Advertisement

Advertisement

tumour

Spinal Lesion: Benign or Malignant? When should you worry?

Teaser: 

Raphaële Charest-Morin, MD, FRCSC,1
Nicolas Dea, MD, MSc, FRCSC,2

1Department of Orthopaedic Surgery, Centre Hospitalier Universitaire de Québec, Laval University, QC.
2Spine Surgeon, Clinical Associate Professor of Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, University of British Columbia, BC.

CLINICAL TOOLS

Abstract: General practitioners are occasionally confronted to unknown lesions of the spine. Recognition of imaging characteristics and anatomic details from the different imaging modalities generally provides sufficient information to generate an appropriate differential diagnosis. Importantly, first line clinicians should recognize worrisome imaging characteristics and initiate timely referral when indicated. On the other hand, lesions expressing benign features should also be identified to avoid anxiety for the patient and overuse of diagnosis imaging studies. In a public health-care system, judicious utilization of imaging is of paramount importance. This article will review an approach to unknown bony lesions of the spine.
Key Words: Spinal lesion, tumour, imaging characteristics, primary bone tumours.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

A solitary spinal lesion warrants a careful investigation. Most of the time, local imaging and systemic staging provide diagnosis.
In patients over 40 years old, most tumours are malignant with metastases and multiple myeloma being the most frequent. Benign and incidental lesions such as bony islands and hemangiomas are, however, also frequently encountered in this age group.
In patients under 30 years old, tumours of the spine are uncommon and are generally benign with the exception of Ewing Sarcoma and Osteosarcoma.
Primary bone tumours of the spine are rare and should be referred to specialized centers.
Worrisome features on imaging include aggressive bony destruction, spinal canal invasion, soft tissue mass and multiple level involvement.
Pyogenic infections usually start in the disc space, whereas tumours generally spare the intervertebral disc.
Most aggressive lesions will initially present with non-specific clinical complaints and as such, a high level of suspicion is warranted. Systemic symptoms are rare with primary bone tumours.
Most incidental findings do not require any follow-up or further investigation.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is only $20 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Disclaimer: 
Disclaimer at the end of each page

Management of Primary Colon Cancer in Older Adults

Management of Primary Colon Cancer in Older Adults

Teaser: 

Robin McLeod, MD, Division of General Surgery, Mount Sinai Hospital, University of Toronto; Department of Health Policy, Management and Evaluation, University of Toronto; Zane Cohen Digestive Diseases Clinical Research Centre; Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, ON.
Selina Schmocker, Zane Cohen Digestive Diseases Clinical Research Centre; Toronto General Research Institute, University Health Network, Toronto, ON.
Erin Kennedy, MD, PhD, Division of General Surgery, University Health Network, University of Toronto; Department of Health Policy, Management and Evaluation, University of Toronto; Zane Cohen Digestive Diseases Clinical Research Centre; Toronto General Research Institute, University Health Network, Toronto, ON.

Colorectal cancer is the third most common cancer worldwide, and more than half of those newly diagnosed with colon cancer are over the age of 70 years. Despite the large proportion of patients over the age of 70 diagnosed with colon cancer annually, this age group is significantly underrepresented in clinical trials and, therefore, there is little high-quality evidence on which to base treatment decisions or treatment guidelines. This article reviews the management of primary colon cancer in older adults, including screening, presentation and diagnosis, treatment, and follow-up in this population.
Key words: colon cancer, colorectal cancer, screening, tumour, older adults.

Dr. Anne Horgan and Dr. Shabbir Alibhai share their views on the current status of research in Colorectal Cancer

Dr. Anne Horgan and Dr. Shabbir Alibhai share their views on the current status of research in Colorectal Cancer

Teaser: 
The incidence of colorectal cancer increases with age, with approximately 60% of patients in the US (and similar numbers in Canada) older than 65 years at diagnosis and 40% over the age of 75. As highlighted by McLeod et al in this issue, the management of older patients with colorectal cancer is challenging. The prevailing difficulty is the lack of randomized trial data to support and guide treatment decisions. Pivotal trials establishing the standard of care for this disease have tended to enroll younger patients. For example, the median age of patients enrolled in phase III studies of systemic chemotherapy for metastatic colorectal cancer is commonly 60-64 years,1,2 with fewer than 20% of patients being 70 years and older. In the large colorectal screening studies, older patients are again under-represented, with only 15-17% of randomized patients being 70 years or older.3, 4 Similarly, elderly patients are less likely to be enrolled in surgical trials than younger patients.5 With this absence of prospective data, evidence regarding safety and efficacy of interventions in older patients with colorectal cancer has come mainly from subgroup analyses or meta-analyses of large randomized clinical trials, both in the adjuvant and metastatic disease settings. These analyses suggest that older patients gain similar benefit from chemotherapy as do younger patients, with little difference in the rates of severe toxicity.6 This should be reassuring to clinicians.  The relation between age and outcomes from colorectal cancer surgery is more complex, however. Poorer outcomes in terms of postoperative morbidity and mortality are reported with increasing age, but these are confounded by presentation with more advanced disease stage, a greater frequency of emergency surgery and fewer curative surgeries compared to younger patients.7 All of these analyses suffer from selection bias with patients in these studies generally being fit and of good performance status. Data from randomized studies will ultimately help optimize management of older patients with colorectal cancer. However, careful consideration should be given to the design of these studies.  A growing appreciation of the heterogeneity of this patient population has led to a better understanding and use of geriatric specific assessments. These assessments which evaluate functional status, comorbid medical conditions, cognitive function, psychological state, and social supports may have value in predicting postoperative complications following surgery and may help better predict tolerance to systemic therapies. Incorporation of these assessments into both the clinical trial setting and daily clinical practice is encouraged but challenging due to time constraints in busy practices. Identifying elder-specific clinical predictors of tolerability to various interventions will ultimately lead to a more tailored approach for these patients. The essential principles of managing colon cancer in the elderly are the same as in younger patients, however, as the authors state, an individualized approach is necessary. Frameworks for determining a patient’s remaining life-expectancy, risks of toxicities and operative complications, and quality of life issues must be developed and should ultimately underlie these individualized decisions. No competing financial interests declared. References: 1.    Goldberg RM, Sargent DJ, Morton RF et al. A randomized controlled trial of fluorouracil plus leucovorin, irinotecan, and oxaliplatin combinations in patients with previously untreated metastatic colorectal cancer. J Clin Oncol 2004; 22: 23-30. 2.    Seymour MT, Maughan TS, Ledermann JA et al. Different strategies of sequential and combination chemotherapy for patients with poor prognosis advanced colorectal cancer (MRC FOCUS): a randomised controlled trial. Lancet 2007; 370: 143-152. 3.    Hardcastle JD, Chamberlain JO, Robinson MH et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996; 348: 1472-1477. 4.    Mandel JS, Bond JH, Church TR et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med 1993; 328: 1365-1371. 5.    Stewart JH, Bertoni AG, Staten JL et al. Participation in surgical oncology clinical trials: gender-, race/ethnicity-, and age-based disparities. Ann Surg Oncol 2007; 14: 3328-3334. 6.    Kumar A, Soares HP, Balducci L, Djulbegovic B. Treatment tolerance and efficacy in geriatric oncology: a systematic review of phase III randomized trials conducted by five National Cancer Institute-sponsored cooperative groups. J Clin Oncol 2007; 25: 1272-1276. 7.    Surgery for colorectal cancer in elderly patients: a systematic review. Colorectal Cancer Collaborative Group. Lancet 2000; 356: 968-974.

Headaches in the Older Adult

Headaches in the Older Adult

Teaser: 


Marek Gawel, MB BCh FRCPC, Department of Medicine (Neurology), Sunnybrook and Women’s Health Sciences Centre, Toronto, ON.

Headache has been classified in an exhaustive classification by the International Headache Society Classification Committee. As people age the presentation of headaches may change, making them more difficult to classify and diagnose. In addition, secondary causes of headache become more common and need to be rigorously sought out. This article describes some of the types of headaches found in older adults.
Key words: headache, older adult, tumour, arteritis, primary headache, secondary headache.

Effects of Radiation Therapy on the Older Brain

Effects of Radiation Therapy on the Older Brain

Teaser: 

Barbara-Ann Millar MB ChB, FRCR, Clinical Fellow, Department of Radiation Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON.

Normand Laperriere MD, FRCPC, Associate Professor, Department of Radiation Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON

Radiation therapy is commonly used in the management of intracranial malignancies. Although the effects on the developing brain have been extensively documented, the impact of this treatment modality on the older brain requires further investigation. The effect of radiation treatment, the intracranial lesion, and associated comorbidities and medications all influence the individual’s overall outcome. This review looks at the pathophysiology of radiation injury within the brain and its impact on cerebral irradiation in older patients.

Key words: radiotherapy, older brain, tumour, neurocognitive effects.

Lung Cancer Screening and Management in the Elderly Patient

Lung Cancer Screening and Management in the Elderly Patient

Teaser: 

Yaron Shargall, MD and Michael R. Johnston, MD, FRCSC, Division of Thoracic Surgery, Department of Surgery, University of Toronto; Division of Thoracic Surgery and Department of Surgical Oncology, Toronto General and Princess Margaret Hospitals, Toronto, ON.

Introduction
Lung cancer is the leading cause of cancer death in Canada and the Western world. In the year 2001, it is estimated that 21,200 people in Canada will be diagnosed with lung cancer, and approximately 18,500 people will die as a result.1 Despite extensive research and clinical efforts, the survival rate has not changed appreciably over the past 30 years and remains poor, with an overall five-year survival of about 13%.2 Lung cancer is predominantly a disease of the elderly, since more than 60% of all lung cancer cases occur in people older than 60 years.3 There is overwhelming experimental and epidemiological data to support the contention that cigarette smoking is the primary risk factor for the development of lung cancer. Of all lung cancers in Canada, 85% are directly attributable to smoking, and another 3% may be caused by second-hand smoking.4 In this article, we summarize the current status of lung cancer screening and treatment, with special emphasis on the elderly population.

Screening for Lung Cancer
Lung cancer screening studies have not clearly demonstrated a reduction in mortality.