Day 1 (14-12-22)

Topic - Overview
1) Tumour - abnormal growth. 2 types - benign & malignant.
= Malignant (cancer) - carcinoma & sarcoma.
= Cancer - metastasise, invades adjucent tissues, immortality, resistant to treatment, recurrence.
2) Oncology department
= Medical oncologist - administer systemic treatment to cancer patients- chemotherapy,
immunotherapy, targeted therapy, endocrine therapy.
= Radiation oncologist - radiation therapy.
= clinical oncologist - medical + radiation oncology.
= Surgical oncologist, oncology nurses, physiologist, rehabilitation specialist, occupational
therapist, patients lawyer.
3) Oncogenes
= Abnormal form of normal genes that regulate various aspects of the cell growth. Mutation of
these genes may result in direct & continuous stimulation of the pathways (eg. intracellular signal
transduction pathways, transcription factors, secreted growth factors) that control cellular growth
& division, DNA repair, angiogenesis, & other physiologic processes.
= Oncogenes - Not mutated called proto-oncogenes.
= Tumour suppressor genes - suppress cell growth (eg. p53).
4) Other
= Environmental factors.
= Immunologic disorders.
= Cancer diagnosis - Step1- awareness and accessing care.
Step2- clinical evaluation, diagnosis & staging.
Step3- access to treatment.
= Grading - is an idea of disease aggressiveness.
Grade 1 or 2 - abnormal, but still look-like normal cells.
Grade 3 - cells vary more in size and shape.
Grade 4 or 5 - they vary even more in size & shape than lower grade cells.
= Staging - is an idea of disease spread.
= Screening - early detection of disease.
= Paraneoplastic Syndromes are symptoms that occur at site distant from a tumor or metastasis.
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Day 2 (15-12-22)

Topic - Tumour immunology

= This process involves recognition of tumor antigens by e ector cells & induction of immunity.
= Tumour antigens - a key role of the immune system is detection of these antigens to permit
subsequent targeting for eradication. However, despite their foreign structure, the immune
response to tumor antigens varies & is often insu cient to prevent tumor growth.
= Sometimes T-cells not active
: Cancer cells stop presenting MHC 1 class molecules.
: Type of antigen presented - TAA ( tumor associated antigens), TSA (tumor speci c antigens).
: Activation of T-cell inhibitory receptors - peripheral tolerance (Modern immunotherapy inhibits
the inhibition).
= The immune response to foreign antigens consists of hum oral (eg. antibodies) & cellular
mechanisms. Most humoral responses cannot prevent tumor growth. Despite the activity of
e ector cells, host immunoreactivity may fail to control tumor occurrence & growth.
= Tumour immunodiagnosis - no tumor marker has all the requisite characteristics to provide
enough speci city or sensitivity to be used in early diagnosis or mass cancer screening programs.
= Immunotherapy- a number of immunologic interventions, both active & passive, can be directed
against tumor cells.
= Most important immunotherapy drugs - permbrolizumab, atezolizumab, nivolumab.
= All monoclonal antibodies end with - mab, All TKI (Tyrosine kinase inhibitors) end with - ib.
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 Day 3 (16-11-22)

Topic - Cancer treatment

= Local (surgery & radiation therapy) & Systemic (chemotherapy, immunotherapy, targeted
therapy, endocrine therapy).
= Chemotherapy- neoadjuvant (before surgery) & adjuvant (after surgery).
= Curative treatment (combination of local + systemic therapy) & Palliative treatment (decrease
symptoms, maintenance or improvement of quality of life).
= Surgery - 5 main roles in the management of cancer patients.(: diagnosis & staging. : curative
surgery. : palliative surgery. : surgery for metastatic disease. : prophylactic surgery.)
= The 3 principal methods of spread of cancer are - direct in ltration, lymphatic, blood-borne.
= Radiation therapy (RT) - high energy X-ray beams, >50% of all patients with malignant disease.
= Radio sensitivity of normal tissues
: High sensitive - lymphocytes, germ cells.
: Moderate sensitive - epithelial cells.
: Resistant - CNS, connective tissue.
= Acute e ects of radiotherapy
: occur within 8wk of treatment.
: problems in skin, GI tract, bone marrow.
: severity depends on total dose of radiation & length of time over which radiotherapy delivered,
: treatment doses selected, so that complete recovery is usual.
= Late e ects of radiotherapy
: problems in lung, kidney, CNS, heart, connective tissue.
: severity depends on total dose of radiation & dose per fraction (small dose per fraction protects).
: recovery may be incomplete.
= many small daily fraction ( every 24 hr dose)
= Advantages -
: less severe acute reactions (longer treatment time).
: reduced late normal tissue damage.
: maximises total dose that can be delivered.
: maximises reoxygenation.
: total dose may be su cient to eradicate all cancer cells.
: total dose may be reduced if unexpectedly severe acute reaction.
= Disadvantages -
: demand on resources & patient.
: potential for repopulation of fast-growing tumor during radiotherapy.
: prolonged acute reaction may need supportive treatment, eg. dietary support for sore mouth or
oesophagitis.
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Day 4 (17-11-22)

Topic - Head & Neck

= Risk factors: smoking+alcohol (combined most imp), HPV (Better prognosis), EBV, genetics,
salted & smoked food.

= Symptoms
: larynx - cough, dysphagia, odynophagia, weight loss. DD- laryngitis, GERD.
: mouth - most common, persistent ulcer, pain.
: nasal - bloody nasal discharge, pain. DD- polyps.

= Diagnostic Tests
: Biopsy through endoscopy or directly from ulcer (Squamous cells- respond very well to RT)
: TNM (Tumour, Nodes, Metastasis) classi cation.
: Head CT or MRI.
: At least chest and abdominal CT.
: PET/CT.
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 = In mouth ulcer patients with HIV
: check for kaposi sarcoma- do endoscopy with biopsy. (GI mucosa is a ected).
: check candida infection - do swab test. (fungal infection).

= Treatment
: Stage 1,2- surgery alone, or RT alone.
High risk stage 2- surgery + adjuvant chemotherapy or de nitive concurrent chemoRT
(with cisplatin).
: Stage 3- de nitive concurrent chemoRT (with cisplatin).
Sometimes specially In nasopharyngeal cancers - Neoadjuvant chemotherapy (TPF-
taxane, platinum, 5FU) + concurrent chemoRT (with cisplatin).
: Stage 4a, 4b- Neoadjuvant chemotherapy (TPF- taxane, platinum, 5FU) + concurrent chemoRT
(with cisplatin).
: Stage 4c- systemic therapy
1st line- chemotherapy (cisplatin + 5FU or carboplatin + paclitaxel).
2nd line- immunotherapy (pembrolizumab).

= Prognosis- not good. Stage 1,2,3 are potentially curable. Stage 4 not curable.
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Day 5 (21-11-22)

Topic - Lung
= Risk factors- smoking, occupational exposures (eg. asbestos, arsenic, etc.), environmental
factors.

=Types- Non-small cell lung cancer(NSCLC) & Small cell lung cancer(SCLC).

= In women NSCLC is common mostly adenocarcinoma.

= In smokers SCLC is common.

1) Non-small cell lung cancer (NSCLC)

: more common.
: origin- epithelial cells of the lung.
: classi cation- adenocarcinoma (most diagnosed), squamous cell carcinoma (smokers most
common), large cell carcinoma.
: metastatic potential- less than SCLC.
: 5 yr survival- stage1 (57-67%), stage2 (39-55%), stage3 (5-25%), stage4 (<1%).

2) Small cell lung cancer (SCLC)

: less common.
: origin- nerve producing cells of the lung (bronchi).
: classi cation- limited stage (no metastasis), extensive stage (metastasis).
: metastatic potential- rapid.
: 5 yr survival- limited (20%), extensive (<1%).

= Sx- Cough, Sputum production, Hemoptysis, Dyspnea, Wheeze, Stridor, Pneumonitis.

= Clinical presentation
: central or endobronchial tumor growth- cough, sputum production, hemoptysis, dyspnea,
wheezing (usually unilateral), strider, pneumonitis with fever & productive cough ( secondary to
obstruction).
: peripheral tumor growth- pain from pleural or chest wall involvement, cough, dyspnea,
pneumonitis.
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: regional involvement (either direct or metastatic spread)- hoarseness (recurrent laryngeal nerve
paralysis), dysphasia (oesophageal compression), dyspnea (pleural e usion, pericardial e usion,
phrenic nerve palsy), Horner’s syndrome (sympathetic nerve palsy).
: metastatic involvement (common sites)- bone (pain exacerbated by movement or weight
bearing, often worse at night; fractures), liver (right hypochondrial pain, icterus, altered mental
status), brain ( altered mental status, seizures, motor & sensory de cits).
: paraneoplastic syndromes- hypertrophic pulmonary osteoarthropathy, hypercalcemia,
dermatomyositis (Eaton-Lambert syndrome), hyper-coagulable state, gynecomastia.

= Diagnostic tests
: heavy smoker > COPD > cancer.
: sputum analysis (in case of central lesions).
: biopsy (before & after radiology).
: radiology shows single pulmonary nodule- chest CT rather than X-ray, PET scan.
: also brain MRI (if brain involvement). bone scan (bone pain).
: transthoracic FNA (peripheral lesions) which can performed under CT or uoroscopic guidance.
: mediastinoscopy- can reveal unsuspected tumor in mediastinal lymph nodes—a negative
implication for survival.

= Single pulmonary nodule DD- tuberculosis, lung abscess, lung brosis, sarcoidosis.

= Treatment
1) NSCLC
Stage 1,2- surgery + adjuvant chemotherapy with platinum doublet.
If any contraindications or don’t want surgery- concomitant chemoRT (platinum doublet).
Stage 3a- surgery + adjuvant chemotherapy with platinum doublet/ concomitant chemoRT
(platinum doublet).
Stage 3b- concomitant chemoRT(platinum doublet).
Stage 4- check for targets:- EGFR, ALK,……
If targets are mutated- treat with targeted therapy.
EGFR- eriotinib, ALK- crizotinib.
If targets are not mutated check high PDL expression- immunotherapy (PDL inhibitors).
If neither above is true- simple chemotherapy (platinum doublet).
Radiosensitive agent- gemcitabine & cisplatin.
Squamous cell carcinoma- gemcitabine + cisplatin.
Adenocarcinoma- pemetrexed + carbopatin.
For both- paclitaxel + carbopatin.

2) SCLC
Limited stage- combined chemotherapy (cisplatin + etoposide) + RT.
Extensive stage- chemotherapy (cisplatin + etoposide) + immunotherapy (atezolizumab).

= No screening test for lung cancer because of radiation exposure. Only for heavy smokers/family
hx/age >50. Low dose CT once per year.
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Day 6 (22-11-22)

Topic - GI
1) Esophageal cancer
= not very common.

= Squamous cell carcinoma: in upper half.

: risk factors- tobacco, alcohol, predisposing conditions (achalasia, HPV, celiac disease, Plummer-
Vinson syndrome).

= Adenocarcinoma: in lower half.

: risk factors- barrett’s esophagus, obesity, GERD.
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 = Symptoms
: dysphagia, weight loss, odynophagia, epigastric/retrosternal pain, cough/hoarseness,
tracheoesophageal stula.

= Signs
: Horner syndrome, left supraclavicular lymphadenopathy, cachexia, hepatomegaly, bone
metastasis.

= DD- GERD, barrett’s esophagus, achalasia.

= Classical triad of esophageal cancer

: asthenia, anorexia, analgesia (for dysphagia).

= Diagnostic tests
: endoscopy with biopsy -> PET/CT of neck & chest.
: barium swallow to rule out stula, achlesia.
: staging- siewert classi cation (on basis of location. Endoscopic US used to staging) (IMP).

= Treatment
: Resection borders- analysed after morphologic examination of the resected tissue.
R0- clear resection margins. For GI cancers:- tumor + 5cm healthy tissue.
R1- microscopic positive resection margins:- theoretically microscopic tumor cells are left in
patient. Add RT after surgery.
R2- macroscopic positive resection margins:- we de nitely left some tumor cells behind:- 2nd
surgery.
: Stage 1,2- surgery + adjuvant chemotherapy (FOLFOX:- 5FU + oxaliplatin).
If patient has a poor surgical candidate or refuses to do surgery:- ChemoRT (5FU +
cisplatin).
: Stage 3- chemoRT (5FU + cisplatin).
: Stage 4- palliative:- only systemic treatment
1st line:- carboplatin + paclitaxel or FOLFOX.
2nd line:- immunotherapy.

2) Gastric cancer
= Risk factors- high salted food, H. pylori infection, family hx (CDH1 mutation), tobacco/alcohol.

= Types- mostly adenocarcinoma.

: intestinal (gland formation by malignant cells).
: di use (signet-ring carcinoma cells).

= Pathophysiology- p53 mutation & gastrectomy are major causes.

Bilroth-2 partial gastrectomy MC cause of gastric cancer which is not performed these days.

= Symptoms- weight loss, abdominal pain, nausea, anorexia, dysphagia, melena, early satiety,
ulcer-type pain, lower extremity edema.

= DD- PUD, gastritis, GERD.

= Tests- CBC (anaemia, hypoproteinemia), abnormal LFTs, fecal occult blood.

: Staging- same as esophageal. Endoscopic US for staging. chest & abdominal CT/PET.

= Physical examination- virchow’s node (enlargement of supraclavicular nodes), periumbilical

lymph nodes (Sister Mary Joseph node), Irish nodes (enlargement of left anterior axillary node),
enlarged ovary (krukenberg tumor; ovarian metastasis), mass in cup-de-sac (blumer shelf). Lesser-
Trealt sign can be seen.

= Treatment
: If very small tumor (T1)- do surgery. Total gastrectomy with extensive lymph node dissection >20
lymph nodes. From around spleen too. After surgery patient cannot tolerate
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 adjuvant chemo that's why give neoadjuvant chemotherapy.
: T1N0M0- upfront surgery & adjuvant chemotherapy with FOLFOX or xelox (Xeloda [capecitabine]
+ oxaliplatin).

: Stage 1,2,3- neoadjuvant chemotherapy 4 cycles of FLOT (5FU + oxaliplatin + docetaxel).

Surgery (total gastrectomy with D2 lymph node dissection) + adjuvant chemotherapy
4 cycles of FLOT (5FU + oxaliplatin + docetaxel).
If D2 resection was not achieved or R0 was not achieved:- add RT after surgery.
: Stage 4- systemic therapy
Check her2 & PDL status
If her2 mutated:- xelox/FOLFOX + transtuzumab (Anti her2 MONOCLONAL
ANTIBODY).
If her2 is not mutated but PDL expression:- immunotherapy (nivolumab) + xelox/FOLFOX
or pembrolizumab.
If neither are expressed:- xelox/FOLFOX.
If both are expressed:- xelox/FOLFOX + transtuzumab (Anti her2 MONOCLONAL
ANTIBODY).

= Prognosis- if her2 mutation:- worse prognosis.

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Day 7 (24-11-22)

Topic - GI (contd.)
3) Pancreatic cancer
= Etiology/risk factors- alcohol, cigarettes, obesity, diabetes mellitus type 2, chronic pancreatitis.

= Use of metformin decrease risk of pancreatic cancer.

= Symptoms- jaundice, itching, pain, indigestion, clay coloured stool, steatorrhea, weight loss,
symptoms from metastatic disease.

= DD- chronic pancreatitis, cholecystitis, peptic ulcer disease.

= Workup
: blood tests:- oncomarker CA19.9 (Pancreatic adenocarcinoma).
: radiology- abdominal MRI + chest CT (PET/CT).

= 20% of pancreatic cancers are resectable at presentation.

= Treatment
: Stage 1,2- Whipple procedure + adjuvant chemotherapy for 6 months (FOLFIRINOX :- 5FU +
irinotecan + oxaliplatin).
: Stage 3- neoadjuvant chemotherapy FOLFIRINOX- For 3 months- repeated scan- surgery- 3
months FOLFIRINOX.
: Stage 4- FOLFIRINOX or gemcitabine + cisplatin or gemcitabine alone.
BRCA mutation:- olaparib.

4) Liver cancer
= Hepatocellular carcinoma (HCC)- most common.

= Etiology/risk factors- hepatitis B&C, alcohol, hemochromatosis, cirrhosis.

= Signs & Symptoms- jaundice, edema, enlarged abdomen, ascites, caput Medusa, itching,
weight loss.

= Tests- abdominal US, blood tests (alpha fetoprotein), abdominal MRI, chest CT/PET scan.
= DD- primary liver cancer, liver metastasis from somewhere else (Gynecological,GI).

= Chemo is not working, liver is very radiosensitive organ- only stereotactic radiosurgery.
Targeted drugs and immunotherapy is useful only in metastatic disease.

= Single nodule in liver- liver failure- liver transplantation.

= Treatment
: Local disease which cannot be resected
TACE- transarterial chemoembolization.
TAE- transarterial embolization.
stereotactic radiosurgery.
: Metastatic disease
1st line- atezolizumab (anti PDLs) + bevacizumab (anti VEGF):- if upper GI endoscopy is
normal.
: Check for esophageal varices, if present don’t give bevacizumab, it will cause bleeding. So give
targeted therapy- sorafenib, sunitinib, pazopanib:- multiple tyrosine kinase inhibitors.

5) Colorectal cancer
= Risk factor- polyps

= Etiology- obesity, sedentary lifestyle, genetics, white male >50 yr.

= Screening- annual colonoscopy every male > 45yr.

= symptoms
: rectal cancer- bright red blood in the stool.
: colon cancer- not as bright red blood in stool.
: both- constipation, diarrhoa, abnormal Bowel movement, iron de ciency anemia, weight loss.

= Most severe cases:- bowel obstruction- an emergency- need emergency surgery.

= Workup
: colonoscopy + biopsy- endoscopic US.
: radiology- abdominal & pelvic MRI + chest CT/PET scan.

= DD- ulcerative colitis, chrons disease, diverticulitis.

= In colon cancer RT is not possible because it’s highly moveable.

= Treatment
: colon cancer
Stage 1,2- surgery + 4-6 months of adjuvant chemotherapy with xelox/FOLFOX.
Stage 3- neoadjuvant chemotherapy for 3-4 months + surgery.
: rectal cancer
Stage 1- surgery + 4-6 months of adjuvant chemotherapy with xelox/FOLFOX.
Stage 2,3- neoadjuvant chemoRT (capecitabine + RT) + surgery.
: Stage 4 colorectal cancer
Check MSI/dMMR
if positive:- pembrolizumab.
if negative:- check BRAF, NRAS, KRAS mutation.
if mutated:- xelox/FOLFOX + bevacizumab.
if not mutated:- xelox/FOLFOX + cetuximab.

(Cetuximab is anti EGFR which is located outside on the cell membrane. So used in negative
mutations. Bevacizumab stops BRAF, KRAS, NRAS mutation which are inside the cell. So if inside
has problem no point in stopping outside signals EGFR.)
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 Day 8 (25-11-22)

Topic - Breast cancer

= most common, female>male.

= Etiology- elevated levels of estrogen, early menarche, late menopause, nulliparity, infertility, late
age at 1st pregnancy after 30yrs age.

= Decreases the risk- multiple pregnancies, breastfeeding, early menopause, early 1st pregnancy
before 20yrs age.

= Screening- mammography after age 40/45 annually. If BRCA 1&2 mutations are known
screening should be done by breast MRI.

= Symptoms- inverted nipple, bloody or any other discharge, pain & mass in breast.
Pathology- common in left breast, MC is ducal carcinoma.

= DD- broadenoma of breast, breast lymphoma, breast abscess.

= Workup
: initial- history, PE, CBC. liver, renal, cardiac function test.
: radiology- mammogram, breast US, core needle biopsy, pathology, immunohistochemistry.
: Lymph node assessment for staging.
: Metastasis- chest & abdominal CT/PET.

= Types
: Luminal A&B common- ER & PgR positive.
: Luminal A&B di erence- Ki67 (high in B), her2 positive in B & negative in A.
: her2 overexpression- her2 positive- ER &PgR negative.
: Triple negative (worst)- ER, PgR, her2 all negative.

= Staging- based on breast US then lymph node involvement & then CT.

= Treatment
: ER+, PgR+, her2-
Stage 1,2- surgery + RT + 4 months of chemo + 5 yr endocrine therapy.
Stage 3- 6 months of neoadjuvant chemo + surgery + RT + 5 yr of endocrine therapy.
Stage 4- endocrine therapy unless patient has visceral crises & until patient responds to
endocrine therapy.
: ER+, PgR+, her2+
Stage 1- surgery + 6 months of chemo + her2 blockade + RT + 1yr additional her2 blockade
+ 5 yr endocrine therapy.
Stage 2,3- 6 months of neoadjuvant chemo + her2 blockade + surgery + RT + 1yr additional
her2 blockade + 5 yr endocrine therapy.
Stage 4- chemo + her2 blockade (docetaxel + transtuzumab + pertuzumab) after 6-8 cycles
continue with transtuzumab + pertuzumab until progression + endocrine therapy.
: ER-, PgR-, her2+
Stage 1- surgery + 6 months of chemo + her2 blockade + RT + 1yr additional her2 blockade.
Stage 2,3- 6 months of neoadjuvant chemo + her2 blockade + surgery + RT + 1yr additional
her2 blockade.
Stage 4- chemo + her2 blockade (docetaxel + transtuzumab + pertuzumab) after 6-8 cycles
continue with transtuzumab + pertuzumab until progression.
: ER-, PgR-, her2- (triple negative)
Metastasis to brain. Refractory to treatment.
Stage 1,2,3- neoadjuvant chemo + immunotherapy + surgery + RT + 1yr immunotherapy.
Stage 4- check PDL status and BRCA status.
If BRCA not mutated & PDL overexpressed:- chemo + immunotherapy .
If BRCA mutated:- Olaparib.
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=Extra info for treatment
: Immunotherapy - pembrolizumab or atezolizumab.
: Chemotherapy - nacpaclitaxel + docetaxel or doxorubicin + cyclophosphamide (AC) or taxanes.
(3 months of AC + 3 months taxanes when 6 months chemo has to be done).
: Surgery:- Breast conserving: lumpectomy, wide excision, quadrantectomy.
Breast removal: mastectomy.
: Risk reducing mastectomy & salpingoopherectomy- done by carriers of BRCA 1&2 genes.
: her2 positive always add trastuzumab (cardiotoxic).
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Day 9 (28-11-22)

Topic - Gynaecological malignancies

= Most common- cervical cancer.
Young women- cervical cancer.
Elder women- ovarian, endometrial cancer.

= Breast, ovarian, endometrial cancers share etiologies- connection with high levels of estrogen.

= Obese individual, diabetes- endometrial cancers.

Infertility, nulliparity- endometrial, ovarian cancers.

= Multiple pregnancies & deliveries- protective against ovarian & endometrial cancers, but
increase risk of cervical cancer.

1) Ovarian cancer
= Etiology- older age, infertility, nulliparity, endometriosis, BRACA mutation.

= Protective factors- multiple pregnancy, breastfeeding, usage of oral contraceptive pill, tubal
ligation, bilateral salpingoopherectomy.

= Symptoms- abdominal enlargement, dull pain.

= DD- ectopic pregnancy, hemorrhagic cyst, ovarian torsion.

= Workup- gynaecological US, CA 125, pelvic & abdominal MRI & chest CT, biopsy (will usually
show epithelial ovarian cancer).

= Treatment
: resectable disease
Stage 1,2,3,4- surgery & 6 cycle of chemotherapy:- paclitaxel & carboplatin.
Or stage 3,4 - 3 cycle paclitaxel & carboplatin + surgery + 3 cycle paclitaxel & carboplatin.
Or stage 3,4 - 6 cycle paclitaxel & carboplatin + surgery + 2 cycle paclitaxel & carboplatin.
: unresectable disease
Stage 4- paclitaxel +carboplatin + bevacizumab.
BRACA mutation- olaparib.
ER positive- letrozole or other hormonal drugs.

2) Endometrial cancer
= Etiology- older age, infertility, nulliparity, BRACA mutation, obesity, diabetes.

= Protective factors- multiple pregnancy, breastfeeding, usage of oral contraceptive pill, tubal
ligation, bilateral salpingoopherectomy.

= Symptoms- postmenopausal bleeding

= DD- endometrial atrophy, endometrial hyperplasia, endometrial/cervical polyps, endometriosis.

 = Workup- gynaecological US, stop the bleeding with curettage:- treatment + diagnosis (biopsy:-
will usually show adenocarcinoma of uterus), CA 125, pelvic & abdominal MRI & chest CT.

= Treatment
: If patient is in very early stage of endometrial cancer:- put hormone IUD and check for
progression every 3 months for a year. If disease does not progress then after a year patient
should have a child. After delivery:- do total hysterectomy & bilateral salpingoopherectomy.

: Stage 1,2,3- de nitive chemoRT (cisplatin) + brachytherapy,

or surgery + adjuvant chemotherapy (Paclitaxel + carboplatin) or chemoRT
(cisplatin) with/without brachytherapy.
: Stage 4- Paclitaxel + carboplatin + bevacizumab.
ER, PgR status:- hormonal therapy. PDL status:- immunotherapy.
: We can divide patient into platinum sensitive, refractory and resistant disease.
Platinum sensitive disease comes back after 6 months of nishing paclitaxel + carboplatin.
Platinum resistant - if disease comes back after 3 months.
Platinum refractory - before 3 months - worst prognosis.
Platinum drugs - cisplatin & carboplatin.

3) Cervical cancer
= Etiology- multiple sex partners, early age of initiation of sexual life, STD:- HPV.

= Protective- HPV vaccine.

= Symptoms- bleeding during or after inercourse, dyspareunia, pain in the back area.

= DD- cervical polyp, cervical lymphoma, metastasis to cervix (Gyn), cervical ectopic pregnancy.

= Workup- gynaecological exam, US, Pap smear, colposcopy, biopsy;- usually shows squamous
cell cancer.
Pelvic MRI, chest & abdominal CT :- for staging.

= Treatment
: Stage 1,2,3- surgery +chemoRT with cisplatin + brachytherapy,
or de nite chemoRT with cisplatin + brachytherapy.
: Stage 4- paclitaxel + carboplatin.
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Day 10 (29-11-22)

Topic - Genitourinary cancers

1) Prostate cancer
= Etiology, Risk factors- family history, male sex, older age, untreated benign prostate
hyperplasia, hormonal disbalance.

= Sx- di culty urinating, nocturia, dribbling, since of incomplete emptying, urgency, frequency.

= DD- benign prostate hyperplasia, UTI, bladder obstruction.

= Workup
: oncomarker- PSA (Prostate speci c antigen). DRE (Digital rectal examination).
: if both DRE & PSA levels are abnormal- biopsy shows GLEASON SOCRE—if shows prostate
adenocarcinoma—pelvic US, pelvic MRI (for staging).
: bone scan- scintigraphy. Chest & abdominal CT
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 If DRE is normal PSA is elevated follow up every 2-3 months.
If DRE is abnormal PSA is normal again follow up every 2-3 months.
If biopsy normal follow up after 3-6 months.
Extensive biopsy should be done. Because prostate is very heterogeneous tissue.

: very heterogeneous.
: histological evaluation instead of simple G1,G2,G3 we use GLEASON SCORE.
Higher the score, more aggressive is the cancer.
GLEASON SCORE consists of 2 numbers-
GLEASON 8:- (4+4).
GLEASON 6:- (4+2)- more aggressive- we have more 4s then 2s, 4s are aggressive than 2s.
GLEASON 6:- (2+4).

= Treatment
: Stage 1,2- Low and Intermittent risk- low/Intermittent PSA, low/Intermittent GLEASON SCORE,
low/Intermittent burden disease:- if patient is old & has no symptoms-
active surveillance, prostatectomy, RT, ADT:- zoladex.
- High risk- high PSA, high GLEASON SCORE, high burden disease:- prostatectomy, RT,
ADT:- zoladex.
We should ask the patient about prostatectomy or RT by telling them the complications
(prostatectomy- erectile dysfunction, loss libido, problems with performance, urinary problems)
(RT- urethritis).
: Stage 3- neoadjuvant ADT for 3-6 months— radical radiation therapy—continue ADT for at least
2 years.
: Stage 4- Low burden disease:- ADT.
High burden disease:- chemotherapy 6 cycles docetaxel + ADT—continue ADT until
disease progression—
2nd line:- abiraterone, 3rd line:- cabazitaxel (2nd gen. taxane).
Bone pain- palliative RT for bones.
(Side e ects of ADT- infertility, low sex drive, changes in hair growth, fatigue, depression, hot
ushes, risk of osteoporosis).

2) Testicular cancer
= Etiology- family history, trauma, cryptorchidism, STD, Klinefelter syndrome XXY.

= Clinical Presentation- enlarged testes (painless)—check US- suspicious cancer—Tumor marker-

alpha fetoprotein, HCG (elevated only if embryonic cancer)—next step:- orchiectomy (check
cancer was there or not).

= DD- Testicular torsion, Trauma.

= Types
: seminoma (not elevated tumor marker)- better prognosis, highly radiosensitive.
: Non-seminoma (embryonic:- elevated tumor markers)- not radiosensitive.
: Mostly Mixed type:- seminoma + non-seminoma (elevated tumor markers).

= Treatment
: Stage 1- semi/non-semi:- orchiectomy—observation or 2 cycles EP.
: Stage 2- semi:- orchiectomy—2-4 cycles of BEP.
non-semi:- orchiectomy—lymph node dissection—2-4 cycles of BEP.
: Stage 3- semi:- orchiectomy—4-6 cycles of BEP.
non-semi:- orchiectomy—lymph node dissection—4-6 cycles of BEP.
: Stage 4- semi/non-semi:- orchiectomy—3 cycles of BEP—reassessment—if disease responds
well—metastasectomy:- complete removal of all places.

B - bleomycin, E - epirubicin, P - carboplatin.

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Day 11 (30-11-22)

Topic - Genitourinary cancer (contd.) and Skin cancer

3) Kidney cancer
= Etiology- chronic kidney disease, dialysis, hypertension, diabetes, working with toxins, paints,
industrial dyes.

= Symptoms- hematuria, pain in ank area, palpable mass, di culty urination, symptoms from
metastasis disease, bone pain, breathlessness, weight lass.

= Classical triad- hematuria, pain in ank area, palpable mass.

= DD- chronic kidney injury, pyelonephritis, polycystic kidney disease.

= Workup- urine test:- hematuria, abdominal US:- ank mass, abdominal CT or MRI.
CT of chest:- biopsy to con rm renal cell clear cell carcinoma.

= Treatment
: Only chance of cure is surgery. Surgery is always an option, even when it’s cytoredution.

: Even metastasectomy.

: Stage 1,2- surgery:- nephrectomy, no adjuvant treatment.

: Stage 3- nephrectomy, adjuvant immunotherapy (pembrolizumab):- for 1yr.
: Stage 4- limited metastasis— potentially resectable:- surgery + metastasectomy.
unresectable—life threatening:- immunotherapy + targeted therapy.
not life threatening:- targeted therapy or only immunotherapy.
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Topic - Skin cancer

Melanoma
= Etiology- UV light, nevus, dysplastic nevus, fair skin, blue eyes, blonde hair.

= Primary metastasis is to bone. Can also metastasis to liver, lung, brain.

= Symptoms- nevus:- gets deformed, changes somehow, starts bleeding.

= DD- basal cell carcinoma, atypical mole (dysplastic nevus)

= Prevention- sunscreen, dermoscopy, removes nevuses, photograph.

= Workup- dermoscopy con rms suspicious nevus, excisional biopsy:- melanoma.

Breslow thickness is cm, while Clarke's scale depends on anatomical depth.
= Next- more surgery:- more extensive borders + sentinel lymph node biopsy.
If sentinel lymph node are positive- complete lymph node dissection or RT.
If sentinal lymph node are negative- no need for additional surgery or RT.

= After surgery- staging is depends on lymph node metastasis, size of the tumor, breslow
thickness.

= Treatment
: Stage 1,2- surgery & observation.
: Stage 3- surgery & immunotherapy (pembrolizumab) for 1yr.
: Stage 4- check for BRAF mutation.
If mutated:- vemurafenib.
If not mutated:- pembrolizumab.
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Day 12 (01-12-22)

Topic - Sarcoma
1) Rhabdomyosarcoma
= PAX3/FKHR genes plays an important role.

= Risk factors- P53 mutations, Familial cancer, Congenital anomalies, Li-fraumeni syndrome,
Parental: smoking/alcohol/drug abuse/chemical exposure.

= Sx- Mass formation, Orbit - proptosis, Nasal discharge, CN palsies, Polyps.

= Type- Embryonal, Alveolar.

= DD- lipoma, non-Hodgkin lymphoma, neuroblastoma.

= Diagnosis : Palpation:- stone hard mass.

: CT/MRI, If metastatic Sx seen we should do PET. If PET not possible then chest CT.
: Bone scans/scintigraphy. Biopsy (Excisional biopsy).
: Check genetics. PCR of CSF for PAX3/FKHR mutations.

= Treatment
: Surgery is the only possible, it should always be kept as an option even is stage 4:- we could
also consider metastasectomy.

: Stage 1,2- surgery + adjuvant chemo for 6 months (cyclophosphamide + vincristine).

: Stage 3- if operable:- surgery + adjuvant chemo for 6 months.
if surgery is not possible or patient wants organ/limb preservation:- neoadjuvant
chemo + surgery.
if R1 resection is done follow up with RT. (anthracycline + ifosfamide).
if chemoRT doesn't work:- do palliative treatment/advanced treatment.
: Stage 4- surgery: if resectable lung/liver metastasis is there or if complete removal of all
metastasis & original tumor is possible.
standard Chemo:- anthracycline + ifosfamide
if PDGFRA mutation:- Olaratumab. if ALK mutation:- Crizotinib.
: if not resectable:- depend on patient how they can handle chemotherapy then
give:- doxorubicin + ifosfamide (associated with hemorrhagic cystitis to avoid
give Mesna) or doxorubicin + olaratumab. Continue until disease progression
or drug toxicity.

= Prognosis max 1 year.

2) Osteosarcoma
= Risk factors- familial cancer, secondary osteosarcoma, Li-fraumeni syndrome, irradiated bones,
loss of p53, bilateral retinoblastoma.

= Sx- Bone pain, Swelling, Mass in metaphysis of bone (MC femur/tibia), MC site knee.

= DD- Osteomyelitis, Giant cell tumors, Rhabdomyosarcoma.

= Tests : Plain radiographs (sunburst sign can be seen). CT/MRI.

: If metastatic Sx seen we should do PET. If PET not possible then chest CT.
: Bone scans.
: Serum LDH levels is prognostic.

=Treatment
: Stage 1,2,3- Neoadjuvant chemotherapy- Methotrexate + adriamycin.
Adriamycin + cisplatin.
Cisplatin + ifosfamide.
 : After imaging- surgery:- if possible then reconstruction by prostheses. Then chemotherapy.
if surgery not possible:- RT. And if limb sparing surgery not possible go for
amputation. Then chemotherapy.
: Stage 4- chemotherapy- Methotrexate + adriamycin.
Adriamycin + cisplatin.
Cisplatin + ifosfamide.
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Day 13 (02-12-22)

Topic - Brain cancer

= Primary brain tumor originates in brain while secondary is from other organ through metastasis.
Very rare. In children common. MC originate from glial cells.

= Sx- Headache,Seizure, Cognitive changes, Neural Sx.

= DD- Metastasis (Rhabdomyosarcoma, lung cancer, skin: 1st bone then brain).

= Complications- Increased ICP, Tentorial or foramen Magnum herniation.

= Test- we need to make sure it is primary and it has not metastasised.

Brain MRI. CT is insu cient.

= No staging and No TNM classi cation (no lymph nodes & no metastasis).

= Astrocytoma
: Pilocytic - grade 1.
: Di use - grade 2.
: Anaplastic - grade 3.
: GBM - aggressive grade 4.

: Grade 1,2,3- Surgery always for treatment. Also for decompression and analysis.

: Genes- IDH1 - comes back, aggressively.

= GBM
: most common adult primary brain tumor. Peak incidence at 45-60 yr.

: Workup- Brain MRI with contrast shows tumor with necrosis & calci cations. PET.

: surgery- complete resection:- better prognosis.

partial resection:- poor prognosis.

: histology- who grade IV glioblastoma.

: After surgery- repeated MRI

: next step RT + chemotherapy (chemoRT)

RT + PCV-toxic (IV- procarbazine, lomustine, vincristine).
RT + temozolomide-less toxic (PO-1 month).

: 1 month break- after which we continue 6 months of temozolomide maintenance treatment.

: after chemoRT every 2 months- repeated MRI.

: after 6 months of temozolomide maintenance treatment if not good condition:-

2nd line-bevacizumab/irinotecan/pembrolizumab.
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**Extra**
ChemoRT for 1 month
After chemoRT- 1 month break.
After chemoRT every 2 months repeated MRI.
After 1 month break 6 months of temozolomide maintenance treatment.
After 6 months temozolomide maintenance treatment if not good condition:-
2nd line- bevacizumab/irinotecan/pembrolizumab.
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