Principles of
Surgical Oncology
M K ALAM
PROFESSOR OF SURGRY
College of Medicine
Al Maarefa University
ILOs
Outline- the pathogenesis of malignant diseases.
Describe general features , diagnostic methods,
staging & screening of malignant diseases.
The multi-modal approach of management.
Introduction
• Neoplasms: a “mass of transformed cells” that
does not respond in a normal way to growth regulatory system.
o No useful function.
o Atypical & uncontrolled growth.
o Genomic abnormality:
Increased cell replication
or
Inhibit cell death (apoptosis).
• Normal cells: Balanced replication & cell death.
Incidence
• 2nd most common cause of death( cardiovascular disease 1 ) – UK
st
• Lung cancer – most common cause of death
• Breast cancer- most common cause of death in female
• GIT cancer- next most common
Pathogenesis
Multifactorial, complex mechanisms & influenced by:
• Inherited genetic makeup. (FAP)
• Environment factors- BCC, melanoma
• Radiation exposure - skin tumors, leukaemia
• Carcinogens -bladder carcinoma, mesothelioma.
• Viral infection- HCC (HBV), cervical carcinoma (HPV), Kaposi’s sarcoma, B-cell
lymphoma (HIV), nasopharyngeal carcinoma, Burkitt’s lymphoma (EBV)
• Diet.(Aflatoxins- ca-esophagus, smoked foods- gastric carcinoma)
• Hormonal imbalances-HRT
• Life style.
Mechanism of gene mutation
• DNA mutation (spontaneous/ aetiological factors) → cancer.
• Carcinogenesis- multistep process
• Mutation leads to- disruption of cell replication cycle either
by:
o Activation or overexpression of oncogenes.
o Inactivation of tumor suppressor gene
• Unregulated expression of genes in certain tumour produce proteins
used as tumour markers- CEA, alpha-fetoprotein
Natural protective mechanisms
• Repair error in DNA replication
• Immune surveillance
• Wastage of cells from surface
• Apoptosis
Neoplasms: Benign or Malignant
• Malignant cells- invasive & metastasize
• Malignant genotype develops as result of progressive
acquisition of cancer mutation (chromosomal loss or translocation).
• Progressive accumulation of mutation give rise to cancer
stem cell (Pluripotent)
• Pluripotent cells- give rise to different type of cells- epithelial,
vascular, structural cells
• Concept of progression from benign to malignant-
rationale behind screening & early detection plan
Features of malignancy
• Malignant tumors:
- Invade
- Metastasize (autonomous tumour deposits).
• Dependent on biology of the tumor.
• Metastasis – further mutation in cancer cell occur.
Metastasis
Mechanism: complex & unclear.
• Local pressure effects from expanding tumors
• Loss of adhesion
• Increased motility of cancer cells
• Secretion of multiple factors
• Embolization of cancer cells
• Survival of metastatic deposits – local angiogenesis
Routes of metastasis
• Direct invasion
• Haematogenous- liver, lung
• Lymphatic- Troisier’s
• Transcelomic spread- Sister Joseph’s nodule,
Krukenberg’s tumours, peritoneal deposits
METASTASIS
Sister Joseph’s nodule
Natural history
• 3/4th of tumor life span- pre-clinical or occult.
• Carcinoma in situ (pre-invasive) → early invasive
→ advanced invasive → metastatic.
Cure in Malignancy
• A rigid definition: Every malignant cell eradicated, no
recurrence during patient’s life time & no residual tumor
at death - rarely attainable
• A practical definition: normal duration of life without
further clinical evidence of disease
Goals of Management of malignant diseases
• Prevention: Smoking, sunlight, chemoprevention
• Screening: Early detection for cure.
-Targeted at risk groups. * Cervical cytology,
mammography,
* CRC(FOB, sigmoidoscopy/colonoscopy), PSA
* Inherited cancers- BRCA 1, BRCA 2
• Cure
• Palliation
Presentation of malignant diseases
Symptomatic patients:
• Swellings: Painless, irregular, firm or hard.
• Anemia: Chronic blood loss from GI tumors.
• Obstruction of hollow tubes: Dysphagia, bowel
obstruction, jaundice, hydronephrosis.
• Metastasis: Lymphadenopathy, hepatomegaly, ascites, pleural
effusion, pathological fracture.
Asymptomatic patients: Discovered during routine checkup.
Management of malignant diseases
• Multidisciplinary team approach:
More efficient
Complete care
• Surgeon- diagnosis, staging, removal of tumour.
• Oncologist- radiotherapy, chemotherapy.
• Radiologist.
• Pathologist.
• Specialist nurse.
Diagnosis of malignant diseases
• History:
Wt. loss,
Bleeding GI/urinary),
Lump,
Obstruction-dysphagia, bowel obstruction
Persistent non-specific symptoms.
• Examination:
Primary lesion,
Local spread,
Metastasis.
Investigations
• Blood tests: Hematology, biochemistry, tumor markers-
(α-fetoprotein, CEA, CA 125, PSA, CA 15-3,CA 19-9).
• Radiology: Plain x-rays, contrast studies, US, CT, MRI, PET scan.
• Endoscopy: Upper GI, lower GI, ERCP.
• Cytology/histology: FNA, core biopsy, excision/ incision biopsy,
endoscopic brushings, radiology guided FNA.
• Staging investigations
• Operative: EUA & biopsy, Lymph node excision biopsy, SLNB
diagnostic laparoscopy & biopsy
Tumor staging
• Purpose of staging:
o Define extent of disease.
o Development of treatment plan.
o Assess likely prognosis.
• Investigations for staging:
CT, MRI, PET scan, endoscopic ultrasound,
bone scans, laparoscopy
Tumor staging- TNM
• Tumor:
• T0- primary unknown, Tis- tumor in-situ
• T1- < 2cm tumor, T2- > 2cm tumor,
• T3- > 5cm or reaching serosa (GI tumors)
• T4- infiltrating into surrounding tissues.
• Nodes:
• N0- not involved
• N1- local nodes involved
• N2- distant nodes involved (fixed nodes- breast, N3- distant nodes involved)
• Metastasis:
• M0- no metastasis.
• M1- metastasis present.
• Mx- status unknown
Tumor Grading (Histological)
• Grade 1: Well differentiated- recognizable structures of
parent tissue
• Grade 2: Moderately differentiated- some degree of
organization
• Grade 3: Poorly differentiated- Architecture totally
disorganized, cells not recognizable from parent tissue
Principles of surgical treatment
• Benign: Complete excision with sufficient surrounding tissue.
• Malignant: multidisciplinary team discussion before/after surgery.
-Radical surgery: Complete removal of tumor bearing
tissue together with margin of unaffected tissue
-En bloc resection: removal of tumour with loco-regional
lymph nodes.
-Sentinel lymph node biopsy (SLNB): Carcinoma breast
ADJUVANT THERAPY
• Accurate staging- histopathological examination of resected tumor.
• Multidisciplinary team discussion.
• Chemotherapy/ radiotherapy/ hormone/ combinations
• Aim: Local and systemic disease control.
Chemotherapy
• Helps control local (residual) & systemic disease.
• Adjuvant: given after surgery
• Neoadjuvant: before surgery to downstage
• Success varies in different types of cancer.
• Chemotherapy is toxic.
• Affects quality of life.
• Benefits, morbidity & quality of life must be balanced.
Radiotherapy
• Post-operative: Local control
(incompletely removed tumor, close margin resection)
• Neoadjuvant: before surgery to downstage, or shrink a
bulky and fixed tumors ( rectum)
• Part of radical treatment: to improve cosmetic result in
radiosensitive tumors ( breast- lumpectomy vs mastectomy)
Other forms of adjuvant therapy
• Hormone therapy: Anti-oestrogen- Tamoxifen,
Orchiectomy (prostate cancer)
• Immunotherapy: Monoclonal antibodies –
Herceptin in breast carcinoma.
• Gene therapy: Restore function of tumor
suppressor gene.
Management of advanced malignant diseases
• Surgery for metastasis: colorectal liver metastasis.
Improved 5- year survival- 40%.
• Palliative surgery: relief of distressing symptoms.
• Chemotherapy, radiotherapy, pain relief,
psychological & social aspect management.
• Care of dying: palliative team, hospice care
Regular follow-up
• Local recurrence- History, examination, investigations-
tumor markers, radiology, endoscopy.
• Metastasis.
• Symptom relief.
• Seen more frequently in early months after surgery.
• Interval increased later.
Thank you!
