General Concepts

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    General Approach

    • Diagnosis of cancer
    • Staging
      • Tumor specific staging systems exist (such as lymphoma and small cell lung ca)
      • Most solid tumor malignancies described by TNM
        • T0-4 --> Increasing tumor size or extent of local invasion
          • T0 = no disease
          • Prefixes! (can be with T or N)
            • "p" means pathology - (surgically resected & pathologically staged)
            • I.e. pT3 tumor (pathology done staging).
            • "y" means treated preoperatively (affected true stage) (letter y doesn't stand for anything). 
            • i.e. ypT (means treated, and when resected - no evidence of disease).
        • N0-3 --> N0 - no node involvement (i.e. sentinel LN negative) N1-3 --> Increasing LN involvement
        • M0-1 --> presence of metastasis (MX - cannot comment mets)
      • Often TNM staging is grouped into disease-specific staging (I-IV) (prognostic info, treatment, etc.)
      • Staging workup varies for each cancer.  I.E:
        • Lung Cancer --> requires bone and brain imaging (mets to bone and brain common)
        • Locoregional colorectal cancer --> May not require bone/brain imaging b/c it's rare.
    • Identify Performance Status
      • Determines treatment strategies:
        • ECOG/WHO Performance Scale
      • ECOG Self Care
        0 Fully Active; no restrictions FULL
        1 NO strenuous activity, able to carry out light housework/sedentary activities FULL
        2 Able to walk, unable to work; out of bed > 50% of waking hours FULL
        3 Bed or chair > 50% of waking hours (Limited self-care) LIMITED
        4 Completely disabled.  (Unable to do self-care) NONE
        5 Death  
    • Define goals of therapy
      • Cure vs. Palliative
      • I.e. Hodghkin & Testicular (if you survive several years, you are basically cured)
      • I.e. Estrogen-positive Breast Ca (Late relapses are common)

     

    Definitions

    • Adjuvant Therapy
      • Primary tumor resected, had imaging showing no metastatic disease
      • However, micro-metastatic disease can exist
      • Adjuvant therapy is therapy designed to target "micro-mets" to improve 
      • Historically: colon + breast, but now shown as beneficial to many!
    • Cure
      • Not quoted in studies, because all studies have an end-date.
      • "Disease Free Survival" is the closest term
    • Disease Free Survival
      • Length of time after primary treatment for a cancer ends that the patient survives without any signs or symptoms of that cancer.
      • Used in clinical trials to define treatment effectiveness
      • note: focuses on: can they live with cancer? (even if don't shrink).
      • I.e. pancreatic cancer: Gemcitabine does not decrease tumor size, but improves survival. 
    • Response Rate
      • Does lesion shrink?
    • Partial Response
      • 50% reduction in tumor size 
      • (In the past used to guage intervention efficacy).
    • Remission
      • Complete Remission - All visible evidence of disease eliminated
      • Partial Remission - at least 50% shrinkage + no new tumors
      • Stable Remission - Less than 50% shrinkage, but no new tumors.

     

    Cancer of Unknown Primary

    • Identified as its own clinical entity:
      • No evidence of primary cancer (even on autopsy hard to identify)
    • Typically need a good pathologist guiding immunohistochemistry.
      • Biopsy of most accessible tumors for immunohistochemical analysis
    • Tumor markers (CEA, CA19-9, CA15-3, CA125) NOT warranted.
    • Follow symptoms: (examples)
      • Cervical Lymphadenopathy --> Head & Neck Cancers
      • Axillary lymphadenopathy --> Breast cancer until proven otherwise
    • Exhaustive search for primary tumors should not be done with cancer of unknown primary because finding asymptomatic and occult primary tumor has not been show to improve outcome. 

     

    Poorly Differentiated Carcinoma

    • Undifferentiated - looks like squamous or sarcoma, etc..

    Tumor Markers / Receptor Cheatsheet

    (TODO, under construction)

    • Very non-specific
    • Cancer Tumor Markers Tumor Receptors
      Breast Cancer

      CEA

      CA15-3

      CA27-29

      Her2neu (more aggressive)
      • Trastuzumab[Herceptin]
      Lung Cancer  

      eGFR (Erlotinib & Gefibinib)

        - Epidermal growth factor

        - Usually women who never smoked

      Colon Cancer CEA  
      Prostate PSA  

     

     

    Oncologic Emergencies

    Tumor Lysis Syndrome

    • Large cell turnover and lysis, releases electrolytes & procoagulants into circulation

      • High levels of these agents can cause life-threatening TLS.

    • Spontaneous:

      • Leukemia

      • Burkitt Lymphoma
    • Treatment Associated: 
      • Bulky Large B-Cell Lymphoma
      • Advanced CLL
    • Syndrome:
      • Hyperkalemia
      • Hyperphosphatemia
      • Hyperuricemia  (Urate Nephropathy, AKI)
      • Hypocalcemia
      • DIC
    • Prevention:
      • IV Hydration (LARGE volumes!)
      • Allopurinol (limit hyperuricemia)
        • Rasburicase often before chemo if Renal Disease
      • Dialysis (for fluid overload, uremia, severe hyperK, HyperPhos)
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