Field of oncology has evolved since many decades! This presentation will demonstrate how oncology had evolved. Special focus is on current radiation oncology and surgical oncology practices along with principles of oncology.

1. PAST, PRESENT AND FUTURE OF
ONCOLOGY
Dr. Malhar Patel, DNB
Radiation Oncologist
CIMS Cancer

2. Cancer is CURABLE **Terms & conditions apply!!
*If detected EARLY
Cancer is CANCEL???!!!

3. What Does it Take to Make a Tumor?

6. Cancer: Current scenario, intervention strategies and
projections for 2015

7. ગરવી ગુજરાત
According to the figures tabled in the Lok Sabha recently by Union health minister
J P Nadda, Gujarat recorded 25,387 cancer deaths and 57,699
cases in 2015. India, which registers around ten lakh cancer cases each
year, has 7.5% of the world's cancer cases. Gujarat accounts for 5%
of India's cancer cases.
Gujarat recorded 23,285, 23,966 and 24,667 cancer-related
mortalities in 2012, 2013 and 2014, respectively . The state recorded
52,920, 54,469 and 56,061 cases of cancer in those three years.

8. Apart from the state, Ahmedabad has also been witnessing an
alarming trend in oral cancer. Ahmedabad is considered the oral cancer capital with
an incidence rate as high as 22 cases per lakh population. This is
alarming, especially when viewed against the country's incidence ratio, which is 9
cancer patients per lakh. According to Gujarat Cancer Registry,
which register the number of cancer cases, around 17,500 men and 12,000 women
fall prey to the deadly disease every year. Cancers of the mouth, lung,
food-pipe, prostate and larynx are most prevalent among men, where as cancers of
the breast, cervix, ovary and food pipe are most common in women.
ગરવી ગુજરાત

9. Chewing tobacco consumption has
increased the risk of head and neck cancer among the
urban and semi urban population of Ahmedabad by
between 13% and 15% in people between of the
35 to 40 years age group, who are at most risk.
ગરવી ગુજરાત

10. Pillars of Oncology

11. Team Work!!!!
• Surgical Oncologist
• Radiation Oncologist
• Medical Oncologist
• Dentist
• Radiologist
• Pathologist
• Physiotherapist
• Dietician
• Nursing & Support Staff
• Psychiatrist

12. Fundamentals of Oncology
• Biology is King
• Selection is Queen
• Technical maneuvers are the Prince and
Princess
Occasionally the prince and princess try to
overthrow the powerful forces of the King and
Queen, sometimes with temporary apparent
victories, usually to no long term avail.
-Blake Cady, MD

13. SURGERY

14. Surgery as Curative
• To cure a patient with “ONLY” surgery is still
relatively rare
• Some percentage (one third?) cured
• Earlier detection is best chance for cure
• Clarify the goal of your operation
Prevention
Diagnosis
Definitive treatment
Palliation
Rehabilitation

15. History of Surgical Oncology

16. Recent Advances!!
Fibular free flap
Breast conservation
Hemi-Laryngectomy
Forearm flap
PMMC
Composite resection Robotic Surgery
Base Skull Maxillo-Facial
Surgery
Micro-Vascular
Surgery

18. Surgery as Preventative
• Underlying condition
cryptochidism
polyposis coli
familial colon cancer
ulcerative colitis
MEN type II, III
familial breast cancer
familial ovarian cancer
• Prophylactic surgery
Orchiopexy
Colectomy
Colectomy
Colectomy
Thyroidectomy
Mastectomy
Oophorectomy
BRCA 1 & BRCA 2

19. Principles of Biopsies
• Know your tumor biology
• Will it change treatment plan?
• Biopsy options
• Aspiration, Core, Incisional, Excisional
• Avoid hematoma
• Plan to excise needle or biopsy site

20. Staging – the TNM System
American Joint Commission on Cancer (AJCC)
T = Tumor (size, grade) N = Nodes (number) M = Metastasis
Goals
• Estimate prognosis
• Facilitate treatment planning
• Allow comparisons between
treatment groups
General Classification
Stage I - Superficial early cancer
Stage II - Locally advanced - nodes
Stage III - Regionally advanced + nodes
Stage IV - Metastatic beyond regional
nodes

21. Diagnosis of Cancer
• Acquisition of tissue for histologic
diagnosis
• Staging of patients

22. Cancer surgery - Principles
• Enucleation or incomplete excision of tumor
mass is never indicated as a therapeutic
measure
• Prevention of tumor cell implantation during
surgery
• Prevention of vascular dissemination at
surgery

23. Surgery for Local Control
• Local control should be a top priority
• First operation is best chance for control
• Apply basic surgical fundamentals to reduce
local recurrences
• Salvage surgery to achieve local control
problematic

24. Principles of Margins : Be Negative!!
• Factor in location
• Goal of margin is reduced local recurrence
• R0 - no cancerous cells seen microscopically;
• R1 - cancerous cells can be seen microscopically
• R2 - even gross examination by the naked eye shows
tumor tissue on the margin.

25. Principles of Lymph Nodes
Harvest lymph nodes for:
1. Staging
2. Local control
3. Interrupt metastatic cascade
Factor in risk/benefit ratio

26. Surgery for residual
disease/metastasis
• Surgical resection of residual disease after
radical treatment!
• Metastatectomy!! (Liver, Lung)

27. Surgery for oncologic emergencies
• Exsanguinating hemorrhage
• Perforation
• Tracheostomy
• Impending destruction of vital organs

28. Quality of life and Rehabilitation

29. Future of Surgical Oncology
• Aging population
• Integration of multiple therapies
• Field wide open for basic and clinical research
• Molecular evaluation of tumor
• 3D Prosthesis
• Online robotic surgery!!!!

30. RADIATION THERAPY

31. What is Radiation??!!
• Treatment of tumor with Ionizing Radiation
• Cobalt machine  Gamma Rays
• Linear Accelerators  High Energy X – Rays

32. Myths About Radiotherapy
• It is Hot
• It is given only in “last stage of cancer”
• It is “ONLY” palliative
• It causes side effects only
• After surgery – No role of adjuvant radiotherapy
• Loss of body hair
• Cancer spreads after giving radiation

33. Role of Radiotherapy
• Malignant and Benign
• External RT (Teletherapy) and Brachytherapy
• Radical Radiotherapy and Adjuvant Radiotherapy
• Concurrent Chemo-Radiotherapy
• Palliative Radiotherapy

34. General Management Guidelines
• Aim
– Highest Loco-Regional control
– Function preservation
– Minimal morbidity
• Stage I & II – Single Modality ( Surgery / RT )
• Stage III & IV – Combined Modality
» Surgery + RT
» Surgery + RT + CT
» RT + CT

35. Radical Radiotherapy
• NasopharynX
• OropharynX
(Tonsil, Base Tongue, Soft Palate)
• HypopharynX
• LarynX
• CerviX
• Prostate
• Oesophagus
• Lung
• Anal Canal
Adjuvant Radiotherapy
• Oral Cavity
• Breast
• Oesophagus
• Rectum
• Cervix
• Endometrium
• Soft Tissue Sarcoma
• Brain Tumors
• Lung
• Pre – Op RT + CT  Rectum,
Oesophagus

36. First Linac and
Basic Collimatoghr
1960
The Evolution of Radiation Therapy
Therapy
Cerrobend Blocking
Electron Blocking
1970s
Computerized 3D Treatment
Planning Multileaf Collimator
1980s
Dynamic MLC
and IMRT
1990s
High-Resolution IMRT & IGRT
2000s
Image Guided Radiotherapy
2006
Cyber Knife
2008
VMAT - IMRT & IGRT
2011
VERSA HD
2014

37. Problems with conventional
Radiotherapy
Xerostomia
Proctitis
Dental caries Cataract
Lung fibrosis
Acute Mucositis Cystitis
Fibrosis

38. Intensity Modulated Radiotherapy
(IMRT)
• Targeted Radiotherapy
• Precise Treatment
• High dose to target
• Spares Normal Structures
• High Cure Rates
• Less Side Effects
Accuracy?????

39. Accuracy & Precision!!
Conventional
IMRT
IGRT

40. Why IGRT???
• Set up error
• Intra & Inter fraction movement
• Change in target or normal tissue
• Daily verification
• Accurate Treatment Delivery

41. Immobilization & Imaging for
planning

42. Conventional Radiation
IMRT

43. Imaging Modalities

44. Fusion

46. SBRT & SRS
• Stereotactic Body Radiotherapy
• Small Lesions in Lung, Brain, Liver, Lymph Nodes
• High dose in 1 – 5 sittings
• Alternate Day treatment
• Accurate & Precise Treatment

47. Future of Radiation Oncology
• Radiobiology!!!
• Radical treatment / Organ preservation
• Newer Techniques like IMRT / IGRT
– Less Late Side Effects
– Higher Cure Rates
• SBRT
– Small Lesions
– Good Results / Less complications

48. CHEMOTHERAPY

49. History of chemotherapy

50. Wide role of chemotherapy
Neo-Adjuvant Concurrent Adjuvant
• Locally advanced head and
neck cancer
• Breast cancer
• Stomach
• Rectum/Colon
• Any locally advanced
cancer
• Head & Neck cancer
• Cervix cancer
• Glioblastoma Multiforme
• Oesophagus
• Advanced cancer
• Colo-Rectal cancer
• Glioblastoma
Multiforme
• Stomach cancer
DEFINITIVE ROLE
Hematological Malignancies
Leukemia & Lymphoma

51. Side Effects

52. Ye Dosti Hum Nahi Todenge!!

53. Evolution of Oncology!!

54. Thank You