Download surg oncology

Principles of Surgical
Oncology
Amr Mohsen
General Surgery Department
Faculty of Medicine
Cairo University
Principles of Surgical
Oncology
1.
2.
3.
4.
5.
6.
7.
8.
9.
How cancer arises
Aetiology of cancer
Stages of cancer development
Cancer grading
Spread of cancer
Diagnosis
Treatment
Prognosis
Hope for the future
Contents page
1. How cancer arises
Gene mutation


Proto-oncogenes >>mutation>> oncogenes
>>>> stimulate growth
Tumour suppressor genes >>mutation>>
defective function
Escaping body defense mechanisms


Escaping apoptosis
Escaping immune system
Contents page
1. How cancer arises
Examples

Oncogenes
Tumour suppressor genes

Escaping immune system

erb-B
P53
BRCA1
BRCA2
AIDS & Kaposi
Transplant for CA
Contents page
2. Aetiology of cancer
Initiators that damage genes
Chemical agents
Viruses
Idiopathic (aging)
Physical agents
Diet
Factors enhancing tumour growth
Hormones
Contents page
3. Stages of cancer
development
1. Hyperplasia
2. Metaplasia
Contents page
3. Stages of cancer development
3. Dysplasia
Contents page
3. Stages of cancer development
4. In situ CA
Contents page
3. Stages of cancer development
5. Invasion
6. Mets
Contents page
4. Cancer grading
Grading is a measure of CA
aggression



Well-differentiated
Moderatelydifferentiated
Poorly-differentiated
& undifferentiated
Contents page
5. Cancer spread
Properties that allow metastasis
1. Defective cell adhesion
2. Tumour angiogenesis
3. Escaping apoptosis as they reach distant
tissues
Contents page
5. Cancer spread
Modes of metastasis
Local spread
2. Lymphatic spread
3. Blood-born spread
4. Trans-cavitary spread
5. Perineural
1.
6.
Contact spread
Contents page
5. Cancer spread
Contents page
5. Cancer spread
Contents page
5. Cancer spread
Contents page
5. Cancer spread
Contents page
5. Cancer spread
Contents page
5. Cancer spread
Contents page
5. Cancer spread
Stepwise versus explosion concept of
metastasis
Contents page
5. Cancer spread
Contents page
6. Diagnosis
Early detection of asymptomatic cases
(screening)
Mammography PSA colonoscopy for APC
Diagnosis of symptomatic cases
Clinical
Imaging
Tumour sampling
Tumour markers
Endoscopy
Contents page
6. Diagnosis
Contents page
6. Diagnosis
Tumour sampling
Types



Tissue biopsy – cytology
Image-guided – unguided
Frozen section – paraffin sections
Contents page
6. Diagnosis
Tumour sampling
Tissue biopsy



Needle, endoscopic or operative biopsies
Obtains a piece of tissue
Diagnosis depends on cellular morphology &
tissue architecture (orientation and invasion)
Cytology




e.g., FNAC & exfoliative cytology
Obtains cells
Diagnosis depends on cellular morphology only
Requires an expert cytologist
Contents page
6. Diagnosis
Incision
Site & direction
Contents page
6. Diagnosis
Contents page
6. Diagnosis
Healthy
Cancer
Contents page
6. Diagnosis
Contents page
6. Diagnosis
Tumours markers
Help in the diagnosis of certain tumours and in the
follow-up of the patients after treatment.
•Alpha-feto protein
•CEA
•PSA
•CA 15-3
•CA 19-9
•Thyroglobulin
HCC & testicular teratoma
GIT, pancreas and breast CA.
Prostate CA.
Breast CA.
GIT & pancreas CA.
Thyroid CA.
Contents page
7. Treatment
Prevention
•Smoking
•APC
•UC with dysplasia or old pancolitis
Contents page
7. Treatment
Early
Late
Disease
Local
Systemic
Fate
Potentially curable
Incurable
Aim of ttt
Cure
Palliation
Main ttt
Loco-regional
Surgery + RT
Systemic
Chemo + hormo
Pain control
Adjuvant ttt
Chemo + hormo
Surg + RT
Contents page
7. Treatment
Standard modalities
A. Surgery
B. RT
C. Chemotherapy
D. Hormone therapy
E. Immunotherapy
Contents page
7. Treatment
A. Surgery
Definition of radical surgery
Primary tumour
Safety margin
Lymph nodes
•GIT CA
•Breast CA
•Head & neck & skin
Routinely resected
Excision or irradiation
Treated only if involved
Whenever possible lymph nodes are removed in
continuity with the primary tumour = block excision.
Contents page
7. Treatment
A. Surgery
Precautions
Avoid spillage of malignant cells, local & blood
Advantages
•Quick
•Effective
•The largest number of cures
•Confirms full ablation of a tumour (clear safety margin).
Disadvantages and Limitations
•Functional and cosmetic disabilities
•Not applied if fixed to a vital structure or with mets.
Contents page
7. Treatment
B. Radiotherapy
May replace surgery or may be given in addition
Common indications
1. Cancer of the larynx so as to preserve the voice
2. Early Hodgkin's disease
3. Early prostate cancer
4. As part of conservative therapy for early breast
cancer (after surgery)
Contents page
7. Treatment
B. Radiotherapy
Methods
Powerful X-rays, gamma rays, electrons, or heavy
particles are directed to the tumour by one of two
main methods
1. Teletherapy (cobalt & linear accelerator)
2. Brachytherapy (implanted needle)
Contents page
7. Treatment
B. Radiotherapy
Advantages
• Preserves surrounding structures
• Can destroy microscopic extensions around a
tumour that a scalpel might miss
• Safer option for old frail patients
• Usually does not require hospitalization
• SCC is sensitive
Disadvantages
• Adenocarcinoma is much less sensitive
• Burns of the skin or enteritis - difficult to treat
• Compared to surgery, radiotherapy is slower
• Like surgery, it is not suitable for mets
Contents page
7. Treatment
C. Chemotherapy
Common indications
•
•
Blood & lymphoid CA
For solid tumours
-Main modality in case of detected metastases
-Adjuvant to surgery in early cases where
microscopic metastases are possibly present
Better results are obtained from
combination chemotherapy
Contents page
7. Treatment
C. Chemotherapy
Advantages
1. Can reach malignant cells anywhere in the body
2. Leukaemias, lymphomas and testicular cancer are
successfully treated by new combination drugs.
Disadvantages
1. Chemotherapy kills the rapidly growing cells of the
bone marrow, causes anemia, leucopenia and
thrombocytopenia.
2. Other side effects of chemotherapy include
diarrhoea, nausea vomiting and hair loss.
Contents page
7. Treatment
D. Hormone therapy
Examples
•
•
•
Anti-oestrogens for with ER +ve breast CA
Androgen blockade for men with prostate cancer
Thyroxin to suppress TSH for papillary thyroid CA
Advantages
Mild side effects
Disadvantages
Limited to tissues with hormone receptors
Contents page
7. Treatment
E. Immune therapy
Non-specific
BCG
TCC of urinary bladder
Specific
Monoclonal antibodies from a single clone of
lymphocytes that have been stimulated by a
specific protein of the cancer cells
Contents page
7. Treatment
Bone marrow transplantation
Not a therapy in itself
Indications
To strengthen depleted bone marrow that is weakened
by high, potentially curative doses of RT or
chemotherapy
Sources
•Allogeneic donations
•Autologous donations
Contents page
8. Prognosis
Measures of prognosis
Survival
Recurrence
Usually 5-10 years
Contents page
8. Prognosis
Patient
Tumour




Stage most important
Grade
Site
Type



Age
Debilitating illness
Immunosuppression
Treatment


Early detection
Treatment in specialized centres
Contents page
8. Prognosis
Good prognosis




Skin, SCC BCC
Leukaemias
Lymphomas
Testis
Bad prognosis




Melanoma
Oesophagus
Stomach
Pancreas
Contents page
9. Hope for the future
•Wider application of early detection programs
•Refinement of established modalities of treatment
•Gene therapy
•Control of angiogenesis
•Better targeting of therapy
Thanks