INTERNAL MEDICINE - ONCOLOGY

TABLE SUMMARY

SCREENING TESTS DIAGNOSIS

BREAST CANCER MAMMOGRAPHY CORE NEEDLE BIOPSY preferred over Fine Needle
- gold standard for screening biopsy, excisional and incisional biopsy
- annual or biannual for women past the age of 40

MRI
- for women who are BRCA-1 and BRCA-2 carrier
- with hx of radiation therapy bet. ages 10 & 30 yrs
- Hx of Li-Fraumeni, Cowden or Banayan-Riley -
Ruvalcaba

LUNG CANCER Routine CT scan screening cannot be recommended for SPUTUM CYTOLOGY
any risk group - for larger and centrally located tumors
- sensitivity <70%
Majority of patients with lung cancer present with advanced - specificity: close to 100%
disease
TRANSBRONCHIAL FINE NEEDLE BIOPSY
*so based lang sa presentation and hx, request for Chest - highest sensitivity of 80%
X-ray to look for a mass - for larger lesions & peripheral tumors

TRANSTHORACIC FINE NEEDLE BIOPSY

- 70-95% sensitivity
- usually for peripheral tumors

The decision as to what kind of biopsy will do will

depend on the location of the tumor
(peripheral/central)

COLON CANCER COLONOSCOPY Biopsy done during Colonoscopy na rin if may

- gold standard for screening makitang polyps

other methods:
- DRE
- Barium enema: if there is no obstruction
- Flexible Sigmoidoscopy

Fecal occult blood testing is no longer being done

ESOPHAGEAL CANCER PERIODIC ENDOSCOPIC Biopsy done at the same time with endoscopy
- for HIGH RISK groups only: Barrett’s esophagus
esp. with dysplasia for 3 mos

no recommended screening for asymptomatic general

population

GASTRIC CANCER no routine screening GASTROSCOPIC BIOPSY and BRUSH CYTOLOGY

should be done for all patients with a gastric ulcer in
order to exclude a malignancy

PANCREATIC CANCER No routine screening DUAL-PHASE CONTRAST ENHANCED SPIRAL CT

Core needle biopsy
Serum Markers

LIVER CANCER ULTRASONOGRAPHY Radiologic Diagnosis

- For high risk groups FOUR-PHASE CONTRAST ENHANCED CT
- Every 6 months with or without AFP - Hallmark: contrast uptake in arterial phase
- <1 cm nodule: shorter follow-up interval and washout in venous or delayed phase
- >1 cm nodule: do FOUR-PHASE
CONTRAST-ENHANCED CT Biopsy
PERCUTANEOUS LIVER BIOPSY
CT and MRI not recommended as screening tools - Required in:
AFP alone has high false-positive results - People with cirrhosis
- If imaging is not typical (either CT
and MRI)

AVIS
 INTERNAL MEDICINE - ONCOLOGY
TABLE SUMMARY
High Risk lesions
● ATYPICAL DUCTAL
HYPERPLASIA
○ 86% risk reduction with
tamoxifen
○ Close follow-up
● LOBULAR CARCINOMA IN
SITU (LCIS)
○ 56% reduction with
tamoxifen
○ Bilateral prophylactic
mastectomy considered
○ Close follow-up
STAGE 1 & 2 NSCLC
Surgery + Adjuvant
chemotherapy
- Lobectomy: superior to
wedge resection;
- Pneumonectomy:
reserved for very central
tumors
- chemo: Cisplatin +
Vinorelbine
AVIS
TREATMENT/MANAGEMENT
BREAST CANCER
Non-Invasive Breast cancer Invasive Breast Cancer Male Breast Ca
● DUCTAL CARCINOMA IN ● EARLY STAGE BREAST ● Mastectomy and axillary
SITU (DCIS) CA (I IIA IIB) lymph node dissection or
○ Lumpectomy + RT ○ Surgery; MRM or SLNB
○ Simple mastectomy as lumpectomy + RT, axillary
alternative lymph node dissection
○ tamoxifen
○ RT: post mastectomy RT to
chest wall and
supraclavicular LN
○ Systemic therapy: chemo +
hormonal therapy
> premenopausal ER/PR+ :
chemo + hormonal
> postmenopausal ER/PR+ :
Hormonal therapy
> ER/PR– : chemo only
● LOCALLY ADVANCED
AND INFLAMMATORY
BREAST CA (IIIA IIIB)
○ Neoadjuvant chemotherapy
○ Surgery after best response
to preop chemo
○ RT to chest wall and
supraclavicular area
● METASTATIC BREAST CA
○ Palliation
○ ER/PR+ : hormonal tx as
first line
○ ER/PR- : chemo tx as first
line
LUNG CANCER
STAGE 3 NSCLC STAGE 4 NSCLC SCLC
Chemotherapy + Radiotherapy Standard medical mngt, pain - Chemoradiotherapy with
medications, use of RT & cisplatin-etoposide for 4
chemotherapy
cycles
● Chemotherapy
○ Superior to best supportive
care
○ 1st line: platinum based
❖ Adenocarcinoma:
paclitaxel-carboplatin
❖ SCC:
gemcitabine-cisplatin
❖ *no mention of histology:
choose
f
paclitaxel-carboplatin
○ 2nd line:
Erlotinib-Gefitinib
❖ For EGFR (+)
❖ Works best for
Adenocarcinoma
 INTERNAL MEDICINE - ONCOLOGY
TABLE SUMMARY
STAGE 1
Surgery
(Polypectomy and Local Excision)
SYSTEMIC CHEMOTHERAPY
● Backbone treatment: 5-FU
● FOLFIRI REGIMEN: irinotecan, 5 FU, leucovorin
○ Side effect: Diarrhea
● FOLFOX REGIMEN: oxaliplatin, 5 FU, leucovorin
○ Side effect: Sensory Neuropathy
VERY EARLY & EARLY STAGE
● Very early stage:
Endomucosal resection
alone
● Early stage: Surgery alone ~
Esophagectomies
*(with Chemo-RT?)
EARLY STAGE (STAGE I)
Surgery without perioperative
systemic therapy
RESECTABLE DISEASE
Surgery
● Tumor in the head or uncinate
body: PYLORUS SPARING
PANCREATICODUODENECTO
MY (Modified Whipple)
● Tumor in the body or tail:
DISTAL PANCREATECTOMY
PostOp adjuvant therapy with
mFOLFIRINOX (modified folinic
acid, 5 FU, irinotecan, oxaliplatin)
AVIS
COLON CANCER
STAGE 2
Surgery +/- Adjuvant
chemotherapy
● Decision to add adjuvant
chemotherapy is whether
there are predictors of poor
outcome
ESOPHAGEAL CANCER
ADVANCED METASTATIC
STAGE
● PALLIATION
○ Repeated endoscopic
dilatation
○ Gastrostomy or jejunostomy
for feeding
○ Metal stent to bypass the
tumor
○ Endoscopic fulguration
GASTRIC CANCER
LOCALLY ADVANCED TUMORS
(IIA, IIB, III)
Multimodality therapy (surgery
and systemic chemo)
~neoadjuvant and post op therapy:
Platinum + 5FU given 3-4 cycles
FOLFOX, FLOT
PANCREATIC CANCER
LOCALLY ADVANCED DISEASE
Chemotherapy + RT or
chemotherapy alone
- Goal is to reduce the bulk to
become resectable
STAGE 3
Surgery + adjuvant
chemotherapy (oxaliplatin
based)
**
STAGE I and II
- Surgery
- Chemo-RT after surgery
STAGE III and IV
- Chemo-RT only
LOCALLY ADVANCED CA (T3/T4
OR NODE POSITIVE)
Preop therapy then surgery then
post op chemo or post op
chemo-RT
~ Chemo-RT:
Platinum + 5FU (FOLFOX)
If HER2+, give trastuzumab +
cytotoxic chemotherapy
ADVANCED METASTATIC
DISEASE
Systemic chemotherapy
● Single agent Gemcitabine
STAGE 4
Palliative chemotherapy +
targeted therapy
● Bevacizumab
● Cetuximab
● Panitumumab
*Harrison’s
Standard of care option:
Systemic drug therapy + external
beam radiation therapy
SCC of upper and mid
esophagus:
Combined chemo-RT with surgery
reserved for patients not achieving
a complete radiographic and
endoscopic response (standard of
care option)
Metastatic disease:
Goal of therapy is symptom
palliation and life extension
**
STAGE I and II
● Surgery, determine the location
○ Distal carcinoma: subtotal
gastrectomy
○ Proximal carcinoma: total
or near-total gastrectomy
STAGE III and IV
● Usually Chemo-RT alone
Patients with SPECIFIC
MOLECULAR PROFILE
● BRCA1, BRCA2, PALB2:
○ PARP inhibitors
● Microsatellite instability
○ Checkpoint inhibitors,
anti-PD-1 and anti-PD-L1
antibodies
 INTERNAL MEDICINE - ONCOLOGY
TABLE SUMMARY
LIVER CANCER

AVIS