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

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