TUMOR REVIEW 2013 Flashcards
Early stage esophageal cancer treatment
surgery alone
stage I and II
T1-2; N0-1
Up to T3 N0
workup for esophageal cancer
EUS - best
PET for distal mets
workup for gastric cancer
EGD
EUS
PET
treatment of T1 gastric cancer
surgery alone
treatment of T2 and greater gastric cancer
neoadjuvant chemotherapy:
plantar laparoscopy
implants are positive cells on washing abort
4-5 cm margin
D1 (slight benefit of D2 for long term survival) - increased morbidity
need 15 lymph nodes
careful, Colon and rectum 12
treatment of lymphoma of the stomach (not MALT)
chemotherapy:
CHOP
With or without Rituxan
functional reserve needed for hepatocellular carcinoma resection
20% functional if normal
40% functional child A./B.
best treatment for hepatocellular carcinoma and cirrhotic
transplant
Milan Criteria for transplant
no mass greater than 5 cm
if more than one lesion not greater than 3 cm and not more than 3 lesions total
no vascular invasion
no metastases
stage I gallbladder cancer
T1
Confined the mucosa
cholecystectomy alone
stage II gallbladder cancer
T2
Extent into muscularis propria
segment IVb and 5 resection
Node dissection
cholangiocarcinoma
intrahepatic:
Resection of possible
Transplant poor results
Extrahepatic: proximal third: hilar resection Lymph nodes In block liver resection include caudate
middle third:
Bile duct excision
Nodes
Frozen section of common bile duct margin
distal third
Whipple!
Best imaging to workup pancreatic cancer
triple phase CT scan
defined unresectable pancreatic cancer
SMA-did not have impingement
( SMA left and posterior to SMV)
SMV U./portal vein- CAN have abutment or encasement but they must be patent
borderline:
Abutment of the mass to SMA
short segment SMV occlusion
UNRESECTABLE:
Encasement of SMA
occlusion the portal vein
treatment unresectable pancreatic cancer
biliary drainage:
Gastro J
vs
stents if obstruction
Celiac ganglion block with alcohol
can’t be percutaneous or endoscopic
( for failed narcotics)
best overall test for neuroendocrine tumor of the pancreas and algorithm
chromogranin A
Neg:
he did not have in her endocrine tumor your done
order presentation of MEN 1 tumors
parathyroid hyperplasia 90% pituitary adenoma 66% ( angiofibroma 64%) pancreatic: Gastrinoma 50% ( more likely benign then when sporadic) insulinoma 20%
order presentation of MEN 2a
medullary thyroid cancer 100%
parathyroid hyperplasia and 50%
pheochromocytoma >33% ( possibly up to 50%)
order presentation of MEN 2b
medullary thyroid cancer 85-100%
mucosal neuroma 100%
pheochromocytoma 50%
best localization test for gastrinoma
octreotide scan
endoscopic ultrasound for pancreatic
endoluminal inspection and palpation for duodenal
can’t find insulinoma intraoperatively
venous sampling
surgical treatment for neuroendocrine tumors
less than 2 cm:
enucleate
greater than 2 cm:
resect- Whipple
medication to stabilize the patient with insulinoma
diazoxide
by screening test for carcinoid and subsequent algorithm
chromogranin A (same as screening test as pancreatic neuroendocrine tumor)
Pos:
5HIAA
preop medical management of carcinoid
octreotide-avoid serotonin syndrome
treatment of rectal carcinoid
just to enucleate
do not cause carcinoid syndrome
bronchopulmonary carcinoids
can get carcinoid syndrome-bypass liver
effects mitral valve
careful, abdominal carcinoma his affect tricuspid via drainage
algorithm for working up pheochromocytoma
chromogranin A positive
plasma free metanephrine x2
24-hour urine metanephrine
substances producing pheochromocytoma when adrenal medulla versus sympathetic chain
adrenal medulla:
Norepinephrine and epinephrine
sympathetic chain/extra-adrenal:
epinephrine only
localization test for pheochromocytoma
MIBG scan - analog norepinephrine
alpha blockers
phenoxybenzamine
prazosin
treatment of intraoperative hypertension during pheochromocytoma resection
nicardipine
short-acting beta blocker ( labetalol)
extrapancreatic manifestation of glucagonoma
migratory necrolytic erythema
where our glucagonomas found
body and tail
treatment of glucagonoma
if body or tail can excise it
colon Surveillance if polyp is excised
colonoscopy 3-5 years
if negative:
q 10 years
stage I colon cancer
T1
T2
stage II colon cancer
T3
T4
right colon cancers get chemotherapy
all stage III
high risk
includes stage IIB:
T4 lesion with invasion of extracolonic viscera
HNPCC
Lynch syndrome
Lynch 2:
uterus
Brain
Not breast?
FAP
APC
flex sig or colonoscope yearly
starting age 10-15 yo!
Desmoid tumors ( also seen in Gardner syndrome)
Duodenal cancer more likely after ileorectal anastomosis IJAA
because resorbed bile and ileal rectal anastomosis carcinogenic to the duodenum
medical treatment of FAP
nonsteroidal anti-inflammatories and a decrease polyp formation
Peutz-Jeghers syndrome
STK11 weird name weird gene tumor suppressor
early colectomy
mucosal pigmented
juvenile polyposis syndrome
BMPRIA and SMAD
dominant
only cancer of 10%
Cowden syndrome
PTEN mutation tumors or pressor gene
dominant
extracolonic: Breast Endometrial Thyroid Kidney Skin papillomas Neurologic - nonmalignant brain tumors
colorectal cancer
hematomas:
Mucous membranes mouth and nose and skin
benign breast disease
non-medullary thyroid cancer
multinodular goiters
serrated polyp syndrome
also called a sessile ulcerated polyp syndrome
premalignant
Path:
Edges serrated
Non-hyperchromic nuclei
most common sites:
CECUM
ASCENDING colon
inactivated APC gene
treatment:
Endoscopic excision
treatment of rectal cancer
formal resection
T1 and T2 node neg:
done
All others (T3 or any nodes): NEOadjuvant chemo and XRT
Adjuvant chemo and XRT: Capecitabine or 5FU / leucovorin 4500-5000 Gy
treatment of colorectal hepatic metastasis
treated simultaneously or stage
Neoadjuvant or adjuvant chemotherapy
Treatment of pulmonary colorectal metastases
more common with rectal
Consider resection
Ultrasound rectal findings
First black layer: Muscularis propria/lamina propria
this layer is penetrated to be T1
Second black layer:
T2
Past the second Black layer:
T3-4
squamous cell carcinoma of the anus
Niagro protocol
mitomycin-C
5-FU
4500 gray
persistent disease after nigra protocol with squamous cell carcinoma of the anus
Second line chemotherapy/XRT
Or
Excision
Failed second line:
APR with groin dissection if node positive
Melanoma Of the anus
Local excision
Only APR sphincters involved
adenocarcinoma the anus
treated with rectal adenocarcinoma protocol
Neoadjuvant chemoradiation
Excision APR
Treatment of squamous and basal cell skin cancer
surgery radiation for either
management of clinically enlarged nodes with squamous cell of the lip and
FNA
drainage of skin cancer parietal region of the head
parotid gland
May need superficial parotidectomy for melanoma’s
indications for sentinel node for melanoma
1 mm greater
possible no sentinel node F. greater than 4 mm-patient most likely has systemic disease
melanoma management went groin node is positive
superficial node dissection
STOP at Cloquet’s node end do frozen section
the frozen section positive:
Proceed with deep femoral node dissection
includes region along femoral artery
NOT up to iliacs
alternate treatment for squamous cell carcinoma in situ SCC Cis (and name for this)
Bowman’s disease
consider topical: 5-FU imiquimod Photodynamic cryotherapy
management squamous cell carcinoma Considered more advanced: large tumor OR positive nodes
this is unusual
less than 3 cm positive node:
excision ipsilateral selective neck dissection
greater than 3 cm or multiple nodes:
excision and comprehensive neck dissection
with postoperative radiation for squamous cell carcinoma
extracapsular invasion
Greater than 2 positive nodes
Lymph node greater than 3 cm in size
Positive margin
staging for squamous cell carcinoma skin cancer
T1 up to 2 cm
T2 greater than 2 cm with high-risk features
T3 invasion maxilla mandible
T4 Skeletal invasion neuro invasion skull base
adjuvant treatment for melanoma
interferon first
If fails:
Interloop and 2 by protocol
new drug for melanoma
Ipilimumab
(Yervoy)
Used for metastatic disease
most common type of melanoma
superficial spreading
best prognosis type of melanoma
lentigo
worsed prognosis melanoma
nodular
Merkel cell
wide excision
Include node dissection
Postop chemotherapy and radiation
low risk GIST criteria
less than 5 cm
less than 5 mitoses per high-power field
intermediate GIST
5-10 cm
5-10 mitoses
high risk GIST
greater than 10 cm
greater than 10 mitoses
when is Gleevack given for GIST ( generic name for Gleevack)
Imatinib
high risk:
Greater than 10 cm
Greater than 10 mitoses
now treat for 5 years
other medication for GIST
Sunitinib
Adjuvant for soft tissue sarcoma
Greater than 5 cm
close margin or sparing major involved structure or close / pos margin
workup and treatment for soft tissue sarcoma
less than 3 cm:
start with wide excisional biopsy
3 cm or greater:
core needle biopsy
if positive:
Wide excision 2 cm margin
en bloc vascular resection with reconstruction
spare muscle group and nerves
NEOadjuvant CHEMO: Ewings Rhabdo Osteosarcoma synovial sarcoma Round cell liposarcoma LARGE pleomorphic liposarcoma
management of positive margin soft tissue sarcoma
brachy therapy
NOT reexcision
staging a soft tissue sarcoma
less than 5 cm
5-10 cm
Greater than 10 cm
nuclear grade
soft tissue sarcoma that go to lymph nodes
synovial - lots of drainage here
Clear cell - cell is clear like lymph
Epitheloid
Rhabdomyosarcoma
common soft tissue sarcoma
Most common:
Epithelioid malignant histiocytoma
Second:
Liposarcoma
Third:
Leiomyosarcoma
treatment of retroperitoneal sarcoma
complete resection
en bloc adjacent organs
treatment of papillary thyroid cancer
less than 1 cm:
Total thyroidectomy and done
postoperative levothyroxine
greater than 1 cm:
Total thyroidectomy
Central node dissection (VI)
Palpable nodes: Modified radical neck dissection or central neck level VI Lateral levels 2 through 5b Ablation
postop thyroglobulin elevated:
metastatic workup
iodine-131
treatment of thyroid Hurthle cell
positive tissue diagnosis
Thyroidectomy and central node dissection
how is a follicular or Hürthle cell carcinoma diagnosed by pathology
vascular or capsular invasion-cannot be determined on FNA
prognosticators for papillary carcinoma
AMES age 45 Mets Extension Size > 4 cm
Aggressive: tall cell, columnar cell, poorly differentiated
treatment of residual positive margin papillary thyroid
re resect if possible
indications for iodine-131
greater than 1 cm papillary
Greater than 2 cm follicular/ Hurthle cell
cervical nodes
treatment of follicular thyroid cancer
thyroidectomy
NO central node dissection
iodine-131
follow thyroglobulin
treatment of medullary thyroid cancer
Get chromogranin a - negative no pheo
total thyroidectomy
4 gland parathyroidectomy with reimplantation
Central node dissection
NO iodine-131 ablation - will not work on medullary tissue
follow with calcitonin
age for recommended thyroidectomy in MEN 2a vs MEN 2b
MEN 2b WORSE :
total thyroidectomy before one year of age!
MEN 2a:
Total thyroidectomy before the age of 5
most common location for medullary cancer in the thyroid gland
UPPER lobes
because the fourth pouch settles and upper
for head and neck cancer adjuvant therapy recommended if node dissection done
radiation therapy
lip, oral cavity, salivary gland T. stage
TI - less than 2 cm
T2 2-4 cm
T3 greater than 4 cm
( and or extraparenchymal extension)
T4a invaded skin and bone, other adjacent structures, ear canal, facial nerve
T4b invades skull base, masticator space, pterygoid plates, encases internal carotid
lip, oral cavity, salivary gland N stage
N1 single ipsilateral less than 3 cm
N2 single ipsilateral 3-6 cm
(or multiple ipsilateral, bilateral, contralateral less than 6 cm)
N3 greater than 6 cm
lip oral cavity salivary gland stage
I TI less than 2 cm
II T2 2-4 cm
III T3 ( greater than 4 cm / extension)
or
N1 ( single ipsilateral node less than 3 cm)
IV T4 invades skin bone and nerve
or
N2 single node 3-6 cm; bilateral nodes less than 6 cm
or
N3 greater than 6 cm
mucosal melanoma adjuvant treatment
stage III-4
wide local excision
neck dissection
postoperative radiation therapy
stage IV:
chemotherapy or radiation therapy
occult primary head and neck cancer
FNA node workup likely source: adenocarcinoma female breast male prostate
defined high-risk breast cancer
1.66% in 5 years
20% lifetime
management of nipple discharge from isolated duct
one duct
excised duct
diagnosis intraductal papilloma
management of nipple discharge from multiple ducts
mammography
breast cancer stage
TI less than 2 cm
T2 2- 5 cm
T3 greater than 5 cm
T4 extra lesional extension chest wall skin
N1 1-3
N2 4-9
N3 10 or greater
stage I
T1 less than 2 cm
micro-node met less than 2 mm
stage II
T1-3
N0-1
stage III
T3 N1-2
T4
breast cancer that gets chemotherapy
greater than 1 cm
who gets tamoxifen
premenopausal DCIS LCIS ER PR Positive ER/PR NEGATIVE - reduces chance of second primary
negative effect of aromatase inhibitor
decreased bone density
who can avoid chemotherapy
elderly woman with ER/PR positive
tamoxifen instead
breast cancer types associated with decreased survival
luminal type a
Luminal type B
Basal
implication of triple negative
ER/PRHer2neu negative bad prognosis ( even though HER-2/neu is more aggressive- being positive means there is Herceptin available)
breast cancer first trimester
modified radical mastectomy with node dissection
breast cancer second trimester
lumpectomy
start chemotherapy second trimester
start radiation therapy post delivery
breast cancer third trimester
lumpectomy start chemotherapy
Radiation therapy post delivery
sentinel node for pregnancy
no
no data on isotope and dye safety and pregnancy
management of inflammatory breast cancer not responding to neoadjuvant chemotherapy
continue chemotherapy
At radiation therapy
management of patient not responding to neoadjuvant chemotherapy and tried adding radiation therapy with no response
no surgery
when the sentinel node done for DCIS
high-grade
if mastectomy is being done
recent study demonstrated what regarding completion lymphadenectomy with sentinel node positive
Z0011
it less than 2 sentinel nodes positive and there is no lymphovascular invasion or capsular extension:
no value in completion lymphadenectomy..
treatment mesothelioma
localize:
Extrapulmonary pneumonectomy
chemotherapy
radiation therapy
unresectable or sarcomatoid:
( diffuse-entire pleural surface,contralateral pleura, extension chest wall etc.)
Just sclerose pleural cavity with talc
lung cancer treated with resection
stage I and 2
possible stage IIIa ( with good response to neoadjuvant)
abdomen considered for all resected patient’s
what stage is chest wall expansion
stage IIB ONLY - proceed
what lung cancer nodal stage is not resectable in most cases
N2
value of postoperative radiation
decreased local recurrence
NO survival bandage
where metastatic exceptions where a surgery for lung cancer and metastatic excision was performed
solitary brain metastasis
excise symptomatic organ first - example, seizures mandate metastasis excision first
lung cancer tumor stage
T1 less than 3 cm
T2 3-7 cm
or
involved: main bronchus, distal to the carina, visceral pleura, obstructive pneumonitis,
T3 greater than 7 cm
PARIETAL pleura, IN main bronchus, entire lung pneumonitis
T4 any size mediastinum, heart ( careful, not just pericardium), great vessels Trachea Recurrent laryngeal nerve Esophagus Carina different ipsilateral lobe ( careful, contralaterals metastatic disease)
lung cancer node stage
N1 ipsilateral
intrapulmonary node
peribronchial
hilar
N2 ipsilateral
mediastinum
subcarinal
N3 contralateral mediastinum hilar or any scalene any supraclavicular
lung cancer stage
I
T1 less than 3 cm
T2 3-5 (notb 5-7)
II
T1-3
N1
III a
T1-3 and T4!
N 1-2 (NOT N3)
IIIb
T4 ALSO or N3
Supraclavicular node out for resection!
