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MBBS V - Senior Clerkship - Block C CCT > Oncology Teaching Clinic - 3 > Flashcards

Oncology Teaching Clinic - 3 Flashcards

1
Q

What are the general and specific risk factors for colorectal cancer (CRC)?

A
  • Dietary
  • Alcohol
  • Obesity
  • Cigarette smoking
  • Presence of coronary artery disease

Specific genetic disorders
◦ Familial adenomatous polyposis (FAP)
◦ germline mutations in the adenomatosis polyposis coli (APC) gene which is located on chromosome 5
◦ Hereditary non-polyposis colorectal cancer (HNPCC)
◦ Lynch syndrome, autosomal dominant
◦ Personal or family history of CRC or adenomatous polyps

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2
Q

What are the common symptoms of CRC?

A

◦ Change of bowel habits
◦ PR bleed
◦ Tenesmus
◦ Pain from metastasis
◦ Weight loss
◦ Anorexia
◦ Anaemic symptoms

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3
Q
A

Bilobal heterogenous non contrast enhancing
w ring enhancement with central necrosis
No ascites

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4
Q

What surgery for colon/ rectum?

A

Colon: colectomy

Rectum: abdominoperineal resection
Low anterior resection

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5
Q

What is the neoadjuvant therapy for CRC and what stage of cancer?

A

Locoregionally advanced rectal cancer (T3-4, N+, M0)
Neoadjuvant chemoirradiation
Chemotherapy: 5FU or capecitabine
Radiotherapy: 25-28 daily fractions

Pros:
Pros:
* Tumor downstage
* Facilitate complete resection
* Sphincter preservation
* In-vivo testing of chemosensitivity
* Early treatment of micrometastasis

Cons
* Delay definitive surgery
* Overtreatment
* Additional toxicities

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6
Q

What is the adjuvant therapy for CRC?
When is it’s recommended usage?

A

Recommended for all stage III (ie N+ve) and high-risk stage II (ie T3,4N-ve) disease
◦ IO, perforation, T4, PD, LVI/ PNI, LND <12, margin+

Common regimen
◦ FOLFOX4
◦ 5-FU, leucovorin, oxaliplatin
◦ CAPOX (XELOX)
◦ Capecitabine, oxaliplatin
◦ Capecitabine alone for high-risk stage II disease or old patients

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7
Q

What is the role of VEGF in CRC?

A

-Tumours >2mm in diameter require an independent blood supply to survive and grow
 -Tumours continually require VEGF to recruit new vasculature
 -VEGF continues to be expressed throughout tumour progression, even as secondary pathways emerge

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8
Q

What are the side effects of VEGF as the target in CRC?

A

Common side effects: Hypertension, proteinuria
Uncommon but severe: Bleeding, thromboembolic events, bowel perforation, wound healing problem

Bevacizumab: humanized IgG1mAb that blocks VEGF-A
Aflibercept: Fusion protein that blocks VEGF-A isoforms, VEGF-B, and placental
growth factor (PlGF)
Ramucirumab: human IgG1 mAb targets VEGFR-2 Regorafenib: multikinase inhibitor

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9
Q

What mutation is predictive of response to cetuximab therapy in colorectal cancer?

A

KRAS mutation

Mutated KRAS causes increased signaling despite inhibition of upstream EGFR dimeraization

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10
Q

What are some toxicities of anti-EGFR monoclonal antibodies?

A

Acneiform rash
Diarrhoea
Electrolyte disturbance
Infusion reaction
Paronychia
Conjunctivitis

Increased magnesium

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11
Q

What is the mechanism of immunotherapy in mCRC?

A

By blocking PD-1 receptors from binding to immune dampening PD-1 and PD- 2 ligands expressed on antigen presenting tumour cells, anti- PD1 mAb reactivates tumour- specific cytotoxic T- lymphocytes in the tumour microenvironment and restimulates anti-tumour immunity.

Pembrolizumab in MMR deficicent patient

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12
Q

What is the distribution of lung cancer?

A
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13
Q

What is most common histological type of lung cancer?
What key associated factors?

A

Adenocarcinoma
Non smoking history
EGFR and ALK (EML4-ALK) mutation

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14
Q

What are the symptoms of lung cancer?

A

Local symptoms
◦ Cough
◦ Sputum (color and any presence of haemoptysis) ◦ Dyspnoea
◦ Chest pain (pleuritic)
◦ Reduced exercise tolerance
◦ Neck and facial swelling (pemberton sign: IVC obstruction)

Regional symptoms
◦ Cough
◦ Sputum (color and any presence of haemoptysis)
◦ Neck and facial swelling (why?)
◦ Neck or supraclavicular fossa mass/swelling (why?)

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15
Q

What are paraneoplastic manifestations of lung cancer?

A

◦ Symptoms of Cushing syndrome
◦ Symptoms of SIADH
◦ Symptoms of Lambert-Eaton syndrome
◦ Symptoms of hypertrophic osteoarthopathy

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16
Q

Lung Ca, reasons for dyspnea?

A

Mass compressing on trachea, superior vena cava
Collapsed lung
Pneumonia in distal region (from obstruction)
Aspiration pneumonia
Pleural effusion

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17
Q

Lung CA

What needs to be reported?

A

contrast CT
Bilateral multiple hyperdense lesions

No ICH (intracerebral hemorrhage =important)
No MLS (midline shift)
Hydrocephalus, herniation, head injury

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18
Q

What is treatment for stage 2 lung CA?

A

Surgery followed by adjuvant chemotherapy (cisplatin-based doublets)
Adjuvant RT is required for incomplete resection or resection with positive margins: stereotactic body radiation therapy with active breathin control technique that employs gating technique (as tumor moves with breathing)

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19
Q

What is treatment for stage 2 lung CA?

A

Surgery followed by adjuvant chemotherapy (cisplatin-based doublets)
Adjuvant RT is required for incomplete resection or resection with positive margins: stereotactic body radiation therapy with active breathin control technique that employs gating technique (as tumor moves with breathing)

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20
Q

What is treatment for stage 3A lung CA?

A

Adjuvant chemotherapy and radiation therapy after surgery
For unresectable stage IIIA disease, concurrent chemoradiation (platinum-based) +/- induction chemotherapy is the standard of choice
Common radiotherapy regimen
◦ 63Gy/35fr/7 weeks
◦ 60-66Gy/30-33fr/6-6.5 weeks

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21
Q

What is treatment for stage 3B lung Ca?

A

Concurrent chemoRT or sequential chemoRT
Targeted therapy for targetable mutation-driven tumours (e.g. EGFR, ALK, ROS- 1 etc)
Palliative chemotherapy or radiotherapy Best supportive care

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22
Q

What is treatment/management of stage 4 lung CA?

A

Chemotherapy
Targeted therapy
Palliative radiotherapy
◦ For dyspnoea, chest pain, haemoptysis ◦ For distant metastasis e.g. bone, brain
Best supportive treatment Palliative and hospice care

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23
Q

What is chemotherapy related general side effects?

A

Nausea/vomiting
Diarrhoea/constipation
Alopecia
Immunosuppression
Subfertility

24
Q

What are the specific side effects of cisplatin, paclitaxel, docetaxel, gemcitabine, vinorelbine, pemetrexed?

A

Cisplatin – peripheral neuropathy, nephropathy, ototoxicity Paclitaxel – hypersensitivity, peripheral neuropathy Docetaxel – hypersensitivity, neutropenia
Gemcitabine – hypersensitivity, flu-like symptom
Vinorelbine – peripheral neuropathy, phlebitis
Pemetrexed - hypersensitivity

25
Q

What is the incidence of EGFR mutation in what cell type lung cancer?
What EGFR mutations?

A

50% asian patients with adenocarcinoma have EGFR mutation

Most common EGFR mutation
◦ Exon 19 deletion
◦ Exon 21 L858R point mutation
◦ Rarer mutations include exon 18 (G719A, G719X, S768I), double mutations

26
Q

What is the most common drug resistance mutation after 1st and 2nd generation EGFR TKI?

A

Exon 20 T790M mutation develops in about 50% of patients as drug resistant mutation after failure to 1st/2nd generation TKI
Other resistant mechanisms
◦ MET amplification
◦ HER2 amplification
◦ Mesenchymal transformation
◦ Small cell carcinoma

27
Q

What is the triple assessment of breast cancer?

A

Clinical exam
Imaging
Needle biopsy

28
Q

What imaging used for breast cancer?

A

Mammogram and Ultrasound of bilateral breast
◦ To define the extent of tumor
◦ To detect the presence of multifocal tumors
MRI of bilateral breast
◦ Helpful in scarred breast and breast with implants
◦ Useful for identifying primary cancer in axillary nodal adenocarcinoma and occult (or unidentified) primary cancer
◦ Helpful for breast cancer evaluation pre and post preoperative systemic therapy to define extent of disease, response to treatment, feasibility for breast conserving therapy
◦ High false positive rate (~50%)
Bone scan, CT scan or FDG PET/CT scan
◦ Routine staging bone scan, CT scan or FDG PET/CT scan is not indicated
◦ Clinical stage I-IIB: consider only if there is suspicious symptom or abnormal blood tests (e.g. raised ALP)
◦ FDG PET/CT is most helpful in situations where standard staging studies are equivocal or suspicious, especially in the setting of locally advanced (stage III or above) or metastatic stage

29
Q

What biopsies done for breast cancer?

A

Core-needle biopsy
◦ Provide accurate pathological diagnosis to guide management
Excisional biopsy
◦ Reserved for lesions in which the diagnosis remains equivocal despite imaging and core biopsy assessment
Fine needle aspiration
◦ For axillary lymph node staging

30
Q

What are the histological subtypes of breast cancer?

A

Histological subtypes
◦ Invasive ductal carcinoma (IDC)
◦ Invasive lobular carcinoma (ILC)
◦ Other less common histologies (Medullary carcinoma, mucinous carcinoma, tubular carcinoma, papillary carcinoma, metaplastic breast cancer (MBC), phyllodes tumors)
◦ Lymphoma
◦ Metastatic tumors

31
Q

What are histological features and biomarkers for breast cancer?

A

Histological features
◦ Size
◦ Status of surgical margin
◦ Grade
◦ Proliferation
◦ Vascular invasion
◦ Quantity of intraductal component
Biomarkers
◦ Estrogen and progesterone receptors (ER/PR) status
◦ HER-2 status: by immunohistochemistry (IHC) or fluorescence in-situ hybridization (FISH)

32
Q

pT2N0 breast cancer management?

A

Patient received breast conservative therapy (BCT) plus sentinel lymph node dissection (SLND)
Systemic adjuvant therapy: Adjuvant chemotherapy – Docetaxel + cyclophosphamide for 4 cycles was given
Adjuvant whole breast radiation therapy WBRT after BCT

33
Q

What is the surgical locoregional management of breast cancer?

A

Primary tumor
◦ Modified radical mastectomy (MRM)
◦ Breast conserving therapy (BCT) / lumpectomy
Axillary lymph node
◦ Axillary dissection (AD)
◦ Sentinal lymph node dissection (SLND)

34
Q

What is the radiation therapy locoregional management of breast cancer?

A

Radiation therapy
◦ To reduce the chance of loco-regional recurrence by ~60%
◦ Post-mastectomy chest wall irradiation ◦ For N1, T3 or above, positive margin patients
◦ Post-lumpectomy whole breast irradiation
◦ Essential for most patients after BCT to reduce local recurrence
◦ Regional lymph nodes RT
◦ Supra-clavicular lymph node
◦ Internal mammary chain
◦ Axillary region

35
Q

What is the endocrine therapy systemic management of breast cancer?

A

Blockade of Estrogen Receptors
◦ Selective Estrogen Receptor Modulators
◦ Tamoxifen
Pure estrogen receptor downregulator
◦ Fulvestrant

Suppression of Estrogen Synthesis
◦ Ovarian Ablation
◦ Surgical oophorectomy
◦ Irradiation of ovary
Ovarian Suppression (premenopausal women)
◦ Luteinizing hormone releasing hormone analog (LHRHa)
Aromatase Inhibitors (post-menopausal women)
◦ Anastrozole, letrozole, exemestane

36
Q

What is the chemotherapy systemic management of breast cancer?

A

◦ Anthracycline-based: doxorubicin – cyclophosphamide (AC)
◦ Taxane-based: docetaxel – cyclophosphamide (TC)
◦ Pyrimidine analogue: fluorouracil, capecitabine, gemcitabine
◦ Platinum: carboplatin
◦ Vinca alkaloid: Vinorelbine

37
Q

What is targeted therapy for breast cancer?

A

Indicated for HER2 overexpressed breast cancer
◦ Adjuvanttreatmentwithchemotherapyto reduce recurrence
◦ Active treatment in metastatic stage – alone, concurrent with chemotherapy or hormonal therapy
Anti-HER2 therapies
◦ Trastuzumab
◦ Pertuzumab
◦ Trastuzumabemtansine (TDM-1)
◦ Lapatinib

38
Q

What are noval agents for systemic management of breast cancer?

A
  • Cyclin – dependent kinase 4/6 inhibitor: indicated to be used in conjunction with hormonal therapy in ER +ve / HER2 –ve metastatic breast cancer
  • Inhibitor Mammalian target of rapamycin (mTOR) signal transduction pathway: indicated to be used in conjunction with hormonal therapy in ER +ve / HER2 – ve metastatic breast cancer
  • Poly (ADP-ribose) polymerase (PARP) inhibitors: indicated in BRCA mutation- associated metastatic breast cancer
  • Immune checkpoint inhibitor in triple-negative breast cancer
39
Q

What is the general approach of breast cancer?

A
40
Q

What is standard treatment of stage 0 breast cancer?

A

Ductal carcinoma in situ (DCIS)
Local treatment only
Standard treatment
1. Modified radical mastectomy (MRM)
2. Breast conserving therapy (BCT)/lumpectomy, followed by whole breast radiation therapy

41
Q

What is management of stage 1 breast cancer?

A
42
Q

What is management of stage 2-3A breast cancer?

A
43
Q

What is management of stage 3B-3C (T3-4, N2-3) breast cancer?

A
44
Q

Systemic management of stage 4 breast cancer

A
45
Q

What are the toxicities of chemotherapy and management of late stage diseases?

A

Cardiac toxicity due to anthracycline based chemo and/or RT (not reversible heart damage)
Bone health, esp those on aromatase inhibitor
Lymphedema
Anxiety, depression and fear of recurrence
Early menopause / fertility
Sexuality
Sleep disorder
Healthy lifestyle and physical exercise

46
Q

What investigations to order with left middle ear effusion, bilaterally enlarged cervical LNs?

A

Blood for Complete blood count, LRFT, creatinine clearance, LDH Hep B serology
EBV serology incl. Anti-EBV EA, Anti-EBV VCA
EBV DNA – a very sensitive tumour marker for NPC Nasopharyngoscopy and biopsy
Pure-tone audiography (PTA)
Dental checkup
MRI of NP and neck region +/- PET scan Dietician consultation

47
Q

What is management of advanced stage NPC?

A

◦ Concurrent chemoradiation is the standard
◦ Cisplatin
◦ 100mg/m2 on D1, D22, D43 ◦ 40mg/m2 weekly
◦ RT still 70Gy in 35 fractions over 7 weeks, further dose escalation does not improve survival

48
Q

What are the radiotherapy techniques for NPC?

A

2-dimensional conventional RT
3-dimensional conformal RT
IMRT
Brachytherapy (for persistent/recurrent disease) Stereotactic radiosurgery (for persistent/recurrent disease) Cyberknife (for persistent recurrent disease)

49
Q

What is 2D conventional radiotherapy and long term issues?

A

Lateral opposing beams to both sides of head and neck regions
RT to swallowing muscles and parotid gland

50
Q

What are the acute side effects of radiation therapy?

A

◦ Mucositis/sore throat (口腔黏膜炎)
◦ Odynophagia/dysphagia (吞咽痛楚及困難)
◦ Xerostomia (口乾)
◦ Oral candidiasis (口腔念珠菌病)
◦ Hearing impairment/tinnitus/otitis media (聽力減弱,耳鳴,中耳炎)
◦ Desquamation (脫皮)

51
Q

What are the common and uncommon chronic side effects of radiotherapy?

A

Chronic (common) 常見長期副作用
◦ Xerostomia (口乾)
◦ Hearing impairment/tinnitus/otitis media
◦ Hyperpigmentation of skin (皮膚色素加深) ◦ Fibrosis of neck muscles (頸部肌肉纖維化)
Chronic (uncommon) 不常見長期副作用
◦ Trismus (牙關緊閉)
◦ Osteoradionecrosis of jaw (顎骨壞死)
◦ Hypopituitarism (腦下垂體功能減退)
◦ Oesophageal stricture (食管狹窄)
◦ Radiation-induced 2nd malignancy (放療引發第二種癌症)

52
Q

What is chemotherapy for NPC?

A

Cisplatin (given if renal function is fit)
Carboplatin (Used if renal function not optimal)
5-FU
Chemosensitizing effect with RT

53
Q

What is treatment of local recurrence of NPC?

A

Surgical resection e.g. maxillary-swing nasopharyngectomy ◦ 5-year local control rate: 65%
◦ 5-year progression-free survival: 54%
Stereotactic radiosurgery/radiotherapy
Intensity Modulated Radiation therapy
Cyberknife
+/- Concurrent chemotherapy

54
Q

What is treatment for neck LN recurence?

A

IMRT
Radical dissection
Interstitial brachytherapy (has already undergone RT before)

55
Q

What is choice of chemotherapy for NPC?

A

MBBS V - Senior Clerkship - Block C CCT (52 decks)

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