and dullness to percussion over the lower half of the right lung.
CXR reveals a large right pleural effusion. A thoracentesis demonstrates an
exudate, with cytologic analysis indicating adenocarcinoma. A chest tube is
placed, and talc pleurodesis is performed. A CT scan reveals a 4-cm right
peripheral lung mass with no obvious lymphadenopathy. A bone scan and
brain MRI are normal.
Which of the following is the most appropriate treatment?
A. Combination chemotherapy and radiation
B. Radiation
C. Surgical resection of the lung mass
D. Systemic chemotherapy
Patients with non-small cell lung
cancer and a malignant pleural
effusion have, by definition, metastatic
disease, and the most appropriate
therapy is palliative systemic
chemotherapy.
Not a small deal
A 65-year-old man is evaluated for a 3-week history of hemoptysis
and a recent 10-lb weight loss. He has a 90-pack-year smoking
history.
On physical exam, vital signs are normal. The pulmonary exam
reveals occasional crackles at the posterior right midlung field.
CT of the chest shows a 5-cm right hilar mass with bulky mediastinal
lymphadenopathy. Bronchoscopy reveals small cell lung cancer. MRI
brain and bone scan are negative.
The patient receives 6 cycles of cisplatin and etoposide chemotherapy
with radiation to the lung mass and regional disease concurrent with
the first cycle of chemotherapy. A follow-up CT chest shows a residual
1.5-cm right hilar abnormality.
Which of the following is the most appropriate next step in this
patient's management?
A. Biopsy of the residual mass
B. Three additional cycles of chemotherapy
C. Whole-brain radiation
D. Observation
Patients with limited-stage small cell
lung cancer who respond to
chemotherapy and radiation should
receive prophylactic brain irradiation to
decrease central nervous system
relapses and prolong median survival.
In small cell, they all
do!
In small cell, no one
does! (at least for
the board exam)




Patients with limited stage disease – to the
chest
Patients with limited stage disease and
good response to chest therapy – to the
brain prophylactically
Patients with extensive stage disease (and
no brain mets) who respond to therapy
Patients with brain mets
Remember that we’re talking
about small cell here!
A 63-year-old man is evaluated for fatigue and a persistent cough of 7
weeks' duration. He has a 60-pack-year smoking history.
Physical exam is unremarkable.
CT of the thorax shows a right perihilar mass and enlarged hilar and
mediastinal lymph nodes.
An endobronchial mass is identified by bronchoscopy; brushings and
biopsy reveal small cell lung cancer. CT of the abdomen and pelvis is
negative. A bone scan and MRI brain are negative.
Which of the following is the most appropriate next step in the
management of this patient?
A. Chemotherapy with adjunctive radiation therapy
B. Mediastinoscopy
C. Radiation therapy
D. Resection for cure
Patients with limited-stage small cell
lung cancer are treated with
combination chemotherapy and
radiation therapy.
th
4
The
most common
nd
malignancy, the 2
leading cause of
death


Screening measures
Colon cancer





Treatment for node negative disease – surgery
Treatment for node positive disease – surgery,
then adjuvant chemotherapy
Treatment for metastatic disease – surgery, then
chemotherapy (with bevacizumab)
Treatment for isolated recurrence in the liver –
resection
Treatment for localized rectal cancer –
surgery, then adjuvant chemoradiation
All patients with
colorectal cancer
need surgery! All of
them!




Hair-splitting questions about high-risk
Stage II disease
The use of monoclonal antibodies other
than bevacizumab
Chemotherapy combinations for
metastatic rectal cancer
2nd line chemotherapy

FAP – Familial Adenomatous Polyposis


Mutation in the APC gene
HNPCC – Hereditary Non-Polyposis Colorectal
Cancer
Mutation in the MSH2, PMS1, or PMS2 genes
 At risk for ovarian and endometrial cancer


Or any of the following
Personal history of adenomatous, villous, or tubulovillous
polyps
 Family history of the same
 Inflammatory bowel disease
 Diabetes, obesity, tobacco, alcohol



Average risk – age 50
1st degree relative affected (by cancer or
with adenomatous polyp)
Age 40, OR
 10 years younger than the family member
was diagnosed





Guaiac FOBT – annual
Fecal Immunochemical Testing (FIT) –
annual
Sigmoidoscopy – every 5 years (with
FOBT every 3 years)
Colonoscopy – every 10 years (or every
3-5 for those with relatives diagnosed at
<60)

Colon cancer





Perioperative colonoscopy
Colonoscopy at 1 year, repeat in 3 years, then repeat
in 5 years (assuming all were normal)
CEA every 3 months for 2 years, every 6 months for
3 more years
CT Chest/Abdomen/Pelvis annually for 3 years
Rectal cancer


Same as above, PLUS
Proctosigmoidoscopy every 3 to 6 months for 3
years

Colon
Above the peritoneal reflection
 Tends to metastasize to the liver first
 NO ROLE WHATSOEVER FOR RADIATION


Rectal
Below the peritoneal reflection
 Can spread to the lungs before the liver
 Radiation used to reduce local recurrence


Colon
Oxaliplatin based (often with 5-FU)
 With bevacizumab for metastatic disease


Rectal
5-FU based for localized disease
 Metastatic depends on squamous vs.
adenocarcinoma (highly unlikely to be tested)

A 51-year-old man is evaluated for 6 months of increased fatigue and decreased
exercise tolerance. He is otherwise well with no significant medical history.
Physical exam is unremarkable. FOBT discloses brown, guaiac-positive stool.
Labs: Hgb 8.4; MCV 80.
Colonoscopy reveals a 5-cm mass in the cecum. Biopsy shows moderately
differentiated adenocarcinoma. CT of the chest, abdomen, and pelvis
demonstrates the cecal mass and no evidence of metastatic disease. Final
pathology from right hemicolectomy reveals a tumor penetrating into the
pericolonic fat with clear margins, and 3 of 28 lymph nodes have cancer
(T3N1M0; stage III).
Which of the following is the most appropriate management?
A. 5-Fluorouracil and leucovorin
B. 5-Fluorouracil, leucovorin, and oxaliplatin (FOLFOX)
C. Radiation therapy
D. Radiation therapy plus 5-fluorouracil followed by FOLFOX
An adjuvant chemotherapy regimen of
5-fluorouracil, leucovorin, and
oxaliplatin (FOLFOX) has been shown
to improve disease-free survival in
patients with stage III colon cancer.
A 68-year-old woman underwent right hemicolectomy 2 years ago for stage III
colon cancer. She received 6 months of chemotherapy with 5-fluorouracil,
leucovorin, and oxaliplatin (FOLFOX) after surgery. On a recent follow-up visit,
CEA was 43 ng/mL (upper limit of normal, 5 ng/mL). She has no comorbidities
and takes no medications. She works full time and is fully functional.
Physical exam reveals a palpable liver edge just below the right costal margin.
Labs: Hgb 13.5, WBC 9000, platelets 288,000.
CT of the chest, abdomen, and pelvis shows 3 hypodense lesions on the right
lobe of the liver ranging from 1.5 to 4.0 cm.
Which of the following is the most appropriate management?
A. CT-guided fine-needle aspiration of liver lesion
B. Hepatic arterial embolization
C. Palliative systemic chemotherapy
D. Radiation therapy to the liver
E. Right hepatectomy
Surgical resection of a few isolated
metastatic lesions may be curative for
patients with colorectal cancer.
The most common
cancer in men




Making a decision on whether or not
to treat – risk categories
Treatment for disease confined to
prostate
Side effects of therapy
Cord compression



Screening recommendations
Differentiating between types of
radiation
Chemotherapy other than docetaxel
Risk
Tumor
Not
Low
palpable or
visible
Confined
Intermediate
to prostate
Extends
High
outside
prostate
Gleason
PSA
2-6
<10
7
10-20
8-10
>20
Risk
Low
Life
Expectancy
Treatment Options
<10 years
Observe
10-20 years
Observe, or XRT, or
prostatectomy
>20 years
XRT, or prostatectomy
<10 years
Intermediate
Observe, or XRT, or
prostatectomy
≥10 years
XRT, or prostatectomy
High
<5 years
Observe with hormone therapy
≥5 years
XRT with hormone therapy, or
XRT alone, or prostatectomy
An 80-year-old man undergoes an annual physical exam. He
has had mild stable nocturia for many years. He reports no
bone pain, weight loss, fever, chest pain, or shortness of
breath. Medical history is notable for HTN and type 2 DM for
which he takes antihypertensive and diabetic medications.
Rectal exam reveals an enlarged prostate gland with a nodule
on the right side.
PSA 6.4 ng/mL.
Prostate biopsy reveals several small foci of adenocarcinoma in
2 of 12 cores on the right side, with a Gleason score of 6.
Which of the following is the most appropriate
management?
A. Androgen deprivation therapy
B. Radiation with androgen deprivation therapy
C. Radical prostatectomy
D. Observation
Patients with low-risk prostate cancer
and a short life expectancy are
optimally managed with observation.
A 73-year-old man is evaluated for a 6-month history of progressive
nocturia.
Rectal exam reveals a hard, irregular, and markedly enlarged prostate
gland.
PSA is 22.5 ng/mL. Bone scan is negative. CT scan reveals a
markedly enlarged prostate gland and extension into the seminal
vesicles. No lymphadenopathy or evidence of metastatic disease is
present. Prostate biopsy reveals adenocarcinoma in all 12 cores with
a Gleason score of 8. He has high-risk T3 stage III prostate cancer.
Which of the following is the most appropriate treatment?
A. Androgen deprivation therapy (ADT)
B. ADT and radiation therapy
C. Brachytherapy
D. Radiation therapy
E. Radical prostatectomy
Patients with high-risk prostate cancer
are optimally managed with a
combination of androgen deprivation
therapy and radiation.



Surgery and radiation equally effective for early
stages
Check PSA q6-12 months x 5 years after
primary treatment
Goal with recurrence: achieve castrate levels of
testosterone



Orchiectomy or androgen deprivation therapy (ADT)
Surgical and hormonal (ADT) castration equivalent
Docetaxel based chemotherapy for those who
are hormone refractory

Potential side effects:










Impotence
Hot flashes
Weight gain
Fatigue
Gynecomastia
Osteopenia
Diarrhea
Hepatotoxicity
Diabetes
Cardiovascular disease
Observation
doesn’t
sound so
bad

Radiation side effects:
Proctitis
 Cystitis
 Erectile dysfunction


Prostatectomy side effects:
Erectile dysfunction
 Urinary incontinence

A 55-year-old man is evaluated in the ER for gradually increasing
midback pain for 3 weeks. Metastatic prostate cancer was diagnosed
18 months ago and progressed on antiandrogen therapy. He is now
taking bicalutamide, zoledronic acid, docetaxel, and prednisone.
On physical exam, the lower extremities are diffusely weak. He has
diminished pinprick sensation from the nipples downward. Reflexes are
2+ in the biceps and triceps and 3+ in the knees and ankles. An
extensor plantar response is present bilaterally. Anal sphincter tone is
diminished.
IV dexamethasone is administered.
MRI confirms spinal cord compression at the 4th thoracic vertebra.
Which of the following is the most appropriate next step in
treatment?
A. Addition of leuprolide
B. Anterior surgical decompression
C. Radiation therapy
D. Substitution of paclitaxel for docetaxel
Clinical outcomes in solid tumors are
better with surgical decompression of
spinal cord compression than they are
with radiation or chemotherapy.




Breast, Lung, Prostate (blastic only),
Renal, Lymphoma, and Myeloma (lytic
only)
MRI of the entire spine
IV Decadron to reduce vasogenic edema,
relieve pain
Neurosurgical consultation for surgical
decompression and spine stabilization
A 63-year-old woman presents with abrupt onset left upper-extremity weakness
and no other symptoms. Until today, she has been active and fully functional.
She had stage IIB non-small cell lung cancer diagnosed 1 year ago and
underwent right upper lobectomy followed by adjuvant cisplatin and vinorelbine
chemotherapy. Mediastinoscopy at the time was negative, and PET showed no
metastatic disease.
Neurologic exam shows weakness of the left arm with hyperreflexia of the
brachioradialis reflex.
MRI brain demonstrates a right parietal lesion measuring 1.5 cm, with evidence
of significant edema. She has no evidence of extracranial disease.
Dexamethasone is initiated.
Which of the following is the most appropriate next step in management?
A. Best supportive care
B. Initiation of erlotinib
C. Initiation of temozolomide followed by radiation therapy
D. Surgical resection of metastasis
Resect isolated brain (or liver)
metastases when there is no other
evidence of cancer.
Brain mets are life-limiting; they
must always be addressed
immediately when found.
Decadron immediately
 Surgery
 Radiation
 Chemotherapy

A 46-year-old woman is evaluated for the recent onset of headaches
that are most intense on waking in the morning and are not relieved
by analgesics. She has no nausea or vomiting but notes some
difficulty with fine motor skills when using her right hand. The patient
has a 2-year history of stage II breast cancer last treated with
chemotherapy 2 years ago.
Funduscopic exam reveals papilledema. She has reduced strength
(4/5+) in her right hand.
A CT of the head reveals 2 separate masses in the left temporal lobe
with associated edema, as well as blastic lesions involving the skull.
Which of the following is the most appropriate management?
A. Chemotherapy
B. Intravenous dexamethasone and radiation therapy
C. Lumbar puncture
D. Resection of the masses
Immediate corticosteroid
administration and early initiation of
radiation therapy are indicated to treat
brain metastasis and increased
intracranial pressure.
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The most significant risk factor for ovarian cancer,
especially in premenopausal women, is the presence of
BRCA1/BRCA2 gene mutations; hereditary
nonpolyposis colorectal cancer syndrome also confers
a significantly increased risk.
Use of oral contraceptive agents decreases the risk of
ovarian cancer by as much as 50% with the protective
effect lasting up to 20 years after oral contraception
cessation.
Screening for ovarian cancer is not recommended for
average-risk women.
In women at high risk for developing ovarian cancer,
prophylactic bilateral salpingo-oophorectomy before
age 40 years reduces the risk of developing cancer by
95%.
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Most patients with ovarian cancer have
advanced disease at initial evaluation.
Findings on ultrasonography suggestive of
ovarian cancer include a solid mass, a cyst
with thick septations, and ascites.
The diagnosis of advanced ovarian cancer is
usually made by CT or ultrasound-guided
biopsy of a suspicious mass or cytologic
examination of ascitic fluid.
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Optimal tumor debulking (no residual tumor
mass >1 cm) is associated with increased
survival in patients with ovarian cancer.
Surgical resection is appropriate for patients
with a recurrent solitary ovarian tumor or with
limited relapse of cancer at sites favorable for
surgical removal.
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Adjuvant chemotherapy is indicated for patients
with high-risk, early-stage ovarian cancer and
those with advanced disease.
Use of hematopoietic growth factors to
maintain adequate blood counts has helped
improve the quality of life and decrease
complication rates in patients with ovarian
cancer who are receiving chemotherapy.

Patients who have completed initial treatment
for ovarian cancer require routine follow-up
clinical evaluations, including history, physical
examination, and serum CA-125 measurement.
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
Patients with metastatic pancreatic cancer
have a median survival ranging from 4 to 6
months; those with locally unresectable
disease have a median survival of about 1
year.
Surgery is the only potentially curative
intervention for patients with pancreatic cancer
who have an apparent technically resectable
tumor without evidence of metastases.
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Helicobacter pylori infection is a major risk factor
for development of gastric cancer.
In patients who undergo surgery as initial therapy
for gastric cancer, postoperative 5-fluorouracil and
leucovorin plus radiation therapy have been shown
to confer a survival benefit compared with
postoperative observation alone.
Patients with gastric and gastroesophageal
junction adenocarcinoma whose tumors expressed
HER2 experienced statistically significantly
improved median survival when trastuzumab was
added to cisplatin plus 5-fluorouracil or
capecitabine.
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Gastroesophageal reflux disease, Barrett
esophagus, and obesity are risk factors for
esophageal cancer.
The diagnosis of esophageal cancer is
established by upper endoscopy and biopsy.
Local and locoregional esophageal cancers are
usually treated surgically; perioperative
treatment with chemotherapy or chemotherapy
plus radiation therapy may improve survival.
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Anal cancer is treated initially with combined
radiation therapy and chemotherapy.
Mitomycin plus 5-fluorouracil is the standard
chemotherapy regimen used in conjunction
with radiation therapy in the treatment of anal
cancer.

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Superior vena cava syndrome is most often
caused by lung cancer; other causes are
lymphoblastic and diffuse large B-cell lymphoma,
Hodgkin lymphoma, and germ cell tumors.
Primary therapy for the underlying malignancy is
usually associated with rapid and complete
resolution of symptoms and physical findings of
superior vena cava syndrome.
Lumbar puncture is contraindicated when
increased intracranial pressure is due to mass
effect because the procedure may precipitate
catastrophic brainstem herniation.
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Corticosteroids such as dexamethasone are
initially used to treat patients with increased
intracranial pressure.
Patients with breast, lung, and prostate cancer
are most likely to develop spinal cord
compression.
Patients with suspected spinal cord
compression require prompt diagnosis (MRI of
the spine), usually before any motor deficit is
detected, and immediate administration of
corticosteroids.
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
A malignant pleural effusion is most often caused
by lung cancer, breast cancer, and lymphoma, and
less frequently by cancer of unknown primary site.
Thoracentesis is required for immediate palliation
of a symptomatic malignant pleural effusion.
Excessive drainage in patients with malignant
pleural effusion should be avoided to prevent
pulmonary edema following lung re-expansion.
Echocardiography is essential to establish the
diagnosis of malignant pericardial effusion.
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Prevention and treatment of tumor lysis
syndrome require hydration with normal saline
as well as allopurinol or rasburicase in high-risk
patients to limit the degree of hyperuricemia.
Symptoms of hypercalcemia include nausea
and vomiting, constipation, polyuria and
polydipsia, weakness, and confusion.
The mainstays of treatment of hypercalcemia
are aggressive hydration with normal saline for
short-term control and parenteral
bisphosphonates for longer-term control.
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
The risk of life-threatening infection in patients
receiving cancer treatment significantly increases
with absolute neutrophil counts lower than 500/µL
(0.5 × 109/L) and as the duration of neutropenia
increases.
Recombinant granulocyte colony-stimulating factor
and granulocyte-macrophage colony-stimulating
factor are effective in preventing neutropenia and
neutropenic fever and maintaining the dose
intensity of chemotherapy.
Myelodysplasia and leukemia can be caused by
chemotherapy and, to a lesser extent, radiation
therapy.
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Involved-field radiation therapy may cause acute
and chronic cardiac disorders.
Patients with breast cancer who are treated with
combined chemotherapy or radiation have an
increased lifetime risk for developing
myelodysplasia, leukemia, endometrial cancer, and
rarely, soft tissue sarcoma.
Long-term administration of aromatase inhibitors in
women with breast cancer has significantly
increased the incidence of osteopenia and risk for
late pathologic fractures.
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The major risk factors for development of head
and neck cancer are alcohol and tobacco use.
Epstein-Barr virus and human papillomavirus
infection may be responsible for development
of head and neck cancer in a subset of patients
without a history of tobacco use.


Presenting signs and symptoms of head and
neck cancer depend on the location of the
primary tumor.
Patients with cervical lymphadenopathy require
expert evaluation of the upper aerodigestive
tract to identify a primary lesion; fine-needle
aspiration of a palpable lymph node is
performed, followed by a lymph node biopsy if
the aspirate is nondiagnostic.
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Goals of treatment of head and neck cancer focus on
improving survival while preserving organ function and
minimizing complications.
Early-stage (stage I and II) head and neck cancer is
highly curable with surgical resection or radiation
therapy.
Locally advanced stage III and IV head and neck
cancer is treated with a combination of surgical
resection, radiation therapy, and chemotherapy.
Complications following treatment of head and neck
cancer include damage to cranial and sensory nerves,
xerostomia, swallowing dysfunction, voice changes,
altered taste sensation, fibrosis, dental problems, and
esophageal strictures.
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
Testicular cancer is the most common solid
tumor in young men and is one of the most
highly curable of all malignancies.
The primary risk factors for development of
testicular cancer are the presence of Klinefelter
syndrome, cryptorchidism, and a family history
of testicular cancer.
Patients with testicular cancer usually present
with a unilateral mass or testicular swelling.
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Initial urologic evaluation of a patient with
suspected testicular cancer includes a chest
radiograph, CT scan of the abdomen and pelvis,
and determination of serum tumor marker levels.
All patients with testicular cancer (either seminoma
or nonseminoma) require radical orchiectomy as
initial treatment.
Patients with nonseminoma have a poorer
prognosis than those with seminoma and require
more aggressive treatment, but even with
widespread metastases, may be cured with
additional surgery and combination chemotherapy.
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Most bladder cancers occur in men, who are
typically over 60 years of age.
Cigarette smoking is the major risk factor for
development of bladder cancer.
Patients with bladder cancer most often
present with painless hematuria.
All components of the urinary tract must be
evaluated in patients with hematuria to identify
a potential malignant source (or sources) of
bleeding.

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

Approximately 60% of patients with bladder cancer
are found to have noninvasive disease at the time
of initial TNM staging.
Patients with noninvasive bladder cancer are
usually treated with transurethral resection of the
bladder tumor and have an excellent prognosis.
Patients with bladder cancer that invades muscle
usually require radical cystectomy, including
removal of the bladder, adjacent pelvic organs, and
regional lymph nodes.
Metastatic bladder cancer is incurable, and
palliative platinum-based chemotherapy is often
used in this setting.
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Most patients with renal cell cancer present with a
mass found incidentally on a radiographic study
performed for other reasons.
Large solid tumors seen on ultrasound imaging are so
likely to be renal cell carcinoma that needle biopsy is
not needed before definitive surgical resection is
planned.
Partial nephrectomy is appropriate for patients with
renal cell tumors measuring less than 4 cm that are not
adjacent to the renal pelvis.
Molecularly targeted agents such as sunitinib,
sorafenib, bevacizumab, temsirolimus, and everolimus
have been shown to be effective in treating patients
with resected renal cell cancer who develop metastatic
disease.
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Before more specialized studies are done in
patients with cancer of unknown primary site,
biopsy samples of tumor from the most accessible
location should be obtained for
immunohistochemical marker determinations.
An exhaustive search for a primary tumor should
not be done in patients with cancer of unknown
primary site because finding an asymptomatic and
occult primary tumor has not been shown to
improve outcome.
Evaluation of patients with cancer of unknown
primary (CUP) site should focus on whether
findings are consistent with a treatable primary
tumor or a treatable subtype of CUP.

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
Women with cancer of unknown primary site
associated with isolated malignant axillary
lymphadenopathy should be assumed to have
locoregional breast cancer until proved otherwise.
Women with cancer of unknown primary site
presenting as abdominal carcinomatosis and
ascites should be assumed to have ovarian cancer
until proved otherwise.
Patients with cancer of unknown primary site that
is not included in a favorable subgroup generally
have a poor prognosis and typically receive
empiric therapy.

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
Risk factors for melanoma include sun
exposure, a history of multiple sunburns, fair
complexion, the presence of multiple
cutaneous nevi, and a personal or family
history of melanoma or dysplastic nevi.
The primary treatment of local and locoregional
melanoma is surgical resection.
Resection is indicated for patients with limited
metastatic melanoma that is surgically
resectable.

If you get stuck, remember these
generalities:




The only way to “cure” cancer includes surgery.
Cancer that has spread to lymph nodes or
beyond requires systemic treatment (i.e.,
chemotherapy).
If you’re going to act, make it definitive (e.g.,
obtain a diagnosis, prefer curative treatments).
You stand a good chance of guessing correctly.
If you prepare well, you
won’t need it.