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Dec 05, 202336 min read

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PANCREATIC_ADJ

Pancreatic head (uncinate process) ductal (M/D) adenocarcinoma s/p laparoscopic Whipple operation on 2017/00/00, pT3N1(1/9)M0, stage IIB, margin involved by invasive carcinoma, LVI+, perineural invasion+, vascular invasion -, 2017/00/00 CT post-op changes

  • Initial presentation:
  • Treatment plan: adjuvant chemotherapy
  • Follow up parameter: CA-199, abdominal CT scan
  • 2017/00/00: The purpose of adjuvant treatment is to improve DFS and OS but not 100%. Adjuvant treatment should be administered to patients who have not had neoadjuvant chemotherapy and who have adequately ercovered from surgery; treatment would be initiated w/in 12 weeks. If systemic chemotherapy precedes CCRT, restaging with imaging should be done after each treatment modality. Patient who have recieved neoadjuvant CCRT or chemotherapy may be candidates for additional chemotherapy following surgery and multidisciplinary review. The adjuvant therapy options are dependent on the response to neoadjuvant therapy and other clinical considerations.
  • 2017/00/00 Explain adjuvant chemotherapy treatment option, such as Gem alone (CONKO-001 study, 1000mg/m2 D1,8,15, q4w for 6 months, OS HR:0.76), 5FU/LV (425/20 IV bolus D1-D5 QM for 6 months, mOS 23.6 month), and GEM + capcitabine (1660mg/m2 D1-D21, Q4weeks, HR 0.82). Explain indcution chemotherapy followed by CCRT followed by subsequent chemotherapy: GEM/5FU ⇒ CCRT with 5FU or GEM ⇒ GEM/5FU. Explain CCRT with weekly 5FU/LV @ Explain treatment options, after

AMPULLA

Ampulla of Vater adenocarcinoma,(W/D), pT3N1(3/15)M0, stage IIB (AJCC 7th), invade duodenal wall and pancreas, negative washing cytology s/p Whipple and feeding jejunostomy on 2015/6/29, LVI+, perineural invasion -, post op complicated with gastroparesis, UGIB

  • LNs (3/15 totally): positive for metastasis [3/15 (peri-tumoral LN: 2/5, peripancreatic LN: 1/3, perigastric LN: 0/3, CBD LN: 0/1, SMA LN: 0/1, LN8+9: 0/1, LN12P: 0/1, LN12A: 0/0)] with extracapsular spread.
  • Initial presentation: obstructive jaundice at CGMH on 2015/4 s/p stenting
  • Treatment plan: adjuvant chemotherapy will be started post op 4~6 weeks:
  • Feeding: jejunostomy tube ~2015/8/14
  • Follow up parameter: abdominal CT scan (2015/7/6: Peritoneal stranding and small fluid collection in the upper abdomen.Distended stomach. Ileus.) and tumor marker
  • 2015/8/14: the purpose of adjuvant chemotherapy is to prolong disease free survival and overall survival and decrease risk of recurrence and distant mets but not 100%. Explain adjuvant chemotherapy regimen of 5FU D1-D5 (425mg/m2) IV, LV (20mg/m2) Q4W for 6 cycles or self-paid gemcitabine 1000mg/m2 IVF 30 min QW for 3week on 1week off for 6 cycles to reduce risk of mortality by 30% @ Consider start treatment, arrange admission for 5FU D1-D5 (425mg/m2) IV, LV (20mg/m2), check lab and tumor marker @ vascular assessment, nutritional assessment before chemotherapy, pharmacist education

ANAL

Anal cancer, SqCC, cTxNxM0, dx on 2010/00/00

  • Initial presentation:
  • Treatment plan: definitive CCRT and longterm observation
  • 2010/00/00: Explain the purpose of neoadjuvant CCRT, the goal is to decrease recurrence/metastasis as possible, not guarantee cure!! Thus regular follow up is still needed.
  • 2010/00/00 Explain the rationale and strategy with CCRT followed by longterm observation. CCRT (5 weeks) with C/T during week 1 nd week 5. C/T regimen with Mitomycin-C(10mg/m2)/5-FU. Side effects included GI upset(N/V, diarrhea, mucosotis, anal area dermatitis), hair loss, marrow suppression, infection…
  • RT scheduled since 00/00~ @ Arrange admission for #1 MMC(10mg/m2)/5-FU(1000mg/m2) on 00/00 and check lab, and arrange admission @ Vascular assessment (PICC), nutritional assessment before chemotherapy, pharmacist education @ GYN check for risk of cervical cancer and check HIV, explain to patient. Explain AEs of MMC/5FU 5FU: **diarrhea (55%), hand-foot syndrome (15-20%), nausea/vomiting, elevations in LFT, and myelosuppression MMC: ** myelosuppression, nausea/vomting, mucositis, potent vesicant (extravasation can lead to tissue necrosis and chemical thrombophlebitis at the site of injection), anorexia, fatigue, HUS in rare events, intestinal pneumonitis, hepatoveno occlusive disease, and chemical cystitis and bladder contraction. **Emphasize the importance of nutrional support (high protein diet) during C/T period.

APTT

Comfirmed COVID on ?

*COVID-19 Vaccination history?

APTT prolongation, nature?

  • LMP on 2022/11/26, no menorrhgia @ Operation is okay @ APTT prolong, do further survey as uptodate suggested below. @ Do mixing test, if correctable then check factor VIII, IX, or XI. Check for DIC profile as well. If the mixing study fails to correct, we test for the presence of a lupus anticoagulant and factor VIII activity (the latter to detect a rare patient with acquired hemophilia A). @ Survey for autoimmune disease and lupus anticoagulants (APTT prolong with lupus anticoagulant+, do confirmatory test with anti-cardiolipin (aCL) and anti-B2-GP1 IgG and IgM test.). Check VWF antigen and activity (need to send to 榮總) @ Follow up 1 month with APTT. @ Do upper abdominal sono to rule out splenomegaly

APTTPT

Mild PT and severe APTT prolong, etiology to be determined, mild easily ecchymosis recently, no but menorrahgia, suspected asymptomatic lupus anticoagulant, rule out factor deficiency, rule out super wafarin intoxicification but not likely

  • No chinese medicine or other drug exposure except drinking some collagen fiber
  • Previous APTT/PT data if available @ do mixing test @ check for factors IVVV, IX, or XI, and lupus anticoagulant activity @ Check PT/APTT again on ? **If the aPTT is prolonged and the PT is normal, we do a mixing study. If the mixing study corrects, then we perform assays for factors XII, XI, IX, and VIII. Even though factor XII deficiency is not associated with bleeding, it may explain a prolonged aPTT that corrects with mixing. If the mixing study fails to correct, we test for the presence of a lupus anticoagulant and factor VIII activity (the latter to detect a rare patient with acquired hemophilia A).

Adrenal

Dear doctor: This is a patient of esophageal cancer under Pembrolizumab and PF since 2020/12/15. Cortisol level on 12/17 was 1.74ug/dl. However, the patient did not have symptoms suggestive of adrenal insufficiency until days ago when he suffered from shock. He had better appetite today. My opinion is check AM Cortisol and ACTH tomorrow (before 10AM). If cortisol level is still low, you may give him Solu-Cortef 50mg iv stat, than observe the response of blood pressure. If his blood pressure becomes normalized after Solu-Cortef, physical dose supplement of cortisone acetate (25/12.5mg bid) may be necessary. Please contact with me for further management.

BCADJ

Left breast cancer, IDC, s/p MRM, WE+SLNB, SM+SLNB on 2010/00/00, pT2(2cm)SLN0(0/3)M0, NG2, LVI, ER/PR/Her2-neu: 8/8/0, FISH: ,Ki-67 %

  • Menopause, Premenopause
  • Adjuvant chemotherapy: CAF X 6, AC X 4 ⇒ T X 4, Herceptin for 1 yr
  • Consult RT
  • Letrozole x 5 years, Tamoxifen x 5~10 years or consider LHRH agonist + AI for 5 years
  • 2020/00/00: explain purpose of adjuvant treatment is to reduce further risk of local recurrence and distant mets, but not 100% @ Offer oncotype DX for evaluation but self-paid @ Arrange #1 CAF/AC on 00/00 (4~5th week), RTC on 00/00 and check lab for prechemotherapy evaluation @ Olanzepine HS self-paid, akyenzo, dexam, and primperan for emeis. @ Do cardiac echo if has risk factor @ Vascular assessment, rehabilitation, nutritional assessment, dental check before chemotherapy

BCADJH

Left breast cancer, IDC, s/p left SM+ALND on 2020/00/00, pT2(3.3cm)N1mi(1/9, 1.5mm)M0, NG3, LVI-, ER0, PR0, HER2-neu 3+

  • Menopause, premenopause
  • Adjuvant chemotherapy: AC X 4⇒ T X 4/8, Herceptin for 1 yr
  • Consult RT
  • Port A implantation on 2020/00/00
  • 2020/00/00: explain purpose of adjuvant treatment is to reduce further risk of local recurrence and distant mets, but not 100% @ Arrange #1 ? on ?, RTC on ? and check lab @ Vascular assessment, nutritional assessment (high protein diet), consult rehabilitation, dental check and pharmacist education before chemotherapy @ Olanzepine HS self-paid, akyenzo, dexam, and primperan for emeis. @ f/u 2-D echo Q4~5M under herceptin (2020/00/00 EF:%)

BCFU

BC follow up strategy: PE Q3M for 1 years then Q6M for 4 years then Qyear Annual exam Qyear and mammo/breast sono in between for 5 years and then alternatively** *Bone scan during annual exam for stage III disease *For BCS patient, if radiation therapy was given, the 1Y mammogram should be postponed to at least 6 months after finish of radiation therapy *No breast sonogram is indicated for those patients whose mammogram showed to be fatty or scattered fibroglandular. For those mammogram showed to be heterogeneous or extremely dense, do sonogram of breast at 1.5Y, 2.5Y, 3.5Y, 4.5Y **For those mammogram showed to be heterogeneous or extremely dense, do sonogram of breast alternatively with mammogram at yearly interval. For those patients whose mammogram showed to be fatty or scattered fibroglandular, do yearly mammogram.

BCMET

Right breast cancer, IDC, NG?, ER/PR/HER2-neu: ///, DISH?, ki67?%, diagnosed on 2010/00/00, cT4bN3cM1, with skin carcinomatosis, liver, lung, and bony mets, complicated with ? s/p ?

  • menopause, premenopause
  • Initial presentation: palpable right breast mass since 2014/3
  • Follow up parameter: CT scan, bone scan, CXR, liver sonography, breast sonography, CEA/CA153 if elevated
  • 2020/00/00 Palliative chemotherapy, targeted therapy, and RT is suggested. Palliative chemotherapy or hormonal therapy if no visceral crisis. The purpose of treatment is not to cure but symptom relieved and improve Quality of life and prolong survival.
  • 2020/00/00: Explain regimen of chemotherapy such as pertuzumab + herceptin + taxotere or taxol for dual blockade reimbursement
  • Treatment plan:
  • 2020/00/00 Right/Left port A implantation @ pathology review (but no pathology reports) @ CT report sharing @ Give cycle ? @ Explain to give denosumab, supplement with Ca and Vitamin D3, inform ONJ, refer to dentist OPD and then need f/u Q36M. @ Arrange #1 ? on , RTC on ? and check lab for prechemotherapy evaluation @ Vascular assessment, rehabilitation, nutritional assessment (high protein diet), dental check, and pharmacist education before treatment @ Follow up 2-D echo Q45M if under herceptin (2016/00/00 EF:%)

BMD

BMD (2021/4): Lumbar spine: T-score: -2.0 (LOW BONE DENSITY); Right hip: T-score: -2.9 (OSTEOPOROSIS)

BREASTPE

Breast physical exam: Right

right breast : “palpable mass, over OUQ 10*8 cm” right axilla : no palpable mass right subclavian : no palpable lesion right nipple : no discharge , no depression Operation scar : Nil

Left

left breast : no palpable mass left axilla : no palpable mass left subclavian : no palpable lesion left nipple : no discharge , no depression Operation scar : Nil

Bruising

Easy bruising for how long

  • Ask about present complain: how long how freqeutnly has easy brusing occurred? Is it ecchymoses or purpura? How extensive are bruises? Are they located in areas subject to trauma (limbs) or pressure (waist band)? Do petechiae occur? Are bruises painful? How long to resolution? How many currently?
  • Associated symptoms: gum bleeding? prolonged bleeding after skin trauma, dental extraction, childbirth, or surgery? Epistaxis? Menorrhagia? Joint or soft tissue hematoma, hematemesis, melaena, hemoptysis, or hematuria? Is there a history of poor wound healing?
  • Family history:
  • Drug history: aspirin or anticoagulant therapy? medication or supplements
  • Systemic enquiry: hemorrhagic tedency such as hepatic, renal failure, malabsorption, leukemia, connective tissue disorder, or amyloid
  • PE: senile purpura, True purpura is easily D/D from erythema and telangiectasis by pressuer. Splenomegaly or lymphadenpathy in leukemia, s/s of hepatic failure, telangiectasia in Osler-Rendu-Weber syndrome or hyperextensible joints and apper-thin scars in Ehlers-Danlos syndrome. @ Check coagulatory function (CBC-DC, PB SMEAR, APTT/PT, TT/fibrinogen/bleeding time) and basic lab and CXR. @ D/D -Common diagnosis: simple easy bruising; trauma; senile purpura -Hemostatic defects: thrombocytopenia; plt function defects; coagulopathy (rarely) -Vascular defects: corticosteroid excess; collagen disease; uremia; dkysproteinemia; anaphylactoid purpura; Ehlers-Danlos syndrome; scurvey; vasculitis

CCC

Cholangiocarcinoma, with liver mets and malignant ascites, cytology on 2017/1/11 negative, biopsy on 2017/1/20, GYN check negative, Colonscopy and EGD negative s/p gemcis (2017/1/24~2/21), clinically disease progression, suggest 2nd line FOLFOX or immunotherapy

  • Initial presentation:
  • Treatment plan:
  • Follow up parameter: CT scan, CA-199, CEA
  • 2010/00/00: the purpose of palliative chemotherapy is to control disease and prolong life and maintain quality of life but not cure. Explain high risk for bowel obstruction, biliary obstruction, infection, and need frequent paracentesis due to ascites and etc
  • 2010/00/00: explain palliative chemotherapy treatment option, such as Gem-based, 5FU-based. 1st line treatment suggested Gemcis or gemox or gem alone depends on performance status. @ Start palliatve chemotherapy on ?, explain treatment options. @ Vascular assessment, nutritional assessment, dental check before chemotherapy, pharmacist education @ Check viral marker before treatment @ 申請重大傷病

CHEMOAE

side effects of chemotherapy nausea, Gr. 0 vomiting, Gr.0 mucositis, Gr.0 diarrhea, Gr. 0 alopecia, Gr.0 fever: (-) numbness:Gr.0

CRCADJ

Sigmoid colon cancer s/p laparoscopic anterior resection on 2010/00/00, pT3(1.1cm)N0(0/14), M/D adenocarcinoma, LVI present, perineural-, CEA not elevated, MSS

  • Initial presentation: OB+ during routine screen
  • Treatment plan: adjuvant chemotherapy will be started post op 4~6 weeks
  • 2010/00/00: Explain the concept of adjuvant chemotherapy, the goal is to decrease recurrence/metastasis as possible, not guarantee cure!! Thus regular follow up is still needed.
  • Stage II MSI-H patients may have a good prognosis and do not benefit from 5-FU adjuvant therapy.
  • offered chemotherapy regimen with mFOLFOX6, bi-weekly for 12 cycles, self-paid oxaliplatin
  • alternative options included <1> Xeloda(吃2休1) x 8 cycles but self-paid <2> Weekly 5FU/LV, (打3休1) for 8 cycles <3> UFT(UFT 300mg/m2 and LV 30~90mg/m2, D1-D28, 1 wk rest) for 0.5 to 3 year @ Arrange admission for #1 mFOLFOX-6 on ? and check lab. @ Vascular assessment, nutritional assessment, dental check, pharmacist education before chemotherapy.

CRCCHEMOAE

**Bevacizumab AEs: risk of arterial thromboembolic events, including MI and stroke esp in pts with age >=65, hx of angina, stroke, and prior arterial thromboembolic events; GI perforation and wound-healing complications, pulmonary hemorrhage rare, hypertesion, proteinuria with nephrotic syndrome, influsion reaction, CNS events with dizziness and depression **Cetuximab AEs: infusion rnx, pruritus, dry skin, acneiform skin rash, interstitial lung disease <1%, and paronychia when prolonged use **Irinotecan: myelosuppresion, diarrhea (dose-limiting), mild alopecia, and risk of developing GI toxicity if patients has UGTIAI 7/7 genotype **Emphasize the importance of nutrional support (high protein diet) during C/T period.

CRCFU

CRC follow up strategy: PE Q6M for 5 years CEA Q3M for 2 years and then Q6M for 3 years and then Qyear CXR Qyear for 5 yr Whole abdominal CT Qyr for 5 yr Sono of liver 6 month post op once and then Qyear Colonscopy Qyear for 2 years and then Q3year Chest CT for resected lung mets Qyear

CRCM

CRC, sigmoid colon cancer, ? cm AAV (M/D) adenocarcinoma, s/p ? on 2016/00/00, pT3N2b(9/26)M1 with liver mets, RAS wild type

  • Initial presentation: stool OB positive on 2014 but neglected, bloody stool since 2016/5~
  • Treatment plan: palliative chemotherapy
  • Follow up parameter: abdominal CT scan, and sigmoidoscope, CEA and CA199 if elevated
  • 2017/00/00: The purpose of palliative chemotherapy is to control disease and prolong life and maintain quality of life but not cure. Possible late complication, if without treatment or progression despite treatment was told. i.e. liver mets progression, then jaundice, BTI, altered mentation… even life threatening hepatic failure… i.e. lung mets progression, then cough, dyspnea, infection… even life threatening respiratory failure…
  • 2017/00/00 Explain palliative chemotherapy treatment options. Sequential lines of treatment to maximize efficacy/minimize toxicity of each line treatment to control disease for as long as possible. Explained choices of adding target agent including to increase the response of chemotherapy. But the effect might last months only. Regimens such as avastin (NHI reimbused in 1st line oly)+ FOLFIRI in KRAS mutation/wild type or cetuzimab (NHI reimbursed in 1st and 3rd line only) + FOLFIRI in RAS wild type only. Chemotherapy will be started postop 4~6 weeks. @ consult NS for port A implantation @ Start palliatve chemotherapy, explain treatment options, after discussion, patient prefer ? discuss next time @ Apply for avastin, add >6 weeks from surgery @ Arrange admission on for #1 FOLFIRI treatment and check lab (90% dose reduction and omit 5FU bolus) on ? @ Check RAS, HER2-neu, BRAF, and MSI status @ Check UGT1A1 (3ml in EDTA) for irinotecan. @ vascular assessment, nutritional assessment, dental assessment before chemotherapy, pharmacist education

DTIC

DTIC alone (250mg/m2/day) or 5FU 500mg/m2/day + DTIC 200mg/m2/day for 3 days QM; DTIC 400mg/m2 + LV 200mg/m2 + 5FU 400mg/m2 D1-D2 + HDFL 1200mg/m2 D1-D2 Q3W; DTIC 250mg/m2 + 5FU 450mg/m2 D1-D5 Q3W

ESOCA

A+B+C

Esophageal ca, M/D SqCC, dx on, middle third, ?cm from incisor, cT3N2MX, stage IIIAB (LN: )

  • Initial presentation:
  • PET CT:
  • EGD:
  • ENT field negative for second primary tumor
  • Tolerate solid or liquid food
  • Treatment plan: preop/definitive CCRT
  • RT schedule: 4500cGy/25fx, started on 2018/00/00
  • 2010/00/00 Explain that esophageal cancer is a high risk disease, relative refractory to chemotherapy, surgery is the key role for this treatment. CCRT followed by OP may benefit patient with near 50% survival at year 5, but even definitive CCRT (without surgery) only provides patient with 15% survival at year 5. Emphases that there would be up to 25% chance refractory to CCRT, so that the following surgery would become impossible and the prognosis would be very bad.
  • Induction CCRT with P(60)F(600) on W1 and W5 or optional carboplatin (ACU 2) + taxol (50mg/m2) ON D1, 8, 15, 22, and 29
  • Set up feeding route: G-tube or NG @ Arrange W1 PF on the day of RT @ Arrange G-tube feeding on the day of admission @ Vascular assessment, nutritional assessment (consult nutritionist after G-tube setpup for feeding education), dental check, pharmacist education before chemotherapy.

ESRD

Recommendations on the management of the clinical frequently used chemotherapeutic agents in patients undergoing dialysis according to Janus et al and Tomita et al *5FU standard dose After HD *Capecitabine reduced 50% *Cisplatin reduced 50-75% After HD *Cyclophosphamide reduced 25% After HD *Docetaxel 65mg/m2 before or after HD *Doxorubicin standard dose After HD *Epirubicin standard dose After HD *Etoposide reduced 4-50% before or after HD *Gemcitabine standard dose 6-12 hours before HD *Ifosfamide not recommended *irinotecan reduced to 50mg/m2/week after HD *MTX reduced 75% after HD *Oxaliplatin reduced 30% after HD *Taxol standard dose before or after HD *Vcb reduced 25-33% after HD

EYE

OD (right eye); OS (left eye); OU (both eyes)

FL

NHL, follicular lymphoma, low-grade, Ann Arbor stage IV XEA with bone marrow involvement dx on 2010/00/00, IPI 1 (low), FLIPI-2 (intermediate)

  • Initial presentatin:
  • CT scan on 2010/00:
  • PET-CT on 2010/00/00:
  • Treatment plan:
  • Follow up parameters: CT scan, PE, tumor marker
  • Port A implantation on 2015/00/00 @ Vascular and nutritional evaluation before chemotherapy. Pharmacist education before chemotherapy @ Do staging workup @ PET-CT on @ Check basic labs, tumor marker, and viral marker @ Arrange bone marrow study @ 開立重大傷病 @ discuss patient in hematology tumor board meeting

GB

Gallbladder cancer, adenocarcinoma (W/D), LVI-, perineural-, pT2N1(7/9)M0 (AJCC 7th), s/p laparoscopic cholecystectomy

  • LNs (7/9): regional lymph nodes (tumor base) (7/7), peri-CBD lymph node (0/1), group#8a(0/0), group12a(0/0), group12b(0/0), mesentery LN(0/1)
  • Initial presentation:
  • Treatment plan: adjuvant chemotherapy
  • Follow up parameter: abdominal CT scan and tumor marker
  • 2010/00/00: Adjuvant therapy: Patients should be consider adjuvant therapy with complete resected >= T2, node positive, or margin-positive GBC. There is no consensus as to the optimal adjuvant approach. The rate of recurrence is about 50% and above. The purpose of adjuvant CCRT (DFS HR 0.61 for chemotherapy, HR 0.43 for CCRT, recurrence rate 39%, in metaanalysis 2016) is to prolong disease free survival and overall survival and decrease risk of recurrence and distant mets but not 100%. Explain adjuvant chemotherapy regimen of 5FU D1-D5 (425mg/m2) IV, LV (20mg/m2) Q4W for 6 cycles or self-paid gemcitabine 1000mg/m2 IVF 30 min QW for 3 weeks on 1 week off for 6 cycles to reduce risk of mortality by 30%. Post op adjuvant chemotherapy may be started 46 weeks post op. @ Consider start treatment on 00/00, arrange admission for 5FU D1-D5 (425mg/m2) IV, LV (20mg/m2) and check lab. @ Vascular assessment, nutritional assessment before chemotherapy, pharmacist education

GBM

Age⇐ 70, PS 1

Glioblastoma, NOS (WHO grade IV), IDH-wildtype glioblastoma, left parietal 3.8cm with perifocal edema, Ki-67: 33% s/p brain tumor excision on 2018/8/22

**methylated/unmethylated?/indetermine

  • Initial presentation:
  • 2018/9/11 Clinical benefit from temozolomide is likely to be lower in patients whose tumors lack MGMT promoter methylation. Consider temozolomide if tumor is MGMT promoter methylated. Within 1st 3 months after completion of RT and concomitant temozolomide, diagnosis of recurrence can be indistinguishable from pseudoporgression on neuroimaging
  • Follow up parameter: brain MRI 2-6 wk after RT, then every 2-4 mo for 3 yr, then every 6 mo
  • Treatment plan: standard brain RT + concurrent temozolomide and adjuvant temozolomide + alternating eletric field therapy (for supratentorial disease)
  • 2018/9/11 Adjuvant treatment: Concurrent (with RT) temozolomide 75mg/m2 daily (for 42 days, no longer than 49 days), rest for 4 week, Post RT temozolomide 150-200mg/m2 5/28 schedule for 6 cycles (150mg/m2 at first cycle and then titrate to 200mg/m2 in subsequent cycles). PJP prophylaxis during CCRT
  • RT: 60 Gy/30 Fr/6 weeks (2018/9/11~) @ give #1 temozolomide 75mg/m2 today (BSA 1.9, use 120mg first and titrate next cycle), RTC 2 weeks for lab and #2 temozolomide. @ Baktar prophylaxis TIW **AEs of temozolomiade such as myelosuppression (dose-limiting), nausea/vomiting (mild to moderate). headache, fatigue, elevated of AST/ALT, photosensitivity, and teratogenic and carcinogenic

GC

Gastric cancer, (P/D) adenocrcinoma, bormann type III pT4bN3bM1 (AJCC 7th), pancreatic invasion, omentum mets, LN less curvature (7/22), greater curvature (8/28) s/p palliative subtotal gastrectomy on 2017/00/00, LVI+, perineural invasion

  • Initial presentation
  • Treatment plan: palliative chemotherapy
  • Follow up parameter: abdominal CT scan and CEA/CA199 if elevated
  • 2017/00/00: the purpose of palliative chemotherapy is to control disease and prolong life and maintain quality of life but not cure. Explain high risk for local recurrence and distant mets to liver or peritoneum and cause ascites, bowel obstruction and etc
  • 2017/00/00 explain palliative chemotherapy treatment option, such as 5-FU based, capecitabine based, TS-1, taxane based, irinotecan based, and etc, 1st line treatment suggested XELOX, modified ECF, TS-1, or weekly HDFL/LV @ Start palliatve chemotherapy today, explain treatment options @ Vascular assessment, nutritional assessment, dental check, pharmacist education before chemotherapy. @ pending for HER2-neur IHC stain

GCA

Smoking, quite for 8 weeks

Gastric cancer, PW/high body (<3cm from EGJ) (P/D) adenocarcinoma, pT4aN1(2/38)M0 (AJCC 7th), LVI+, perineural invasion, stage IIIa, no ascites, no peritoneal carcinomatosis, negative washed cytology s/p robotic radical total gastrectomy with D2 LN dissection on 2010/00/00, HER2:0

  • Initial presentation:
  • Treatment plan: adjuvant chemotherapy will be started post op 4~6 weeks
  • Follow up parameter: abdominal CT scan, EGD annualy for partial gastrectomy, not necessary for total gastrectomy unless s/s, and tumor marker if elevated: follow up interval: 36 month for 1-2 yr then 612 month for 3-5 yr then annually
  • 2010/00/00: the purpose of adjuvant chemotherapy is to prolong disease free survival and overall survival and decrease risk of recurrence and distant mets but not 100%. Explain adjuvant chemotherapy regimen such as S-1 (80,100,120; 4week on 2 week off) for 1 year (ACTS-GC JP study, DFS HR 0.653; OS HR 0.669), XELOX Q2W for 12 cycles (85/1000 CLASSIC trial, DFS HR 0.58, OS HR 0.66), and weekly 5-FU based regimen (500/200 6 weeks on and 2 weeks off) for 8 months. Consider TS-1 + taxotere (JACCRO GC-07 trial, stage IIIb RFS HR 0.614) [#1 TS-1 (14/7);2-7 + taxotere 40mg/m2,8-11 (28/14)] @ RTC on ? (4th week) for lab and #1 XELOX, S-1 or weekly 5FU/LV @ Vascular assessment, nutritional assessment, dental check, pharmacist education before chemotherapy. TS-1 **explain the AEs of chemotherapy, such as myelosuppression, neutropenic fever, nausea/vomiting, hypersensitivity reaction, diarrhea, and hand-foot-syndrome Capecitabine: **diarrhea (55%), hand-foot syndrome (15-20%), nausea/vomiting, elevations in LFT, and myelosuppression Oxaliplatin: **peripheral sensory neuropathy, nausea/vomting, diarrhea, myelosuppression

GCFU

*History & Physical examination every 3-6 mo for 1-2y, every 6-12 mo for 3-5 yr, then annually ‧CBC, and BCS, as indicated ‧Radiologic imaging or endoscopy, as clinically indicated for 5-8y ‧Supplement B12 Q3-6 mo for total gastrectomy patients

GIST

GIST of stomatch body (distal jejunum (18cm, mitotic count 2-5/5 mm2, low mitotic count, prognostic group 3b, pT4Nx)) s/p laparoscopic assisted partial gastrectomy on 2017/9/28, high risk, DFS 88%

  • Initial presentation: palpable abdominal mass for 3 months
  • Explain optional self-paid adjuvant imatinib for 3 years due to high risk to reduce local recurrence and distant mets but not 100 percent, HR 0.45 if taking imatinib for up to 3 years @ Explain AEs of imatinib @ Start imatinib 400mg QD on 10/24, RTC on 10/24 for drug and check lab @ KBT for possible diarrhea @ Pharmacist education later **nausea and vomiting (40-50%), mild to moderate transient ankle and periorbital edema, occasional myalgias, fluid retention with pleural effusion, ascites, pulmonary edema, and weight gain, diarrhea (25-30%), myelosuppression (weekly⇒biweekly⇒periodically), erythema multiforme and possible Stevens-Johnson syndrome but rare

HBV

Check HBV profile for application of anti-viral agent for prophylaxis of HBV flare up during chemotherapy. Start entecavir (2021/2/xx~ till post chemotherapy for half more year)

HCC

Hepatocellular carcinoma s/p ?

  • Initial presentation:
  • EGD on 2017/00/00:
  • CT on 2017/00/00:
  • Follow up parameter: CXR, Dynamic CT, and AFP
  • Treatment plan: sorafenib +- TACE if feasible: sorafenib 200mg BID 2017/00/00~
  • 2017/00/00: Explain the purpose of palliative treatment is to control disease and prolong life and maintain quality of life but not cure. Discuss treatment choice of sorafenib but very poor response rate. @ Plan to start palliatve targeted therapy with dose of 200mg BID, explain AEs @ Arrange EGD first before started targeted therapy @ Pharmacist education before targeted therapy *possible side effect of sorafenib was told, such as hypertension, hand-food syndrome, skin rash, GI upset, diarrhea, and bleeding

HBV/HCV/Alcoholic liver cirrhosis, child A, complicated with minimal ascites, splenomegaly and portal hypertension

HNSCCAE

**explain risk of airway obstruction due to tumor **explain need for NG insertion or PG insertion if mucositis and tumor compromised basic nutritional needs **explain risk of tumor bleeding and high mortality and might need to refer to teaching hospital for emergent angiography

HNSCCAECCRT

explain the AEs of CCRT, such as nausea/vomiting, mucositis, diarrhea, hypersensitivity reaction, hand-foot-syndrome, hyperpigmentation, nephrotoxicity, radiation dermatitis, radiation esophagitis, radiation pneumonitis, myelosuppression, alopecia, xerostomia, hypothyroidism in the future

HP

H. pylori infections: Clarithromycin 500mg bid & amoxicillin 1g bid in combination with one PPI (pantoprazole 40mg bid, esomeprazole 40mg qd (or 20mg bid), or lansoprazole 30mg q12h or rabeprazole 20mg bid) for 7 days, clarithromycin self-paid for 2nd week.

HYPERLIPIDEMIA

male and smoking, if DM LDH >130, if TG>500 consider treatment, 200~500 diet control

IDA

Microcytic anemia, suspected IDA or thalassemia

  • Family history: no family history of thalassemia
  • GI/GU S/S: no GI or GU bleeding s/s, EGD/Colonoscopy done in 2009. EGD showed duodenal scar. Colonoscopy on 2015/6 hemorrhoid
  • Menses history: LMD on 2010/00/00, blood clots -+, frequent pad changes Q2?H, duration ? days, ? days per cycle
  • Diet history: not vegetarian, no tea
  • NBNC no alcoholism @ survey for anemia, check ferritin, eletrophoresis, albumin, total protein, reticulocyte @ start ferrous 1 PC TID today, explain AEs, RTC next week for CBC @ occult blood and U/A

INDUCTIONBC

Left breast cancer, IDC, dx on on 2020/00/00, cT3(xcm)N1(f)M0, NG3, ER/PR/HER2-neu: 8/8/3+, DISH?, Ki-67: ?%, liver sono, CXR, and bone scan negative

  • Initial presentation: palpable left/right breast masss since ?
  • Menopause, Premenopause
  • Induction chemotherapy: Docetaxel + cisplatin (60/60mg/m2, escate to 75/75 if no grade 3/4 AEs) for 6 cycles and reevaluate for operation, herceptin NHI reimbursed, +- pertuzumab (self-paid) to improve pCR rate but not 100%
  • Induction chemotherapy: AC4 ⇒ DC4 or vice versa, (DC dosage: 60/60mg/m2, escate to 75/75 if no grade 3/4 AEs) and reevaluate for operation to improve pCR rate but not 100%
  • 2023/00/00: explain purpose of induction treatment is to reduce tumor size and make surgery feasible, but not 100% response rate. @ Arrange #1 TCHP (pertuzumab 840 loading, herceptin 8mg/kg loading then 6mg/kg in subsequent cycles, 60/60mg/m2) on 00/00, arrange admission on 00/00 and check lab for prechemotherapy evaluation. NHI reimbursed for herceptin. Sign PSP for pertuzumab/herceptin. @ Self-paid olanzapine HS use for 4 days for emesis. Imodium for diarrhe prevention. @ Vascular assessment (refer to NS), nutritional assessment during admission, dental check during admission, and pharmacist education before chemotherapy @ Arrange 2-D echo under herceptin, F/u Q4-5M (2023/00/00: EF?%) @ Consider clip deployment if breast conservation surgery is considered.

IO

  • Immunotherapy for metastatic melanoma **nivolumab 3 mg/kg iv once every 2 weeks ** pembrolimumab 2 mg/kg once every 3 weeks ** nivolumab 1 mg/kg & ipilimumab 3 mg/kg every 3 weeks for 4 dosese , followed by nivolumab 3 mg/kg once every 2 weeks

ImatinibNIH

Note: Most modern microscopes with wider 40X lenses/fields require approximately 20 to 25 HFP to encompass 5mm2. The microscopes used in KFSYSCC is 25 HFP. Therefore ‧Mitotic count: 4/5 mm2 is equivalent to 8/50 HPF.

KARNOFSKYPS

100% Healthy, no symptoms or signs of disease 90% Capable of normal activity, few symptoms or signs of disease 80% Normal activity with some difficulty, some symptoms or signs 70% Caring for self, not capable of normal activity or work 60% Requiring some help, can take care of most personal requirements 50% Requires help often, requires frequent medical care 40% Disabled, requires special care and help 30% Severely disabled, hospital admission indicated but no risk of death 20% Very ill, urgently requiring admission, requires supportive measures or treatment

LAP

Bilateral axillary lymphadenopathy found during breast sonography, stationary over 3 months, LDH

  • Initial presentation:
  • Survey for bacterial infection (tonsillitis, cellulitis, TB, syphilis), viral infection (EBV, CMV, rubella, HIV, HBV, HCV), or parasite infection, check for lymphoma (B s/s,), check for collagen and other systemic disorders (RA, SLE, sarcoidosis) @ Check CBC and PB smear, ESR, screen for HIV or infectious mononucleosis, screen for autoimmune @ Check CXR, consider chest abdominal +- pelvic CT to help define hialr, retroperitoneal, and PA nodes @ Check for microbiology (blood culture and TB), consider recore or excisional biopsy

LUNGNET

Lung cacer, RLL endobronchial atypical carcinoid, neuroendocrine tumor G2, s/p RLL sleeve lobectomy with RLND on 2021/7/7, pT2bN2b(3/14), angiolymphatic invasion+, mitotic figures (up to 4 mitotic figures per 2 mm2), Ki-67: 21%, no necrosis s/p adjuvant E+P*4 (2021/8/19~2021/11/5)

  • Initial presentation:
  • check for functioning tumor or not: ask s/s such as bronchoconstrition, cardiac valvular fibrosis
  • Treatment plan:
  • 2021/8/3: Explain the purpose of adjuvant chemotherapy is decrease risk of local recurrence or distant metastasis but not 100% prevention. @ Adjuvant chemotherapy will be given 48 weeks post operation on (6th week). Arrange admission for #1 E+P on 00/00, arrange admission for #1 and check lab. @ Vascular assessment, nutritional assessment, dental check, pharmacist education before chemotherapy. @ need to check CGA, gastrin and viral marker. **Follow up parameters: Post op 312 month H&P Biochemical markers as indicated Abdominal +- pelvic CT or MRI Chest CT w/ or w/out contrast

1y post op to 10y Every 12~24 month H&P Biochemical markers as indicated Abdominal +- pelvic CT or MRI Chest CT w/ or w/out contrast 10yr Consider surveillance as clinically indicated

LUNGNETS

Lung NETs, G2 (Ki-67:~25%, lung biopsy), dx on 2019/9/5, cT4N1Mx, stage IIIA or IVA if M1b (right adnexa mets) with clinically significant tumor burder and evidence of progression (hoarsness) intermediat grade (atypical)

*2017 WHO classification of lung NETs: W/D: Low grade (G1): <2 mitoses/10 HPF and no necrosis; intermediate grade (G2): 2-10 mitoses/10 HPF and/or foci of necrosisp; high grade (G3); P/D: >10 mitoses/10 HPF

  • Initial presentation:
  • 2010/0/10 check for functioning tumor or not: ask s/s such as whezzing, cutaneous flushing, and diarrhea, or bronchoconstrition, cardiac valvular fibrosis
  • 2010/0/10 survey for MEN-1 (pituitary tumor and/or hyperparathyroidism) and cushing syndrome: brain MRI (2019/9/9) negative
  • Offer referral to NTUH 核醫科鄭湄芳 (0972653453) for gallium 68 scan clinical trial available since July, 2019 if necessary
  • 2010/0/10 Send pathology for IHC stain (SSRI 2a), contact pathology
  • 2010/0/10 Explain treatment startegy: observe or somatostatin analogue (wait SSTR-2a data), everolimus if NHI reimbursed, PRRT if positive GA68 scan, E+P, or temozolomide +- xeloda @ Explain pathology final result and treatment strategy @ need to check CGA and urine 5-HIAA @ Catastrophic card @ Vascular assessment, rehabilitation, nutritional assessment (high protein diet), dental check (left mandible uptake by PET-CT) and pharmacist education before treatment @ Refer to endocrinologist for survey of cushing’s disease (hypertension since 2018 and mild obesity and lung carcinoid tumor) @ Refer to GYN for right adnexa lesion

MEGESTROL

Cancer cachexia and anorexia, BW loss > 5%, give megestrol 2.5 ml QD use (2010/00/00~)

MYELOMA

Symptomatic multiple myeloma, Ig? lambda/kappa, ISS I-III, Durie-Salmon I-IIIAB

  • Initial presentation:
  • WOrk up: check LDH, Ca, Alb, B2-microglobulin, sPEP, sIFE, uPEP, uIFE, serum FLC, IgG, IgA, IgM, urine 24hr total protein, skeletal survey, bone marrow study, flowcytometry, cytogenetics, FISH if possible
  • Other workup if clinically indicated: MRI, CT scan (avoid contrast), PET/CT, tissue diagnosis if plasmacytoma, staining of marrow and fat pad for amyloid, serum viscosity, HLA typing
  • Follow up parameters: PEP, IFE, CBC-DC, Bun, Cr, Ca, bone survey annually or s/s, bone marrow biopsy, sFLC, MRI/PET/CT if indicated.
  • Treatment plan: candidate for transplantation: induction with VTD X 4 cycles (Bortezomib 1.3mg/m2 SC on D1,8,15,22, thalidomide 100mg QD, Dexamethasone 20mg D1-2, 8-9, 15-16, 22-23 QW, every 5 weeks) ⇒ auto PBSCT ⇒ consolidation VTD x 4 cycles; adjunt treatment with bisphosphonates
  • 2016/00/00 explain purpose of treatment is to cure but not 100%, need long term follow up, and @ myeloma work up: check lab and arrange bone marrow study to send for flowcytometry and chromosome @ apply velcade **explain AEs of treatment, such as peripheral sensory neuropathy, fatigue, emesis, diarrhea, myelosuppression, fever (40%), constipation, increased infection risk, osteoporosis

NET

Metastatic neuroendocrine tumor of liver, M1, G1 (Ki-67:1%, tissue from liver), primary to be determined, dx on 2018/5/21

  • 2018/5/29 check for functioning tumor or not: ask s/s such as hypoglycemia (insulinoma), diarrhea or hypokalemia (VIPoma), hot flush, diarrhea or hyperglycemia (glucagonoma), recurrent gastric ulcers (gastrinoma), or bronchoconstrition, cardiac valvular fibrosis.
  • 2018/5/29 Check for primary site with whole body CT scan or CXR, panendoscope, colonscopy
  • 2018/5/29 survey for MEN-1 (pituitary tumor and/or hyperparathyroidism)
  • 2018/5/29 Offer referal to CGMH Dr Shieh for pre treatment or post treatment gallium 68 scan clinical trial to find primary or follow up treatment response later
  • 2018/5/29 Send pathology for IHC stain (SSTR-2a or SSTR-5; VIP, Glucagon, Gastrin, Insulin), spnsored by Ipsen, SIGN INFORM CONSENT AND PERMIT @ need to arrange brain MRI to rule out pituitary tumor @ need to arrange EGD (patient has GERD s/s) and colonscopy for primary site survey @ need to check CGA, Calcitonin, PTH-rp, GHRH, gastrin, urine 5-HIAA, serum VIP, serum glucagon, serum insulin, pro-insulin, c-peptide @ 請開立重大傷病

NSCLC

Non-smoker/smoker, female/male, Asian

NSCLC, M/D? adenocarcinoma, in LLL, cTxNxMx, stage IV, with ?? mets, dx on 2020/00/00

*EGFR exon 21 L858R/ 19 Del/ Wild type, ALK, ROS-1, PDL-1

  • Initial presentation:
  • Follow up parameter: Primary lung CT, CEA if elevated, and bone scan
  • Chest CT on 2020/00/00:
  • PET CT on 2020/00/00:
  • Treatment plan:
  • 2020/00/00: Explain the purpose of palliative chemotherapy is to control disease and prolong life and maintain quality of life but not cure.
  • 2020/00/00 Discuss treatment choice for EGFR mutated lung cancer in 1st line reimbursed by NHI such as afatinib, tarceva, or Iressa. Osimertinib has first line phase III data but only reimbursed in 19 del without brain mets. @ Start palliatve chemotherapy or targeted therapy on ?, explain treatment options if EGFR mutated or wild type to the patient @ Vascular assessment, nutritional assessment, dental check before chemotherapy, pharmacist education @ Check viral marker before treatment @ Send EGFR testing, ALK, ROS-1 if ALK negative, and PDL-1 @ 申請重大傷病

NSCLCADJ

Nonsmoker/Exsmoker/smoker, Asian, Woman/man 00 y/o year

RUL lung CA s/p VATS RUL lobectomy + RLND with smoothly recovery on 2020/00/00, pT2aN0(0/22)M0, LVI+, M/D ADENOCARCINOMA, papillary predominant, grading 4

  • Initial presentation:
  • Follow up parameter: PE, CEA, and CXR Q3M for 3 years. CT Q6M for 2 years then yearly. Optional bone scan
  • 2020/00/00: Chest CT:
  • 2020/00/00: Brain MRI:
  • Treatment plan: adjuvant chemotherapy with vinorelbine + cisplatin or caboplatin but self-paid 4 cycles, optional UFT (400mg/day divided into 2 doses, post op 3 weeks later, for T1, T2 disease) for 2 year depends on patient’s preference.
  • 2020/00/00: Explain the purpose of adjuvant chemotherapy is decrease risk of local recurrence or distant metastasis but not 100% prevention. The risk of reduction is 20% (HR 0.8189) @ Adjuvant chemotherapy will be given 48 weeks post operation on (6th week) @ Vascular assessment, nutritional assessment, dental check, pharmacist education before chemotherapy. @ Check viral marker before treatment **explain the AEs of chemotherapy, such as myelosuppression, neutropenic fever, alopecia, , moderate nausea/vomiting, constipation(35%), diarrhea(17%), stomatitis(<20%), anorexia (<20%), neurotoxicity and alopecia (1015%) **explain the AEs of carboplatin, such as myelosuppression which is dose-limiting, especially in elder patients, thrombocytopenia is most commonly observed, nausea and vomiting, less renal toxicity as compared to cisplatin, peripheral neuropathy < 10% and less as compared to cisplatin, and hypersensitivity **explain the AEs of cisplatin, such as nephrotoxicity, dose limiting up to 3540%, electrlyte abnormalites (Mg, Ca, K), nausea/vomting, myelosuppresion, neurotoxicity, ototoxicity, and hypersensitivity

NSCLCFU

PE, CEA, and CXR Q3M for 3 years CT Q6M for 2 years then yearly Optional bone scan

PANCREATIC

Pancreatic cancer, head/neck/body/tail, adenocarcinoma (by ascites cytology), stage IV with liver mets (FNA), peritoneal carcinomatosis, malignant ascites, diagnosed on 2010/00/00

  • Initial presentation:
  • Treatment plan: palliative chemotherapy
  • Follow up parameter: CA-199, abdominal CT scan
  • 2010/00/00: the purpose of palliative chemotherapy is to control disease and prolong life and maintain quality of life but not cure. Explain high risk for bowel obstruction, biliary obstruction, infection, and need frequent paracentesis due to ascites and etc
  • 2010/00/00 - explain palliative chemotherapy treatment option, such as Gem-based, 5FU-based such as TS-1, and etc, 1st line treatment suggested Gemcis or gemox or gem or gem + nab-paclitaxel alone depends on performance status, FOLFIRINOX has promising OS benefits but very high toxicity. Other self-paid options includes gemcitabine + erlotinib. 2nd line treatment suggested liposome-irinotecan (NHI reimbursed after gemcitabine failure, or taxol (self-paid)). @ Start palliatve chemotherapy, explain treatment options, after discussion, patient prefer ?. Announce stage IV pancreatic cancer, poor prognosis. @ Vascular assessment (refer to NS for port A), nutritional assessment, dental check, pharmacist education before chemotherapy.

PE

PEGI

PGNG

**explan necessary for set up feeding route due to risk of total stenosis (if severe inflammatory during CCRT), feeding route such as G-tube or NG

PLT

Thrombocytopenia, eitology to be determined, rule out ITP

  • Family history: no family history of thrombocytopenia
  • Bleeding s/s: petechiae or ecchymosis, gum bleeding, epistaxis, life-threatening hemorrhage
  • Duration of symptoms, presence of any prodromal illness, causative medication, or underlying disease:
  • Failure of production: Survey for drugs and chemoicals, viral infection, radiation history, aplastic anemia, leukemia, marrow infiltration, megaloblastic anemia, HIV
  • Increased consumption: survey for ITP, drugs, DIC, infection, massive hemorrhage and transfusion, SLE, indolent lymphoma, heparin, TTP, hypersplenism, post-transfusion purpura, and HIV
  • 2020/3~4 medication hx: Doxazosin (Mesylate) Mecobalamin Acetaminophen for 1 day only Cefazolin (Sodium): didn’t take @ Confirm with PB smear for platelete aggregation to rule out psuedothrombocytopenia. @ Do coagulation screen and BM exaionation. Avoid aspirin. **Return to UCU if any bleeding s/s for transfusion if needed

PNET

Metastatic W/D neuroendocrine tumor, M1, G1 (Ki-67:<2%, tissue from liver), suspected Pan NET with liver mets

  • check for functioning tumor or not: ask s/s such as hypoglycemia (insulinoma), diarrhea or hypokalemia (VIPoma), hot flush, diarrhea or hyperglycemia (glucagonoma), recurrent gastric ulcers (gastrinoma), or bronchoconstrition, cardiac valvular fibrosis
  • survey for MEN-1 (pituitary tumor and/or hyperparathyroidism)
  • Offer referral to NTUH 核醫科鄭湄芳 (0972653453) for gallium 68 scan clinical trial available since July, 2019 if necessary
  • Send pathology for IHC stain (SSRI 2a) @ need to arrange brain MRI to rule out pituitary tumor @ need to arrange EGD (patient has GERD s/s) @ need to check CGA, Calcitonin, PTH-rp, GHRH, gastrin, urine 5-HIAA, serum VIP, serum glucagon, serum insulin, pro-insulin, c-peptide @ 請開立重大傷病 @ refer to Lin-kou CGMH for Gallium 68 scan clinical trial

RECTALADJ

Rectal cancer, 6 cm from anal verge, S/P CCRT(?) s/p laparoscopic proctectomy and ileostomy on 2017/00/00 ypT2N0(0/16)

  • Initial presentation:
  • 2017/00/00 explained the concept of adjuvant chemotherapy, the goal is to decrease recurrence/metastasis as possible, not guarantee cure!! Thus regular follow up is still needed. CEA need F/U. Adjuvant chemotherapy will be started post op 4~6 weeks
  • for N+(1) status, there is HIGH risk of recurrence or metastasis, adjuvant chemotherapy is suggested, offered options included
  • for initial cT3N0 and ypT2N0 status, offered options included <1> mFOLFOX6, oxaliplatin is self-paid, bi-weekly for 12 cycles <2> Weekly 5FU/LV, (打3休1) for 8 cycles <3> XELODA[20002500mg/m2](4# BID),(self-paid) 14 days on/7 days off, for 8 cycles <4> UFT(UFT 300mg/m2 and LV 3090mg/m2, D1-D28, 1 wk rest) for 0.5 to 3 year @ Arrange admission for #1 mFOLFOX-6 on ? and check lab. @ Vascular assessment, nutritional assessment, dental check, pharmacist education before chemotherapy. 5FU: **GI upset(nausea/vomiting/diarrhea), elevations in LFT, myelosuppression, hyperammoninemia, and rare but possible ischemic heart disease Oxaliplatin: **peripheral sensory neuropathy, nausea/vomting, diarrhea, myelosuppression, anaphylaxis **Emphasize the importance of nutrional support (high protein diet) during C/T period.

RECTALCCRT

Rectal cancer, 0 cm from anal verge, cTxNxM0, dx on 2010/00/00 (W/D) adenocarcinoma, 2010/00/00, under preop short course RT (2500cGy/5fr, 2010/00/00~00/00) to pelvis and bil inguinal areas, consolidatin chemotherapy (pending)

  • Initial presentation: bloody stool, tenesmus, decreased stool caliber and bowel habit change from once/day to several times/day
  • Treatment plan: preop induction short course RT follow by consolidation chemotherapy and then LAR or APR
  • 2010/00/00: Explain the purpose of neoadjuvant CCRT, the goal is to decrease recurrence/metastasis as possible, not guarantee cure!! Thus regular follow up is still needed.
  • 2010/00/00 Explain theconcept of CCRT→ OP then adjuvant C/T for localized advanced rectal cancer (stage II and III). As for pre-OP CCRT, options include: 1> Long course: CCRT(5 weeks) , followed by surgery and adjuvant chemotherapy. C/T options included continous 5-FU infusion on W1/W5 or XELODA with RT(self-paid, 825mg/m2 bid 5d/wk 5 weeks) 2> Short course: induction RT1 weeks followed by 1 week rest then mFOLFOX63 (self-paid oxaliplatin) cycles then restaging and surgery (LAR or APR) on 4th or 5th weeks after the last cycle of C/T. Post op adjuvant mFOLFOX69 cycles
  • Restaging on 6-7th week and refer to CRS on 8th week. Restaging with tumor marker, sigmoidoscopy, pelvic MRI, CXR, and liver sonography, low dose CT if has pulmonary nodules or hepatic lesions for follow up. @ Patient decided mFOLFOX6, explain self-paid oxaliplatin @ Arrange admission for #1 mFOLFOX-6 on 2010/00/00 and check lab, and arrange admission @ Vascular assessment, nutritional assessment, dental check, pharmacist education before chemotherapy.

RECTALNET

Rectosigmoid neuroendocrine tumor, WHO 2017 NET G2 (Ki-67:8-18%) s/p laparoscopic low anterior resection on 2019/5/16, pT3(3cm)N0(0/19), LVI-, hepatic hemangiomas or mets?

  • check for functioning tumor or not: ask s/s such as hypoglycemia (insulinoma), diarrhea or hypokalemia (VIPoma), hot flush, diarrhea or hyperglycemia (glucagonoma), recurrent gastric ulcers (gastrinoma), or bronchoconstrition, cardiac valvular fibrosis
  • survey for MEN-1 (pituitary tumor and/or hyperparathyroidism)
  • Offer referral to NTUH 核醫科鄭湄芳 (0972653453) for gallium 68 scan clinical trial available since July, 2019 if necessary
  • Send pathology for IHC stain (SSRI 2a) @ need to arrange EGD (patient has GERD s/s) @ need to check CGA, Calcitonin, PTH-rp, GHRH, gastrin, urine 5-HIAA, serum VIP, serum glucagon, serum insulin, pro-insulin, c-peptide @ Discuss in GI/GS for hepatic hemangioma or liver mets

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