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BALKAN MCO 2011 - R. Popescu and J. Zgajnar - Multidisciplinarity in oncology
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BALKAN MCO 2011 - R. Popescu and J. Zgajnar - Multidisciplinarity in oncology

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  • 1. Janez Žgajnar Institute of Oncology Ljubljana
  • 2.  
  • 3.  
  • 4.  
  • 5.  
  • 6.  
  • 7.  
  • 8.
    • Institute of Oncology Ljubljana
    • Basics of surgical oncology
    • Screen detected breast cancer and multidisciplinary approach
  • 9. Institute of Oncology Ljubljana
  • 10.
    • Founded in 1938
    • Today major comprehensive cancer centre in Slovenia
    • The professional work is based on a high-quality multidisciplinary approach to diagnosis and treatment.
    • The Institute is the central national institution
      • that partially performs, and at a national level, directs the programs of comprehensive cancer care in the fields of prevention, early detection, treatment and rehabilitation.
    • Education and research
    • National cancer registry (www.slora.si)
  • 11.  
  • 12.
    • >3000 major surgery procedures
    • 6000 patients RT
    • ~5000 patients cytotoxic systemic treatment introduced
    • 950 employees (~140 physicians)
  • 13. Multidisciplinary work and the IO
    • 14 different MD meetings weekly at the OI
    • Collaboration in MD meetings in other institutions in Slovenia
    • Teleconference MD meeting introduced this year
  • 14. AIM of the IO as a leading oncology center in the state
    • To improve all aspects of the oncology in Slovenia
    • To enable equal access to high quality diagnostics and treatment for all citizens
    • NATIONAL CANCER PLAN
  • 15. Basics of Surgical Oncology
  • 16. Surgical oncologist
    • “ Surgeons who devote most of their time to the study and treatment of malignant neoplastic disease”
    • Pollock R and Morton D, Cancer Medicine 2003
  • 17. Profound knowledge needed
    • Pathology of the disease
    • Diagnostic procedures
    • Multimodality treatments
      • Systemic treatment
      • Radiotherapy
      • Specific surgical procedures
  • 18.
    • Surgical oncology is more a
    • COGNITIVE ( how and when)
    • than
    • TECHNICAL ( how)
    • surgical specialty
  • 19.  
  • 20. Sentinel node biopsy limfoscintigraphy
  • 21. Sentinel node biopsy surgery
  • 22. Some facts about surgery in cancer treatment
    • Surgery is the oldest modality of cancer treatment
    • When used as a single modality it cures more patients that other modalities
    • It is the most effective treatment of the local disease and the regional lymph nodes
  • 23. Development of cancer surgery
    • Originally only conservative
      • Removal of the gross lesion
    • Extensive surgery with curative intent
      • Mutilating procedures
    • Conservative- with multimodality treatment
  • 24. Surgical components of cancer management (1)
    • Prevention
      • Prophylactic surgery
    • Biopsy and the diagnosis of the tumor
      • Needle biopsy
        • Fine needle, core biopsy
      • Incisional biopsy
      • Excisional biopsy
  • 25. Surgical components of cancer management (2)
    • Staging
    • Preoperative preparation
    • Cancer surgery
  • 26. Types of cancer surgery (1)
    • Wide local resection with removal of a wide margin of healthy tissue
      • Excision of a “ pseudocapsule ” (a zone of a compressed normal tissue interspersed with neoplastic cells)
  • 27.  
  • 28. Types of cancer surgery (2)
    • “ En block” resections to encompass gross and microscopic disease in adjacent anatomical locations
      • i.e. regional lymph nodes with all lymphatic channels
  • 29.  
  • 30.  
  • 31.  
  • 32.  
  • 33. Tearing the rectosacral ligament
  • 34. Pelvic nerves and dissection plane Righ hypograstric n. Left hypograstric n. R.J. Heald (modified)
  • 35. Correct and incorrect plane of dissection Correct plane Incorrect plane
  • 36. Good TME specimen
  • 37. Indications for surgery
    • Primary local or loco-regional treatment
    • Treatment of the locoregional relapse
    • Treatment of the distant metastases
    • Palliative treatment
  • 38.  
  • 39.  
  • 40.  
  • 41.  
  • 42. Case report of a screen detected breast cancer
  • 43. Why this choice?
    • Mammographic screening is an example of a highly complex approach which illustrates the multidisciplinary in oncology in order to achieve measurable results
    • Opportunistic screening is the opposite example A lot of work – no result
  • 44. Breast cancer in Slovenia by stage and period Register raka za Slovenijo
  • 45. 24.848 15.192 14.623 6.252 16.098 Σ = 64.683 8.688 32.103 9.122 42.005 16.056 I. II. III. Target population (50- 69): 255.624 Average cumulative incidence rate 1998 – 2002 4,68-5,37 5,38-6,06 6,06-6,74 6,75-7,42 7,43-8,11 5.954 Σ = 91.655 Σ = 99.286
  • 46. SIEMENS - NOVATION HOLOGIC - SELENIA Mobile units
  • 47. Screening workflow and timing P T T T P P S Č S S Č Č P P P Double reading CONSENSUS Invitation to further assessment ASSESSMENT PREOPERATIVE MDC MEETING The patient is informed 15%-20% 5%-7% 1%-2%
  • 48. Multidisciplinary meetings (1)
    • Breast tumor board
      • Multimodal therapy discussed Surgeon, radiotherapist, medical oncologist, pathologist
    • Nonpalpable lesions
      • From screening after needle biopsies
      • After surgery of the nonpalpable lesions Surgeon, pathologist, radiologist
    • Breast reconstruction meeting Surgeon, reconstructive surgeon
  • 49. Mammography screening MD meetings
    • Consensus conference
    • MDC preoperative meeting Surgeon, pathologist, radiologist
    • MDC postoperative meeting
  • 50.  
  • 51. Screen detected breast cancer (1)
    • 51 year old women, invited for mammography screening
    • M y cro c alcifications revealed in upper outer quadrant of the right breast
  • 52.  
  • 53. CONSENSUS conference
    • Two groups of M y crocalc: 18mm and 22 mm
    • BIRAD 4b
    • RECOMMENDATION: Vacuum assisted core biopsy recommended
  • 54. High grade DCIS
  • 55. High grade DCIS
  • 56. Preoperative conference (radiologist, pathologist, surgeon, nurse)
    • Bifocal, large area, high grade DCIS RECOMMENDATION: mastectomy and sentinel node biopsy +/- reconstruction
  • 57. Reconstruction MD meeting (surgical oncologist, plastic surgeon)
    • RECOMMENDATION: immediate autologous free flap (DIEP) reconstruction
  • 58. Free flaps : DIEP msTRAM SIEA continues to dominate as the workhorse for (autologous tissue) breast reconstruction.
  • 59.  
  • 60.  
  • 61.
    • Invasive ductal cancer and DCIS
    • IDC 13 mm, G2,
    • ER 100%, PR 70%,
    • HER 2 not yet available
    • sentinel node metastasis 7mm
  • 62. Postoperative conference (radiologist, pathologist, surgeon, nurse)
    • RECOMMENDATION: completion axillary node dissection
  • 63. Final histopathology result
    • Invasive ductal cancer and DCIS
    • IDC 13 mm, G2,
    • ER 100%, PR 70%,
    • HER 2 negative
    • MIB 10-15%
    • Axillary lymph node status 1/24
  • 64. Breast cancer tumor board
    • Documentation submitted
  • 65. conclusion
    • No conclusions until Sunday

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