Cancers Flashcards
Gastric Cancer Algorithm
Staging: PET-CT, EUS
T1N0M0 -> surgery
>=T2 or +nodes -> Neoadjuvant chemo -> restage -> OR
Adjuvant chemo for all
OR: Total gastrectomy with D1/D2 lymphadenectomy (Take celiac, splenic, and common hepatic nodes + L/R gastric/gastroepiploeic nodes)
Goal lymph nodes: 16
Neoadjuvant chemo: 5FU and cisplatin
Adjuvant: Cepectabine + oxaliplatin
Surveillance:
H&P: 3-6 mo for years 1-2, 6-12 mo for years 3-5, annual after
CT C/A/P: 6 mo for years 1-2, annual for years 3-5
GIST Algorithm
Staging: CT C/A/P
If high risk -> neoadj imatinib -> restage -> OR
If progression on imatinib, increase dose/duration. If no response then dont operate.
High risk if >5 mit/50hpf or >5 cm.
OR: Wedge resection w 1 cm margin. Goal microscopic negative margin
Surveillance:
H&P w CT: 3-6 mo for years 1-5, annual after
HCC Algorithm
Staging: Multiphase CT. AFP. Chest CT. Bone scan if skeletal symptoms
If no portal HTN and Plt>100k may be resectable.
Noncirrhotic: if liver remnant>25% resect
Child A: if liver remnant >40% resect
Child B/C: transplant if milan criteria met
If liver remnant low, portal vein embo and recheck 4 weeks later
If unresectable, TACE or ablation
OR: R0 resection is goal
Chemotherapy: Bevacizumab, Atezolizumab
Surveillance:
AFP + Imaging: 3-6 month for years 1-2, every 6 months after
Colon Cancer Algorithm
Colonoscopy: Send specimen for mismatch repair protein staining
If positive, check for MSH2 genetic mutation to check for Lynch syndrome
If positive, TAC
S1-2: Resect
If high risk stage 2 or S3+: Resect and adjuvant chemo
12 lymph nodes goal
Chemo: FOLFOX: 5FU, Leukovorin, Oxaliplatin
Surveillance
H&P + CEA q3-6mo x 2y, then q6y until 5y
CT CAP q6-12 mo x 5 y
Colonoscopy 1y, 3y, 5y,
Lynch syndrome:
Proctoscopy for rectal cancer q1-2 years
EGD q3-5 years
UA q1y for urothelial cancer
H&P q1y for CNS cancer
CT C/A/P + CEA
Screen family
Appendiceal carcinoid Algorithm
<1 cm: Appendectomy, no surveillence needed
1-2 cm w mitotic activity>2 cells/mm^3, @base of appendix, positive margin: Appy if high risk pt, R colectomy if younger/healthy
>2 cm: R colectomy
Goblet: R colectomy
Surveillance
H&P + CT A/P q1-2 y x 10 years.
Rectal cancer Algorithm
Staging: Colonoscopy, EUS, MRI Pelvis, CT C/A/P
T1/T2 w negative node: OR
>T3 or +Node: Neoadjuvant chemoradation -> restage -> OR
APR if within 2 cm of anal verge
LAR if > 2 cm
Transanal excision: <30% circ, <3 cm, margin >3 mm, non-fixed, <8 cm from verge, T1, no lymphovascular invasion
OR:
Ideally 5 cm margin, 2 cm acceptable for distal mass
Neoadjuvant: FOLFOX radiation (45 gy x 25 fraction)
Adjuvant: FOLFOX (8 cycles total)
Surveillance
H&P + CEA q3-6mo x 2y, then q6y until 5y
CT CAP q6-12 mo x 5 y
Colonoscopy 1y, 3y, 5y,
Anal Cancer Algorithm
Counsel on safe sex. check for STI
Below anal verge: skin cancer
In anal canal above anal verge: anal cancer
Above dentate line: rectal cancer
Nigro protocol:
5FU + Mitomycin C + Radiation (45 gy in 25 fractions over 5 weeks)
Allow up to 6 months for remission
If persistent at 6 months, APR. If metastatic, abort and do FOLFOX
Surveillance:
H&P w anoscopy q6mo x 3 years. Annual CT x 3 years.
Breast Cancer Algorithm
DCIS - lumpectomy + radiation vs mastectomy s SLNB -> hormonal tx x 5y if needed
(SLNB if comedonecrosis or foci of invasion)
Surveillance: H&P 6-12 mo x 5y, yearly mammogram
Cancer - lumpectomy w adj radiation vs mastectomy. SLNB w both.
Neoadjuvant chemo if HER2+, triple negative, to reduce size for BCS, or delayed surgery
Inflammatory: Doxorubicin, cyclophosphosphomide, paclitaxel (get TTE to look for cardiomypathy)
Z11: T1-2, no preop chemo, 1-2+ nodes, WBRT planned.
Adjuvant chemo: HER2+ or triple negative, Oncotype Dx indicated
Trastuzumab x 1 year
Capecitabine (6-8 cycles)
Surveillance: H&P 1-4 times/year x 5y then annual, genetic counseling, lymphedema monitoring, Mammogram annual
Thyroid (Nonmedullary) Algorithm
Check TSH/US. If low TSH, scintigraphy. If high or normal TSH, FNA
- Nondiagnostic: repeat
- Benign : repeat US in 1-2 years
- FLUS: Repeat FNA vs Molecular testing vs lobectomy
- Follicular neoplasm: Molecular testing vs lobectomy
- Suspicious for malignancy: Total thyroid vs lobectomy
- Malignant: Total vs lobectomy
Papillary
<1 cm: lobectomy
>1 cm:
- Lobectomy if: No prior radiation, mets, lateral nodes, extrathyroid extension, poorly differentiated, >4 cm.
- Completion if > 4cm, +margin, extrathyroidal extension, >45 yo, lymphatic inasion, multifocal, poorly diff, nodal mets, contralateral dz, vascular invasion
- Otherwise go to total (basically always total for follicular)
TSH/Tg/Anti-Tg 6 weeks postop.
Do RAI if high risk: N1b, >4 cm, extrathyroid dz, Tg>10, >5 nodes
Replace thyroid hormone if needed after RAI
Surveillance:
PE + Neck US + TSH/Tg/Tg Ab every year for 5 years
If TSH/Tg/Tg-Ab is positive get I123 scan
Medullary Thyroid Algorithm
Serum calcitonin, CEA
Check RET proto-oncogene, pheo screen, calcium
Laryngoscopy, neck U/S
CT Chest/liver + bone scan if calcitonin<500 or node+ (PETCT not usedful for medullary)
Total thyroidectomy with central lymph node dissection (may not be required for <1 cm)
Men2A: If hyperPTH, surgerize at same time. Total thyroid by age 5
MEN2B: Total thyroid by age 1
Surveillance
If basal CEA/Calcitonin elevated, CT or MRI neck/liver/chest at 2-3 months post-op
if not basal or negative mets, CEA/Calcitonin/neck US annaully
If recurrent, chemotherapy
ACC Algorithm
PET/Ct
Resect
ERBT/Mitotane if High risk (Ki-67 > 10%, ruptures, >5 cm, high grade, positive margins)
If functional, consider resection w mets if >90% can be excised.
Surveillance: H&P annual x 5y w CT C/A/P. Biochem if function.
Esophageal cancer Algorithm
Stage w PET-CT and EUS
T1a (lamina propria/muscularis mucosa)- Endoscopic mucosal therapy
All other non metastatic dz -> Neoadjuvant chemorad -> esophagectomy
Avoid operating on proximal esophageal cancer
Metastatic: Definitive chemotherapy
Chemotherapy:
Neoadjuvant: Paclitaxel/carboplatin
Adjuvant: Nivolumab if Neoadjuvant was given
Radiation: 45 Gy x 24 fraction
Surveillance
H&P q3-6 months for years 1-2, 6-12 mo for years 3-5
EGD:
If endo ablation: q3 month x 1 year, q6month on year 2, annual after
Esophagectomy: CT CAP q6mo x 2y then annual until year 5. EGD if symptomatic.
Neuroendocrine tumor surveillance Algorithm
Pancreatic:
H&P + biochemical markers + CT abdomen in first year, then annual up to 10 years.
Pheo:
H&P + BP + 24h urine metanephrine/normetanephrine CT C/A/P annually up to 10 years.
Pancreatic adenocarcinoma Algorithm
Resectable: No vascular involvement/clear planes
Borderline: <180 SMA or celiac abutment, Short segment encasement of common hepatic artery amenable to recon, SMV/portal vein amenable to recon
Neoadjuvant chemo -> restage -> OR -> adjuvant
Chemo: FOLFIRINOX: 5FU, leucovorin, irinotecan, oxaliplatin
Radiation: 45 gy in 25 fractions
Surveillance:
H&P + CA19-9 + CT q6mo for 2 years then q6-12 months.
Melanoma Algorithm
CXR, LDH, CBC/CMP
If neuro symptoms, CT Brain
If positive lymph node biopsy, PET-CT and MultiDisp Board
Ask for BRAF stain on specimen
<1 mm - 1 cm margin
1-2 mm - 1-2 cm margin
>2 mm - 2 cm margin
SLNB if >= 1 mm deep or ulcerated
If SLNB positive, serial ultrasound q4month x2y then q6h mo until 6 years.
Adjuvant therapy (If node+ or >1 mm deep): PD-1 Pembrolizumab. BRAF V600 activating: Dabrafenib
Surveillance:
In situ: H&P annual
Stage IA/IIA: H&P q6-12mo x 5 y, then annual
Stage IIB-IV: q3-12 month x 2 y then 6-12 month x 3 years.
If SLNB+ not treated with CLNB: Regional U/S q4 month x 2 years then q6mo years 3-5.
