Introduction to the world of oncology


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Introduction to the world of oncology

  1. 1. An Introduction to The World Of ONCOLOGY By Emad Shash Medical Oncology Department National Cancer Institute Cairo University
  2. 2. Origin of the Word Cancer <ul><li>Believe it or not, cancer has affected people for several centuries. It is not a new disease. </li></ul><ul><li>The word cancer came from the father of medicine, Hippocrates , a Greek physician. </li></ul><ul><li>Hippocrates used the Greek words, carcinos and carcinoma to describe tumors, thus calling cancer &quot; karkinos. “ </li></ul><ul><li>The Greek terms actually were words to describe a crab , which Hippocrates thought a tumor resembled. Although Hippocrates may have named &quot;Cancer&quot;; he was certainly not the first to discover the disease. </li></ul><ul><li>The history of cancer actually begins much earlier. </li></ul>The History of Cancer, Lisa Fayed, July,2008
  3. 3. The First Documented Case of Cancer <ul><li>The world's oldest documented case of cancer hails from ancient Egypt, in 1500 b.c. </li></ul><ul><li>The details were recorded on a papyrus, documenting 8 cases of tumors occurring on the breast. </li></ul><ul><li>It was treated by cauterization. It was also recorded that there was no treatment for the disease, only palliative treatment. </li></ul><ul><li>There is evidence that the ancient Egyptians were able to tell the difference between malignant and benign tumors. </li></ul>The History of Cancer, Lisa Fayed, July,2008
  4. 4. Ebers Papyrus treatment for cancer: recounting a &quot; tumor against the god Xenus&quot;, it recommends &quot;do nothing there against&quot; Ancient Egyptian medical instruments depicted in a Ptolemaic period inscription on the Temple of Kom Ombo .
  5. 5. What Early Physicians Thought Caused Cancer <ul><li>Today, we know so much about the human body; however early Greek physicians weren't so fortunate. Hippocrates believed that the body was composed of four fluids: blood, phlegm, yellow bile and black bile. </li></ul><ul><li>He believed that an excess of black bile in any given site in the body caused cancer. This was the general thought of the cause of cancer for the next 1400 years. </li></ul><ul><li>In ancient Egypt, it was believed cancer was caused by the Gods. </li></ul>The History of Cancer, Lisa Fayed, July,2008
  6. 6. The Birth of the Pathological Autopsy <ul><li>Autopsies done by Harvey in 1628 paved the way to learning more about human anatomy and physiology. </li></ul><ul><li>Blood circulation was discovered, opening the doors for more research on diseases. </li></ul><ul><li>It wasn't until 1761 that autopsies were performed to research cause of death in ill patients. </li></ul><ul><li>Giovanni Morgagni of Padua was the first to do such autopsies. </li></ul>The History of Cancer, Lisa Fayed, July,2008
  7. 7. Cancer Staging
  8. 8. What is staging? <ul><li>Staging describes the extent or severity of an individual’s cancer based on the extent of the original (primary) tumor and the extent of spread in the body. </li></ul><ul><li>Why Staging is important? </li></ul><ul><ul><li>1- Staging helps the doctor plan a person’s treatment. </li></ul></ul><ul><li>2- The stage can be used to estimate the person’s prognosis (likely outcome or course of the disease). </li></ul><ul><li>3-Staging helps researchers and health care providers exchange information about patients. It also gives them a common language for evaluating the results of clinical trials and comparing the results of different trials. </li></ul>
  9. 9. What is the basis for staging? <ul><li>Staging is based on knowledge of the way cancer develops. </li></ul><ul><li>Cancer cells divide and grow without control or order to form a mass of tissue , called a growth or tumor. </li></ul><ul><li>As the tumor grows, it can invade nearby organs and tissues. </li></ul><ul><li>Cancer cells can also break away from the tumor and enter the blood stream or lymphatic system. </li></ul><ul><li>By moving through the bloodstream or lymphatic system, cancer can spread from the primary site to form new tumors in other organs. The spread of cancer is called metastasis. </li></ul>
  10. 10. Cancer develops in stages
  11. 11. Colon Cancer Progression
  12. 12. What are the common elements of staging systems? <ul><ul><li>Location of the primary tumor. </li></ul></ul><ul><ul><li>Tumor size and number of tumors. </li></ul></ul><ul><ul><li>Lymph node involvement (spread of cancer into lymph nodes). </li></ul></ul><ul><ul><li>Cell type and tumor grade * (how closely the cancer cells resemble normal tissue). </li></ul></ul><ul><ul><li>Presence or absence of metastasis . </li></ul></ul>*Information about tumor grade is available in the NCI fact sheet Tumor Grade: Questions and Answers , which can be found at on the Internet.
  13. 13. What is the TNM system? <ul><li>The TNM system is one of the most commonly used staging systems. This system has been accepted by the International Union Against Cancer (UICC) and the American Joint Committee on Cancer (AJCC). </li></ul><ul><li>Most medical facilities use the TNM system as their main method for cancer reporting. </li></ul><ul><li>The TNM system is based on the extent of the tumor (T) , the extent of spread to the lymph nodes (N) , and the presence of metastasis (M) . </li></ul><ul><li>A number is added to each letter to indicate the size or extent of the tumor and the extent of spread. </li></ul>
  14. 14. TNM system <ul><li>Primary Tumor (T) </li></ul><ul><li>T X: Primary tumor cannot be evaluated </li></ul><ul><li>T 0: No evidence of primary tumor </li></ul><ul><li>T is: Carcinoma insitu (early cancer that has not spread to neighboring tissue) </li></ul><ul><li>T1, T2, T3, T4: Size and/or extent of the primary tumor </li></ul>
  15. 15. TNM system <ul><li>Regional Lymph Nodes(N) </li></ul><ul><li>N X: Regional lymph nodes cannot be evaluated </li></ul><ul><li>N 0: No regional lymph node involvement (no cancer found in the lymph nodes) </li></ul><ul><li>N1, N2, N3: Involvement of regional lymph nodes (number and/or extent of spread) </li></ul>
  16. 16. TNM system <ul><li>Distant Metastasis (M) </li></ul><ul><li>M X: Distant metastasis cannot be evaluated </li></ul><ul><li>M 0: No distant metastasis (cancer has not spread to other parts of the body) </li></ul><ul><li>M 1: Distant metastasis (cancer has spread to distant parts of the body) </li></ul>
  17. 17. TNM combinations correspond to one of five stages Stage Definition Stage 0 Carcinoma in situ (early cancer that is present only in the layer of cells in which it began). Stage I, Stage II, and Stage III Higher numbers indicate more extensive disease: greater tumor size, and/or spread of the cancer to nearby lymph nodes and/or organs adjacent to the primary tumor. Stage IV The cancer has spread to another organ.
  18. 18. Impact of staging on survival Data from Centre François Baclesse (Breast cancer patients survival)
  19. 19. Impact of staging on survival Data from Centre François Baclesse (Breast cancer patients survival)
  20. 20. Are all cancers staged with TNM classifications? <ul><li>Most types of cancer have TNM designations, but some do not. </li></ul><ul><li>Different staging systems are also used for many cancers of the blood or bone marrow, such as lymphoma . The Ann Arbor staging classification is commonly used to stage lymphomas and has been adopted by both the AJCC and the UICC. </li></ul><ul><li>However, other cancers of the blood or bone marrow, including most types of leukemia , do not have a clear-cut staging system. </li></ul><ul><li>Another staging system, developed by the International Federation of Gynecology and Obstetrics , is used to stage cancers of the cervix, uterus, ovary, vagina, and vulva. </li></ul>
  21. 21. NCI’s Surveillance, Epidemiology, and End Results Program (SEER) <ul><ul><li>In situ is early cancer that is present only in the layer of cells in which it began. </li></ul></ul><ul><ul><li>Localized is cancer that is limited to the organ in which it began, without evidence of spread. </li></ul></ul><ul><ul><li>Regional is cancer that has spread beyond the original (primary) site to nearby lymph nodes or organs and tissues. </li></ul></ul><ul><ul><li>Distant is cancer that has spread from the primary site to distant organs or distant lymph nodes. </li></ul></ul><ul><ul><li>Unknown is used to describe cases for which there is not enough information to indicate a stage. </li></ul></ul>
  22. 22. What types of tests are used to determine stage? <ul><ul><li>Physical exams: </li></ul></ul><ul><ul><li>The doctor examines the body by looking, feeling, and listening for anything unusual. </li></ul></ul><ul><ul><li>The physical exam may show the location and size of the tumor(s) and the spread of the cancer to the lymph nodes and/or to other organs. </li></ul></ul><ul><ul><li>Imaging studies </li></ul></ul><ul><ul><li>These studies are important tools in determining stage. Procedures such as x-rays , computed tomography (CT) scans , magnetic resonance imaging ( MRI ) scans, and positron emission tomography ( PET ) scans can show the location of the cancer, the size of the tumor, and whether the cancer has spread. </li></ul></ul>
  23. 23. What types of tests are used to determine stage? <ul><li>Laboratory tests are studies of blood, urine, other fluids, and tissues taken from the body. For example, tests for liver function and tumor markers can provide information about the cancer. </li></ul><ul><li>Pathology reports may include information about the size of the tumor , the growth of the tumor into other tissues and organs, the type of cancer cells, and the grade of the tumor (how closely the cancer cells resemble normal tissue). </li></ul><ul><li>Biopsy (the removal of cells or tissues for examination under a microscope) may be performed to provide information for the pathology report. </li></ul><ul><li>Cytology reports also describe findings from the examination of cells in body fluids. </li></ul><ul><ul><li>Surgical reports tell what is found during surgery . </li></ul></ul><ul><ul><li>These reports describe the size and appearance of the tumor and often include observations about lymph nodes and nearby organs. </li></ul></ul>
  24. 24. Cancer treatment
  25. 25. Modalities of treatment <ul><li>1- Local therapy : </li></ul><ul><ul><li>Surgery. </li></ul></ul><ul><ul><li>Radiation therapy. </li></ul></ul><ul><li>2- Systemic treatment : </li></ul><ul><ul><li>Chemotherapy. </li></ul></ul><ul><ul><li>Hormonal therapy. </li></ul></ul><ul><ul><li>Monoclonal antibodies. </li></ul></ul><ul><ul><li>Radioactive material. </li></ul></ul><ul><li>3- Supportive care . </li></ul><ul><li>4- Non-conventional therapy. </li></ul>
  26. 26. SURGERY
  27. 27. Surgery <ul><li>Surgery was the first modality used successfully in the treatment of cancer. </li></ul><ul><li>It is the only curative therapy for many common solid tumors. </li></ul><ul><li>The most important determinant of a successful surgical therapy are the absence of distant metastases and no local infiltration . </li></ul>
  28. 28. Selected Historical Milestones in Surgical Oncology Year Surgeon Event 1809 Ephraim McDowell Elective abdominal surgery (excised ovarian tumor) 1846 John Collins Warren Use of ether anesthesia (excised submaxillary gland) 1867 Joseph Lister Introduction of antisepsis 1860-1890 Albert Theodore Billroth First gastrectomy, laryngectomy, and esophagectomy 1878 Richard von Volkmann Excision of cancerous rectum Year Surgeon Event 1880s Theodore Kocher Development of thyroid surgery 1890 William Stewart Halsted Radical mastectomy 1906 Ernest Wertheim Radical hysterectomy 1910-1930 Harvey Cushing Development of surgery for brain tumors 1935 A. O. Whipple Pancreaticoduodenectomy
  29. 29. Surgery <ul><li>Microscopic invasion of surrounding normal tissue will necessitate multiple frozen section. </li></ul><ul><li>Resection or sampling of regional lymph node is usually indicated. </li></ul><ul><li>Surgery may be used for palliation in patients for whom cure is not possible. </li></ul><ul><li>Has significant role in cancer prevention. </li></ul><ul><ul><li>E.g familial polyposis coli. </li></ul></ul>
  30. 30. Surgery for prevention <ul><li>Patients with conditions that predispose them to certain cancers or with genetic traits </li></ul><ul><li>Associated with cancer can have normal life span with prophylactic surgery. </li></ul><ul><li>- Colectomy . </li></ul><ul><li>- Oophorectomy. </li></ul><ul><li>- Thyroidectomy. </li></ul><ul><li>- Removal of premalignant skin lesion . </li></ul>
  31. 31. Determinants of Operative Risk <ul><li>General health status. </li></ul><ul><li>Severity of underlying illness. </li></ul><ul><li>Degree to which surgery disrupts normal physiologic functions. </li></ul><ul><li>Technical complexity of the procedure (related to incidence of complications). </li></ul><ul><li>Type of anesthesia required. </li></ul><ul><li>Experience of personnel. </li></ul>
  32. 32. Radiation therapy
  33. 33. Radiation therapy <ul><li>It is a local modality used in the treatment of cancer . </li></ul><ul><li>Success depends on the difference in the radiosensitivity between the tumor and normal tissue. </li></ul><ul><li>It involves the administration of ionizing radiation in the form of x-ray or gamma rays to the tumor site. </li></ul><ul><li>Method of delivery: </li></ul><ul><li>External beam(teletherapy). </li></ul><ul><li>Internal beam therapy(Brachytherapy). </li></ul>
  34. 34. Radiation therapy <ul><li>Radiation therapy is planned and performed by a team of nurses, physician and radiation oncologist. </li></ul><ul><li>A course of radiation therapy is preceded by a simulation session in which low-energy beam are used to produce radiograghic images that indicate the exact beam location. </li></ul>
  35. 35. Radiation therapy <ul><li>Radiation therapy is usually delivered in fractionated doses such as 180 to 300 cGy per day,five times a week for a total course of 5-8 weeks. </li></ul><ul><li>Radiation therapy with curative intent is the main treatment in limited stage Hodgkin’s disease, some NHL, limited stage cancer prostate, gynecologic tumors & CNS tumors. </li></ul><ul><li>Also can be used in palliative &emergency setting. </li></ul>
  36. 36. Complication of radiation <ul><li>There is two types of toxicity: acute and long term toxicity. </li></ul><ul><li>Systemic symptoms such as Fatigue, local skin reaction, GI toxicity, oro-pharyngeal mucositis & xerostomia. myelosuppression. </li></ul><ul><li>Long-term sequelae: may occur many months or years after radiation therapy. </li></ul><ul><li>Radiation therapy is known to be mutagenic, carcinogenic and teratogenic and having increased risk of developing both secondary leukemia and solid tumor. </li></ul>
  38. 38. Radionuclides <ul><li>For decades have been used systemically to treat malignant disorders. </li></ul><ul><li>They are administer by specialists in nuclear medicine or radiation oncologist. </li></ul><ul><li>Radioactive iodine: In the from of 131 I is effective therapy for well differentiated thyroid ca </li></ul><ul><li>Strontium-89: Is used for the treatment of body metastasis. </li></ul>
  40. 40. Chemotherapy <ul><li>Systemic chemotherapy is the main treatment available for disseminated malignant diseases. </li></ul><ul><li>Progress in chemotherapy resulted in cure for several tumors. </li></ul><ul><li>Chemotherapy usually require multiple cycles. </li></ul>
  41. 41. Classification of cytotoxic drug <ul><li>Cytotoxic agent can be roughly categorized based on their activity in relation to the cell cycle. </li></ul>
  42. 42. Cont. <ul><li>What is the difference between phase specific & phase non specific?….. </li></ul><ul><li>Phase non-specific: </li></ul><ul><ul><li>The drugs generally have a linear dose-response curve(  the drug administration ,the  the fraction of cell killed). </li></ul></ul><ul><li>Phase specific: </li></ul><ul><ul><li>Above a certain dosage level, further increase in drug doesn’t result in more cell killing, but you can play with duration of infusion. </li></ul></ul>
  43. 43. Chemotherapeutic agents <ul><li>Alkylating agents </li></ul><ul><li>Anti-metabolites </li></ul><ul><li>Anti-tumor antibiotic </li></ul><ul><li>Plant alkaloids </li></ul><ul><li>Other agents </li></ul><ul><li>Hormonal agent </li></ul><ul><li>Immunotherapy </li></ul>
  44. 44. Complication of Chemotherapy <ul><li>Every chemotherapeutic will have some deleterious side effect on normal tissue . </li></ul><ul><li>Myelo-suppression </li></ul><ul><li>Nausea & vomiting </li></ul><ul><li>Stomatitis </li></ul><ul><li>Alopecia </li></ul>
  45. 45. Criteria used to describe response are <ul><li>Complete response (complete remission) is the disappearance of all detectable malignant disease. </li></ul><ul><li>Partial response : is decrease by more than 50% in the sum of the products of the perpendicular diameters of all measurable lesions. </li></ul><ul><li>Stable disease : no increase in size of any lesion nor the appearance of any new lesions. </li></ul><ul><li>Progressive disease : means an increase by at least 25% in the sum of the products of the perpendicular diameters of measurable lesion or the appearance of new lesions. </li></ul>
  46. 46. Please check the following web sites <ul><li> </li></ul><ul><li> </li></ul><ul><li> </li></ul><ul><li>If you need help don’t hesitate to contact me: </li></ul><ul><li>[email_address] </li></ul>
  47. 47. THANK YOU