oncology

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Microsurgical Resection of Tumor of the Lateral Ventricle:

The surgical management of tumors of the lateral ventricles (LV) and the third ventricle (TV) remains a distinct challenge for neurosurgeons due to the deep and difficult-to-reach location and frequent involvement of adjacent critical neurovascular structures. An appropriate surgical approach should provide adequate operative working space with minimal brain retraction or brain transgression. To accomplish these goals, neurosurgeons may choose an approach that necessitates a longer distance to reach the tumor if it minimizes the amount of brain tissue that is resected or placed at risk by the approach. Furthermore, selection of the optimal approach to ventricular tumors depends on multiple other factors including the size of the ventricles and the tumor, the location of the arterial supply, pathological features of the tumor, and the surgeon’s experience. This video provides an overview of the open surgical operative corridors to the lateral tumors, highlighting the key surgical principles.

Mast cell tumours (grade III mastocytoma, confirmed by fine needle aspiration cytology) in a 6 years old male Jack Russell Terrier. Mastocytoma is a common skin tumour in dogs, and the lumps can have a variable appearance, some may even resemble a lipoma. Their size can quickly change from large to smaller; mast cells release biologically active compunds such as histamine that cause signs of systemic illnes. Agressive surgical excision is the treatment of choice, followed by chemotherapy( lomustine, or, in our case, vinblastin) or radiotherapy. Before and after the surgery, to minimize the risk of a systemic reaction due to histamine release, the patient has to receive antihistamines (hydroxyzine - Atarax and famotidine, a histamine H2 receptor antagonist). Grade III mastocytoma has a guarded prognosis and local recurrence is likely in most dogs. The cause of mastocytoma is unknown.

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Colon cancer patients might improve their chances of survival if they eat nuts along with an overall healthy diet and regular exercise, new study reports.
In a seven-year study, patients successfully treated for stage 3 colon cancer who ate at least 2 ounces of nuts a week had a 42 percent lower chance of their cancer coming back and a 57 percent lower risk of dying from the disease.
This study involved more than 800 patients who had received surgery and chemotherapy for their colon cancer. They all filled out diet questionnaires, including questions regarding the amount of nuts they ate. The patients were followed for about seven years after completing chemotherapy.
Nearly 1 in 5 patients ( around 19 percent) said they ate at least 2 ounces of nuts a week, and researchers found both a lower risk of cancer recurrence and higher overall survival in that group.
However, this benefit was limited to tree nuts such as Brazil nuts, cashews, pecans, walnuts and pistachios. Tree nuts contain high amounts of healthy fatty acids, fiber and flavonoids.

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Blood Test spots Cancer a year early using ctDNA analysis:
Researchers have taken an important step toward better lung cancer treatment by using blood tests to track genetic changes in tumors as they progress from their very earliest stages.
With experimental tests that detect bits of DNA that tumors shed into the blood, they were able to detect some recurrences of cancer up to a year before imaging scans could, giving a chance to try new therapy sooner.
It’s the latest development for tests called liquid biopsies, which analyze cancer using blood rather than tissue samples. Some doctors use these tests now to guide care for patients with advanced cancers, mostly in research settings. The new work is the first time tests like this have been used to monitor the evolution of lung tumors at an early stage, when there’s a much better chance of cure.

MRI scan of a 4 year old with medulloblastoma. The child presented with vomiting and ataxia, and upon scanning a well defined enhancing mass was found in the fourth ventricle.

Medulloblastoma is far more common in children than in adults, and typically starts in the cerebellum and can metastasise to other areas of the brain or spinal cord. The most common symptoms are vomiting, headaches, nausea, problems with balance, and visual problems.

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FDA approves New Combination Treatment for Acute Myeloid Leukemia (AML):
The U.S. Food and Drug Administration approved Rydapt (midostaurin) for the treatment of adult patients with newly diagnosed acute myeloid leukemia (AML) who have a specific genetic mutation called FLT3, in combination with chemotherapy. The drug is approved for use with a companion diagnostic, the LeukoStrat CDx FLT3 Mutation Assay, which is used to detect the FLT3 mutation in patients with AML.
AML is a rapidly progressing cancer that forms in the bone marrow and results in an increased number of white blood cells in the bloodstream.
Rydapt is a kinase inhibitor that works by blocking several enzymes that promote cell growth. If the FLT3 mutation is detected in blood or bone marrow samples using the LeukoStrat CDx FLT3 Mutation Assay, the patient may be eligible for treatment with Rydapt in combination with chemotherapy.

Cancer pt 1

A cancer-y overview

  • the second most common cause of death in developed countries 
  • 29% of all mortality (13% worldwide) 
  • 12.7 million cases, 7.6million deaths in 2008 
  • 14.1 million cases 8.2 million deaths in 2012 

Tumours originate in epithelial cells, cells of the blood and lymph system, connective tissue cells and neural cells

Hallmarks of cancer

Genetic Factors

  • Cancer Producing Genes are known as oncogenes - “Any mutated gene that contributes to neoplastic transformation” 
  • These genes are activated in cancer 
  • Often promote cell growth & survival 
  • “Remove the brakes” from normal tissue homeostasis 
  • Often repress cell death and differentiation
  • Result = lots more cells

Oncogenes

Prior to mutation these are known as “Proto-oncogenes”. Activation can occur by altering gene expression or protein structure (e.g. constitutive activation). Many common oncogenes promote mitosis/progress through cell cycle OR the evasion of death signals.

Activation is caused by genetic changes, including:

  • Point mutations: can result in production of an abnormally functioning protein product.  
  • Deletions: of a few base pairs to loss of an entire chromosome 
  • Gene amplification: resulting in excessive production of oncogene product 
  • Chromosomal translocations: gene is activated inappropriately by another promoter region; caused by rearrangement of parts between nonhomologous chromosomes

Active oncogenes are found in tumours and are thought to be early events in malignant transformation.

Environmental Factors

Carcinogenesis - the process of initiating and promoting cancer

  • Initiationirreversible genetic alteration of a cancer-related gene (oncogene or tumour suppressing gene (TSG)) 
  • Promotion – clonal expansion of the initiated cell (i.e. stimulation of growth) 
  • Progression – stable alteration of an initiated cell. Gaining ability to invade and metastasise 

Carcinogenic agents (will go into detail in future posts)

  • Chemical Carcinogens 
  • Dietary factors 
  • Biological 
  • Viruses
  • Physical 
  • Exposure to ionising radiation

Following exposure to a carcinogenic agent there can be a long latent period before neoplasia develops. This is because the steps of carcinogenesis must be in the right order (initiation, promotion, progression). eg if exposed to a promoter and then an initiator, all is good until exposed to another promoter after the initiator.

Saw one of my fairly stable patients on a Friday, chatted and joked with her and her family in the clinic. She died within a week from CNS progression of her multiple myeloma despite intrathecal and systemic chemotherapy. Life comes at you fast around here…

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FDA Approves Keytruda for all Cancers with specific Genetic changes:

The U.S. Food and Drug Administration granted accelerated approval to pembrolizumab (Keytruda) for adult and pediatric patients with unresectable or metastatic, microsatellite instability (MSI) or mismatch repair deficient (dMMR) solid tumors that have progressed following prior treatment and who have no satisfactory alternative treatment options or with MSI-H or dMMR colorectal cancer that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan.
This is the FDA’s first tissue/site-agnostic approval.

Here’s something worth sharing, last words from our oncology lecturer Dr. Gracieux Fernando. This actually gave me chills, it’s as if our generation is being addressed. You may belong to another field, may be medical too, but even when you’re not, this is a reminder that the future is our responsibility. Let’s all strive hard and be the best! Fight! :)  

“I may not be here 20 or 30 years from now.  You certainly will.  So I envy your generation so much because you will see the future. A future that I can only guess at as being a possibility.  I feel like I am like Moses.  I can see the promise land, but I will not cross its borders and enjoy the fruits of its trees.  That is up to you.  And that’s why I take efforts to teach you as much as I can about these diseases.  Because as the epidemiology of cancer rises from 1:7 to 1:4 to 1:2 as an incidence rate, it becomes an even greater problem for you rather than for us.  And so, because I want to help these people and I only have a finite lifetime to do it, I task it all to you.  You are my tools to continue my service in the cause of fighting this disease.  When I am gone, you carry on.  And hopefully, everything that I have taught you, if I can even convince one or two of you to come and join us in fighting this disease, then I have done enough in the service of oncology.  I will know that cancer patients will be taken care of when I am no longer practicing.  The underlying reason in my quest of teaching you, is that in the future, if I myself, God forbid, will be fighting this disease across the other side of the table, when I look up, I will see one of your faces and say, ‘Okay, I am in good hands.’  If you can do that for me, everything that I have done for the past 15 years that I have been teaching UERM students in this institution will have been worth it and it will be my legacy.” 

About Me

Hello Everyone!  

As promised, here is a little more about me and my PA School journey.  I will probably have several posts that will go into more depth about certain things, but first we must cover the basics.

Who: 25 year old female (staying somewhat anonymous so I can honestly discuss my program and experiences) Just call me Miss PA-S :)

Where: I am from Texas, but am attending a PA school out of state.

Major: I originally started out as a biomedical engineering major, but upon discovering how much I despised physics, I knew I needed to change my path.  I really love the aspect of communicating between doctors and engineers, but wanted to be more directly involved in patient care.  I changed my major to allied health, which was basically a health degree that allowed enough electives to pursue graduate school but also provided me with a strong background in health education.  

Undergrad: I was fortunate to shadow an ER PA my junior year of college who was incredible and really solidified my decision for me.  I also spent my senior year volunteering in outpatient surgery which was great because I got to observe a ton of procedures. I also had a TON of volunteer hours from my church group, was a member of several health societies and a pre-PA society.  

How many times did I apply to PA School?  In total, I applied 3 different cycles.

The first time was during my senior year in which I got no interviews.  The second was after I had graduated and I got 1 interview and then sat on a waitlist for 9 months. The third time (was a charm) and I also applied to 10 different programs in and out of state.  Previously I had really only applied in state, but then realized I will be in debt regardless of where I go and the certification is national so why not look for a great program that fit me?! 

The 3rd cycle I received 6 overall interviews in 5 different states.  Attended 4 interviews in 4 different states, got into the program I am in now which immediately became my first choice after visiting.  I was waitlisted everywhere else I interviewed at but quickly offered a spot at the only program I got into in Texas.  I choose to go with my initial gut feeling and really felt the program I am currently in, though significantly more expensive, was the best fit for me and the provider I wanted to become. There were a lot of other reasons too that will be discussed in a future post :)

So, you may have noticed that there was basically a 2 year gap between when I graduated college and when I finally started getting my Masters. What did I do in the meantime to boost my application? SCRIBING!

I was an ER scribe for over a year at a level 1 trauma center in Dallas and that experience was so incredibly overwhelming at the time, but seriously I am so much better off in school because of everything I learned.  Again, how scribing helped me get into school and succeed when I felt so lost warrants a post of its own. I also spent 6 months as a clinical coordinator at a family practice to boost the leadership aspects on my application but hated the administration part of things.  After I got into school, I received a sweet offer to come back as a traveling scribe trainer to help set up new teams, and that is what I did until I had to pack up my life, move to a new place all alone and finally start living my dream!

Current year in school: Just finished my first year of pre-clinical. So 3 more months, then clinical rotations start in August and I will graduate December 2018.

Current interests? I still love the ER as that is where I feel the most at home and could definitely see myself going into that after graduation. So far I really enjoyed oncology (may use my elective here) and GI (no one more surprised than my dad lol). I enjoyed the time I spent observing surgeries, but none of it was general and we just finished a fiasco of a surgical course so feeling very hesitatant about that right now.  Also, strongly considering primary care. As I mentioned, my background is heavy in health education and I really value my ability to communicate with my patients and physicians, as well as be involved and primary care affords me that opportunity.  I am currently in a largely under-served area and state, which will be a great test during rotations to see if I love it and how capable at it I am.

That is all I have for now! Looking forward to posting some more and being a sounding board for my colleagues and helping people out with questions as I can who are going through this terrifying process as we all have. Best of luck to you all!

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FDA expands use of Stivarga to treat Liver Cancer (HCC):
The U.S. Food and Drug Administration expanded the approved use of Stivarga (regorafinib) to include treatment of patients with hepatocellular carcinoma (HCC or liver cancer) who have been previously treated with the drug sorafenib. This is the first FDA-approved treatment for a liver cancer in almost a decade.

According to the National Cancer Institute, approximately 40,710 people will be diagnosed with liver cancers in 2017 and approximately 28,920 will die of these diseases. HCC originates in the liver and is the most common form of liver cancer.

Stivarga is a kinase inhibitor that works by blocking several enzymes that promote cancer growth, including enzymes in the vascular endothelial growth factor pathway. Stivarga is also approved to treat colorectal cancer and gastrointestinal stromal tumors that are no longer responding to previous treatments.