2. Cancer Incidence and Diagnosis Dr. Reham Abdulmonem A. Consultant Radiation Oncology KFMC, PSHOC Lecturer Radiation Oncology NCI, Cairo University

3. Radiotherapy Applications RAD 462

4. Course Description This course is designed to provide the student with clinical aspects of radiation oncology as well as techniques used for simulation and treatment delivery. Site specific topics will include brain, head & neck, lung, breast, pelvis and lymphoma.

5. Educational Goals By the end of this course you will be able to: Discuss the patient’s progress from the first indication of serious illness, to diagnostic and surgical work-up, to referral, treatment and follow-up in the radiation oncology department. Discuss the factors influencing the choice of management tools of cancer patient.

6. Educational Goals (cont.,) Explain principles and applications of radiotherapy in the treatment of tumors of the following anatomical system/sites: CNS, head and neck, breast, lung, bladder, rectum, and lymphoid tissue. Describe patient care during RT and the side effects of RT on different body organs and tissues.

7. Educational Goals (cont.,) Identify simple simulation and localization procedures. Identify simple treatment procedures. Describe the steps and materials involved with formation of shielding blocks. Apply principles of radiation protection. Demonstrate professionalism through personal appearance and behavior.

8. Evaluation Your course grade will be based on the following: 40Two mid term exam (W6-W11) 1 15Lab assignment*2 5Course project3 40Final Exam4 100Total * Visits to Radiation Oncology Department

9. References Water and Miller’s: Textbook of Radiotherapy. Gunilla C. Bentel: Radiation Therapy Planning: Faiz M. Khan: Treatment Planning in Radiation Oncology.

10. USA Mortality at 2006 1.Heart Diseases685,089 28.0 2.Cancer556,902 22.7 3.Cerebrovascular diseases157,689 6.4 4.Chronic lower respiratory diseases126,382 5.2 5.Accidents (Unintentional injuries)109,277 4.5 6.Diabetes mellitus 74,219 3.0 7.Influenza and pneumonia 65,163 2.7 8.Alzheimer disease 63,457 2.6 9.Nephritis 42,453 1.7 10.Septicemia 34,069 1.4 RankCause of Death No. of deaths % of all deaths

11. Change in the US Death Rates* by Cause, 1950 & 2003 1950 2003 Rate Per 100,000 Heart Disease Cerebro-vascular Pneumonia-influenza Cancer

12. 2006 Estimated US Cancer Deaths* ONS=Other nervous system. Source: American Cancer Society, 2006. Men 291,270 Women 273,560 26%Lung & bronchus 15%Breast 10%Colon & rectum 6%Pancreas 6%Ovary 4%Leukemia 3%Non-Hodgkin lymphoma 3%Uterine corpus 2%Multiple myeloma 2%Brain/ONS 23% All other sites Lung & bronchus31% Colon & rectum10% Prostate9% Pancreas6% Leukemia4% Liver & intrahepatic4% bile duct Esophagus4% Non-Hodgkin 3% lymphoma Urinary bladder3% Kidney3% All other sites 23%

13. Cancer Death Rates*, for Men, US,1930- 2002 Lung Colon & rectum Stomach Rate Per 100,000 Prostate Pancreas LiverLeukemia

14. Cancer Death Rates*, for Women, US,1930- 2002 Lung Colon & rectum Uterus Stomach Breast Ovary Pancreas Rate Per 100,000

15. 2006 Estimated US Cancer Cases* Men 720,280 Women 679,510 31%Breast 12%Lung & bronchus 11%Colon & rectum 6%Uterine corpus 4%Non-Hodgkin lymphoma 4%Melanoma of skin 3% Thyroid 3%Ovary 2%Urinary bladder 2%Pancreas 22%All Other Sites Prostate33% Lung & bronchus13% Colon & rectum10% Urinary bladder6% Melanoma of skin5% Non-Hodgkin4% lymphoma Kidney3% Oral cavity3% Leukemia3% Pancreas2% All Other Sites18%

16. * For those free of cancer at beginning of age interval. Based on cancer cases diagnosed during 2000 to 2002. Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan Lifetime Probability of Developing Cancer, by Site, Men, 2000-2002* † All Sites exclude basal and squamous cell skin cancers and in situ cancers except urinary bladder. SiteRisk All sites † 1 in 2 Prostate 1 in 6 Lung and bronchus1 in 13 Colon and rectum1 in 17 Urinary bladder ‡ 1 in 28 Non-Hodgkin lymphoma1 in 46 Melanoma1 in 52 Kidney1 in 64 Leukemia1 in 67 Oral Cavity1 in 73 Stomach1 in 82 ‡ Includes invasive and in situ cancer cases

17. Lifetime Probability of Developing Cancer, by Site, Women, US, 2000-2002* SiteRisk All sites † 1 in 3 Breast 1 in 8 Lung & bronchus 1 in 17 Colon & rectum 1 in 18 Uterine corpus 1 in 38 Non-Hodgkin lymphoma 1 in 55 Ovary 1 in 68 Melanoma 1 in 77 Pancreas 1 in 79 Urinary bladder ‡ 1 in 88 Uterine cervix 1 in 135

18. Five-year Relative Survival (%)* during Three Time Periods By Cancer Site Site1974-1976 1983-1985 1995-2001 All sites505365 Breast (female)757888 Colon 505864 Leukemia344148 Lung and bronchus121415 Melanoma808592 Non-Hodgkin lymphoma475460 Ovary3741 45 Pancreas33 5 Prostate6775100 Rectum495565 Urinary bladder737882 †

19. Cancer Incidence Rates* in Children 0-14 Years, by Site, 1998-2002 SiteMaleFemale Total All sites15.6 14.3 15.0 Leukemia 4.9 4.2 4.6 Acute Lymphocytic 3.9 3.4 3.6 Brain/ONS 3.6 3.3 3.5 Soft tissue 1.1 0.9 1.0 Non-Hodgkin lymphoma 1.2 0.6 1.0 Kidney and renal pelvis 0.8 1.0 0.9 Bone and Joint 0.6 0.6 0.6 Hodgkin lymphoma 0.6 0.5 0.5

20. Cancer Death Rates* in Children 0-14 Years, by Site, US, 1998-2002 SiteMaleFemale Total All sites 2.7 2.3 2.5 Leukemia 0.8 0.7 0.8 Acute Lymphocytic 0.4 0.3 0.4 Brain/ONS 0.8 0.7 0.7 Non-Hodgkin lymphoma 0.1 0.1 0.1 Soft tissue 0.1 0.1 0.1 Bone and Joint 0.1 0.1 0.1 Kidney and Renal pelvis 0.1 0.1 0.1

21. Screening Guidelines for the Early Detection of Breast Cancer, American Cancer Society  Yearly mammograms are recommended starting at age 40.  A clinical breast exam should be part of a periodic health exam, about every three years for women in their 20s and 30s, and every year for women 40 and older.  Women should know how their breasts normally feel and report any breast changes promptly to their health care providers. Breast self-exam is an option for women starting in their 20s.  Women at increased risk (e.g., family history, genetic tendency, past breast cancer) should talk with their doctors about the benefits and limitations of starting mammography screening earlier, having additional tests (i.e., breast ultrasound and MRI), or having more frequent exams.

22. Screening Guidelines for the Early Detection of Cervical Cancer, American Cancer Society  Screening should begin approximately three years after a women begins having vaginal intercourse, but no later than 21 years of age.  Screening should be done every year with regular Pap tests or every two years using liquid-based tests.  At or after age 30, women who have had three normal test results in a row may get screened every 2-3 years. However, doctors may suggest a woman get screened more frequently if she has certain risk factors, such as HIV infection or a weakened immune system.  Women 70 and older who have had three or more consecutive Pap tests in the last ten years may choose to stop cervical cancer screening.  Screening after a total hysterectomy (with removal of the cervix) is not necessary unless the surgery was done as a treatment for cervical cancer.

23. Screening Guidelines for the Early Detection of Colorectal Cancer, American Cancer Society Beginning at age 50, men and women should follow one of the following examination schedules:  A fecal occult blood test (FOBT) every year  A flexible sigmoidoscopy (FSIG) every five years  Annual fecal occult blood test and flexible sigmoidoscopy every five years  A double-contrast barium enema every five years  A colonoscopy every ten years

24. Screening Guidelines for the Early Detection of Prostate Cancer, American Cancer Society The prostate-specific antigen (PSA) test and the digital rectal examination (DRE) should be offered annually, beginning at age 50, to men who have a life expectancy of at least 10 years. Men at high risk (African-American men and men with a strong family history of one or more first-degree relatives diagnosed with prostate cancer at an early age) should begin testing at age 45. For men at average risk and high risk, information should be provided about what is known and what is uncertain about the benefits and limitations of early detection and treatment of prostate cancer so that they can make an informed decision about testing.

25. Diagnosis

26. Clinical Presentations Warning Signs of Cancer

27. Diagnostic Workup Purpose: Confirm diagnosis Determine the disease stage, Information required for treatment decision.Methods: History, Examination: General and Local Investigations: Laboratory, Medical Imaging, Endoscopies, and Pathological.

28. Biopsy Importance: Confirm diagnosis (the single most). Histopathologic type: Cararcinoma, sarcoma, lymphoma,.. etc. Grading of cancer: Degree of malignancy (grade 1-4), Therapeutic and prognostic implicationsTypes: Needle, incisional or excisional.

29. Medical Imaging Purpose: –Determine the extent of local disease, –Involvement of regional nodes, and –Presence or absence of distant metastases.Include: –Chest x-ray film, –Mammogram, –Radionuclide scan, –Ultrasonography, –Computed Tomography, –Magnetic Resonance Imaging, –Positron Emission Tomography.

30. Staging Classification Characteristics of workable classification: Useful in making therapy decision, Prognostic implication, Help in evaluating treatment results, Ease with exchange of information. Tumor-node-metastasis (TNM) system. T: primary tumor extension, N: lymphatic involvement, M: distant metsatsis.

31. Diagnosis History Physical Examination Pathology Genetics Tumor Markers Radiological imaging Blood work

32. History of present illness Past Hx (Past Cancer,Sx,CTx,Rx) Family history Gynacological history Social history

33. SymptomsCancer HA,Motor & Sensor dysfunction,Seizure,cognitive dysfunction,Ataxia,gaitCNS Lump, Nipple discharge, Axillary lumpBreast Chest pain, cough, Haemoptysis, SOBLung Pain, constipation, Diarrhea, BleedingColorectal Pain, Haematemesis, VomittingGastric Dysphagia, odynophagai, coughEsophagus Vaginal bleeding, pain,cervix Hearing loss, Neck mass, nasal obstruction, EpistaxisNasopharynx Hoarseness, Sore throat, Otalgia, pain,SOB,larynx Haematuria, dysuria, UrgencyBladder Lump, fatigue, Itching (B symptoms, Fever, Weight loss, sweating)Lymphoma

34. General ( weight, vital sign, appearance, skin, sign of anaemia ) Lymphatic system Breast Respiratory system CVS GYN system RECTAL CNS Head & Neck

36. CBC Ca, Mg, Ph,.. ) ) Eletrolyte RFT LFT Hormones Virology Titer

37. Benign conditionsOther TumorsPrimary TumorTumor Marker Cirrhosis, Viral hepatitis, pregnancy Gastric, biliary, and pancreaticHCCa and nonseminomatous germ cell tumors AFP Ankylosing spondylitis, Reiters syndrome Other B Cell neoplasms, lung, hepatoma, breast Multiple myelomaB-2 microglobulin Menstruation, pregnancy, fibroid, ovarian cysts, cirrhosis, ascites, endometriosis Endometrial, Fallopian tube, breast, lung, esophageal, gastric, hepatic, pancreatic ovarianCA125 Benign breast or ovarian disease, endometriosis, hepatitis, pregnancy, lactation Ovary, lung, prostateBreastCA15-3 Pancreatitis, biliary disease, cirrhosis Colon, esophageal, hepaticPancreatic, biliary tractCA19-9 Breast, liver, kidney disorders, ovarian cysts Colon, gastric, hepatic, lung, pancreatic, ovarian, prostate BreastCA27.29 Zollinger-Ellision syndrome, pernicious anemia,chronic renal, pregnancy Metastatic breast, lung, pancreas, hepatoma, renal cell, carcinoid Medullary Thyroid Calcitonin Paget’s disease, osteoporosis, cirrhosis, pulmonary, embolism, hyperparathyroidism Testicular, leukemia, non-hodgkin’s lymphoma prostateProstatic acid phosphatase Prostatitis, BPH, prostate trauma, after ejaculation noneprostatePSA Hyperthyroidism, subacute thyroiditis, benign adenoma Differentiated thyroid cancer (not medullary ) Thyroglobulin

38. Human cancerChromosomal changes NeuroblastomaDeletion (1), Gene amplification Burkitt’s lymphomaTranslocation (1-8), (8-22) Acute nonlymphocytic LeukemiaDeletion (5) SarcomaDeletion (11) B-Cell LymphomaTranslocation (8-14) Parotid CancerTranslocation (3-8) CarcinomaTranslocation (6-14) Breast CancerGene amplification

40. a = anterior cerebral artery m = middle cerebral artery fh = frontal horn - lateral ventricle ph = posterior horn - lateral ventriclecc = corpus callosum

41. 1 = prostate 2 = rectum 3 = obturator internus 4 = ischium5 = body of pubis 6.= pubic symphysis7 = femoral artery8 = femoral vein

43. 6 cm right posterior parietal lesion Irregular margins, infiltrating tumour Rim-enhancing, central necrosis Mass effect / edema Beware corpus callosum involvement 42

44. 81 yo female with headache, confusion, ? History of fever referred for radiation without biopsy labelled WBC scan + diagnosis = abscess resected/drained - well 2 years later 43