PCSI Tertiary Cancer Treatment Guidelines (2014)

TERTIARY PREVENTION OF CANCER:
CLINICAL TREATMENT GUIDELINES

The Philippine Cancer Society Guidelines are constructed using the Clinical Algorithm Standards of the Society of Medical Decision Making
[1]. These charts are made of conditional logic (if/then) statements that have been mapped out. In navigating through these maps, 4 kinds
of symbols are used:
1.
Clinical State Boxes (rounded rectangles) These boxes define the clinical state or problem. They have only one exit path,
and may or may not have an entry path. Clinical state boxes always appear at the beginning of an algorithm.
2.
Decision Boxes (hexagons) These boxes contain a question (?) that is answerable by yes or no. Two alternative paths
always branch out from these boxes the yes (Y) path usually exists to the right, while the no (N) path usually exits
downwards. Decision boxes always have an entry path.
3.
Action Boxes (angles rectangles) These boxes contain an action, commonly either therapeutic or diagnostic in nature. They
may not have an exit, but they always have an entry path.
4.
Link Boxes (small ovals) These boxes are used to link algorithms that cannot fit in a single page, to maintain path continuity.
Annotations ((A), (B), (C)) are given as needed for a particular algorithm. The algorithms are so designed so that a large majority of
patients presenting with a particular oncology problem can be handled with a minimum of tests, interventions or referrals, particularly in
consideration of the Philippine setting. They serve as guidelines to the management of common oncology problems (with typical
presentations), aiding the thinking process of the physician. It must be added, however, that some patients have clinical cancer
presentations that are atypical, hence the need for other diagnostic procedures that may not be mentioned in the algorithms.
The major resource and reference of the cancer treatment guidelines is the National Comprehensive Cancer Network
Clinical Practice Guidelines in Oncology (NCCN). For further information go to http://www.nccn.org/
The Philippine Cancer Society Inc has the following Clinical Cancer Treatment algorithms for:
1.
2.
3.
4.
Primary Cancer Sites

a.
Breast
b.
Lung
c.
Lymph Node, Primary
d.
H & N, un-resectable
e.
Nasopharynx
f.
Esophagus
g.
Stomach
h.
Colon
i.
Rectum
j.
Liver
k.
Pancreas
l.
Ovary
m. Uterine Fundus
n.
Uterine Cervix
o.
Prostate
p.
Testis
q.
Renal
r.
Urinary Bladder
s.
Soft Tissue
t.
Bone
u.
Brain
v.
Unknown Primary
Palliative Management Advanced Cancer
Oncologic Emergencies
w. Superior Vena Cava Syndrome
x.
Spinal Cord Compression
y.
Malignant Pleural Effusion
Supportive Care
z.
Cancer Pain
aa. Chemotherapy-induced Anemia
bb. Chemotherapy-induced Neutropenia
cc. Chemotherapy-induce Emesis
BREAST CANCER
The management of breast cancer must be multi-disciplinary interdisciplinary, with each discipline
respecting the specialty expertise of the other, all for the benefit of the cancer patient.
(A) Most breast cancer (hard, painless, movable, then becomes fixed to the chest wall/skin, with/without nipple
retraction) are found by palpation by the patient, her partner or her physician. As tumor site increases, the
likelihood that distant metastasis has taken place rises. It is better to detect and treat early (asymptomatic
<1cm diameter tumor size). Mammography can detect very early <1 cm tumor mass and hence effective in
screening.
(B) If total mastectomy is anticipated, it is best to confirm the diagnosis with open biopsy. For preliminary
screens, FNAB cytology is done. A (-) FNAB should not dissuade the surgeon from excision biopsy if a discrete
lump is present, particularly if there is high clinical suspicion of cancer.
Mammography can be done to localize areas with high probability of cancer aiding direction of FNAB.
Review of slides is done to verify presence and type of cancer for those patients already with biopsy slides.
(C) Majority of breast cancer are invasive ductal carcinoma.
Three major cancer types are: noninvasive
(intraductal and lobular), invasive, and Pagets disease of the nipple. Poor prognosis types are atypical
medullary and not otherwise specified. Other histopathologic findings that correlate with poor prognosis are
low nuclear grade and presence of tubule formation.
For treatment purposes, breast cancer may be divided into:
a.
Pure noninvasive carcinoma (Stage 0)
i. ductal carcinoma in situ (DCIS; Stage 0)
ii. lobular carcinoma in situ (LCIS)
b.
Operable locoregional invasive carcinoma (Stage I, II and some stage IIIA)
c.
Inoperable locoregional invasive carcinoma (Stage IIIB, IIIC and some stage IIIA tumors)
d.
Metastatic or recurrent carcinoma (Stage IV)
(D)
Staging considerations:
History and physical exam (PE), and at a minimum alkaline phosphatase, chest x-ray, abdominal ultrasound
are done for baseline. Bone scan is indicated if the patient has symptoms related to bone or if there is
elevated alkaline phosphatase level. CT scan of whole abdomen is indicated if abdominal ultrasound is
inconclusive but there are symptoms referable to the abdominal organs.
At a minimum baseline CBC, creatinine, and ECG are done in preparation for treatment.
PET scan can be an option to determine presence of metastatic sites highly suspected but not shown by CT
scan/ bone scan. For brain metastasis suspect, MRI may be the better option compared to CT scan.
(E)
The goal of treatment of in-situ carcinoma is either preventing the occurrence of invasive disease or diagnosing
the invasive component when still localized to the breast.
Observation alone is the preferred option for women diagnosed with lobular carcinoma-in-situ (LCIS) because
their risk of developing invasive carcinoma is low. Bilateral mastectomy may be considered in special
circumstances.
Tamoxifen treatment may be considered in women with estrogen receptor-positive [ER(+)] ductal carcinomain-situ (DCIS) treated with breast conserving therapy or with mastectomy.
(F)
Fresh surgical breast mass specimen must be routinely taken at FIRST surgery for estrogen receptor/
progesterone receptor (ER/PR) assay and level of HER-2/neu expression, needed to plan drug treatment of
patient. For Stage IV or for those cases not previously performed, it is best to determine from the excision
biopsy specimen the ER/PR and HER-2 status.
Hormonal therapy (Tx) has been shown to reduce overall tumor recurrence and mortality in ER(+) women.
Tamoxifen or an aromatase inhibitor agent is the usual hormonotherapy drug. The best responder would be an
ER(+)/PR(+) patient; for those premenopausal, tamoxifen can be given; for those post-menopausal, tamoxifen
or aromatase inhibitor can be given. For those ER(+)/PR(-), the PR(-) status may be a marker for epidermal
growth factor overexpression (Her-2 overexpression) and this subgroup of post-menopausal patients may be
best started on aromatase inhibitors.
HER-2-neu overexpression denotes an aggressive cancer, resistance to CMF but responsiveness to anti-Her-2neu immunotherapy (trastuzumab). A combination of HER-2-neu >++/ PR(-) connotes resistance to CMFbased regimen and tamoxifen.
(G) The purpose of surgery is to remove the local and regional disease. A number of randomized trials document
that in the majority of women with Stage I and II invasive breast CA, mastectomy with axillary dissection
versus breast conserving therapy with lumpectomy, axillary dissection and breast irradiation (breast conserving
therapy) are medically equivalent primary therapeutic options. MRM still remains the better option for clinical
settings with low patient follow-up rates or low resource settings.
Surgical management is the responsibility of the surgical oncologist.
(H) For high risk patients with >4 (+)LN and (-)ER or for those premenopausal and (-)LN or with HER-2-neu over
expression, anthracycline-containing adjuvant chemotherapy is given.
Otherwise, CMF can be given,
particularly for elderly and or patients with heart disease; taxanes can also be given particularly for young,
ALN(+) 0-3, aggressive and ER/PR(-) tumors.
(I)
If adjuvant chemotherapy is indicated, RT should be given after chemotherapy is completed. Radiotherapy is

the responsibility of the radiation oncologist.
It was hoped that post-op RT could prevent locoregional recurrence and improve disease-free and overall
survival. It is now evident, however that this has not occurred to the degree hoped for, probably because
remaining tumor burden is too great. Hence, adjuvant systemic chemotherapy is given.
More common chemotherapeutic drugs used currently in breast cancer management (neoadjuvant, adjuvant,
or palliative setting) are doxorubicin and the other anthracylcines, cyclophosphamide, fluorouracil, taxanes,
navelbine, capecitabine, gemcitabine, methotrexate, vincristine, mitomycin-c, carboplatin, trastuzumab.
Drug management (from hormonotherapy to gene therapy in the adjuvant to palliative setting) is the
responsibility of the medical oncologist who does the planning, the administration, and the monitoring of drug
therapeutic and safety effects.
(J)
Preoperative chemotherapy for large clinical Stage IIA and IIB tumors and T3N1Mo tumors should be
considered for women who meet the criteria for breast conserving therapy.
(K) Metastatic sites for breast cancer are usually the regional LNs, skin, lung, liver, bone, brain, etc.
breast cancer can be those with:
1.
2.
Stage IV
operable-like breast mass but with distant metastasis wherein simple mastectomy followed by
radiotherapy of target breast &
and regional LNs sites and symptomatic metastatic sites plus
chemotherapy/ hormonotherapy, OR wherein radiotherapy to target breast lesion/ other symptomatic
metastatic sites plus chemotherapy/ hormonotherapy can be done,
inoperable-like breast mass (adherent, ulcerated, etc) with distant metastasis, wherein toilette
mastectomy can be done with chemotherapy/ hormonotherapy or radiotherapy or best supportive care.
Surgery, chemotherapy, radiotherapy procedures in Stage IV disease are all palliative in goal, although several
patients can respond very well to chemotherapy + radiotherapy and have significantly long time to disease
progression interval.
Best supportive care mainly includes management of nutrition, pain, infection,
psychological well-being, nursing and rehabilitative care, and other pertinent quality of life patient care.
5
1
Stage
(D)
Breast CA
Suspect (A)
6
2
O?
Open
biopsy (B)
10
DCIS
Positive
cancer?
(C)
Adjuvant
Hormonal Tx
ER/PR
+? (F)
Lumpectomy
w/ nodal
sampling
or MRM
13
14
Y
1 or 11?
Breast
Conservation
or MRM (G)
Refer
22
19
20
ER / PR/HER2
(-)? (F)
28
30
Hormonal +
Adjuvant
Chemotx +
Trastuzumab
18
Observe
35
34
Y
111?
37
40
Y
Operable
?
ER/PR +/
Her2+? (F)
MRM
N
Neoadjuvant
Chemotherapy (J)
43
39
Adjuvant
Chemotherapy
+ Hormonal Tx +
Trastuzumab
32
Positive
margin?
Adjuvant
Radiotherapy
42
Adjuvant
RT to breast &
regional nodes
33
N
Observe
48
38
47
Chemotherapy w/ RT
IV (K)
Adjuvant
RT to breast &
regional nodes
N
45
44
Adjuvant
Chemotherapy
MRM
Adjuvant
Radiotherapy
31
41
36
Observe
Menopausal
27
Positive
margin ?
Adjuvant
Chemotx +
Hormonal Tx +
Trastuzumab
29
26
25
Pre-menopausal?
Tumor size >= 1.0 cm or w/

unfavorable
prognostic factors?
Adjuvant
Radiotherapy
(I)
Observe
Adjuvant
Chemotherapy
24
17
23
Y
Observe
16
Ax LN+?
(H)
21
Positive
margin?
19
15
12
11
Excision8 Observation
LCIS
?(E)
46
Palliative surgery (F)
Palliative
Chemotherapy/ Hormonal
Therapy/ Trastuzumab or
BSC
Palliative
Radiotherapy or Best
Supportive Care (BSC)
LUNG CANCER
The management of lung cancer must be multi-disciplinary & interdisciplinary, with each discipline
(A)
A change in pulmonary habits is the most significant sign of lung cancer. Coughs, chest pain, rust coloredstreaked sputum, hemoptysis, hoarseness, weight loss, and dyspnea are common symptoms of lung cancer.
(B)
Postero-anterior and lateral chest films are the most valuable first tools to establish the diagnosis when there
is clinical suspicion of lung cancer.
(C)
The CT scan can detect asymptomatic smaller tumors. For lung cancer suspect, do CT scan of chest, upper
abdomen and adrenal glands. CT scan is also the most useful of all modalities for determining the
characteristics of T and N in the thorax and M in the brain and liver.
(D)
Bronchoscopy yields (+) histology only if the lung cancer is centrally located or has invaded centrally.
Cytological studies include sputum and bronchial washing exams by Papaniculao technique.
(E)
Percutaneous needle biopsy guided by fluoroscopy or CT scan gives accurate cytologic diagnosis from
peripheral lung lesions and also from liver/bone metastatic lesions.
(F)
Pleural fluid can undergo cytologic exam when pleural effusion is the presenting symptomatology.
(G)
There are 2 major histological types, whose management differ accordingly: 1) small cell
carcinoma (SCLC)- tends to be disseminated at diagnosis; rapidly growing, 2) Non-small cell
(NSCLC)- slow growing; with three cell types: a) epidermoid carcinoma most common centrally
adenocarcinoma tends to be peripherally located, c) large cell anaplastic carcinoma
adenocarcinoma in metastatic pattern.
anaplastic
carcinoma
located, b)
similar to
For both SCLC and NSCLC, staging work-up includes CT scan of chest, upper abdomen and adrenal glands (if
not yet done in diagnostic work-up), ultrasound of the liver (if upper abdomen CT scan was not done), brain
and bone scans (if symptomatic).
(H)
SCLC Stage:
1) Limited disease confined to lung and regional lymph nodes.
2) Extensive disease denotes metastasis outside lung and regional lymph nodes.
(I)
NSCLC
A.
a.
b.
c.
d.
e.
(J)
stage by TNM classification

TNM
T1S carcinoma in situ
T1 <3 cm tumor size not involving the visceral pleura
T2 >3 cm tumor size, >2cm from the carina, (+) visceral
i. pleural involvement, partial atelectasis
T3 tumor involves the chest wall, diaphragm, mediastinum
i. pleura or parietal pericardium, <2 cm from the carina, complete atelectasis of either lung
T4 tumor involves the mediastinum, heart, trachea,
i. carina, vertebral body; presence of malignant pleural/pericardial effusion; presence of
satellite nodule/tumor
No spread to lymph nodes (LN)
Spread to LN within the lungs, ipsilateral hilar LNs
Spread to subcarinal or ipsilateral mediastinal LNs
Spread to cervical LNs or contralateral hilar and
i. mediastinal LNs
f.
g.
h.
i.
N0
N1
N2
N3
j.
k.
M0 No distant spread
M1 Spread to distant organs, to other lobes of the
i. lungs or to LNs further than those mentioned in N stage
B.
a.
b.
c.
d.
e.
f.
g.
h.
STAGE
0 - TisN0M0
IA T1N0M0
IB T2N0M0
IIA T1N1M0
IIB T2N1M0, T3N0M0
IIIA T1-T3N2M0,T3N1M0
IIIB AnyTN3M0, T4AnyNM0
IVB AnyT AnyN M1
In SCLC T1-2N0M0 and NSCLC Stage I and II, surgery is done to achieve complete tumor resection. Avoid an
exploratory thoracotomy or an incomplete surgical resection. The choice of surgical procedure lobectomy,
pneumonectomy, segmental or sleeve resection depends on disease extent and patients functional status.
Here, surgery may not be done if with medical contraindications. The presence of distant metastases or
extrahepatic metastasis is indicative of inoperability and a surgical procedure is an absolute contraindication.
Surgical management is the responsibility of the surgical thoracic oncologist.
(K)
Irradiation is used to achieve:

1) Definitive irradiation of localized lung cancer
2) As part of a combined treatment approach
3) Palliation of symptoms
Radiotherapy can be given in combination with chemotherapy if a patient is assessed (age, ECOG performance
status, co-morbidities, preference) to be able to receive combination modality of treatment.
Radiotherapy is the responsibility of the Radiation Oncologist.
(L)
In SCLC, combination chemotherapy is the treatment of choice for all stages. Drugs used are cisplatin,
carboplatin, paclitaxel, docetaxel, adriamycin, vincristine, cyclophosphamide, etoposide, ifosfamide,
irinotecan.
In NSCLC, chemotherapy is used for recurrent or metastatic disease and for palliation of inoperable
symptomatic patients whose disease is beyond radiotherapy control. Recent data also suggested benefits for
Stage III disease after surgery or radiotherapy. In NSCLC, common chemotherapeutic agents used are
cisplatin, carboplatin, paclitaxel, docetaxel, gemcitabine, vinorelbine, ifosfamide, etoposide, erlotinib, and
gefitinib (gefitinib for Asian, female, adenocarcinoma).
Neoadjuvant chemotherapy is reported to be promising due to better staging procedures and use of
cisplatin/taxane containing regimens. Drugs used are cisplatin, carboplatin, paclitaxel, docetaxel, etoposide.
Drug therapy for cancer is the responsibility of the Medical Oncologist.

Initial work up prior to chemotherapy includes baseline CBC, creatinine, serum electrolytes, LDH, ECG.
Lung CA
Suspect (A)
6
2
No other
CA site?
Chest
X-ray PAL (B)
5
CT scan
(C)
No
Mass
?
Close
follow up;
Refer
3
Y
No
Mass?
Manage by
case; Refer
N
10
9
Y
Centrally
located?
Bronchoscopy
w/ biopsy or
cytology (D)
12
N
11
Y
Peripheral
location?
Percutaneous
FNAB (E)
21
Cancer?
(G)
14
N
13
Y
Enlarged
neck nodes?
Thoracentesis
w/ cytology (F)
18
17
Highly suspect
cancer?
N
19
Refer
Radiotx
25
23
N
24
Highly
suspect
cancer?
16
Pleural
effusion?
N
22
15
Biopsy
Refer
Close
follow-up
Radiotx
20
Close
surveillance
Positive lung
cancer? (G)
24
30
23
29
Stage T1T2
NoMo?
(H)
SCLC?
Not
operable?
Rt +/Chemo
32
N
31
Adjuvant RT (K)
&/or Chemo (L)
Lobectomy
(J)
25
26
Y
Stage T3T4
N1-3Mo?
Chemo +/RT
28
N
27
Palliative
chemo
+/- RT
Metastatic
33
37
34
NSCLC
Stage I?
(I)
36
Operable
?
35
38
Positive
margins?
Surgery (J)
39
RT
Close
follow-up
RT
40
41
Stage
II/III?
43
Operable
?
42
45
44
Positive
margins?
Surgery
46
RT
47
Chemo +/RT (L)
Stage IV
48
Close
follow-up
50
Single site
metastasis
?
51
Operable
?
Palliative
Surgery
52
Chemo
+/- RT
N
N
53
49
Palliative
Treatment
Chemo +/RT
MALIGNANT LYMPHOMA
The management of malignant lymphoma must be multi-disciplinary interdisciplinary, with each discipline
respecting the specialty expertise of the other, all for the benefit of the cancer patient. The main responsible
is the medical oncologist.
(A)
The typical presentation of lymphoma is painless node enlargement. Symptoms and signs of nonHodgkins Lymphoma (NHL) are similar to those in Hodgkins Lymphoma (HD), except for the following
generalizations: 1) unlike HD, noncontiguous spread is the rule in NHL, and the mediastinum is often
spared. Unsuspected bone marrow involvement occurs much more frequently. Early involvement of
oropharyngeal lymphoid tissue, skin, the GI tract, and bone is frequent; 2) leukemic transformation with a
high peripheral lymphocyte count occurs in about 13% of patients with lymphocytic lymphoma; 3)
autoimmune anemia with positive antiglobulin (Coombs) tests occurs in a minority of NHL patients.
Complete PE is done with CBC, LDG, Calcium, Urinalysis, Kidney and Liver function test, Chest X-ray, CTScan of the abdomen and pelvis
(B)
Surgical biopsy establishes the diagnosis. The most suspicious node should be selected for excision
biopsy. The largest most central node in an enlarged group is most likely to be diagnostic. The biopsy of
cervical node is preferred because chronic inflammatory changes are more commonly present in inguinal
and axillary nodes. Frozen sections and needle biopsies are discouraged. Aspiration of bone marrow or
effusions may provide the diagnostics and obviate the need for a LN biopsy. Special tests of blood, LN, or
bone marrow establish the exact type of lymphoma e.g. cell surface markers and genetic studies (if
needed). Cell surface markers are proteins in the surface of lymphoma cells that identify the kind of
lymphoma. In chronic lymphocytic lymphoma (CLL), CD5, CD19, CD23 and CD20 are present. For
leukemia the presence of CD38 helps determine prognosis. For mucosa-associated lymphoid tissue (MALT)
lymphoma, cell tumor markers include (+) CD20, (-) CD10, (-) CD5.
Surgery is often used to get a tissue sample to diagnose and classify lymphoma but it is very rarely used
as a treatment option because lymphoma is a cancer of the lymphatic system that circulates lymph fluid
throughout the body. It is a systemic disease. However, surgery is sometimes used to treat lymphoma
that start in certain extra nodal organs, such as thyroid, stomach, that have not spread beyond these
organs.
Surgery is the responsibility of the surgical oncologists.
(C)
The presence of Reed Sternberg (RS) cells (in HD) differentiates Hodgkins from Non-Hodgkins
lymphoma. NHL types are 1) Slow-growing/Indolent 2) Aggressive 3) Highly aggressive. NHL is of T-cell or
B-cell origin. Included in the slow growing group are: Chronic Lymphocytic Leukemia/Small Lymphocytic
Lymphoma, Follicular Lymphoma, and MALT Lymphoma. Diffuse Large B Cell Lymphoma is classified under
the Aggressive type of NHL Lymphoma.
Burkitts Lymphoma, Lymphoblastic Lymphoma and AIDS-related Lymphoma is considered Highly
Aggressive NHL.
The many specific types are sometimes grouped together into slow-growing (indolent), aggressive, or very
aggressive categories. Aggressive and highly aggressive lymphomas grow more rapidly and spread
throughout the body quickly. Without treatment most patients live only a short time. Fortunately,
aggressive and highly aggressive lymphoma responds well to chemotherapy, and many can be cured.
(D)
For NHL, the stage of disease is less predictive of outcome compared with HD. The histological type of NHL
is the most important prognostic determinant. Staging system is the same for HD and NHL (Ann Arbor).
(E)
Stage I
The lymphoma is in lymph node or nodes in only one region, such as the neck,
groin or underarm.
Stage II
The lymphoma is in two groups of lymph nodes, and these are on the same side
of the diaphragm.
Stage III
The lymphoma is only in lymph nodes but on both sides of the diaphragm.
Stage IV
The lymphoma is widespread in an organ or organs or skin including bone

marrow.
*All stages:
A without weight loss/fever/sweats

B with weight loss/fever/sweats
Treatment should be considered in patients:

a.
who have large tumor masses,
b.
with a steady tumor growth in the past 6 months,
c.
with immune system that is destroying the blood cells,
d.
with occurrence of frequent serious infections,
e.
with vital organ damage,
f.
with low blood counts,
g.
with lymphocyte count doubling within a year,
h.
i.
eligible for a clinical trial and

who wants treatment.
Chemotherapy (CTx/ chemotx) is the mainstay of treatment when lymphoma is not a localized disease; it
is the treatment of choice for majority of NHL. The general approach is to treat patients until they achieve
CR and then administer 2 additional cycles.
In stage 1/II, tumor lesion < 4 inches, subsequent 3-4 cycles of chemotherapy are given before RT, more
cycles may be given if lactic dehydrogenase (LDH) or Beta-2 microglobulin level is high or if lymphoma is
in the chest. If lymphoma is > 4 inches, 6-8 cycles may be given. Each cycle is given every 3 weeks.
Rituximab may be given for CD20 positive patients.
Stage III/IV disease, is treated mainly with CHOP therapy. If International Prognostic Index (IPI) is low,
6-8 cycles are given with or without Rituximab. If the IPI is high, a clinical trial with peripheral stem cell
transplantation may be done. If lymphoma never shrunk by 50% or not completely given by end of
treatment or lymphoma is recurrent, new treatment is needed. Favorable IPI for all patients are age <60
years, Stage 1-II, number of extranodal sites <1, ECOG 0-1, and LDH normal; in patients <60 years,
favorable IPI are Stage I-II, ECOG 0-1, LDH normal.
Chemotherapy can be used alone or in combination with radiotherapy. Drugs can be used singly (e.g.,
rituximab particularly for CD-20(+) lymphoma) or usually in combination (CHOP, CHOP-Rituximab, DHAP,
ICE, MIME)).
In recurrent or aggressive NHL, high dose chemotherapy plus autologous stem cell transplant is an option.
Chemotherapy is the responsibility of the medical oncologists.
(F)
Radiotherapy (RT) is the primary treatment modality for majority of patients with early stages of HD
(Stage I/II). The role of radiotherapy for NHL has progressively decreased as chemotherapy regimens
have become more effective; it can be the primary or adjuvant treatment in selected patients. It is also
used in the palliative setting for lesions in the brain, and in spinal cord compression or in nerve
compression causing pain.
Radiotherapy is the responsibility of radio-oncologists.
(G)
For Gastric MALT, re-staging and re-evaluation with follow-up endoscopy with biopsy is done every 3
months. If neither lymphoma nor H pylori is found no further treatment is needed. If H pylori is gone but
lymphoma persists, then 3 more months of observation is suggested or radiation therapy can be given to
the stomach, particularly if there are symptoms. If lymphoma is gone but H pylori persist, then another
course of different antibiotics should be given. If both lymphoma and H pylori persist, a second course of
different antibiotics can be given if lymphoma is not growing. If it is growing, RT to the stomach and
surrounding area is suggested. If lymphoma has returned after RT, it should be treated like follicular
lymphoma. If lymphoma has returned after antibiotic therapy, RT is given. If it has spread away from the
stomach, treat as follicular lymphoma.
(H)
H. pylori can cause acute and chronic gastritis, duodenitis, gastric peptic ulcer and duodenal ulcer and
non-ulcer dyspepsia. H. pylori has been identified as a risk factor for gastric carcinoma and MALT
Lymphoma. Nearly 90% of patients with duodenal ulcer and > 70% of those with gastric ulcer and > 80%
of patient with gastric cancer have H. pylori infection. Several effective treatments include use of
antibiotic such as, clarithromycin, metronidazole and omeprazole.
(I)
Stage Ie-II Stage III-IV
localized to one area of the body.

low grade
(J)
Treatment with only antibiotic is suggested if the lymphoma is confined to the stomach and infection with
H. pylori is found. If the lymphoma is a little more advanced and affects surrounding lymph nodes,
radiation therapy maybe added.
(K)
For more advanced stages, widespread lymph node or organ involvement, chemotherapy maybe given if
there are reasons for treatment. Reasons for treatment are presence of bleeding from stomach, vital organ
damage, very large tumor, steady growth of lymphoma, symptoms, or patient wants treatment. For these
stages, the lymphoma may be treated as if it were a slow growing or follicular lymphoma.
(L)
Usual sites of non-gastric MALT lymphomas are salivary glands, skin, breast, small or large intestines,
thyroid, tissue around the eyes, and lung.
1
11
8
Lymphoma
suspect (A)
Slow
growing
?
NHL
2
N
10
Stage
N
13
Biopsy
(B)
12
Close ff-up;
RT (F)
3
Y
18
17
Aggressive
&
Highly
Aggressive?
19
Stage
(D)
I/II ?
Bulky
?
RT+/-Chemotx
+/- Rituximab
N
24
Close
follow-up;
Refer
Recurrent?
N
26
Manage as
NHL
III, IV
25
21
Chemotx +/RT
+/- Rituximab
Chemotx (6-8 cycles)

+ Rituximab
RT OR
High Dose Chemotx +
Stem Cell Transplant
Primary
Extranodal
27
32
Hodgkins
disease
Primary
bone or
thyroid or
skin or
CNS?
Y
20
22
N
5
Chemotx RT
II, III, IV
16
Highly
suspect
cancer?
RT + CTx
(E)
15
14
With
cancer
?
Bulky?
( > 4 in.)
I?
23
Chemotx (6-8) + Rituximab

+ RT OR
High Dose Chemotx +
Stem Cell Transplant (E)
28
Y
RT +
Chemotx
29
33
MALT
? (G)
Stage (D)
30
A
31
35
Y
34
IA-IIA?
Other
Primary
Extranodal
RT
RT +
Chemotx
N
36
37
IB-IIB,
IIIA,
IIIB?
38
IV or
Recurrent
Chemotx + RT
39
40
Chemotx
Consolidation
RT
MALT
Gastric
MALT?
(G)
H pylori
(+)?
(H)
Re-stage: Repeat
endoscopy &
diagnostics at 3
months
(Re-assess)
Standard antibiotic
treatment for
H pylori
N
N
Stage
Ie-II?
(I)
N
9
Stage IIIIV
13
Standard antibiotic
treatment for H pylori
Or Low Dose
Radiotherapy
(J)
Re-staging
10
Chemotherapy with
>1 drugs OR
RT to stomach &
surrounding area
(K)
11
Close
Surveillance
Non-Gastric
MALT (L)
14
15
Occurring along
with large cell
lymphoma?
17
N
16
Stage IeII?
Treat like diffuse

large B-cell
lymphoma
RT or Surgery may
be used for
lymphoma in lung,
breast (+ RT), skin,
thyroid, or intestine
N
18
Stage
III-IV
19
Treat like follicular

lymphoma
UNRESECTABLE HEAD AND NECK CANCER

The management of unresectable H&N cancer must be multi-disciplinary & interdisciplinary, with each
discipline respecting the specialty expertise of the other, all for the benefit of the cancer patient. Here,
members of the team are surgeon, supportive care internist, radio-oncologist, and medical oncologist.
(A)
Unresectable head and neck (H&N) cancer refers to newly diagnosed T4b (tumor regionally), any N, or
unresectable N+, M0 disease, or disease wherein surgeon doubts the ability to remove all gross tumor on
anatomic grounds or unable to remove without imposing unacceptable morbidity.
(B)
Histological diagnosis of cancer is ascertained by review of slides. Symptomatic relief (pain, nutrition, infection,
support group) is done while preparing the patient for definitive treatment. M0 stage is ascertained do chest
x-ray (chest CT is considered for patients at high risk for thoracic metastasis), ultrasound of liver, bone scan/
brain scan (if symptomatic). Do dental clearance. Do speech and swallowing evaluation as indicated.
(C)
Treatment is usually concurrent chemoradiation with >70 Gy for primary and gross adenopathy and 44-50 Gy
to low risk neck nodes. Higher doses of definitive RT without chemotherapy can be given for medically unfit or
those who refuse chemotherapy.
The choice of chemotherapy should be individualized based on patient characteristics (performance status,
goals of therapy). Chemotherapy drugs active in H&N cancers are cisplatin, 5-FU, hydroxyurea, paclitaxel,
carboplatin, docetaxel, capecitabine, methotrexate, ifosfamide, bleomycin, gemcitabine, cetuximab, fluorouracil
Uncontrolled disease can be given 2nd line chemotherapy +/- radiotherapy.
(D)
For those patients post neck dissection or in complete response (CR) or major response, follow-up can be done
as follows:
Physical exam:
Year 1, every 1-3 months
Year 2, every 2-4 months
Year 3-5, every 4-6 months
Thyroid stimulating hormone (TSH) every 6-12 months, if neck irradiated
Speech and swallowing evaluation and rehabilitation as indicated
Unresectable H&N
Cancer (A)
2
Biopsy or Review of Slides;

Symptomatic Relief;
Preparation for Treatment (B)
4
3
ECOG
3?
5
Definitive RT or
Best supportive care
8
N
ECOG
2?
Induction chemotherapy
followed by RT or
Definitive RT
N
ECOG 0-1
10
9
Concurrent ChemoRadiotherapy or
Induction chemotherapy
followed by RT (C)
Primary site
uncontrolled
11
13
N
Residual neck
disease?
Best Supportive Care/

Chemotherapy
Neck
dissection
14
12
N
Best Supportive
Care/
Chemotherapy

Close follow-up (D)
15
Relapse or
recurrence
16

Palliative Chemotherapy/
Radiotherapy
10
NASOPHARYNGEAL CARCINOMA (NPCA)

The management of NPCA must be multi-disciplinary & interdisciplinary, with each discipline respecting the
specialty expertise of the other, all for the benefit of the cancer patient. Here, members of the team are
surgeon, supportive care internist, radio-oncologist, and medical oncologist.
(A)
Common presentations are lymph adenopathies (cervical LNs), otologic (obstruction to Eustachian tube), and
nasal. Atypical pain is due to trigeminal nerve involvement. Cranial nerve involvement occurs in 15% of cases
and commonly involves CN V and/or VI.
(B)
Nasopharyngoscopy with a nasopharyngeal mirror or via fiber optic nasopharyngoscope is mandatory.
(C)
Do complete history & PE. Do chest x-ray or chest CT (considered for patients at high risk for thoracic
metastasis), CT with contrast or MRI with gadolinium of nasopharynx and base of skull to clavicles. CTscan
allows excellent visualization of the nasopharynx (and its extent) and can detect lesions not seen on
nasopharyngoscope.
Do dental evaluation and clearance. Do speech and swallowing evaluation as indicated.
(D)
Imaging for distant metastases (chest, liver, bone) for N2-3 disease includes CT. PET scan can be done, as
indicated. Staging is according to AJCC 2006:
Stage 0
Stage I
Stage IIA
Stage IIB
Stage III
Stage IVA T4
Stage IVB Any

Stage IVC Any
Tis Carcinoma-in-situ N0M0

T1 Confined to nasopharynx N0M0
T2a Extends to oropharynx and/or nasal cavity w/out parapharyngeal
extension N0M0
T1N1 Unilateral LN metastasis, <=6cm in greatest dimension, above
supraclavicular fossa
T2 Extends to soft tissues N1M0
T2aN1M0
T2b Any tumor with parapharyngeal extension N0M0
T2bN1M0
T1N2 Bilateral metastasis in LNs, <=6 cm in greatest dimension, above
supraclavicular fossa
T2aN2M0
T2bN2M0
T3 Invades bony structures and/or paransal sinuses N0M0
T3N1M0
T3N2M0
Intracranial extension and/or involvement of cranial nerves,
infratemporal fossa, hypopharynx, orbit, or masticator space N0M0
T4N1M0
T4N2M0
T N3 Metastasis in a LN/s >6cm and/or to supraclavicular fossa M0
T Any NM1
(E)
The inaccessibility of the nasopharynx, the proximity of tumors to skull base and to cranial nerves and the
widespread lymphatic involvement, dictate radiotherapy rather than surgery as the procedure of choice.
Occasionally, neck dissection may be indicated for persistent lymph adenopathy if primary is controlled and
distant metastasis is absent. Definitive radiotherapy (RT) includes >70 Gy for primary and gross adenopathy,
and >50 Gy for low-risk nodal stations.
(F)
Concurrent chemotherapy-RT (chemoRT) followed by chemotherapy (chemotx) alone is preferred for T1, N1-3;
T2b-T4, any N disease:
Commonly cisplatin+RT followed by cisplatin-FU. Other drugs include gemcitabine, methotrexate, bleomycin,
capecitabine, carboplatin, paclitaxel, docetaxel.
(G)
Follow-up schedule includes PE every 1-3 months for year 1, every 2-4 months for year 2, every 4-6 months
for year 3-5, and every 6-12 months thereafter after 5 years. TSH is taken every 6-12 months, if neck is
irradiated. Speech and swallowing rehabilitation is done as indicated.
11
1
16
NPCA suspect (A)
Stage (D)
2
Nasopharyngoscopy
(B)
18
17
8
With
lesion?
T1-2a, N0,
M0?
Positive
cancer?
Biopsy
Radiotherapy
(E)
19
Y
N
Close
follow-up
CTscan with
contrast or MRI
with gadolinium
(C)
20
10
21
T1, N1-3;
T2b-4, any
N, M0?
Close
follow-up;
Refer
Y
Concurrent
chemoRT
22
5
Chemotherapy (F)
With
lesion?
Y
N
24
23
N
Enlarged
neck
nodes?
Complete
response?
11
14
Positive
cancer?
13
Close
follow-up
(G)
Biopsy
12
Close
follow-up;
Refer
Primary
cancer?
Medically
fit?
15
Neck
dissection
28
26
N
Close
follow-up;
Refer
27
25
Close
follow-up
(G)
BSC
Manage by
cancer site
30
32
Any T, any
N, M1, PS
<2?
Chemotherapy
35
33
31
N
Palliative
Treatment/
Best
Supportive
Care (BSC)
Complete
response?
N
34
Palliative
Treatment/
BSC
RT
36
Close
follow-up
(G)
12
CANCER OF THE ESOPHAGUS

The management of esophageal cancer must be multi-disciplinary & interdisciplinary, with each discipline
(E)
Dysphagia and weight loss are the most common symptom at presentation in about 90% of patients.
Hematemasis is an uncommon occurrence and can herald a rapid fatal outcome due to aortic wall penetration
by the cancer. Early symptomatology includes chest pain or odynophagia but usually not severe enough to
stimulate medical attention. Signs of invasion of adjacent organs are late and include hoarseness, SVC
syndrome, cough due to tracheo- or bronchio-esophageal fistula, Horners syndrome, paralyzed diaphragm,
malignant pleural effusion or massive hematemesis.
(F)
Esophagogastroduodenoscopy to visualize entire upper GI tract, if possible, with biopsy. Do complete history &
physical exam (H&P).
Esophagogram is useful alternative to detect and define primary lesions. Irregular filling defects or ulcerative
strictures, deviation or angulations of the barium column are signs of malignancy. Double contrast with air and
barium is useful for smaller lesions. Barium swallow determines the length of the lesion, extent and
circumferential involvement and degree of obstruction but the combination of endoscopy with cytology brushing
and perimeter biopsies of a mass will have the diagnosis of cancer with 90% accuracy.
SMA-12 can be done as a tumor marker.
(G)
Do chest x-ray or chest CT scan. Abdominal CT scan can evaluate the presence of nodal involvement, invasion
to adjacent structures and metastatic areas. AJCC staging (2002) is as follows:
Stage
Stage
Stage
Stage
Stage
Stage
Stage
M1
I
IIA
IIB
III
IV
IVA
IVB
T1N0M0, tumor invades lamina propia or submucosa

T2-3N0M0, tumor invades muscularis propria-adventitia
T1-2N1M0, regional LN involvement
T3N1M0/ T4anyNM0, tumor invades adventitia-adjacent structures
anyTanyNM1
anyTanyNM1a,
anyTanyNM1b
Distant metastasis
Tumors of the lower thoracic esophagus:
Tumors of the mid-thoracic esophagus:
Tumors of the upper thoracic esophagus:
M1a
M1b
M1a
M1b
metastasis in celiac LNs

other distant metastasis
not applicable
nonregional LNs &/or other
distant metastasis
M1a metastasis in cervical nodes
M1b other distant metastasis
(H)
Medically fit to tolerate major abdominal and/or thoracic surgery. A cardiopulmonary clearance is required.
(I)
Resectable T4 involvement of pleura, pericardium or diaphragm; unresectable T4 invasion of aorta, trachea,

heart, great vessels
(J)
Transhiatal or trans-thoracic, or minimally invasive; gastric reconstruction preferred. Feeding jejunostomy for
postoperative nutritional support, generally preferred
(K)
Chemoradiotherapy is the preferred modality for cervical esophageal carcinoma.

5FU/cisplatin in conjunction with RT (50-50.4 Gy) is usual therapy.
Esophageal squamous cell carcinoma (more common histopathological diagnosis) is radiosensitive and local
tumor eradication for T1 disease is frequently attainable. Other chemotherapy drugs include taxane-based,
irinotecan-based; investigational drugs include capecitabine, gemcitabine, oxaliplatin
Pre-op and/ or post-op chemotherapy can be given.
For metastatic cancer, chemotherapy may be tried for 2 sequential regimens; if failed, do BSC.
G-1: In T2N0M0 adenocarcinoma, just surgery may be done, except for higher risk patients such as poorly
differentiated histology, lumphovascular ivasion, neurovascular invasion or young patients. Limit to esophageal
or GE junction patients.
(L)
Assessment >=4 weeks, endoscopy with biopsy and brushings
(M) Close surveillance in asymptomatic patients includes H&P with nutritional counseling every 4 months for 1
year, every 6 months for 2 years, then annually. As indicated tests are chemistry profile/ CBC, chest x-ray,
radiology and endoscopy (eg, persistent or recurrent dysphagia), dilatation for anastomotic stenosis.
For recurrent disease surgery can be done if recurrence limited to anastomosis, otherwise radiotherapy (RT)chemotherapy (chemotx) and/or endoscopic therapy is done as salvage therapy.
(N)
Best supportive care (BSC) includes: a) obstruction stent, laser, photodynamic therapy, RT, b) nutrition
enteral feeding, c) bleeding RT or surgery and/ or endoscopic therapy, d) esophageal dilatation
13
Cancer of
esophagus
suspect (A)
Stage (C)
Esophagogastroduodenoscopy
with biopsy (B)
13
6
Stage I-III,
IVA (locoregional)?
16
Medically
fit for
surgery? (D)
18
Resectable
(E)?
Noncervical
T1 disease?
Malignant
?
N
7
14
Medically fit
for chemotherapy? (D)
Stage IVB;
Metastatic
cancer
N
4
Close
follow-up;
refer
15
29
19
17
Y
Concurrent
Chemo-RT
(G)
20
Re-assess (H)
22
21
23
No evidence
of disease?
10
ECOG
<=2?
11
Chemotherapy
N
9
12
ECOG>=3
BSC (J)
Concurrent
Chemo-RT
BSC (J)
Esophagectomy (F)
Esophagectomy or
Observe
Close
follow-up
(I)
N
BSC (J)
24
25
Persistent
local disease;
no metastasis?
27
N
Progressive
or metastatic
disease
26
Esophagectomy or
Palliative
Treatment (Tx)
28
Palliative Tx;
BSC (J)
Close
follow-up
(I)
A
37
44
30
R0- no cancer
at resection
margins?
Node
negative?
52
Adenocarcinoma
?
47
T1,
N0?
N
N
N
33
45
39
N
34
35
RT +
chemotx or
Salvage Tx
N
41
36
Close
follow-up
(I)
Squamous cell
carcinoma
40
Squamous
cell
carcinoma?
R2- macroscopic
residual cancer or
M1b
T2, N0?
Node
positive
RT +
chemotx
(G)
Close
follow-up
(I)
46
53
54
48
38
32
R1microscopic
residual
cancer?
Close
follow-up
(I)
49
Low risk for

recurrence/
PD? (G-1)
Close
follow-up
N
55
T3, N0
N
Chemotx/RT
(G)
50
Close followup (I)
Chemotx/ RT
(G)
51
Adenoca,
proximal or
midesohpagus
Close followup (I)
42
Close followup or
Chemotx (G)
43
Close followup (I)
15
GASTRIC (STOMACH) CARCINOMA

The management of gastric carcinoma must be multi-disciplinary & interdisciplinary, with each discipline respecting
the specialty expertise of the other, all for the benefit of the cancer patient.
(A)
Vague epigastric discomfort is the most frequent symptom associated with gastric cancer and 90% of patients experience
epigastric pain. Weight loss occurs in 80% of patients, early satiety in 65%, anorexia in 60%, and 50% of patients
experience dysphagia and vomiting. Only 1% of patients are symptomatic.
The physical signs of gastric cancer are invariably related to metastatic or unresectbale disease. 1/3 of patients will have
signs of metastatic disease, i.e., palpable epigastric mass, ascitis, jaundice, supraclavicular adenopathy, left axillary
adenopathy, hepatomegaly, rectal shelf, generalized cachexia, on their initial presentation.
A complete history and PE is done.
(B)
Flexible esophagogastroduodenoscopy or gastroscopy is a very accurate modality for detecting and defining primary
lesions, and allows biopsies of most gastric lesions. Generous biopsies of all gastric ulcers should be performed.
Infiltrative lesions are the type least likely to undergo biopsy accurately.
The gross appearance of gastric adenocarcinoma is characterized by 4 different types of presentation which are important
for their varied prognosis:
Ulcerative carcinoma most common
Polypoid cancers or fungating
Scirrhous carcinoma worst prognosis, with lesions infiltrating the gastric wall producing a thickened, nodular,
forshortened stomach (called linitis plastica)
Superficial gastric cancer is an uncommon variety, characterized by sheet-like collections of cancer cells
replacing the normal mucosa
(C)
Abdomeno-pelvis CT scan is the most valuable of all modalities for determining local invasion and distant metastasis. Do
chest x-ray PA-L, LFT, CEA, CA 19-9. In preparation for therapy, get CBC, creatinine.
AJCC TNM Staging (2002) is used:
T1 Tumor invades lamina propria or submucosa
T2 Tumor invades muscularis propria or subserosa
T2a Tumor invades muscularis propria
T2bTumor invades subserosa
T3 Tumor penetrates serosa (visceral peritoneum) without invasion of adjacent structures
T4 Tumor invades adjacent structures
N0
No regional LN metastatis
N+ N1 (1-6 LNs), N2 (7-15 LNs), N3 (>15 LNs)
M0 No distant metastasis
M1 Distant metastasis
(D)
Medically able to tolerate major abdominal surgery usually ECOG <2 without co-morbidities
(E)
Criteria for unresectability for cure are:

Peritoneal seeding or distant metastasis
Inability to perform a complete resection
Invasion or encasement of major vascular structure
(F)
Surgery is the standard modality of treatment. The surgery procedures are:

Distal (body + antrum) prefer subtotal gastrectomy
Proximal (cardia) total or proximal gastrectomy
Subtotal gastectomy entails removal of a large part of the stomach en bloc with greater and lesser omenta, and distal
pancreatectomy, with regional lymph node dissection (include greater curvature, lesser curvature, splenic, celiac, and
hepatic LNs). Splenectomy is avoided. Consider placing a feeding jejunostomy tube. A >5cm proximal and distal
margins from gross tumor is preferred. A minimum of 15 LNs should be evaluated. Give Vitamin B12 supplement for
gastrectomized patients.
(G)
R classification refers to amount of residual cancer remaining after tumor resection:

R0 No macroscopic/ microscopic residual disease (i.e., negative lines of resection or margins)
R1 Positive microscopic residual disease (i.e., positive lines of resection)
R2 Positive macroscopic residual disease; no distant metastasis
(H)
Concurrent chemo-radiotherapy can be given as follows - Chemotherapy is used as a cytotoxic and/ or preferably a
radiosensitization agent.
Pre-operative recommended in localized unresectable cases
5-FU+leucovorin
Capecitabine-based
Cisplatin-based
Taxane-based
Irinotecan-based
Post-operative
5-FU+leucovorin
26
Capecitabine-based
5-FU+ cisplatin
Taxane-based
Radiotherapy in combination with chemotherapy is given at 45-50.4 Gy. For R0 T2-N0 patients, adjunctive treatment can
be observe or chemotherapy (5-FU-based) +/- RT (with RT if with high risk features such as poorly differentiated or
higher grade cancer, lymphovascular invasion, neural invasion, or <50 years of age).
(I)
Chemotherapy alone can be given as single or combination (e,g., ECF, DCF, FOLFIRI, XELIRI) with the following drugs 5-FU+leucovorin, capecitabine, irinotecan, oxaliplatin, cisplatin, taxane (e.g., docetaxel), anthracycline (e.g., epirubicin),
mitomycin-C, nitrosureas.
(J)
Supportive care modalities include stent/ laser/ photodynamic therapy/ RT/ surgery (for obstruction), enteral feeding/
nutritional counselling (for nutrition), RT/ analgesics (for pain control), RT/ surgery/ endoscopic therapy (for bleeding)
(K)
For R0, T1-N0 patients and other patients in complete response (CR) or major response after post-operative adjunctive
treatment, close surveillance is done every 4-6 months for 3 years and then annually, with radiologic imaging (CXR,
ultrasound or abdomino-pelvic CT), or endoscopy as clinically indicated. PET scan can be used to find suspected
metastasis upon surveillance.
27
Gastric Cancer
Suspect (A)
4
Consider
other disease
Esophagogastroduodenoscopy,
with Biopsy (B)
7
3
Stage (C)
No Gastric
Lesion?
8
Metastatic
(M1)?
N
5
Y
Malignant?
10
ECOG
>2?
Best
Supportive
Care
N
11
Chemotherapy/ Best
Supportive Care
N
6
Close follow-up;
Refer for further
management
12
13
Medically
unfit? (D)
Y
Concurrent
ChemoRadiotherapy or
Chemotherapy/ BSC
N
14
15
Unresectable
? (E)
Concurrent
ChemoRadiotherapy or
Chemotherapy
N
16
Surgery (F)
17
19
18
Positive margins
R1-R2? (G)
Adjuvant Concurrent
ChemoRadiotherapy
Y
R1?
22
21
20
R0
R2
Concurrent ChemoRT or Chemotherapy (I) or

Best Supportive Care (J)
23
Any T,
N+?
24
Adjuvant Concurrent
ChemoRadiotherapy (H)
N
25
T1, N0?
26
Close follow-up (K)
N
27
28
T2, N0
Close follow-up or
Adjuvant Chemotherapy or Radiotherapy
28
COLON RECTUM CANCER

The management of colon rectum cancer must be multi-disciplinary interdisciplinary, with each discipline respecting
(A)
A change in bowel habit, whether constipation or diarrhea, in a patient >40 years old directs suspicion of colon cancer.
COLON: A tumor in the ascending colon may present with microcytic anemia, occult blood in the stool, or a palpable
mass in the right lower quadrant. A tumor in the descending colon presents with hematochezia, obstructive symptoms
and small caliber stools.
RECTUM: Lesions in the rectum present with local bleeding, pain, change in bowel habits and stool caliber, and then
tenesmus.
(B)
COLON: Colonoscopy is a very accurate diagnostic tool for detecting and defining primary colon lesions. Double
contrast barium enema can also be a useful tool in detecting and defining primary colon lesions, particularly in absence of
colonoscopy equipment.
RECTUM: Most cancers can be detected by simple digital exam (65-80%). Once discovered, proctosigmoidoscopy with
biopsy follows to establish diagnosis.
(C)
First-degree relatives of patients with diagnosed adenomas or invasive carcinoma are at increased risk for colorectal
cancer. Colon cancer patients, especially those 50 years or younger and those with suspected hereditary non-polyposis
colon cancer (HNPCC), familial adenomatous polyposis (FAP) and attenuated FAP should be counseled regarding family
history.
(D)
Carcinoembryonic antigen (CEA) is a tumor marker for colorectal cancer. It is not recommended for use as a screening
tool for colorectal cancer because of high false positive rates. Elevated levels upon serial determination, however, may
raise the suspicion of an occult malignancy. Consider doing tumors markers for a highly suspected cancer case who is
negative for biopsy (CEA, CA-19-9, CA-125, AFP).
(E)
More than 90% of colorectal cancers are adenocarcinomas.
(F)
The TNM staging according to the AJCC (6th ed.) depends on the depth of wall invasion and presence or absence of nodal
metastases. Minimum staging workup aside from the pathological evidence includes chest x-ray PA-L and CT scan of
whole abdomen. Colon rectum cancer usually metastasizes to the adjacent structures (e.g., mesentery, LNs), liver, lung,
and bone. CT scan is the most valuable of all modalities for detecting local invasion and distant metastasis.
Rectal cancer should be fully staged. Endoscopic biopsy specimens of the lesions should undergo careful pathology review
for evidence of invasion into the muscularis mucosa. Endorectal UTZ and MRI are recommended to assess the depth of
invasion and lymph node status. T1-2 N0 should be based on assessment of endorectal UTZ or MRI
Primary
Tx
T0
Tis
T1
T2
T3
T4
Tumor (T)
Primary tumor can not be assessed
No evidence of primary tumor
Carcinoma in situ: intraepithelial or invasion of lamina propria
Tumor invades submucosa
Tumor invades muscularis propria
Tumor invades through the muscularis propria into the subserosa, or into non-peritoneum pericoloic or
perirectal tissues
Tumor directly invades other organs or structures, and/or perforates visceral peritoneum
Regional Lymph Node (N)

Nx
Regional lymph nodes can not be assessed
N0
No regional lymph node metastasis
N1
Metastasis in 1 to 3 regional lymph nodes
N2
Metastasis in 4 or more regional lymph nodes
Distant Metastasis (M)
Mx
Distant metastasis can not be assessed
M0
No distant metastasis
M1
Distant metastasis
Stage Grouping
Stage
0
I
IIA
IIB
IIIA
IIIB
IIIC
IV
T
Tis
T1
T2
T3
T4
T1-T2
T3-T4
Any T
Any T
N
N0
N0
N0
N0
N0
N1
N1
N2
Any N
M
M0
M0
M0
M0
M0
M0
M0
M0
M1
Dukes
A
A
B
B
C
C
C
D
29
(G)
Surgery is the primary mode of treatment for colorectal cancer. The principles of surgical treatment are: 1) laparotomy
for staging, 2) wide en bloc resection of the tumor, 3) lymphadenectomy for staging as well as possible therapeutic
benefit. By-pass surgery (e.g., colostomy) can be done for palliation.
RECTUM: For abdomino-perineal resection or low anterior resection or colo-anal anastomosis using total meso-rectal
excision, a minimum of 4 lymph nodes is to be examined.
CRITERIA FOR RESECTABILITY OF METASTASES:
Liver: Complete resection must be feasible. There should be no unresectable extrahepatic sites of disease. Re-evaluation
for resection can be considered in otherwise unresectable patients after neoadjuvant therapy.
Lung: Complete resection based on anatomic location and extent of disease with maintenance of adequate function is
required. Resectable extrapulmonary metastases do not preclude resection. The primary tumor must be
controlled. Re-resection can be considered in selected patients.
(H)
Chemotherapy is the primary mode of treatment after surgery. Medical oncology specialists plan for, administer and
monitor effects of the chemotherapy, after the surgical oncology physicians have done the definitive surgery.
Chemotherapy can either be: 1) neo-adjuvant before definitive surgery mainly to decrease tumor to operable size, 2)
adjuvant after definitive surgery to eradicate micro metastasis and to prolong window prior tumor recurrence/ metastasis,
and 3) palliative to reduce pain, obstruction, mainly promoting cancer disease symptom control. Chemotherapy can be
given as 1st line or 2nd line or 3rd line, such that colon cancer can be responsive to another drug regimen if it recurred or
progressed after a previous drug regimen.
Currently more frequently used chemotherapy drugs in colon
adenocarcinomas are 5-FU, capecitabine, CPT-11 or irinotecan, oxaliplatin, bevacizumab.
Usual chemotherapy
2nd line combination
combination regimens are FUFA, FOLFOX, FOLFIRI, XELOX, or XELIRI + bevacizumab.
chemotherapy + cetuximab can be used in K-ras wild type colon cancers.
(I)
Colon cancer patients who are high risk for systemic recurrence after colon resection are those with histological grade 34, lymphatic/vascular invasion and bowel obstruction.
Probability for rectum cancer to recur is relatively low if: 1) < 30 % circumference of bowel, 2) < 3 cm in size, 3) margin
clear (3 > mm), 4) mobile, non fixed, 5) within 8 cm of anal verge, 6) T1 or T2, 7) fragmented polyp, 8) no
lymphovascular or perineural invasion, 9) well to moderately differentiated, and or 10) no evidence of lymphadenopathy
on pretreatment imaging.
Minimum surveillance work-up aside from complete physical exam (plus colostomy site), symptom & weight monitoring,
are chest x-ray PA-L and CT scan of whole abdomen every 4-6 months during the 1st 2 years and every year or as
symptoms dictate thereafter.
(J)
Best Supportive Care mainly includes management of nutrition, pain, infection, psychosocial well-being, nursing and
rehabilitative care, and other pertinent quality of life patient care.
(K)
Radiotherapy under the responsibility of the radiation oncologists is usually an adjunct to surgery/ chemotherapy and for
symptom relief particularly in bone pain (metastatic bone lesions).
COLON: There is no well-defined role of radiotherapy for primary therapy or adjuvant therapy of colon cancers; it can be
used for palliation.
RECTUM:
1)
2)
3)
4)
Radiation
The roles of radiotherapy in rectum cancer are:

primary treatment if patient is considered medically inoperable
palliative treatment for pain/ bleeding
treatment for recurrent disease
adjuvant treatment after disease resection of Dukes B and C
treatment fields should include tumor with a 2-5 cm margin, the pre-sacral nodes and internal iliac nodes
30
8
Polyp with
invasive CA?
1
Colon CA suspect
(A)
Completely removed with

clearly negative margins?
9
Close follow-up
11
10
Stage (F)
12
13
Colon CA
appropriate for
resection? (E)
14
Resectable?
(G)
Colonoscopy
with biopsy (B)
15
16
Stage (F)
Obstructing?
Colectomy with en bloc removal

of nodes OR stent OR diversion
N
18
N
17
Diversion
or stent
3
Positive
cancer
lesion?
Colectomy, liver metastasectomy

+/- neoadjuvant chemotherapy
Resectable? (G)
Close follow-up;
Consider tumor
markers (D)
N
27
5
Refer
Consider limited colon resection

+/- ablative therapy
A
Y
1-3 lung
nodules?
N
33
Colon tumor
resectable?
Adjuvant
chemotherapy if no
neoadjuvant therapy
given
Y
Consider colon
resection
34
N
A
Abdominal/
peritoneal
metastases
Colectomy and lung

nodule resection
+/- neoadjuvant
chemotherapy
Lung mets
resectable?
N
32
36
Close followup (I)
31
30
29
28
24
Adjuvant chemotherapy if no
neoadjuvant therapy given (H)
26
Low risk for obstruction

and/or low liver burden?
Metastases to
lungs?
N
25
Stage (F)
23
22
N
6
19
Colectomy with en bloc
removal of nodes
21
20
Metastasis to
liver?
4
Highly
suspect CA?
(C)
Colectomy with en bloc

removal of nodes
37
Adjuvant chemotherapy if
no neoadjuvant therapy
given
35
Follow-up
38
Obstructing?
N
A
Consider colon resection

or diverting colostomy
26
1
First-line chemotherapy
(G)
4
2
3
Worsening
functional status
after 2nd cycle?
Second-line
chemotherapy (H) or
Best supportive care
(J)
Progressive
disease?
N
N
6
5
Continue first-line
chemotherapy
Continue first-line
chemotherapy
Tis,
T1-2 N0
2
Close follow-up (I)
N
3
4
T3 N0 M0?
>12 nodes or
more
removed?
Y
Close follow-up
7
6
Adjuvant
chemotherapy
(H)
Close follow-up
8
T-3 N1-2 M0
or high risk for
systemic
recurrence?
10
Adjuvant
chemotherapy
Close follow-up
N
12
11
T4 N0-2 M0 or
T3 with perforation,
indeterminate or
(+) margins
Adjuvant
chemotherapy
+/- RT (K)
13
Close follow-up
27
Rectal Cancer
Suspect (A)
11
2
10
9
Rectal exam (B)
Trans-abdominal or
Transanal Resection (G)
T1-2 N0?
Stage (F)
12
13
Observe
Chemotx (H)
14
Y
19
Refer
Colonoscopy
& Biopsy
Chemotx
21
Chemo-RT
Surveillance
(I)
Y 23
Chemo-RT
25
24
29
Resectable? (G)
T any, N any, M1
or Recurrent
Cancer?(E)
Trans-abdominal
Resection (G)
N
T4 and/or locally
resectable?
18
20
Y
22
Surveillance
Surgery
(G)
Pre-op Chemo-RT
T3N0 or
TanyN1-2?
N
Highly suspect
CA? (C)
17
15
(+) lesion?
16
Transabdominal
Resection (G)
28
26
Chemotx
27
Chemotx
Surveillance
30
Metastasis
Resectable? (G)
Refer
31
32
Metastasis Resection
Chemo-RT
33
34
N
Chemotx alone or Chemo-RT (K)
30
Best Supportive
Care (BSC)
Best Supportive
Care (J)
28
PRIMARY HEPATOCELLULAR CARCINOMA (HCC)

The management of HCC must be multi-disciplinary & interdisciplinary, with each discipline respecting the specialty
expertise of the other, all for the benefit of the cancer patient.
(A)
When seen, most Filipino patients (Domingo EO, 1982) will manifest right upper quadrant pain, hepatomegaly, weight
loss, and anorexia. Jaundice can occur. On physical exam (PE), there is usually hepatomegaly, ascitis, portal
hypertension associated with esophageal varices and splenomegaly. Hepatocellualr carcinoma has been associated with
cirrhosis (50% or more; mostly macronodular), hepatitis B (70-90% with hepatitis B antigen) and aflatoxin.
Do complete history and PE, Hepatitis profile (HepB surface antigen, Hep C antibodies), LFT, creatinine, CBC, AFP, Chest
x-ray, prothrombin time (PT).
(B)
Imaging studies with ultrasound are highly sensitive for detecting the disease and directing percutaneous fine needle
aspirate biopsies. Using AFP and ultrasound is a sensitive screening system for high-risk population.
If there is a history of rising AFP, and ultrasound is negative, do CTscan of the whole abdomen; if no mass is seen, screen
every 3 months with AFP, liver ultrasound
(C)
Biopsy can be achieved percutaneously (ultrasound or CTScan-guided) or visually (laparoscopy). 70-90% of primary liver
cancer is hepatocellular carcinoma.
(D)
Using radioimmunoassay technique, 70-85% of patients (in high incidence areas, i.e., Asia) with primary liver cancer
have elevated AFP (>400 mg/mL).
If there is a history of rising AFP, and ultrasound is negative, do CTscan of the whole abdomen; if no mass is seen, screen
every 3 months with AFP, liver ultrasound.
If AFP is >4000 ng/mL, HepBsAg(+) or AFP is >400 ng/mL, HepBsAg(-), biopsy is not required.
In highly suspected metastatic HCC, where AFP<400 ng/mL, HepBsAg(-) or AFP <4000 ng/mL, Hep BsAg(+), in the
absence of no biopsy, consider biopsy.
(E)
Once diagnosis is made, further diagnostic workup is necessary to determine disease stage and thus respectability CXR/
CTscan; CTscan of the whole abdomen; if with elevated alkaline phosphatase, do bone scan. CTscan defines extent and
number of primary lesions, vascular anatomy, involvement with tumor, and extrahepatic disease; helical CT includes
arterial phase enhancement.
TNM classification for carcinoma of liver (HCC; intrahepatic bile duct carcinoma) can be used:
T1 solitary, <=2 cm, without vascular invasion
T2 solitary, <=2 cm, with vascular invasion, or
multiple, one lobe, <=2 cm, without vascular invasion or
solitary, >2 cm, without vascular invasion
T3 solitary, >2 cm, with vascular invasion, or
multiple, one lobe, <=2 cm, with vascular invasion, or
multiple, one lobe, >2 cm, with or
without vascular invasion, or multiple, >1 lobe
T4 tumor beyond the confines of the liver
N N0 or N(+)
MM0 or M(+)
(F)
Two stages of HCC are defined, which dictate choice of subsequent management:
T1-3, N0 = resectable
T4, Nany; M(+) = unresectable
Operability in respectable tumors depends on the performance status or comorbidity of the patient. The Child-Pugh Score,
reflecting liver reserve and comorbidity, can be used to determine operative risk of patient (Pugh R et al. Br J Surg 973):
Chemical and Biochemical
Scores (Points) for increasing abnormality
Parameters
1
2
3
Encephalopathy
None
1-2
3-4
Ascitis
None
Slight
Moderate
Albumin (g/dL)
>3.5
2.8-3.5
<2.8
Prolonged PT
1-4
4-6
>6
Bilirubin (mg/dL)
1-2
2-3
>3
Primary Cirrhosis
1-4
4-10
>10
Class A: 5-6 points, good operative risk
Class B: 7-9 points, moderate operative risk
Class C: 10-15 points, poor operative risk
(G)
For T1-3, N0, total hepatic lobectomy can be performed. Tumor resection is the only curative therapy. Concomitant
cirrhosis generally precludes surgery because of associated high operative mortality. The non-cirrhotic patient must be
free of jaundice and ascitis and the lesion must be solitary or localized to a single lobe of the liver; there must be no
nodal or distant spread.
Discuss surgical treatment with patient and determine whether patient is amenable to surgery.
Ablation options are radiofrequency, alcohol, cryotherapy or microwave.
Surveillance after resection includes imaging every 3-6 months for 2 years, and then annually, plus AFP (if initially
elevated) is done every 3 months for 12 years, then every 6 months
(H)
Criteria for cadaveric transplant (UNOS criteria) are (Mazzaferro V et al. NEJM 1996):
29
Patient is not a liver resection candidate

Patient has a tumor <=5 cm in diameter or 2-3 tumors <=3 cm each
No macrovascular involvement
No extrahepatic spread of tumor to surrounding lymph nodes, lungs, abdominal organs, or bone
Surveillance after transplant includes imaging every 3-6 months for 2 years and then annually, plus AFP (if initially
elevated) is done every 3 months for 12 years, then every 6 months
(I)
There have been efforts to treat unresectable HCC with systemic, intrahepatic artery chemotherapy, or
chemoembolization, or radiotherapy (conformal or stereotactic or microspheres).
Chemoembolization is contraindicated in cases of main portal thrombosis or Childs C.
Doxorubicin, etoposide, 5-FU, capecitabine have been used. In a small percentage of cases, there is shrinkage of the
tumor but the effect is temporary and of no advantage to patient survival compared with the untreated patients. Best
supportive care is always part of the management. Biological drugs like erlotinib, bevacizumab, cetuximab, sorafinib,
sunitinib, have been tested in clinical trials to benefit HCC.
30
11
Primary Liver
Cancer Suspect (A)
5
Can Biopsy
Liver Mass?
Ultrasound of
HBT (B)
Stage (E)
Primary HCC
by biopsy? (C)
Metastatic
?
N
3
N
Liver
Mass?
N
4
Consider
other cancer
site/ disease
N
17
Resectable?
Operable?
(F)
Stage (E)
Consider
other cancer
site
Resection+/Ablation (G)
Foll
15
14
Not a
transplant
candidate?
18
Patient
Consents to
Surgery?
N
7
Best
Supportive
Care
14
10
AFP
>400ng/mL
(D)?
Consider
other
diseases
13
12
Best Supportive Care +/Definitive Treatment (G)
N
16
Transplant (H)
31
PANCREATIC ADENOCARCINOMA
The management of pancreatic cancer must be multi-disciplinary & interdisciplinary, with each discipline respecting
(A)
Very early evidence of this cancer is dilated duct (stricture), even if without a mass in pancreas on imaging.
Unfortunately this cancer is invariably diagnosed when it is advanced because of lack of specific symptoms or signs. Most
Filipino cases were seen at advanced stage (Pantangco, 1958; Solano, 1983; Limson, 1987), with abdominal or back pain,
weight loss and jaundice top be the common manifestations. Other symptoms are anorexia, early satiety, dyspepsia,
weakness, fatigue, bloating, nausea and vomiting. If the cancer is located in the head of the pancreas, signs of
obstructive jaundice will predominate. Lesions in the tail of the gland often go undiagnosed until there are advanced
extensions or distant metastasis.
Physical exam (PE) may include weight loss, jaundice, abdominal mass, epigastric tenderness, palpable gallbladder, and
hepatomegaly; at least half of the patients have no physical findings. Metastatic sign include supraclavicular adenopathy.
(B)
The current test of choice for pancreatic carcinoma and the initial test for suspected carcinoma of the head and tail of the
pancreas, is the CT scan, preferably dynamic-phase spiral CT. It is more reliable (85%-95% accuracy) than ultrasound in
detecting a mass in the gland and in determining the level of obstruction, and is also helpful in determining direct
extension to duodenum, stomach, retroperitoneum, portal vein, lymph nodes (LNs) and liver.
CA 19-9 can be done as a tumor marker; in presence of jaundice, get CA 19-9 if biliary decompression is complete and
bilirubin is within normal range.
Do also chest x-ray and LFT as routine metastatic and medical tests.
(C)
1-57% of cases in some series do not have histological proof of cancer. Surgeons have been reluctant to perform
operative pancreatic wedge or needle biopsies directly because of high biopsy complications. CT scan-guided
transduodenal biopsies for lesions of the head of the pancreas are popular and fine needle biopsies are usually done.
Endoscopic ultrasonography (EUS) and/ or endoscopic retrograde cholangiopancreatography (ERCP) with biopsy may be
done as clinically indicated. EUS may be complimentary to CT. EUS-directed FNA biopsy may be preferable to a CTguided FNA in patients with respectable disease because of the lower risk of peritoneal seeding with EUS FNA when
compared with the percutaneous approach. A negative biopsy should be confirmed by at least 1 repeat EUS biopsy.
ERCP is helpful, if patient is jaundiced and the site of obstruction is not defined; it allows visualization (and biopsy) of the
duodenum and Vaters ampulla, and visualization (and cytology) of both the pancreatic and bile duct, which could be
important for resection.
Frequently, however, the diagnosis is made indirectly by a biopsy of a metastatic site that reveals a histology compatible
with pancreatic origin, and other findings that include a) appropriate presentation for pancreatic carcinoma, b) a mass
in the pancreas detected by imaging, b) absence of another primary. 80% of pancreatic cancer is of adenocarcinoma
histopathology.
(D)
Criteria for resectability:
Resectable
o
Head/Body/Tail
No distant metastasis
Clear flat plane around celiac and superior mesenteric arteries (SMA)
Patent superior mesenteric vein (SMV)/ portal vein
Borderline Resectable for any of these tumors where an incomplete resection is anticipated, prefer
chemoradiation prior surgery
o
Head/Body
Severe unilateral SMV/ portal impairment
Tumor abutment on SMA
Gastroduodenal artery (GDA) encasement up to origin at hepatic artery
Tumors briefly involving the IVC
SMV occlusion, if of a short segment, with open vein both proximally and distally (if proximal
SMV were occluded up to the portal vein branches then it would be unresectable)
o
Tail
Adrenal, colon or mesocolon, or kidney invasion
Preoperative evidence of biopsy-positive peripancreatic LN
Unresectable
o
Head
Distant metastases (includes celiac and/ or para-aortic LNs)
SMA, celiac encasement
SMV/ portal occlusion
Aortic, inferior vena cava (IVC) invasion or encasement
Invasion of SMV below transverse mesocolon
o
Body
Distant metastases (includes celiac and/ or para-aortic LNs; body and tail lesions that have
positive celiac and/or paraaortic nodes in close vicinity to the primary may also be borderline
rather than unresectable)
SMA, celiac, hepatic encasement
SMV/ portal occlusion
Aortic encasement
o
Tail
32
Distant metastases (includes celiac and/ or para-aortic LNs; body/ tail lesions that have
positive celiac and/ or paraaortic nodes in close vicinity to the primary may also be borderline
rather than unresectable)
SMA, celiac encasement
Rib, vertebral invasion
(E)
The standard operation for lesions in the tail of the pancreas is partial pancreatectomy. For lesions in the head, a
pancreaticoduodenostomy or Whipples procedure is standard. This operation consists of en bloc removal of the
duodenum, head of pancreas, distal portion of the common duct, and distal stomach with the pylorus.
Palliation procedures include biliary-enteric bypass to relieve the jaundice, gastroenteric bypass if duodenal obstruction
exists or is highly likely, and celiac axis alcohol or phenol block for pain relief.
(F)
Radiation therapy is indicated as:
Adjuvant when there is no residual disease but highly likely to recur or when microscopic or macroscopic disease
has been left behind. Standard of care is 5 FU-based chemoradiotherapy. Capecitabine is an alternative drug.
Definitive particularly when the disease is considered locally unresectable, and there is no evidence of distant
metastasis. 5-FU, capecitabine, gemcitabine plus radiotherapy can be given.
(G)
Chemotherapy is used in the adjuvant and in the management of locally advanced unresectable and metastatic disease.
Gemcitabine is considered standard front-line therapy for patients with metastatic disease. Gemcitabine or gemcitabinebased combination therapy without RT may be considered as an alternative to 5-FU-based chemoradiation for patients
with locally advanced, unresectable disease or as adjuvant therapy. Gemcitabine can be combined with cisplatin,
oxaliplatin, erlotinib, capecitabine, cetuximab, bevacizumab.
Second-line therapy after gemcitabine includes capecitabine or 5-FU + oxaliplatin
(H)
Close surveillance every 3-6 months for 2 years, then annually with clinical history and physical exam (H&P), CT scan, CA
19-9.
33
Pancreatic
cancer suspect
(A)
Metastatic
disease?
10
Y
11
CT scan,
abdomenopelvic (B)
Mass on
imaging?
ECOG
>=2?
14
Chemotherapy (G)
16
Close followup (H)
BSC
With
cholangitis
or fever?
(C)
19
Temporary
stent
ECOG
>=2?
No mass
on imaging
23
Unresectable
? (D)
Y
21
26
27
Candidate for
neoadjuvant
chemoRT?
Jaundice?
Permanent
stent or
Biliary
bypass +/duodenal
bypass
28
Neo-adjuvant
chemo +/- RT (F)
Laparotomy
EUS/ERCP-biopsy/
CA 19-9 (+)?
29
25
Close follow-up
(H)
37
Unresectable at
surgery?
Laparotomy
32
Adjuvant chemo
+/- RT (F)
34
ECOG
>=2?
33
30
Biopsy; CA
19-9 (C)
31
Chemotherapy (G)
BSC
20
24
22
Metastatic
disease?
15
13
Biopsy; CA
19-9 (C)
18
Jaundice?
Permanent stent
N
17
12
No Biliary
obstruction?
N
Best
Supportive
Care
35
Chemotherapy (G)
Close
follow-up
(H)
N
N
8
Close follow-up;
Refer
36
Surgical
resection (E)
38
Close follow-up
(H)
34
35
26
CANCER OF THE UTERINE FUNDUS

The management of uterine cancer must be multi-disciplinary & interdisciplinary, with each discipline
(A)
The most common symptom is abnormal uterine bleeding which occurs in >90%. Post-menopausal
bleeding is always abnormal and uterine tissue sampling is mandatory.
(B)
Fractional dilatation & curettage (D&C) of uterus has been the standard diagnostic method for
endometrial carcinoma.
For suspected or gross cervical involvement, do cervical biopsy.
Pathology results may reveal endometrioid histologies (carcinoma), papillary serous or clear cell
carcinoma or sarcoma.
Endometrioid histologies can be classified to: 1) disease limited to uterus, 2) gross cervical
involvement, and 3) extrauterine disease (intra-abdominal ascites, omentum, nodal, ovarian,
peritoneal; pelvis vaginal, bladder, bowel/ rectum, parametrial; liver).
Pathologic assessment should include: 1) ratio of depth of myometrial invasion to myometrial
thickness, 2) tumor size, 3) tumor location (fundus vs lower uterine segment/ cervix), 4) histologic
subtype with grade, 5) lymphovascular space invasion, and 6) frozen section as indicated.
(C)
Routine tests include complete history & PE, chest x-ray, CBC, evaluation of hepatic and renal
function. If pelvic mass is present, CT scan or MRI and CA-125 are often performed. Staging is by
FIGO, 2000:
Stage 0
Carcinoma-in-situ
Stage I
Confined to corpus uteri
Stage IA
Limited to endometrium
Stage IB
Invades <= of myometirum
Stage IC
Invades > of myometrium
Stage II
Invades cervix but does not extend beyond uterus
Stage IIA
Endocervical glandular involvement only
Stage IIB
Cervical stromal invasion
Stage III
Local and/ or regional spread as specified in IIIA, B, C
Stage IIIA
Involves serosa and/ or adnexa (direct extension or metastasis) and/ or
cancer cells in ascites or peritoneal washings
Stage IIIB
Vaginal involvement (direct extension or metastasis)
Stage IIIC
Metastasis to pelvic and/ or para-aortic LNs
Stage IVA
Invades bladder mucosa and/ or bowel mucosa (the presence of bullus
edema is not sufficient to classify tumor as T4)
Stage IVB
Distant metastasis (excluding metastasis to vagina, pelvic serosa, or
adnexa; including metastasis to intra-abdominal LNs other than para-aortic
and/ or inguinal LNs)
(D)
Surgery for operable lesions is THBSO (total hysterectomy and bilateral salpingoophorectomy) with
lymph node dissection (pelvic lymphadenectomy and para-aotic lymphadenectomy); sometimes
radical hysterectomy (RH) + BSO.
(E)
Therapy for metastatic disease includes Hormonal therapy (progestational agents, tamoxifen, or
aromatase inhibitors). Tumors with high levels of estrogen and progesterone receptors are more
likely to respond to progestin therapy; receptor (+) tumor is more likely to be well differentiated.
Tamoxifen may be of benefit for patients progressing on progestin therapy or on an alternating
schedule with a progestin.
Cytotoxic chemotherapy can be given to patients with an unresectable recurrence within a previously
irradiated field, or to patients with systemic disease in either a recurrent or primary setting. Drugs
include cisplatin, carboplatin, paclitaxel, and doxorubicin.
(F)
Surveillance includes PE every 3-6 months for 2 years, then 6 months or annually, with CA-125,
annual chest x-ray, every 6 monthly vaginal cytology for 2 years then annually
(G)
Risk factors include: >60 years age, positive lymphovascular invasion, large tumor size, lower
uterine involvement
35
Cancer of Uterus
suspect (A)
TH/BSO, pelvic/ para-aortic

LND, cytology, omentectomy,
biopsies of peritoneal surfaces;
maximal tumor debulking
2
Fractional
D&C/ Biopsy
(B)
6
5
Surgical stage
as with ovarian
cancer
Stage III, IV
(inadequately
debulked)?
3
Papillary
serous or clear
cell
carcinoma?
Chemotherapy
(E)
Vaginal
brachytherapy or
Chemotx +/brachytx or Whole
abdominopelvic
RT +/- vaginal
brachytx
N
8
Stage I, II, & III/IV

(adequately
debulked)
N
10
11
Disease
limited to
uterus?
13
Close followup (F)
RT
15
16
14
12
Medically
inoperable?
TH/BSO, pelvic/
para-aortic
LND, cytology
(D)
Operable
Completely
surgically
staged? (C)
20
18
AI
19
With cervical
involvement?
17
Pelvic RT +
brachytx
Medically
inoperable?
Incompletely
surgically
staged
21
Close follow-up
(F)
24
Completely
surgically
staged? (C)
23
22
RH/BSO, pelvic/
para-aortic
LND, cytology
Operable
Y
AI
N
25
Incompletely
surgically staged
26
27
RT to point
A
31
Intraabdominal?
Extrauterine
disease
28
TH/BSO, paraaortic LND
30
29
Close followup (F)

32
TH/BSO + cytology +
maximal debulking +/pelvic/ para-aortic LND,
Y omentectomy
34
Completely
surgically
staged
AI
35
33
Pelvis?
N
36
Liver
RT +/- Surgery +
brachytx +/- chemotx
37
Close followup/ BSC

38
Hormonal therapy +/chemotherapy
Close followup/ BSC
36
1
AI
2
Stage IA?
With risk
factors? (G)
4
Histologic
G1, G2?
Close
follow-up
N
5
N
N
Vaginal brachytx
+/- pelvic RT
G3
8
7
Histologic
G1, G2?
No risk
factors
Close
follow-up
11
N
10
Vaginal
brachytx
G3
12
13
Stage IB?
14
With risk
factors? (G)
15
Vaginal
brachytx
Histologic
G1?
N
16
17
Histologic
G2?
Vaginal brachytx
+/- pelvic RT
19
N
18
Pelvic RT and/or
vaginal brachytx +/-
G3
22
20
21
No risk
factors
Close
follow-up
Histologic
G1?
24
N
23
Vaginal
brachytx
G2, G3
25
26
Stage IC?
With risk
factors? (G)
27
N
28
29
No risk
factors
31
Stage IIB,
G1-G3?
Pelvic RT and/or
vaginal brachytx +/pelvic RT
30
Histologic
G1-G2?
Vaginal
brachytx
32
Pelvic RT+ vaginal
brachytx
34
33
G3
Pelvic RT and/or
vaginal brachytx +/pelvic RT
N
35
Stage IIA,
myometrial
invasion<50%?
36
37
Histologic
G1?
N
N
38
G2, G3
Vaginal
brachytx
39
Vaginal brachytx
+/- pelvic RT
AII
37
40
41
Stage IIA,
myometrial
invasion>50%,
G1-G3?
AII
Pelvic RT+
vaginal
brachytx
42
N
42
Pelvic RT+/- vaginal brachytx or

Tumor-directed RT + chemotherapy or
Chemotx +/- RT or Whole
abdominopelvic RT +/- vaginal bracytx
Stage
IIIA?
N
43
44
Tumordirected RT
+/- chemotx
Stage
IIIB?
N
45
46
Tumordirected RT +
chemotx
Stage
IIIC?
48
47
Chemotherapy +/-RT
or RT +/- vaginal
brachytx
Stage IV
1
2
Stage IA,
G1-2, no risk
factors?
Close
follow-up
N
3
4
Stage IB-IIA,
G1-2,
myometrial
invasion <50%?
5
CT scan or
MRI or
Petscan
6
Vaginal brachytx
+/- pelvic RT
Negative?
N
7
Surgical restage
AI
N
8
Stage IC; IIA
(myometrial
invasion >=50%);
Stage IIB or G3
10
CT scan or
MRI or
Petscan
11
Negative?
Pelvic RT +
Vaginal brachytx
+/- para-aortic RT
N
12
Surgical
re-stage
AI
38
OVARIAN CANCER
The management of ovarian cancer must be multi-disciplinary & interdisciplinary, with each discipline
(A)
Presentation ranges from completely asymptomatic to vague complaints abdominal pain, dyspneic,
bowel pain, abnormal vaginal bleeding, dyspareunia, constipation, dyspnea, pleuritic pain, cachexia and
fatigue. Physical exam (PE) shows ascitis, cul-de-sac nodularity, pleural effusion among others. A
palpable ovary in a postmenopausal patient is highly suspected for ovarian neoplasm
(B)
Ultrasound or better CTscan provide information regarding pelvic mass as possible cancer complex
adnexal mass, ascitis, cul-de-sac nodules, omental disease, pelvic or paraortic nodes, pleural effusion and/
or large adnexal masses.
(C)
A number of tumor antigens may be elevated: 1) CA-125 may detect persistent disease prior surgery, 2)
AFP and BHCG are also extremely useful in the follow-up response to treatment and in detecting persistent
diseases in germ-cell tumors that are antigen positive (such as endodermal sinus tumor, embryonal
carcinoma, and choriocarcinoma)
(D)
Diagnosis depends on obtaining an adequate histologic specimen which usually entails exploratory
laparotomy with ovarian resection. If an ovarian cancer is confirmed, disease extent is determined and
surgical removal of all possible tumor done. Anatomical staging is according to FIGO (2002):
Stage
IA
IB
IC
IIA
IIB
IIC
III
IV
T1aN0M0 Limited to one ovary, capsule intact, no tumor on surface

T1bN0M0 Limited to both ovaries, capsule intact, no tumor on surface
T1cN0M0 Capsule ruptured, tumor on surface, +ca in ascetic/ peritoneal fluid
T2aN0M0 Pelvic extension uterus, tube/s
T2bN0M0 Other pelvic masses; (-) ca in ascitic/peritoneal fluid
T2cN0M0 (+) cancer in ascitic/peritoneal fluid
Peritoneal metastasis beyond pelvis and/or regional lymph node metastasis
Distant metastasis (excludes peritoneal metastasis)
Complete PE and history is done. Chest x-ray, GI evaluation, creatinine, LFT, CBC are done for epithelial
carcinomas. For non-epithelial tumors, include magnesium, LDH. Family history evaluation is done.
Consider fertility sparing particularly in Stage I tumors.
(E)
Less common ovarian histology types (aside from more common epithelial carcinoma) are Germ Cell
tumors (dysgerminoma, immature teratoma, embryonal tumor, endodermal sinus tumor), Stromal tumors,
and Mixed Mullerian tumors (carcinosarcoma).
(F)
Chemotherapy is currently the predominant approach to treating ovarian carcinoma. Preferred 1st line
adjuvant for epithelial carcinoma is paclitaxel/ docetaxel + carboplatin. Acceptable recurrence
chemotherapy drugs in epithelial carcinomas are bevacizumab, anastrozole, carboplatin, cisplatin,
cyclophosphamide, docetaxel, gemcitabine, ifosfamide, irinotecan, letrozole, liposomal doxorubicin,
melphalan, etoposide, oxaliplatin, paclitaxel, tamoxifen, vinorelbine.
Patients receiving primary chemotherapy will be monitored as follows:
Pelvic exams at least every 2 cycles
Interim CBC with platelets as indicated
Chemistry profiles if indicated
CA-125 levels prior to each cycle of chemotherapy, if informative
Radiographic imaging if indicated
For germ cell tumors, etoposide-carboplatin, or BEP (belomycin-etoposide-cisplatin) or TIP (paclitaxelifosfamide-cisplatin) is used. For stromal tumors, cisplatin or carboplatin/ paclitaxel are preferred. For
non-epithelial tumors, acceptable recurrence modalities are cisplaitn. etoposide, TIP, docetaxel/
carboplatin, VIP, VelP (vinblastin, ifosfamide, cisplatin), VAC (vincristine, dactinomycin, cyclophosphamide),
paclitaxel, docetaxel, leuprolide.
(G)
Clear-cell pathology is Grade 3.
(H)
Monitoring follow-up includes:

Visits every 2-4 months for 2 years, then every 6 months for 3 years, then annually
CBC every 12 month
CA-125 every visit if initially elevated
Chemistry profile as indicated
PE with pelvic exam
Chest/ abdominal/ pelvic CT or PET as clinically indicated
Chest x-ray as indicated
(I)
Patients who progress on 2 consecutive single-agent regimens without evidence of clinical benefit are
unlikely to benefit from additional chemotherapy regimens and may be offered best supportive care or
clinical trial.
Ancillary palliative surgical procedures include paracentesis, thoracentesis/ pleurodesis, ureteral stents/
nephrostomy, surgical relief of intestinal obstruction, enteral feeding tube, gastrostomy tube, vascular
access device, indwelling peritoneal or pleural catheter, intestinal stents, video-assisted thoracoscopy.
39
(J)
1
High risk e.g., ruptured Stage IC or poorly differentiated Stage I
Ovarian cancer
suspect (A)
7
FIGO
Stage (D)
Non Epithelial
cancer? (E)
2
Abdomino-pelvic
Ultrasound or
CTscan (B)
Epithelial Cancer
3
Positive
lesion?
10
Oophorectomy
with tumor
resection
Stage IAB?
14
N
Positive bHCG/ Ca-125/
AFP? (C)
11
12
5
Close
follow-up
Y
Grade 1?
N
13
Grade 2-3
(F)
Chemotherapy
Close follow-up;
work-up for GI &
urinary tract cancer
16
15
Radical
hysterectomy
& BSO,
omentectomy
Y
Stage IC?
17
Chemotherapy
(G)
18
Close followup (H)
21
20
Radical HBSO,
omentectomy,
adhesiolysis,
diaphragm & pelvic
biopsy omentectomy
Y
Stage II?
22
Chemotherapy
+/- RT
N
24
23
Stage III-IV?
Cytoreductive surgery
+ chemotherapy or
whole abdomen-pelvic
RT or IP
chemotherapy in lowvolume optimally
debulked Stage III
25
2nd Adjuvant
chemotherapy
27
26
Complete
remission?
28
Close
follow-up
N
Chemotherapy/
BSC (I)
40
29
Non-epithelial tumors
30
32
Mixed
Mullerian
tumor?
31
Close follow-up or
Chemotherapy or RT
Y
Stage I?
N
33
34
35
36
Stromal
tumor?
42
Treat as Uterine
Cancer
Stage IIIV
37
Stage I,
Low risk?
38
Germ Cell
tumors
Close
follow-up
39
Stage I,
High risk?
(J)
Close follow-up
or Chemotherapy
or RT
41
40
Chemotherapy or
leuprolide or RT
or BSC
N
Stage II-IV
43
44
Stage I
dysgerminoma or
Stage I, Gr I
immature teratoma?
Close
follow-up
N
48
45
Embryonal or
Endodermal sinus
tumor or Stage II-IV
Dysgerminoma or
Stage I, Gr2/3 or
Stage II-IV Immature
Teratoma
46
47
Chemotherapy
Complete
remission?
Close
follow-up
50
49
Residual tumor;
markers
normal?
Surgical
resection or
Close followup
N
51
52
Persistently
elevated
markers
Chemotherapy
or BSC
41
CANCER OF THE UTERINE CERVIX

The management of cervix cancer must be multi-disciplinary & interdisciplinary, with each discipline
respecting the specialty expertise of the other, all for the benefit of the cancer patient. The gynecologist
oncologist takes the primary role.
(A)
Early stage clinical presentation includes vaginal bleeding, usually contact bleeding, vaginal discharge,
irregularities of menstruation.
Advanced stage clinical presentation includes pelvic discomfort or flank pain in the suprapubic or sacral
region, urinary frequency, change of bowel habits, dysuria, hematuria, pain radiating to thighs, unilateral
leg edema, white patches (leukoplakia), extensive red patches (erythroplasia).
History may reveal risk factors such as early age at first sexual intercourse, multiparity, multiple sexual
partners or partner with multiple sexual partners, exposure to human papilloma virus types 16, 18, 31, 45,
56, and herpes simplex
(B)
Clinical examination includes internal examination with speculum and Pap smear, followed by a
gynecological rectal examination, which may show a palpable pelvic mass. On internal exam a frank
cervix lesion may be seen, and biopsy can be done.
(C)
Pap test can show pre-cancerous lesions: cervical intraneoplasia (CIN) I, II, III and invasive carcinoma.
CIN III (or carcinoma-in-situ (CIS)) has a very high probability of becoming invasive carcinoma.
(D)
Colposcopy with colpo-guided biopsy to get better biopsy specimen can follow an abnormal Pap smear. In
the absence of a colposcope, Schillers test is done (painting of cervix and vaginal mucosa with Lugols
solution); samples for biopsy are taken from the unstained areas.
Endocervical curettage (ECC) is done if the lesion seen colposcopically disappears into the endocervical
canal so that the upper limit of the lesion is not visualized. If this turns out to be positive, a cone biopsy is
done to rule out stromal invasion.
(E)
The invasive carcinomas are commonly of squamous cell type (squamous cell carcinoma, verrucous
carcinoma. condylomatous carcinoma, papillary squamous cell carcinoma, lymphoepithelioma-like
carcinoma) followed by glandular type (adenocarcinoma-in-situ, mucinous adenocarcinoma, clear cell
adenocarcinoma, serous adenocarcinoma, mesonephric carcinoma, villoglandular adenocarcinoma, minimal
deviation adenocarcinoma). Other non-common pathology types are adenosquamous carcinoma, glassy
cell carcinoma, adenoid cystic carcinoma, adenoid basal carcinoma, carcinoid tumor, small cell carcinoma,
undifferentiated carcinoma.
(F)
Conization is a cone-shaped biopsy encompassing the lining of the endocervical canal below the internal os
and the squamous-columnar junction, the lateral margin to include the lesions visualized colposcopically or
delineated by Schillars test. An alternative procedure is the loop electrosurgical excision procedure (LEEP)
or large loop excision of the transformation zone (LLETZ) which makes use of thin wire loop electrodes and
electrosurgical generators to excise the lesions.
(G)
Pap smear every 6 months for the first 2 years, then yearly thereafter, with complete physical exam and
careful recto vaginal exam.
(H)
Cervical cancer generally spreads by direct extension to neighbouring tissues. Procedures for clinical
staging includes chest x-ray, CTScan of lower abdomen to pelvis, and optional - bone scan,
proctosignoidoscopy, cystoscopy, KUB-IVB. FIGO staging is as follows:
Tis
T1
T1a
T1a1
T1a2
T1b
T1b1
T1b2
T2
T2a
T2b
T3
T3a
T3b
T4
T4a
M1
(I)
Carcinoma-in-situ; CIN III

Confined to cervix only
Microinvasive carcinoma
Stromal invasion of notmore than 3.0mm in depth and extension of not more than 7.0mm
Stromal invasion of more than 3.0 mm and not more than 5.0mm with an extension of not more
than 7.0mm
Clinical visible lesions limited to cervix or subclinical cancers greater than Stage IA
Clinical visible lesions not larger than 4.0cm
Clinically visible lesions larger than 4.0cm
Carcinoma extends beyond cervix but has not extended to pelvic wall; involves vagina but not
lower third
No obvious parametrial involvement
Obvious parametrial involvement
Carcinoma extended to pelvic wall and lower third of vagina, including all cases with cancerrelated hydronpehrosis or nonfunctioning kidney
No extension to pelvic wall
Extension to pelvic wall and/ or hydronephrosis or non-functioning kidney
Carcinoma extended beyond true pelvis or has clinically involved mucosa of the bladder or
rectum
Spread to adjacent organs
Spread to distant organs
If the patient is already pregnant;

a.
During 1st half of pregnancy,
i. for Stage I-IIA
1.
good surgical risk do radical hysterectomy and bilateral lymph node
dissection (RHBLND) with or without bilateral salphingo-oophorectomy
(BSO);
42
b.
(J)
2.
poor surgical risk, do complete radiotherapy;
ii. for Stage IIB-IV, do chemoradiation
During 2nd half of pregnancy
i. for Stage I-IIA
1.
good surgical risk, do cesarian section (at earliest time for fetal survival)
and RHBLND with or without BSO;
2.
poor surgical risk do cesarian section then complete radiotherapy;
ii. for Stage IIB-IV, do cesarian section followed by chemoradiation.
Chemoradiation is the standard treatment for Stage IB2 and above or for unfavourable histologic types
(small cell, clear cell, galssy cell, adenosquamous cell).
Usual chemoradiation regimen is cisplatin weekly or every 21 days concomitant with radiotherapy
(external and internal). Other drugs include capecitabine, gemcitabine, fluorouracil.
For bulky Stage IB and IIA diseases neoadjuvant chemotherapy or radiotherapy or chemoradiation is
followed by radical surgery. There is also a potential for adjuvant chemotherapy to delay/ prevent distant
metastasis. Poor prognostic factors are tumor size >2cm, positive LN metastasis, >50% stromal invasion,
positive lines of resection.
(K)
Individualization also applies to special clinical situations:

a.
Unfavorable cell types
i. Stage IA/IB/IIA give neoadjuvant chemotherapy followed by RHBSO-BLND then
adjuvant chemotherapy
ii. Stage IB2/IIA give chemoradiation OR neoadjuvant chemoradiation followed by
RHBSO-BLND, then adjuvant chemotherapy
iii. Stage IIB, III - chemoradiation
b.
Pelvic inflammatory disease and/ or adnexal masses do BSO before chemoradiation or
laparoscopic BSO
c.
Barrel-shaped tumors do total or radical hysterectomy, BSO with or without BLND after
chemoradiation; interstitial brachytherapy
d.
Primary cases with urinary obstruction urinary diversion, followed by complete RT with or
without chemotherapy
e.
Primary cases with GUT obstruction medical decompression (or surgical decompression)
followed by complete RT with or without chemotherapy
(L)
Follow-up
a.
After completion of treatment, complete PE with careful rectovaginal examination
b.
Pap smear every 6 months for the 1st 2 years, then yearly thereafter
c.
Chest x-ray every 6 months (more often if symptomatic).
d.
Annual CTScan of pelvis for the 1st 3 years post-treatment
43
20
1
Cancer of uterine
cervix suspect (A)
21
Stage IA1?
(H)
Colposcopy
with Biopsy +
ECC (D)
Good surgical
risk?
22
23
25
Desire
pregnancy? (I)
24
Brachytherapy
2
Internal exam with vaginal

speculum and Pap smear,
Gynecological rectovaginal
examination (B)
Observe or
Cryotherapy;
Pap & Colpo
29
Good surgical
risk?
TH+BSO
27
Stage IA2?
N
CIN I?
30
Desire
pregnancy?
28
Radical
Trachelectomy
+ BLND
Complete RT
Pap smear
abnormal? (C)
10
31
N
4
26
Carcinoma
? (E)
7
Cone Biopsy
Cold Knife or
LEEP/ LLETZ
CIN II?
Advise regular
follow-up and
annual Pap smear
11
13
Cone biopsy (F)

or LEEP
34
Good surgical
risk?
12
N
CIN III?
Cryotherapy;
Pap & Colpo
32
Stage IB1IIA?
35
RHBLND +
BSO (K)
Complete RT
33
Complete RT
36
Stage IB2IIA, IIB, III?
15
37
Chemo-RT (J)
17
Normal
Micro-invasive
CA, CINIII,
CIS?
14
Advise regular
follow-up and Pap
smear (G)
Treat as Stage
IA1
N
38
19
16
N
CIN II
18
Follow-Up (L)
Stage IV;
Persistent or
Recurrent Disease
39
Individualize
(K); Best
supportive care
Cryotherapy;
Pap & Colpo
35
CANCER OF THE PROSTATE

The management of prostate cancer must be multi-disciplinary & interdisciplinary, with each discipline
(A)
Usual symptomatology includes hematuria, UTI, azotemia, and edema, but usually it is detected on
routine rectal exam, or after signs of obstruction, after TUR, and when symptomatology of metastatic bone
lesions appears.
A digital rectal exam (DRE) should always be performed, which may reveal an enlarged prostate and local
extent.
(B)
Trans-rectal sonography has 90% sensitivity and 95% specificity for prostatic mass detection. For
extracapsular penetration, overall accuracy is 90% but detection of seminal vesicle invasion is only 77%.
(C)
Prostatic specific antigen (PSA) is elevated (>10ng/mL): Stage I 38-57%, Stage II 95%, Stage III-IV
100%. However, with cutoff level of 10ng/mL, the specificity versus benign diseases of the prostate is
90%. PSA levels may be temporarily elevated after DRE, urinary retention, lasering, ergometry, prostatitc
surgery, cystoscopy, catheterization or needle biopsy, hence do the PSA test prior these procedures or a
week after.
The 2 main applications of PSA assay are firstly for monitoring the course and therapeutic response of
prostatic cancer, and secondly for monitoring patients with BPH so as to detect the presence of prostatic
carcinoma as early as possible.
(D)
Chest x-ray, bone scan, CT scan of pelvis and abdomen are done for staging. AJCC (2002) gives the
following staging
T1
Clinically inapparent tumor neither palpable nor visible by imaging
T1a
tumor incidental histologic finding in <=5% of tissue resected
T1b
>5% of tissue
T1c
tumor identified by needle biopsy (e.g., because of high PSA)
T2
Tumor confined within the prostate
T2a
tumor involves of <=1 lobe
T2b
>1/2 of one lobe but not both lobes
T2c
both lobes
T3
Tumor extends through the prostatic capsule
T3a
extracapsular extension (unilateral or bilateral)
T3b
tumor invades seminal vessel/s
T4
Tumor is fixed or invades adjacent structures other than seminal vesicles: bladder
neck, external sphincter, rectum, levator muscles, and/ or pelvic wall
N0
N1
No positive regional node

Metastases in regional node/s
M0
M1
No distant metastases
Distant metastases
M1a
Non-regional LNs
M1b
Bone/s
M1c
other site/s with or without bone disease
Histopathology Grade by Gleason Score is the optimal method of grading:

GX
grade cannot be assessed
G1
well differentiated (slight anaplasia) Gleason 2-4
G2
moderately differentiated (moderate anaplasia) Gleason 5-6
G3-4
poorly differentiated or undifferentiated (marked anaplasia) Gleason 7-10
PSA, Tumor burden (T), and/
expectancy:
Clinically
o
o
or Gleason score together predicts risk for clinical recurrence and life
localized:
Low risk: T1-2a and Gleason score 2-6 and PSA <10ng/mL
Intermediate risk: T2b-T2c or Gleason score 7 or PSA 10-20 ng/mL
(patients with multiple adverse factors may be shifted to next higher risk
group)
o
High risk: T3a or Gleason score 8-10 or PSA >20ng/mL
Locally advanced: Very high T3b-T4
Metastatic: anyT, anyN, M1
(E)
Expectant management involves actively monitoring the course of disease with the expectation to
intervene if the cancer progresses or if symptoms become imminent. Patients should have regular followup with: a) DRE and PSA every 6 months, b) needle biopsy repeated within 6 months of diagnosis if initial
biopsy was <10 cores or assessment discordant or repeated within 18 months if >10 cores obtained
initially, then periodically, c) repeat biopsy is indicated for any sign of disease progression by exam or
markers
(F)
Radiotherapy includes external beam RT preferably 3D conformal or IMRT at doses 70-75 Gy in 35-41
fractions to prostate (+/- seminal vesicles) in low risk cases. For intermediate or high risk cases, 74-80
Gy. Those at high-risk are candidates for pelvic LN RT and addition of neoadjuvant +/- adjuvant ablation
therapy.
Radiotherapy can also be done using brachytherapy as monotherapy in low risk cases and combined with
neoadjuvant androgen ablation in intermediate risk patients. Patients with large prostate (>60 gm),
symptoms of bladder outlet obstruction (IPSS score >15), or a previous TURP are not ideal candidates
35
because of increased risk of urinary morbidity. Neoadjuvant androgen ablation may shrink prostate to
acceptable size.
Adjuvant RT can be given in positive margins (N0) after radical prostatectomy in clinically localized disease
patients.
(G)
Radical prostatectomy (retropubic or perineal approach RRP or RPP) is done for any patient with clinically
localized prostate cancer that can be completely excised surgically, who have a life expectancy of 10 years
or more and no serious co-morbid conditions that would contraindicate an elective operation. Radical
prostatectomy (RP) and pelvic LN dissection (PLND) may be done in selected patients with T3 or N+ cancer.
Adverse events are blood loss, urinary incontinence, loss of erection, anastomotic strictures.
(H)
Medical (LHRH agonist alone +/- antiandrogen for 2-4 weeks for flare or LHRH agonist + antiandrogen or
high dose antiandrogen) or surgical (orchiectomy) castration seems to be more effective than
antiandrogen monotherapy. Intermittent androgen ablation can reduce side effects in long term treatment.
LHRH agonist and bilateral orchiectomy are equally effective.
In inadequate serum testosterone suppression (<50 ng/mL) with medical or surgical castration, additional
hormonal therapy with estrogen, antiandrogens or steroids can be given.
In failure of initial androgen ablation (AAT), may give antiandrogens such as ketoconazole or estrogens.
Patients being treated with medical or surgical castration are at risk for having or developing osteoporosis.
Supplemental calcium (500 mg daily) and vit D (400 IU) is given. For treatment of osteoporosis, give
bisphosphonate therapy (e.g., ibandronic acid 150 mg tab monthly).
In clinically localized disease patients, androgen ablation is given for 2-3 years.
Adjuvant androgen ablation can be given in presence of LN metastasis after radical prostatectomy in
clinically localized disease patients.
(I)
After initial-definitive therapy, follow-up includes: PSA every 6 months for 6 years, then every year, and
DRE every year.
For N1 or M1, follow-up includes PE + DRE +PSA every 3-6 months.
(J)
A rising PSA value consists of 3 consecutive rising PSA values at least 3 months apart. For post-radical
prostatectomy, 2 consecutive rising PSA levels. If PSA doubling time is >10 months or PSA <2 ng/mL,
there is a lower risk of metastasis. If PSA doubling time is <3 months or positive seminal vesicles or LNs,
there is higher risk of metastasis.
Bone scan +/- abd/pelvic CT is done upon rising PSA (>0.3 ng/mL and rising on >=2 determinations) and
or DRE, particularly for those patients who are candidates for local therapy: (a) original clinical stager T1T2, NX or M0, b) life expectancy >10 years, c) PSA now <10ng/mL).
(K)
Salvage radical prostatectomy is an option for highly selected patients with local recurrence after EBRT,
brachytherapy, or cryotherapy in the absence of metastases, but the morbidity (incontinence, loss of
erection, anastomotic stricture) is high.
Primary salvage therapy when PSA does not fall to undetectable levels with persistent local tumor is
preferably RT +/- androgen ablation or androgen ablation alone. For those without evidence of persistent
local tumor burden but low risk for metastasis, primary salvage therapy is preferably RT or androgen
ablation or observation; for those at high risk of metastasis, androgen ablation (AAT) or observation. If
patient has metastatic diseae, androgen ablation is preferred or observation. Assure castrate levels of
testosterone
Secondary salvage therapy after AAT failure includes bisphosphonate treatment (such as ibandronate,
zolendronate, clodronate, icandronate) for metastatic bone disease and any of - chemotherapy (docetaxelbased preferred with prednisone or estramustine) or supportive care or systemic RT (samarium or
strontium). Other drugs include ketoconazole/ doxorubicin, etoposide/estramustine, mitoxantrone/
prednisone, estramustine/ paclitaxel. For visceral or soft tissue masses of neuroendocrine type give
cisplatin/ etoposide or carboplatin/ etoposide.
36
1
Prostatic cancer
suspect (A)
2
Trans-rectal
sonography with
biopsy (B)
8
3
Cancer?
Stage/
Recurrence
risk (D)
PSA test
PSA
>10ng/mL?
(C)
11
12
<10 yrs
expected
patient
survival?
Expectant
management
(E) or RT (F)
14
13
Expectant
management or
RT or Radical
prostatectomy
+ pelvic LN
dissection (G)
N
>=10 yrs
Highly suspect
cancer?
10
Clinically
localized? (E)
Low risk?
Close followup; Refer
16
15
Intermediate
risk?
15
<10 yrs
expected
patient
survival?
18
Expectant
management or RT
or Radical
prostatectomy
+ pelvic LN
dissection
RT or Radical
prostatectomy
+ pelvic LN
dissection
17
>=10 yrs
20
19
Androgen ablation +RT

or RT or Radical
prostatectomy+pelvic
LN dissection
High risk
21
22
Locally
advanced T3b-4?
Androgen ablation
(H) or Androgen
ablation +RT
27
23
Any T, N1?
25
24
Androgen ablation
or Androgen
ablation +RT
Close follow-up (I)
26
29
Androgen ablation
28
M1
Rising PSA? (J)
30
Salvage
therapy (K)
N
Close follow-up
(I)
37
TESTICULAR CANCER
The management of testicular cancer must be multi-disciplinary & interdisciplinary, with each discipline
(A)
Testicular cancer gradually presents as a painless mass. Minor trauma to the testes often draws attention
to the mass. Symptoms related to metastases includes abdominal fullness, palpable mass, pain, lower
extremity edema, left supraclavicular mass, and systemic symptoms, such as fatigue. Crytorchidism is a
risk factor, and abdominal testes have 4x the risk of inguinal testicular cancer. Do complete clinical history
& physical exam (H&P).
(B)
Scrotal ultrasound is the test of choice to distinguish between intratesticular and extratesticular location of
the mass. Extratesticular masses are generally benign (i.e., varicoele, hydrocoele, hematocoele, orchitis,
and hernia) and subsequent management may be just conservative or surgical. Intratesticular masses are
malignant unless proven otherwise.
(C)
85% of cases will have elevation of at least one of the 2 markers alpha-feto protein (AFP) and betahuman chorionic gonadotrophin (b-HCG). 10% of patients with early-stage seminomas can have elevated
b-HCG whereas AFP is never elevated in pure seminomas. Patients with elevated AFP, regardless of the
histology should be treated as non-seminomatous germ cell tumors. Pure seminomas, dysgerminoms, and
differentiated teratomas are always AFP-(-), pure yolk-sac tumors are always AFP-(+), while embryonic
carcinomas and combined tumors can depending on the mass of endodermal structures be more or
less strongly AFP-(+) or (-). AFP is the 2nd most important marker for germ cell tumors aside from b-HCG.
(D)
Radical orchiectomy (performed by inguinal approach) establishes accurate histopathologic diagnoses and
provides other information needed for anatomic staging. 96% of testicular tumors are germ cell tumors
(the other 4% are benign stromal tumors).
(E)
Seminomas are the most common (40% of all germ cell tumors). Nonseminomas include embryonal
carcinoma, teratocarcinoma, and yolk sac tumors. Treatment of pure seminomas and nonseminomas
differ.
(F)
CT is the method of choice for staging and follow-up. Pelvic, abdominal, and chest CTscans are used to
uncover nodal or pulmonary metastasis. If CTscan is not available or affordable, chest tomography and
pelvic/abdominal ultrasound are used, although with less sensitivity and specificity. Do also chemistry
profile, including LDH.
The AJCC (2002) staging indicates:
Stage I
Stage IIA
Stage IIB
Stage IIC
Stage IIIA
Stage IIIB
Stage IIIC
pT1-4N0M0S0
S0 marker study levels within normal limits
anypTN1M0S0-1
S1 LDH<1.5N, HCG<5000mlu/mL, AFP<1000 ng/mL
N1 mets with LN mass <=2cm or multiple LNs, none >2cm in
greatest dimension
anypTN2M0S0-1
N2 mets with LN mass >2, <5 cm or multiple LNs any one mass
>2cm but not >5 cm in greatest dimension
anypTN3M0S0-1
N3 mets with LN mass >5cm in greatest dimension
anypTanyNM1aS2
S2 LDH=1.5-10xN or HCG=5000-50000 or AFP= 1000-10000
M1a Non-regional nodal or pulmonary metastasis
anypTN1-3M0S2 or anypTanyNM0S3
S3 LDH>10xN or HCG>50000 or AFP>10000
anypTN1-3M0S3 or anyptanyNM1aS3 or anypTanyNM1banyS
M1b distant metastasis other than to non-regional LNs and lungs
(G)
For Stage IA, IB, IS seminoma, primary treatment is RT to infradiaphragmatic or paraaortic LN; consider
also to ipsilateral ileoinguinal nodes.
(H)
Follow-up for Stage IA, IB, IS post radical orchiectomy, post-RT includes H&P, chest x-ray, AFP, bHCG,
LDH every 3-4 months for year 1, every 6 month for year 2, then annually; pelvic CT annually for 3 years
for s/p aortic RT
(I)
For Stage IA, IB, IS post radical orchiectomy followed by observation, follow-up includes H&P, AFP, bHCG,
LDH every 3-4 months for years 1-3, every 6 months for years 4-7, then annually; abdominal/ pelvic CT is
done at each visit with chest x-ray at alternative visits up to year 10
38
(J)
Seminoma risk classification: 1) Good risk = any primary site, absence of nonpulmonary visceral
metastases, normal AFP, any bHCG, any LHD; 2) Intermediate risk = any primary site, presence of
nonplumonary metastases and normal AFP, any HCG, any LDH
(K)
Chemotherapy regimen: a) EP = etoposide/ cisplatin, b) BEP = bleomycin/etoposide/cisplatin
(L)
For seminomas, favourable prognosis for salvage therapy is predicted by - low markers, low volume, CR on
1st line therapy, and testis primary; unfavourable prognosticators are incomplete response, high markers,
high volume, extratesticular primary, late relapse
(M) For seminomas Stage IIA, IIB post-RT primary treatment, follow-up includes H&P, chest x-ray, AFP, b-HCG,
LDH every 3-4 months for years 1-3, every 6 months for year 4, then annually; abdominal CT at month 4
of year 1
(N)
Seminoma can develop locoregional recurrence of small volume (<5 cm) or abdominal/ retroperitoneal
recurrence meeting criteria for clinical N2 or less. Distant recurrence is appearance of bulky nodal disease
(>5 cm).
(O)
For seminoma, follow-up after treatment of 1st relapse includes H&P, chest x-ray, AFP bHCG, LDH every 2
months for year 1, every 3 months for year 2, every 4 months for year 3, every 6 months for year 4, then
annually. Abdominal/ pelvic CT at month 4 of year 1 s/p surgery, otherwise abdominal/pelvic CT every 3
months until stable. May do PET scan.
(P)
Follow-up for non-seminoma: Stage IA, IB markers & chest x-ray every 1-2 months year 1, every 2
months year 2, every 3 months year 3, every 4 months year 4, every 5 months year 6, annually
thereafter; abdominal/ pelvic CT every 2-3 months year 1, every 3-4 months year 2, every 4 months year
3, every 6 months year 4, then annually thereafter. For follow-up after CR to chemotherapy and/ or
RPLND, follow-up includes markers, chest x-ray every 2-3 months years 1-2, every 4 months years 3-4,
every 6 months year 5, then annually thereafter; abdomino/pelvic CT every 6 months year 1, every 12
months years thereafter
(Q)
Nonseminoma risk classification: 1) Good risk =testicular or retroperitoneal primary tumor, no pulmonary
visceral metastases, all of markers - AFP<1000 ng/mL, bHCG<5000 iu/L, LDH<1.5 x ULN; 2) Intermediate
risk = testicular or retroperitoneal primary tumor, no pulmonary visceral metastases, any of markers - AFP
1000-10000 ng/mL, bHCG 5000-50000 iu/L, LDH 1.5-10 x ULN; 3) Poor risk = mediatinal primary tumor
or nonpulmonary visceral metastases or any of markers AFP> 10000 ng/mL, bHCG> 50000 iu/L, LDH>
10xUNL
(R)
Chemotherapy regimen: TIP = paclitaxel/ ifosfamide/ cisplatin; VelP = vinblastine/ ifosfamide/ cisplatin
39
1
5
Testicular cancer
suspect (A)
AFP, bHCG
assay (C)
Radical
orchiectomy (D)
9
Seminoma?
(E)
Y
Stage (F)
Scrotal UTZ (B)
Nonseminoma
3
Intra-testicular
mass?
14
18
10
15
IA, IB,
IS?
Refer
11
Horseshoe/ pelvic
kidney?
Inflammatory bowel
disease? Prior RT?
Close follow-up
(H)
Recurrence?
16
13
A
12
21
Good risk?
(J)
EP x 4 or
BEP x 3
20
19
Close
follow-up
Close followup (I)
RT (G)
17
BEP x 4
(K)
Intermediate
risk
22
Good
response? (J)
Close
follow-up
29
23
24
26
Favorable
prognosis? (L)
SALVAGE
Therapy
25
N
Chemotx/
BSC
27
Vbl/Ifos/Cis
or Doce/Ifos/Cis
28
CR?
N
Pallative
Chemotx/ RT/
BSC
Close
follow-up
30
Relapse
40
A
31
33
IIA, IIB?
32
Y
RT
34
Close followup (M)
47
36
Recurrence?
37
RT
Close follow-up
(O)
N
N
35
IIC, III
Close
follow-up
48
39
Distant
49
Good
risk?
50
38
Locoregional? (N)
EP x 4 or
BEP x 3
42
40
Good
risk?
EP x 4 or
BEP x 3
44
51
BEP x 4
Intermediate
risk
41
54
Intermediate risk
52
Close
follow-up
(O)
Close
follow-up
(O)
43
BEP x 4
45
Good
response? (J)
53
46
Good
response? (J)
N
SALVAGE
Therapy
N
SALVAGE
Therapy
41
58
57
55
EP x 4 or
BEP x 3
Persistent
markers?
Non-seminoma
62
61
Y
N
59
56
64
63
IA, IB, IIA?
Close followup (P)
pN0?
Close followup (P)
60
pN1?
Nerve sparing
RPLND
Observe or
EP x 2 or
BEP x 2
69
N
65
66
pN2?
N
67
EP x 2 or
BEP x 2
68
EP x 4 or
BEP x 3
pN3
71
70
72
LNmets w/in
landing zone by
CT?
IIB?
74
73
RPLND + adj
chemotx
Close followup (P)
RPLND or
observe
Good risk?
(Q)
CR?
Y
III?
92
N
Brain
metastases
Close followup (P)
86
PR, residual
mass, norml
AFP, bHCG??
Surgical
resection of
residual
mass/es
87
Observe or EP
or TIP or VelP
x2
Close followup (P)
BEP x 4
82
RPLND or
observe
85
81
89
N
RPLND or
observe
EP x 4 or
BEP x 3
84
80
77
IIC?
88
75
EP x 4 or
BEP x 3
79
76
Close
follow-up
(P)
90
83
78
BEP x 4
N
Incomplete
response
91
SALVAGE
Therapy
93
Chemotx + RT +/Surgery / BSC
42
43
RENAL CELL CARCINOMA (RCC)

The management of RCC must be multi-disciplinary & interdisciplinary, with each discipline respecting
(A)
The most frequent traditional presentations are hematuria (56%), pain (38%), palpable mass (36%),
weight loss and fatigue (27%), fever (11%), varicocole (2%), and incidental (6%). When asymptomatic,
it is found incidentally by ultrasound, CT scan, or MRI scan for other regions. Other presentations are
related to metastasis (lung, bone, skin, liver, brain) and paraneoplastic signs (30%), like anemia,
gynecomastia, etc.
A complete history & PE is done. Do CBC, LDH, urinalysis, metabolic panel.
(B)
CT scan is currently the more sensitive and specific affordable test (90% accuracy). MRI is competitive
with CT and gives similar if not more information with similar accuracy (96%). The latter has the
advantage of demonstrating vascular invasion and renal hilar nodes better. Patients allergic to contrast
media are ideal for MRI. Disadvantage of MRI is higher cost.
Ultrasound is helpful in differentiating a cystic lesion from a solid tumor. It is less sensitive and less
specific than CT for tumor extent.
(C)
Biopsy can be fluoroscopic, ultrasound or CT-guided. Histologic diagnosis is 80-90% adenocarcinoma.

The terms renal cell carcinoma, renal adenocarcinoma, clear cell carcinoma, hypernephroma, and Grawitz
tumor are synonymous.
(D)
Staging is based on AJCC (2002), and guided by CT scan prior operation:

Stage I T1N0M0 T1
Stage II T2N0M0 T2
Stage III T1N1M0 T3
T2N1M0
T3aN0-1M0
T3bN0-1M0
Stage IV T4NanyM0
TanyN2-3M0
TanyNanyM1
Tumor <=2.5cm/ limited to kidney

Tumor >2.5cm/ Limited to kidney
a)
perinephric invasion
b)
major veins
T4
Invades beyond Gerotas capsule
N1
N2
M1
Single, <=2cm
Single, >2cm and <=5cm; N3 Multiple, <=5cm or >5cm
With distant metastasis
Do Chest CT if abnormal chest x-ray and or advanced lesions, bone scan or brain MRI if clinically indicated.
(E)
Cornerstone of renal cancer therapy is radical nephrectomy. Early ligation of renal vein pedicle to preclude
tumor embolization is a principle of the operation.
Nephron-sparing surgery may be indicated in selected patients multiple primaries, uninephric state, renal
insufficiency, small (<4 cm) unilateral tumors. Lymph node dissection is optional.
(F)
For post-nephrectomy Stage I-III cases, follow-up every 4-6 months for 2 years, then every 6 months for
3-5 years, then annually, looking at complete history & PE, chest x-ray, metabolic panel, LDH. At 4-6
months, then annually or as indicated do abdominal CT.
(G)
1st line therapy in non-clear cell RCC includes sorafenib, sunitinib, bevacizumab; for sarcomatoid
histologies, gemcitabine, capecitabine, 5-FU, doxorubicin. Palliative RT or metastatectomy and BSC can be
done. Radiotherapy may be effective for the relief of pain, bone and CNS metastasis. Adjuvant RT for
Stage I-III cases is optional. Under Best Supportive Care (BSC), bisphosphonates can be given for
Metastatic Bone Disease (MBD).
(H)
1st line therapy in predominantly clear cell RCC includes high dose IL-2 for selected patients, sorafenib,
sunitinib, bevacizumab, IFN or low dose IL-2+/-IFN. Palliative RT or metastatectomy and BSC can be
done.
(I)
2nd line therapy (use cross-over regimen) includes sorafenib, sunitinib, IFN, IL-2, bevacizumab. Palliative
RT or metastatectomy and BSC can be done.
45
Renal cell cancer

suspect (A)
Renal CTscan
(B)
5
Mass lesion?
Biopsy (C)
N
Refer
Stage (D)
Malignant?
16
Stage I-III?
Nephrectomy (E)
Refer
17
Close follow-up (F)
10
Stage IV
18
19
No Relapse?
Close
follow-up
N
11
20
Not medically/
surgically
unresectable?
21
Y
Non Clear Cell?
22
N
12
Predominant
Clear Cell
13
Potentially
surgically resectable
solitary metastasis?
1st line therapy

(G)
Nephrectomy +
metastasectomy
23
1st line
therapy (H)
N
14
Potentially surgically
resectable primary
15
25
Cytoreductive
Nephrectomy,
selected patients
24
Progression?
26
2nd line
therapy (I)
N
Close
follow-up
46
URETHELIAL CANCER OF THE URINARY BLADDER

The management of urinary bladder cancer must be multi-disciplinary & interdisciplinary, with each
discipline respecting the specialty expertise of the other, all for the benefit of the cancer patient.
(A)
The most common symptom is hematuria (70-95%); there can also be dysuria, UTI, and symptoms
related to distant metastasis. Do complete history & PE.
(B)
Cystoscopic with biopsy appearance may reveal non-invasive disease, muscle invasion, and
metastatic disease.
(C)
Primary tumor assessment includes bimanual examination under anesthesia before and after
endoscopic surgery (biopsy or transurethral resection) and histologic verification of the presence or
absence of tumor when indicated Clinical Staging (c). The finding of bladder wall thickening, a
mobile mass or a fixed mass suggests the presence of T3a, T3b, and T4b disease, respectively.
Appropriate imaging techniques for lymph node evaluation is used. Evaluate for distant metastases.
Imaging may include IVP, CI urography, renal ultrasound with retrograde pyelogram, or MRI urogram.
Do CBC, alkaline phosphatase, chest x-ray, bone scan if alkaline phosphatase elevated or with
symptoms, ECG, creatinine clearance.
(D)
Pathologic Staging microscopic examination and confirmation of extent are required. Total
cystectomy and LN dissection generally required for this staging.
The histopathologic types are Urothelial (transitional cell) carcinoma in situ (papillary, flat, with
squamous metaplasia, with glandular metaplasia, with squamous and glandular metaplaisa),
squamous cell carcinoma, adenocarcinoma, undifferentiated carcinoma.
Histopathologic Grade (G):
GX
G1
G2
G3-4
not assessed
well differentiated
moderately differentiated
poorly differentiated or undifferentiated
AJCC 2002 Stage Grouping is as follows:

Stage
Stage
Stage
Stage
Stage
Stage
Stage
Stage
Stage
0a
0is
I
IIA
IIB
IIIA
IIIB
IIIC
IV
Ta- non-invasive papillary carcinoma N0 M0

Tis carcinoma-in-situ, flat tumor N0 M0
T1 invades subepithelial connective tissue N0 M0
T2a invades superficial muscle (inner half) N0 M0
T2b invades deep muscle (outer half) N0 M0
T3a invades perivesical tissue microscopically N0 M0
T3b invades perivesical tissue macroscopically N0 M0
T4a invades prostate, uterus, vagina N0 M0
T4b invades pelvic wall, abdominal wall N0 M0
Any T N1M0
Any T N2M0
Any T N3M0
Any T Any NM1
(E)
Pathologic risk positive nodes, positive margin, high-grade, pT3c.

Uncertain complete resection is based on size/ location, no muscle in specimen, inadequate staging,
lymphovascular invasion
(F)
Close follow-up includes urinalysis and cystoscopy initially at 3 months and increasing interval as
appropriate ( 3monthly for 2 years, then every 6 months for 2 years, then annually); biopsy/
cytology as needed; imaging of upper collecting system every 1-2 years (IVP, CT urography,
retrograde pyelogram, or MRI urogram); vitamin B12
(G)
Chemotherapy includes MVAC, gemcitabine/ paclitaxel and cisplatin/ carboplatin for transitional cell
carcinoma; for adenocarcinoma 5FU-based chemotherapy
47
1
Bladder cancer
suspect (A)
10
Stage (D)
2
Cystoscopy (B)
11
Noninvasive?
Bimanaual exam
under anesthesia
(C)
12
cTa, G1-2;
cTa, G3;
cT1, G1-2?
TURBT
Intravesical
chemotx (BCG or
mitomycin-c)
13
6
Papillary or
solid?
Close follow-up (F)
14
15
Cystectomy
cT1, G3?
Tis
16
17
9
8
Close
follow-up
BCG
22
18
19
Muscle
invasive?
See muscle invasive

(18)
cT2 or greater
Bimanaual exam
under anesthesia
(C)
24
20
Solitary lesion,
accessible
location, not
CIS?
TURBT
21
25
cT2?
Pathologic
risk? (E)
N
23
Segmental
Cystectomy
Radical
cystectomy
41
26
Metastasis
27
Close follow-up
29
42
28
Chemotx +/RT
No
nodes?
cT3?
N
43
Y 30
Radical cystectomy +/neoadjuvant chemotx

31
N
33
BSC
Adjuvant chemotx
With nodes
32
Close follow-up
34
35
36
Chemotx (G)
+/- RT
cT4a-b grossly
(+) nodes
Cystoscopy
37
38
Positive
Tumor?
Chemotx +/RT
N
39
40
Surgery or
Boost RT
Close followup
48
Adjuvant RT
or Chemotx
SOFT TISSUE SARCOMA (STS)

The management of STS must be multi-disciplinary & interdisciplinary, with each discipline respecting the specialty
expertise of the other, all for the benefit of the cancer patient.
(A)
A high index of suspicion is invaluable these can be unexplained soft tissues masses. These tumors grow insidiously,
are often in inaccessible sites, and have poor encapsulation. Most sarcomas are not painful at presentation. Fixation of a
mass to subcutaneous tissue or skin, or underlying fascia or muscle and presence of warmth or a distended local venous
pattern are all clinical indications of a malignant lesion.
A complete history & PE is done. Do imaging of primary site with CT or MRI with contrast, as clinically indicated. Do
Chest imaging.
(B)
Any soft tissue mass should undergo biopsy at once. Because the mode of therapy is determined in large part by the
histology of the tumor, ample tissue must be delivered to the pathologist. CT-guided core biopsy is preferred, particularly
for patients receiving pre-op RT or chemotherapy. Pre-resection biopsy may not be done for respectable retroperitoneal
sarcoma. Incisional biopsy should be done for low-grade or intermediate lesions, lesions with extensive necrosis, and/ or
insufficient tissue for definitive diagnosis.
(C)
The STS discussed in this guideline are desmoid tumors, sarcomas of the extremity, retroperitoneum, and intraabomen
(except GIST) alveolar soft-part sarcoma, desmoplastic small round cell tumor, epithelioid sarcoma, clear cell sarcoma,
chondrosarcoma, extraskeletal, osteosarcoma extraskeletal, primitive neuroectodermal tumor, fibrosarcoma,
leiomyosarcoma, liposarcoma, malignant fibrous histiocytoma, malignant hemangiopericytoma, malignant peripheral
nerve sheath tumor, rhabdomyosarcoma, synovial sarcoma, sarcoma, NOS.
(D)
For desmoids, microscopic positive margins may be acceptable if achieving negative margins would produce excessive
morbidity
(E)
Physical exam with appropriate imaging every 3-6 months for 2-3 years, then annually
(F)
Combination chemotherapy regimens include AIM (doxorubicin, ifosfamide, mesna), MAID (mesna, doxorubicin,
ifosfamide, dacarbazine), AD (doxorubicin, dacarbazine), gemcitabine/docetaxel. For desmoid tumors tamoxiphen,
methotrexate, vinblastine, low-dose interferon, doxorubicin-based regimens can be used. For rhabdomyosarcoma,
second-line therapy can be irinotecan, cyclophosphamide/topotecan. For angiosarcoma taxanes, interferon, vinorelbine.
(G)
The most important prognostic factor for STS patients is the histologic grade (AJCC 2002):
GX
G1
G2
G3
G4
Grade cannot be assessed

Well differentiated
Moderately differentiated
Poorly differentiated
Poorly differentiated or undifferentiated (4-tiered systems only)
The grade of the sarcoma dominates the stage determination not the anatomic extent of the tumor (AJCC 2002):
Stage I T1a-2bN0M0
G1-2
G1
Low
Stage II T1a-2aN0M0
G3-4
G2-3
High
Stage III T2bN0M0 G3-4
G2-3
High
Stage IV anyTN1M0
any G
any G
High or Low
anyTN0M1
any G
any G
High or Low
CT or MRI is useful to stage tumor locally for medullary and soft tumor extension (CT) as well as presence of matrix or
cortical disruption (MRI) an information essential in planning limb conservation surgery and radiation portal shaping.
Chest roentgenograms are essential for all tumor types. CTscan of lungs is done if CXR is negative for lesions and if
treatment decisions hinge upon presence or absence of lung metastasis. Bone scan can be done to evaluate presence of
multiple bone lesions, particularly if metastatic bone disease is being considered.
(H)
Physical exam (PE) with imaging (chest/abdominal/pelvic CT) every 3-6 months for 2-3 years, then annually for
respectable low grade intra-abdominal sarcomas. For resectable high grade, PE with imaging (chest/abdominal/pelvic
CT) every 3-4 months for 3 years, then every 6 months for the next 2 years, then annually. For others (unresectbale,
with limited liver metastasis, disseminated disease), clinical history & physical exam (H&P) every 3-6 month for 5 years,
then annually; abdominal/ pelvic CT every 3-6 months for 3-5 years then annually.
(I)
Resectability is defined as follows: a) respectable not close to adjacent viscera or critical neurovascular structure and
<5cm, b) marginally respectable high probability of positive margins, abutment of neurovascular structures, requiring
resection of adjacent viscera, and c) unresectable or metastasis.
(J)
For low grade retroperitoneal STS, follow-up includes physical exam (PE) with imaging (abdominal/ pelvic CT) every 3-6
months for 2-3 years, then annually; for high grade, PE with imaging (abdominal/ pelvic CT) every 3-6 months for 2-3
years, then every 6 months for next 2 years, then annually. Consider Chest imaging.
(K)
For unresectable or metastatic retroperitoneal STS, balance the risks of the treatment options, with the likelihood of
rendering patient respectable, performance status of patient, and potential clinical benefits. Best supportive care (BSC)
may also be the best option.
58
(L)
T1 tumor 5cm or less in greatest dimension: T1a superficial tumor (above superficial fascia without invasion of
fascia); T1b deep tumor located either exclusively beneath the superficial fascia, superficial to the fascia with invasion
of or through the fascia, or both superficial yet beneath the fascia retroperitoneal, mediastinal, pelvic sarcomas are
classified as deep tumors.
T2 Tumor more than 5 cm in greatest dimension: T2a superficial tumor; T2b deep tumor
(M)
Surgery for STS has the following guides: a) optimal margins and oncologic control. Re-resection may be required to
achieve optimal margins, b) maximal function with minimal morbidity, c) limb sparing generally preferable, d) consider
preoperative chemotherapy (chemotx)/ radiotherapy (RT), e) pathology expertise in sarcomas important.
(N)
Pre-operative RT is EBRT followed by surgery with clips, followed by post-op brachytherapy.
(O)
Follow-up after treatment of Stage I extremity STS includes history and physical exam (H&P) every 3-6 months for 2-3
years, then annually with periodic imaging of surgical site; chest x-ray every 6-12 months; for stage II-III, H&P and
chest imaging (CXR or CT) every 3-6 months for 2-3 years, then every 6 months for the next 2 years, then annually, with
periodic imaging of primary site.
59
Soft Tissue Sarcoma

suspect (A)
2
Biopsy (B)
3
With
cancer (C)?
Desmoid
tumor?
13
N
Refer
Total
resection (D)
Resectable
?
9
Negative
margins?
Unresectable
14
RT or
Chemotx (G)
or BSC
Close followup (E)
11
10
Reresection or
RT or Close
follow-up (F)
Positive
Margins
12
Recurrent/
Progressive
disease
15
21
16
Intraabdominal
sarcoma?
17
Resectable
?
18
Total
resection
N
N
24
Resectable
primary/
isolated liver
mets?
Resection of
primary +/metastasectomy
20
RT
High
grade
25
A
19
22
Recurrent/
Progressive
disease
26
23
Chemotherapy
30
Close
follow-up
(H)
Low
grade?
RT or
Chemotx or
BSC
Unresectable
Primary/
Disseminated
metastases
27
28
Recurrent/
Progressive
disease?
Close followup (I)
31
BSC/ RT/
Chemotx/
Palliative
Surgery
29
N
BSC/ RT/
Chemotx/
Palliative
Surgery
60
A
32
33
Retroperitoneal
sarcoma?
34
Resectable
? (J)
Total
Resection
?
36
40
37
High grade
Incomplete
resection
Extremity
sarcoma
Close followup (K)
Low
grade?
41
42
58
35
Chemotx/
RT/ BSC
Recurrent /
Progressive
disease
39
38
Close followup (L)
RT
43
Chemotx/
RT/ BSC
B
44
45
Marginally
resectable?
Surgery +/Neoadjuvant
RT/Chemotx
46
56
Total
Resection
?
Unresectable
or metastases
57
Chemotx/ RT/
BSC (M)
54
47
Low
grade?
N
Incomplete
resection
Close followup (K)

52
49
53
Recurrent
disease
High
grade
55
48
Chemotx/
RT/ BSC
51
Chemotx/
RT/ BSC
50
RT
Close followup (L)
61
58
Extremity
sarcoma
59
59
Resectable
?
62
61
60
T1a-1b,
N0M0, low
grade? (N)
?
Margins >1.0
cm/ intact
fascial plane?
Y
Surgery
N
N
Close followup (P)
66
63
67
T2a-1b,
N0M0, low
grade?
Surgery +/RT +/Chemotx
64
Margins
<=1.0
cm
65
68
71
Close
follow-up
69
Close
follow-up
RT
Recurrent/
Progressive
disease
70
Surgery + pre-op or
post-op RT (0) +/pre-op or post-op
Chemotx
Stage II,
III
72
BSC/ Surgery
+/- RT +/Chemotx
73
74
75
Marginally
resectable?
Close
follow-up
Pre-op RT or
Chemotx or Combined
Chemo/RT
76
77
Resectable
?
78
Surgery +/- RT +/Chemotx
Close
follow-up
N
79
N
Unresectable
80
81
Metastatic
BSC/ Surgery
+/- RT +/Chemotx
62
PRIMARY BONE SARCOMA

The management of primary bone sarcoma must be multi-disciplinary & interdisciplinary, with each discipline
respecting the specialty expertise of the other, all for the benefit of the cancer patient. The core group includes an
orthopedic oncologist, bone pathologist, medical/ pediatric oncologist, radiation oncologist, and musculoskeletal
radiologist.
(A)
Pain in area of lesion, which is not activity-related and commonly worsens at night, is the usual signal for a bone tumor.
In more advanced cases, a mass or swelling (with significant periosteal reaction or erosion through bony cortex) or
pathologic fracture, or with stiffness of joint.
(B)
Roentgenograms are the single most important diagnostic tool which also indicate prognosis. They can detect lesions
which are >2cm. Lesions may be
Lytic destroying bone or
Blastic forming bone or inducing reactive bone formation:
Circumscribed area of bone destruction slow growing (e.g., lower grade tumor giant cell tumor or
chondrosarcoma)
Moth-eaten aggressive with cortical destruction, multiple intermediate growth
Permeative pattern extremely rapid with diffuse lytic destruction associated with cortical disruption
and extraosseous tissue mass
(C)
Work-up for potential bone metastasis includes complete history and PE, bone scan, chest x-ray, ALP, CBC, LDH,
chest/abdominal/ pelvic CT, PSA, mammogram. Definitive treatment is according to primary site. Metastatic bone
disease (MBD) is usually from carcinomas. Consider use of bisphosphonates particularly for multiple and or painful
metastatic bone disease from carcinoma:
May use:
Ibandronic acid 6 mg IV every 21 days or 50 mg/ tab daily
Zoledronic acid 4 mg IV every 3-4 weeks
Pamidronic acid 90 mg IV every 3-4 weeks
Clodronate 1600 mg/ day or 1040 mg/ day po or 300 mg/day IV for 5-7 days
Incadronate 10 mg IV single dose or 2 mg IV every 2 weeks
In absence of hypercalcemia, give Vit D 400 IU cap po daily and calcium 500 mg tab po dialy as supplement
(D)
Bone scan is essential to determine if bone lesion is monostotic or polyostotic and can detect tumor foci not visualized on
standard radiographs
(E)
CTscan or MRI is useful to stage tumor locally for medullary and soft tissue extension as well as presence of matrix or
cortical disruption, particularly for monostotic primary bone tumor
(F)
Biopsy (preferable incisional) should be performed after CT and bone scan evaluations of local extent of lesion is
completed and accurate localization of lesion is done. Take the periphery of the lesion, where less interface
differentiation of cancer cell occurs between normal and tumor tissues can be assessed, and so as not to predispose to
pathologic fracture. Biopsy is optimally performed at hospital which will do definitive management, following same
principle for open/needle biopsy. Fresh tissue is needed for molecular studies.
(G)
4 types of Bone Sarcoma are included in this algorithm:

Osteosarcoma - work-up includes Chest x-ray, Chest CT, MRI+/- CT of lesion, bone scan, LDH, CBC, alkaline
phosphatase. 20% of surface tumors will be high-grade surface osteosarcomas
Ewings sarcoma work-up includes MRI+/- CT, Chest CT, bone scan, optional bone marrow biopsy,
cytogenetics/ molecular studies (90% of Ewings family tumors will have 1 of 4 specific cytogentic
translocations- t(11;22) translocation), LDH
Chondrosarcoma
Giant cell sarcoma
(H)
Stage is according to Musculoskeletal Tumor Society (MTS):

STAGE
IA
IB
IIA
IIB
III
GRADE
G1
G1
G2
G2
Any G
SITE
T1
T2
T1
T2
Any T
METASTASIS
M0
M0
M0
M0
Regional or distant metastasis
T1 intracompartmental or within cortex; T2 extracompartmental or beyond cortex

Histopathologic Grade (G):
Gx grade cannot be assessed
G1 well differentiated Low Grade
G2 moderately differentiated Low Grade
G3 poorly differentiated High Grade
G4 undifferentiated High Grade
Note: Ewings sarcoma is classified as G4;
Spread of bone sarcoma to LNs is rare; usual pattern is heterogenous to pulmonary and other sites. Prognosis is similar
whether metastasis to LN or other sites. Chest x-ray is routine. CTscan can detect small metastasis to lung.
63
(I)
Chemotherapy may be IV or intra-arterial, given for 2-6 cycles, and include at least 2 of doxorubicin, cisplatin,
ifosfamide, high-dose methotrexate, and growth factors
(J)
Wide excision implies histological negative margins and is necessary to optimize local control. Limb preservation is
desirable, where possible, without compromising satisfactory oncologic outcome. Surgical margins should be negative,
wide enough to minimize potential local recurrence and narrow enough to maximize function. In the individual case,
either amputation or limb sparing surgery may be the most appropriate.
Selected elderly patients may benefit from immediate surgery
(K)
Response defined by pathologic mapping is either good (pathological complete response or no residual disease) or poor
(pathological positive residual disease)
(L)
Osteosarcoma - Close follow-up schedule is every 3 months for years 1-2, every 4 months for year 3, every 6 months for
years 4-5 and yearly thereafter, looking at PE, chest imaging, CBC, bone scan or local primary site imaging, with
reassessment of function every visit.
Ewings sarcoma PE, chest x-ray, and local primary site imaging every 2-3 months, CBC annually, MRI every 6 months
for 2 years, bone scan as indicated; increase intervals for PE, chest and local imaging after 24 months; annually after 5
years (indefinitely).
Chondrosarcoma PE, chest and primary site imaging every 3-6 months for 5 years, then yearly for a minimum of 10
years; reassess function at every visit for high-grade lesions. PE, chest and lesion x-ray every 6 months for 2 years then
yearly as appropriate for low-grade lesions.
(M) Chemotherapy should include the following ifosfamide and or cyclophosphamide, etoposide, doxorubicin, vincristine
treat for 12-24 weeks
(N)
Restage with chest x-ray, local imaging, bone scan (optional), and repeat other at-baseline abnormal studies
(O)
Negative margins in surgery should be obtained. Wide excision may include radical resection and/ or amputation; and
may be required to achieve negative margins.
64
1
Bone Cancer
Suspect (A)
11
2
Bone X-ray
(B)
Bone scan
(D)
>40 years
old?
3
Positive bone
destruction due
to cancer?
13
12
15
14
Biopsy
(F)
Polyostotic
Negative for
METASTATIC
BONE work-up?
(C)
CTscan/M
RI (E)
Monostotic
?
4
Bone
scan
N
9
Manage
according to
primary site
16
10
Consider
bisphosphonates
21
Positive Primary
Bone Sarcoma?
(G)
5
Positive bone
cancer lesion
suspect?
N
6
Close
follow-up;
Refer
OSTEOSARCOMA?
19
17
Highly
suspect
cancer?
20
Stage
(H)
Radiotherapy
Y
22
23
EWINGS
SARCOMA?
18
Close
follow-up;
Refer
Stage
(H)
24
25
CHONDROSARCOMA?
Y
Stage
(H)
26
GIANT CELL
SARCOMA
28
27
Stage (H)
Resection if
possible +
Radiotherapy
65
1
OSTEOSARCOMA
2
Periosteal?
4
Consider
Chemotherapy
(I)
5
Wide
Excision (J)
Low
Grade?
N
9
6
10
Low Grade;
intramedullary +
surface,
Parostreal?
High
Grade
Wide
Excision (J)
7
Consider
Chemotherapy
N
11
High Grade:
intramedullary +
surface
8
Close
follow-up
12
Pre-operative
Chemotherapy
13
14
15
Radiotherapy
+/- Sensitizers
Post-chemo
unresectable?
Chemotherapy
(I)
N
10
Surgery (J)
18
19
17
Positive
margins?
Pathologic
mapping good
response?
Continue
Chemotherapy
+ RT
N
N
20
Change
Chemotherapy
+ RT
22
21
Close followup (L)
23
Pathologic
mapping good
response? (K)
Continue
Chemotherapy;
Physical therapy
27
26
N
25
24
Change
Chemotherapy
No
Relapse?
Close
follow-up
Close
follow-up
N
28
Chemotherapy
and/or surgery and/
or RT and/ or BSC
66
Neoadjuvant
multiagent
chemotherapy (M)
EWINGS
SARCOMA
3
Re-stage
(N)
5
4
6
RT and/or surgery
for local control/
palliation
Progressive
disease?
Chemotherapy/
BSC
11
13
Wide
excision
Primary
RT
9
Negative
margins?
16
Preoperative
RT
Amputation,
selected cases
(e.g., foot
tumors)
14
Wide
excision
Chemotherapy
(12-24 wk)
17
15
12
Chemotherapy
(12-24 wk) +/RT
Chemotherapy
Post-op
chemotherapy;
+RT if positive
margins
10
Chemotherapy (12-24
wk) followed by RT
OR RT followed by
Chemotherapy (12-24
wk)
18
Close follow-up (L)
19
20
Early
relapse?
Radiotherapy
N
22
21
Late
relapse
Re-treat with
previously
effective regimen
67
CHONDROSARCOMA
3
2
Treat as
Ewings
Sarcoma
Mesenchymal
?
N
4
5
Treat as
Osteosarcoma
Defifferentiated
?
N
6
7
Low grade or
Intracompartmental
?
Intralesional excision
+/- surgical adjuvant
or Wide excision or
RT, if unresectable
8
Close followup (L)
10
9
Local
Recurrence?
12
High grade (Gr IIIII) or Clear cell
Excision +/RT
or RT for
unresectable
disease
N
11
Close followup (L)
13
Wide excision (O) or
RT, if unresectable
14
Close
follow-up
16
15
Local
relapse?
Wide excision
+/- RT or
Amputation
N
17
18
Systemic
relapse
Palliative
surgery
68
PRIMARY CNS TUMORS

The management of CNS tumors must be multi-disciplinary & interdisciplinary, with each discipline respecting the
specialty expertise of the other, all for the benefit of the cancer patient.
(A)
Increased intracranial pressure (ICP) due to increasing tumor mass and/ or associated edema or hemorrhage/ infarction
within the tumor, inside an enclosed rigid compartment (i.e., skull and spinal canal), can cause symptoms such as
headache, nausea and vomiting, and later depression of mental status (somnolence, lethargy, disorientation). Epileptic
seizures in an adult who has never had them are high suspects. Suboccipital tenderness is common with posterior fossa
tumors. Degrees of aphasia or apraxia, asymmetry of CN function, incoordination, musculature weakness, and loss of
extremity sensation can occur. Always do fundoscopic and visual field (VF) exam to detect increased ICP or VF
alterations, respectively.
(B)
Lumbar puncture (LP) is avoided when there is obvious evidence of increased ICP. LP can be useful to determine whether
ICP is elevated and to be able to get CSF for exam. CSF protein is elevated approximately 1/3 of the time if with
intracranial tumor and almost always in presence of a spinal cord tumor. CSF glucose may be low in presence of highly
malignant tumors or metastatic meningeal deposits. CSF cytology is (+) in meningeal carcinomatosis and in tumors that
involve the meninges or are situated in a subependymal location. Cerebral spinal fluid cytology should be evaluated in
primitive neuronal tumors (PNET) and primary non-Hodgkins lymphoma.
(C)
MRI is non-invasive, safe, painless, highly sensitive and efficient technique, and can detect neoplasia which is <1 cm in
largest diameter. It is the screening procedure of choice in diagnosing and localizing tumors of the brain stem, posterior
fossa and spinal cord, and for defining the extent of low-grade gliomas. It can differentiate between intrinsic and
extrinsic spinal cord problems and metastatic disease versus disc problems. It can provide 3-dimensional tumor imaging
and with contrast agent gadolinium, can identify regions of the tumor where the blood-brain barrier is altered. It does
not need iodinated contrast. It will replace myelogram as an initial procedure for evaluating spinal cord tumors and discs.
CT scanning can be performed if MRI is not available or affordable. CT complements the information available from MRI.
CT can detect intracranial calcification and separate them from acute hemorrhage. MRI cannot detect calcifications and
can only demonstrate acute hemorrhage with special techniques. CT is more economical in following progress of patients
in post-op period.
(D)
Biopsy is required for most CNS tumors. Biopsy can be done with MRI or CT stereotactic guidance. In absence of
stereotactic biopsy, a high index of suspicion based on clinical picture can suffice to treat the tumor as malignant.
(E)
Histopathology is more important than staging in determining the clinical behaviour and prognosis of primary brain
tumors and their treatment. Astrocytomas are divided into low-grade or benign gliomas, astrocytomas with foci of
anaplasia (AAF), and glioblastoma multiforme (GBM), which has the worst prognosis. Medulloblastomas are primitive
neuronal tumors (PNET) which are rapidly growing, infiltrative, with marked tendency to spread throughout the
subarachnoid space and to produce disseminated meningeal foci. Meningiomas and neurilenomas are tumor of
supporting structures of the nervous system and they can cause compression of spinal cord and spinal roots.
Meningiomas are almost always histologically benign, but recur quite commonly. Developmental tumors arising from
cells that have developed abnormally and persisted throughout post-natal growth include craniopharyngiomas (an
expanding lesion), pituitary tumors (benign, slow-growing, encapsulated but can increase ICP and be actively causing
endocrinopathy).
(F)
Initial treatment for all intracranial tumors is surgical excision. Removal is limited by the tumor location and invasiveness
of the particular lesion, or, in the case of some benign lesions, by technical problems at the time of operation. Working
with a unique computer-guided stereotactic coupled laser system with use of magnified vision and microscopic
instrumentation, neurosurgeons are able to eradicate a large number of varying types of cortical tumors with relatively
benign post-op courses.
(G)
Most malignant brain tumors respond to external irradiation. Radiation therapy is the most important treatment
modality; it produces cures in certain tumors and prolonged survival in others. Radiation therapy is generally indicated
when the tumor is: 1) malignant (AAF, GBM, gliosarcomas, meningiosarcomas, medulloblastomas, ependymomas,
ependymoblastomas, pinealoma, pinealoblastomas, and germinomas); 2) incompletely excised or recurrent low grade
tumors; 3) centrally located and involves critical structures so that surgical intervention is not possible, such as tumors in
the midbrain, 3rd ventricle, brains tem; 4) pituitary tumor; and 5) metastatic deposit.
(H)
Unfortunately, when the tumors are malignant, recurrence of the tumor has not been prevented, even when it appeared
to have been destroyed radiologically. For malignant brain tumor, chemotherapy is given concomitantly with radiation
therapy or for recurrence after radiation. Lipid-soluble drugs (nitrosureas, lomustine, carmustine, semustine,
procarbazine, and vincristine) remain the mainstay of therapy, together with temozolamide. For pituitary adenomas,
bromocriptine is used to lower prolactin levels.
69
(I)
Corticosteroid therapy (dexamethasone at 16 mg daily dose) will control edema around a brain tumor, providing dramatic
relief of symptoms often within a day, and making it easier to prepare patients for surgery. Corticosteroid therapy has
proven considerable benefits in palliative care of brain cancer patients.
1
Primary CNS
cancer suspect
(A)
16
LP/ CSF
exam,
cytology (B)
Not CNS
primary
cancer?
ICP not
increased?
8
No
malignant
cells?
17
CNS
mass ?
CNS MRI
scan
Decompres
sion (I);
Partial
resection
&/or RT
(G) +/Chemotx
(H)
18
Malignant
glioma,
AAF,
GBM?
11
5
19
N
CNS MRI
scan (C)
Manage as
metastatic
cancer
Biopsy
feasible?
(D)
15
Malignant
? (E)
N
N
10
N
Refer
20
12
21
14
CNS
primary
cancer ?
CNS
cancer not
highly
suspected?
Medulloblastoma/
Ependymo
blastoma ?
Refer
N
22
N
Manage as
metastatic
cancer
23
7
13
Other
cancers
RT +/intrathecal
chemotx
24
Low grade glioma?
Meningioma?
Craniopharyngioma
?
Complete
resection
(F) & RT
Surgery/
RT/
Chemotx/
Observe
25
Y
Complete resection
or RT
N
26
27
Pituitary
adenoma?
Complete resection
or RT;
Bromocriptine
N
28
Pinealoma?
29
Stereotactic +/-RT
N
30
31
Midbrain or
brain stem?
Y
Stereotactic biopsy; RT
N
32
33
Other benign
tumors
Stereotactic
Surgery/ Observe
70
CARCINOMA OF UNKNOWN PRIMARY SITE

The management of cancer of unknown primary site must be multi-disciplinary & interdisciplinary, with each
(A)
Carcinoma of unknown primary is defined as a histological diagnosis of carcinoma with no apparent primary site after
complete history and physical examination, basic laboratory studies (including urinalysis, CBC, occult blood in stool),
chest x-ray, and ultrasound/ CT scan of abdomen & pelvic organs. Additional studies are done only as suggested by
detectable abnormalities. For example, PET scan is not recommended for routine use, but may be done in some
situations when considering local/ regional therapy. The goal of additional studies is to identify the primary site,
particularly in clinical situations in which potentially curative or effective therapy is available.
An extensive blind work-up is not cost-effective and therefore not recommended. Palliation of symptoms takes priority
in these patients, particularly since this is advanced disease by stage.
(B)
The pathologic examination is the single most important step in determining the primary site. In any situation wherein
cancer is highly suspected, adequate tissue samples should be provided to experienced pathologists. Aids in identifying
primary sites include electron microscopy and histochemical and immunohistochemical staining. At the time of biopsy/
surgery, the biopsy specimen should be divided into 3 portions: 1 portion snap frozen without fixation for
immunohistochemical studies, 1 placed in glutaraldehyde for electron microscopy, and 1 into formalin for routine
processing.
(C)
Once the results of pathological slide review are known, the clinical history and a complete physical examination which
includes careful and thorough evaluation of the lymph-node-bearing areas, skin, and breast, and internal examination of
the ENT, gynaecologic/ pelvic organs and testis. If the pathology evaluation does not suggest a primary site and labels
the specimen as adenocarcinoma or poorly differentiated carcinoma, identify the patients main or predominant
presenting sign and/ or where the biopsy specimen turned out positive for cancer.
3 major histopathological types are commonly associated with unknown primary site: 1) adenocarcinoma or carcinoma,
NOS, 2) squamous cell carcinoma, and 3) small cell, anaplastic carcinoma.
(D)
The most common presenting sign of patients with carcinoma of unknown primary site is lymphadenopathy.
Supraclavicular lymphadenopathy is usually associated with cancers of the lung (particularly in men with a background of
heavy cigarette smoking), gastrointestinal tract, and breast (in women). If lung cancer is suspected, CTscan can detect
lung lesions missed out by chest x-ray.
(E)
Colorectal carcinomas account for 89% of gastrointestinal cancers and CEA is the preferred marker. A combination of CA
72-4 and CEA achieves the highest specificity (95%) in case gastric cancer is suspected. Liver cancer occurs commonly
in the Philippines, and alpha-fetoprotein (AFP) is a particularly useful marker (relatively high in primary liver cancer;
relatively low AFP in combination with high CEA usually occurs in metastatic liver cancer).
If tumor markers for gastrointestinal tumors are not useful, CT scan of upper abdomen may be able to detect lesions not
detected by ultrasound of the hepatobiliary system. PET scan may also be done.
If still no primary site is identified, radiotherapy+/- chemotherapy against the enlarged LN may be done. Usually GIactive and/or radiosensitizer chemotherapeutic agents can be used e.g., FU, cisplatin, capecitabine.
(F)
Squamous cell carcinoma is found in >70% of patients whose involved nodes are high in the neck or midneck. The most
common occult primary sites include the nasopharynx, tonsil, base of the tongue, and hypopharynx. An MRI of the head
and neck is done followed by direct laryngoscopy with random biopsies from suspected lesions in the tonsils, nasopharynx,
and base of the tongue.
If still no primary site is identified, radiotherapy+/- chemotherapy can be given to enlarged LNs/ site. Usually H&N-active
and/or radiosensitizer chemotherapeutic agents can be used e.g., FU, cisplatin, capecitabine, gemcitabine.
(G)
The most common cause of adenocarcinoma or poorly differentiated carcinoma confined to the axillary nodes is occult
breast cancer, with or without supraclavicular lymph adenopathy. Biopsy material should be analyzed for estrogen and
progesterone receptors, and also HER-2/neu. For women, a mammography may be done; if still with negative results,
treat the patient as a breast cancer. For men, particularly >40 years of age, do PSA; consider also testicular ultrasound/
tumor markers.
(H)
Inguinal LN metastasis of unknown origin is a rare clinical presentation. Careful inspection of the skin, endoscopic
evaluation of the anal canal and rectum, and gynecologic examination are of major importance. Patients in whom the
primary tumor cannot be identified should undergo LN dissection of the affected areas.
71
(I)
In female patients with ascitis, ovarian carcinoma is highly suspected. A positive CA-125 is an important marker for
ovarian cancer. AFP and B-HCG can be positive in germ cell tumors of the ovary. CT scan can detect lesions in the pelvic
area. Even in the absence of detectable ovarian disease, treat women who present with peritoneal carcinomatosis
according to guidelines for Stage III ovarian cancer disease.
(J)
Ascitis may be due to cancers of the ovary and GI tract, carcinomas that can be palliated with cisplatin-containing
chemotherapeutic regimens. Supportive care with/ without cytotoxic chemotherapy can be done for poor performance
status patients.
(K)
Bone metastasis can be from breast, lung, or GI (particularly colorectal) cancers among female patients; among males,
common primary sites are lung, prostate, and colorectal cancers. A thorough evaluation of these possible sites should be
done. Elevated PSA and acid phosphatase (prostatic fraction) is suggestive of prostate cancer.
(L)
If primary site is still unknown, palliative RT to symptomatic and weight-bearing affected bone areas can be done; pain
relief can also be achieved by analgesics and osteoclast-inhibiting agents, such as bisphosphonates (e.g., ibandronate,
zolendronate, clodronate).
(M) A special clinical subset includes males <50 years old with rapidly growing, poorly differentiated carcinomas involving
predominantly midline structures (mediastinum, retroperitoneum) with or without bilateral pulmonary nodules. This
clinical presentation is termed extragonodal germ cell cancer syndrome. Approximately 10-15% of these patients may
be cured with cisplatin-containing chemotherapy.
(N)
Small cell carcinomas of unknown primary site may be lung (SCLC) or lymphoma-related; these cancers have common
chemotherapeutic agents cyclophosphamide, vincristine, doxorubicin which can be given.
72
14
9
Unknown Primary
Cancer Suspect (A)
10
6
2
20
21
Diseasespecific
Dx/ Tx
N
13
MRI, H&N
AFP/
CEA +?
(E)
1o GI Ca
suspect?
N
15
22
23
RT+/Chemotx to
LN;
Follow-up
1o H&N Ca
suspect?
Diseasespecific
Dx/ Tx
RT+/-Chemotx
to LN; Follow-up
16
N
Id main sign
& positive
biopsy site
24
CT scan
upper
abdomen
26
LN?
25
18
Axillary?
Treat as
breast ca
17
1o GI Ca
suspect?
N
5
Disease-specific
Dx/ Tx
12
High or
mid-neck?
4
Consistent with
sarcoma,
lymphoma,
melanoma,
neuroendocrine,
germ cell tumor
1o lung
Ca
suspect?
CT scan
chest (D)
N
Review Hx;
Do complete
PE: LNs,
mediastinumlung, pleural,
peritoneaum,
liver, bone,
brain, ENT,
breast, rectum,
gyne/ pelvic/
testis, skin
Review of slides
with special
stains (B)
Adenoca or
poorly
differentiated
ca? (C)
Supraclavicular?
11
Diseasespecific
Dx/ Tx
N
N
19
RT+/Chemotx to
LN;
Follow-up
28
29
27
Skin/ Proctoscopy/ Gyne
exam +?
Inguinal
(H)
Diseasespecific
Dx/ Tx
N
30
LN dissection;
RT +/- Chemotx;
Follow-up
73
31
32
Ascitis?
32
Female?
(I)
31
CA-125?
33
N
32
34
Other
Gyne Ca
suspect?
CT scan
pelvic
organs
Treat as
ovarian ca
Diseasespecific
Dx/ Tx
N
35
36
37
AFP/
CEA +?
(E)
Treat as
ovarian ca
Liver/
colorectal
Ca Dx/ Tx
N
38
39
CT scan
upper
abdomen
40
o
1 GI Ca
suspect?
Diseasespecific
Dx/ Tx
N
41
Palliation
(J)
44
42
45
43
Bone?
Female
? (K)
Breast/
Lung/ GI
1o Ca?
Diseasespecific
Dx/ Tx
N
46
Palliation
(L);
Follow-up
47
48
Lung/
prostate/
colorectal
1o Ca?
Disease-specific
Dx/ Tx
N
50
49
Poorly
differentiated,
midline mass,
bilateral lung
mets, males,
<50yrs age?
Palliation (L);
Follow-up
51
Treat as
Testis
Ca (M)
74
N
53
52
Small cell
cancer
Consider SCLC/
Lymphoma (N)
GENERAL GUIDELINES FOR PALLIATIVE MANAGEMENT OF

ADVANCED CANCER
The management of patient with advanced cancer must be multi-disciplinary interdisciplinary, with each discipline
The Medical Oncologist heads the Palliative Care of a cancer patient; in his her absence the Internist or the Family
Medicine practitioner with hospice care expertise.
(A)
At some point, a persons cancer may start growing and spread to vital organs. This is called advanced cancer. As the
cancer progresses and choices for further cancer treatment become limited, palliative care increases and becomes the
major focus of care for the patient and the family. Symptoms increase and more attention is needed to help control them.
As an example, the person with advanced cancer receiving medicines to control his/her cancer pain near the end of life is
receiving palliative care.
Although palliative care is given throughout all stages of the cancer to some degree, this general guideline focuses on
care given during the last year of life.
Palliative care is care that relieves suffering and improves the quality of a patients life. It is care that treats symptoms
caused by the cancer treatment or symptoms caused by the disease. Some health workers call this supportive care.
Common symptoms that are treated and controlled or relieved by palliative care include:
Pain
Difficulty of breathing
Lost of appetite and weight loss
Fatigue
Weakness
Sleep problems
Depression& anxiety
Confusion
The purpose of screening is to determine if palliative care is needed. The health care team does this screening. Palliative
care is considered for patients who:
Have advanced cancer that cannot be cured.
Are expected to live less than a year.
Request palliative care.
Have other serious medical problems.
(B)
The cancer care team considers several factors to help them determine if the patient is expected to live a year or less.
These factors include:
How well the person can care for him or herself and carry out daily activities.
The presence of complications of advanced cancer such as:
Too much calcium in the blood (hypercalcemia)
Liver or kidney problems
Other serious medical conditions
Involvement of the central nervous system (brain and spinal cord)
Superior vena cava syndrome
(C)
The cancer care team will determine if any symptoms or any other serious medical condition/s (e.g., NIDDM,
hypertension, CHF, etc) are present. Symptoms include - pain, difficulty of breathing, fatigue and weakness, loss of
appetite and weight loss, sleep problems, confusion, depression or anxiety. Infection may also occur. The treatment is
directed at the specific symptoms.
The patients may develop advance care plans.
readiness for hospice or special palliative care.
(D)
This includes a living will, power of attorney, CPR preference and
Considerations for definitive treatment of cancer will include:

Typical history of the cancer type
Likelihood of a response to treatment
Effect of cancer on vital organs
The patients ability to take care of self and do daily activity
Plus the life expectancy of the patient:
Years-months may do disease-specific definitive treatment
Months-weeks consider no further definitive cancer treatment
Weeks-days symptom control only
(E)
Considerations of definitive treatment of cancer will include:

Patients wishes and family needs
75
Spiritual and religious needs

Cultural needs
Readiness for hospice or special palliative care services
For those with life expectancy of years-weeks, the doctor will:
Determine how much information the patient wishes to have
Determine how much information the patient wishes his family to have
Determine how the patient and his family make decisions and help resolve any conflicts between the
patients goals and expectations with those of his family
Determine the patients ability to make decisions for himself
Determine the patients desires with respect to quality of life
Encourage the patient to review and revise his priorities, identify unfinished business, resolve personal
relationships, and put affairs in order
Determine the patients readiness for hospice/specialized palliative care
Provide clear, consistent discussion with the patient and the patients family about prognosis on an
ongoing basis
Make arrangements to ensure that the patient do not die alone.
For those with life expectancy of weeks-days, the doctor will:
Help the patient and his family prepare for the end of the patients life
Facilitate anticipatory grief work
Help the patient and his family understand what is happening
Ensure that the patient do not die alone
Social support given to patients by people who care about them is also necessary. This might include someone to talk to
and discuss goals and plans with, someone to hold their hand or take them for a walk, or someone to help with buying
groceries. This support can be provided by family, community, cultural, spiritual or religious groups. The patients past
coping abilities, strengths, and vulnerabilities will be considered.
76
1
Advanced
Cancer (A)
2
4
Cannot be
controlled
with definitive
treatment?
5
Life
expectancy of
1 year? (B)
6
Patient/ Family
request only
palliative care?
Other serious
medical
problem (C)
3
Treat according
to diseasespecific
guidelines
7
Consider
Benefits/ Risks
of Cancer Tx (D)
vis--vis Life
Expectancy
10
Life
expectancy
years-months?
Cancer Tx to prolong life

includes usual disease-specific
definitive Tx guidelines
N
8
11
Consider
patient/ family
goals &
expectation (E)
12
Life expectancy
months-weeks?
N
13
Life expectancy
weeks-days
Measures to improve quality of

life with consideration of no
further definitive cancer Tx
14
Focus on symptom control
& comfort with no further
definitive cancer Tx
77
SUPERIOR VENA CAVA SYNDROME (SVC)

The management of SVC must be multi-disciplinary & interdisciplinary, with each discipline respecting the
(A)
Obstruction of the superior vena cava is usually caused by lung cancer, but it can also be due to lymphoma and
other mediastinal tumor and metastatic tumors. Headache, nausea, vomiting, visual disturbances, and
syncope are presenting complaints. Symptoms of vocal hoarseness, dyspnea, dysphagia, back pain suggest
involvement of other mediastinal structures. Upper body venous distention, edema, and cyanosis are
prominent physical findings.
(B)
Chest film may reveal a right-sided paratracheal or mediastinal mass.
(C)
CT scan of the chest is diagnostic and helpful in defining disease extent, guiding biopsy attempts,
differentiating extrinsic caval compression from intrinsic obstruction, and planning radiation therapy.
(D)
Tissue diagnosis may be pursued during the treatment of the severely symptomatic patient. Attempts at tissue
diagnosis must be deferred in favor of urgent therapy.
(E)
Emergency treatment usually prompts administration of radiation therapy to the obstructing mediastinal mass.
Symptoms are ameliorated in 70% of cases.
(F)
Chemotherapy is given for patients with lymphoma or small cell lung cancer (SCLC), and simultaneously treats
overt or suspected metastatic disease. Radiotherapy can be given with chemotherapy for bulky tumors.
9
10
SVC suspect
(A)
CANNOT
take biopsy?
(D)
Highly
suspect
cancer?
Y
RT
2
02, Bed rest,
Upright,
IV line
11
3
Chest x-ray
PA-upright
12
Biopsy NOT
malignant?
14
Refer
13
SCLC?
4
Chest
mass?
RT (E) +
Chemotx
(F)
Y
15
16
Lymphoma
?
N
5
RT +
Chemotx
CT scan
N
17
18
NSCLC?
6
Chest
mass?
RT +/Chemotx
Y
N
19
20
Other
cancers
RT +/Chemotx
7
Refer
79
SPINAL CORD COMPRESSION (SpCC)

The management of SpCC must be multi-disciplinary & interdisciplinary, with each discipline respecting the
(A)
Recognition of incipient cord compression is essential because expeditious treatment at this stage
prevents irreversible neurologic injury. Neoplastic cord compression is almost always secondary to
extramedullary, extradural metastasis (most frequently from breast, lung, prostate, lymphoma, or
kidney). In 70% of cases, the thoracic spinal cord is most often involved. Almost all patients present
initially with neck or back pain, which may be central or radicular. Leg weakness, numbness, and
paresthesias follow; loss of sphincter control is a late event. Spine tenderness is common and neck
flexion or straight leg raising may provoke radicular pain. The specific neurologic findings depend on the
level of the cord lesion.
(B)
Plain film of the spine frequently demonstrates associated vertebral blastic or lytic lesions.
(C)
Corticosteroids are administered promptly to reduce peritumoral edema. Traditionally, dexamethasone 16

mg/day in divided doses is given.
(D)
MRI of the spine is the procedure of choice for detection and localization of cord compression.
Myelography may be employed if MRI techniques are not available. At the time of myelography, CSF
should be obtained for cytology.
(E)
Decompression laminectomy is indicated initially if: 1) a tissue diagnosis is required, 2) the cord
compression is in a previously irradiated area, 3) neurologic deterioration occurs during radiation therapy,
4) with radioresistant tumor, and/ or 5) with rapid evolution of paraplegia.
(F)
Radiation therapy alone is used for patients with: 1) radiosensitive tumors, 2) lesions below conus
medullaris, 3) slow onset of compression, 4) medical contraindications to surgery, 5) surgically
unapproachable disease. Patients treated initially with decompression laminectomy should also receive
post-radiation radiotherapy.
(G)
Chemotherapy may be considered for patients with chemosensitive tumors who can no longer benefit from
surgical intervention or radiotherapy.
1
Spinal cord
compression
suspect (A)
IV
dexamethasone
(C)
10
Laminectomy
done?
7
Bed rest;
IV line
13
Malignant?
14
MRI (D)
N
11
Highly
suspect
cancer?
Plain
film of
spine (B)
Tumor
lesion?
Refer
Y
15
N
4
9
Lytic/ blastic
bone lesions?
Need
urgent
RT?
12
Refer
16
Refer
Radiotherapy
(F)
N
N
5
MRI (D)
17
Chemotherapy
(G)
80
MALIGNANT PLEURAL EFFUSION

The management of malignant pleural effusion must be multi-disciplinary & interdisciplinary, with each
(A)
Malignant pleural effusions are exudative processes usually related to the presence of tumor cell implants
in the visceral or parietal pleura. Metastatic breast and lung cancer and lymphoma account for more than
75% of malignant pleural effusions. Sometimes the effusion is due to impairment of pleural lymphatic
drainage by mediastinal tumor. Symptoms of dyspnea, unproductive cough, and dull chest discomfort are
reported. PE includes decreased breath sounds and percussion dullness on the area of effusion. A
significant fraction of effusion is asymptomatic, however.
(B)
Significant pleural effusions are visible on chest radiographs. Lateral films confirm free-flowing fluid.
Ultrasonography differentiates fluid portion from tumor mass.
(C)
Diagnostic thoracentesis is required to confirm a malignant etiology. Large-volume thoracentesis can also
evaluate minimal to moderate fluid flow from the pleura.
(D)
For significant pleural effusions, a chest tube thoracostomy is done to drain fluid and for pleurodysis. Do
pleurodysis when drainage is <100 cc/day. If drainage is persistently >100 cc/day, indwelling chest
drainage tube may be maintained by the thoracic surgeon.
(E)
A large volume of fluid should be sent for cytologic analysis, pleural fluid chemistries (lactate
dehydrogenase, protein, glucose, pH levels), blood cell count, and cultures if needed.
(F)
In patients with negative cytology and in isolated exudative effusion (pleural fluid LDH>200, a pleural
fluid-to-blood LDH ratio>0.6, or protein ratio>0.5), high amylase, glucose >60, HCT >5% but <50%
ratio, predominantly small lymphocytes and mononuclear cells, pleural biopsy may not be indicated,
particularly if patient has history of cancer (Ca Hx).
(G)
In the absence of effective anti-neoplastic treatment, fluid accumulates a few days. Lasting control of
effusion is achieved by pleurodysis in 70-85%. Agents used for pleurodysis are tetracycline, doxorubicin,
or bleomycin.
(H)
Radiotherapy can be done for NSCLC, and for bulky chest tumors (lymphoma, malignant thymoma, germ
cell tumor).
(I)
Pleural effusions due to lymphoma, breast cancer, SCLC, malignant mediastinal germ cell tumor or
thymoma, often respond to chemotherapy.
1
6
Malignant
pleural effusion
suspect (A)
CTT (D)
13
With
cancer
cells?
Fluid cytology/
Exam (E)
O2; High back

rest; IV line
14
Drain
Pleurodysis
15
Radiotherapy
(H)
Ca Hx, HCT>5%<50%; glucose ratio

<60, high amylase,
>mononuclear cells?
CXR, PA Lateral
decubitus (B)
16
Chemotherapy (I)
4
Massive
fluid?
5
10
11
Pleural
biopsy (F)
Malignant?
N
Thoracentesis (C)
12
Refer
81
PAIN IN CANCER
Pain in cancer is a major problem in cancer management.
(A)
Pain assessment should include a complete neurologic examination and the patients description of
Site of pain
Quality of pain
Temporal pattern
Exacerbating and relieving factors
Exact onset
Associated signs and symptoms
Interference of activities
Impact on patients psychological state
Response to previous treatment and present treatment
(B)
Somatic pain results when nociceptors are activated in cutaneous/ deep tissues. It is typically well localized
and described as dull or aching. Examples are metastatic bone pain, post-surgical incisional pain,
musculoskeletal pain.
Visceral pain results from activation of nociceptors from infiltrates, compression, extension or stretching of
thoracic, abdominal or pelvic viscera. It is usually poorly localized, usually described as deep, squeezing,
pressure-like.
These two types of pain account for about 80% of pain problems in cancer patients.
(C)
Neuropathic pain results from injury to the peripheral or central nervous system as a consequence of tumor
compression or infiltration of peripheral nerve or spinal cord. It is usually intermittent and described as
burning or electric-shock-like sensation.
The adjuvant analgesic drugs are particularly useful in the treatment of this type of pain.
Trial of tricyclic antidepressant: Start with low dose and increase every 3-5 days if tolerated or
lengthen interval up to 14 days (e.g., nortriptyline 10-100 mg/day) AND/ OR
Trial of anticonvulsant: Start with low dose and increase every 3-5 days if tolerated or lengthen
interval up to 14 days (e.g., gabapentin 100-1200 mg tid; pregabalin 75 mg bid-tid up to 600
mg/day; carbamazepine 100-400 mg bid) AND/ OR
Consider topical anaesthetics or capsasin
If results are unsatisfactory after a 2-3 week trial, consider referral to pain expert or
anaesthesiologist/ neurosurgeon for an appropriate invasive procedure.
(D)
Drug therapy should be given to provide pain relief to patient as the cause of pain is being sought after or
when the pain is being treated by radiation/ chemotherapy/ surgery and has not yet produced the pain-free
state for the patient. When/ If the cause of pain is resolved thru radiotherapy, chemotherapy/ surgery,
analgesic drug therapy may be discontinued.
The general principles of drug therapy for pain relief are:
1) The drug should be given per orem, unless patient cannot take oral medication.
2) The drug should be given around the clock, not on pro re nata basis.
3) The drug should be given by the analgesic ladder recommended by WHO:
Non-opioid analgesic (paracetamol or NSAID) with or without adjuvant drug
If no relief, Give weak
opioid analgesic (codeine or tramadol HCl) +/- NSAID +/- adjuvant drug
If no relief, Give strong
opioid analgesic (morphine, oxycodone, fentanyl) +/- NSAID +/- adjuvant drug.
(E)
Paracetamol 650 mg every 4 hours; caution for liver toxicity. NSAID equivalent to ibuprofen 400 mg qid;
caution for renal/ GI toxicity and hypersensitivity. Selective COX-2 inhibitors are with lesser renal/ GI toxicity.
Patients high risk for renal toxicity age >60 years, compromised renal function/ concomitant renal pathology,
use of other nephrotoxic drugs; high risk for GI toxicity age >60 years, history of peptic ulcer disease, >
alcohol intake, major organ dysfunction, high dose NSAID intake for long periods.
Monitor for toxicities BP, BUN, creatinine every 3 months. Discontinue NSAID if with toxicity.
If two NSAID are tried in succession and no pain relief discontinue; use weak opioid.
(F)
Short acting Tramadol HCl 50 mg every 6-8 hours; may shift to long acting Tramadol HCl 100-300 mg every 12
hours with short acting form as rescue dose.
(G)
The appropriate opioid dose is the dose that relieves the patients pain throughout its dosing interval without
causing unmanageable side effects.
Calculate increase based upon total opioid dose (around the clock/ scheduled and as needed) taken in the
previous 24 hour.
Increase both around the clock and as needed doses. The rapidity of dose escalation should be related to the
severity of the symptoms:
83
For example:
Pain 7-10
Pain 4-6
Pain 1-3
Consider increasing dose by 50-100%

Increase by 25-50%
Increase by 25%
If patient is experiencing unmanageable side effects and pain is <4, consider downward titration by
approximately 25% and re-evaluate.
The following are approximate dose equivalents of opioids based on single dose data;
Opioid analgesic
Oral dose
Parenteral dose
Duration of action
Codeine
100 mg
50 mg
q 3-4 hours
Oxycodone
7.5-10 mg
N/A
q 3-4 hours
Morphine
15 mg
5 mg
q 3-4 hours
Transdermal fentanyl
N/A
50 mcg/h
q 48-72 hours
Consider converting from short-acting opioids to sustained release opioids for control of chronic persistent pain
when 24 hour opioid requirement is stable:
Sustained-release morphine sulfate tablet/ capsule every 8-24 hours.
Sustained-release oxycodone HCl tablet every 8-12 hours
Transdermal fentanyl patch every 48-72 hours
Provide rescue doses of short-acting opioids for pain not relieved by sustained-release opioids including acute
exacerbations of pain, activity, or position related pain or pain at the end of dosing interval:
Use short-acting form of the sustained release opioid whenever possible
Allow immediate-release rescue doses of 10-20% of 24-hour oral dose (mg) every 1 hour prn
The 24-hour adult morphine dose equivalent of transdermal fentanyl is 2 x ug/hour dose.
Increase dose of sustained release opioid if patient persistently needs doses of as needed opioids or when dose
of around the clock opioid fails to relieve pain at peak effect or at end of the dose.
Common side effects of opioid analgesics are:
Constipation Start stimulant laxative + stool softener (senna + docusate, 2 tablets every morning)
when opioids are started; increase dose if opioid dose is increased; increase fluids, dietary fiber,
exercise as appropriate. If constipation persists add bisacodyl 2-3 tabs po daily or 1 rectal
suppository daily/ lactulose 30-60 mL daily.
Nausea/ Vomiting Make antiemetics available with opioid prescription. If nausea develops, give
metoclopramide 10-20 mg po every 6 hours prn or around the clock for 1 week then change to prn.
Consider adding granisetron 1-2 mg IV then 1-2 mg po daily or ondansetron 8 mg IV then 8 mg po
tid or ramosetron 300 mcg IV then 100 mcg tab daily or tropisetron 5 mg IV then 5 mg po daily.
Consider ice chips, sour candies. Consider reduce opioid dose and add another analgesic.
Sedation Consider a lower dose of opioid given more frequently. Consider add caffeine 100-200
mg po every 6 hours. Consider co-analgesic to reduce opioid dose.
Delirium Consider changing the opioid or coanalgesic to reduce opioid dose.
Assure patient side effects may happen during the first 3-5 days of initial opioid use, but to persevere as this
can be transient.
(H)
The adjuvant analgesic drugs are used to increase the analgesic effects of the opioids to counteract their side
effects or to act as analgesics themselves. They include:
Antidepressants if depression persists despite improved pain control; the tricyclic anti-depressants
may be the most useful in pain management.
Anti-convulsants e.g., carbamazepine, pregabalin, clonazepam. The anti-depressants and anticonvulsants are not use only for their anti-depressant/ anti-convulsant effect, respectively, but they
in smaller doses also have primary analgesic effect, particularly for neuropathic pain.
Oral local anesthetics considered as second line drugs (with anti-depressants and anti-convulsants)
for neuropathic pain that has proven to be resistant to treatment
Try glucocorticoids for pain-associated with inflammation and or nerve compression.
For diffuse pain consider bisphosphonates.
Other adjuncts are the anti-histamines, anti-psychotics, amphetamines, laxatives, and anti-emetics.
Reassess the patient regularly and consider adjuvant therapy when patients pain is unrelieved by non-opioid or
opioid analgesics.
(I)
The pathologic process responsible for pain can be altered with radiotherapy, chemotherapy, hormonal therapy,
and even whole-body hyperthermia. It is important to note that palliative anti-tumor measures have definite
limitations related to efficacy, patient acceptance, side effects, and complications. The decision to pursue antitumor therapy does not imply that analgesic drugs and other supportive treatment should be discontinued.
(J)
Almost 80-90% of pain in cancer patients can be adequately controlled with drug therapy. The remainder may
be controlled with alternative modes of treatment, like psychological approaches (e.g., cognitive-behaviour
therapy, psychotherapy), anaesthetic and neuro-surgical approaches (e.g., nerve blocks, trigger point injection,
neuroablative procedures). All these need to be done by specialists.
Consider local radiation therapy or nerve block for local bone pain.
For resistant pain, consider anesthetic, orthopedic, or neuro-surgical approaches.
84
(K)
Intensity of pain can be assessed clinically by the following tools:

Categorical scales in which patients are asked to describe their pain as mild, moderate, severe or
excruciating.
Numerical scales in which patients are asked to rate their pain between 0-10, where 0= no pain and
10=worst pain.
Visual analogue scales in which patients are shown a 10-cm straight horizontal line. The line is
anchored on either end by two points no pain and worst possible pain and the patient is asked to
work on the line the intensity of the pain.
No pain /--------------------------------------------/ Worst possible pain
Relief of pain is measured by using a visual analogue scale, wherein a 10-cm straight line is anchored
on either end of two points no relief of pain and complete relief of pain. The patient is asked to
mark on the line the degree of pain relief.
No relief of pain /----------------------------------/ Complete pain relief
(L)
When there is pain recurrence after adequate control, two major considerations are:
Patient has become tolerant to drugs being given to him/ her.
There is progression of disease and/ or appearance of new causes of pain.
Careful and thorough reassessment is imperative. Constant reassessment of both diagnosis and treatment is a
must in the treatment of pain in cancer patients.
85
1
Pain in a
cancer patient
2
Assess type
of pain (A)
6
3
Somatic or
visceral
pain? (B)
Need addition
of other
modalities to
analgesic drug
therapy? (D)
Anti-tumor
therapy (I)
N
4
Pain
relief?
Neuropathic
pain (C)
N
9
5
Manage
accordingly;
Refer
Relieved by
non-opioid
analgesic? (E)
10
N
15
Relieved by
weak opioid
analgesic? (F)
Continue treatment
16
Pain
recurrence?
(L)
11
Relieved by
strong po opioid
analgesic? (G)
12
N
Reassess;
Consider
adjuvant
analgesic/s (H)
13
Pain relief?
(K)
N
14
Refer (J)
86
ANEMIA IN CANCER
Anemia is a major occurrence among cancer patients.
(A)
Anemia is defined as Hb <11 g/dL. Do CBC with indices, reticulocyte count, iron studies (serum iron, total iron
binding capacity, serum ferritin), B12/ folate, stool guaiac, LDH, fractionated bilirubin, bone marrow
examination, direct Coombs, Hb electrophoresis, creatinine and or creatinine clearance. Review peripheral
smear as needed.
(B)
Anemia can either be:

Non-cancer or non-cancer-treatment-related bleeding, hemolysis, nutritional deficiency, hereditary,
renal dysfunction, iron deficiency
Cancer or anti-cancer treatment related severity maybe:
o
Mild: Hb 10-11 g/dL
o
Moderate: Hb 8-10 g/dL
o
Severe: Hb <8 g/dL
(C)
Anemia may be symptomatic cardiac symptoms (chest pain, dyspnea on exertion, peripheral edema,
sustained tachycardia, orthostatic lightheadedness/ near syncope, syncope) and fatigue. Symptoms may be
more pronounced in presence of co-morbidities such as cardiac history/ decompensation, chronic pulmonary
disease, and cerebral vascular disease.
In symptomatic moderate to severe anemia, immediate correction with blood transfusion may be required,
particularly in frank bleeding. RBC transfusion is an option depending upon severity of anemia or clinical
circumstances.
Consider epoetin therapy to maintain Hb levels after BT.
In symptomatic Hb 10-11 g/dL, consider epoetin therapy;
In symptomatic Hb <10 g/dL, strongly consider epoetin therapy:
Epoetin
Epoetin alfa
Initial dosing
150 units/kg 3x weekly SC
Epoetin alfa
40000 units q week SC
Epoetin alfa
60000 units loading dose

SC than 120000 units q 3
weeks maintenance SC
450 units/kg weekly SC
(~10000 units per week
for a 70 kg person)
Epoetin beta
Titration for response

If Hb increase by > 1 g/dL
in a 2 week period, dose
should be reduced by 25%
If Hb exceeds 12 g/dL,
hold therapy. Re-initiate
therapy if Hb falls <12
g/dL at 25% dose
reduction of the prior dose.
-as above-
If after 4 weeks, no
response, double the dose.
If Hb increases by > 2 g/dL
in a months period, dose
should be reduced by 50%.
If Hb exceeds 14 g/dL,
hold therapy, until <=12
g/dL. Re-initiate therapy if
Hb falls <12 g/dL at 50%
reduction of the prior dose.
If Hb falls by > 1g/dL
during 1st cycle of
chemotherapy, then
epoetin therapy may be be
effective
Titration for no response

Increase dose to 300 units/kg
3 x weekly SC
Increase dose to 60000 units q

week SC
-
Double initial dose
Epoetin is recommended as treatment option for patients with chemotherapy-associated anemia and Hgb
concentration that has declined to <10 g/dL level
For patients with declining Hgb levels but less severe anemia (Hgb<12g/dL but never <10g/dL) decision
whether to use epoetin immediately or to wait until Hgb levels fall closer to 10g/dL should be determined by
clinical circumstances. Usually start epoetin when Hgb <10g/dL
Recommended starting dose is 150 U/kg 3xwk (~10,000 U for a 70 kg patient) for a minimum of 4 weeks, with
consideration given for dose escalation to 300 U/kg for an additional 4-8 weeks in those who do not respond to
the initial dose (Hgb has not risen by at least 1-2g/dL). An alternative weekly dosing regimen (30,000 U/wk
epoetin B) can be given; dose escalation similar to 3xwkly regimens.
87
Continuing epoetin tx beyond 6-8 weeks in absence of response (e.g., <1-2 g/dL rise in Hgb), assuming
appropriate dose increase has been attempted in non-responders does not appear to be beneficial. Patients
who do not respond should be investigated for underlying tumor progression or iron deficiency. Discontinue
medication.
Hg levels can be raised to (or near) a concentration of 12g/dL (10,11,12g/dL) at which time the dosage of
epoetin should be titrated to maintain that level or restored when the level falls to near 10g/dL. Decrease wkly
dose or hold dose until Hgb drops to target range & reinstitute at that time. Insufficient evidence to date
supports the normalization of Hgb levels to >12g/dL. Epoetin should be titrated once Hgb increase to
>12g/dL reduce dose or frequency of injections according to clinical situation. Baseline and periodic
monitoring of iron, total iron-binding capacity, transferrin saturation or ferritin levels and instituting iron
repletion when indicated may be valuable in limiting the need for epoetin, maximizing symptomatic
improvements for patients, and determining the reason for failure to respond adequately to epoetin.
EPOETIN (40)
Mean days of observation
114
Mean changes in max Hgb levels
3.3g/dL
% achieving >1g/dL Hgb increase
87.5%
% achieving >2g/dL Hgb increase
77.5%
Route of administration
SC/ IV
*Pujade-Lauraine E et al, Onco Reports, 2005
EPOETIN (42)
103
2.8g/dL
85.7%
66.7%
IV/ SC
(D)
Give oral iron supplementation if ferritin <100, transferrin saturation <20%. Iron will be needed as long as
epoetin therapy is being given.
(E)
Anemia may be asymptomatic. Risk factors for developing symptomatic anemia are:
Transfusion in past 6 months
History of prior myelosupressive therapy (e.g., BMT)
History of radiotherapy >20% of skeleton
Myelosuppression potential of current therapy duration, schedule, agents
Age (>= 65 years)
Hemoglobin level
If asymptomatic with no risk factor present, particularly in mild anemia, do close follow-up.
If asymptomatic with presence of risk factors, particularly in moderate to severe anemia, consider epoetin
therapy.
(F)
Favourable response from epoetin therapy is seen when Hb increases by 1 g/dL within 4 weeks. Titrate dosage
to maintain optimal Hb at 12 g/dL. If HB exceeds 12 g/dL, hold therapy. Re-initiate if Hb falls <12 g/dL at
25% dose reduction of the prior dose.
If there is no initial response is seen, increase dose of epoetin (+/- iron supplementation as indicated) aiming a
Hb increase by 1 g/dL at 8-12 weeks, then titrating dosage to maintain optimal Hb at 12 g/dL. If Hb level stays
within 1-2 g/dL of baseline while receiving chemotherapy, continue epoetin therapy. If there is no Hb response
at 8-12 weeks, discontinue epoetin therapy, give BT as needed, delay chemotherapy cycles/ radiotherapy, and
reduce next chemotherapy dosages accordingly or consider change chemotherapy regimen.
(G)
Periodic re-evaluation for symptoms and risk factors for anemia development at every visit. If Hb levels
decreases, check for iron stores and evaluate for development of other anemia specific causes.
88
Anemia in a
cancer patient (A)
4
Cancer/ anticancer
treatment
related? (B)
5
With
symptoms?
(C)
6
Need
immediate
correction?
Transfuse;
Manage cause
N
N
Consider epoetin
therapy to maintain
Hb levels
3
Manage
accordingly;
Refer
8
11
With risk
factors? (E)
12
Consider
epoetin
therapy
Give iron
supplements
as needed (D)
17
N
9
13
Moderatesevere
anemia?
10
Favourable
response?
(F)
Titrate epoetin
therapy; maintain
Hb 12 g/dL
N
14
Close follow-up;
Assess for
presence of
symptoms
Increase
epoetin
dose
15
18
Favourable
response
within 8-12
weeks? (F)
Close
follow-up
(G)
N
16
Discontinue epoetin
therapy; Consider BT;
Delay chemotx/ RT;
Reduce chemotx
dosage/ Change
chemotx
89
CHEMOTHERAPY-INDUCED NEUTROPENIA
Neutropenia can occur among cancer patients receiving chemotherapy and radiotherapy.
(A)
Chemotherapy for cancer particularly high dose, dose dense, as well as standard dose therapy) can cause
neutropenia. Neutropenia of significant medical concern is neutrophils/mcL of <500 or <1,000 neutrophil/mcL
and a predicted decline to <=500 mcL over the next 48 hours.
There are patient risk factors for chemotherapy-induced neutropenia (in adult patients with solid tumors and
non-myeloid cancers), wherein prophylaxis with myeloid growth factors can be considered, so that the
scheduled chemotherapy cycle will be given on time on planned dose:
Treatment-related:
o
Previous history of severe neutropenia with similar chemotherapy
o
Type of chemotherapy (e.g., anthracycline)
o
Planned relative dose intensity >80%
o
Pre-existing neutropenia (<1000) or lymphocytopenia
o
Extensive prior chemotherapy
o
Concurrent or prior radiation therapy to marrow containing bone
Patient-related:
o
Age (>65 years)
o
Female gender
o
Poor performance status (ECOG >=2)
o
Poor nutritional status (e.g., low albumin)
o
Decrease immune function
Cancer-related:
o
Bone marrow involvement with tumor
o
Advanced or uncontrolled cancer
o
Elevated lactate dehydrogenase (Lymphoma)
o
Lymphoma
o
Lung cancer
Conditions associated with risk of serious infection:
o
Open wounds
o
Active tissue infection
Co-morbidities:
o
COPD
o
Cardiovascular disease
o
Liver disease (elevated bilirubin, alkaline phosphatase)
o
Diabetes mellitus
o
Low baseline haemoglobin
Give prophylaxis myeloid growth factors in the presence of the above risk factors particularly when the
treatment intent is curative/ adjuvant, prolonging survival/ QoL.
If myeloid growth factors are not available accessible then chemotherapeutic dose is reduced and or delayed
for 1 week upon re-evaluate of WBC counts.
(B)
Such neturopenia can be accompanied by fever single temperature >=38.3oC orally or >=38.0oC over 1 hour
(so-called febrile neutropenia). In presence of fever, evaluation is focused on determining potential sites of
infection and causative organisms septic work-up and referable to an infectious disease expert.
(C)
There is level 1 evidence to support the CSF or myeloid growth factor filgrastim or pegfilgrastim for the
prevention of febrile neutropenia; these can also be used for maintenance of scheduled dose delivery:
Filgrastim daily subcutaneous dose of 5 mcg/kg (rounded to nearest vial size) until post-nadir ANC
recovery to normal or near-normal levels by laboratory standards
Pegfilgrastim 1 dose of 6 mg per cycle; start 1-3 days after completion of chemotherapy and treat
through post-nadir recovery. This is for chemotherapy given every 3 weeks.
90
1
Cancer patient for
chemotherapy
2
3
High-risk for
chemotherapyinduced
neutropenia? (A)
5
CSF available/
accessible?
8
Still develops
next cycle
neutropenia?
Plan & choose

chemotherapy
reducing
potential
neutropenia
event
Prophylactic
CSF (C)
Dose reduction
or Change
chemotherapy
regimen
N
Continue CSF
every cycle of
chemotherapy;
Close follow-up
12
11
Develops
neutropenia
during
chemotherapy?
With
fever? (B)
Manage as with
Infection; Septic
work-up;
Empiric
antibiotic; Refer
N
13
N
10
14
CSF available/
accessible?
Continue
chemotherapy;
Close follow-up
15
Give CSF
(C)
N
17
Reduce
chemotherapy dose
or delay; Plan next
cycle accordingly
16
Still with next
cycle
neutropenia?
Change
chemotherapy
regimen
N
18
Continue CSF every
cycle of
chemotherapy;
Close follow-up
91
CHEMOTHERAPY-INDUCED EMESIS
Emesis is a common and bothersome complication of chemotherapy.
(A)
From the cancer patients point of view, nausea and vomiting are the most distressing complications of
chemotherapy.
Three types of chemotherapy-induced emesis are: 1) acute emesis occurs soon after drug administration, 2)
delayed emesis begins about 24 hours after chemotherapy administration and may persist for 6-7 days, and
3) anticipatory emesis occurs in anticipation of a subsequent course of treatment usually when there has
been poor emetic control during previous course/s.
The principles of emesis treatment are:
Assess for and treat underlying cause
Use of anti-emetics
If unresponsive assess for psychological factors, reassess for missed physical causes, and try
different anti-emetics and/ or combinations.
Commence anti-emetic drug use before the vomiting starts:
in adequate doses,
in combination if necessary and
by parenteral or rectal route if necessary.

The patient should eat only lightly; treatment environment should be quiet and reassuring.
(B)
Antineoplastic drugs differ quantitatively and qualitatively in their emetogenic potential: 1) High (e.g.,
cisplatin), 2) Moderate (e.g., cyclophosphamide), and 3) Low (e.g., methotrexate). Emetogenic potential
increases in combination therapy.
Emesis can begin 4-6 hours post-chemotherapy and can last up to 5 days, or can also begin 3-4 days postchemotherapy and can last up to 5 days, or can occur bi-phasically hours after and then again days after.
(C)
5-HT3 receptor antagonists are more effective anti-emetic agents than metoclopramide. These are
granisetron, ondansetron, and ramosetron. Choose an agent wherein the per orem and the parenteral forms
are both available and accessible; in instances wherein frank vomiting occurs, the parenteral form is the
preferred drug.
Adjunct anti-emetic drugs such as diphenhydramine, lorazepam, and dexamethasone can be used particularly
in highly emetogenic drug/s administration, moderate-severe emesis, and anticipatory emesis.
Start parenteral anti-emetic pre-medication 1-2 hours (not less then 30 minutes) prior chemotherapy
administration in all anticancer chemotherapy administration sessions.
Delayed nausea and vomiting occurring more than 24 hours after therapy is treated with anti-emetics for a
further 2 or more days. Maintenance anti-emetic can be in the per orem form.
Conditioned or anticipatory emesis is managed by giving pre-medications with anti-emetics and anxiolytics
(e.g., lorazepam), starting the night before chemotherapy, either given per orem (when at home) or parenteral
(when in hospital).
Relaxation and distractions such as television may be of benefit. Ice chips, mentholated or sour candies may
be of benefit.
(D)
Emesis in a cancer patient can also be caused by a variety of other conditions that one should always consider
before beginning anti-emetic treatment and when reassessing the patient for persistent emesis. The majority
of patients with advanced disease will suffer nausea and vomiting at some stage of their illness. The anticancer dugs can also be stopped and the patient given time to recover. Then alternative drugs can be chosen
with less emetogenic potential.
92
1
Cancer patient given
emetogenic anticancer drug/s (A)
3
Low emetogenic
potential? (B)
Metoclopramide OR
5-HT3 antagonist (C)
Add
Dexamethasone
Still with
N&V?
N
5
7
Close
followup
Add Lorazepam OR
Dihenhydramine
Still with
N&V?
11
N
10
Close
followup
14
13
Moderate
emetogenic
potential?
Still with
N&V?
Metoclopramide +
Dexamethasone +
Lorazepam
12
Reassess
patient (D)
N
Close follow-up
15
Still with
N&V?
17
5-HT3 antagonist
N
16
18
Close
followup
20
Still with
N&V?
26
24
High emetogenic
potential?
19
5-HT3 antagonist +
Metoclopramide +
Dexamethasone +/Lorazepam +/Diphenhydramine
Add
Dexamethasone
+ Lorazepam
22
21
Close
followup
Still with
N&V?
Reassess
patient
25
23
27
Close
follow-up
Close
follow-up
Still with
N&V?
28
N
29
Close
follow-up
Reassess
patient
93

PCSI Tertiary Cancer Treatment Guidelines (2014)

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PCSI Tertiary Cancer Treatment Guidelines (2014)

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TERTIARY PREVENTION OF CANCER:

CLINICAL TREATMENT GUIDELINES

Primary Cancer Sites

If adjuvant chemotherapy is indicated, RT should be given after chemotherapy is completed. Radiotherapy is

Tumor size >= 1.0 cm or w/

stage by TNM classification

Irradiation is used to achieve:

Drug therapy for cancer is the responsibility of the Medical Oncologist.

Chemo +/RT (L)

The lymphoma is widespread in an organ or organs or skin including bone

A without weight loss/fever/sweats

Treatment should be considered in patients:

eligible for a clinical trial and

Stage Ie-II Stage III-IV

localized to one area of the body.

Chemotx (6-8 cycles)

Chemotx (6-8) + Rituximab

Treat like diffuse

Treat like follicular

UNRESECTABLE HEAD AND NECK CANCER

Biopsy or Review of Slides;

Best Supportive Care/

Best Supportive Care/

Best Supportive Care/

NASOPHARYNGEAL CARCINOMA (NPCA)

Nasopharyngoscopy with a nasopharyngeal mirror or via fiber optic nasopharyngoscope is mandatory.

Stage IVB Any

Tis Carcinoma-in-situ N0M0

NPCA suspect (A)

CANCER OF THE ESOPHAGUS

T1N0M0, tumor invades lamina propia or submucosa

Tumors of the upper thoracic esophagus:

metastasis in celiac LNs

Resectable T4 involvement of pleura, pericardium or diaphragm; unresectable T4 invasion of aorta, trachea,

Chemoradiotherapy is the preferred modality for cervical esophageal carcinoma.

Assessment >=4 weeks, endoscopy with biopsy and brushings

Low risk for

Close followup (I)

Close followup (I)

GASTRIC (STOMACH) CARCINOMA

Criteria for unresectability for cure are:

Surgery is the standard modality of treatment. The surgery procedures are:

R classification refers to amount of residual cancer remaining after tumor resection:

Concurrent ChemoRT or Chemotherapy (I) or

Close follow-up (K)

COLON RECTUM CANCER

More than 90% of colorectal cancers are adenocarcinomas.

Regional Lymph Node (N)

The roles of radiotherapy in rectum cancer are:

Completely removed with

Colectomy with en bloc removal

Colectomy, liver metastasectomy

Consider limited colon resection

Colectomy and lung

Close followup (I)

Low risk for obstruction

Colectomy with en bloc

Consider colon resection

Rectal exam (B)

PRIMARY HEPATOCELLULAR CARCINOMA (HCC)

Patient is not a liver resection candidate

Best Supportive Care +/Definitive Treatment (G)

Criteria for resectability:

Radiation therapy is indicated as: