Oncology General Principles L A U R I E S I M A R D B R E A S T S U R G I C A L O N C O L O G Y F E L L O W D E C E M B E R 2 0 1 2
Objectives Discuss Diagnostic and staging strategies in oncology Know possible modalities of treatment for different cancer Adapt and integrate those depending on Origin of the tumor Presentation of the patient Think multidisciplinary team
Plan Case discussions Discuss a variety of neoplasm Role of the surgeon Diagnosis Staging Treatment Primary tumor Metastasis / Palliation Modalities of treatment
Case Discussion History and physical exam Differential diagnosis Diagnostic techniques Type of biopsy Staging Local vs systemic Full staging not always necessary Treatment Multimodal
1rst case
46 yo male PMH Non contributive No medication No family history Presents with abdominal distension and discomfort Exam Palpable mass, appears slightly mobile No nodes
CT scan
Differential Diagnosis? Malignant Lymphoma LDH measurement Primary germ cell tumor / Metastatic testicular cancer AFP, β-hcg Pancreas, duodenum, kidney, adrenal primary Paraganglioma Benign Retroperitoneal fibrosis
Next Step? Tissue diagnosis CT guided core biopsy Staging CT thorax, abdomen and pelvis Additional investigation? Kidney function evaluation
Treatment? Multidisciplinary approach centralization of care Modalities frequently used? Radiation Role of chemotherapy uncertain Mostly in extremity sarcomas Surgery En bloc resection with negative margins Kidney, colon, pancreas, spleen
Radiation General Principles Pre operative radiation advantages Accurate targeting Relative protection of other organs higher doses achievable Facilitation of the surgery Higher sensibility of tissues Possible harm Wound complications
Sarcomas Generalities Wide variety Important prognostic factors Grade and size Metastasis Lung and liver Carefully plan tissue biopsy Core vs excisional Treatment Surgery primary therapy Wide margin, en bloc Treatment of choice in oligo metastasis Radiation +/- chemo +/- isolated limb perfusion
1rst case F O L L O W U P AT 2 Y E A R S
Presents at emergency department Occlusive symptoms Differential diagnosis? Investigations?
Complications of Radiation Therapy Early Due to damage in self renewing tissues Ex: Bone marrow, skin and mucosal surfaces Mucositis, desquamation, malnutrition Late Due to direct cell damage or indirectly through microvascular damage Ex: fibrosis, necrosis, ulceration and bleeding, chronic edema Intestinal: Obstruction/stricture, fistula Neoplasm induction
2 nd case
56 yo female PMH Non contributive No medication Negative family history Presents for evaluation of a skin lesion
Differential diagnosis? Completion of physical exam? Tissue diagnosis Incisional vs excisional biopsy Evolution
Treatment Local Wide excision
Sentinel node biopsy Previously, concepts of Elective node dissection Therapeutic node dissection Sentinel node biopsy Allows selection of patients for nodal dissection Prevents unnecessary elective dissection
Staging Indications for SLNB T2 or more T1 >0,75mm with Mitosis 1/mm2 Ulceration Lymphoscintigraphy ALND cn+ FNA Bx +SLNB Controversial, ongoing trial (MSLT-II)
Staging Stage I-II No indication for routine blood work/imaging Depending on symptoms Stage III Consider CT/PET/brain MRI Minimum of pelvic CT for inguinal nodal disease Stage IV Imaging with CT/PET/brain MRI LDH
Treatment Other Modalities Chemo Ineffective Radiation For regional control of nodal basins Cervical > axillary > groin For high risk disease Immunotherapy High dose INF To be considered in high risk resected disease IL-2 In cases of metastatic disease Side effects ++
Treatment Newer agents Targeted therapy in metastatic disease Ipilimumab Monoclonal antibody against CTLA-4 Verumafenib BRAF inhibition No trial comparing IL-2, ipilimumab and verumafenib Depending on pt and disease Presence of BRAF mutation
Special Circumstances In-transit disease (Stage III)
Special Circumstances Acral lentiginous melanoma Subungual Biopsy??
3 rd case
62 yo male PMH Non contributive No medication Negative family history Presents with results of CT scan done for suspicion of kidney stone
Differential Diagnosis? Next step? Completion of exam? Palpable nodes in cervical + axillary and inguinal areas Tissue diagnosis Core biopsy Vs node excisional / incisional biopsy
Staging CT chest + abdomen + pelvis PET scan Bone marrow Biopsy Ann Arbor system Classification Hodgkin Non-Hodgkin 1/3 extra-nodal origin Multiple types
Treatment Chemo First line Radiation Localized indolent Surgery For Diagnosis Historically for staging
Special Circumstances Gastrointestinal lymphoma Treatment Chemo Surgery for Sx/Cx otherwise not treatable Obstruction Bleeding Perforation Symptomatic splenomegaly
Gastric MALT 1/2 of gastric lymphomas Treatment H pylori eradication CR in 50-80% Radiation Chemo + immunotherapy Surgery For Cx non otherwise treatable No survival benefit Special Circumstances
4 th case
45 yo female PMH Non contributive No medication Negative family history Presents for Nausea, vomiting and weight loss Investigation?
Differential Diagnosis? Next step? Tissue diagnosis Staging? CT scan abdomen + pelvis + thorax EGD EUS +/- PET scan +/- staging laparoscopy CT scan under stages in 20-30%
1rst Scenario Biopsies + for ADK Modalities of treatment? Chemo Mostly neo adjuvant Chemo-Radiation Mostly adjuvant Surgery Targeted therapy anti-her 2 Advanced disease
At the time of surgery: Cancer adherent to Transverse colon what next? Pancreas? what next? Importance of en bloc resection
Presence of peritoneal disease What next? Palliation - Generalities Symptoms/complications that need palliation? Role of palliative resection Factors to consider? Other types of surgical/non surgical palliation?
2 nd Scenario Submucosal lesion on EGD Dx? Biopsy? Positive for GIST Modalities of treatment? Surgery Targeted therapy (Imatinib) based on Size Mitosis Localization Residual disease
5 th case
52 yo female PMH Non contributive No medication Family history + for BC Presents with Palpable left sided breast lump
Differential diagnosis? Exam? Investigation? Mammogram US breast and axilla Biopsy? FNA vs core Staging evaluation? Stage dependent
1rst Scenario Clinically node Modalities of treatment? Loco-regional Surgery Radiation Systemic Hormonal therapy Chemotherapy Targeted therapy
Adjuvant Systemic Therapy Systemic therapy in adjuvant setting Treat possible small systemic tumor deposits Improve likelihood of cure post surgery Decrease risk of recurrence Decision to administer it based on Risk benefit ratio
2 nd Scenario Clinically node + / large tumor Change in treatment order? Indications of neo-adjuvant treatment? Advantages? Conversion of the type of surgery Rendering a tumor resectable In vivo monitoring of response Early treatment of systemic disease Drawbacks? Possible loss of staging information
Conclusion Oncology Wide spectrum of disease Role of the surgeon Diagnosis Staging Orchestration of treatment Think multimodal treatment, multidisciplinary team Don t jump in the operating room!!
Questions?