Download Neoplasms

NEOPLASMS
Chapter 3
TERMINOLOGY TO NEOPLASMS &
TUMORS
• Neoplasm (neo=new,plasm=growth)
• Tumors may be defined as swelling or as a neoplasm.
Remember Not all neoplasms form tumors.
• Ex: Leukemia (Leuk=white, emia=blood) is a malignant
disease of the bone marrow that causes an increase in white
blood cells and might not form distinctive tumors.
• Likewise, not all tumors are neoplasms. Ex: Hematoma
(hemat=blood, toma=tumor) is a large tumor or selling filled
with blood, commonly known as a bruise.
CLASSIFICATIONS OF NEOPLASMS
• Two of the most common ways to classify neoplasms are
according to
1) The appearance and growth pattern and
2) Tissue of origin, or type of body tissue from which they grow
• Neoplasm tumors can be benign or malignant.
MALIGNANT & BENIGN
NEOPLASMS
• Benign- are confined to a local area and do not spread.
Commonly called tumors and are generally harmless unless
they are growing in a confined space such as the brain.
• Malignant- are deadly because they exhibit characteristics
of invasion and metastasis.
• Invasion refers to the spreading of the neoplasms into local or
surrounding tissue.
• Metastasis- the spread of the neoplasm to distant sites.
Commonly known as cancer.
TISSUE OF ORIGIN
• Neoplasms will be classified or named according to the
tissue from which they grow along with the suffix,
“oma”, for tumor.
• A benign tumor will have suffix “oma” added AFTER the
name of the TISSUE.
• Ex: Lipoma, a benign tumor of fatty tissue.
• A malignant tumor will have the term “Carcinoma” or
“Sarcoma” added to the name of its tissue.
EPITHELIAL TISSUE (SKIN OR
GLAND)
• A benign tumor of epithelial tissue such as a
gland would be adenoma; if it is malignant then
the name becomes adenocarcinoma.
• Carcinoma denotes the largest group of
malignant neoplasms, indicating a tumor of
epithelial tissues found on external or internal
body surfaces.
CONNECTIVE TISSUE (BONE,
MUSCLE, OR FAT)
• A benign tumor of connective tissue such as bone would be
osteoma; if it’s a malignant neoplasm it would be
osteosarcoma.
• Sarcoma- is the term used if the neoplasm is from
connective tissue such as muscle, fat, and bone.
• Sarcomas are less common than carcinomas, but spread
more rapidly and are highly malignant.
LYMPHATIC OR BLOOD-FORMING
TISSUE
• Lymphomas and leukemias are malignant neoplasms of
lymphatic and blood forming organs and lymphatic tissues,
respectively.
• These malignant neoplasms do not have benign
counterparts. All leukemias and lymphomas are malignant.
OTHER TISSUES
• Some tissues do not follow the typical pattern.
• For example, malignant melanoma, a malignant neoplasm
of melanocytes (skin cells).
• Glioma refers to all tumors of the glial cells of the brain.
Don’t fit the classification system.
• Are benign in appearance and do not metastasize, but are
malignant because most are fatal.
GROWTH OF BENIGN AND
MALIGNANT NEOPLASMS
• Normal cells grow and function for a purpose regulated by
several factors.
1. Built in genetic program regulates growth pattern.
2. Normal cell growth is limited by contact with other cells.
• When two normal cells come together they tend to stick
together sending a signal called contact inhibition, telling
cells to stop growing.
3. After Normal cell growth, cells start to perform specialized
functions called differentiation.
BENIGN NEOPLASM GROWTH
• Benign neoplasm tumors might have some normal structure and
function, similar to their origin.
• They are encapsulated or covered with capsule like material,
making removal or excision easier.
• Have limited growth potential and are slower growing that
metastasized neoplasms.
• They are expansive (grow and enlarge in the area) but are not
invasive or metastic.
BENIGN NEOPLASM GROWTH
• Benign neoplasms not being metastatic does not mean
they are harmless.
• The presence and growth of any tumor can obstruct
passageways such as those in the digestive an respiratory
tact, leading to difficulty eating or breathing.
• Tumors can also put pressure on nerves, causing pain and
loss of sensation. Can also affect glands causing over and
under secretion of hormones, and pressure on brain
causing cell and tissue death.
MALIGNANT NEOPLASM GROWTH
• Have a growth pattern that has no purpose and is uncontrollable.
Neoplastic cells grow autonomously or independent of growth
factors.
• These cells to not follow cell regulation such as contact inhibition.
• Malignant neoplastic cells do not have the structure or function of
the cells of their origin, and do not look alike as benign tumors do.
• Structure is not uniform but haphazard and inconsistent, are not
differentiated and do not have specialized functions.
MALIGNANT NEOPLASM GROWTH
• The surface area of malignant neoplasms are not
encapsulated, Rather it is more crab like in appearance, with
multiple claw like extensions invading surrounding tissue.
• Also malignant tumors metastasize to distant areas of the body,
and are fast growing.
• Metabolism of cancerous cells are aimed to rapid reproduction
and growth, outgrowing normal cells, leading to increase for
the need of nutrients and oxygen.
MALIGNANT NEOPLASM GROWTH
• To meet the need of nutrients causes Angiogenisis
(ango=vessel, genisis=growth or new growth of blood vessels)
• This occurs to increase of blood flow, providing increased
nutrients to the neoplasm allowing the continuation of rapid
uncontrolled growth.
• At this point normal cells are deprived of needed nutrients,
causing the individual to appear thin, frail and weak, a
condition called cachexia.
• http://www.youtube.com/watch?v=6UXxmTFsNf0
• Stop here for Quiz #1
HYPERPLASIAS AND NEOPLASMS
• Hyperplasia (hyper=too much, plasia=growth and neoplasms
(neo=new, plasm=growth) are both overgrowths of cells that
cause increase in the size of tissue.
• Both commonly produce masses that need to be identified
because each treatment is drastically different.
• Neoplasms and hyperplasias differ in cause and extent of their
growth.
HYPERPLASIAS
• Usually occur in response to stimulus, plus growth stops when
stimulus stops.
• Ex: Skin callus on the foot; the stimulus is the irritation or rubbing of a
shoe on that particular area.
• Hormone excess or deficiency can also cause hyperplasia, making
the thyroid gland to become enlarged (Goiter).
• Chronic inflammation can also cause hyperplasia or adenoid
hyperplasia, as well as prostatic hyperplasia in older men.
http://www.youtube.com/watch?v=aLPqzYMg42Y
DEVELOPMENT OF MALIGNANT
NEOPLASMS
• Genetic alteration causes the development of malignant
neoplasm, or cancer.
• Cells throughout the body can go through alterations or mutations
but only few develop into cancer.
• The cell must undergo a series of changes to its DNA structure to
acquire the altered growth pattern of cancer.
• Genetic mutations can occur from viruses, chemicals, radiation(
UV, X-ray), or biological agents called carcinogen
(carcino=cancer, gen=arising).
DEVELOPMENT OF MALIGNANT
NEOPLASMS
• Continued exposure to carcinogens increase the abnormality of the
cell. Abnormal cell can revert to normal cells, appear as benign
tumors, or digress to malignant tumors.
• Immune system can help reverse or prevent development of
cancer, as well as removing or stopping the carcinogen.
• If development is not stopped, abnormal cells will establish
themselves to become cancerous and must grow faster to establish
a site.
• Cancer cells will have to fight against normal body cells for nutrients
and space.
DEVELOPMENT OF MALIGNANT
NEOPLASMS
• As long as abnormal cells are not established, hey are considered
preneoplastic or precancerous. Discovery at this point leads to the
surgical removal of the cells.
• Unfortunately very few potential cancers are discovered at this
stage.
• Squamous epithelial tissue often progresses through a slow series of
changes including hyperplasia, abnormal hyperplasia called
dysplasia, and finally, stage called carcinoma in situ (atypical cells
sitting in epithelial layer of tissue).
• https://www.youtube.com/watch?v=nSp1l2AmqSU
DEVELOPMENT OF MALIGNANT
NEOPLASMS
• Carcinoma in situ (Location) commonly occurs in the uterine cervix,
larynx, and mouth and are cells that at this stage have not broken
through the basement membrane or surrounding tissue.
• Cancer can be avoided at this stage by surgical removal of
dysplasia, or in situ tumor.
• Final stage of cancer development is the invasion by the
precancerous cells to the surrounding tissue, showing change from
precancerous tissue to malignant neoplasm.
DEVELOPMENT OF MALIGNANT
NEOPLASMS
• Once carcinogens break through the basement membrane
(tissue separating epithelial tissue from connective),
carcinogens will spread quickly.
• Invasion will not only occur in local tissue but through
lymphatic system (Lymph fluid) and circulatory syst. (Blood)
LYMPHATIC SYSTEM METASTASIS
• Carcinomas- epithelial tissue neoplasms- commonly spread
through lymphatic system. Because lymph nodes can catch or filter
cancer cells, lymph nodes are commonly removed surgically and
examined for presence of cancer cells.
• As the cells continue to move through lymph nodes, they begin to
fill the node causing it to be unable to filter anymore carcinogens.
• When this occurs neoplastic cells can now begin to enter the
bloodstream.
• https://www.youtube.com/watch?v=DbLexEGh4uU
LYMPHATIC SYSTEM METASTASIS
• Absence of lymph node involvement is favorable because it
means surgical cure is possible.
• The higher the number lymph nodes involved the lower the
chance of survival.
BLOODSTREAM METASTASIS
• Sarcomas do not use the lymphatic system as often as
carcinomas because carcinomas shed neoplastic cells
directly into the blood to distribute throughout the body.
• Common sites of bloodstream metastasis are the liver, lungs,
and brain.
GRADING AND STAGING OF
CANCER
• Grading is the microscopic examination of the tumor to determine
the degree of differentiation.
• The more abnormal the tissue appears to normal tissue, the more
undifferentiated or anaplastic it is (Different to normal tissue).
• Because cells are anaplastic or undifferentiated, prognosis is easily
available.
• Tumors are typically graded from I to IV, grade I tumors are less
aggressive while grade IV are most aggressive and serious in
nature.
GRADING AND STAGING OF
CANCER
• Staging determines the event of the spread of the neoplasm.
• Clinical examinations such as x-ray and biopsy can be used to
evaluate the degree of spread by the stages of I to IV used in
grading,
• Second most detailed staging is TNM system. In this system, tumors
are staged according to the size and extent to the primary tumor,
number of lymph nodes, and metastasis of other sites.
• Of grading and staging, staging is the better indicator.
Stop here for Quiz 2
CAUSES OF CANCER
• Actual cause of cancer is unknown, and is usually due to a
variety of circumstances, suggesting that there is more than one
factor involved in its development.
• One thing that stays consistent is the development of cancer:
genetic alterations allowing the cells to grow independently and
uncontrollably.
• It is theorized that that the human immune system catches and
destroys abnormal cells as soon as they occur.
CAUSES OF CANCER
• In some respects, cancer might be present on some failure
of the immune system in the individual.
• Prevention and cure of cancer will depend on finding the
initiating agents causing genetic alterations in the cell or the
event that causes the altered cells to become malignant.
• We currently have hundreds of carcinogenic compounds
that have been identified.
CAUSES OF CANCER
• Carcinogenisis (cancer development) might take several
years to develop, start and stop, or even reverse.
• Usually there is continued progression of cellular changes
from hyperplasia, to dysplasia to metaplasia, to neoplasia.
• http://www.youtube.com/watch?v=46Xh7OFkkCE
CHEMICAL CARCINOGENS
• The frequency of exposure, strength, and potency of a chemical
are important factors in the development of cancer.
• Chemicals that do not cause cancer by themselves might
enhance cancer development when used in combination with
other chemicals.
• Ex: Napthylamine found in certain dyes causes bladder cancer,
asbestos: previously used in roofing and insulation is identified as a
carcinogen leading to lung cancer, and insecticides lead to skin
and lung cancer.
HORMONES
• Can increase the incidence of cancer, and at times hormones
can be used as a form of cancer treatment.
• Action of hormones related to cancer is unknown, Ex: benign moles
don’t become malignant until sex hormones increase in puberty.
• Negativity of hormones: diethylstilbestrol, a synthetic estrogen
compound given to pregnant women during the 1940’s and 50’s
lead to rare vaginal adenocarcinoma in female children and
testicular abnormalities in male children.
HORMONES
• Excessive production of estrogen in the female can lead to cancer
of their breast and uterus. Estrogen medication used to treat
menopausal symptoms has shown to cause an increase in
endometrial cancer.
• Ovaries are sometimes removed after breast cancer in effort to
decrease stimulation of other possible tumors.
• The connection to birth control and cancer have been
inconclusive. Birth control combine estrogen with progestin(
synthetic progesterone: hormone released by ovaries to regulate
menstrual cycle and maintain pregnancy) may decrease risk of
ovarian and endometrial cancer.
HYSTERECTOMY
• In a supracervial or subtotal hysterectomy, a surgeon removes
only the upper part of the uterus, keeping the cervix in place.
• A total hysterectomy removes the whole uterus and cervix.
• In a radical hysterectomy, a surgeon removes the whole
uterus, tissue on the sides of the uterus, the cervix, and the top
part of the vagina. Radical hysterectomy is generally only done
when cancer is present.
• The ovaries may also be removed -- a procedure called
oophorectomy -- or may be left in place.
HORMONES
• Prostate cancer is stimulated by the male hormone
testosterone but slowed or inhibited by estrogen treatment.
• Estrogen medication will counteract the effects of
testosterone. Decreasing testosterone production might also
include orchiectomy- the removal of the testes, in effort to
decrease or slow the growth of prostatic tumor or decrease
stimulation of other tumors.
• https://www.youtube.com/watch?v=27PATuCznI8&list=PL9Z
6E7OKwgMLAoFxwNznka4aLkK8zUb07
• Risks
ORCHIECTOMY
• Orchiectomy causes sudden hormone changes in the body. Side effects from
hormone changes may include:
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Sterility.
Loss of sexual interest.
Erection problems.
Hot flashes.
Larger breasts (gynecomastia).
Weight gain.
Loss of muscle mass.
Thin or brittle bones (osteoporosis).
RADIATION
• Ultraviolet (UV) radiation, X- radiation, radioactive materials,
are all known carcinogens.
• Over 2 million cases of skin cancer are diagnosed each year
from farmers, sun bathers, fisherman, construction workers,
mariners, and anyone with exposure to UV rays.
• Melanomas occur more frequently due to extreme, blistering
burns at a young age. Fair skinned people mare at greater risk
due to low amounts of melanin. (black people don’t get skin
cancer) ;D
RADIATION
• High dosage of radiation may be used as treatment for some cancers, but
has a risk of developing secondary tumors.
• These tumors take between 20 to 25 years to actually develop so the
benefits of radiation therapy outweigh its risk.
• Radioactive materials release Alpha, Beta, and Gamma rays making them
potential carcinogens.
• Wearing protective clothing when exposed to these materials can
decrease the risk of cancer.
VIRUSES
• Have been proven to cause cancer in laboratory animals, but no clear cut
views in humans. For example:
• The Epstein-Barr virus causes infectious Mononucleosis.
• Hepatitis B virus has been linked to liver cancer.
• Individuals with cervical cancer also tend to have the herpes simplex virus.
GENETIC PREDISPOSITION
• Discoveries of certain cancer suppressor genes, and most recently a
breast cancer gene, has aided research efforts, but has not given us a
complete understanding of correlation to genetics and cancer.
• It is known that breast and colon cancer have a higher incidence in
certain families.
• Relatives that have these genes can pass them to other family members.
PERSONAL RISK BEHAVIOR
• Smoking and tobacco products
• Diet
• Alcohol use
• Sexual Behavior
SMOKING AND TOBACCO PRODUCTS
• Cigarette smoke is a carcinogen. It kills approximately 443,000 people
yearly according to the ACS (American Cancer Society, 2011)
• According to ACS, cigarettes kill more people than car accidents,
alcohol, AIDS, murders, illegal drugs, and suicides combined.
• Smoking also doubles the incidence of cancer in the bladder and
pancreas.
SMOKING AND TOBACCO PRODUCTS
• Chemicals in cigarette smoke affect all organs in the body because the
chemical are absorbed from the lungs to the bloodstream circulating to
all the organs.
• These chemicals are found in increased concentrations in the urine of
smokers.
• Secondhand smoke is also detrimental, leading to 46,000 heart disease
deaths, and 3,400 lung cancer deaths. Cigarette smoking currently costs
the U.S. $139 billion per year in health care costs and related losses.
• Oral cancer occurs in tobacco chewers than non tobacco users.
(baseball)
DIET
• There is a consistent relationship in the increase in weight in women and
the risk of cancer, but no relationship between the two in men.
• Obesity and high consumption of dietary fat is a consistent risk factor for
endometrial, breast, and colon cancer.
• Food additives like saccharin (Artificial sugar) have been found to cause
cancer in the bladder in rats but no correlation has been found in
humans.
• Nitrates are preservatives used in meats and have shown to produce
stomach cancer in animals. (Japan- high rates of gastric cancer)
DIET
• Colon cancer rates are lower in countries that have lower
consumption in dietary fat, and higher consumption in fiber
and the U.S.
• The Western plains area of the U.S. is high in Selenium
(mineral) found in meats has the lowest colon cancer rates,
supporting concepts of correlation between selenium level
and colon cancer.
ALCOHOL USE
• Cancer of the mouth, throat, and esophagus, occurs more often in
people who smoke and drink alcohol excessively.
• Alcohol is not a proven carcinogen at the moment but, recent studies
have shown higher incidence of breast cancer in women who drink
even in moderate amounts (3 drinks a week)
SEXUAL BEHAVIOR
• The risk of cervical cancer is related to the age of first sexual
intercourse and the number of sexual partners.
• The younger the female, and larger the amount of sex partners, the
greater the risk. (Amount of sex partners from both sexes causes the
risk)
• Medical studies confirm that Human Papilloma Virus (HPV) is
associated with most cervical cancers and it is easily transmitted
between partners.
SEXUAL BEHAVIOR
• Incidence of cervical cancer is two times greater In black women
than white, and is found more commonly in lower socioeconomic
groups.
• Women who marry men that have had relations with a woman that
has cervical cancer, are at greater risk of developing cervical cancer.
• Pregnancy and childbirth appear to be protective mechanisms for
cancer of the ovaries, endometrium, and breast for women.
SEXUAL BEHAVIOR
• Females that start menstrual cycles at a later age, have early
menopause, bear first child at an early age, or experience all or some
of these behaviors are at decreased risk for breast cancer.
CANCER PREVENTION
• Cancer of the lung, breast, prostate, and colon are responsible for the
majority of cancer deaths.
• Having a preventative lifestyle will help prevent any of these cancers.
• Smoking and tobacco use lead to approximately 30% of all cancers.
• Cigarette smoking is the single most preventable cause of lung
cancer, other disease of the lung and heart disease.
CANCER PREVENTION
• Preventative measures include a reduction of fat intake and high fiber
foods, as well as calorie intake and exercise properly.
• No Smoking (associated with at least 15 cancers)
• Limit alcohol intake
• Protect skin from excessive sun exposure (use sunblock spf 15 or higher)
• Refuse needless X-rays.
CANCER PREVENTION
• Avoid heavily polluted air
• Follow label instructions when using pesticides, fungicides, and other
chemicals.
• Maintain healthy body weight
• Women should perform self breast examinations.
• HPV vaccines are recommended for boys and girls.
CANCER PREVENTION
• Have regular checkups by physicians. Mammogram (Women over 50)
and PAP test yearly for cervical cancer.
• Men no longer have to have testicular self exams, but need to tell
doctor about change in feel or look of testicles.
• Rectal examinations should be a part of every medical checkup for
men and women, and stool samples for blood as indicator of colon
cancer.
FREQUENCY OF CANCER
• Cancer affects people of all ages and both males and females. The most
common type of cancer is basal and squamous cell skin cancer.
• These cancers are seldom fatal because they are very visible and are slow
growing, and can be completely excised.
• Malignant melanoma is a deadly form of skin cancer that comprises
approximately only 1% of all skin malignancies.
DIAGNOSIS OF CANCER
• Recognition of cancer warning signs by an individual are important. These
signs are listed by the ACS by having letters form the acronym CAUTION. An
individual with one or more of these signs should be evaluated immediately.
• Change in bladder or bowel habits
• A soar that does NOT heal
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Unusual bleeding or discharge
Thickening, or lump on breast or elsewhere
Indigestion or difficulty swallowing
Obvious chance in wart or mole
Nagging cough or hoarseness
DIAGNOSIS OF CANCER
• You can find more information by having a more detailed
exam by using a computerized tomography (CT), Magnetic
Resonance Imaging (MRI), and Position Emission Tomography
(PET) by finding the size and location of tumors.
• Examination of the actual cells is called cytology (cyto=cell,
ology=study)
• The definitive exam of a cell is by doing a biopsy.
DIAGNOSIS OF CANCER
• A papanicolaou or Pap test (Derived from developer named Dr.
George Papanicolaou) can be used to examine cells.
• This is actually a simple staining test that can be used on cells and
other body fluids like urine, feces, sputum, prostatic fluids, or
vaginal fluids.
• Sample is stained and put under a microscope to examine for
abnormal cells.
DIAGNOSIS OF CANCER
• To examine Live tissue, a biopsy must be done. Biopsys can be
obtained by aspiration, needle biopsy, endoscopy, or surgery.
• Aspiration biopsy uses a needle attached to a suction device
to remove a small piece of tissue from the tumor.
• Needle biopsy is obtained by punching a needle through the
tumor using the tissue caught on the lumen of the needle for
examination.
DIAGNOSIS OF CANCER
• Surgical biopsy can be performed with the patients consent to
excise the tumor if foundto be cancerous.
• When biopsy is obtained, it is sent to a pathologist for
diagnosis. Pasitient will remain under anesthesia while surgeon
get results.
• A technique called “Frozen sections” enables the pathologist
to make a rapid determination if the tumor is benign or
malignant.
SIGHS AND SYMPTOMS OF
CANCER
• Pain
• Obstruction
• Hemorrhage
• Anemia
• Fractures
• Infection
• Cachexia
SIGNS AND SYMPTOMS OF
CANCER
• Pain:
• Usually a later symptom from destruction of normal tissue,
obstructing the Lumen of hollow organs like the intestines,
placing pressure on nerve endings, and causing
inflammation and discomfort.
SIGNS AND SYMPTOMS OF
CANCER
• Obstruction:
• Obstruction of hollow organ can occur from cancer
growing inside or outside the organ that compresses or
pushes into the organ.
SIGNS AND SYMPTOMS OF
CANCER
• Hemorrhage:
• Can be caused by the cancerous tissue ulcerating and
bleeding, leading to acute or chronic blood loss and often
results in anemia. Hiden blood in the feces can be detected
by blood stool test.
SIGNS AND SYMPTOMS OF
CANCER
• Anemia:
• Very common in individuals with malignant neoplasms and
might be the result of tumor hemorrhage or a decrease in
red cell production as a result of cancer treatment.
SIGNS AND SYMPTOMS OF
CANCER
• Fractures:
• Can occur if tumor has invaded the bone and caused
weakness at the site. Fracture occurring from minimal injury
might be an indicator, but for older people it might be a
sign of osteoporosis. Bone cancer might be primary or
secondary with cancer of lungs, breast, or prostate
metatasizing to the bone.
• Infection:
SIGNS AND SYMPTOMS OF
CANCER
• Often common and can lead to the demise(death) of the
individual. Tumor ulceration can allow entry of microorganisms
that can cause an infection, or might have impaired immunity
to Chemotherapy and radiation treatments, affecting bone
marrow and decrease production of white blood cells.
• Loss of appetite during cancer is also common causing poor
nutrition and increases the chance of infection.
SIGNS AND SYMPTOMS OF
CANCER
• Cachexia:
• Condition of general ill health and malnutrition normally
seen in terminally ill patients. This condition is evidence of
demands on the body by the rapidly growing tumor and
treatment modalities, couples with poor nutritional intake,
CANCER TREATMENT
• Surgery: Can be curative, papillative, or preventative.
• Curative: aimed to complete removal of tumor (lung, stomach, skin, breast,
intestine, and female reproductive organs respond well to this type of
surgery.
• Palliative: Surgery is not possible but surgery will alleviate pain and
discomfort. (Intestinal cancer or performed to severe nerves to reduce pain)
• Preventative: might be performed to prevent cancer if you are at high risk or
precancerous
CANCER TREATMENT
• Chemotherapy:
• Can be the medication of choice or used In combination with surgery and
radiation therapy. Usually used to treat rapid growing tumors, directly
stopping the growth of malignant cells and having small affect on normal
cells. Some normal cells will be damaged due to small variation in both
cells.
• Symptoms of Chemotherapy are rapid growing cells found in the
epithelium, hair, and bone marrow suffer most, leading to nausea,
vomiting, loss of appetite, hair loss, anemia, and impaired immunity.
CANCER TREATMENT
• Radiation:
• Used in residual neoplasm postoperatively