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Cervical Cancer
Screening Guidelines
HPV quadrivalent vaccine (6/11/16/18)
16 & 18 is 70% of cervical cancer
FDA approved for males and females from ages 9 -26.
IF
- ASCUS: Pap smear q 3-6 months or colposcopy
- HGSIL CIN II/ CIN III : Colposcopy + cryotherapy or cone biopsy (f/u pap smear q 4months for 3 years)
- LGSIL/ CIN I (15% progresses to cancer) : Colposcopy q 6 months or cryotherapy
*** Squamous cell 80% (arises from CIN) , Adenocarcinoma 20%
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BREAST CANCER
Most important prognostic factor: Presence of lymph node.
Tx:Surgery PLUS
- If <1cm : just surgery
- If LN positive or >1cm: chemotherapy (anthracyclines, Cyclophosphamide, Taxanes, 5FU)
- If Hormone positive: tamoxifen (premenopausal) or aromatase inh (post menopausal)
- If HER2/neu positive: Trastuzumab (monoclonal antibody)
Pregnant woman and breast cancer
- Surgery 2nd-3rd trimester
- Chemotherapy 3rd trimester
Carcinomas:
- LCIS: observation or tamoxifen
- DCIS: Mastectomy
Most important prognostic factor: Presence of lymph node.
Tx:Surgery PLUS
- If <1cm : just surgery
- If LN positive or >1cm: chemotherapy (anthracyclines, Cyclophosphamide, Taxanes, 5FU)
- If Hormone positive: tamoxifen (premenopausal) or aromatase inh (post menopausal)
- If HER2/neu positive: Trastuzumab (monoclonal antibody)
Pregnant woman and breast cancer
- Surgery 2nd-3rd trimester
- Chemotherapy 3rd trimester
Carcinomas:
- LCIS: observation or tamoxifen
- DCIS: Mastectomy
Tamoxifen
Side effects: - Hot flashes - Weight gain - increase risk of thromboembolic event - risk of endometrial cancer (ask GYN symptoms each visit) - Increase bone density - Decreases LDL & CAD risk - Cataracts - Hypercalcemia |
Aromatize Inhibitors (letrozole, anastrozole, exemestane)
Side effects - Risk of arthralgias, myalgias and osteoporosis - Not associated with rick of endometrial cancer - Not associated with risk of thrombotic events |
OVARIAN CANCER
Screening not recommended, but if high risk do pelvic exam, transvaginal ultrasound and CA125
10% genetic: BRCA1 BRCA2 and Lynch II syndrome
OCP: Protective
If mass CA125 increased in 80% of ovarian cancer
Tx: surgery ( TAH-BSO with omentectomy and lymph node sampling) + chemo (paclitaxel and cisplatin)
Pathology : most are epithelial
Screening not recommended, but if high risk do pelvic exam, transvaginal ultrasound and CA125
10% genetic: BRCA1 BRCA2 and Lynch II syndrome
OCP: Protective
If mass CA125 increased in 80% of ovarian cancer
Tx: surgery ( TAH-BSO with omentectomy and lymph node sampling) + chemo (paclitaxel and cisplatin)
Pathology : most are epithelial
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TESTICULAR CANCER
Men ages 15-35 (usually germ cell)
If >55 yo likely lymphoma
Presentation: painless mass in testicle.
If mass palpable do u/s
95% of testicular carcinoma are GERM CELL TUMORS.
Risk factors: cryptorchidism, family hx of testicular cancer, infertility, HIV, klinesfelter
Types seminoma and nonseminoma (nonseminoma more aggressive)
Tumor markers: AFP (increased in nonseminomas), hCG (increased on seminoma and non seminoma)
AFP (half life 5 days), hCG (half life 18h a 36h).
Biopsy via high inguinal incision
Stages:
Stage I: limited to testicles
Stage II: involves retroperitoneal nodes
Stage III: metastatic disease (brain, lungs)
Treatment: Radical Orchiectomy via high inguinal incision, then according to stage treat
- Seminomas: Radiosensitive (until node <5cm), Chemotherapy if node >5cm or metastatic.
- Non seminoma: (no role on RT) Orchioectomy, add chemotherapy if lymphovascular invasion. Stage II chemo+retroperitoneal lymph node dissection. Stage III chemotherapy
** After treatment screening of AML and GI malignancy
Men ages 15-35 (usually germ cell)
If >55 yo likely lymphoma
Presentation: painless mass in testicle.
If mass palpable do u/s
95% of testicular carcinoma are GERM CELL TUMORS.
Risk factors: cryptorchidism, family hx of testicular cancer, infertility, HIV, klinesfelter
Types seminoma and nonseminoma (nonseminoma more aggressive)
Tumor markers: AFP (increased in nonseminomas), hCG (increased on seminoma and non seminoma)
AFP (half life 5 days), hCG (half life 18h a 36h).
Biopsy via high inguinal incision
Stages:
Stage I: limited to testicles
Stage II: involves retroperitoneal nodes
Stage III: metastatic disease (brain, lungs)
Treatment: Radical Orchiectomy via high inguinal incision, then according to stage treat
- Seminomas: Radiosensitive (until node <5cm), Chemotherapy if node >5cm or metastatic.
- Non seminoma: (no role on RT) Orchioectomy, add chemotherapy if lymphovascular invasion. Stage II chemo+retroperitoneal lymph node dissection. Stage III chemotherapy
** After treatment screening of AML and GI malignancy
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PROSTATE CANCER
95% adenocarcinoma
If PSA >4ng/ml do transrectal u/s and biopsy
Gleason grade scoring from 2 (less aggressive) to 10 (most aggressive) and it determines prognosis (>7 poor prognosis)
Pre treatment : Bone scan and CT pelvis
At least 6 biopsies
Treatment: radical prostactectomy , radiotherapy
Hormonal therapy if infiltrates capsule, pelvic node involvement or diffuse mets: LHRH agonist (leuprolide, goserelin) combined with testosterone receptor antagonist (flutamide, bicalutamide)
RT if localized bone met
Side effects of hormonal therapy : weight gain, osteoporosis, gynecomastia, loss of muscle mass, anemia, sexual dysfunction, hot flushes, dm.
95% adenocarcinoma
If PSA >4ng/ml do transrectal u/s and biopsy
Gleason grade scoring from 2 (less aggressive) to 10 (most aggressive) and it determines prognosis (>7 poor prognosis)
Pre treatment : Bone scan and CT pelvis
At least 6 biopsies
Treatment: radical prostactectomy , radiotherapy
Hormonal therapy if infiltrates capsule, pelvic node involvement or diffuse mets: LHRH agonist (leuprolide, goserelin) combined with testosterone receptor antagonist (flutamide, bicalutamide)
RT if localized bone met
Side effects of hormonal therapy : weight gain, osteoporosis, gynecomastia, loss of muscle mass, anemia, sexual dysfunction, hot flushes, dm.
HEAD AND NECK CANCER
Viral association: EBV, HPV 16&18
Majority Squamous cell in origin
Viral association: EBV, HPV 16&18
Majority Squamous cell in origin
CARCINOID
Neuroendocrine tumor
Flushing + Abdominal cramping+ Diarrhea + Wheezing + Palpitations
Associated with valvular heart disease : Tricuspid and Pulmonary valves
Dx: Biopsy + 24h urine 5HIAA
Tx:
- If tumor local: resection
- If metastasis: no cure, just treat symptoms Octreotide
Neuroendocrine tumor
Flushing + Abdominal cramping+ Diarrhea + Wheezing + Palpitations
Associated with valvular heart disease : Tricuspid and Pulmonary valves
Dx: Biopsy + 24h urine 5HIAA
Tx:
- If tumor local: resection
- If metastasis: no cure, just treat symptoms Octreotide
LUNG CANCER
Smoking Cessation
* Small Cell Carcinoma ***central***
- Hyponatremia 2 to SIADH
- Cushing Syndrome 2 to ACTH
- Carcinoid
- Eaton Lambert Sd (power increases with repetition)
* Squamous Cell Carcinoma (tends to cavitate) ****central*****
- Hypercalcemia
- Pancoast syndrome
- Horners syndrome
* Adenocarcinoma
-Pulmonary osteoarthropathy
- Marantic endocarditis
* Large cell carcinoma (scar carcinoma)
- SVC syndrome
- Gynecomastia
Smoking Cessation
* Small Cell Carcinoma ***central***
- Hyponatremia 2 to SIADH
- Cushing Syndrome 2 to ACTH
- Carcinoid
- Eaton Lambert Sd (power increases with repetition)
* Squamous Cell Carcinoma (tends to cavitate) ****central*****
- Hypercalcemia
- Pancoast syndrome
- Horners syndrome
* Adenocarcinoma
-Pulmonary osteoarthropathy
- Marantic endocarditis
* Large cell carcinoma (scar carcinoma)
- SVC syndrome
- Gynecomastia
RENAL CELL CARCINOMA
Common in von Hippel Lindau disease
Triad: Flank pain + Hematuria + Abdominal Mass
Paraneoplastic sd: Erythrocytosis, HTN, Hypercalcemia, Amyloidosis
Dx: CT, MRI, U/S
Pathology: Typically clear cell carcinoma
Tx: Radical nephrectomy is localized, if solitary met resect it
Alpha interferon and IL2, sunitinib and sorafenib (small molecule tyrosine kinase inhibitor) in metastatic disease
Common in von Hippel Lindau disease
Triad: Flank pain + Hematuria + Abdominal Mass
Paraneoplastic sd: Erythrocytosis, HTN, Hypercalcemia, Amyloidosis
Dx: CT, MRI, U/S
Pathology: Typically clear cell carcinoma
Tx: Radical nephrectomy is localized, if solitary met resect it
Alpha interferon and IL2, sunitinib and sorafenib (small molecule tyrosine kinase inhibitor) in metastatic disease
COLON CANCER
Increased in UC
Screening (50yo annual FOBT, sigmoidoscopy q5y, colonoscopy q10y)
- If hyperplastic polyp: colonoscopy q10y
- If adenoma <2polyps, <1cm: colonoscopy q5y
- If adenoma >3 polyps, >1cm, or tubule villous q3y
- If polyp>2.2cm:colonoscopy q1y
Treatment
- Duke A (mucosa, submucosa) or Duke B1 (submucosa, muscularis) Resection
- Duke B2 (involves serosa) or Duke C (LN) : Resection and 5FU + Leucovorin
- Duke D (distant met): if solitary distant Liver mass, resection
Increased in UC
Screening (50yo annual FOBT, sigmoidoscopy q5y, colonoscopy q10y)
- If hyperplastic polyp: colonoscopy q10y
- If adenoma <2polyps, <1cm: colonoscopy q5y
- If adenoma >3 polyps, >1cm, or tubule villous q3y
- If polyp>2.2cm:colonoscopy q1y
Treatment
- Duke A (mucosa, submucosa) or Duke B1 (submucosa, muscularis) Resection
- Duke B2 (involves serosa) or Duke C (LN) : Resection and 5FU + Leucovorin
- Duke D (distant met): if solitary distant Liver mass, resection
ANAL CANCER
Cancer of anal margin: Local excision
Cancer of anal canal mucosa: External bean radiation + 5FU + Mitomyci
Cancer of anal margin: Local excision
Cancer of anal canal mucosa: External bean radiation + 5FU + Mitomyci
MELANOMA
Most important is depth of invasion
Tx: IL2 or alpha interferon
Most important is depth of invasion
Tx: IL2 or alpha interferon
LYMPHOMA
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THYROID CANCER
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MULTIPLE MYELOMA
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TUMOR LYSIS SYNDROME
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MISCELLANEOUS
NEUTROPENIC COLITIS/TYPHLITIS
Occurs after prolonged neutropenia and broad spectrum antibiotic treatment
Symptoms: abdominal pain and bloody diarrhea
Gram negative bacteria
Most commonly in leukemia
Surgery for perforation
Occurs after prolonged neutropenia and broad spectrum antibiotic treatment
Symptoms: abdominal pain and bloody diarrhea
Gram negative bacteria
Most commonly in leukemia
Surgery for perforation
SIDE EFFECTS OF MEDICATIONS
Cyclophosphamide: Hemorrhagic cystitis (prevention hydration and MESNA), can cause SIADH
Cisplatin: renal damage (prevent with hydration), Mg waist, ototoxicity, peripheral neuropathy
Carboplatin: Myelosuppresion
Cyclophosphamide: Hemorrhagic cystitis (prevention hydration and MESNA), can cause SIADH
Cisplatin: renal damage (prevent with hydration), Mg waist, ototoxicity, peripheral neuropathy
Carboplatin: Myelosuppresion