Cancer Incidence and Diagnosis Dr. Reham Abdulmonem A. Consultant Radiation Oncology KFMC, PSHOC Lecturer Radiation Oncology NCI, Cairo University
Jan 20, 2016
Cancer Incidence and Diagnosis
Dr. Reham AbdulmonemA. Consultant Radiation Oncology
KFMC, PSHOC
Lecturer Radiation Oncology
NCI, Cairo University
Radiotherapy Applications
RAD 462
Course Description
This course is designed to provide the student with clinical aspects of radiation oncology as well as techniques used for simulation and treatment delivery.
Site specific topics will include brain, head & neck, lung, breast, pelvis and lymphoma.
Educational Goals
By the end of this course you will be able to:
Discuss the patient’s progress from the first indication of serious illness, to diagnostic and surgical work-up, to referral, treatment and follow-up in the radiation oncology department.
Discuss the factors influencing the choice of management tools of cancer patient.
Educational Goals (cont.,)
Explain principles and applications of radiotherapy in the treatment of tumors of the following anatomical system/sites: CNS, head and neck, breast, lung, bladder, rectum, and lymphoid tissue.
Describe patient care during RT and the side effects of RT on different body organs and tissues.
Educational Goals (cont.,)
Identify simple simulation and localization procedures.
Identify simple treatment procedures.
Describe the steps and materials involved with formation of shielding blocks.
Apply principles of radiation protection.
Demonstrate professionalism through personal appearance and behavior.
Evaluation
Your course grade will be based on the following:
1 Two mid term exam (W6-W11)
40
2 Lab assignment* 15
3 Course project 5
4 Final Exam 40
Total 100* Visits to Radiation Oncology
Department
References
•Water and Miller’s: Textbook of
Radiotherapy.
•Gunilla C. Bentel: Radiation Therapy
Planning:
•Faiz M. Khan: Treatment Planning in
Radiation Oncology.
USA Mortality at 2006
1. Heart Diseases 685,089 28.0
2. Cancer 556,902 22.7
3. Cerebrovascular diseases 157,689 6.4
4. Chronic lower respiratory diseases 126,382 5.2
5. Accidents (Unintentional injuries) 109,277 4.5
6. Diabetes mellitus 74,219 3.0
7. Influenza and pneumonia 65,163 2.7
8. Alzheimer disease 63,457 2.6
9. Nephritis 42,453 1.7
10. Septicemia 34,069 1.4
Rank Cause of DeathNo. of deaths
% of all deaths
Change in the US Death Rates* by Cause, 1950 & 2003
1950
2003
21.9
180.7
48.1
586.8
193.9
53.3
190.1
231.6
0
100
200
300
400
500
600
Rate Per 100,000
Heart Disease Cerebro-vascular Pneumonia-influenza Cancer
2006 Estimated US Cancer Deaths*
ONS=Other nervous system.Source: American Cancer Society, 2006.
Men291,270
Women273,560
26% Lung & bronchus
15% Breast
10% Colon & rectum
6% Pancreas
6% Ovary
4% Leukemia
3% Non-Hodgkin lymphoma
3% Uterine corpus
2% Multiple myeloma
2% Brain/ONS
23% All other sites
Lung & bronchus 31%
Colon & rectum 10%
Prostate 9%
Pancreas 6%
Leukemia 4%
Liver & intrahepatic 4%bile duct
Esophagus 4%
Non-Hodgkin 3% lymphoma
Urinary bladder 3%
Kidney 3%
All other sites 23%
Cancer Death Rates*, for Men, US,1930-2002
0
20
40
60
80
100
1930
1935
1940
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
Lung
Colon & rectum
Stomach
Rate Per 100,000
Prostate
Pancreas
LiverLeukemia
Cancer Death Rates*, for Women, US,1930-2002
0
20
40
60
80
100
1930
1935
1940
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
Lung
Colon & rectum
Uterus
Stomach
Breast
Ovary
Pancreas
Rate Per 100,000
2006 Estimated US Cancer Cases*
Men720,280
Women679,510
31% Breast
12% Lung & bronchus
11% Colon & rectum
6% Uterine corpus
4% Non-Hodgkin lymphoma
4% Melanoma of skin
3% Thyroid
3% Ovary
2% Urinary bladder
2% Pancreas
22% All Other Sites
Prostate 33%
Lung & bronchus 13%
Colon & rectum 10%
Urinary bladder 6%
Melanoma of skin 5%
Non-Hodgkin4% lymphoma
Kidney 3%
Oral cavity 3%
Leukemia 3%
Pancreas 2%
All Other Sites 18%
* For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2000 to 2002.
Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan
Lifetime Probability of Developing Cancer, by Site, Men, 2000-2002*
† All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary bladder .
Site Risk
All sites† 1 in 2
Prostate 1 in 6
Lung and bronchus 1 in 13
Colon and rectum 1 in 17
Urinary bladder‡ 1 in 28
Non-Hodgkin lymphoma 1 in 46
Melanoma 1 in 52
Kidney 1 in 64
Leukemia 1 in 67
Oral Cavity 1 in 73
Stomach 1 in 82
‡ Includes invasive and in situ cancer cases
Lifetime Probability of Developing Cancer, by Site, Women, US, 2000-2002*
Site Risk
All sites† 1 in 3
Breast 1 in 8
Lung & bronchus 1 in 17
Colon & rectum 1 in 18
Uterine corpus 1 in 38
Non-Hodgkin lymphoma 1 in 55
Ovary 1 in 68
Melanoma 1 in 77
Pancreas 1 in 79
Urinary bladder‡ 1 in 88
Uterine cervix 1 in 135
Five-year Relative Survival (%)* during Three Time Periods By Cancer Site
Site 1974-1976 1983-1985 1995-2001All sites 50 53 65
Breast (female) 75 78 88
Colon 50 58 64
Leukemia 34 41 48
Lung and bronchus 12 14 15
Melanoma 80 85 92
Non-Hodgkin lymphoma 47 54 60
Ovary 37 41 45
Pancreas 3 3 5
Prostate 67 75 100
Rectum 49 55 65
Urinary bladder 73 78 82
†
Cancer Incidence Rates* in Children 0-14 Years, by Site, 1998-2002
Site Male Female Total
All sites 15.6 14.3 15.0
Leukemia 4.9 4.2 4.6
Acute Lymphocytic 3.9 3.4 3.6
Brain/ONS 3.6 3.3 3.5
Soft tissue 1.1 0.9 1.0
Non-Hodgkin lymphoma 1.2 0.6 1.0
Kidney and renal pelvis 0.8 1.0 0.9
Bone and Joint 0.6 0.6 0.6
Hodgkin lymphoma 0.6 0.5 0.5
Cancer Death Rates* in Children 0-14 Years, by Site, US, 1998-2002
Site Male Female Total
All sites 2.7 2.3 2.5
Leukemia 0.8 0.7 0.8
Acute Lymphocytic 0.4 0.3 0.4
Brain/ONS 0.8 0.7 0.7
Non-Hodgkin lymphoma 0.1 0.1 0.1
Soft tissue 0.1 0.1 0.1
Bone and Joint 0.1 0.1 0.1
Kidney and Renal pelvis 0.1 0.1 0.1
Screening Guidelines for the Early Detection of Breast Cancer, American Cancer Society
Yearly mammograms are recommended starting at age 40.
A clinical breast exam should be part of a periodic health exam, about every three years for women in their 20s and 30s, and every year for women 40 and older.
Women should know how their breasts normally feel and report any breast changes promptly to their health care providers. Breast self-exam is an option for women starting in their 20s.
Women at increased risk (e.g., family history, genetic tendency, past breast cancer) should talk with their doctors about the benefits and limitations of starting mammography screening earlier, having additional tests (i.e., breast ultrasound and MRI), or having more frequent exams.
Screening Guidelines for the Early Detection of Cervical Cancer, American Cancer Society
Screening should begin approximately three years after a women begins having vaginal intercourse, but no later than 21 years of age.
Screening should be done every year with regular Pap tests or every two years using liquid-based tests.
At or after age 30, women who have had three normal test results in a row may get screened every 2-3 years. However, doctors may suggest a woman get screened more frequently if she has certain risk factors, such as HIV infection or a weakened immune system.
Women 70 and older who have had three or more consecutive Pap tests in the last ten years may choose to stop cervical cancer screening.
Screening after a total hysterectomy (with removal of the cervix) is not necessary unless the surgery was done as a treatment for cervical cancer.
Screening Guidelines for the Early Detection of Colorectal Cancer, American Cancer Society
Beginning at age 50, men and women should follow one of the following examination schedules:
A fecal occult blood test (FOBT) every year
A flexible sigmoidoscopy (FSIG) every five years
Annual fecal occult blood test and flexible sigmoidoscopy every five years
A double-contrast barium enema every five years
A colonoscopy every ten years
Screening Guidelines for the Early Detection of Prostate Cancer, American Cancer Society
The prostate-specific antigen (PSA) test and the digital rectal examination (DRE) should be offered annually, beginning at age 50, to men who have a life expectancy of at least 10 years.
Men at high risk (African-American men and men with a strong family history of one or more first-degree relatives diagnosed with prostate cancer at an early age) should begin testing at age 45.
For men at average risk and high risk, information should be provided about what is known and what is uncertain about the benefits and limitations of early detection and treatment of prostate cancer so that they can make an informed decision about testing.
Diagnosis
Clinical Presentations
Warning
Signs of
Cancer
Diagnostic Workup
Purpose:Purpose:
Confirm diagnosis
Determine the disease stage,
Information required for treatment decision.
Methods:Methods:
History,
Examination: General and Local
Investigations: Laboratory, Medical Imaging, Endoscopies, and Pathological.
Biopsy
Importance:Importance:Confirm diagnosis (the single most).
Histopathologic type:• Cararcinoma, sarcoma, lymphoma,. .
etc.
Grading of cancer:• Degree of malignancy (grade 1-4),
• Therapeutic and prognostic implications
Types:Types:Needle, incisional or excisional.
Medical ImagingPurpose:Purpose:
–Determine the extent of local disease,
–Involvement of regional nodes, and
–Presence or absence of distant metastases.
Include:Include:
–Chest x-ray film,Chest x-ray film,
–Mammogram, Mammogram,
–Radionuclide scan,Radionuclide scan,
–Ultrasonography,Ultrasonography,
–Computed Tomography,Computed Tomography,
–Magnetic Resonance Imaging,Magnetic Resonance Imaging,
–Positron Emission Tomography.Positron Emission Tomography.
Staging Classification
Characteristics of workable Characteristics of workable classification:classification:
Useful in making therapy decision,
Prognostic implication,
Help in evaluating treatment results,
Ease with exchange of information.
Tumor-node-metastasis (TNM) Tumor-node-metastasis (TNM) system.system.
T: primary tumor extension,
N: lymphatic involvement,
M: distant metsatsis.
Diagnosis
History
Physical Examination
Pathology
Genetics
Tumor Markers
Radiological imaging
Blood work
History of present illness
Past Hx (Past Cancer,Sx,CTx,Rx)
Family history
Gynacological history
Social history
Cancer Symptoms
CNS HA,Motor & Sensor dysfunction,Seizure,cognitive dysfunction,Ataxia,gait
Breast Lump, Nipple discharge, Axillary lump
Lung Chest pain, cough, Haemoptysis, SOB
Colorectal Pain, constipation, Diarrhea, Bleeding
Gastric Pain, Haematemesis, Vomitting
Esophagus Dysphagia, odynophagai, cough
cervix Vaginal bleeding, pain,
Nasopharynx Hearing loss, Neck mass, nasal obstruction, Epistaxis
larynx Hoarseness, Sore throat, Otalgia, pain,SOB ,
Bladder Haematuria, dysuria, Urgency
Lymphoma Lump, fatigue, Itching (B symptoms, Fever, Weight loss, sweating)
General ( weight , vital sign , appearance , skin, sign of anaemia )
Lymphatic system
Breast
Respiratory system
CVS
GYN system
RECTAL
CNS
Head & Neck
CBC
Ca , Mg , Ph , .. ) ) Eletrolyte
RFT
LFT
Hormones
Virology Titer
Tumor Marker
Primary Tumor Other Tumors Benign conditions
AFP HCCa and nonseminomatous germ cell tumors
Gastric, biliary, and pancreatic Cirrhosis, Viral hepatitis , pregnancy
B-2 microglobulin Multiple myeloma Other B Cell neoplasms, lung, hepatoma, breast
Ankylosing spondylitis, Reiters syndromeCA125 ovarian Endometrial, Fallopian tube,
breast, lung, esophageal, gastric, hepatic, pancreatic
Menstruation, pregnancy, fibroid, ovarian cysts, cirrhosis, ascites, endometriosis
CA15-3 Breast Ovary, lung, prostate Benign breast or ovarian disease, endometriosis, hepatitis, pregnancy , lactation
CA19-9 Pancreatic, biliary tract Colon, esophageal, hepatic Pancreatitis, biliary disease, cirrhosis
CA27.29 Breast Colon, gastric, hepatic, lung, pancreatic, ovarian, prostate
Breast, liver, kidney disorders, ovarian cysts
Calcitonin Medullary
Thyroid
Metastatic breast, lung, pancreas, hepatoma, renal cell, carcinoid
Zollinger-Ellision syndrome, pernicious anemia,chronic renal, pregnancy
Prostatic acid phosphatase
prostate Testicular, leukemia, non-hodgkin’s lymphoma
Paget’s disease , osteoporosis, cirrhosis, pulmonary, embolism, hyperparathyroidism
PSA prostate none Prostatitis, BPH, prostate trauma, after ejaculation
Thyroglobulin Differentiated thyroid cancer (not medullary )
Hyperthyroidism, subacute thyroiditis, benign adenoma
Chromosomal changes Human cancer
Deletion (1), Gene amplification Neuroblastoma
Translocation (1-8) , (8-22) Burkitt’s lymphoma
Deletion (5) Acute nonlymphocytic Leukemia
Deletion (11) Sarcoma
Translocation (8-14) B-Cell Lymphoma
Translocation (3-8) Parotid Cancer
Translocation (6-14) Carcinoma
Gene amplification Breast Cancer
a = anterior cerebral artery m = middle cerebral artery fh = frontal horn - lateral ventricleph = posterior horn - lateral ventriclecc = corpus callosum
1 = prostate 2 = rectum 3 = obturator internus 4 = ischium5 = body of pubis6.= pubic symphysis7 = femoral artery8 = femoral vein
6 cm right posterior parietal lesion
Irregular margins, infiltrating tumour
Rim-enhancing, central necrosis
Mass effect / edema
Beware corpus callosum involvement
42
81 yo female with headache, confusion, ? History of fever
referred for radiation without biopsy
labelled WBC scan +
diagnosis = abscess
resected/drained - well 2 years later
43