What is Cancer? Petra Ketterl, MD Medical Oncology and Functional Medicine
What is Cancer? Layman s terms: cancer starts when cells grow out of control (in any place in the body) and crowd out normal cells
Cancer Basics Normal cells: do their job, divide and die in an orderly and predictable manner Cancer cells: grow out of control and faster than and often crowd out normal cells
Cancer Basics Initially, cancer cells grow only in the part of the body where they started Eventually, they spread to other parts of the body (called metastasis/ metastases) If cancer spreads from the lung to the bone, it is still lung cancer cells in the bone (and not bone cancer)
Cancer Basics: Differences between Cancer Types Speed of growth: some cancers grow slow and some fast Response to treatments Where they metastasise (spread) to What kind of problems they cause (depending on location, hormones produced)
Cancer Basics: Hematologic vs Non-Hematologic Cancers Hematologic = of the blood, like leukemia. = Do not form solid tumors. Non-Hematologic = also called solid tumors
Cancer Basics Cancer is not just one disease Based on where it starts, cancer can behave very differently and have different characteristics Examples: - pancreatic cancer is often found late in the disease (when it is no longer curable) because it can grow very large in the abdomen before the patient notices any problems - Breast cancer on the other hand (being external) is most often found early and therefore much more curable
Cancer Basics: Cancer Staging It is a measure of the extent of the cancer Used for communication with other professionals Determines the treatment course based on studies in a particular cancer and stage
Cancer Basics: Staging Stages of cancer range from 1 to 4: Stage 1 and 2 = lower stages = cancer has not spread very much Stage 3 Stage 4: = cancer has spread a lot locally, like to lymph nodes = cancer has spread to other organs
Treatments for Cancer Treatment Trifecta: - Surgery - Chemotherapy - Radiation
Treatment of Cancer: Surgery If surgery can be done on a cancer it usually means it is considered curable
Treatment of cancer: Surgery Example: Breast cancer Types of surgery - Lumpectomy = small amount of tissue removed - = the tumor and a little of the surrounding tissues - Mastectomy = removal of the entire breast Also: Lymph node disection - Sentinel lymph nodes = dye is injected around the breast tumor and the dye is followed to the axillary lymph nodes. Only a few lymph nodes, the first ones the dye gets to, are removed - If there is cancer in the sentinel lymph nodes, then a complete axillary disection (of lymph nodes) is done
Treatment of Cancer: Surgery Example: Pancreatic Cancer Type of surgery in pancreatic cancer depends on the location of the cancer : in the head or the tail of the pancreas
Tail of Pancreas Tumor
Head of Pancreas Tumor Whipple Procedure
Treatment of Cancer: Chemotherapy Use of drugs to kill cancer or slow their growth Most chemo is IV but some are pills Chemotherapy circulates to nearly all parts of the body and is most useful for cancer that has spread or if you are trying to kill any remaining cancer cells Used for cure, control or palliation
Definition: Chemotherapy Use of any drug to treat any disease
Treatment of Cancer: Chemotherapy 2 different types of chemotherapy: 1. Regular chemotherapy 2. Targeted therapies
Treatment of Cancer: Regular Chemotherapy Drugs that kill fast growing cells --> Cancer but also Hair follicles (hair can fall out) Blood cells (white blood cells, red blood cells and platelets) Cells of the GI tract (causes nausea, vomiting, diarrhea)
Treatment of Cancer: Targeted Therapies
Treatment of Cancer: Targeted Therapies
Treatment of Cancer: Targeted Therapies
Treatment of Cancer: Targeted Therapies
Treatment of Cancer: Radiation Uses high energy particles or waves (x-rays, gamma rays, electron beams, protons) to destroy or damage cancer cells AKA radiation therapy, radiotherapy, irradiation Can be given along with chemotherapy - certain drugs can be radiosensitizers (make the cancer cell more sensitive to radiation)
Treatment of Cancer: Radiation
Treatment of Cancer: Radiation
Treatment of Cancer: Proton Beam
Treatment of cancer: Proton Beam Conformal radiation therapy shapes the beams of radiation to the shape of the tumor Uses protons rather than standard radiation Causes less normal tissue damage
Treatment of Cancer: Example Breast Cancer 33 year old female with previous breast implants Found a lump on self exam in the shower Mammogram shows a Suspicious mass in the left breast, confirmed on ultrasound Breast MRI shows a 2 cm mass in the upper outer quadrant of the breast, one lymph node in the axilla is suspicious
Mammogram and Ultrasound
Breast MRI
Next Step: Biopsy - Fine needle aspiration (FNA) - uses a thin needle to remove a small amount of tissue - Core needle biopsy - uses a wider needle to get a sample (preferred) - Surgical biopsy or excisional biopsy - larger amount of tissue - Image-guided biopsy - needle is guided by Ultrasound, mammogram or MRI. It sometimes involves placing titanium clips
Results of the Biopsy Invasive ductal carcinoma Invasive lobular carcinoma Ductal or lobular carcinoma in situ
Cancer Evolution:
Next Step: Surgery 1. Lumpectomy 2. Mastectomy
Also: Lymph Node Disection 1. Sentinel node disection 2. Axillary node disection
Pathology Report 1. Type of breast cancer 2. Histological grade 3. Tumor size 4. Margins 5. Lymphovascular invasion 6. Lymph node status 7. Hormone receptor status 8. Her-2 status
Pathology report: Histological Grade - Grading is NOT staging - Grade describes the structure of tumor cells - Lower grade = looks more like normal cells - The higher the grade, the more aggressive the cancer is
Pathology report: Tumor Size Reported in cm
Pathology report: Margins
Pathology report: Lymphovascular Invasion Aka LVI Inside the tumor, have the tumor cells grown into the lymph or blood vessels
Pathology report: Lymph Node Status Reports how many lymph nodes have cancer in them Staging and treatment recommendations depends on lymph node status
Pathology report: Hormone Receptor Status Estrogen and Progesterone receptors
Pathology report: HER-2 Status
Trastuzumab (Herceptin)
Back to our Patient Our patient has a lumpectomy and sentinel node disection She has a 2cm tumor in the left breast and one lymph node of 10 positive for cancer, grade 3 Margins are negative It is a ductal carcinoma Triple Negative -negative ER, PR and HER2 receptors
Staging
Staging: Our Patient T1N1MX What about metastases? she will need further testing CT scans or PET scan. Bone scan if bone pain
PET Scan If our patient s PET scan is positive for liver metastases that makes her a stage 4/IV
Luckily, her PET scan is negative... Stage IIA tumor = T1N1M0
Next Step: Treatment 1. Radiation + lumpectomy = mastectomy in recurrence results so radiation to the left breast is recommended also after radiation it is recommended she have adjuvant chemotherapy Def: adjuvant = applied after initial treatment for cancer to suppress seconadry tumor formation since her tumor is triple negative hormone blockers and Herceptin targeted therapy would not work
Survival in Breast Cancer
Triple Negative Breast Cancer TNBC
Thank you Petra Ketterl, MD pjketterl@hotmail.com