Oncology Teaching Clinic - 3 Flashcards

Question

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

Answer 1

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

Answer 2

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

Answer 3

Clinical exam Imaging Needle biopsy

Answer 4

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

Answer 5

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

Answer 6

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

Answer 7

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)

Answer 8

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

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

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

Answer 13

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

Answer 14

* 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

Answer 15

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

Answer 16

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

Answer 17

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

Answer 18

◦ 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

Answer 19

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)

Answer 20

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

Answer 21

◦ 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)

Answer 22

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)

Answer 23

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

Answer 24

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

Answer 25

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

Oncology Teaching Clinic - 3 Flashcards

(55 cards)