2. introduction
• Cancer is one of the most common diseases in the world
• 1 in 4 deaths are due to cancer
• 1 in 17 deaths are due to lung cancer
• Lung cancer is the most common cancer in men
• Breast cancer is the most common cancer in women
• There are over 100 different forms of cancer
3. • >9.7 million cases are detected each year
• 6.7 million people will die from cancer
• Every day, around 1700 Americans die of the disease
• 20.4 million people living with cancer in the world
today
• 1 in 3 people will be diagnosed with cancer in the UK
and 1 in 4 will die from their disease
4. Cancer
• The division of normal cells is precisely controlled
• New cells are only formed for growth or to replace dead
ones
• Cancerous cells divide repeatedly out of control even
though they are not needed, they crowd out other
normal cells and function abnormally
• They can also destroy the correct functioning of major
organs
5. What causes cancer?
• Cancer arises from the mutation of a normal gene
• Mutated genes that cause cancer are called
oncogenes
• It is thought that several mutations need to occur to
give rise to cancer
• Cells that are old or not functioning properly normally
self destruct and are replaced by new cells
• However, cancerous cells do not self destruct and
continue to divide rapidly producing millions of new
cancerous cells
6. • A factor which brings about a mutation is
called a mutagen.
• Any agent that causes cancer is called a
carcinogen
• So some mutagens are carcinogenic
• Both inheritance and environment are
important determinants of cancer dev,nt
7. Carcinogens
• Ionising radiation – X Rays, UV light
• Chemicals – tar from cigarettes
• Virus infection – papilloma virus can be responsible
for cervical cancer.
• Hereditary predisposition – Some families are more
susceptible to getting certain cancers
• Remember you can’t inherit cancer its just that you
maybe more susceptible to getting it.
8. Benign or malignant?
• Benign tumours do not spread from their site of origin, but
can crowd out (squash) surrounding cells eg brain tumour,
warts.
• Malignant tumours can spread from the original site and
cause secondary tumours
• This is called metastasis. They interfere with neighbouring
cells and can block blood vessels, the gut, glands, lungs etc.
• Both types of tumour can tire the body out as they both
need a huge amount of nutrients to sustain the rapid
growth and division of the cells.
9. cancer
• is the uncontrolled proliferation of transformed
cells
• The term tumor, which was originally used to
describe the swelling caused by inflammation, is
now used interchangeably with neoplasm.
• Transformation is the multistep process in which
normal cells acquire malignant characteristics
10. six properties
• Self-sufficiency in growth signals
• Insensitivity to antigrowth signals
• Evading apoptosis
• Limitless replicative potential
• Sustained angiogenesis
• Tissue invasion and metastases
11. Histologic alterations in
epithelial dysplasia
• Enlarged nuclei and cells
• Increased nuclear-to-cytoplasmic ratio
• Hyperchromatic nuclei
• Pleomorphic (abnormally shaped) nuclei and cells
• Increased mitotic activity
• Abnormal mitotic figures
• Multinucleation of cells
• Keratin or epithelial pearls
• Loss of typical epithelial cell cohesiveness
Neville, Damm, & Bouquot (2002). Oral and maxillofacial pathology (2nd ed.) Philadelphia: Saunders
Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2nd ed.) St. Louis: Mosby
13. • Genetic mutations that are inherited from one's parents
and are present in all cells of the body are called germline
(or constitutional) mutations
• somatic mutations are acquired during an individual's
lifetime and cannot be passed to one's children.
• Somatic mutations, which account for most mutations in
cancer, may be caused by exposure to carcinogens in the
form of radiation, chemicals, or chronic inflammation
• A tumor that arises in an individual may be classified as
either hereditary or sporadic
14. • Major risk
– Ageing population
– Obesity
– Smoking
– Viral
– Bacterial
– Chemical
– Alcohol
– Diet
– etc
15. Staging and grading of
tumor
• Stage and grade determine prognosis
• Staging reflects the clinical extent of the tumor
• Grading a tumor reflects its histology subtype
• Of the two, staging is the primary indicator of
prognosis
• In cancer dx is not adequate to plan rx
16. Staging
• Based upon the size and extent of metastatic
spread of the lesion
– Lymphatic
– Hematogeneous
– Transcelomic
• Tumor-node-metastasis (TNM) system used
for most cancers
17. Why Use TNM?
• Allows the health professional to determine
appropriate treatment ( primary, adjuvant)
• Allows assessment of prognosis and outcomes
• Enables the reliable evaluation of treatment
results
• Results in quality cancer care
• Enables comparison of results
18. The Basics of TNM Staging
• Premises:
– Cancers of the same anatomic site and histology
share similar patterns of growth and similar
outcomes
– As the size of the primary tumor (T) increases,
regional lymph node involvement (N) and/or
distant metastases (M) become more likely.
19. TNM Classification System
Describes the anatomic extent of disease
based on assessment of three components
T Primary tumor size and extent
N Regional lymph node involvement
M Distant metastasis absent or present
20. TNM Classification System
• Primary tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1,T2 Increasing size or local extension
T3,T4 Increasing extent of primary tumor
21. TNM Classification System
• Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1,N2,N3 Increasing involvement of regional
lymph nodes
22. TNM Classification System
• Distant metastasis (M)
MX Presence of distant metastasis cannot be
assessed
M0 No distant metastasis
M1 Distant metastasis (may be further specified
according to size of occurrence)
23. The Basics of TNM Staging
• Stage Grouping
– After assignment of TNM categories
– Stage 0, I, II, III or IV
• Multiple Simultaneous Tumors
– The tumor with the highest T category is the one
selected for classification and staging
– Simultaneous bilateral cancers in paired organs are
staged separately
• Staging of primary unknown tumors can be
based on clinical suspicion of the primary
origin
24. Grading
• Degree of differentiation exhibited by cells
• How closely cells resemble normal tissue
structure
• Grade I – low grade
• Grade II – moderately differentiated
• Grade III – poorly differentiated
Neville, B. W., Damm, D. D., Allen, C. M., & Bouquot, J. E. (2002). Oral and maxillofacial pathology (2nd ed.). Philadelphia: W. B. Saunders.
25. Summary
• Stage and grade of tumors indicates prognosis
• Treatment plans based upon stage and grade,
among other factors
• TNM system used with most cancers
26. Roles of Surgeon in Management of
Cancer Patients
• Prevention
• Diagnosis and proper staging
• Definitive treatment
• Palliation
• Rehabilitation
27. Role of surgery in cancer managment
• Surgery is the treatment of choice for most
localized, solid neoplasms
• Surgery has recognized limits in its application
• Surgery is increasingly combined with other
treatment modalities.
29. Sugery That can Prevent Cancer
• Underlying condition
polyposis coli
familial colon cancer
ulcerative colitis
MEN type II, III
familial breast cancer
familial ovarian cancer
• Prophylactic surgery
Colectomy
Colectomy
Colectomy
Thyroidectomy
Mastectomy
Oophorectomy
30. 2. Diagnosis of Cancer
• Acquisition of tissue for histologic
diagnosis
• Staging of patients
• Techniques for Obtaining Tissue
– Needle biopsy
– Incisional biopsy
– Excisional biopsy
31. Needle biopsy ; advantages
• Simplest method
• Inexpensive
• Causes minimal disturbance of the surrounding tissue
• disadvantages
– Danger of implanting tumor cells in a needle tract
– Not representative of the total tumor
– The needle misses the lesion
32. Needle biopsy ; types
• Fine needle aspiration biopsy
• Large bore needle biopsy
33. Principles of the performance of all
surgical biopsies
• Do not contaminate new tissue plane during
the biopsy
• Needle tract or scar should be removed as part
of subsquent definitive surgical procedure
• Choice of biopsy technique should be
selected carefully in order to obtain
an adequate tissue sample for the
needs of the pathologist
34. Role of Surgeon in Management of
Cancer Patients
• Prevention
• Diagnosis
• Definitive treatment
• Palliation
• Rehabilitation
35. Surgery:
• Surgery was the first modality used
successfully in the treatment of cancer.
• It is the only curative therapy for many
common solid tumors
• The most important determinant of a
successful surgical therapy are the absence of
distant metastases and no local infiltration
36. Considerations in choosing therapy
• Disease and results obtained from each
type of therapy
• Patient’s general conditions and co-existing
disease
• Patient’s life situation and psychological
makeup
37. Major Challenges Confronting the
Surgical Oncologist II
• Development and selection of local treatments
that provide the best balance between local cure
and the impact of treatment morbidity on the
quality of life
• Accurate identification of patients who can be
cured by local treatment alone
• Development and application of adjuvant
treatments that can improve the control of local
and distant invasive and metastatic disease
38. 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
39. Types of cancer operations
• Local resection
• Radical local resection
• Radical resection with en bloc excision of lymphatics
• Extensive surgical procedures
40. Adequate margin of Resection
• A complete margin of normal tissue around the
primary lesion
• Frozen sections used to evaluate tissue margins in
instances of doubt
• Complete removal of involved regional lymph nodes
• Resection of involved adjacent organ
• En bloc resection of biopsy tracts and tumor sinuses
41. Roles of Surgery in the Treatment of Cancer
• Definitive surgical treatment for primary cancer
• Surgery for reduce the bulk of residual disease
• Surgical resection of metastatic disease with curative intention
• Surgery for treatment of oncologic emergencies
42. Surgery for residual disease
• In selected cancers, surgical resection
of bulk disease may lead to
improvement in the ability to control
residual gross disease that has not been
resected
43. Surgery for metastatic disease
• Resection of pulmonary metastasis in patients with soft tissue and bony
sarcomas
• Resection of pulmonary metastasis in patients with colon cancer
• Resection of hepatic metastasis in patients with colorectal cancer
44. Surgery for oncologic emergencies
• exsanguinating hemorrhage
• Perforation
• drainage of abscess
• impending destruction of vital organs
45. Role of Surgeon in Management of
Cancer Patients
• Prevention
• Diagnosis
• Definitive treatment
• Palliation
• Rehabilitation
46. Surgery for Palliation
• To improve the quality of life
• Relief pain
• By pass obstruction
• To treat complication
48. Radiation therapy:
• Radiation therapy: is a local modality used in the
treatment of cancer
• Success depend in the difference in the radio
sensitivity between the tumor and normal tissue
• It involves the administration of ionizing radiation in
the form of x-ray or gamma rays to the tumor site
• Method of delivery: External beam(teletherapy).
Internal beam therapy(Brachytherapy).
49. Cont:
• Radiation therapy with curative intent is the main
treatment in limited stage Hodgkin’s disease,some
NHL,limited stage ca prostate,gynecologic
tumors&CNS tumor
• Also can use in palliative &emergency setting.
50. Complication of radiation:
• There is two types of toxicity ,acute and long term toxicity
• Systemic symptoms such as Fatigue,local skin reaction,GI
toxicity, oropharyngeal
• mucositis&xerostomia.myelosuppression
• Long-term sequelae:may occur many months or years after
radiation therapy
• Radiation therapy is known to be mutagenic,carcinogenic,and
teratogen,and having increased risk of developing both
secondary leukemia and solid tumor
51. Radionuclides:
• For decades have been used systemically to treat
malignant disorders.
• Radioactive iodine:in the from of 131I is effective
therapy for well differentiated thyroid ca
• Strontium-89. Is used for the treatment of body
metastasis
• it is an alkaline earth element in the same family as
calcium
52. Chemotherapy:
• Systemic chemotherapy is the main treatment
available for disseminated malignant diseases
• Progress in chemotherapy resulted in cure for
several tumors
• Chemotherapy usually require multiple cycles.
53. Classification of cytotoxic drug:
• Cytotoxic agent can be roughly categorized
based on their activity in relation to the cell
cycle.
phase nonspecific. phase specific
cytotoxic drug
54. Cont :
• Phase non-specific:
– The drugs generally have a linear dose-response
curve( the drug administration ,the the
fraction of cell killed)
• Phase specific:
– Above a certain dosage level,further increase in
drug doesn’t result in more cell killing.but you can
play with duration of infusion.
56. Complication of Chemotherapy:
• Every chemotherapeutic will have some
deleterious side effect on normal tissue
• E.G; Myelosuppression,nausea&vomiting,
Stomatitis,and alopecia are the most frequently
observed side effects
57. 10 Rules to Avoid Cancer
2. Don’t smoke.
3. Don’t smoke.
4. Avoid exposure to other known carcinogens,
including aflatoxin, asbestos and UV light.
6. Eat fresh fruit and vegetables several times a day.
7. Be physically active and avoid obesity.
8. Have vaccination against, or early detection/treatment
of, cancer causing chronic infections.
9. Have the right genes.
5. Enjoy a healthy diet, moderate in calories,
salt and fat, and low in alcohol.
1. Don’t smoke
