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Surgical Oncology


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Surgical Oncology

  2. 2. <ul><li>Study of neoplastic diseases: </li></ul><ul><ul><li>ONCOS = tumor LOGOS = study </li></ul></ul><ul><li>Neoplasm : </li></ul><ul><ul><li>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 tissue. </li></ul></ul>
  3. 3. Neoplasm: <ul><li>Malignant: </li></ul><ul><ul><li>Cancer cells that exhibit uncontrolled proliferation and impair the function of normal organs by local tissue invasion and metastatic spread to distant anatomic sites. </li></ul></ul><ul><li>Benign: </li></ul><ul><ul><li>Composed of normal appearing cells that do not invade locally or metastasize to other sites </li></ul></ul>
  4. 4. EPIDEMIOLOGY: <ul><li>Overall cancer death rates shows slow steady increase </li></ul><ul><li>Lower death rates during past 50yrs: </li></ul><ul><ul><li>Stomach </li></ul></ul><ul><ul><li>Uterus </li></ul></ul><ul><li>Increase death rates: </li></ul><ul><ul><li>Lung </li></ul></ul><ul><ul><li>Pancreas </li></ul></ul>
  5. 5. EPIDEMIOLOGY: <ul><li>Cancer incidence by sites and sex: </li></ul>Male Female Lung 20% Breast 27% Prostate 20% Colon & Rectum 16% Colon & Rectum 14% Lung 11% Urinary 10% Uterus 10% Leukemia & Lymphoma 8% Leukemia & Lymphoma 7% Skin, pancreas and oral 3-4% Skin, pancreas and oral 3-4%
  6. 6. EPIDEMIOLOGY: <ul><li>Cancer death by sites and sex: </li></ul>Male Female Lung 36% Lung 20% Colon & Rectum 11% Breast 18% Prostate 10% Colon & Rectum 14% Leukemia & Lymphoma 9% Leukemia & Lymphoma 9% Pancreas & Urinary 5% each Pancreas & Ovary 5% Urinary & Uterus 4% each
  7. 7. <ul><li>The most significant 5 yrs survival rates are achieved in patients w/ cancer of skin, thyroid, cervix, uterus and bladder ; w/ the lowest survival w/ pancreatic cancer </li></ul><ul><li>Females tend to have a greater number of 5yrs survival w/ cancer of any given primary site than males, reason (?) </li></ul><ul><ul><ul><li>5 yr survival female = 50% </li></ul></ul></ul><ul><ul><ul><li>5 yr survival male = 31% </li></ul></ul></ul>
  8. 8. ETIOLOGY: <ul><li>Chemical carcinogens : </li></ul><ul><ul><li>Hydrocarbons from coal tar = skin, larynx & bronchial CA </li></ul></ul><ul><ul><li>Aromatic amines = urinary tract CA </li></ul></ul><ul><ul><li>Benzene = leukemia </li></ul></ul><ul><ul><li>Asbestos = mesothelioma </li></ul></ul><ul><li>Physical carcinogens: </li></ul><ul><ul><li>Ionizing radiations = bone cancer </li></ul></ul><ul><ul><ul><li>Multiple x-rays = skin/thyroid CA </li></ul></ul></ul><ul><ul><li>Atomic bomb (Japan) = leukemia </li></ul></ul>
  9. 9. ETIOLOGY: <ul><li>Mechanical (chronic irritation): </li></ul><ul><ul><li>Marjolin’s ulcer = burn scar cancer </li></ul></ul><ul><li>Infection: </li></ul><ul><ul><li>Parasitic: </li></ul></ul><ul><ul><ul><li>Schistosomas – Liver & bladder CA </li></ul></ul></ul><ul><ul><li>Viruses: </li></ul></ul><ul><ul><ul><li>Hepatitis B – hepatocellular CA </li></ul></ul></ul><ul><ul><ul><li>Epstein-Barr virus – Burkitts lymphoma </li></ul></ul></ul><ul><ul><ul><li>Herpes simplex virus 2 – cervical CA </li></ul></ul></ul><ul><ul><ul><li>Aids </li></ul></ul></ul>
  10. 10. ETIOLOGY: <ul><li>Geographic factors: </li></ul><ul><ul><li>Inc. CA of stomach – Scandinavian, </li></ul></ul><ul><ul><li>Iceland and Japan </li></ul></ul><ul><ul><li>Inc. CA of liver – South & West Africa </li></ul></ul><ul><ul><li>Inc. CA of Nasopharynx – China </li></ul></ul><ul><ul><li>Inc. CA of urinary bladder – Egypt </li></ul></ul><ul><ul><li>Dec. CA of colon – Black/Africa </li></ul></ul><ul><ul><li>Dec. CA prostate / breast – Japan </li></ul></ul><ul><ul><li>Dec. CA of uterine/cervix – Israel/Jewish </li></ul></ul><ul><ul><li>Dec. CA of skin – Blacks </li></ul></ul><ul><li>customs & environment plays an important role in the development of CA. </li></ul><ul><li>migration of populations usually causes a shift towards the patterns of cancer incidence of the host country </li></ul>
  11. 11. ETIOLOGY: <ul><li>Precancerous conditions: </li></ul><ul><ul><li>Leucoplakia </li></ul></ul><ul><ul><li>Actinic keratosis </li></ul></ul><ul><ul><li>Polyps of colon & rectum </li></ul></ul><ul><ul><li>Neurofibromas </li></ul></ul><ul><ul><li>Dysplasia of cervix, bronchial </li></ul></ul><ul><ul><li>Chronic ulcerative colitis </li></ul></ul><ul><li>Hereditary factors: </li></ul><ul><ul><li>Familial polyposis – colonic CA </li></ul></ul><ul><ul><li>Breast CA – 2-3x in daughters and in younger age </li></ul></ul>
  12. 12. ETIOLOGY: <ul><li>Oncogenes & Growth Factors: </li></ul><ul><ul><li>RNA tumor viruses cause: </li></ul></ul><ul><ul><ul><li>Carcinomas </li></ul></ul></ul><ul><ul><ul><li>Sarcoma </li></ul></ul></ul><ul><ul><ul><li>Leukemia </li></ul></ul></ul><ul><ul><ul><li>Lymphomas </li></ul></ul></ul><ul><ul><li>Retrovirus have an enzyme that alters genomic RNA resulting to abnormal growth and differentiation of the cell. </li></ul></ul><ul><li>Multi-factorial: </li></ul><ul><ul><li>Lung / breast CA </li></ul></ul>
  13. 13. CANCER BIOLOGY <ul><li>Morphologic changes: </li></ul><ul><ul><li>Rise from a single cell </li></ul></ul><ul><ul><li>Revert to more primitive cell types </li></ul></ul><ul><ul><li>Normal orderly tissue patterns are lost or replaced by the random pilling up of malignant cells w/o definite pattern </li></ul></ul><ul><ul><li>High index of mitoses </li></ul></ul><ul><ul><li>Invasion of adjacent structures </li></ul></ul>
  14. 14. CANCER BIOLOGY <ul><li>Biochemical changes: </li></ul><ul><ul><li>Changes in DNA, RNA and chemical architecture results to LOSS of CONTACT INHIBITION to proliferation and intercellular adhesiveness </li></ul></ul><ul><ul><li>Reversion of normal cellular biochemistry to that of the embryonal cells that produces EMBRYONAL subs. (CEA, alpha fetoprotein) </li></ul></ul>
  15. 15. CANCER BIOLOGY <ul><li>Biochemical changes: </li></ul><ul><ul><li>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) </li></ul></ul><ul><li>Growth rates of neoplasm: </li></ul><ul><ul><li>Doubling time is doubled </li></ul></ul><ul><ul><li>Takes 30 doubling time to produce 1cm nodule </li></ul></ul>
  16. 16. CANCER BIOLOGY <ul><li>Effector mechanism in tumor immunity: </li></ul><ul><ul><li>Host provides a number of effector mechs. that destroys the tumor: </li></ul></ul><ul><ul><ul><li>Tumor-antigen-specific antibodies </li></ul></ul></ul><ul><ul><ul><li>Mononuclear phagocytes </li></ul></ul></ul><ul><ul><ul><li>Natural killer cells </li></ul></ul></ul><ul><ul><ul><li>Cytotoxic T lymphocytes </li></ul></ul></ul><ul><ul><ul><li>Neutrophils </li></ul></ul></ul><ul><ul><ul><li>K cells </li></ul></ul></ul>
  17. 17. CANCER BIOLOGY <ul><li>Effector mechanism in tumor immunity: </li></ul><ul><ul><li>Tumor Necrosis Factor (TNF): </li></ul></ul><ul><ul><ul><li>Cytokines produced by monocytes, machrophage, endothelial cells, large granular lymphocytes and neutrophils </li></ul></ul></ul><ul><ul><ul><li>Properties: </li></ul></ul></ul><ul><ul><ul><ul><li>Direct cytotoxicity for certain cells </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Stimulation of procoagulant activity by vascular endothelial cells </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Induction of fever by direct effect on the hypothalamic thermoregulatory center </li></ul></ul></ul></ul>
  18. 18. CANCER PATHOLOGY <ul><li>Classification of Neoplasm: </li></ul><ul><ul><li>Carcinoma – arising from epithelial cells </li></ul></ul><ul><ul><li>Sarcoma – arise from connective tissue and cells of mesenchymal origin (fibrous, muscular, fatty, vascular & skeletal). </li></ul></ul>
  19. 19. CANCER PATHOLOGY <ul><li>Grading of malignancy: </li></ul><ul><ul><li>Broders classified carcinoma into 4 grades according to: </li></ul></ul><ul><ul><ul><li>Degree of differentiation </li></ul></ul></ul><ul><ul><ul><li>Appearance of cells, their nuclei and the number of mitotic figures </li></ul></ul></ul><ul><ul><li>Grade I – least malignant </li></ul></ul><ul><ul><li>Grade IV – most malignant </li></ul></ul>
  20. 20. CANCER PATHOLOGY <ul><ul><li>Carcinoma in Situ: </li></ul></ul><ul><ul><ul><li>Has cytologic characteristic of malignant tumors but w/ no detectable invasion into the surrounding tissue or infiltration into deeper cell layers </li></ul></ul></ul>
  21. 21. ROUTES OF SPREAD: <ul><li>Metastasis may entirely dominate the clinical picture, while the primary tumor remains latent and asymptomatic </li></ul><ul><ul><li>Direct extension </li></ul></ul><ul><ul><li>Lymphatic spread </li></ul></ul><ul><ul><ul><li>Common in epithelial neoplasms of all types (except for basal cell CA) </li></ul></ul></ul>
  22. 22. ROUTES OF SPREAD: <ul><li>Vascular spread </li></ul><ul><ul><li>Either thru the thoracic duct or by the invasion of blood vessels </li></ul></ul><ul><ul><li>Capillaries are almost invaded, veins invaded frequently but arteries rarely. </li></ul></ul><ul><ul><li>More common in sarcomas </li></ul></ul><ul><li>Spread through serous cavities </li></ul><ul><ul><li>Peritoneal seedings (gastrointestinal CA) </li></ul></ul>
  23. 23. CLINICAL MANIFESTATION : <ul><li>The onset of neoplastic state is difficult to date (asymptomatic). </li></ul><ul><ul><li>Seven Danger Signals of Cancer (Direct manifestation): </li></ul></ul><ul><ul><li>Change in bowel or bladder habits </li></ul></ul><ul><ul><li>A sore that does not heal </li></ul></ul><ul><ul><li>Unusual bleeding or discharge </li></ul></ul><ul><ul><li>Thickening or lump in breast or elsewhere </li></ul></ul><ul><ul><li>Indigestion or difficult in swallowing </li></ul></ul><ul><ul><li>Obvious change in wart or mole </li></ul></ul><ul><ul><li>Nagging cough or hoarseness </li></ul></ul>
  24. 24. CLINICAL MANIFESTATION : <ul><li>Indirect or Systemic Manifestation : </li></ul><ul><ul><li>Secondary to metastasis </li></ul></ul><ul><ul><ul><li>Cachexia </li></ul></ul></ul><ul><ul><li>Secondary to none metastatic: </li></ul></ul><ul><ul><ul><li>Ectopic production of known hormones </li></ul></ul></ul><ul><ul><ul><li>Secretion of unidentified, hormone like substances </li></ul></ul></ul><ul><ul><ul><li>Toxic substances secreted from the tumor </li></ul></ul></ul><ul><ul><ul><li>Autoimmune – host is sensitized to an antigen from the tumor </li></ul></ul></ul>
  25. 25. CLINICAL MANIFESTATION : <ul><li>Signs of Expansile growth: </li></ul><ul><li>Obstruction </li></ul><ul><li>Destruction </li></ul><ul><li>Signs of Infiltrative Growth: </li></ul><ul><ul><li>Tumor infiltrates the nerves </li></ul></ul><ul><li>Pain </li></ul><ul><li>Numbness </li></ul><ul><li>paralysis </li></ul>
  26. 26. CLINICAL MANIFESTATION : <ul><li>Signs of Tumor necrosis (Bleeding & Infection): </li></ul><ul><ul><li>Tumor may become necrotic, ulcerate and bleed </li></ul></ul><ul><ul><li>Fatigue and weakness in right colon cancer due to anemia </li></ul></ul><ul><ul><li>Inflammation caused by cecal CA can mimic the clinical symptoms of acute AP or cholecystitis. </li></ul></ul><ul><li>Unknown primary tumors presenting as metastases </li></ul>
  27. 27. DIAGNOSIS OF CANCER: <ul><li>Clinical History: </li></ul><ul><ul><li>Warning signs for Cancer: </li></ul></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Loss of Appetite </li></ul></ul><ul><ul><li>Bleeding or a discharge from any body orifice or nipple </li></ul></ul><ul><ul><li>Sore that is slow to heal </li></ul></ul>
  28. 28. DIAGNOSIS OF CANCER: <ul><li>Clinical History: </li></ul><ul><ul><li>Warning signs for Cancer: </li></ul></ul><ul><ul><li>Persistent cough or wheeze </li></ul></ul><ul><ul><li>Change in voice </li></ul></ul><ul><ul><li>Difficulty of swallowing </li></ul></ul><ul><ul><li>Change in bowel habit </li></ul></ul><ul><ul><li>Growing lump in the skin, breast, abdomen or muscle </li></ul></ul>
  29. 29. DIAGNOSIS OF CANCER: <ul><li>Physical Examination: </li></ul><ul><ul><li>Palpable masses (movable, non-movable) </li></ul></ul><ul><ul><li>LN enlargement </li></ul></ul><ul><li>Laboratory Examination: </li></ul><ul><ul><li>Blood examination </li></ul></ul><ul><ul><li>Radiological procedure: </li></ul></ul><ul><ul><ul><li>X-ray, esophagoram, Barium enema, mammography, thyroid scan, CT scan, MRI </li></ul></ul></ul>
  30. 30. DIAGNOSIS OF CANCER: <ul><li>Laboratory Examination: </li></ul><ul><ul><li>Endoscopy: </li></ul></ul><ul><ul><ul><li>Bronchoscopy, esophagoscopy, gastroscopy, proctosigmoidoscopy, colonoscopy, cystoscopy </li></ul></ul></ul>
  31. 31. DIAGNOSIS OF CANCER: <ul><li>Laboratory Examination: </li></ul><ul><ul><li>Biopsy: </li></ul></ul><ul><ul><ul><li>To document presence of malignancy </li></ul></ul></ul><ul><ul><ul><li>Types: </li></ul></ul></ul><ul><ul><ul><ul><li>Needle biopsy (cytological) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Incisional biopsy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Excisional biopsy </li></ul></ul></ul></ul><ul><ul><ul><li>Rapid frozen biopsy / exfoliative cytology (Pap smear) </li></ul></ul></ul>
  32. 32. STAGING OF CANCER: <ul><li>Clinical Staging of Cancer: </li></ul><ul><ul><li>TNM: </li></ul></ul><ul><li>Stage I = cancer confined to it’s primary site </li></ul><ul><li>Stage II = more locally advanced disease </li></ul><ul><li>Stage III = metastasis to regional LN </li></ul><ul><li>Stage IV = metastasis to distant sites </li></ul><ul><ul><li>Use all information available prior to 1 st definitive treatment: </li></ul></ul>
  33. 33. STAGING OF CANCER: <ul><li>Post-surgical Resection Staging: </li></ul><ul><ul><li>Pathological Staging: </li></ul></ul><ul><ul><ul><li>The extent of disease using all data available at the time of surgery and on examination of a completely resected specimen. </li></ul></ul></ul><ul><li>Re-treatment Staging: </li></ul><ul><ul><li>Restaging is necessary for additional or secondary definitive treatment after a (disease-free) interval following 1 st treatment. </li></ul></ul><ul><li>Autopsy Staging: </li></ul><ul><ul><li>Used only when the cancer is 1 st diagnosed at autopsy. </li></ul></ul>
  34. 34. CANCER TREATMENT: <ul><li>Interdisciplinary Approach: </li></ul><ul><ul><li>Surgical resection 55% (40% alone) </li></ul></ul><ul><ul><li>Radiation therapy 34% (16% alone) </li></ul></ul><ul><ul><li>Chemotherapy 22% (alone or combination) </li></ul></ul><ul><li>Surgery & radiation tx represents treatment of cancers that remains localized to it’s primary site or regional LN. </li></ul><ul><li>Chemotherapy and Immunotherapy – tx effective against tumor cells already metastatic to distant organ sites. </li></ul>
  35. 35. CANCER TREATMENT: <ul><li>GOALS of Therapy: </li></ul><ul><li>Vary w/ extent of the cancer : </li></ul><ul><ul><li>Localized w/o evidence of spread: </li></ul></ul><ul><ul><ul><li>Eradicate the cancer and CURE THE PATIENT </li></ul></ul></ul><ul><ul><li>Spread beyond the local site: </li></ul></ul><ul><ul><ul><li>Control patient’s symptoms and to maintain maximum activity for the longest possible period of time. </li></ul></ul></ul>
  36. 36. CANCER TREATMENT: <ul><li>CRITERIA of Incurability: </li></ul><ul><li>Distant metastasis (most common) </li></ul><ul><li>Evidence of extensive local infiltration of adjacent organs or structures </li></ul><ul><ul><li>Pt’s general condition and the presence of any co-existing disease must be considered in planning therapy. </li></ul></ul><ul><ul><li>The PSYCHOLOGICAL makeup of the patient and the patient’s life situation must be considered. </li></ul></ul>
  37. 37. CANCER TREATMENT: <ul><li>SURGICAL RESECTION: </li></ul><ul><li>Surgical Curative Resection: </li></ul><ul><ul><li>Wide local resection: </li></ul></ul><ul><ul><ul><li>Low grade malignancy </li></ul></ul></ul><ul><ul><ul><li>Basal cell CA of the skin </li></ul></ul></ul><ul><ul><li>Radical Local Resection: </li></ul></ul><ul><ul><ul><li>High grade malignancy </li></ul></ul></ul><ul><ul><ul><li>En Bloc LN dissection for breast, esophagus, gastric, colorectal CA </li></ul></ul></ul><ul><li>Surgical Palliative Resection: </li></ul><ul><ul><li>To relieve symptoms </li></ul></ul><ul><ul><li>To prolong a useful comfortable life </li></ul></ul><ul><ul><li>Gastrojejunostomy, colostomy </li></ul></ul>
  38. 38. CANCER TREATMENT: <ul><li>RADIOTHERAPY: </li></ul><ul><ul><li>Destroy tumor with preservation of anatomic structures </li></ul></ul><ul><ul><li>Direct toxic effect to cells due to ionization of water </li></ul></ul>
  39. 39. CANCER TREATMENT: <ul><li>CHEMOTHERAPY: </li></ul><ul><ul><li>Antimetabolites: </li></ul></ul><ul><ul><ul><li>Inhibit enzymes of nucleic acid synthesis </li></ul></ul></ul><ul><ul><ul><li>Methotrexate & 5-FU </li></ul></ul></ul><ul><ul><li>Alkylating agents: </li></ul></ul><ul><ul><ul><li>Substitute alkyl grp for the hydrogen atom </li></ul></ul></ul><ul><ul><ul><li>Alkylation of DNA molecule interferes with replication in transcription </li></ul></ul></ul>
  40. 40. CANCER TREATMENT: <ul><li>CHEMOTHERAPY: </li></ul><ul><ul><li>Antibiotics: </li></ul></ul><ul><ul><ul><li>From soil fungi </li></ul></ul></ul><ul><ul><ul><li>Forms stable complexes with DNA and inhibit synthesis of DNA and RNA </li></ul></ul></ul><ul><ul><ul><li>Actinomycin D, Doxorubicin, Bleomycin </li></ul></ul></ul><ul><ul><li>Vinca Alkaloids: </li></ul></ul><ul><ul><ul><li>Bind to microtubular proteins necessary for cell division causing cell death during mitosis </li></ul></ul></ul><ul><ul><ul><li>Vincristine & Vinblastine </li></ul></ul></ul>
  41. 41. CANCER TREATMENT: <ul><li>IMMUNOTHERAPY: </li></ul><ul><ul><li>Inhibit proliferation of cancer cells w/o affecting function of normal cells </li></ul></ul><ul><ul><li>Stimulates the host to generate specific immune response to its tumor-vaccine from tumor cells </li></ul></ul><ul><ul><li>TUMOR SPECIFIC ANTISERUM: </li></ul></ul><ul><ul><ul><li>Murine monoclonal antibodies </li></ul></ul></ul><ul><ul><ul><li>Immunotoxins </li></ul></ul></ul><ul><ul><li>None-specific immunotherapy=BCG vaccine </li></ul></ul>
  42. 42. PROGNOSIS: <ul><li>DETERMINANTS: </li></ul><ul><ul><li>Site of origin of primary tumor </li></ul></ul><ul><ul><li>Stage of the disease </li></ul></ul><ul><ul><li>Histologic features of the cancer </li></ul></ul><ul><ul><li>Host immune factors </li></ul></ul><ul><ul><li>Age of the patients </li></ul></ul>
  43. 43. THANK YOU