PRINCIPLES OF ONCOLOGY .pptx FRANK JOSHUA RUHAZWE

PRINCIPLES OF ONCOLOGY
PRESENTER :FRANK JOSHUA
RESIDENT GENERAL SURGERY 1.2
KAMPALA INTERNATIONAL UNIVERSITY
drfranktz@gmail.com
Whatsaap +255623793940
5/7/2024 1
FRANK JOSHUA RUHAZWE

OUTLINE
GENERAL OVERVIEW
1. Introduction
Definition
Cancer Nomenclature
2. Epidemiology
3. Risk factors
4. Oncogenesis
SURGICAL ONCOLOGY
1. TYPES OF TUMOR
2. SPREADING OF TUMOR
3. STAGING OF TUMORS
4. TUMOR MANIFESTATIONS
5. INVESTIGATIONS
6. TREATMENTS
7. FOLLOW UP
8. PREVENTION
9. REFERENCES
5/7/2024 2

1. INTRODUCTION
DEFINITIONS:
Oncology is a branch of medicine that deals with the study,
diagnosis, treatments and prevention of cancer.
Oncology is the Greek word ὄγκος (ónkos) which means
"tumor", "volume" or "mass".
The four main divisions
Medical oncology
Surgical oncology
Radiation oncology
Clinical oncology.
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The principle of oncology Refers to the fundamental concepts
and approaches used in the followings-
The diagnosis
Therapy (e.g. surgery, chemotherapy, radiotherapy and
other modalities)
Follow-up of cancer patients after successful treatment
Palliative care of patients with terminal malignancies
Screening efforts
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5/7/2024 5

2. EPIDERMIOLOGY OF CANCER
• List of the most frequent cancers
from the World Health Organization
(WHO) Global Cancer Observatory
(GLOBOCAN) 2018
•
5/7/2024 6

Incidence in 2020 Globally
Breast (2.26 million cases);
Lung (2.21 million cases);
Colon and rectum (1.93 million
cases);
Prostate (1.41 million cases);
Skin (non-melanoma) (1.20
million cases); and
Stomach (1.09 million cases).
10 million deaths in 2020, or
nearly one in six deaths
The most common causes of
cancer death in 2020 were:
Lung (1.80 million deaths);
Colon and rectum (916 000
deaths);
Liver (830 000 deaths);
Stomach (769 000 deaths); and
Breast (685 000 deaths).
5/7/2024 7

UGANDA
• Study done southwestern Uganda in Estimating cancer
incidence in Uganda.
• The Age-Standardised Incidence Rates for all cancers
combined were 109.9 and 91.9 per 100,000 in males and
females, respectively.
• In males, the most commonly diagnosed cancers were
prostate, oesophagus, stomach, Kaposi's sarcoma and liver.
• In females, the most common malignancies were cervix,
breast, stomach, liver and ovary.
• Approx, 1 in 8 males and 1 in 10 females would develop
cancer before the age of 75 years. (Nakaganda et al., 2023)
5/7/2024 8

3. RISK FACTORS
According to (CDC Cancer data and statistics 2020),Two major Risk Factors
GENETIC FACTORS
• Some 90–95% of cases, are due to genetic mutation.
• The remaining 5–10% are due to inherited genetics.
ENVIRONMENT FACTORS
• Tobacco use (25–30%)
• Diet and obesity (30–35%)
• Radiation (both ionizing and non-ionizing, up to 10%)
• Lack of physical activity, and pollution. (5%)
• Infections (15–20%)
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INFECTIONS /ONCOGENIC MICROBES
5/7/2024 10

Risk factors classification (The International Agency for
Research on Cancer (IARC)) –WHO 2018.
Group 1:Carcinogenic to Humans:
• There is sufficient The evidence may
come from epidemiological studies,
animal experiments, or mechanistic
studies.
• Examples include tobacco smoke,
asbestos, benzene, and ultraviolet
radiation from sunlight. alcoholic
beverages, Chinese-style salted fish
and consumption of processed meat.
Group 2A:
Probably Carcinogenic to Humans:
• Limited evidence of carcinogenicity
in humans but sufficient evidence in
animal studies.
• Alternatively, they may have strong
evidence from mechanistic studies.
• Includes substances like
consumption of red meat
formaldehyde and glyphosate
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Group 2B: Possibly Carcinogenic to
Humans:
• Limited evidence of carcinogenicity in
humans and less convincing evidence in
animal studies.
Includes substances such as
 Diesel engine exhaust,
Certain chemicals found in hair dyes
Occupational exposures manufacturing
industry
Traditional Asian pickled vegetables
Radiofrequency electromagnetic fields.
Group 3:Not Classifiable as to its
Carcinogenicity to Humans:
• Inadequate evidence to
determine whether or not they
cause cancer in humans.
• May arise due to limited or
conflicting evidence from
studies.
• Group 3 includes substances
like coffee and caprolactam
5/7/2024 12

Group 4:
Probably Not Carcinogenic to Humans:
This group includes agents for which there is strong evidence
suggesting that they do not cause cancer in humans.
This classification is relatively rare, as IARC focuses more on identifying
potential carcinogens. Few substances fall into this category.
5/7/2024 13

4. CARCINOGENESIS
Genetics( Oncogenomics)
Epigenetics ( Cancer Epigenetics)
Metastasis
Metabolism (Tumor Metabolome)
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Genetics( Oncogenomics)
Multiple alterations oncogenes, and tumor suppressor genes
are necessary for normal cells to become cancerous.
Genetic changes in cancer can occur at various levels and by
different mechanisms:-
Chromosomal abnormalities
Mutations in DNA sequences.
These mutations
large-scale changes such as chromosomal deletions or gains
Small-scale mutations like point mutations or insertions
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Cancer cells acquire different
characteristics abilities such as
 Resistance to cell death
 Insensitivity to anti-growth signals
Sustained blood vessel formation
(angiogenesis)
Unlimited replication potential,
metastasis.
Altered energy metabolism.
 Evasion of immune surveillance.
5/7/2024 16

Cancer Epigenetics
Epigenetic alterations are
functionally relevant
modifications to the genome that
do not change the nucleotide
sequence.
DNA methylation
(hypermethylation and
hypomethylation)
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Metabolism/Tumor metabolome
Normal cells typically generate only about 30% of energy
from glycolysis whereas most cancers rely on glycolysis for energy
production followed by lactic acid fermentation (Warburg effect).
Even in these cases, however, the use of glycolysis as an energy
source rarely exceeds 60%.
A few cancers use glutamine as the major energy source, partly
because it provides nitrogen required for nucleotide (DNA, RNA)
synthesis.
5/7/2024 20

Metastasis
• Metastasis is the spread of
cancer to other locations in the
body.
• The dispersed cancerous cells
are called metastatic tumors,
while the original is called the
primary tumor.
• Almost all cancers can
metastasize.
• It can occur via the blood or the
lymphatic system or both.
The typical steps in metastasis
are
local invasion
Intravasation into the blood
or lymph
Circulation through the body
Extravasation into the new
tissue Proliferation
Angiogenesis
 The most common places for
metastases to occur are the
lungs, liver, brain and the
bones
5/7/2024 21

Normal Cell Malignant Cell
Characteristics It has controlled
growth, contact
phenomena, and
whenever it gains
unrepaired damage it
will suicide
“apoptosis”
Uncontrolled growth and loss of
contact phenomena (Not very
well-understood phenomena, that
when cells get close to each other
during healing, they connect and
form junctions, and stop
proliferating, otherwise they will
continue multiplying “cancer”)
Cytology Large cytoplasm Small cytoplasm (because of the
large nucleus)
Single and regular
Nucleus
Multiple, irregular shape, dark
stained Nuclei → (lot of mitotic
Comparison between Normal and Malignant
Cells
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SURGICAL ONCOLOGY
5/7/2024 23

1. TYPES OF MALIGNANT TUMORS
1. Carcinoma:
Arises from epithelial tissue
Carcinomas include cancers of the:
breast, lung, kidney, thyroid,colon,
prostate, stomach and many others.
Adenocarcinoma of the stomach
Transitional cell carcinoma of the
bladder
Squamous cell carcinoma of the
skin Follicular carcinoma of the
thyroid.
Endoscopic image of Linitis
Plastica, a type of stomach cancer
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2. Sarcoma:
Arises from connective
tissue(mesodermal tissue)
Cancers of the bone, muscle, fat,
nerves, cartilage and fibrous tissue,
such as ligaments and connective
tissue. liposarcoma
Fibrosarcoma
Myosarcoma
Rhabdomyosarcomas
Leiomyosarcomas
Fungating Rhabdomycarcoma
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TERATOMA :
Type of germ cell tumor that may
contain several different types of
tissue such as hair, muscle, and bone.
• Arises from the embryonic
“totipotential cells”, which are
capable of developing into any
variety of cells.
• Found in germ cell areas (testes
and ovaries)
• Could be benign or malignant
Ex: Dermoid ovarian cyst
Mature cystic teratoma of the
ovary (dermoid cyst)
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HARMATOMA :
A large hamartoma of the spleen
Benign tumor-like growth that
results from an overgrowth of
mature cells and tissues native to
the organ in which it occurs.
• Comprise normal cells that grow
in a disorganized manner, often
resembling the structure of the
surrounding tissue.
• Develop in lungs, liver, kidneys,
skin, and brain. Ex
Cardiac rhabdomyomas
 Myoepithelial hamartoma
5/7/2024 27

Comparison between Benign and Malignant
tumors
feature Benign Malignant
Capsule Encapsulated Non encapsulated “Sometimes, there is a capsule but
it’s a “false capsule”, meaning it’s a fibrous capsule
from the same tissue. “
Invasion Non invasive Usually invade
Treatment Local excision for
benign
Radical excision (excision with surrounding lymph
nodes)
+- Chemotherapy or Radiotherapy or both.
Spread Doesn’t spread  local invasion: within the organ itself or adjacent
organ
 Metastasis: 1 Lymphatic: Regional & distant lymph
nodes. 2 Haematogenous: mostly to liver, lung,
bones. 3 Transcoelomic: e.g peritoneal & pleural
cavity. 4 Implantation e.g. needle tracks, wounds.
5/7/2024 28

2. SPREAD OF MALIGNANT TUMORS
5/7/2024 29

3. STAGING
Staging describes the primary tumor, its relation with
 Organ of origin
 Adjacent and distant organs
 Distant organs and lymph nodes.
Why Do We Stage Malignant Tumors?
Treatment Planning.
Prognosis:
Clinical Trials:
Communication:
Follow-Up and Monitoring:
5/7/2024 30

TYPES OF STAGING
Clinical Staging
It determines cancer by physical examination, imaging tests,
and biopsy.
Pathologic Staging
This can be done during surgical exploration of cancer or during
surgical removal of the tumor mass.
Post Neoadjuvant Therapy Staging
This helps in determining cancer after systemic therapy
(chemotherapy or immunotherapy or radiotherapy) and before
surgery.
Restaging:
This is done when cancer has recurred. Restaging helps to determine
the treatment options for an individual.
5/7/2024 31

WAYS /METHODS OF STAGING
1- Classical staging :
• Stage I & II confined to the organ
• Stage III  direct invasion
• Stage IV  metastasis
2-TNM Classification/ AJCC & UICC Staging system.
• T – Tumor (size)
• N – Lymph node
• M - Metastasis
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5/7/2024 33

M: Presence of distant metastasis
• M0: no distant metastasis
• M1: metastasis to distant organs (beyond regional lymph nodes)
NB-Not applicable to leukaemia or tumors of the central nervous system.
Special staging of some organs
1. Duke's Staging System for Colorectal Cancer:
Classifies colorectal cancer into four stages:
• Stage A: Cancer confined to the inner lining of the colon or rectum.
• Stage B: Cancer invading through the wall of the colon or rectum but
not spreading to nearby lymph nodes.
• Stage C: Cancer spreading to nearby lymph nodes.
• Stage D: Cancer metastasizing to distant organs or tissues
5/7/2024 34

2. Ann Arbor Staging System for Hodgkin Lymphoma:
Classifies Hodgkin lymphoma into four stages based on the involvement of
lymph nodes and other organs:
Stage I: Involvement of a single lymph node region or a single extralymphatic
organ.
Stage II: Involvement of two or more lymph node regions on the same side of the
diaphragm.
Stage III: Involvement of lymph node regions on both sides of the diaphragm.
Stage IV: Disseminated involvement of one or more extralymphatic organs or
tissues.
Others
Barcelona Clinical staging for Liver Cancer (BCLC)
Fuhrman Grade for Renal Cell Carcinoma. etc
5/7/2024 35

4. MANIFESTATIONS OF MALIGANT
TUMORS
5/7/2024 36

5) INVESTIGATIONS
DIAGNOSIS
BIOPSY
Genetic testing
Cytology test
Imaging (x ray, CT scan ,MRI ,PET
SCAN)
Endoscpy followed by biopsy
STAGING
• Lab chemistry (RFT,LFT)
• Haematology (CBC,CRP)
• Radiology X RAY,CT SCAN ,MRI,PET-
SCAN
PROGNOSIS
• Hormonal Assay
• Tumor markers
• Radiology
SCREENING
• Brest examinations
• Tumor marker
• Colnoscopy ,CT scan and
Mammography
5/7/2024 37

Biopsy (Examination of the tissue)
Fine-needle
aspiration
Core
biopsy
Incisional
biopsy
Excisional
biopsy
E.g. Tru-cut: core of tissue removed
for histological examination
Usually done if the lump is apparent
and distinct and localized
Commonly done through endoscope
Removes a small accessible piece of the lesion for histological
examination (forceps, needle...)
Many ways of obtaining it
- Like in ulcer
you take a small sample by a knife then send it to histology
– Needle
E.g. if having breast cancer for example under x-ray, US or CT control
-Gastroscope or colonoscope
If we suspect a gastric ulcer to be malignant
 Complete removal of a discrete lesion without a
wide margin and without it being considered
curative of the malignancy
 E.g. Remove breast lump for histology
 Sometimes, this cannot be done because the tumor
is disseminated or cannot be removed alone
5/7/2024 38

Tumor Markers-examples
5/7/2024 39

6. TREATMENTS
OBJECTIVES
• Eradication of Cancer:
• Control of Disease Progression
• Symptom Management:
• Preservation of Organ Function:
• Improvement of Survival Rates:
• Enhancement of Quality of Life
• Prevention of Recurrence
5/7/2024 40

TREATMENTS OPTIONS
Chemotherapy
Radiotherapy
Immunotherapy
Surgery
Psychotherapy
Combination/mult model therapy (Neoadjuvant , surgery
adjuvant therapy )
5/7/2024 41

CHEMOTHERAPY
• Destroy cancer cells or inhibit their growth and spread
throughout the body.
• Common types of chemotherapy drugs include alkylating agents,
antimetabolites, anthracyclines, taxanes, and platinum
compounds.
• Common side effects of chemotherapy include nausea and
vomiting, fatigue, hair loss, loss of appetite, mouth sores,
diarrhea or constipation, and. Immunosupression.
• Chemotherapy is typically given in cycles, with each cycle
consisting of a period of treatment followed by a rest period to
allow the body to recover from side effects.
5/7/2024 42

5/7/2024 43

Radiotherapy
When people hear the word “radiation” they often
think…
The reality of medical use of
radiation therapy is very different
Radiotherapy It involves the use of high-energy radiation to destroy
or damage cancer cells, thereby preventing their growth and spread.
5/7/2024 44

How Does Radiation Work?
Rays interact with water
radiolysis
free radicals
bind to and damage DNA
cell death
(by mitotic catastrophe)
80%
20%
Cancer cells are more susceptible to RT
due to impaired DNA repair pathways
5/7/2024 45

TYPES OF RADIOTHERAPIES
1. External Beam Radiation
Therapy (EBRT):
• In EBRT, a machine Called a
linear accelerator delivers
high-energy x-rays or other
types of radiation to the
tumor and surrounding
tissues from outside the
body
5/7/2024 46

Stereotactic Radiosurgery
Use of a high dose/fraction of RT
in a very focused way.
Most common two types
Gamma Knife stereotactic
Radiotherapy.
• Head frame immobilization
• 192 Co-60 sources
• Used to treat brain tumors
with high precision
5/7/2024 47

2. Cyber Knife stereotactic
radiosurgery
• Robotic arm can treat tumors
throughout body.
• High precision, but very long
treatment times
5/7/2024 48

2. Internal radiation therapy (brachytherapy).
• Radioactive sources are placed directly
inside or next to the tumor, delivering
radiation internally.
• This allows for higher doses of radiation
to be delivered directly to the tumor
while minimizing exposure to
surrounding healthy tissues.
5/7/2024 49

IMMUNOTHERAPY
Works by enhancing or modulating the body's immune response to
better recognize and eliminate cancer cells.
TYPES OF IMMUNOTHERAPY
Immune Checkpoint Inhibitors-Blocks proteins called checkpoints
((PD-1) and (PD-L1), which cancer cells use to evade detection by
the immune system.Includes Pembrolizumab and nivolumab.
 Chimeric antigen receptor (CAR) T Therapy -Genetically modifying
a patient's own T cells to better recognize and attack cancer cells.
Include Axicabtagene ciloleucel (Yescarta) for blood cancers and
refractory large B-cell lymphoma in adult patients
5/7/2024 50

SURGERY
Indications & AIM
• To remove the primary tumor and achieve complete
eradication of cancer.
• To alleviate symptoms caused by the tumor, such as pain,
obstruction, or compression of nearby organs.
• To obtain tissue for diagnostic purposes (biopsy) and determine
the type, stage, and aggressiveness of the cancer.
• As part of a multimodal treatment approach, such as adjuvant
therapy (chemotherapy, radiation therapy) or neoadjuvant
therapy (to shrink the tumor before surgery).
5/7/2024 51

Surgical Techniques:
• Tumor resection depends on
factors such as the tumor location,
size, and extent of spread.
1. Common surgical approaches:
• Open Surgery:
• Minimally Invasive
5/7/2024 52

Extent of Resection
The extent of tumor resection depends on factors such as the
tumor type, location, size, and proximity to critical structures
(e.g., blood vessels, nerves, organs).
5/7/2024 53

TYPES OF SURGICAL RESECTION OF TUMOR
5/7/2024 54

5/7/2024 55

Curative Surgery:
This aims to remove the entire tumor and any nearby tissue
that may contain cancer cells, with the goal of curing the
cancer.
This may involves Radical surgical procedures like
Radical mastectomy for breast Ca
Radical prostatectomy for prostate Ca
Radical hysterectomy
Radical esophagectomy
5/7/2024 56

Palliative surgery
Palliative surgery for cancer aims to relieve symptoms,
improve quality of life, and alleviate suffering in patients with
advanced or incurable cancer. Includes
• Debulking Surgery
• Bypass Surgery
• Stent Placement
• Pleurodesis
5/7/2024 57

Psychotherapy
Emotional Support:
Coping Strategies
Improving Quality of Life
Support for Caregivers:
Faith and spiritual therapy
5/7/2024 58

Hormones And Cancer
Hormones related to tumor growth:
Usually sex hormones (testosterone, estrogen)
Related with tumor growth, so inhibition of the
receptors of these hormones can be used in treatment
→E.g.
In breast cancer, ask the histologist to find any
estrogen receptors. That will affect the treatment
plan and prognosis.
Growth of the prostate and the malignant cells are
dependent on the testosterone ,so if we block the
testosterone secretion by drugs, the tumor will stop
growing
5/7/2024 59

7. FOLLOW UP
Generally every 3 to 4 months for the first 2 to 3 years
Scheduled Follow-up Appointments:
Physical Examinations
Imaging Tests:
Laboratory Tests:.
Symptom Management:.
Screening for Second Cancers:
Psychosocial Support:.
Survivorship Care Plans.
5/7/2024 60

8. PREVENTION
a) Healthy Lifestyle Choices
–Quit Smoking
–Limit Alcohol Consumption.
–Maintain a Healthy Weight:
–Healthy Diet:
b) Vaccinations:,
–The HPV Vaccine Gardasil for
Cacx and hepatitis B vaccine
can prevent liver cancer.
c) Avoiding Carcinogens:
Occupational Hazards
asbestos, benzene, and
formaldehyde.
Environmental Factors:
environmental carcinogens such
Air pollutants
• Radon gas,
• Contaminated water
5/7/2024 61

d) Sun Protection:
o Wearing sunscreen with a high
SPF, seeking shade,
o Wearing protective clothing.
e) Breastfeeding
Reduce the risk of breast and
ovarian cancer. (USA-NCI 2016)
5/7/2024 62

f) Cancer Screening:
Regular Screening Tests:
–mammograms for breast cancer
– Pap smears for cervical cancer
–Colonoscopies for colorectal cancer
– Prostate-specific antigen (PSA) tests
5/7/2024 63

New Technological Screening Techniques.
• Biosensors
• Microfluidic technology
• Artificial Intelligence
5/7/2024 64

BIOSENSOR CANCER DETECTION
Work on the principle of detecting
specific biological molecules, such as
proteins, nucleic acids, or biomarkers,
by converting the biochemical signal
into a measurable signal, often
electrical or optical.
IMPLANTABLE BIONSOR
5/7/2024 65

Microfluidic device Cancer Screening
• Microfluidic devices Enable the
manipulation and analysis of tiny
volumes of body fluids.
• Automate sample preparation
steps, such as cell isolation, DNA
extraction, and protein
purification, making them highly
efficient tools for cancer
biomarker detection and
analysis.
5/7/2024 66

ARTIFICIAL INTELLIGENCE CANCER SCREENING
5/7/2024 67

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