Surgical Oncology

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Surgical Oncology. Definition of Neoplasia. a disorder of cell growth in which there is a permanent and inherited change in cells resulting in a pathological proliferation of tissue. The Etiology of Cancer. Viruses(papilloma, Epstein-Barr, Hepatitis B, retroviruses,HIV) Radiation exposure - PowerPoint PPT Presentation

Text of Surgical Oncology

  • Definition of Neoplasia

    a disorder of cell growth in which there is a permanent and inherited change in cells resulting in a pathological proliferation of tissue.

  • KarkinosKarkinoma

  • The Etiology of CancerViruses(papilloma, Epstein-Barr, Hepatitis B, retroviruses,HIV)Radiation exposureEnvironmental industrial carcinogensTobacco and alcohol consumptionGenetic susceptibility syndromes

  • Historical Observation of Chemical CarcinogensDateObservationCarcinogen1761Excessive use of Nitrosaminessnuff lead to nasal polyps1775Scrotal cancer in soot chimney sweeps1860sbladder cancer Aromatic amines1915Rabbit ears painted Benzpyrenewith tar developed papillomas

  • Cancer Mortality & Behavior/environmental FactorsFactorPercentage of cancer deathsSmoking30Diet30Infectious agents5Alcohol3Sedentary lifestyle3Ultraviolet 2Air pollution2

  • Smoking-related cancersLung cancerOropharyngeal cancerStomach cancer Cervical cancerPancreatic cancerRenal cancerBladder cancerLiver cancer Leukemia

  • Viruses Associated with CancerVirusCancerHepatitis B, CHepatocellular CancerHIVKaposis sarcomaEpstein-Barr virusNasopharyngeal cancerBurkitts lymphomaHuman Papilloma virusCervical cancer

  • Internal causesHereditary susceptibility

    Endocrine factors

    Immune factors

  • PreventionFirst step etiologySecond step early detection and treatmentThird step improve quality of life

  • Major Genes in Development of CancerOncogenesTumor suppressor genesDNA repair genes

  • OncogenesGrowth factorsEGF, TGF-Growth factor receptorsEGFR, PTKIntracellular transducerscAMPTranscription factorsc-myc

  • Inactivation of DNA repair genesInactivation of Tumor suppressor genesActivation of OncogenesTumor Cell

  • Multi-step nature of Colon CancerNormal epitheliumHyperproliferationEarly adenomaCarcinomaLate adenomaIntermediate adenomaInactivation of APC TSGDNA hypomethylationActivation of K-ras oncogeneInactivation of DCC TSGInactivation of P53 TSG

  • Modern Viewpoint of Cancer as a Long-term ProcessPrecancerous phaseDissemination phaseInvasion phaseIn-site phaseUp to 10~30 years3~10 years1~5 years1~5 years

  • The classification and nomination of tumors

  • Nomenclature of Malignant TumorNames of tumorTissue of origin ExamplesCarcinomaEpithelium AdenocarcinomasSarcomaMesenchymal LiposarcomaMalig. lymphomaLymphocytes LymphomaMalig. melanomaMelanocytes Malignant melanomaMalig. Mesothelioma Mesothelium Pleural malig. MesotheliomaTeratomaGerm Cells Testicular teratomaChoriocarcinomaTrophoblast Uterine choriocarcinoma

  • Benign Tumorsa limited growth potentialthe neoplastic cells closely resemble those of the parent tissue ( well diff.)growing slowly by expansiona well-encapsulated lesiondo not usually produce serious effect

  • Malignant Tumorsproliferate rapidlymore poorly differentiated cellsprogressive growth and invasion of the surrounding tissuesmetastases by lymphatic & blood vesselsif not treated early, eventually cause death

  • The Degree of DifferentiationWell differentiatedModerately differentiatedPoorly differentiated

  • The Objectives of Cancer Staging & Histological Classificationto aid the clinician in planning of treatmentto give some indication of prognosisto evaluate the efficiency of treatmentto facilitate exchange of informationto assist in continuing clinical studies of cancer

  • Histopathological Staging & ClassificationAdenocarcinomasSquamous carcinomasSmall cell carcinomas Large cell carcinomasSarcomas LymphomasLeukemias GliomasSeminomas Teratomas

  • The Hallmark of MalignancyLocal Destructive InvasionDistant Metastasis

    ------ the cardinal behavior to distinguish benign & malignant tumor

  • Pathological Features of Malignancy an infiltrative uncapsulated margin invasion of baseline membrane or surrounding structure evidence of invasion of blood vessels or lymphatics or metastases tumor necrosis

  • Pathological Features of Malignancy architecture abnormalities e.g. increased gland/stroma ratio cytological abnormalities e.g. increased nuclear/cytoplasm ratio numerous mitotic figures & abnormal mitoses

  • Gross Types of CarcinomaPapillaryNodularUlcerativeCysticMultipleDiffuseStricture

  • Two TermsMetaplasia---- the replacement of one fully differentiated tissue by anotherCarcinoma in situthe histological abnormalities are sufficiently severe to suggest carcinoma , but in the absence of basement membrane invasion

  • Effects of MalignancyTumor arising within a hollow viscusobstruction Tumor arising from surface of organulceration and bleeding

  • Spread of Malignant TumorsDirect invasion--- Rectal cancerLymphatic system to local lymph nodes-- Breast carcinoma, Gastric cancerBloodstream to distant organs-- Liver, lung & brainAcross body cavities-- Ovarian carcinoma

  • Lymphatic Spread of Gastric Cancer

  • DiagnosisHistory

    Physical Examination

    Laboratory Tests

    Specific Procedures

  • Symptoms or Signs of Cancer

    Alteration in eating habitLoss of appetiteProblems in swallowingChange in bowel habitThe presence of a lump at any site

  • Symptoms or Signs of Cancer

    The appearance of bleedingUnexplained recurrent painRecurrent feversUnexplained weight lossRepeated infections which do not clear with treatment

  • Breast Cancer

  • Para-neoplastic SyndromeSmall cell carcinomas secret ACTHCushings syndrome Renal carcinomas secret erythropoitinpolycythaemiaMucin-secreting adenomas increasing the coagulability thromboembolism

  • The Diagnostic Procedures of CancerHistoryFamily History Individual HabitsSocial History OccupationMarital & Sex HistoryPast History

  • The Diagnostic Procedures of CancerPhysical ExaminationSystemicLocal TumorMetastatic foci

  • The Diagnostic Procedures of CancerSpecial Procedures Diagnostic RadiologyChest X-raysBarium enema radiographyGastro-intestinal series radiographyArteriographyComputerized tomography(CT)Radioisotope scanning techniquesMammographyPositron emission tomography(PET)

  • The Diagnostic Procedures of CancerSpecial ProceduresUltrasonic examinationEndoscopyCytologyBiopsybone-marrow biopsyneedle biopsyendoscopic biopsyMagnetic resonance imagine(MRI)

  • The Diagnostic Procedures of CancerLab Test Routine test: blood, urine, stool Serum test:enzyme, hormoneglycoprotein, tumor markers Immunology test:AFP, CEA, tumor-related antigens Flow-cytometry(FCM):DNA ploidyDNA index Gene Test: Oncogenes, DNA repair gensTumor suppressor genes

  • Tools For Early Clinical Detection Complete physical examination Regular mammography and breast self exam Haemoccult for occult blood in feces Urine analysis and blood count A complete clinical history An in-depth family medical history

  • Cachexia

  • Tumor MarkersTumor markerExamplesTumor antigensAFP, CEAEnzymesPSAHormones-HCGOncogenesRas, c-myc,P53Tumor associated antigensCA 19-9,CA-242

  • MSCT Metastatic LN

  • Endoscopic Ultrasonography

  • TNM stagingT--- primary tumorN--- regional lymph nodeM--- metastases

  • The Principles of Cancer Surgery

  • Loebs Rules of Therapeutics If what you are doing is doing good, keep doing it. If what you are doing is not doing good, stop doing it. If you do not know what to do, doing nothing. Never make the treatment worse than the disease.

  • Oncology Multidisciplinary Team Surgical oncologists Radiation oncologists Medical oncologists Palliative care specialists Psychologists Social workers Nurses Chaplains

  • Landmark advances in Surgical OncologyYearEventSurgeon1809Elective oophorectomyP. Pott1846Ether as anesthesiaJ. C.Warren1867Carbolic acid as antisepsisJoseph. Lister1873LaryngectomyA. T. Billroth1878Resection of rectal tumorR.von Volkman1881GastrectomyA. T. Billroth1890Radical mastectomyW.S. Halstead1908Abdominoperineal resectionW. E. Miles1909Thyroid SurgeryT. M. Kocher1935PancreaticoduodenectomyA.O.Whipple

  • Surgical Oncology Preventive surgery Diagnostic surgery Resection biopsy Sample biopsy Laparotomy

  • Surgical Oncology Radical operation Lumpectomy Extended resection Radical or Extended radical operation

  • Surgical Oncology Palliative Surgery Palliative resection Bypass or Ostomy Endocrine glands resection Cytoreductive surgery

  • Surgical Oncology Surgery for recurrence or metastasis Reconstruction and recovery Surgical oncology technique non-cutting en-bloc non-touching

  • The Principles of Cancer Surgery Staging Clinical staging Imaging--preoperative Fine needle aspiration--preoperative Intra-operative imaging Intra-operative pathology Resection specimen

  • Key Points of Cancer Surgery Combined treatment modalities Preoperative chemotherapy--breast Postoperative chemotherapy--breast, colon Preoperative radiotherapy--rectum Postoperative radiotherapy--lung, breast, rectum

  • Cancer Treatment are Based Upon the biological behavior of the cancer the mortality and morbidity of therapeutic procedures the efficacy of the therapeutic procedure the performance status of the patient

  • Cancer Treatment are Based Upon with localized cancers are curable presenting with positive Lymph Nodes tend to bad outcome with distant metastases are rarely curable the most commonly parameters to measure survival and