CANCER 2.

Familial Adenomatous Polyposis

• Disease in which abnormal cells: ▪ Mutation in FAP gene
➢ divide without control ▪ Thousands of polyps in the colon
➢ invade nearby tissues ▪ Manifestation: mucoid diarrhea
➢ spread to different parts of the body via the blood and lymphatic ▪ Treatment: Prophylactic colectomy
system 3. Neurofibromatosis
▪ Mutation in NF11 or NF22 genes
Types of Cancer ▪ Manifestation: freckle that develops into a neurofibroma
▪ Usually manifested in women; Men are carriers
4. Hereditary Breast-Ovarian Cancer Syndrome (HBOCS)
▪ Mutation in BRCA1 or BRCA2 gene
▪ Chance of inheritance:
o Breast cancer: 88%
o Ovarian cancer: 44%
Carcinoma ▪ Treatment: prophylactic mastectomy and ovariectomy
• Origin: Lining epithelium  Example: Case of Angelina Jolie
• Treatment: surgery followed by chemotherapy − had skin-sparing mastectomy – the areola was incised
• Most are radioresistant circular and everything inside the breast except the skin
• Usually spread through the lymphatics that’s why an integral was removed then an implant was placed (subcutaneous
part of treatment is lymph node surgery mastectomy)
❖ In situ carcinoma 5. Gardner’s Syndrome
- carcinoma that leaves the basement membrane intact ▪ Manifestation: multiple cysts on the skin
- hasn’t spread yet because all the means for spreading 6. Multiple Endocrine Neoplasia Type 2 (MEN Type 2)
(blood vessels, lymphatics, nerves) are found beneath the ▪ Cancer of parathyroid, pituitary, pancreas and adrenal
basement membrane glands
- treatment: surgery alone (chemotherapy not needed ▪ Hypercalcemia leads to recurrent kidney stones
because there is no spread) ▪ Tumors in the adrenals will cause elevated blood pressure
❖ Invasive (Infiltrating) Cancer ❖ All colorants used for clothes, bags, paint, food are possible
- when the basement membrane has been invaded
carcinogens.
❖ Most toxic: (found in cheese, Doritos, ketchup, etc.)
Sarcoma
➢ Yellow #5
• Affects structures located beneath the basement membrane
➢ Yellow #6
(blood vessels, nerves, fats, bones, etc.)
❖ Least carcinogenic: Blue
• Treatment: surgery followed by radiation
• Most are chemo-resistant Cancer Diagnosis
• Do not metastasize to the lymph nodes • Radiology will give the idea, but definitive diagnosis is made by
❖ The treatment for most solid tumors is surgery followed by getting a piece of the mass – biopsy.
either chemotherapy (for carcinomas) or radiation (for • Biopsy
➢ Accessible/Palpable
sarcomas).
o Excision Biopsy
- Removal of the whole mass
Leukemia, Lymphoma and Multiple Myeloma (LLMM) (≤ 3cm)
• Role of surgery: for biopsy and complications only
• Treatment: Chemotherapy alone

CNS Cancers
• Contained by dura

Causes of Cancer o Incision Biopsy

- Removal of a piece of the
mass (>3cm)

• Sporadic – usually affects a single person in the family

• Familial – best example is thyroid cancer
▪ Papillary thyroid cancer – related to iodine excess
▪ Follicular thyroid cancer – capsular invasion
− seen in people in highlands o Fine Needle Aspiration Biopsy
• Hereditary Cancers - Uses 23 or 21-gauge needle
− Treatment: Prophylactic Surgery - For cytology
❖ Tuberculosis - chalk-like substance
− Penetrance is almost always 100%
is aspirated from cervical lymph node
− Clues of hereditary cancers:
➢ Unusual age
o Breast: 5th decade (41-50 years old)
o Others: 6th decade onwards (50 years and above)
➢ Paired organ with cancer (Bilateral)
1. Retinoblastoma
▪ Mutation in RB1 gene, a tumor suppressor gene
▪ First sign in children: Absence of red orange reflex (ROR)
▪ Eventually the eye pops out
▪ Treatment: Removal of the eye before tumor growth
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Lecturer: Roberto B. Acuña, MD, FPCS, FPSGS, FPALES, FPBCS
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 o Core Needle Biopsy Stage 3 Invasion of nearby structures Surgery,
- Uses 14 or 16-gauge needle ❖ Neoadjuvant chemo for Chemotherapy and
- More used today breast, liver and pancreatic Radiotherapy
❖ Sarcomas – excision biopsy cancers gives better
should not be done prognosis than Stage 2
(Photo = rhabdomyosarcoma)
Stage 4 Metastatic disease/Distant Chemotherapy – for
Metastasis visceral metastasis
(lung, liver, brain)
❖ Cancer Clues Radiation – for
✓ Nonhealing persistent wound bone metastasis
✓ Painless something (ex: painless pag-ihi ng dugo) ❖ Example: Patient has solitary tumor in pancreas, multiple
✓ Weight loss tumors in the liver and lungs.
❖ Cancer – cauliflower texture, kulay fresh meat giniling ➢ Solitary tumor – most likely the primary tumor
➢ Diagnosis – biopsy tumors from all organs or liquid biopsy
➢ Not Accessible
o Imaging-guided biopsy Tumor Markers
❖ Limitation of ultrasound: air • Prognostic and predictive tumor markers
o Endoscopic biopsy o Prognostic – to know the likely outcome of the cancer
o Predictive – to predict whether patient responds to treatment or
❖ Three common causes of liver cirrhosis in the Philippines: not
1. Alcoholism • 2 types of tumor markers:
2. Infectious Hepatitis 1. From the cancer specimen
3. Fatty liver (NASH – Non-Alcoholic Steatohepatitis) - Ex: Stage 1 breast cancer, node negative
- Old name: NANISH – Non-Alcoholic, Non-Infectious ➢ Give chemo if (+) KI67, HER1/EGFR, p53
Steatohepatitis ➢ Give Hormonal therapy (tamoxifen and aromatase
- Advice carbohydrate restriction inhibitors) if (+) ER, PR
➢ Give targeted chemotherapy if (+) Her2
➢ Liquid Biopsy 2. Serum Tumor Markers
• Also called Fluid Biopsy of Fluid Phase Biopsy - Predictor of new cancer, response to treatment, recurrence
• Searches for tumor DNA or its fragment in blood - Useful only if determined prior to surgery
• CTC, ctDNA - For surveillance (may cancer ka na, na-operahan ka na), not
• Specimen: blood or CSF for screening:
✓ PSA – for prostate cancer
Cancer Staging ✓ CEA – for colon cancer
• Only after histopathologic diagnosis ✓ CA 19-9 – for pancreatic cancer
• Look for distant metastasis or local invasion ✓ CA 15-3 – for breast cancer
• Types: ✓ CA 27-29 – for breast cancer
o cTNM/TNM (clinical) – before surgery - For screening (wala pang manifestation ng cancer): AFP
o pTNM (pathological) – after surgery
o rTNM (recurrent) – recurrent tumor Cancer Treatment
o aTNM (autopsy) • Surgery – for most solid tumors
o yPT – tumor shrinkage after neoadjuvant chemotherapy • Chemotherapy – main treatment for LLMM
• Reasons for Staging: − adjuvant systemic treatment
➢ Selection of therapy • Radiotherapy – for sarcomas, recurrence, bone, positive margin
➢ Determines prognosis ❖ Positive margin
▪ Stage 1: 90%-95% survival
- Margins of the organ are cancer positive
▪ Stage 2: 75%-80% survival
▪ Stage 3: 50%-60% survival (before: less than 50%) - Example: inoperahan ang isang cancer, positive
▪ Stage 4: less than 50% survival (before: 0%) margin, may naiwang cancer, you have 2 options:
❖ Improvement of cancer survival rate is attributable to ➢ Radiation
chemotherapy ➢ Surgery ulit
➢ Compare treatment results with other centers
❖ Metastasis is very predictable • Hormonal Therapy – breast, prostate, thyroid
• Immunotherapy – -mab, -nib
• Cancers above the diaphragm – go to the lungs ➔ liver
• Cancers below the diaphragm – go to the GIT/GUT ➔ liver ➔ Definitions:
lungs • Primary Tumor
• Small bowel metastasis – seen in melanoma - removal of primary tumor is called local control/primary
• Bone metastasis – seen in prostate and lung cancer (males), surgery/definitive surgery
and breast and thyroid cancer (females) - surgery and/or radiotherapy
❖ Hormone-responsive cancers: • Regional Spread = Lymph Nodes
✓ Prostate cancer - Carcinomas
✓ Breast cancer - Lymph node dissection
✓ Thyroid cancer - Surgery and/or radiotherapy
Head and neck ➔ Cervical lymph nodes
Chest ➔ Hilar lymph nodes
Simplified Cancer Staging Treatment Gastrointestinal ➔ Mesenteric lymph nodes
❖ Exception: Virchow’s node, a supraclavicular left lymph node
Stage 1 Tumor < 2cm Surgery
(T1N0M0) No lymph node involvement – sign of disseminated pancreatic or gastric cancer
• Metastasis
Stage 2 T 2-4 or T 2-5 cm Surgery then - Common sites
With or without lymph node Chemotherapy - Treatment for metastatic disease: surgery, chemotherapy
involvement and/or radiotherapy

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Lecturer: Roberto B. Acuña, MD, FPCS, FPSGS, FPALES, FPBCS
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SURGERY ➢ Radioresistant tumors (GI except mouth & esophagus and pwet,
• For most solid tumors RT)
• +/- lymph node dissection • Types:
• Often followed by adjuvant ➢ External Beam RT (EBRT)
treatment ➢ Brachytherapy
• Goal: Curative Resection or ➢ Systemic Radioactive Iodine – for thyroid cancer
“Oncologic Control”
HORMONAL THERAPY
• Breast cancer
• Surgery for Primary Tumor o Tamoxifen for pre-menopausal
➢ Wide Local Excision (Lumpectomy) o Aromatase inhibitors for post-menopausal
- Cancer is removed with a 1-cm rim of pathologically • Prostate cancer
determined negative margin • Thyroid cancer
➢ Partial or Segmental Resection o Levothyroxine to inhibit TSH secretion
➢ Modified Radical Surgery
IMMUNOTHERAPY

➢ Radical Surgery
- Organ is removed together with the surrounding structures
- Examples:
o Stomach with the liver
o Kidney with gerota’s fascia
o Stomach with the omentum
o Thyroid with resection of carotid or strap muscles
o Ovary with bladder
❖ Survival rate is the same. Survival improves because of
advances in chemotherapy.
❖ Thyroid Cancer
• Chemotherapy is not used; treatment for distant metastasis is
radiotherapy
• Only cancer wherein age is the most significant prognosticator
o <55 years old – Stage 2, regardless of metastasis

• Surgery for Lymph Node

➢ Lymph node dissection
➢ Sentinel lymph node dissection
❖ Survival is the same. The difference is possibility of local
recurrence

• Surgery for Distant Metastasis

- Must be resectable: solitary, accessible

CHEMOTHERAPY
• 70 years old – relative contraindication to chemo
• As primary treatment – for LLMM
• As adjuvant – to stop systemic disease
• As neoadjuvant – to shrink tumor to make it resectable
• As palliation – to improve the quality of remaining life
• Given 6-8 times, 21 days apart for about 6 months

Targeted Chemotherapy (smart chemotherapy)

o Trastuzumab for breast cancer – targets HER2
o Bevacizumab for colon cancer
o Imatinib for GIST
o Sorafenib tablets for HCC
o Crizotinib for NSCLC

RADIOTHERAPY
• Indications:
➢ Sarcomas, H&N, Lymphomas, Breast, Gyne, Rectum
➢ Positive margins for surgery Source:
➢ Reduce locoregional recurrence rates of large carcinomas ✓ 2019 PPT and lecture
➢ Bone and brain metastasis
• Contraindication:
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Lecturer: Roberto B. Acuña, MD, FPCS, FPSGS, FPALES, FPBCS
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