Lodovico Balducci MD Senior Member Emeritus Moffitt Cancer Center Tampa FL Clinical Case 83 year old man with cough CT chest reveals a 3 cm mass Left Lower Lobe Biopsy reveals an adenocarcinoma primary lung ID: 916408
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Slide1
General strategies of Cancer Treatment and evaluation of Response
Lodovico Balducci M.D.Senior Member EmeritusMoffitt Cancer CenterTampa, FL
Slide2Clinical Case
83 year old man with coughCT chest reveals a 3 cm mass Left Lower LobeBiopsy reveals an adenocarcinoma primary lungPS 1; Lives alone, Independent ADL IADL
Slide3Clinical Case
ROS: osteoarthritis, type II DMPMH: MI age 65: CABPG; quit smoking Colon cancer stage II age 71; surgery Fracture right tibia age 19 Appendectomy age 41
Slide4Clinical case
HB 13.8; Ca 10.1Physical exam:Lung moving 3 cm bilaterallyDeformity Left kneeOverweight
Slide5Strategy of cancer treatment
CLINICAL DECISIONS
Patient
Life expectancy
Treatment tolerance
Goals
Cancer
Stage
Aggressiveness
Treatment Sensitivity
Tumor sanctuary
Treatment
Effectiveness
Toxicity
Slide6What do we want to know
Stage: PET scan; CT scan, MRISensitivity to treatment:EGFR mutationRos MutationALK mutation
RAS mutation
PDL1
Slide7What will we do with the information
Local disease: surgery; radiosurgery, ablationMetastatic disease: systemic treatment according to sensitivityLoco-regional disease: combination of local and systemic treatmentBrain metastases: may add radiation
Slide8Forms of cancer treatment
Loco-regional treatmentSurgeryRadiation Therapy
Loco-regional infusions
Local ablation
Systemic treatment
Hormonal therapy
Cytotoxic chemotherapy
Targeted therapy
Immune check-point inhibitors
Vaccines
Radio-isotopes
Slide9Examples of tumor markers
Lung: Ras, Ros, EGFR, ALKBreast: hormone receptors, HER, BrcaColorectal: Ras, MSIAll MSI?
Slide10New techniques to
assess cancerCirculating tumor
cells
Liquid
biosy
Molecular response in
hematological
malignancies
Slide11Adjuvant and neoadjuvant treatment
65 year old woman with a 2 cm tumor of the left breastHas breast sparing surgery. LNs are negativeTumor is positive for ER and PR and negative for HER
55 year old woman with a reddened mass of the left breast, adherent to the chest wall and edematous left upper extremity
No distant metastases; ER-PR-
Slide12Clinical case
79 year old man with colon cancer metastatic to the liver . Previously controlled with chemotherapy but now disease is progressingMSI negativeWants to live 6 more months to the wedding of his granddaughter
Slide13Evaluation of response
to treatmentMetastatic disease
Adjuvant
Treatment
Neoadjuvant
treatment
Slide14Evaluation of response: Metastatic disease
Measurable disease
Change in size (RECIST)
Vitality
New lesions
Time to progression
Survival
CTC
Liquid Biopsy
non-
measurable
disease
DisappearanceVitalityNew lesionsTime to progressionSurvivalCTCLiquid biopsy
Slide15Evaluation of response: adjuvant and neoadjuvant
NeoadjuvantChange in
size
Vitality
Disease
free
survival
Survival
Adjuvant
Disease
free
survival
Survival
Slide16Conclusions
Treatment related decisions include assessment of patient’s condition and goals, stage of diseases, sensitivity to treatment and treatment toxicityAssessment of response in the presence of measurable disease involves: size, tumor vitality, time to progression and survivalAssessment of response in the adjuvant setting includes disease free survival and overall survival