Cancer is commonly mistaken for being one disease, but in fact it is a general term covering many distinct diseases. Cancer is characterized by the uncontrolled growth of cells. Cell reproduction is carefully controlled by the body. However, these controls can malfunction, resulting in abnormal cell growth and the development of a lump, mass, or tumor. Some cancers involving the blood and blood-forming organs do not form tumors but circulate through other tissues where they grow. This variety of cancer types requires a variety of cancer treatments.
Because every patient is different and because there are so many variables, different types of treatments are required for each patient and no single cancer treatment is right for everyone. That is why our team customizes cancer treatment plans to meet each patient’s specific condition and requirements.
The bladder is an organ that stores urine. The bladder wall is lined by layers of cells called transitional cells. These cells make up more than 90% of all bladder cancers. Bladder cancer usually occurs in elderly men and less frequently in younger men and women. The most important risk factor for bladder cancer is smoking. Other risk factor includes a certain type of dye “azo compounds.”
Bladder Cancer Symptoms:
The initial symptoms of bladder cancer are often mistaken for a urinary tract infection or kidney stones. They include blood in the urine, flank pain, as well as voiding symptoms, fatigue, weight loss, and lack of appetite.
Bladder Cancer Diagnosis:
The initial testing includes urinalysis and urine cytology. A pathologist exams a sample of urine with a microscope to see if there are abnormal appearing cells being shed from the lining of the bladder.
The patient also undergoes CT scan and intravenous pyelogram where the dye collected is excreted by the kidneys. As the dye passes into the bladder, it allows them to be visualized on the x-ray. Another option would be a cystoscopy where the physician passes a small tube with a camera and inserts it into the bladder through the urethra.
Bladder Cancer Staging and Grading:
The staging of bladder cancer is based upon how far the cancer has penetrated the bladder, lymph node involvement, or has the cancer spread beyond the bladder to other organs. Cancer grading is used to predict how likely the cancer is to recur after initial treatment.
The best treatment for bladder cancer is surgery. It may entail removing the entire bladder or bladder preservation (meaning removing part of the bladder). Some patients who need cystectomy are sometimes advised to undergo chemotherapy before surgery. This is to eliminate undetectable cancer cells that are often found in other areas of the body.
National Cancer Institute, Bladder and other Urothelial Cancers
National Cancer Institute, Bladder Cancer Treatment
The types of bone cancer include primary bone cancer that happens when normal cells in the bone transform into abnormal cells and they grow out of control. The other type of bone cancer is secondary where it started from other parts of the body that spreads to the bones.
The common types of bone cancer are osteosarcoma, chondrosarcoma, and Ewing sarcoma.
Bone cancer usually presents with pain and swelling in the area of involvement. The pain is usually worse with exercise and mostly noted in the evening. Some patients will feel a lump in the bone that is involved.
If bone cancer is suspected, x-ray, CT scan, MRI, or PET imaging tests are usually performed, then a biopsy wherein a sample of the tumor is removed for analysis.
When bone cancer is confirmed, then additional testing is performed to determine the stage.
Therapy of bone cancer includes surgery which is the main modality of treatment. At times, chemotherapy may be required before or after surgery.
Radiation therapy is used if the patient cannot undergo surgery or when the cancer cannot be totally removed safely with surgery.
After the patient has undergone standard therapy, the patient usually undergoes examination like blood tests, chest x-ray, and other imaging modalities for followup.
Chondrosarcoma is a type of bone cancer that normally involves the cartilage (connective tissue where 2 bones meet). Ewing sarcomas usually happen in children and teenagers. They often involve the legs, arms, and pelvis.
Osteosarcomas are the most common bone cancer affecting children and adolescence. It is characterized by the production of immature bone by the cancer.
Brain cancer arises from the brain, and the meninges (membrane that covers the brain and the spinal cord).
Symptoms of Brain Cancer:
The patient presents with seizure, loss of muscle control throughout the body, jerking movements of the arms and legs, passing out, headache, nausea and vomiting, double vision, loss of vision, memory problems, or personality changes.
Testing for Brain Cancer:
Patients usually undergo diagnostic imaging such as a CT scan or MRI of the brain.
After the imaging study, a biopsy is usually performed where they take a small sample of brain tissue and analyzed under a microscope. Appropriate treatment will depend on the type of brain cancer.
Therapy for Brain Cancer:
Remove the tumor or to reduce symptoms of the cancer. Other options include radiation or chemotherapy. Some patients are treated with combined treatment such as chemotherapy with radiation.
Types of Brain Tumor:
- Low-grade gliomas
- High-grade gliomas
Breast cancer is the most common type of female cancer in the United States. It is the second leading cause of cancer death in women after lung cancer. If breast cancer is found early and treated early, it is often curable.
Breast cancer can also happen in men as well as run in families.
Symptoms of Breast Cancer:
Breast cancer can be found when there is a change in the breast or armpit or a lump is palpated by self-examination or a healthcare provider. Additional changes include changes in size or shape of the breast, pulling in of the nipple, discoloration of the skin of the breast, or dimpling of the skin.
To evaluate the above symptoms, the following are performed.
- Mammogram wherein a low-dose x-ray is performed on the breasts.
- Breast ultrasound where sound waves are used to look at the breast tissue and determine whether the lump is solid or cystic.
- Breast MRI is using a strong magnet to obtained detailed image of the breast. Breast MRI is an aid in diagnosing breast cancer and not recommended to detect breast cancer. Many experts restrict breast MRI in patients with mutations of the BRCA1 and BRCA2, in newly diagnosed breast cancer patients with extremely dense breasts on mammogram, and evaluation for breast cancer in women diagnosed with breast cancer through lymph nodes without mammographic changes or no signs of breast cancer on physical examination.
- Breast biopsy. The next step in diagnosing breast cancer is performing a biopsy to confirm the diagnosis.
Types of Breast Cancer:
- In situ breast cancer, this is the earliest form of cancer that does not grow outside the ducts.
- Ductal carcinoma in situ
- Lobular carcinoma in situ
- Invasive breast cancer. This is breast cancer that have grown or invaded the beyond the ducts or lobules of the breast. Varieties include ductal, lobular, medullary, tubular, and metaplastic.
Features of Breast Cancer That Influence the Choice of Therapy:
- Hormone receptors, namely estrogen receptor and progesterone receptor. If the hormone receptors are positive, the patient will benefit from endocrine or hormonal therapies.
- HER-2/neu status. Approximately 1 in 5 will be HER-2/neu positive. Patients will benefit from targeted therapies that include Herceptin and Tykerb.
Staging for Breast Cancer:
Once breast cancer has been diagnosed, additional testing which involves lymph node status, bone scan, x-rays, CT scans, or a PET scan is performed.
Stages of Breast Cancer:
- Patients with Stage I breast cancer refers to tumor less than 2 cm and are node negative.
- Stage II breast cancer refers to patients with involvement of the axillary lymph nodes and/or the tumor size is greater than 2 cm but less than 5 cm.
- Stage III breast cancer refers to patients with greater than 5 cm tumor with lymph node involvement.
- Stage IV breast cancer refers to patients whose cancer has spread outside the breast and lymph nodes. Example: Bone, skin, brain, liver, lung, or other organ involvement.
Overview of Treatment:
Early stage or localized breast cancer, Stage I and II are treated with breast conserving surgery or mastectomy. Breast reconstruction is an important option for patients who undergo mastectomy. This can be done at the time of mastectomy or on a later date. This is usually is performed by a plastic surgeon.
Additional treatment is recommended for the majority of patients with Stage II breast cancer and some patients with Stage I breast cancer. For patients with receptor positive breast cancer, a 21 gene recurrent score has allowed identification for women with stable prognosis and are usually treated with adjuvant hormonal therapy. For patients with hormone receptor negative early stage breast cancer, adjuvant chemotherapy is generally recommended. For her HER-2/neu positive early stage breast cancer, Herceptin plus chemotherapy is generally recommended.
Locally Advanced or Inflammatory Breast Cancer:
Patients usually undergo post surgery chemotherapy and endocrine therapy plus radiation therapy. For HER-2/neu positive locally advanced breast cancer, then adjuvant Herceptin is included. An option is neoadjuvant chemotherapy wherein combination chemotherapy is given prior to surgery.
Metastatic Breast Cancer:
The patient is treated with chemotherapy, endocrine therapy, targeted therapy, or in combination. Surgery and radiation are options to control the disease in certain areas. The goal of treatment is to prolong life, delay progression of cancer, relieve cancer symptoms, and improve quality of life.
Genetic Testing for Breast Cancer
What is Genetic Testing:
Genetic testing is performed to determine if a patient has abnormal genes. Our genes can sometime have mutations and lead to certain diseases. The 2 genes that are especially important in both breast and ovarian cancer are called BRCA1 and BRCA2. Patients who carry either one or both BRCA1 and BRCA2 have increased risks for breast or ovarian cancer. These genes are passed down in families.
Who Should Be Tested for Breast and Ovarian Cancer Genes:
The tests are usually performed if the patient has 2 or more close relatives with breast or ovarian cancer, especially if one or more relatives are diagnosed with breast cancer before the age of 50. If a close family member with more than one cancer such as cancer of both breasts or cancer in the ovary or breast, a family member from different generations with breast or ovarian cancer. However, most women with a family history of breast or ovarian cancer do not have the abnormal gene.
The cervix is part of the female reproductive organ located in the lower portion of the uterus or womb. It is on top of the vagina in between the bladder and the rectum. Cancer of the cervix occurs when the cervical cells grows out of control invading and destroying neighboring organs or spread by blood or the lymphatic system to other parts of the body.
Women routinely undergo pelvic examination and Pap smear to screen for cervical cancer.
Symptoms of Cervical Cancer:
At first, usually cervical cancer does not cause any symptoms. When symptoms do occur, it usually causes vaginal bleeding in between menstrual cycles, after sex, or after menopause.
Staging is used to find out how far a cancer has spread and appropriate therapy will depend on the stage of the cancer.
Thearpy for Cervical Cancer:
Cervical cancer treatment includes surgery to remove the cervix, uterus, and upper part of the vagina. This is usually called radical hysterectomy. At times, they only remove all or part of the cervix and leave the uterus in place, and this is done only in special cases. Other options include radiation alone or radiation in combination with chemotherapy. If a patient has cervical cancer and wants to be pregnant, please discuss this with your physician before undergoing treatment. Women are often able to get pregnant after other types of treatment but are advised to wait about 6 months or up to a year before trying to get pregnant so the body can heal.
Cervical Cancer Prevention:
In most cases, it is a preventable disease. Almost all cervical cancer is caused by a virus called human papilloma virus that spreads through skin-to-skin contact and sex. Vaccines that prevent the patient from getting infected with human papilloma virus are now available.
New England Journal of Medicine 2002; 347:1645
Obstetric and Oncology 2005; 106:645
The colon is part of the digestive system that extends about 6 feet in length. Adenocarcinoma is the cancer type accounting for over 95% of colon cancers.
Colon cancer begins in the cells that line the colon. They spread circumferentially around the colon (napkin ring).
Symptoms of Colon Cancer:
- Blood in the stool.
- Change in bowel movements; size, texture, and number.
- Abdominal pain.
- Feeling fatigued.
Staging of the colon cancer determines the extent of disease and will determine the mode of therapy. The patient may undergo a CT scan, MRI, ultrasound, and colonoscopy.
Treatment of Colon Cancer:
- Surgery. This is the usual initial treatment. The cancerous part of the colon, surrounding tissues, and the lymph nodes are removed. However, if there is a high chance that the reconnection will fail, the patient will undergo a temporary ostomy.
- Chemotherapy usually called “adjuvant” is given after surgery for a patient with high risk of cancer coming back. Chemotherapy is usually recommended for most patients with Stage III colon cancer (spread to the lymph nodes) and for some patients with Stage II colon cancer with high risk for recurrence. A test that can be used to help guide treatment decisions for Stage II colon cancer is called Oncotype DX2. This test estimates the risk of cancer recurrence through analysis of the upset in genes in the tumor.
- For patients with advanced disease, KRAS testing is performed. Colon cancer that contain KRAS mutations are unlikely to respond to targeted therapies.
National Comprehensive Cancer Network. Clinical Practice Guidelines 2015
New England Journal of Medicine 2008; 359:1757-65
Journal of Clinical Oncology 2008; 26:1626-1634
The esophagus is an organ that transports food from the throat to the stomach. It is located behind the sternum. The most common type of esophageal cancer is adenocarcinoma. It commonly affects the lower part of the esophagus. The other type of esophageal cancer is squamous cell carcinoma.
Symptoms of Esophageal Cancer:
Usually the patient will have trouble swallowing that gets worse over time, unexplained weight loss, hoarseness, pain or burning sensation in the chest.
Testing for Esophageal Cancer:
The patient usually undergoes a procedure called upper endoscopy. The physician uses an endoscope which is a tube with a camera and light on the end goes through your mouth and into the esophagus.
Staging of Esophageal Cancer:
The patient usually undergoes CT scans, endoscopic ultrasound, bronchoscopy, or laparoscopy to determine the stage. At times, a PET scan is needed especially to detect lymph node involvement.
Treatment of Esophageal Cancer:
Options for treatment include surgery to remove the cancer. Other modalities include radiation or chemotherapy.
American Cancer Society. Cancer Facts & Figures 2012
The stomach is part of the digestive system after the esophagus and before the small intestine. Cancer of the stomach is called gastric cancer. Gastric adenocarcinoma is the most common type of cancer of the stomach. It usually arises from the lining surface of the stomach. A bacterium called Helicobacter pylori is a primary risk factor. Surgery is the main treatment for gastric cancer.
Symptoms of Stomach Cancer:
Early stomach cancer might not cause any symptoms. When patients become symptomatic, symptoms include unexplained weight loss, abdominal pain usually in the upper belly, problems swallowing, no appetite or feeling full even with a small amount of food, nausea, and fatigue.
Testing for Stomach Cancer:
A procedure called an upper endoscopy is the most often procedure performed. The doctor places a thin tube with a camera and light on the end into the mouth and down to your stomach. During the procedure, a biopsy is done where the physician takes a small sample of tissue of an abnormal looking area in the stomach. Other testing includes a CT scan or ultrasound.
Staging for Stomach Cancer:
Staging is performed to determine how far the cancer has spread before initiating treatment in order to select the best treatment option. Unfortunately, in many cases stomach cancer can only be determined at the time of surgery. Staging options include endoscopy, laparoscopy, CT scans, gastroscopy, and a PET scan.
Therapy for Stomach Cancer:
Surgery is the primary choice of treatment by removing part or all the stomach. Other options include radiation therapy and chemotherapy. Some patients require chemotherapy before surgery.
Annuals of Internal Medicine 2009; 151:121-8
American Cancer Society, Cancer Facts and Figures 2010
AJCC Cancer Staging Manual 7th Edition
Head and Neck Cancer
Head and neck cancer originates from the oral cavity, the salivary glands, throat, pharynx, and the larynx (voice box). Most head and neck cancers are squamous cell carcinomas. Squamous cells line the mouth, throat, and other structures.
This cancer often presents with a patch often called leukoplakia.
Head and neck cancer usually spreads to the lymph glands in the neck. About 10-15% of head and neck cancer patients have a second cancer which is often asymptomatic.
Diagnosing head and neck cancer usually involves taking a sample of the suspected cancer. Then, the patient usually undergoes evaluation of the upper esophagus as well as the throat.
Staging scan, MRI, ultrasound, and PET scans are used to determine the extent of the disease.
Patients with head and neck cancer are usually treated in a multidisciplinary approach wherein a radiation oncologist, medical oncologist, head and neck surgeon, dentist, pathologist, and social services are involved.
Treatment modalities consist of surgery, radiation, chemotherapy, biological therapy, or a combination.
After the patient has undergone therapy, the patient is often followed up with physical examination, blood tests, and imaging tests. The patient is also instructed to watch for symptoms.
If a patient is found to have a recurrent head and neck cancer, options include more surgery, radiation, chemotherapy, or a combination of therapies.
Hodgkin’s lymphoma is a type of cancer that involves the body’s lymphatic system. The lymphatic system composed of interconnecting lymph vessels and network of lymph nodes. The lymphatic vessels carry lymphatic fluid that contains the lymphocytes. The lymphocytes are a type of white blood cells that fight infection.
In Hodgkin’s lymphoma, the tumor develops in the lymph nodes usually involving the neck or chest then it usually spreads to the nearby lymph nodes and then to the liver, bone marrow, and spleen. As the disease worsens, the body’s ability to fight infection is compromised. The exact etiology of Hodgkin’s lymphoma is not known in the majority of cases.
Hodgkin’s lymphoma is one of the most treatable forms of cancer. About 3 out 4 patients diagnosed with Hodgkin’s lymphoma can be cured. More than 90% of patients live at least 10 years after their chemotherapy.
Symptoms of Hodgkin’s Lymphoma:
Most patients present with enlarged lymph nodes in the neck that are painless. Others present with lymph nodes above the collarbone, the groin, or the armpit. Some patients presents with cough, shortness of breathing, or chest discomfort if the mass is located in the chest. Some patients can have fever, weight loss, or night sweats known as B symptoms.
Diagnosing Hodgkin’s Lymphoma:
- Removal of the enlarged lymph node to be examined and determine whether it is consistent with the diagnosis.
- Bone marrow biopsy. Bone marrow biopsy is sometimes performed in patients with night sweats, weight loss, fever, an abnormal blood count, or in certain stages of the disease.
Staging for Hodgkin’s Lymphoma:
The stage of Hodgkin’s lymphoma is based upon the number of lymph nodes involved, location of the affected lymph nodes, signs of cancer outside the lymphatic system, and the B symptoms.
Hodgkin’s lymphoma staging ranges from Stage I to Stage IV disease. The lower the stage the more likely the patient can be cured. Stage I and Stage II Hodgkin’s lymphoma are referred to as early stage. Stage III and IV Hodgkin’s lymphoma are advanced stages.
- The letter “A” means no fever, night sweats, or weight loss (10% of the body weight is present).
- The letter “B” designates positive for B symptoms.
Testing Using Staging:
- Blood tests.
- CT of the chest, abdomen, and pelvis with or without PET scan.
- Bone marrow biopsy.
Treatment for Hodgkin’s Lymphoma:
Chemotherapy is medication used to stop the growth of cancer cells. Combination of several chemotherapy drugs known as regimens is commonly used. They are administered through the vein. Chemotherapy is given in cycles, usually from 21 to 28 days. This will allow the body to recover from the adverse effect of chemotherapy. Examples of chemotherapy regimens for Hodgkin’s lymphoma include Adriamycin, Bleomycin, Velban, and DTIC (ABVD), Stanford 5 and BEACOPP.
Side Effects of Chemotherapy:
The most common side effects of chemotherapy include temporary hair loss, fatigue, nausea, vomiting, loss of appetite, easy bruising or bleeding, and susceptibility to infection. Long-term side effects include infertility, lung damage, and secondary cancers.
Treatment with Radiation Therapy for Hodgkin’s Lymphoma:
Radiation therapy is sometimes required to treat Hodgkin’s lymphoma usually given after finishing the chemotherapy regimen. It is directed to the affected area. It is usually given in small daily doses to minimize adverse effects.
For patients with Stage I or Stage II Hodgkin’s lymphoma, chemotherapy with radiation or in certain cases only chemotherapy is given.
For Stage III and Stage IV disease, chemotherapy is the main modality of treatment.
Hematopoietic Stem Cell Transplantation:
This is commonly known as bone marrow transplantation. This is indicated for a patient with recurrent Hodgkin’s lymphoma or patients with Hodgkin’s lymphoma that are resistant to other modalities of therapy. This is also indicated for patients whose lymphoma recurs after the first round of treatment.
A clinical trial is a controlled way to study new treatment or treatment combinations.
National Cancer Institute
American Society of Clinical Oncology
Leukemia is a form of blood cancer. Blood is made in the bone marrow. When the patient has leukemia, the bone marrow produces abnormal blood cells. They grow out of control, travel around the body, and at times collect in certain parts of the body.
There are different types of leukemia. Some are fast growing and some are very slow growing. Some patients with a slow or indolent type of lymphoma can progress fast growing leukemia.
Symptoms of Leukemia:
The most common symptoms include feeling fatigue, bleeding more easily, and easily getting sick from infections.
Testing for Leukemia:
- Blood test.
- Bone marrow biopsy.
Treatment of Leukemia:
Leukemia is treated in different ways. Some slow growing leukemias do not require treatment but need to be watched closely, whereas the aggressive leukemias are treated immediately. Treatment may include the following.
- Chemotherapy: A form of medicine that kills cancer cells.
- Radiation Therapy: A form of radiation that is used to kill cancer cells.
Bone marrow transplantation. After the patient receives chemotherapy or radiation, donor cells are used to replace the bone marrow. The donor cells come from different places. It could be taken out of your bone marrow before you get treated, a relative, or another compatible donor.
Acute Lymphoblastic Leukemia
Acute lymphoblastic leukemia is a type of cancer that involves the white blood cells known as lymphocytes. Lymphocytes are made in the bone marrow. In acute lymphoblastic leukemia, a large number of lymphocytes known as lymphoblasts are released in the blood stream. This leads to anemia infection and bleeding.
Treatment for acute lymphoblastic leukemia is divided into 3 phases: Induction, consolidation/intensification, and maintenance.
This phase of treatment usually takes around 4 weeks and is performed in the hospital. The following chemotherapy is often used: vincristine, daunorubicin or doxorubicin, and prednisone. For patients with Philadelphia chromosome positive acute lymphoblastic leukemia, additional medications known as tyrosine kinase inhibitors are added.
Approximately 4 out of 5 patients with acute lymphoblastic leukemia go into complete remission after the first treatment.
Additional therapy is needed to avoid recurrence or relapse. This is due to undetected leukemia cells in the blood or bone marrow.
The treatment lasts for several months. Usually the same chemotherapy is used during this phase. In addition, treatment of the brain and spinal cord are also included.
Stem Cell Transplantation:
A patient is usually given a very high dose of chemotherapy or body radiation. This leads to eradication of cancer cells, but it also destroys the normal cells in the bone marrow. Then, the patient is given stem cells to re-establish the blood cell production in the bone marrow.
A cure is from the effects of chemotherapy or radiation therapy and also from the new immune system derived from the transplantation.
Maintenance therapy is continuation of treatment and often last for 3 years. This entails involving intravenous chemotherapy and also involves oral medication on certain days of the treatment.
Surveillance After Completion of Treatment:
A patient usually undergoes bone marrow aspiration and biopsy every 3-6 months for the next 2 years. This will allow detection of recurrent disease. A patient who does not have a sign of recurrence after 5 years is considered cured. However, up to 1 out of 4 patients with acute lymphoblastic leukemia is resistant to initial therapy.
Treatment of Resistant or Relapsed Disease:
If recurrent disease occurs more than 2 years from the initial therapy, similar regimens are used. If relapse occurs less than 2 years, a clinical trial is recommended. Allogeneic stem cell transplantation is another approach.
Acute Myeloid Leukemia
This type of leukemia affects a group of white blood cells called myeloid cells. They affect the red blood cells, white blood cells, as well as platelets. This often leads to anemia, increased susceptibility to infection and bleeding.
Treatment for Acute Myelocytic Leukemia:
The first phase of treatment is called remission induction or induction therapy. The goal is to decrease the number of leukemia cells to an undetected level and restoring production of normal blood cells in the bone marrow. The most common regimens used include cytarabine given continuously for 7 days and anthracycline given in the first 3 days. This is often called 7 + 3 regimen. They usually kill the leukemia cells in the first 7 to 14 days. The bone marrow takes about 14 days to recover and able to produce normal blood cells.
The induction phase usually consists of 1 or 2 cycles. This usually results in complete remission.
Post Remission Therapy for Acute Myeloid Leukemia:
This is part of the therapy where the intention is to kill leukemia cells that remain undetected under a microscope. There are 3 basic choices: Additional chemotherapy, stem cell transplantation from a donor, or your own stem cells. The best treatment option depends on several factors like how aggressive the leukemia is.
- Patients with favorable risk factors are usually advised to continue chemotherapy.
- Additional chemotherapy: Cytarabine is usually given at a high dose in the hospital setting. This will last for approximately 3-4 months.
- Patients with unfavorable risk factors are usually given stem cell transplantation.
- A low genetic transplantation uses stem cells from a related donor called HLA match and from an unrelated donor called match unrelated donor. The donor cells develop into immune cells, identify that the leukemia cells are foreign, and launches an immune attack killing the remaining leukemia cells. This is called graft versus tumor or graft versus leukemia effect. However, the graft versus leukemia or graft versus tumor effect can lead to graft versus host disease. The immune response attacks the patient’s own healthy organs. It often leads to liver damage, diarrhea, as well as skin rash. Autologous transplant uses the patient’s own stem cells that are collected after remission is achieved. High-dose chemotherapy or radiation is given to remove any remaining leukemia cells. There is no graft versus host disease because the donor cells are from the patient. However, this is less effective than allogenic transplantation in fighting leukemia. This form of transplantation is less often recommended for that reason.
- For intermediate risk disease, a clinical trial is recommended.
Treatment of Acute Myelocytic Leukemia in Older Patients (Over 60 Years Old):
Patients over 60 years of age usually do not respond well to treatment for acute myeloid leukemia. This is due to patients having resistance to standard chemotherapy as well as the presence of other disorders such as heart disease, diabetes, lung, or kidney disease that increases complications from chemotherapy.
Treatment decisions for older patients with acute myeloid leukemia are done on a case-to-case basis. For healthy patients, induction chemotherapy is generally recommended. However, for patients with severe underlying health problems, the benefit of chemotherapy is outweighed by potential side effects, and then supportive measures are usually recommended. Another option would possibly be a clinical trial.
Treatment for Resistant or Recurrent Acute Myeloid Leukemia:
In this situation, management is very difficult. There are limited numbers of effective treatments available. Approximately one-half of patients can achieve long-term remission (greater than 1 year) with second induction chemotherapy. However, the duration of the second remission is usually short. Stem cell transplantation is often considered.
Patients who have recurrent disease within 12 months of initial diagnosis have a very high degree of resistance to medication and a lower rate of achieving a second complete response. Often, the patients are enrolled in clinical trials or experimental agents and followed by stem cell transplantation.
Long-Term Monitoring of Acute Myeloid Leukemia:
Patients who achieve a complete response often are monitored long term for any recurrent disease. Most recurrences occur within the first 2 years after completion of treatment.
Chronic Lymphocytic Leukemia
Chronic lymphocytic leukemia is often called CLL, it is a type of cancer of the blood it affects a type of white blood cell known as a lymphocyte. The normal lymphocytes help the body fight infections but not the leukemia cells. A small lymphocytic lymphoma and chronic lymphocytic leukemia are variants of the same disease.
In chronic lymphocytic leukemia, there are an abnormally high number of CLL lymphocytes in the bone marrow and in the blood. In small lymphocytic lymphoma, the same type of cells is commonly found in the lymph nodes.
These abnormal cells cannot fight infection and instead they collect in the lymph nodes and other areas of the body such as the spleen and the liver. These ineffective lymphocytes impair the production of other blood cells such as the red cells, platelets, and also affect the immune system.
CLL and ALL usually are indolent diseases. Usually, patients are asymptomatic in the early stages. Most patients survive for decades after diagnosis. A minority of patients have an aggressive course and a shorter life span. Most cases are diagnosed incidentally on routine blood tests, such as a complete blood count (CBC).
Staging for Chronic Lymphocytic Leukemia:
The natural history of CLL is variable from patient-to-patient. Most of the patients have no symptoms, and a minority will have symptoms and are candidates for therapy. The 2 staging systems are the Rai system and the Binet system.
- Stage 0: Increased number of abnormal lymphocytes in the blood or bone marrow.
- Stage I: Increased abnormal lymphocytes and enlarged lymph nodes.
- Stage II: Increased abnormal lymphocytes with or without enlarged lymph nodes.
- Stage III: Increased abnormal lymphocytes with accompanying anemia with or without enlarged liver, lymph nodes, or spleen.
- Stage IV: Increased abnormal lymphocytes with low platelets, with or without anemia, enlarged spleen, lymph nodes, or liver.
- Stage A: Fewer than 3 involved sites; the platelets and red cells are not significantly affected.
- Stage B: Three or more involved sites; the platelets and red cells are not significantly affected.
- Stage C: Presence of anemia and/or low platelet count.
What Do the Stages of CLL Mean?
Staging of CLL is one of the parameters used to determine if therapy is required. For patients with Rai Stage 0, patients are considered low risk. Those with Stage I and II are intermediate risks. Those with Stage III and IV are considered high risk. In the Binet system, Stage A is the lowest risk while Stage C is the highest risk group.
When is Treatment Required for CLL?
- Symptomatic anemia and/or low platelet count.
- Symptoms especially night sweats, unexplained weight loss, weakness, fever, swollen and painful lymph nodes.
- Rapidly increasing white cells, rapidly enlarging lymph nodes, liver, or spleen.
- Repeated infections.
- Autoimmune process wherein the immune system destroys the platelets and red cells and not responding to steroids.
Treatment for Early Stage Asymptomatic CLL:
Patients who are asymptomatic from CLL are usually not treated. They are usually followed on a regular basis with blood tests and physical examinations.
Treatment Options for Symptomatic or Advanced CLL:
- Chemotherapy: Chemotherapy works by stopping the growth of cancer cells.
- Leukeran (chlorambucil): This may be given alone or in combination with other treatments. The most common side effect is lowering of the blood counts.
- Treanda (bendamustine) is a chemotherapy given in combination with immunotherapy as first line treatment. Common side effects include nausea, vomiting, allergic reactions, and low blood counts.
- Cytoxan (cyclophosphamide): This chemotherapy is either given orally or through an intravenously. Common side effects include nausea, vomiting, hair loss, low blood counts, and irritation of the bladder.
- Fludara (fludarabine): This is a chemotherapy drug often used in combination with other chemotherapy drugs. Common side effects include fever, low blood counts, and risk for severe infections.
- Rituxan (rituximab) is a monoclonal antibody, a purified protein that targets a specific substance on the surface of the leukemia cells.
- Gazyva (obinutuzumab) is a monoclonal antibody that targets the B lymphocytes.
- Arzerra (ofatumumab) is a monoclonal antibody that targets B lymphocytes.
- Imbruvica (ibrutinib) is an oral medication given for patients who have recurrent CLL and used as front line therapy for patients with certain types of CLL (mutation of TP53 and deletion 17p). This treatment is associated with bleeding and should be used with caution with patients taking anticlotting medications such as Plavix or Coumadin.
- Zydelig (idelalisib) is a drug used in combination with rituximab for patients with recurrent CLL and also front line therapy for certain types of CLL (TP53 mutation or deletion of 17p).
Choice of Regimen:
There is no best standard treatment regimen for symptomatic chronic lymphocytic leukemia. Patients with markers such as 17p deletion or mutation of TP53 are often difficult to treat. Treatment options include clinical trials or newer drugs such as Zydelig and Imbruvica.
The combination of fludarabine, cyclophosphamide, and rituximab (FCR) are often used as first line treatment for symptomatic or advanced CLL. However, this is not very effective and not well tolerated for older patients. The combination of chlorambucil plus immune therapy may be preferred for older patients with symptomatic CLL.
Therapy for Relapsed Disease:
If a patient had a long interval prior to relapse, it is possible to use the same chemotherapy regimen or another chemotherapy regimen.
For patients who are refractory or relapsed earlier than 6 months prior to the last treatment, options for treatment are limited.
- Clinical trial.
- Novel agents like ibrutinib or idelalisib.
- Stem cell transplantation.
- Removal of the spleen. Some patients with CLL develop a very large spleen. This is currently rarely done due to response to chemotherapy or radiation therapy.
- Bone marrow transplantation. This is considered for younger patients with high risk CLL.
Treatment of Chronic Lymphocytic Leukemia Complications:
- Treatment options include use of medication called erythropoietin to boost red blood cell production. Another option is use of steroids or blood transfusion.
- Low platelet count. Patients with low platelet counts are given platelet transfusions as needed. At times, steroids or removal of the spleen are considered to suppress the immune system and improving the platelet count.
- This is a serious risk from treatment of chronic lymphocytic leukemia. It often involves the upper respiratory tract. Influenza vaccine and pneumococcal vaccines should be up to date. However, patients are usually not advised to get live vaccines such as zoster vaccination. Patients with respiratory tract infection often have low levels of immunoglobulin or fighting proteins. Patients are usually treated with intravenous immunoglobulins. This treatment is recommended for patients have repeated infections with low serum gamma globulin.
Low white blood count. Patients are usually given growth factor to boost production of white blood count and decrease the chance of infection.
Chronic Myeloid Leukemia
Chronic myeloid leukemia, also called CML, is a bone marrow disorder caused by a strand of genes that break off and attach to another gene that result in an abnormality known as Philadelphia chromosome. This results in fusion of 2 genes called BCR and ABL, called BCR-ABL.
The BCR-ABL gene results in an abnormal production of enzymes known as BCR-ABL tyrosine kinase. This results in white blood cell overgrowth resulting in elevations of white blood count and increasing spleen size. This will eventually lead to more aggressive disease called acute leukemia.
In leukemia, there is overgrowth of immature cells or blast cells and limits the production of the red blood cells and platelets. This will lead to bleeding or infections.
Phases of Chronic Myeloid Leukemia:
- Chronic phase: In the chronic phase, less than 5% immature cells are in the bone marrow. This phase generally lasts several years and controlled with oral medications. Approximately 85% of patients are in this phase when diagnosed.
- Accelerated phase: There are approximately 10-19% blasts in the bone marrow. Maturation of white cells is impaired and the disease is more difficult to control with medications due to new mutations.
- Blast phase: There are more than 20-30% immature cells in the blood or bone marrow. This is often unresponsive to treatment. This typically occurs within 4-5 years upon diagnosis.
Treatment for Chronic Myeloid Leukemia:
- Oral tyrosine kinase inhibitor (TKI) known as Gleevec, Sprycel, and Tasigna.
- Possible cure with bone marrow transplantation. This is done after the TKIs have stopped working.
- Chemotherapy like hydroxyurea, busulfan, interferon alpha, and cytarabine are used to reduce symptoms.
The choice of treatment will depend upon the phase of the leukemia, availability of stem cell donor, patient’s eligibility for stem cell transplantation and preference.
Response to Therapy:
The treatment goal is to reduce or eliminate the abnormal Philadelphia chromosome. This is termed as a cytogenetic response. When the blood count returns to normal, this is known as hematologic response.
The severity of symptoms is reduced by achieving a hematologic response. However, progression to the accelerated or blastic phase will continue unless the patient achieves a cytogenetic response.
A more sensitive molecular testing is performed, and if there is no evidence of the BCR-ABL gene, the patient is said to have a complete molecular response. This is hardly achieved with chemotherapy. This is also the goal for hematopoietic stem cell transplantation.
Tyrosine Kinase Inhibitors:
The tyrosine kinase inhibitor slows or stops the action of the BCR-ABL gene leading to cell death. However, they have not been proven to cure the chronic myeloid leukemia. TKIs are the initial treatment of choice for almost all patients with newly diagnosed chronic myeloid leukemia. These medications are able to achieve long-term control of the leukemia. They are able to achieve hematologic and cytogenetic response. Avoid taking acetaminophen, St. John’s Wart, and grapefruit juice with this treatment.
Gleevec has been compared with interferon plus cytarabine for newly diagnosed chronic phase CML. 97% of patients who were given imatinib had complete hematologic response and 76% achieved a complete cytogenetic response. This medication is given by mouth once a day with a meal and a large glass of water.
Common side effects include nausea and vomiting, diarrhea, muscle cramps, skin rash, breast enlargement, mild anemia, and fatigue.
There is risk for miscarriage and birth defects while taking imatinib.
Dasatinib is a second-generation TKI usually given after imatinib. It is taken by mouth once or twice daily. The main side effect includes pleural fluid collection in the space between the lining of the lung and the chest wall. This complication usually requires a dose reduction, temporary break in treatment, or draining the fluid. Women who are pregnant or breastfeeding should not use dasatinib due to potential harm to the infant.
Nilotinib is another second-generation TKI for the treatment of CML. It is taken by mouth on an empty stomach every 12 hours.
Side effects include nausea, constipation, rash, itching, and abnormal heart rhythm. Women who are pregnant or breastfeeding should not use nilotinib.
Bosutinib is another TKI for treatment of CML after failure of another TKI. It is taken daily by mouth with food. Major side effects include nausea, vomiting, abnormal liver function tests, diarrhea, and fluid retention (lungs and legs). Women who are pregnant or breastfeeding should not take bosutinib.
Ponatinib is another TKI recommended for treatment of CML that is unresponsive or relapsed with another TKI. This medication is especially active for patients with certain mutations like T315I. Potential complications of this medication include stroke, heart attack, inflammation of the pancreas, and liver failure. Women who are pregnant or breastfeeding should not use ponatinib.
Recurrent disease after treatment with TKI is often due to development of new mutations in the BCR-ABL gene. Patients are usually encouraged to consider transplantation.
If transplantation is not an option, a clinical trial or therapy with omacetaxine (Synribo) may be an option. This medication is given as an injection under the skin daily for 2 weeks and repeated every 4 weeks for 6 cycles. Common side effects include nausea, diarrhea, fatigue, infections, and fever.
A major cause of treatment failure is skipping doses or not taking the medication as directed.
National Library of Medicine
American Cancer Society
The Leukemia and Lymphoma Society
National Marrow Donor Program
American Society of Hematology
American Society of Clinical Oncology
The liver is the biggest organ in the body. It is located on the right side of the abdomen behind the ribs. The liver is responsible for storing sugar in the body, making bile that helps with the digestion of fats, and removing harmful substances from our bloodstream.
When a cancer is identified in the liver, it is important to know whether it originated in the liver or was spread to the liver from other organs.
Hepatocellular carcinoma is the most common type of liver cancer in adults. Other cancers like cholangiocarcinoma that develops in the cells that line the bile ducts. Rare forms of liver cancer like angiosarcoma and hemangiosarcoma start in the blood vessels of the liver.
Symptoms of Liver Cancer:
Symptoms for liver cancer are nonspecific. The most common involves pain in the upper abdomen on the right side which may extend to the back or shoulder. Other symptoms include unexplained fever, jaundice (yellow skin or eyes), dark urine, nausea, vomiting, fatigue, loss of appetite, feeling of fullness, and bloating sensation. These symptoms do not necessarily mean you have liver cancer.
When cancer of the liver is suspected, imaging tests such as a CT scan, ultrasound, or MRI may be performed.
Assessing the level of a protein called alpha fetoprotein in the blood can also be performed. An elevated alpha fetoprotein in combination with a mass in the liver is a common indication for cancer of the liver. A biopsy of the liver is often not required for a diagnosis, particularly in patients with history of cirrhosis.
Treatment for Liver Cancer:
Cancer of the liver is treated in different ways. This includes surgery, a liver transplant, ablation therapy using heat, injection of a special alcohol or acid, or laser. Other ways include blocking the cancer’s blood supply called embolization, radiation therapy, or medicines that kill cancer cells.
National Cancer Institute, Adult Primary Liver Cancer Treatment (PDQ), December 2, 2008
American Cancer Society, Cancer Facts & Figures, 2008, December 4, 2008
National Cancer Institute. What You Need to Know About Liver Cancer, December 4, 2008
Lung cancer is the most common cause of death in men and women in the United States. There are 2 main types, namely the small cell lung cancer and the non-small cell lung cancer.
Symptoms of Lung Cancer:
Common symptoms include coughing up blood, trouble breathing, chest pain, hoarseness, swelling of the face, arms, or neck.
For certain types of lung cancer that grows in the top part of the lung, the patient may experience weakness of the hand muscles, droopy eyelids, pain in the arm, neck, or shoulder.
Testing for Lung Cancer:
Patients usually have a baseline chest x-ray. Further imaging is done through a CT scan and PET scan.
The patient will undergo a biopsy where a small sample of the lung tissue is removed and read under a microscope. At times, a bronchoscopy is required where a tube with a light at the end is passed through the nostril through the airway.
Staging for Lung Cancer:
Staging is performed to determine how far the cancer has spread. It usually entails a CT scan and PET scan.
Treatment for Lung Cancer:
Surgery is performed to remove the cancer. Further therapy with chemotherapy with or without radiation is given.
Radiation therapy is given for patients who are not candidates for surgery.
Chemotherapy is used mainly for advanced lung cancer to palliate symptoms.
Targeted therapy: Some medication works for certain tumor characteristics. Examples are epidermal growth factor receptor (EGFR) blockers, anaplastic lymphoma kinase, ALK inhibitors.
National Cancer Institute
American Cancer Society of Clinical Oncology
Lung cancer is characterized by uncontrolled growth of normal cells into abnormal cells, involving one or both lungs. Most lung cancers start in the bronchial tubes and classified according to their appearance under a microscope.
There are 2 main types of lung cancer; non-small cell accounts for approximately 3/4 of cases and consisting of large cells, adenocarcinoma, and squamous cell carcinoma. Small cell lung cancer represents approximately 1/4 of all lung cancers. This was previously referred as oat cell cancer.
A patient with lung cancer usually presents with coughing up blood, chest pain, shortness of breathing, hoarseness; swelling of the face, arms, and neck, or headaches.
Diagnosing Lung Cancer:
A biopsy is required for a diagnosis. It involves removing a small tissue sample to be read under a microscope.
Bronchoscopy: A lighted tube that passes through the nose or mouth into the windpipe through the airway passages that leads to the lung.
Fine needle aspiration: It entails inserting a needle through the chest into the cancer to remove a tissue sample and placed under a microscope.
Thoracotomy: A surgical procedure that involves opening the chest to obtain a tissue sample for a diagnosis.
Sputum cytology: The mucus is obtained and placed under a microscope to detect cancer cells.
Thoracentesis: A needle is inserted and fluid that surrounds the lung is removed to check for cancer cells.
The patient usually undergoes positron emission tomography (PET scan), computed tomography (CT scan), magnetic resonance imaging (MRI), mediastinoscopy wherein a surgeon inserts a scope through a small incision of the neck to examine the lymph nodes.
EGFR Gene Testing: Epidermal growth factor receptor gene may affect how the lung cancer responds to treatment. Medications can block the activity of EGFR and slows the cancer growth. An example of this medication is Tarceva (erlotinib).
ALK Gene: ALK gene contributes to cancer growth. Xalkori (crizotinib) is a pill that blocks growth and development of cancer cells.
American Cancer Society
Melanoma is a type of skin cancer. It can occur anywhere on the skin, the lining of the mouth, nose, as well as the genitals.
Melanoma usually looks like a birthmark or a mole. The abnormal features of melanoma are asymmetry, border, color, and diameter (ABCD). Asymmetry means the other half looks different. Border means uneven edge or jagged appearance. Color means they can present with different colors on a single lesion. Diameter means larger than the area of a pencil.
The skin involved by melanoma is crusty, red, swollen, or at times they can bleed.
The majority of birthmarks and moles are normal and are not melanomas.
Testing for Melanoma:
If a patient suspects or your provider suspects a melanoma, a biopsy is usually performed. This is a procedure that removes a piece of the abnormal area or the whole abnormal area. The samples are sent for testing.
Once the melanoma is confirmed, the patient usually undergoes staging. The American Joint Committee on Cancer defines the staging system for melanoma that includes the thickness of the tumor, ulceration over the surface of the melanoma, number of dividing cells in the tumor per mm2 (square millimeter), involvement of draining lymph nodes, and evidence of tumor spread beyond the lymph nodes.
A physical examination, chest x-ray, and blood tests are usually performed to evaluate the possibility of spread of the disease. Additional imaging tests such as CT scan may be required for patients with advanced melanoma.
Treatment of Melanoma:
Surgery is performed to remove the entire melanoma in most patients. Usually 1 or 2 cm of normal skin surrounding the lesion must also be removed. This is called wide local excision. This will decrease the chance of the melanoma recurring at the same area. Most surgeries are performed as one-day surgery or a surgical center and are usually discharged on the same day. Some patients may require skin grafting if they involve the face or neck since removing a sufficient amount of normal skin for adequate margins can be difficult.
Evaluating Lymph Nodes:
The lymph nodes are the most common site of melanoma spread. At times, it is not clinically detectable and sometimes it is obvious. Removal of the lymph node in the area called therapeutic nodal dissection provides the chance to cure the melanoma.
If lymph nodes cannot be detected, then a sentinel lymph node biopsy is performed. A blue dye or radioactive material is injected around the primary tumor before the wide local excision. The node absorbs the dye or radioactive tracer at the time of surgery. The sentinel lymph node biopsy is usually done on the same day as the wide excision is performed. This is also done as an outpatient and the patient can be discharged the same day. A sentinel lymph node biopsy is usually not recommended for melanomas less than 1 mm in thickness without ulceration and mitosis less than 1/mm2. The likelihood of tumor spread to the regional lymph nodes in these cases is less than 5%.
After the staging workup is completed, then the patient assigned a pathological stage from I through IV. Based on the pathologic stage, optimal treatment is chosen. For patients with localized disease, the goals of treatment are complete surgical removal of the melanoma, evaluation of the lymph nodes for evidence of involvement, and preventing further spread or recurrent disease.
Melanoma Adjuvant Therapy:
Adjuvant therapy means any additional anticancer treatment after the cancer has been removed. It is to stop or slow the growth of any remaining cancer cells that are not removed during surgery. This usually involves immunotherapy (Interferon Alpha). This is used to treat patients with melanoma who have a high chance for recurrent disease. The treatment lasts up to 12 months. It usually starts with a high dose of intravenous therapy given 5 days per week for 4 weeks then followed by low-dose injections under the skin 3 times a week for 11 months. Adjuvant Interferon therapy is recommended for patients with Stage IIB, IIC, and III who have no serious underlying medical problems and life expectancy of at least 10 years or more.
The potential side effects of Interferon include flu-like symptoms, drop in blood count, temporary increase in liver enzymes, fatigue, and depression. The side effects can be managed with supportive measures or temporary reducing the dose of Interferon.
Monthly self-examinations, care provider examination, as well as routine blood and imaging tests are usually performed at periodic intervals to evaluate the possibility of recurrent disease.
Prevention of Future Melanoma:
Patients who have had prior melanomas have increased risks of developing melanoma again. These patients are instructed to reduce exposure to ultraviolet (UV) radiation from sunlight.
National Cancer Institute
American Cancer Society
National Comprehensive Cancer Network
Malignant pleural mesothelioma is an uncommon type of cancer that begins in the thin membrane that surrounds the lungs and lines the chest cavity called the pleura. The pleura is lined by mesothelial cells.
Malignant pleural mesothelioma is predominantly caused by exposure to asbestos. The development of lung cancer is worsened by cigarette smoking. The association between inhaled asbestos particles and mesothelioma was recognized in 1960.
Types of Malignant Pleural Mesothelioma:
Pleural mesothelioma is classified into 3 categories: Epithelioid, sarcomatoid, and mixed type. Epithelioid is the most common occurring in 60-70% of patients. The sarcomatoid type (10-20%) is the least common and most aggressive. Mixed type (20-30%) shows features of both epithelioid and sarcomatoid.
Signs and Symptoms of Malignant Pleural Mesothelioma:
The majority of patients with malignant pleural mesothelioma experience shortness of breath and a third experience chest pain. Weight loss, cough, weakness, fever, and loss of appetite are also common. Fluid between the lungs and chest wall (pleural effusion) is also present in the majority of the patients. Most patients have a significant history of asbestos exposure which occurred 30-40 years prior to exhibiting signs of the disease. Men are 3 times more likely to have the disease than women because of work-related exposure and high-risk occupations such as ship construction, manufacturing, and mining.
Determining the presence of malignant pleural mesothelioma and the type requires biopsy (examination of tissues) from the lung. Needle biopsy of the pleura is a safe procedure that detects malignant mesothelioma approximately 86% of the time.
Bronchoscopy: This involves insertion of a thin lighted tube called a bronchoscope through the nose or mouth into the trachea (windpipe) and bronchi (air passages that lead to the lung) enabling collection of small tissue samples from inside the trachea, bronchi, and lung tissue.
Fine Needle Aspiration: During this procedure, a surgeon inserts a needle through the chest into the area of suspected cancer to remove tissue for examination.
Thoracotomy: A thoracotomy is a major surgery which involves opening the chest in order to remove a sample of tissue.
Sputum Cytology: Examination of mucus that is coughed up from the lungs.
Thoracentesis: Removal of a sample of fluid that surrounds the lungs in order to check for the presence of cancer cells.
This involves an evaluation to determine how far the cancer has spread in order to determine the stage of the disease. It is important to determine the stage of disease in order to select the most optimal treatment option.
Chest x-ray: A chest x-ray may show pleural effusions or pleural thickening.
Computed Tomography: A CT shows whether there is fluid thickening or irregularities in the pleura as well as determining whether the cancer has spread beyond the pleura into the chest wall, pericardium (sac around the heart), diaphragm (breathing muscle), or the lymph nodes.
Magnetic Resonance Imaging (MRI): This is particularly used to determine how extensive the cancer is and whether it can be removed with surgery.
Positron Emission Tomography (PET): In contrast to providing anatomical images (x-rays, CT, and MRI), PET shows chemical and physiological changes related to metabolism. These functional changes often occur before structural changes are seen in tissues. Therefore, these abnormalities may be detected long before they would be revealed by x-ray, CT, or MRI.
Antman KH, Pass HI, DeLaney T, et al. Benign and malignant mesothelioma. In: Devita VT Jr, Hellman S, Rosenberg Staphylococcus aureus eds. Cancer Principles and Practice of Oncology, 4th Edition Philadelphia, PA:JB Lippincott Co; 1993:1489-1508
Journal of Clinical Oncology 1989;7:1168-1168
Current Opinion in Oncology 2003;15:131-138
Multiple myeloma is a cancer of plasma cells which are a special type of white blood cells belonging to the body’s immune system. Plasma cells are found in the bone marrow and make specific proteins called antibodies that circulate in the blood and help fight certain types of infections. Plasma cells also secrete a hormone called osteoclast activating factor which causes the breakdown of bone. Patients with multiple myeloma have increased numbers of abnormal plasma cells that produce increased quantities of dysfunctional antibodies detectable in the blood and/or urine. These abnormal antibodies are referred to as paraproteins or monoclonal proteins in the blood (M proteins) or urine (Bence-Jones protein).
In multiple myeloma, plasma cells infiltrate the bone marrow spreading into the cavities of all the large bones of the body. Patients with multiple myeloma develop holes in their bones referred to as osteolytic lesions that cause the bones to be fragile and susceptible to fracture. Osteolytic lesions are caused by the rapid growth of myeloma cells pushing aside normal bone-forming cells, thus, preventing them from repairing general wear and tear of the bones. The myeloma cells cause the secretion of osteoclast- activating factor, a substance that contributes to bone degradation.
Other complications of multiple myeloma include kidney malfunction and decreased blood counts from bone marrow malfunction. Kidney problems develop when abnormal proteins produced by the myeloma cells are deposited in the kidneys thereby clogging the tubules. The decreased bone marrow blood cell production results from the infiltration and replacement of the normal bone marrow cells with abnormal plasma cells leading to problems such as anemia. Due to decreased quantities of normal antibodies necessary to fight certain types of infection, patients with multiple myeloma may be prone to these infections.
Multiple myeloma may be preceded by 2 precancerous conditions: Monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma. These conditions do not cause symptoms and are generally not treated but can eventually progress to the full expression of multiple myeloma. The rate of progression to multiple myeloma from MGUS is roughly 1% per year. Smoldering multiple myeloma causes a high risk of progression (up to 10% per year).
An estimated 20,000 individuals were diagnosed with multiple myeloma in 2008. Half of these new diagnoses occur in individuals over the age of 70 years. When multiple myeloma is diagnosed, approximately 70% of patients will have bone marrow involvement with their cancer and 1/3 will have impaired kidney function. In order to understand the best treatment option for the treatment of myeloma, the amount of cancer in the body needs to be determined by a staging procedure that requires several tests including:
- Measurement of the amount and type of abnormal myeloma protein in the urine (urine protein electrophoresis).
- Measuring the amount and type of abnormal myeloma protein in the blood (serum protein electrophoresis).
- Measurement of beta 2 microglobulin in the blood which provides information about the amount of tumor mass.
- Detection of bone damage via a series of x-rays called the skeletal survey.
- Sampling cells removed from the bone marrow in order to determine the percentage of myeloma cells in the marrow and to assess specific characteristics of the myeloma cells (such as chromosomal abnormalities) that may influence prognosis via bone marrow biopsy and aspiration.
- Blood test to measure kidney function.
- Complete blood count (CBC) to identify problems such as anemia.
- Measurement of blood calcium levels as an estimated 15-20% of patients with multiple myeloma have increased calcium levels (hypercalcemia) at the time of diagnosis due to myeloma-related bone destruction. Hypercalcemia can cause excessive thirst, frequent urination, dehydration, constipation, and even coma.
The results of these tests will determine the stage of the disease.
Blade J Rosinol L. Complications of multiple myeloma. Hematology/Oncology Clinics of North America. 2007:21(6): 1231-1246
Kyle RA Rajkumar SV. Monoclonal gammopathies of undetermined significance and smoldering myeloma. Hematology/Oncology Clinics of North America. 2007;21(6): 1093-113
America Cancer Society. Cancer Facts & Figures 2008
SEER Cancer Statistics Review, 1975-2004. National Cancer Institute. Bethesda, MD
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology
AJCC Cancer Staging Manual, 6th ed. New York (NY): Springer-Verlag; 2002
Myelodysplastic syndrome is a group of blood disorders associated with low blood counts due to abnormal production of blood cells by the bone marrow. In MDS, the bone marrow is overactive producing many immature cells and few mature cells. Any or all blood types may be affected by MDS. MDS may occur on its own or after being exposed to a certain type of chemotherapy or radiation.
Symptoms of Myelodysplastic Syndrome:
Some patients with MDS may have no symptoms and are usually diagnosed after routine laboratory testing. Most patients with MDS present with fatigue, weakness, dizziness, shortness of breathing, chest pain, easy bruising, bleeding, or recurrent infections.
Diagnosis of Myelodysplastic Syndrome:
Diagnosis of MDS is based on laboratory testing that includes a complete blood count, a blood smear examination, bone marrow biopsy, and genetic analysis.
Types of Myelodysplastic Syndrome:
There are mainly 5 types that include refractory anemia, refractory anemia with ringed sideroblasts, refractory anemia with excess blasts, refractory anemia with blasts in transition, and chronic myelomonocytic leukemia.
Treatment Options for Myelodysplastic Syndrome:
- Supportive measures include administration of medication that stimulate the immature cells to develop into mature cells.
- Chemotherapy to destroy the abnormal cells at low conventional or high doses.
- Stem cell transplantation wherein the damaged bone marrow is replaced with healthy cells.
- Targeted therapy which regulates the immune system.
Blood 2004; 104:579-585
Leukemia Lymphoma Society
National Cancer Institute
National Library of Medicine
Myeloproliferative Neoplasms (MPN)
Myeloproliferative neoplasms (MPN) are a group of blood cancers that are in the bone marrow and produce blood cells that function and develop abnormally.
There are 3 main types of myeloproliferative neoplasia, namely polycythemia vera, essential thrombocythemia, and primary myelofibrosis.
Polycythemia vera and essential thrombocythemia results from over-production of a certain type of blood cells. Whereas primary myelofibrosis involves scarring of the bone marrow affecting blood cell production.
Polycythemia vera and essential thrombocythemia tend to be slow growing and have minimal effect of life expectancy. Primary myelofibrosis tends to progress rapidly; however, the course can vary.
Myeloproliferative neoplasia commonly occurs in older adults.
Polycythemia vera results from too much production of red blood cells.
Essential thrombocythemia results from overproduction of platelets.
Myelofibrosis results in scar formation of the bone marrow and affects production of red blood cells, white blood cells, and the platelets.
American Society of Clinical Oncology 2012; 30:2995-3001
Leukemia and Lymphoma 2013
Cancer Journal Clinics 2009; 59:171-191
Lymphoma is a type of cancer that involves the lymphatic system. The lymphatic system makes and stores cells to fight infection. The infection-fighting cells grow out of control and travels to different parts of the body. They often collect in organs called lymph nodes. This leads to swelling of the lymph nodes.
There are 3 basic types of lymphoma.
- Low grade.
- Intermediate grade.
- High grade.
Symptoms of Lymphoma:
The patient usually notices or feels an enlarged lymph node. It is often not painful. It is commonly found in the neck, armpit, and in the groin. Other symptoms include unexplained weight loss, fever, and drenching night sweats.
Testing for Lymphoma:
- A lymph node biopsy wherein a part of the node or the whole node is removed for analysis.
- Bone marrow biopsy. A small sample of the bone marrow is removed and analyzed under a microscope.
- CT scan and/or PET scan to determine the extent of disease.
Patients with lymphoma are treated in different ways. Patients with slow-growing or low-grade lymphomas are sometimes observed. Patients with intermediate grade lymphoma and high-grade lymphoma are treated immediately.
Patients with lymphoma often are treated with chemotherapy alone, chemotherapy with radiation, and in certain cases bone marrow transplantation.
Follicular Lymphoma or Low-Grade Lymphoma:
This type of lymphoma grows slowly. Often, patients are usually observed unless they have symptoms such as fever, unexplained weight loss, drenching night sweats, pain, obstruction of the urinary or digestive tract, or patients that are very weak and tired.
Options for treatment include chemotherapy, immune therapy, radiation therapy, and bone marrow transplantation.
Diffuse large B cell lymphoma is the most common type, approximately 30% of all lymphomas. This lymphoma is fast growing and if untreated this could be fatal. Approximately 60% of patients can be cured. This lymphoma commonly involves the middle aged or the elderly.
Diffuse large B cell lymphoma develops from the first occurrence of lymphoma or from a less aggressive form of lymphoma called transformation.
Patients with diffuse large B cell lymphoma often present with a non-painful and fast-growing lymph node in the neck, groin, or abdomen. This is often accompanied by fever, weight loss, and drenching night sweats called B symptoms. The majority of patients with diffuse large B cell lymphoma are often diagnosed in advanced stages.
Patients usually undergo blood tests, bone marrow biopsy, CT scan, and PET scan to determine the extent of the disease.
Stage Grouping of Lymphoma:
- Stage I – only 1 lymph node region is involved.
- Stage II – 2 or more lymph nodes regions or structures are involved on the same side of the diaphragm.
- Stage III – lymph node regions or structures are seen on both sides of the diaphragm.
- Stage IV – there is diffuse involvement of organs or tissues other than the lymph node structures. Examples are the liver, bone marrow, or lungs.
Treatment for Diffuse Large B Cell Lymphoma:
Patients usually receive chemotherapy plus immune therapy to target a specific group of cells. The most common chemotherapy regimen is called R-CHOP. The first 4 medications are given through the vein for 1 day and prednisone is taken by mouth for 5 days. It is usually given every 3 weeks for 6-8 cycles.
Side Effects of Chemotherapy:
- The most common side effect includes fever with low blood count. This could be a life-threatening adverse effect of chemotherapy. It is known as febrile neutropenia.
- Nausea and vomiting.
- Tumor lysis syndrome. This occurs when the tumor cells die quickly and release toxic byproducts in the blood stream. This is usually prevented by giving fluids and medications before chemotherapy.
- Allergic reactions to chemotherapy.
- Damage to the heart, damage to the nerves, inability to have children, and fatigue.
Radiation is exposing the tumor with high energy x-rays to stop or slow the growth of the cancer. It is usually given daily, 5 days a week, for approximately 3-4 weeks.
Prognosis for Diffuse Large B Cell Lymphoma:
The chance of surviving diffuse large B cell lymphoma depends on several factors: Age older than 60, serum lactate dehydrogenase level higher than normal, poor health status, Stage III or IV disease, and more than 1 involved extranodal disease site reduces survival.
Evaluation for Response:
The patient after completing the planned course of treatment will undergo physical examinations, medical history, laboratory testing, and imaging tests.
The patient is rendered as having a complete response if there is no evidence of disease or symptoms on history and physical examination. The PET scan is negative.
Patients who do not have a complete response are treated for refractory disease.
Followup After Response:
Patients are usually seen on a regular basis after completion of treatment. It involves physical examination, medical history, blood tests, as well as imaging tests such as CT scan.
The majority of recurrent lymphomas occur during the first 2 years after completion of treatment. Patients usually develop symptoms.
Recurrent or refractory diffuse large B cell lymphoma is a term that is used to describe the disease that relapses after responding to initial treatment. Refractory disease is a term used for patients who did not respond to the initial treatment. Patients with recurrent or refractory disease have a very small chance of cure. High-dose chemotherapy followed by transplantation is usually recommended. This will depend on the patient’s underlying medical condition as well as the patient’s age.
American Cancer Society
National Cancer Institute
National Library of Medicine
Leukemia and Lymphoma Society
The ovaries are female reproductive organs that store the egg cells and make female hormones. This type of cancer usually occurs between ages 50 to 65 and sometimes runs in the family.
Risk Factors for Ovarian Cancer:
- Never being pregnant.
- Early age of onset of menstrual period or late age of menopause.
- Family history of breast, ovarian, or uterine cancer.
- Family history of Lynch syndrome (hereditary non-polyposis colorectal cancer).
Symptoms of Ovarian Cancer:
- Abdominal pain.
- Bloating sensation.
- Feeling full.
- Needs to urinate often.
- Enlarging abdomen.
Testing for Ovarian Cancer:
- Blood test called CA-125.
- Ultrasound or CT scan.
- During surgery, a sample is obtained and is read under a microscope. If ovarian cancer is detected, then your doctor will continue surgery to treat the ovarian cancer by removing as much as possible. Usually it involves removing the uterus, both ovaries, and the fallopian tubes as well as analysis of the fluid in the pelvis. If the cancer has spread to other nearby organs, your physician will also remove them.
- Exploratory laparotomy is usually performed for a patient suspected of having ovarian cancer. It is the most accurate in staging and usually performed by gynecologic oncologist. During the procedure, samples of tissues and fluid are taken from the abdominal cavity, the ovaries, nearby lymph nodes, other abdominal organs, surface of the diaphragm, and the omentum. The omentum (fat that covers and connects the organs to the abdomen and pelvis).
Treatment for Ovarian Cancer:
For most patients, surgery is performed first. Then, additional treatment will depend on the Stage, the patient’s age, and other medical issues. Some patients may not need any further treatment or chemotherapy. Others will need additional treatment that includes chemotherapy.
For Patients Who Wish to Become Pregnant:
Tell your physician before undergoing treatment if you plan to be pregnant. This is due to the fact that treatment of ovarian cancer usually leaves the women unable to become pregnant. In certain cases, it is possible to plan treatment so that pregnancy can still happen.
Tumor recurrence is highest in women with more advanced disease at diagnosis and if the initial debulking surgery was unable to remove all visible tumors. Signs of recurrent ovarian cancer include back pain, abdominal bloating, new findings on the scans, as well as rising blood level of CA-125.
Women’s Cancer Network
National Comprehensive Cancer Network
Gynecologic Oncology Group
National Cancer Institute
National Ovarian Cancer Coalition
The pancreas is an organ that makes hormones and regulates blood sugar levels as well as produce digestive juices to breakdown food. It is located behind the stomach.
There are 2 types of pancreatic cancer. The most common type originates in the ducts of the pancreas. This is known as pancreatic ductal adenocarcinoma. The other type is called pancreatic endocrine tumor.
Symptoms of Pancreatic Cancer:
The majority of patients with pancreatic cancer presents with weight loss, abdominal pain with or without yellowing of the skin.
The abdominal pain usually wraps around to the back and sometimes is worse after eating. At times, the stool looks greasy and floats in the toilet bowl because it contains undigested fats.
For a patient with yellow skin and yellowing of the white portion of the eyes, the stool becomes gray in appearance. This is due to the blockage of bowel from the gallbladder.
Diagnosis for Pancreatic Cancer:
The patient will undergo blood tests with a tumor marker called CA19-9. In addition, imaging tests such as CT scan and ultrasound in conjunction with endoscopic retrograde cholangiopancreatography (ERCP) performed. These tests are done in order to determine whether removal of the cancer is possible or not.
This is a test that removes a small piece of the cancer and is examined under a microscope to confirm the diagnosis. This is usually obtained through the ERCP, endoscopic ultrasound (EUS), or CT-guided needle biopsy.
Pancreatic cancer ranges from Stage I, early stage, to Stage IV or late stage. Patients with Stage I and Stage II are usually treated with removal of the cancer with surgery; Stage III known as locally advanced and known as surgically unresectable; Stage IV which is metastatic.
In certain cases, a tube with a camera is inserted through a small incision in the abdomen to obtain more information regarding the location and the size of the cancer.
Pancreas Cancer Treatment:
Early stage pancreas cancer is actually treated and cured with surgery. After the surgery, further treatment known as adjuvant therapy is often recommended. This entails chemotherapy or radiation therapy. However, oftentimes, the pancreas cancer is advanced at the time it is diagnosed.
Surgery for cancer that involves the head of the pancreas usually called Whipple procedure. The surgeon removes the head of the pancreas, first part of the small intestine, a part of the next portion of the small intestine known as jejunum, the common bile duct, part of the stomach, as well as the gallbladder.
Adjuvant Therapy After Surgery:
Adjuvant therapy is performed to prolong survival by eliminating cancer cells before they have a chance to grow. For patients with Stage II and Stage III pancreas cancer, patients are either given combination chemotherapy with radiation therapy or chemotherapy alone. For patients with locally advanced pancreas cancer, they are treated with chemotherapy alone or in combination with chemo and radiation.
Treatment for Stage IV Pancreas Cancer:
Chemotherapy is the recommended treatment to slow the spread of cancer and to relieve symptoms. It does not cure the pancreas cancer. An option is to participate in a clinical trial.
Treatment for Jaundice:
The most common treatment is placing a stent wherein a small tube is inserted into a duct to keep it open. It is performed during ERCP. With pain, the patient is usually given pain medication or at times requires radiation to help shrink the tumor. A celiac plexus block is an option wherein injections of alcohol into the nerves are performed. For patients with weight loss, they are sometimes given pancreatic enzyme replacement to help the body absorb the fat.
National Cancer Institute
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National Comprehensive Cancer Network
The prostate is a male sex gland that produces fluid to form semen. It is in front of the rectum and below the bladder.
Prostate cancer occurs when the cells grow out of control and spread to neighboring organs or through the blood stream and lymphatic system.
An elevated prostatic specific antigen (PSA) usually arises in prostate cancer. The PSA is a protein that is secreted by the prostate gland. If a patient has an elevated PSA, more tests are needed such as a prostate exam and prostate biopsy.
Advanced prostate cancer could spread outside the prostate gland to the lymph nodes or to other distant areas, especially the bones.
Androgen deprivation therapy (ADT) is usually the first treatment for men with metastatic or advanced prostate cancer. It decreases the body’s level of androgen thereby decreasing the size of the prostate gland. ADT can be done by removing the testicles or use of medications.
Side effects of ADT include decreased sex drive, erectile dysfunction, hot flashes, enlargement of the breasts, increase in body fat, loss of muscle mass, and thinning of the bones.
Other therapies include medication that blocks the production of androgen by the prostate gland as well as from the testes and adrenal glands.
National Cancer Institute
National Library of Medicine
Rectal cancer is a type of cancer that affects the rectum. Adenocarcinoma is the most common type of cancer that starts in the rectum.
Testing for Rectal Cancer:
A procedure called colonoscopy is where a tube with a camera is inserted into the anus up to the colon.
Symptoms of Rectal Cancer:
- Blood in the stool.
- Change in the size, texture, or number of bowel movements.
- Dull pain.
- Feeling fatigued.
Options for Treatment for Colon Cancer:
- Surgery to remove part of the rectum that has cancer.
- Radiation therapy.
Once rectal cancer is diagnosed, the next step is staging. This is to describe how aggressive and how far the cancer has gone. It involves your provider performing a physical examination in collaboration with CT scans or MRIs or other tests. Rectal cancer ranges from Stage I to Stage IV. Your treatment will depend on the stage.
Stages I, II, III known as localized rectal cancer are treated with surgery, chemotherapy, and radiation.
The treatment for Stage I rectal cancer surgery alone can cure the cancer.
Stages II and III should be chemotherapy and radiation therapy are typically performed along with surgery. Chemotherapy and radiation are usually given before surgery. Additional chemotherapy is given after surgery.
Stage IV rectal cancer is treated with chemotherapy. In certain cases, surgery to remove the rectal cancer and sometimes the metastases is performed.
Surgery is performed to remove the cancerous part of the rectum as well as the lymph nodes. In certain cases, the anus needs to be removed along with the rectum. Then, an opening called ostomy is performed. The patient will wear a bag over the opening. Ask your surgeon regarding the best surgery for you.
Followup After Treatment:
After completion of treatment, the patient is followed on a regular basis for a number of years to monitor cancer recurrence. A colonoscopy is usually done 1 year after the surgery. If it is normal, then it is performed every 3-5 years. However, if a polyp or new cancer is discovered, then the schedule is adjusted accordingly. The patient is usually seen every 3-4 months for the first 2-3 years and then every 6 months for the next 2 years. A blood test called colorectal cancer tumor marker (CEA) is done with each office visit. A CT scan is usually recommended once per year for at least 3 years for patients with Stage II or Stage III rectal cancer.
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Renal Cancer (Kidney Cancer)
The kidneys are bean-shaped organs approximately the size of your fist, located on each side of the mid back, below your rib cage. They are the organs for eliminating waste material from the blood through urination. They also produce hormones which regulate our blood pressure and our red blood cell production. In the United States, kidney cancer accounts for approximately 4% of all cancer with approximately 13,000 kidney cancer deaths each year.
Symptoms of Kidney Cancer:
Most patients with kidney cancer do not have obvious symptoms; thus, the reason why most kidney cancers are not detected early. The most common symptoms include blood in the urine, flank pain, back, mid back pain, unexplained weight loss, unexplained fever, night sweats, or a mass palpable in the abdomen or in the back.
Kidney Cancer Diagnosis:
Your physician usually will order an ultrasound or a CT scan to assess the kidneys.
Unlike other cancers, biopsy of a kidney mass is not always performed; instead, the kidney is removed by surgery.
The staging system is used to determine the size, how aggressive the cancer is, and to assess the spread of cancer. This will help guide your physician about your treatment and long-term outlook. The staging system is based on how big the tumor, any spread to nearby lymph nodes, or spread to other organs. In general, the lower the stage of the cancer the less aggressive and less likely it is to come back.
Treatment for Localized Kidney Cancer:
The ideal treatment for a patient with localized kidney cancer is surgery to remove a part or all of the kidneys, and if required, to remove the lymph nodes. Further treatment after surgery is not required due to absence of decreasing the chance of the cancer coming back.
Treatment for Advanced Kidney Cancer:
Surgery may be done before medical treatment because surgery usually does not cure the cancer but it helps reduce the symptoms. The most common medical treatment for advanced kidney cancer includes immunotherapy, medicines that reduce the blood supply to slow or stop the growth of the tumor, or targeted treatment; the medicines that inhibit the growth of cancer.
Advanced kidney cancer is hard to cure that is why patients with advanced kidney cancer are encouraged to enroll in clinical trials.
J urol 2009; 182:881.
J urol 2009; 182:2172
Kidney Institute 2005; 67:2069
National Cancer Institute 2008; 113:293
The skin is the largest organ and protects us against germs, regulates body temperature, and covers the internal organs. There are 2 main layers; the epidermis which is the top outer layer, and the dermis which is the thicker layer beneath the epidermis.
Skin cancer generally develops in the epidermis. There are 3 main types of cells in the epidermis; melanocytes, basal cells, and squamous cells.
Skin cancer is usually categorized as non-melanoma or melanoma. The melanoma begins in the melanocytes which is less common but is more aggressive.
The 2 most common types of non-melanoma skin cancers, basal cell carcinoma that rarely spreads to other parts of the body but can be disfiguring. The other type is squamous cell carcinoma that is more likely to spread to other sites of the body.
Both squamous cell carcinoma and basal cell carcinoma develop on the sun-exposed parts of the skin.
American Cancer Society, Cancer Facts and Figures, 2006
Journal of American Medical Association, 2005; 294:681-690
The testicles are the male reproductive organs which are located in the scrotum. Testicular cancer can develop in one or both testicles.
Approximately 95% of cancer of the testicle is known as germ cell tumor. These are further subdivided into seminoma versus non-seminomatous germ cell tumors.
Approximately one-third is seminomas and the remainder is non-seminomatous germ cell tumors.
Men between the ages of 15 and 35 years old are commonly affected. Seminoma occurs slightly in the older age group.
Symptoms of Testicular Cancer:
Majority of patients present with painless swelling in the scrotum or painless lump. Some present with a heavy sensation in the lower belly or around the scrotum or anus. Pain occurs in about 10% of men.
Diagnosing Testicular Cancer:
Patients who detect a lump in their testicle should see their healthcare provider as soon as they can. The patient usually undergoes an ultrasound of the testicle to determine whether the lump or mass is solid or contains fluid. Usually, testicular cancer is a solid mass.
The patient usually undergoes removal of the testicle to confirm the diagnosis. This is often called a radical inguinal orchiectomy.
Staging of Testicular Cancer:
- Stage I testicular cancer means the cancer is limited to the testes.
- Stage II testicular cancer means it has spread to the lymph nodes located in the abdomen.
- Stage III testicular cancer means the cancer has spread to other organs.
Blood is obtained to measure the tumor markers, namely alpha fetoprotein (AFP), beta human chorionic gonadotropin (beta HCG), and lactate dehydrogenase (LDH).
High levels of this tumor marker are suggestive of testicular cancer and are helpful in determining the specific type of testicular cancer. This marker is also used during or after treatment to monitor the disease process.
Most patients with suspected testicular cancer will undergo a CT scan of the abdomen and pelvis and also of the chest. This is to determine the spread of the disease. The most common sites of metastasis include the lungs, liver, bones, and the brain.
- Good prognosis: Men with seminoma usually have a good prognosis even if the cancer has spread to other organs. They usually have a normal alpha fetoprotein. Patients with non-seminomatous germ cell tumor also have a good prognosis if the tumor has not metastasized to other organs except the lungs, and the tumor markers are only mildly elevated.
- Intermediate prognosis: Patients with seminoma have an intermediate prognosis if the cancer has spread to other organs other than the lungs and their alpha fetoprotein is in the normal range. Patients with non-seminomatous germ cell tumors have an intermediate prognosis if the tumor has not spread to other organs than the lungs, and the tumor markers are not significantly elevated.
- Poor prognosis: Men with non-seminomatous germ cell tumor has classified as having a poor prognosis if the cancer has spread to the center of the chest known as the mediastinum, spread to other organs other than the lungs, and if the tumor markers are markedly elevated. Approximately one-half are cured with aggressive treatment even patients with a poor prognosis.
Testicular Cancer Treatment:
- Radical inguinal orchiectomy. This is the first step in diagnosis and treatment. The entire testicle is removed to avoid spreading the disease within the scrotum.
- Adjuvant chemotherapy. This refers to additional anticancer treatments given after surgery to eliminate any remaining cancer cells in the body. This decreases the chance of recurrent cancer and improves survival.
- Lymph node removal called retroperitoneal lymph node dissection. This is performed to remove the lymph nodes in the back of the abdomen where testicular cancer commonly spreads. Alternative to retroperitoneal lymph node dissection includes close physical examination and CT scans. Others are given low dose radiation therapy.
- Radiation therapy. Radiation is often given after orchiectomy for men with seminoma to decrease the chance of recurrence. It may be used after orchiectomy for men with non-bulky Stage II seminoma.
- Most patients with Stage I testicular cancer do not require additional treatment after orchiectomy. However, they need to be closely monitored. For patients who are unable to undergo surveillance, then additional treatment in the form of chemoradiation is given.
Side Effects of Chemotherapy:
- Side effects of chemotherapy include fertility issues. Patients who are preparing to undergo treatment for testicular cancer are counseled regarding semen cryopreservation.
- Short-term side effects include hair loss, nausea and vomiting, as well as fatigue and drop in blood counts.
- Long-term complications include possible kidney damage, nerve damage, lung scarring, and damage to blood vessels in the heart leading to higher risks for cardiovascular disease.
- For patients who had undergone retroperitoneal lymph node dissection, there is a decreased or absent semen in ejaculation.
Side Effects of Radiation:
- Fatigue is the most common side effect and usually not debilitating. Other may experience nausea, vomiting, increased stool frequency, rapid gastric emptying, and tanning of the skin.
American Cancer Society
National Cancer Institute
American Society of Clinical Oncology