Treatments of Different Cancer

Tumor has spread to lymph nodes

Chemoradiation: radiotherapy and chemotherapy are given simultaneously. Drug used usually is cisplatin. Sometimes 5FU is also added. Radiation is usually external beam and IMRT(intensity modulated radiation therapy)

Induction chemo followed by chemoradiotherapy

Tumor has spread beyond the nasopharynx to other parts of the body

Chemoradiotherapy

Induction chemo to reduce tumor cells and size before chemoradiotherapy

Tumor has spread beyond the nasopharynx to other parts of the body

Stage IV A & B

Chemoradiation.

Induction chemo followed by chemoradiation.

Stage IV C

Chemotherapy.

If chemotherapy is successful, radiotherapy will follow to target the tumor usually Stereotactic radiosurgery(Gamma knife). Rarely, brachytherapy may be used.

If unsuccessful, another regimen of chemotherapy will be tried.

Adding targeted therapy, usually cetuximab is another option.

Depending on location, treatment is different.

If recurrence is in other parts of the body, chemotherapy is the option.

If recurrence is in the local area, surgery is an option, endoscopic skull based surgery.

If both does not work, immunotherapy pembrolixumab or nivolumab may be tried.

If recurrence is in the lymph nodes, radiation to the lymph nodes is the first option. Neck dissection of these lymph nodes is another option. It could be conservative, modified radical, or radical.

Tumor is relatively small with no metastasis or a small tumor that has spread only to one or two sentinel nodes

Breast conserving surgery with or without wire localization usually a lumpectomy

May need radiation(external beam: accelerated or internal radiation) therapy following surgery

Adjuvant chemotherapy(Anthracyclines, Taxanes, 5-fluorouracil (5-FU), Cyclophosphamide, Carboplatin) is an option

Hormone therapy for those with Er/PR positive tumor cells for five years (tamoxifen, with/without aromatase inhibitors such as Letrozole, Anastrozole, Exemestane)

Target therapy : Trastuzumab , Neratinib cells(tamoxifen, toremifene with/without aromatase inhibitors such as Letrozole, Anastrozole, Exemestane)

Target therapy : Trastuzumab, Pertuzumab, Neratinib

Larger tumor and has spread to a few nearby lymph nodes

Breast conserving surgery: lumpectomy, quadrantectomy, partial or segmental mastectomy. Plus axillary lymph node dissection

Radiation therapy( external beam or internal radiation) following surgery

Breast reconstructive surgery may be needed

Adjuvant chemotherapy(Anthracyclines, Taxanes, 5-fluorouracil (5-FU), Cyclophosphamide, Carboplatin)

Hormone therapy for those with Er/PR positive tumor cells(tamoxifen, toremifene with/without aromatase inhibitors such as Letrozole, Anastrozole, Exemestane)

Target therapy : Trastuzumab, Pertuzumab, Neratinib

Larger tumor that has spread to nearby tissues and many nearby lymph nodes

Neoadjuvant chemotherapy(Anthracyclines, Taxanes, 5-fluorouracil (5-FU, Cyclophosphamide, Carboplatin)may be used to shrink the tumor before surgery. Mastectomy

Radiation following mastectomy( external beam or internal radiation) often required

Breast reconstructive surgery is an option

Chemotherapy(Anthracyclines, Taxanes, 5-fluorouracil (5-FU, Cyclophosphamide, Carboplatin)

Hormone therapy for those with ER/PR positive tumor cells(tamoxifen and toremifene, Fulvestrant with/without aromatase inhibitors such as Letrozole, Anastrozole, Exemestane)

Target therapy :
a) Her2 positive: Trastuzumab, Pertuzumab, Neratinib
b) Her2 negative: CD/K4 inhibitors:Palbociclib , ribociclib, and abemaciclib

Tumor cells have spread to other parts of the body

Chemotherapy(Anthracyclines, Taxanes, 5-fluorouracil (5-FU), Cyclophosphamide. Carboplatin, Platinum agents, Vinorelbine, Capecitabine, Gemcitabine, Ixabepilone, Eribulin)

Radiation therapy to the breast or to affected areas

Palliative surgery to remove tumor, metastatic tumor, to relieve symptoms

Hormone therapy for those with ER/PR positive tumor cells(tamoxifen and toremifene with/without aromatase inhibitors such as Letrozole, Anastrozole, Exemestane)

Target therapy
a) Her2 positive: Trastuzumab, Pertuzumab, Ado-trastuzumab emtansine, Lapatinib
b) Her2 negative: CD/K4 inhibitors:Palbociclib , ribociclib, and abemaciclib
c) Everolimus for menopausal Her2 positive patients.

Tumor cells do not have any hormone receptors

Surgery

Radiation

Chemotherapy(Carboplatin, Platinum agents, Vinorelbine, Capecitabine, Gemcitabine, Ixabepilone, Eribulin)

Consider conventional therapy plus targeted therapy : PARP inhibitors: Olaparib and talazoparib

cancer is localized only in the endometrium or spread only to half of the myometrium

Minimally invasive surgery : laparoscopic hysterectomy or via vaginal hysterectomy

Surgery: hysterectomy via the abdomen

Radiation for higher grade tumors or no endometrial cancers

Chemotherapy for higher grade cancers

cancer has spread beyond half of the myometrium Treatment is similar to stage IA but often with radical hysterectomy

cancer has spread to the cervix but still limited to the uterus

Surgery: radical hysterectomy; radiation before surgery is an option

Radiation following surgery: external beam and vaginal brachytherapy

Chemotherapy carboplatin and paclitaxel is an postsurgical option

Hormone therapy(progesterone pills or aromatase inhibitors (AIs), such as anastrozole, letrozole, and exemestane)

cancer has spread to the pelvis

Surgery: radical hysterectomy and lymphadenectomy

Radiation before and after surgery

Chemotherapy after surgery with carboplatin and paclitaxel and ifosfamide , plus cisplatin or carboplatin as an option

Hormone therapy

cancer has spread beyond the pelvis

Surgery: radical hysterectomy plus lymphadenectomy and others

Radiation

Hormone therapy: progestin and tamoxifen

Chemotherapy: paclitaxel, doxorubicin, and either carboplatin or cisplatin

Surgery either locally or in remote areas if feasible

Radiation in affected areas

Hormone therapy with progestin and tamoxifen if cancer cells are hormone receptive

Chemotherapy used alone or often used in addition to the above mentioned treatment

Tumor is larger and has not grown beyond the prostate but higher scores and higher PSA levels

For older patients: wait and see

Radiation therapy(external beam or brachytherapy)

Radical prostatectomy with removal of lymph nodes

Plus hormonal therapy:

a) (Luteinizing hormone-releasing hormone (LHRH) agonists injected or implanted in the skin: Leuprolide, Goserelin, Triptorelin, Histrelin)

b) LHRH antagonist: degarelix

Tumor has grown beyond the prostate but has not spread to lymph nodes or other tissues

Radiation( external beam only) therapy plus hormonal therapy

Radiation therapy includes external beam and brachytherapy followed by hormonal therapy

a) (Luteinizing hormone-releasing hormone (LHRH) agonists injected or implanted in the skin Leuprolide, Goserelin, Triptorelin, Histrelin)

b) LHRH antagonist: degarelix

Radical prostatectomy with removal of pelvic lymph nodes followed by radiation therapy

Tumor has spread beyond the prostate and spread into the surrounding tissues or to distant organs

For very old patients; wait and see

Radical prostatectomy if possible, plus radiation, hormone and chemotherapy(docetaxel,or cabazitaxel)

Radiation therapy plus hormone and chemotherapy Hormone therapy:

a) (Luteinizing hormone-releasing hormone (LHRH) agonists injected or implanted in the skin Leuprolide, Goserelin, Triptorelin, Histrelin)

b) LHRH antagonist: degarelix

c) Cyb 17 inhibitor

d) Antiandrogens with chemotherapy(docetaxel or cabazitaxel)

For those with bone metastases, add denosumab

For hormone refractory cases, may use the following: abiraterone, enzalutamide, apalutamide, ketoconazole, estrogens, and corticosteroids

Prostate cancer vaccine sipuleucel-T may be used to prolong survival

Tumor is limited to the stomach

Surgery: total or subtotal resection of the stomach. Usually nearby lymph nodes are also removed

Surgery total or subtotal

Chemo or Chemoradiation before surgery to shrink the tumor and thus facilitate surgery

Chemo or chemoradiation after surgery

Surgery: Total or subtotal resection of the stomach plus removal of the omentum and the nearby lymph nodes

Chemo or chemoradiation before surgery to shrink the tumor

Chemo/chemoradiation after surgery

Surgery is the mainstay treatment

Chemo/chemoradiation before surgery

Chemo/chemoradiation after surgery

Tumor has spread beyond the stomach and its nearby lymph nodes and/or to other parts of the body

Palliative surgery: subtotal, gastric bypass etc

Palliative endoscopic laser surgery, stent insertion

Chemo/chemoradiation to shrink the tumor

Targeted therapy: Herceptin

Immunotherapy: pembrolizumab is an option

Same as Stage IV

Stage IAI

Maintaining fertility : cone biopsy, repeat cone biopsy, radical trachlectomy

Forfeiting fertility: hysterectomy, radical hysterectomy with removal of pelvic lymph nodes

Stage IAII

Maintaining fertility: cone biopsy with removal of pelvic lymph nodes, radical trachlectomy with pelvic lymph node dissection

Forfeiting fertility: external beam radiation plus pelvic brachytherapy; radical hysterectomy with removal of pelvic lymph nodes and sampling of aortic nodes, plus chemotherapy if node positive

Stage IBI
surgery:

Maintaining fertility: cone biopsy with removal of pelvic lymph nodes, radical trachlectomy with pelvic lymph node dissection

Forfeiting fertility: external beam radiation plus pelvic brachytherapy; radical hysterectomy with removal of pelvic lymph nodes and sampling of aortic nodes, plus chemotherapy if node positive

radiation:

If tumor has spread to surrounding tissues: external beam is added

radiation plus chemotherapy:

If cancer has spread to surrounding tissues or positive margins. May be administered concurrently

Stage IBI2

Radical hysterectomy with pelvic node dissection and para aortic node sampling; or dhemo before surgery

Chemoradiation concurrently

Stage IIA

Same as stage IB

Stage IIA2

Same as Stage IB2

Stage IIB

Chemoradiation

Chemoradiation

Tumor has spread beyond the pelvis

Radiation

Radiation plus chemo(cisplatin or carboplatin plus paclitaxel gemcitabine , or topotecan)

Targeted therapy: avastin may be added

Locally: pelvic exenteration

Radiation

Chemotherapy

Targeted therapy

Immunotherapy: Pembrolizumab

Cancer cells have spread to the deeper layer of the colon wall but have not grown outside the wall.

Polypectomy

Partial colectomy

Cancer cells have grown through the wall of the colon, probably spread to the surrounding tissues, but have not yet spread to the lymph nodes.

Partial colectomy along with resection of nearby lymph nodes

Chemotherapy with 5-FU and leucovorin, oxaliplatin, or capecitabine and other options, after surgery if

Obstruction is present

A hole is present in the colon

Cancer cells are considered very virulent

Cancer cells found in the margin of the resected tissue

Less than 12 lymph nodes have been removed

Cancer cells have spread to nearby lymph nodes, but they have not yet invaded other parts of the body.

Partial colectomy along with resection of nearby lymph nodes followed by adjuvant chemotherapy using FOLFOX (5-FU, leucovorin, and oxaliplatin) or CapeOx (capecitabine and oxaliplatin) regimens. Other options are available.

Radiation and chemotherapy without surgery for those who are too weak to undergo surgery.

Colon cancer cells have spread from the colon to distant organs and tissues.

Partial colectomy with resection of nearby lymph nodes, plus surgery to remove the areas of cancer spread plus chemotherapy

Neoadjuvant chemo which is giving chemo before surgery to shrink the tumor plus surgery as well as post-op chemo.

Ablation or embolization of metastatic lesions in the liver plus surgery and chemo

Palliative surgery plus chemotherapy

Chemotherapy plus target therapy

a) FOLFOX: leucovorin, 5-FU, and oxaliplatin (Eloxatin)
b) FOLFIRI: leucovorin, 5-FU, and irinotecan (Camptosar)
c) CAPEOX or CAPOX : capecitabine (Xeloda) and oxaliplatin
d) FOLFOXIRI: leucovorin, 5-FU, oxaliplatin, and irinotecan
e) One of the above combinations plus either a drug that targets VEGF, (bevacizumab [Avastin], ziv-aflibercept [Zaltrap], or ramucirumab [Cyramza]), or a drug that targets EGFR (cetuximab [Erbitux] or panitumumab [Vectibix])
f) 5-FU and leucovorin, with or without a targeted drug
g) Capecitabine, with or without a targeted drug
h) Irinotecan, with or without a targeted drug
g) Cetuximab alone
h) Panitumumab alone
i) Regorafenib (Stivarga) alone
j)Trifluridine and tipiracil (Lonsurf)

Immunotherapy: pembrolizumab (Keytruda)

Radiation therapy

Local recurrence

Surgery plus chemo

Neochemo plus surgery as well as postop chemo

Local recurrence

Surgery

Neochemo plus surgery as well as postop chemo

Ablation or embolization if the lesions are in the liver

Chemo/ Chemo plus targeted therapy (regimes identical to Stage 4 treatment)

Immunotherapy

Radiotherapy

Palliative surgery

Concurrent chemoradiation: chemo and radiation together. The chemo drugs used are usually etoposide plus either cisplatin or carboplatin

Chemotherapy followed by radiation therapy to the chest

Prophylactic radiation to the brain after 1/2

Chemotherapy: usually etoposide plus either cisplatin or carboplatin

Radiation to the chest and prophylactic radiation to the brain

Palliative surgery, radiation and other care

Chemotherapy using another regime

Immunotherapy with nivolumab

Surgery: partial or total thyroidectomy/ lymphadenectomy
Modified neck dissection

Stage I

Surgery

Radioactive iodine treatment

Hormone therapy six weeks post treatment

Stage II

Surgery

Radioactive iodine treatment

Hormone therapy six weeks post treatment

Stage III/IV

Surgery

Radioactive iodine treatment

Radiation: external beam

Targeted therapy

Chemotherapy

Hormone therapy six weeks post-treatment

Recurrent cancer

Surgery if resectable

Radioactive iodine

Radiation

Targeted therapy : sorafenib and lenvatinib to be used if the above does not work

Lobectomy

Thyroid completion thyroidectomy

Modified neck dissectiont

Radioactive iodine therapy is an option

Radiation: external beam may be needed

Lobectomy

Completion thyroidectomy

Modified neck dissection

Radioactive iodine therapy may be an option

Radiation : external beam is an option

Surgery

Radioactive iodine

Radiation with external beam

Targeted therapy

Chemotherapy

As patient may also suffer from other cancers, he/she must be screened for pheochromocytoma, and genetic testing must be done for the patient and his family

Stage I/II

Surgery: total thyroidectomy with modified neck dissection

Thyroid hormone therapy

Hormone therapy six weeks post treatment

Stage III/IV

Surgery: total thyroidectomy with modified neck dissection

Radiation to affected areas

Targeted therapy if the above cannot be used : vandetanib, cabozantinib

Chemotherapy

Surgery

Radiation

Targeted therapy

Chemotherapy

Surgery if possible

Radiation to shrink the tumor or to control spread of the tumor

Chemotherapy

Targeted therapy : dabrafenib and trametinib if the cancer cells have the BRAF gene

Adult T cell lymphoma/ leukemia

Chronic or smoldering subtype: Observation or radiation or chemotherapy

Acute subtype: Antiviral drugs or chemo(CHOP) plus stem cell transplant as an option for patients going into remission

Lymphoma type: Chemotherapy plus stem cell transplant for remitted patients

Angioimmunoblastic T cell Lymphoma

Prednisolone

Chemotherapy

Radiation

Chemotherapy plus monoclonal antibody (brentuximab vedotin)

Stem cell transplant for remitted patients

Enteropathy associated T cell Lymphoma

Develops in the small intestine or the colon

Intensive chemotherapy

Radiation therapy

Surgery

Stem cell transplantation

Anaplastic large cell Lymphoma

Fast growing but usually responsive to treatment with good long term survival rates

Chemotherapy (CHOP)

Chemotherapy plus monoclonal antibody(brentuximab vedotin)

Radiation therapy

Stem cell transplant for patients without ALK protein

Peripheral T cell Lymphoma

Poor prognosis

Chemotherapy (CHOP)

Chemotherapy plus monoclonal antibody (brentuximab vedotin)

Radiation

Stem cell transplant

This lymphoma grows from the mediastinum

6 courses of R-CHOP

Assessment with PET/CT to ascertain whether there are residual tumors

Radiation to the mediastinum

One option is DA-EPOCH-R(dose-adjusted etoposide, doxorubicin , cyclophosphamide plus vincristine, prednisone and rituximab)

If chemotherapy does not work, immunotherapy with the drug pembrolizumab may be considered

Grows very slowly but are very difficult to cure. Therefore, may not need immediate treatment.

Stage I–II

Tumor limited to one or two lymph node groups above or below the diaphragm.

Radiation to the lymph nodes

Chemotherapy plus a monoclonal antibody drug before radiation

Stage IIB/III/IV

Chemotherapy: single drug bendamustine or CHOP, CVP(cyclophosphamide, vincristine, prednisone)

Radiation for those too sick to receive chemotherapy

Radioactive monoclonal antibody ibritumomab is an option

For slightly weaker patients, one drug rituximab alone, or rituximab with milder chemo drugs may be considered

Resistant or recurrent cancer

Other chemotherapeutic regimes

Stem cell transplant

These two diseases are considered to be the same cancer, the difference lies in the location: the former concentrates in the lymph nodes and the latter mostly in the blood and marrow. Both are difficult to cure.

Slow growing tumors are watched and observed closely only

Chemotherapy plus or minus rituximab (Chlorambucil, fludarabine, or bendamustine)

Targeted therapy alone with rituximab or ibrutinib

Recurrent or resistant cancers are treated with other chemotherapeutic regimes or other targeted cell therapeutic agents

When found, most have already disseminated. They are hard to cure

Stage I/II

spread only to one or two nearby lymph node groups

Radiation

Chemotherapy plus rituximab

Stage III/IV

Intense chemotherapy:

a)Hyper-CVAD: cyclophosphamide, vincristine, doxorubicin (Adriamycin), and dexamethasone, alternating with high-dose methotrexate plus cytarabine)
b)Dose-intensified” R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone), alternating with rituximab and cytarabine
c)RDHAP (Rituximab, dexamethasone, cytarabine, cisplatin)

Stem cell transplant for patients responsive to the intensive chemotherapy

Gastric lymphoma:

Caused by H pylori and limited to the stomach

Stage I/II (Tested positive for H pylori)

Antibiotics plus proton pump inhibitors for 10-14 days, may be repeated

Endoscopic examination to see if the lymphoma has shrunken

If lymphoma does not shrink after repeated treatment, may be followed by radiation or rituximab

Stage I/II (Tested negative for H pylori)

Radiation

Rituximab

Stage III/IV

Small tumors may be watched and observed closely

Others may be treated with radiation

Rituximab

Rituximab plus chemotherapy similar to treatment for follicular lymphoma

Stage I/II

Radiation

Surgery

Stage III/IV

Chemotherapy similar to that for gastric MALT lymphoma

Rare tumor that grows very slowly

Stage I/II

limited to one or two groups of nearby lymph node

Radiation

Chemotherapy with or without rituximab

Stage III/IV

Chemotherapy plus rituximab. A total of 6 cycles for responders

Radiation for patients too sick to receive chemotherapyb

Follow up with two years of rituximab

Recurrent or resistant tumors may require other more aggressive chemotherapy or targeted cell therapy

Slow growing tumor

For Hepatitis C virus carrier, treating the infection will shrink the tumor

For hepatitis virus negative patients, splenectomy will shrink the tumor

Rituximab is an option

Advanced tumor is treated with chemotherapy

A very fast growing tumor which is similar to acute leukemia

Intensive chemotherapy with 5 or more drugs: HYPER-CVAD, CODOX-M, EPOCH

Intrathecal therapy with methotrexate

Plenty of fluids is required for these patients

For advanced cases, other chemotherapeutic regimes are options

Stem Cell Transplant for patients who go into remission

Radiation: external beam to the eye or to the brain and spinal cord as well

Chemotherapy plus radiation

Rituximab is an option to add

Resistant or recurrent cancers may be treated with intensive chemotherapy plus stem cell transplant