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Surgical Mamnagent  Of  Cancer

Surgical Mamnagent Of Cancer



A Slide show on the Principles of Management of Cancer by Surgery, having practiced this branch for almost 25 years ,I decided to crystalize this knowledge.

A Slide show on the Principles of Management of Cancer by Surgery, having practiced this branch for almost 25 years ,I decided to crystalize this knowledge.



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    Surgical Mamnagent  Of  Cancer Surgical Mamnagent Of Cancer Presentation Transcript

    • NIMACON 2010.
      • Divisional Conference 2010
      • Organized by NIMA SOLAPUR BRANCH.
      • Maharashtra Council of Indian Medicines.
    • Surgical Management OF Cancer Dr.Shirish Kumthekar. Surgeon Oncologist Kumthekar General Hospital & Cancer Research Center Solapur.
    • Cancer
      • Cancer is one of the most formidable Health Problems facing mankind today.
      • Cancer is not a modern day disease!
      • Ramayana (C.2000B.C.)presents the earliest record to identify malignant tumor as a disease entity.
      • Egyptians (C.1500B.C.) were the first to identify that different tumors have different behavior.
      • Sushruta samhita(c.700 B.C.) mentions tumor disease by various categories
      • Hippocrates (C.460-375 B.C.) was the first to name this disease as Cancer.
      • Galen (A.D.131-201) called it a “Neoplasm”.
    • Cancer
      • This being a complex disease, No single approach is sufficient to treat it adequately.
      • A classical multimodality approach, employing 1.Surgery. 2. Chemotherapy.
      • 3.Radiation therapy &
      • wherever required Hormonal Therapy/ Immuno- therapy/ Genetic therapy are employed.
    • Surgical Management OF Cancer
      • Surgery happens to be the oldest known methods to treat cancer. But certainly not the only one!)
      • Surgery ..as we are all aware deals with knife!
      • The surgical treatment of cancer has changed dramatically over the last several decades.
    • Surgical Management OF Cancer
      • Historical Perspective.
      • The earliest discussions of the surgical treatment of Tumors are found in the Edwin Smith Egyptian Papyrus from the middle kingdom (Circa 1600B.C.)
      • E.Mcdowell U.S.A. removed 22 lbs Ovarian Tumor in 1809.
    • Historical Perspective.
      • Two subsequent developments in Surgery
      • 1. Introduction General Anesthesia in 1846 & Introduction of the Principles of Antisepsis in 1867, freed surgery from Pain & sepsis, & greatly increased its use in tumor Surgery.
    • Historical Perspective.
      • 1860-90
      • + Alber Billroth = First Gastrectomy, Laryngectomy & Oesophagectomy .
      • 1878.
      • + Richard Volkman = First Excision of Ca. Rectum.
      • 1880.
      • +Theodore Kocher= First thyroidectomy.
    • Historical Perspective.
      • 1890.
      • William Halstedt= Radical Mastectomy.
      • 1896.
      • G.Beatson.= First Oophorectomy Ca.breast.
      • 1904.
      • H.Young = First Radical Prostatectomy.
    • Historical Perspective.
      • 1906.
      • E.Wertheim= Radical Hysterectomy.
      • 1908.
      • W.Miles = Abdomino Perenial Resection for Ca.rectum.
      • 1913.
      • Torek= Resection of Thoracic Oesophagus .
    • Historical Perspective.
      • 1935.
      • A.Whipple = Pancreatico Duodenectomy .
      • 1945 onwards…….
      • In the Post Second World war era of
      • Science & technology Revolution the surgeons knife has not left any part of Human Anatomy untouched!
    • The Modern Era……..
      • As of Today Management Of Cancer with Surgery i.e. Surgical Oncology has evolved from being the only treatment modality to being one essential component in the multimodality approach in treating cancer.
    • What is the Meaning of the word “Management” in Clinical Practice?
      • The term “Management “in the context of clinical practice, includes not only treatment ,but prevention, diagnosis, & as & when required palliation!
    • The Role of Surgery in the management of cancer
      • Surgery now encompasses all areas of cancer care…
      • 1.Prevention.
      • 2.Diagnosis.
      • 3.Staging.
      • 4.Treatment.
      • 5.Palliation.
    • Role Of Surgery in Prevention of Cancer.
      • The Role of Surgery is not limited to the Diagnosis & treatment of Cancer but extends to intervening earlier in the natural history of Malignant transformation.
    • Prophylactic Surgery
      • Undescended Testis (Cryptorchidism)
      • Can cause Testicular Cancer
      • Treatment is = Orchiopexy/ Orchidectomy
    • Prophylactic Surgery
      • 2.Multiple Polyposis coli :
      • Can cause Colonic cancer..
      • Treated with Prophylactic Proctocolectomy
    • Prophylactic Surgery
      • 3. Familial Colonic cancer :
      • Treated with Prophylactic Colectomy
    • Prophylactic Surgery
      • 4.Ulcerative Colitis = Colonic Cancer
      • Treated with prophylactic Colectomy.
    • Prophylactic Surgery
      • 5.Multiple Endocrine Neoplasia Type 2/3
      • Usually Causes Medullary
      • Cancer Of Thyroid.
      • Treated with Thyroidectomy.
    • Prophylactic Surgery
      • Strong history of Familial Breast cancer & Familial History of Ovarian Cancer.
      • ? Prophylactic Mastectomy.
      • ? Prophylactic Oophorectomy.
    • Prophylactic Surgery
      • Leucoplakia / Erythroplakia in Oral Cavity.
      • Treated with Surgery
    • Prophylactic Surgery.
      • Probably the Religious Practice of Circumcision in males in very early age avoids the occurrence of Cancer of the Penis.
    • Role Of Surgery in Diagnosis Of Cancer.
      • Apart from the Process of history taking & thorough clinical Examination the Role of Surgery in the Diagnosis of Cancer basically deals with obtaining a Sample of tissue (Biopsy) so as to arrive at correct Histo-pathological diagnosis.
      • Biopsies are carried by surgeons in various ways……..
    • Various Methods of biopsy….
      • Aspiration Biopsy (FNAC)
      • Needle Biopsy ( Tissue Core biopsy)
      • Incisional Biopsy.
      • Excisional Biopsy.
    • Guiding Principals for all Surgical Biopsies…….
      • 1.Needle tracks Or Biopsy Incisions should be placed carefully.
      • 2.Care should be taken so as not to contaminate new tissue planes.
      • 3.Adequate tissue sample should be obtained.
      • 4.The biopsy sample should be properly labeled, preserved & sent to the pathologist. Sufficient data is a must!
    • Role of surgery in staging Cancer.
      • Staging of a Cancer means knowing the extent & spread of the disease.
      • Correct staging has the potential of altering treatment strategies.
      • Surgical staging procedures are more sensitive than currently available imaging modalities in many Cancers.
    • Staging Of Cancer
      • Since 1959 all solid tumors are staged under the Universally accepted TNM System.
      • T = Tumor Size(TIS T0, T1,T2,T3,T4, TX.)
      • N = Lymph Node Status (Nx N0, N1,N2,)
      • M = Metastatic Spread status.
    • Various procedures used for surgical staging of cancer.
      • Laparotomy.
      • Laparoscopy.
      • Mediastinoscopy.
      • Lymphadenectomy.
      • Sentinel node biopsy.
    • Cancers in whom staging is useful are…
      • Hodgkin's Lymphoma.
      • Melanoma.
      • Breast Cancer.
      • Ovarian Cancer.
      • Testicular tumors.
      • Brochogenic Carcinoma.
    • Role Of Surgery in Definitive Treatment of Cancer
      • Surgery has been & remains the mainstay of treatment for most solid tumors.
      • In the early & middle part of the 20 th century, surgeons were performing more radical operations in attempt to cure patients & prevent recurrence.
      • With the advent of modern multimodality therapy ,surgical oncology has transformed from anatomic basis to biologic basis
    • Role Of Surgery in Cancer treatment.
      • Definitive surgical treatment for Primary cancer.
      • Surgery to reduce the bulk of primary or residual disease.
      • Surgical resection of Metastatic disease with curative intent.
      • Surgery for the treatment of Oncologic emergencies.
      • Surgery for palliation.
      • Surgery for Reconstruction & Rehabilitation.
    • Definitive surgical treatment of Primary Cancer…..
      • Surgery in primary resections is dictated by…
      • 1.Stage of the Cancer.
      • 2.Mechanism & knowledge of local spread.
      • 3. Morbidity & mortality of the procedure.
      • 4.General condition of the patient.
      • 5. Risk of Anesthesia.
    • Role of Definitive surgery….
      • Primary goal of surgery is complete removal of Local & regional disease.
      • This provides local control & reduces the risk of local recurrence.
      • The extent of resection depends on the organ involved & method of local spread.
      • Adequate margins of excision range from 1mm to 5cm for cutaneous & hollow/solid organs.
    • Role of definitive surgery…
      • Resection of solid organ tumors is guided by the blood supply.
      • It is mandatory to include any biopsy incision or needle track of a previously performed procedure.
      • If required & as a rule always the contagious organs & regional Lymph nodes are required to be removed.
      • If after resection the margins are positive , a redo surgery or addition of Radiotherapy and /or chemotherapy are mandatory.
    • Cytoreductive / Debulking Surgery
      • In some instances the extensive local spread of cancer precludes the removal of all gross disease by surgery.
      • This type of Surgery is of benefit only when other effective therapies are available to control the disease.
      • Classical examples are Burkitts lymphoma & Ovarian cancer.
    • Surgical Management of Metastatic Disease/ Recurrent disease.
      • Cancer is characterized by its ability to spread to distant organs (Metastasis).
      • Cancer is also known to recur at the same site (Where primary excision has been done.
      • In such instances ,surgical excision of metastatic/ Recurrent disease can greatly increase the possibility of cure.
    • Surgery for Metastatic disease
      • Liver Metastasis from colorectal cancer.
      • Lung metastasis from , Testicular Cancer, Soft tissue sarcoma, Osteosarcoma, Renal cell carcinoma.
      • Excision of solitary brain metastasis.
    • Surgical Management of Oncologic Emergencies.
      • Emergency /life threatening situations do arise in cancer patients.
      • These situations usually include…
      • Exsanguinating Blood loss.
      • Hollow organ perforations.
      • Acute abscesses.
      • Surgical decompression of central nervous system.
      • Bowel / urinary obstruction.
      • Biliary obstruction with jaundice.
      • Asphyxiation due to tracheal obstruction.
    • Palliative surgery.
      • In many cases of advanced, inoperable, unresectable cancers, significant improvement in the quality of life & alleviations of symptoms can be achieved by palliative surgical intervention..
      • E.g. pleural/ pericardial tapping
      • Ascitic tapping.
      • Local excision of Fungating Tumors.
      • Hollow viscus bypasses.
      • Ileostomies, colostomies, Feeding Gastrostomies, feedind Jejunostomies,Oesophageal stenting, Teacheostomies etc.
    • Reconstructive & Rehabilitative Surgery.
      • Many Radical Cancer surgeries cause massive tissue losses, resulting in dysfunction & bad cosmesis.
      • This applies particularly to Head & Neck cancers, Breast Cancer, Cancer of Testis, Bone cancers.
      • Latest advances in Plastic surgery, Bio Prosthesis has radically improved this scene.
    • What lies in Future ?
      • Increasing application of Laparoscopic Surgery , Video assisted surgery.
      • Increasing use of Lasers, Harmonic scalpels, Automatic stapling devices.
      • Use of Robotic Surgery.
      • Use of Nano Surgical techniques.
      • Use of Super high voltage Gamma Knives (Cyber knife)
    • Fergusson: A 19 th century Surgeon Stated that ……….
      • A Surgeon is supposed to have,
      • 1.The Eye of an eagle.
      • 2.The heart of a Lion.
      • 3.The Hands of A Lady.
      • 4. & the flair of an accomplished actor .
      • The personality of a surgeon has always reflected his desire to perform the art of surgery in front of an appreciative audience!
    • A surgeon with his knowledge & skills happens to be the main hero in this real life situational drama that goes on while treating Cancer He happens to be the captain of a Ship…… A ship that has to sail safely with minimum turbulence.!
    • Role Of General Practioners in Cancer Management
      • To keep a high level of Suspicion about Cancer.
      • To seek actively for early diagnosis of Cancer.
      • To encourage the patient for further investigations & treatment.
      • To provide moral support to the patient & his family.
      • To keep in communication with the Oncologist treating the said patient.
    • To Summarize……..
      • Advances in the Surgical techniques , Anesthesia, & a better understanding of Tumor Biology has allowed surgeons to perform successful resections for an increased number of patients.
      • The development of alternate treatment strategies has prompted surgeons to reassess the magnitude of surgery necessary.
    • Thank You.