"A surgeon is surrounded by people who are sick, discouraged, afraid, embittered, dying - but also courageous, loving, wise, compassionate and alive" Bernie Siegel

1. Surgical Oncology
DR. MOHSIN KHAN

2. Oncology
The study of tumor (neoplastic diseases) .
Neoplasm
Altered cell population characterized by an excessive , non-
useful proliferation of cells that are unresponsive to normal control
mechanisms and to organizing influences of adjacent tissues .

3. Classification of Neoplasms
Benign Tumors:
Well differentiated tumors that do not
invade locally and metastatize to other sites.
Malignant Tumors:
Less differentiated tumor that show
uncontrolled proliferation and impair the function of
normal tissue by local invasion & metastatic to
distant sites.

4. Etiology
Chemical Carcinogens
Hydrocarbons from coal tar = Skin , Larynx & Bronchial carcinoma
Aromatic amines = Urinary tract carcinoma
Benzenes = Leukemia
Asbestos = Mesothelioma

5. Etiology
Physical Carcinogens
Ionizing radiations = Bone cancers
Multiple X-rays = Skin & Thyroid cancers
Atomic Bomb (Japan) = Leukemia
Mechanical (Chronic Irritation)
Marjolin`s ulcers = Burn scar cancer

6. Etiology
Infections
Viruses
Hepatitis B & C = Hepatocellular carcinoma
Epstein Barr virus = Burkitts Lymphoma
Herpes Simplex virus type 2 = Cervical Carcinoma
AIDS
Parasites
Schistosomas = Bladdar & Liver Carcinoma

7. Etiology
Precancerous conditions
Leucoplakia
Actinic keratosis
Polyps of colon & rectum
Neurofibromas
Dysplasia of cervix, bronchial
Chronic ulcerative colitis
Hereditary factors:
Familial polyposis – colonic CA
Breast CA – 2-3x in daughters and in younger age

8. Etiology
Oncogenes & Growth Factors:
◦ RNA tumor viruses cause:
◦ Carcinomas
◦ Sarcoma
◦ Leukemia
◦ Lymphomas
◦ Retrovirus have an enzyme that alters genomic RNA resulting to abnormal
growth and differentiation of the cell.
◦ Multi-factorial:
◦ Lung and Breast CA

9. Cancer Biology
Morphologic changes:
◦ Rise from a single cell
◦ Revert to more primitive cell types
◦ Normal orderly tissue patterns are lost or replaced
by the random pilling up of malignant cells
without definite pattern
◦ High index of mitoses
◦ Invasion of adjacent structures

10. Cancer Biology
Biochemical changes:
◦ Changes in DNA, RNA and chemical architecture
results to LOSS of CONTACT INHIBITION to
proliferation and intercellular adhesiveness.
◦ Reversion of normal cellular biochemistry to that
of the embryonal cells that produces
EMBRYONAL subs. (CEA, alpha fetoprotein).

11. Cancer Biology
Biochemical changes:
◦ Also produced biologically active subs. Normally
produced by the cells. (hyperparathyroidism);
also that are not normally produced by the cells of
origin (bronchogenic CA=ACTH)
Growth rates of neoplasm:
◦ Doubling time is doubled

12. Cancer Pathology
Carcinoma in Situ:
◦ Has cytologic characteristic of malignant
tumors but without any detectable invasion
into the surrounding tissue or infiltration
into deeper cell layers

13. Cancer Pathology
Classification of Neoplasm:
◦ Carcinoma – arising from epithelial cells
◦ Sarcoma – arise from connective tissue and cells of
mesenchymal origin (fibrous, muscular, fatty,
vascular & skeletal).

14. ROUTES OF SPREAD:
Metastasis may entirely dominate the clinical
picture, while the primary tumor remains latent and
asymptomatic
◦ Direct extension
◦ Lymphatic spread
◦ Common in epithelial neoplasms of all types.

15. ROUTES OF SPREAD:
Vascular spread
◦ Either through the thoracic duct or by the
invasion of blood vessels
◦ Capillaries are almost invaded, veins invaded
frequently but arteries rarely.
◦ More common in sarcomas
Spread through serous cavities
◦ Peritoneal seedings (gastrointestinal CA)

16. Clinical Menifestation:
The onset of neoplastic state is difficult to date
(asymptomatic) .
Danger Signs :
◦ Change in bowel or bladder habits
◦ A sore that does not heal
◦ Unusual bleeding or discharge
◦ Thickening or lump in breast or elsewhere
◦ Indigestion or difficult in swallowing
◦ Obvious change in wart
◦ Nagging cough or hoarseness

17. Clinical Menifestation:
Signs of Expansile growth:
Obstruction
Destruction
Signs of Infiltrative Growth:
◦ Tumor infiltrates the nerves
Pain
Numbness
paralysis

18. Clinical History
Warning symptoms for Cancer:
◦ Weight loss
◦ Loss of Appetite
◦ Bleeding or a discharge from an orifice
◦ Persistent cough or wheeze
◦ Change in voice
◦ Difficulty of swallowing
◦ Change in bowel habit
Growing lump in the skin,breast,abdomen or muscle

19. Clinical Examinations
Physical Examination:
◦ Palpable masses (movable, non-movable)
◦ Lymph Nodes enlargement
Laboratory Examination:
◦ Blood examination
◦ Radiological procedure:
◦ X-ray, Barium enema, mammography, thyroid
scan, CT scan, MRI

20. Clinical Examinations
Endoscopy:
◦ Bronchoscopy, esophagoscopy, gastroscopy,
proctosigmoidoscopy, colonoscopy, cystoscopy
Biopsy:
◦ To document presence of malignancy
◦ Types:
◦ Needle biopsy (cytological)
◦ Incisional biopsy
◦ Excisional biopsy
◦ Rapid frozen biopsy / exfoliative cytology (Pap smear)

21. Staging of Cancer
Clinical Staging of Cancer:
◦ TNM:
Stage I = cancer confined to it’s primary site
Stage II = more locally advanced disease
Stage III = metastasis to regional LN
Stage IV = metastasis to distant sites

22. Staging of Cancer
Post-surgical Resection Staging:
◦ Pathological Staging:
◦ The extent of disease using all data available at the time
of surgery and on examination of a completely resected
specimen.
Re-treatment Staging:
◦ Restaging is necessary for additional or secondary definitive treatment after a
(disease-free) interval following 1st treatment.
Autopsy Staging:
◦ Used only when the cancer is 1 st diagnosed at autopsy.

23. Treatment of Cancer
The treatment of choice in cancers is Surgical
resection
◦ Radiation therapy
◦ Chemotherapy
Surgery & radiation therapy represents treatment of
cancers that remains localized to it’s primary site or
regional LN.
Chemotherapy and Immunotherapy are effective
against tumor cells already metastatic to distant
organ sites.

24. Treatment of Cancer
Goals of Therapy:
Vary with extent of the cancer :
◦ Localized without evidence of spread:
◦ Eradicate the cancer and CURE THE PATIENT
◦ Spread beyond the local site:
◦ Control patient’s symptoms and to maintain
maximum activity for the longest possible
period of time.

25. Treatment of Cancer
CRITERIAs of Incurability:
Distant metastasis (most common)
Evidence of extensive local infiltration of adjacent
organs or structures
◦ Patient’s general condition and the presence of any
co-existing disease must be considered in planning
therapy.
◦ The PSYCHOLOGICAL makeup of the patient and
the patient’s life situation must be considered

26. Treatment of Cancer
SURGICAL RESECTION:
Surgical Curative Resection:
Wide Local Resection:
 Low grade malignancy
Radical Local Resection:
 High grade malignancy
 En Bloc Lymph Nodes dissection for breast, esophagus, gastric,
colorectal CA

27. Treatment of Cancer
Surgical Palliative Resection:
◦ To relieve symptoms
◦ To prolong a useful comfortable life
RADIOTHERAPY:
◦ Destroy tumor with preservation of anatomic
structures
◦ Direct toxic effect to cells due to ionization of
water

28. Treatment of Cancer
CHEMOTHERAPY:
◦ Antimetabolites:
◦ Inhibit enzymes of nucleic acid synthesis
◦ Methotrexate & 5-FU
◦ Alkylating agents:
◦ Substitute alkyl group for the hydrogen atom
◦ Alkylation of DNA molecule interferes with
replication in transcription

29. Treatment of Cancer
◦ Antibiotics:
◦ From soil fungi
◦ Forms stable complexes with DNA and inhibit
synthesis of DNA and RNA
◦ Actinomycin D, Doxorubicin, Bleomycin
◦ Vinca Alkaloids:
◦ Bind to microtubular proteins necessary for cell
division causing cell death during mitosis
◦ Vincristine & Vinblastine

30. Treatment of Cancer
IMMUNOTHERAPY:
◦ Inhibit proliferation of cancer cells without affecting
function of normal cells
◦ Stimulates the host to generate specific immune response to its tumor-
vaccine from tumor cells
◦ TUMOR SPECIFIC ANTISERUM:
◦ Murine monoclonal antibodies
◦ Immunotoxins
◦ None-specific immunotherapy=BCG vaccine

31. Prognosis
DETERMINANTS:
◦ Site of origin of primary tumor
◦ Stage of the disease
◦ Histologic features of the cancer
◦ Host immune factors
◦ Age of the patients

32. Thank You