Surgical principle of Management of TumorsM.A.Kubtan , MD FRCS

1st Lecture

1M.A.K . . ( ) .M.A.Kubtan2 A new growth or neoplasm has been defined as a :Mass of cells .Tissues .Organ .

Grows at the expense of the organism without at the same time subserving any useful purpose . Tumors3M.A.K

They have no respect for the rights of other cells.They violate the democratic principles of normal cellular organization.Their proliferation is uncontrolled;Their ability to spread is unbounded.Their inexorable ( ), relentless ( ) progress destroys first the tissue and then the host.Loss of function in a tumors suppressor gene will contribute to malignant transformation.

M.A.Kubtan4Cancer cells are psychopaths

Cancer cells will be able to evade apoptosis ( ( , which means that the wrong cells can be in the wrong places at the wrong times.The ability of a tumors to form blood vessels is termed angiogenic competence and is key feature of malignant transformation.Cancer cells acquire the ability to breach the basement membrane and thus gain direct access to blood and lymph vessels.

M.A.Kubtan5continue

A neoplasm is composed of living cells derived from normal cells of the body .Proliferated cells is the disease .Neoplasia cells continue proliferating without limit , Liver proliferation on demand ( Hyperplasia ) .Neoplasm grows at the expense of the organism and without reference to the needs of the body , Lipoma . In highly malignant tumors the cells revert to primitive form and subserve no purpose except multiplication .

M.A.K6A Mass of Cells

Less malignant tumors retain a certain amount of differentiation but their secretory activity serves no useful purpose .Alimentary canal will secret mucin .Chondrosarcoma will produce cartilage .Osteosarcoma will produce bone .Endocrine tumors produce hormones with a chemical structure identical with the normal .

In neither case is there any evidence of benefit to the organism.M.A.K7Continue

Continued growth is seen in grate majority of neoplasm .Usually it may not exceed the rate of growth of the normal cells .The most malignant of neoplasm enlarges less rapidly than most innocent of tumors , ( the normal fetus ) or normal tissues ( bone marrow or the Intestinal epithelium ) .Role of cytotoxic drugs

M.A.K8Rate of Growth

Governed by the rate of cell division .In normal tissues there is a continuous wastage of cells .In neoplasm unless the surface is ulcerated the derivative cells remain in place an contribute to the bulk of the tumor . M.A.K9The size of tumor

Assuming a tumor will originate from a single cell and it divide at regular intervals , it will take approximately 30 doubling to produce a tumor of 1cm diameter .The doubling time is believed to be of : 10 25 days for fast growing tumor such as some types of Sarcoma . In slow-growing tumors the doubling time in the order of 100 days .In between cancers of the Breast and Alimentary tract . M.A.K10The Doubling effect

M.A.K11If these assumptions are accurate it is clear that many tumors must have been in existence for a long time even several years before reaching a size to be detected

M.A.Kubtan12

Simple Tumors .Malignant Tumors .M.A.K13Classification of Tumors

M.A.K14ContinueSimple Tumors Tend to reproduce .The appearance an functional attributes of the cells from which originated .Tend to grow slowly and some times rate of growth slows down .

Malignant Tumors Tend to deviate towards more primitive forms .Shows no limitation of growth .

M.A.K15Continue Simple TumorsTend to grow by expanding .They may cause pressure atrophy of the surrounding paranchymatous tissues .Thus become encapsulated within a capsule derived from the surrounding Stroma .Malignant Tumors Extend by Invasion destroying adjacent normal cells and permeating tissue spaces .Ignores contact inhibition .

Surgical principle of Management of TumorsM.A.Kubtan , MD FRCS

2nd Lecture

16M.A.KSite-specialist surgeon Surgical oncologist Plastic and reconstructive surgeon Clinical oncologist/radiotherapist Medical oncologist Diagnostic radiologist Pathologist Speech therapist Physiotherapist Prosthetist Clinical nurse specialist (rehabilitation, supportive care) Palliative care nurse (symptom control, palliation) Social worker/counsellor Medical secretary/administrator Audit and information coordinatorM.A.K17Members of the multiprofessional team

Staging is the process whereby the extent of disease is mapped out.A change in staging system, or in the techniques used to provide baseline information concerning staging, can produce benefits to patients at all stages of the disease.

M.A.K18Investigation and staging

18M.A.K19

Diagnosis and staging : Aspirated fluids . FNA . Needle Biopsy . Surgical Biopsy . Excisional Biopsy. Lymph node biopsy . Sentinel node biopsy (Here, a radiolabelled colloid is injected into or around the primary tumour) . Diagnostic Laparoscopy with ultrasound & Biopsy Diagnostic Thoracoscopy & Biopsy . Diagnostic Cystoscopy & Biopsy . Others .

M.A.K20Principles of cancer surgery

Radical surgery for cancer involves removal of the primary tumor .Although the principle of local control is still extremely important, it is now recognized that ultra radical surgery probably has little effect on the development of metastatic disease.Meticulous surgery taking care not to disrupt the primary tumor at the time of excision is of the utmost importance in obtaining a cure in localized disease .M.A.K21Removal of primary disease

In certain circumstances, surgery for metastatic disease may be appropriate.This is particularly true for liver metastases arising from colorectal cancer .With multiple liver metastases, it may still be possible to take a surgical approach by using in situ ablation with cryotherapy or radiofrequency energy.Another situation where surgery may be of value is pulmonary resection for isolated lung metastases, particularly from renal cell carcinoma.

M.A.K22Removal of metastatic disease

May increase the patients quality of life .have little effect on the ultimate outcome. Other examples include bypass procedures such as an ileotransverse colon anastmosis .Gastrojujenostomy ( Gastric outlet obstruction , Ca head of Pancrease or ampulla Cholecysto jujenostomy ( Ca Head of Pancrease or ampulla ) .Chledocojujenostomy ( Ca Head of Pancrease or ampulla ) .

M.A.K23Palliation

Role of Surgery .Role of Chemotherapy .Role of Hormonal Therapy .Role of radiotherapy .

M.A.K24Over all Management