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Basic principles of oncology I amarasinghe MS FRCS Surgical oncologist Definition of a principle A fundamental truth That serves.. As a foundation… For a chain of reasoning Cancer documentation • Risk factors • Cancer families..3 types No cancer in any generation Assortment of cancers Same cancer repeating…gene typing • Knudsons two hit hypothesis Investigating a patient with a primary diagnosis of cancer • Investigations to confirm diagnosis • Investigations to detect spread Investigation for spread • Common inv such as CXR.us scan. CT .Mri. Bone scans,mammography etc Vs • PETCT Usefulness of whole body pet ct in comprehensive oncological management When used as a diagnostic tool • 30% showed metastatic disease where CT was inconclusive or negative • In 20% it changed the management completely In diagnostic investigations • Eg mammography combined with ultrasound breast is 99% accurate. • Triple assessment • Core biopsy? • Even tho fnac is less expensive ultimately as it is non diagnostic it proves more cost effective to do core via Trucut or VABB???? Principles of treatment of a breast mass in a young girl • Clinically benign mass on examination • Reassure and dismiss???? Guidelines from American National Cancer Institute • Do a bilateral us of both breasts for impalpable lesions • If she wants follow up…do an fnac to exclude early phylloides • Follow up 6 monthly • Be cautious over 40 years of age Principle of trends in oncology • • • • • More and more towards organ preservation Breast conservation Volume replacement for tongue Modified block dissections for nodes Sentinel nodes for axilla and groin Surgery for cancer Address margins Address regional spread Margins…Point of contention • 40 years of BCS • The problem of Ipsilateral Breast Tumour Recurrence (IBTR) • Directly related to margins of surgical excision. Methods of assessing margins • Frozen section outdated and laborious • Imprint cytology • Cavity margin shave assessment…good but still re excision may occur • technology..Margin probe..electromagnetic . device Mico ct How negative should a margin be? • An meta analysis of 14,571 patients indicated there was no statistically significant difference of negative margins less than 1 mm in terms of local recurrence (int journal surgical oncology 2012) Problems of positive margins • Further surgery • • • • Cosmetic outcome impaired Further health cost for repeat surgery Emotional conflict for patient Delays adjuvant therapy • In the UK >70% opt for BCS rather than mastectomy • Due to the screening program Finally…guidelines after 40 years • Combined consensus • American society of radiation oncologists ASTRO • Society of surgical Oncology SSO.(.annals of surgical oncology) Recommendations • Positive margins are defined as ink on invasive cancer or DCIS • Associated with at least two fold increase in IBTR (Ipsilateral breast tumor recurrence) • This increased risk is NOT NULLIFIED BY DELIVERY OF BOOST SYSTEMIC THERAPY FAVOURABLE BIOLOGY Summary • • • • • • 40 years of BCS globally Aim must be to avoid IBTR Adequate Margin mandatory.1 cm or > However recurring positive margins still 5-17% Advent of oncoplastic flaps Guidelines by ASTRO and SSO indicate only ink on tumor significant for local recurrence. • EIC, young age, Invasive lobular., close margins not an indication for re excision. Surgery for advanced cancer • Always biopsy for markers • Consider cytoreductive surgery to enhance subsequent treatment with adjuvant therapy Markers on tumors must be done at all stages of presentation • Absolutely essential for overall treatment • Eg Basic markers ER PR .Her2 • Advanced molecular markers ki-67 proliferation index • Genetic markers chemotherapy • Is systemic so can eliminate hidden tumor burden • Toxic side effects must be carefully but positively addressed Support is a fundamental need • Needs to be very carefully evaluated • Most complicated are single non religious males…. • can lead to depression and suicide • The most needy time is at the first recurrence and the terminal stage • Can a clinician handle this???? Palliative care • Needs tactful interaction on all fronts • Main aim is control of Pain • must understand the difference in prolonging life and prolonging death Thank you