Education Sessions: Key learning points from Sunday

Diagnosis and management issues in lymphoma

• Lymphomas comprise heterogeneous disease subtypes, which reflect the heterogeneity of lymphoid tissues in the human body. Advance research methods, such as next generation sequencin technologies, are unravelling a complex landscape of molecular alterations. These finding are refining sub-classification and helping to identify new biomarkers and drug targets
• A new addition to the therapeutic armamentaria are agents, known as immunotoxins, which use monoclonal antibodies to deliver radiotherapy or toxins directly to the tumour cell. Examples include: brentuximab vedotin, an anti-CD30 antibody conjugated to a antitubulin; and inotuzumab ozogamicin, a cytotoxic agent linked to an anti-CD22 antibody, which has shown a promising response rate in refractory indolent B-cell non-Hodgkin lymphoma
• The role of nuclear imaging methods such as 8F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) and bone marrow examination for lymphoma staging was also considered. While the sensitivity of FDG-PET allows for the detection of nodal and extranodal tumour manifestations and might change clinical patient management, its routine use is compromised by relatively high radiation exposure and high costs. On the other hand, bone marrow biopsy reliably detects bone marrow infiltration but is an invasive and an unpleasant procedure, and in some cases, patchy infiltration may result in false negative results. So it was concluded that FDG-PET bone marrow biopsy is complementary, and one should not replace the other

Towards integrated management of patients with carcinoma of an unknown primary site

• It is important to note that cancer of unknown primary (CUP) represents 3% of patients with cancer. The prognosis for patients with CUP is poor. As a group, the median survival is approximately 3 to 4 months with less than 25% and 10% of patients alive at 1 and 5 years, respectively
• Although the majority of diseases are relatively refractory to systemic treatments, certain clinical presentations of CUP carry a much better prognosis. In each instance, distinct clinical and pathologic details should be considered for appropriate and potentially curative management
• Molecular studies have shown that CUP is a heterogeneous group of tumours with active angiogenesis and common expression of oncoproteins, such as c-myc, ras, HER2, Bcl2. The major intracellular AKT and MAPK axes are frequently activated and carry adverse prognostic significance

Updates in supportive and palliative care

• The prevalence of depression among cancer patients is estimated to be approximately 38% for major depression, and 57% for depression spectrum syndromes, such as demoralisation syndrome. Risk factors for depression in cancer patients include young age, low socioeconomic status, and tumour location, with the highest rates of depression seen in patients with lung, pancreatic and head and neck cancer. There is scientific evidence indicating that biological mechanisms related to the cancer itself or it treatments, such as production of pro-inflammatory cytokines, contribute to the development of depression syndrome in cancer patients. Depression leads to increased length of stay in hospital, reduced adherence to treatment, and increase risk of suicide. The optimal treatment of depression should be a combination of control or elimination of potential organic causes, psychotherapy, pharmacotherapy and working with the patient’s family and staff members 
• Pain is a serious issue in oncology and effects 33% of patients after curative treatment, 59% of patients on anticancer treatment, and 64% of patients with metastatic, advanced, or terminal disease. According to the recently released ESMO recommendations, the intensity of pain and treatment outcomes should be regularly assessed by the treating physicians using validated assessment tools. The treatment of cancer pain should rely, not only on drug treatment, but also on non-pharmacological interventions such as intraspinal interventions or celiac plexus blockade. The formulation of specific recommendations is at the moment complicated by the lack of randomised controlled trials and further well-designed studies are needed to improve cancer pain management