Oncology for Family Medicine Residents Module 1: Workup of Suspected Malignancy Anna N Wilkinson, MD, MSc, CCFP

1.Work up of suspected malignancies 2.Oncology Basics Chemotherapy and Radiation Therapy 3.Oncology Emergencies 4.Survivorship care Ongoing monitoring of patients and management of sfx treatment and longer term drugs Objectives

 Family Physicians are first line for workup of malignancy  Patients may present to primary care with signs or symptoms prompting diagnosis of already metastatic cancer  Patients continue to see their family physician during treatment  Patients present to ER with acute complications of malignancy or treatment  Some emergencies are reversible, or morbidity minimised if treated promptly  Patients value their relationship with their FP and often seek their advice to assist in decision making  More and more survivorship care the responsibility of FPs Why do I need to know about Oncology???

 High Index of Suspicion  Once a Cancer Patient Always a Cancer Patient

Lung Prostate Colon Breast Work up of Suspected Malignancies

Workup of Lung ca

Mr X is a 72 yo male with a 50 pack year smoking history. He presents to your office with a non- resolving cough and 15 lbs weight loss over the last 3 months. Given his smoking history, you order a chest xray. Case #1

Chest X Ray

 Physical Exam  Labs  CBC, electrolytes, Cr, Ca, Albumin, LDH, LFT’s, INR  CT chest (with contrast)  Referral to rapid assessment centre if possible Next Steps

CT Thorax

 Tissue Diagnosis  Referral Next Steps

 Any suspected malignancy requires tissue confirmation, pathology will dictate treatment options  Tissue may be obtained via Mediastinoscopy Endoscopy Endobronchoscopy Percutaneous FNA  Consider obtaining biopsy through Radiology, Respirology Thoracics, or Cancer Assessment Centre, depending on local resources Tissue Diagnosis

 Fine Needle Aspiration  Two essentials: Prior imaging (CT ) Blood work: INR and Platelets Lung Biopsy

FNA of lung lesion: “Abnormal cells with enlarged hyperchromatic nuclei and scant cytoplasm are present. Findings are consistent with a small cell carcinoma.” Pathology

 Blood Work CBC, electrolytes, LFT’s, Ca, Alb, LDH, Cr, INR  Pulmonary Function Testing (PFT’s)  Imaging Chest: CT Chest Abdomen: CT Abdomen Brain: CT or MRI Bone: Bone Scan or MRI axial skeleton PET/CT (oncology to order, if no evidence of metastatic disease on workup) Initial Evaluation of a Patient with Lung Cancer

Abdomen CT

 CT is easy to obtain and good screening technique  CT with contrast  MRI may be better if there is consideration of Leptomeningeal disease Cranial nerve involvement MRI vs CT brain

CT Brain

Mr. X is seen by medical oncology and found to have extensive small cell lung cancer. He is treated with cisplatinum/etoposide chemotherapy x 4 cycles, initially with good response. He also undergoes XRT for brain met. He declines after a further 3 months, and you provide palliative care for him at home until his death. Case Resolution

Workup of Prostate ca

 Mr. P, a 65 yo male, comes to you for his Periodic Health Exam. You detect a hard nodule on the superior aspect of his prostate. He endorses some mild urinary symptoms, including frequency and nocturia. He has no other systemic symptoms. Case #2

 Blood work  PSA, Cr, CBC, Ca, Alb, LFTs  PSA 21.4 ng/mL  Imaging/Biopsy What Should You Do Next?

 Do I need imaging prior to biopsy? No imaging is needed  Who does the biopsy? Ultrasound guided by Urology or Radiology Consider Cancer Assessment Centre if available Prostate Biopsy

Anticoagulation Management Avoid Aspirin, Advil, Ibuprofen for 5 days prior Coumadin- d/c 5 days prior and bridge with LMWH NOACs- stop 2-3 days prior and restart 2 days post Prophylactic Antibiotic Cipro 500mg bid at the day of the biopsy, duration 1-3d Preparation Fleet enema, available over the counter, 2 to 3 hours prior Light meal only prior to the appointment 2 hours total at the hospital Arrange for a ride home. Post biopsy 48 hours following biopsy, no heavy lifting or strenuous activity. Expect some blood with urine and stool for up to 3 days If febrile within 1 week post procedure seek medical attention Trans-rectal Prostate Biopsy

Core Biopsy: “Adenocarcinoma, Gleason 4+3 = 7” Biopsy Results

 Tumour Size  T1: Tumour not palpable and not visible with imaging  T2: Tumour confined within prostate  T3: Tumour extends through prostatic capsule  T4: Tumour is fixed or invades adjacent structures  Nodes  N0: no regional lymph node metastases  N1: Metastases in regional nodes  Metastases  M0: No metastases  M1: Distant metastases Staging of Prostate Cancer

 Life expectancy <5yrs and no clinical sx: no further workup  Life expectancy >5 yrs or symptomatic: staging appropriate Bone Scan if:  T1 + PSA > 20 or T2 + PSA >10  Gleason ≥ 8  T3 or T4  Symptomatic MRI Pelvis if:  T3 or T4 disease  T1 or T2 disease with high risk of nodal involvement Staging of Prostate Cancer

Pelvis MRI Bone Scan If equivocal consider MRI Urology/ Radiotherapy consult

 PSA  CT abdomen  MRI Pelvis  Bone Scan Staging Investigations

 CT Abdomen/Pelvis helpful for evaluation of lymph nodes  MRI pelvis for local staging to determine presence of extra-prostatic spread CT Pelvis vs MRI Pelvis

Palpable nodule: T2 Gleason: 7 PSA: 21.4 Therefore MRI, Bone Scan ordered Staging- Mr. P.

MRI

Wilkinson et al, Can Fam Physician Feb; 54(2): 204–210.

Mr P is treated with a radical prostatectomy. 5 years later, his PSA remains undetectable. Case Resolution

Workup of Colon ca

 Mr. C has a positive FOBT test. You refer him for colonoscopy and a mass is biopsied and found to be an adenocarcinoma. What are your next steps? Case #3

 Colonoscopy due to positive FOBT or clinical concern  Once malignancy confirmed from colonoscopy bx  CBC, chemistry profile, CEA  Chest/abdominal/pelvic CT  Tumour (T) and Nodal (N)data from post operative pathology  Referral  Cancer assessment centre, surgical oncologist, medical oncology Work up of Colon Cancer

 You order the appropriate lab and imaging for Mr C and refer him to the Cancer Assessment Centre in your area. He goes on to have a hemicolectomy and remains disease free post procedure. Case Resolution

Workup of Breast ca

 Mrs. B presents to your clinic with a breast lump. On physical exam you confirm the 1 cm breast lump, and palpate no axillary nodes. What are your next steps? Case #4

 Early stage disease vs. locally advanced or inflammatory breast ca???  Early breast cancer:  Mass <5cm  Ipsilateral nodes may be present, but freely mobile  Locally advanced breast cancer:  Mass > 5 cm  Growing into the skin or chest wall  Present in ipsilateral axillary lymph nodes, nodes fixed or matted Breast Cancer Workup

 Clinically Stage 1-2: (tumours <5cm, or smaller with mobile axillary nodes)  Physical Exam  Diagnostic bilateral mammogram, ultrasound as necessary  Blood work: cbc, LFT, ALP  Bone Scan if symptoms  CT C/A/P if symptoms present only Diagnostic Workup for Breast Cancer- Early Stage Disease

 Biopsy if suggested by imaging results  Referral to Breast Surgeon or Cancer Assessment Centre if positive pathology Diagnostic Workup for Breast Cancer- Early Stage Disease

Locally Advanced or Inflammatory Breast Cancer Clinically Stage 3- (tumour >5cm, +axillary nodes) Locally Advanced Breast cancer Inflammatory Breast Cancer

 Biopsy  Rapid Referral  Staging Investigations  CBC, LFT, ALP  Chest CT  Abdominal/Pelvic CT  Bone Scan Diagnostic Workup for Breast Cancer- Locally Advanced or Inflammatory

 Mrs. B had reassuring imaging which showed a breast cyst only. You aspirated the cyst successfully, and continued with her regular screening mammograms. Case Resolution

Workup of Unknown Primary

Mrs Y, a 63 yo woman, comes to your office with symptoms of vague abdominal pain, low energy and unintentional weight loss of 10 lbs over the last two months. Case #2

 ROS otherwise negative  PMHx: 2 C-sections, hypertension  Meds: Altace 10mg od  Fam Hx: father prostate ca  Physical Exam: Normal with the exception of vague discomfort periumbilically  You order ultrasound abdomen/pelvis to further assess Physical

 Liver lesion 1.7 cm, suspicious for malignancy, small amount of ascites Ultrasound

Liver Lesion

 Complete hx/px Breast, pelvic, rectal, skin, adenopathy  Labs  Imaging CT Abdomen/Pelvis  Biopsy Liver Lesion What is next?

 Solitary hepatic lesion with features suggestive of metastasis CT Abdomen

Requirements pre-biopsy Prior CT or MRI INR and platelets Stop anticoagulation 6 hrs NPO prior to procedure Post-biopsy Arrange for a ride home No heavy lifting or strenuous activity for 48 hours following biopsy Deep Organ Biopsy

FNA of liver lesion: “Poorly differentiated adenocarcinoma, immunohistochemical results non diagnostic” Pathology Results

Symptom oriented workup Use pathology to guide investigations Lab Tumor Markers: BHCG, AFP, PSA, CA125, CA19-9, CEA urine cytology Imaging CT head CT Chest/Abdomen/Pelvis Mammogram Testicular ultrasound (in male with retroperitoneal mass) Bone scan Workup of Unknown Primary

 Procedures (if applicable)  Colonoscopy  Endoscopy  Cystoscopy  Thoracentesis  Paracentesis  Excisional biopsy if amenable lesion  Referral to Medical Oncology Workup of Unknown Primary

After extensive workup, Mrs. Y is diagnosed as cancer of unknown primary. She is treated with multiple lines of palliative chemotherapy. Case Resolution

 Wilkinson et al, Can Fam Physician Feb; 54(2): 204–210  References

 Cancer Care Ontario   National Comprehensive Cancer Network   BC Cancer Agency  Resources