SURGICAL ONCOLOGY

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SURGICAL ONCOLOGY

• James Taclin C. Banez, MD, FPSGS, FPCS

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• Study of neoplastic diseases
• ONCOS tumor LOGOS study
• 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 tissue.

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Neoplasm

• Malignant
• Cancer cells that exhibit uncontrolled
  proliferation and impair the function of normal
  organs by local tissue invasion and metastatic
  spread to distant anatomic sites.
• Benign
• Composed of normal appearing cells that do not
  invade locally or metastasize to other sites

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EPIDEMIOLOGY

• Overall cancer death rates shows slow steady
  increase
• Lower death rates during past 50yrs
• Stomach
• Uterus
• Increase death ratea
• Lung
• pancreas

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EPIDEMIOLOGY

• Cancer incidence by sites and sex

Male Male Female 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
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EPIDEMIOLOGY

• Cancer death by sites and sex

Male Male Female 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
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• The most significant 5 yrs survival rates are
  achieved in patients w/ cancer of skin, cervix,
  uterus and bladder w/ the lowest survival w/
  pancreatic cancer
• Females tend to have a greater number of 5yrs
  survival w/ cancer of any given primary site than
  males, reason (?)
• 5 yr survival female 50
• 5 yr survival male 31

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ETIOLOGY

• Chemical carcinogens
• Hydrocarbons from coal tar skin, larynx
  bronchial CA
• Aromatic amines urinary tract CA
• Benzene leukemia
• Asbestos mesothelioma
• Physical carcinogens
• Ionizing radiations bone cancer
• Multiple x-rays skin/thyroid CA
• Atomic bomb (Japan) leukemia

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ETIOLOGY

• Mechanical (chronic irritation)
• Marjolins ulcer burn scar cancer
• Infection
• Parasitic
• Schistosomas Liver bladder CA
• Viruses
• Hepatitis B hepatocellular CA
• Epstein-Barr virus Burkitts lymphoma
• Herpes simplex virus 2 cervical CA
• Aids

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ETIOLOGY

• Hereditary factors
• Familial polyposis colonic CA
• Breast CA 2-3x in daughters and in younger age
• Geographic factors
• Inc. CA of stomach Scandinavian,
• Iceland and Japan
• Inc. CA of liver South West Africa
• Inc. CA of Nasopharynx China
• Inc. CA of urinary bladder Egypt
• Dec. CA of colon Black/Africa
• Dec. CA prostate / breast Japan
• Dec. CA of uterine/cervix Israel/Jewish
• Dec. CA of skin Blacks
• Customs environment plays an important role in
  the development of CA.
• Migration of populations usually causes a shift
  towards the patterns of cancer incidence of the
  host country

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ETIOLOGY

• Precancerous conditions
• Leuplakia
• Actinic keratosis
• Polyps of colon rectum
• Neurofibromas
• Dysplasia of cervix, bronchial
• Chronic ulcerative colitis

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ETIOLOGY

• Oncogenes Growth Factors
• RNA tumor viruses cause
• Carcinomas
• Sarcoma
• Leukemia
• Lymphomas
• Retrovirus have an enzyme that alters the viral
  genomic RNA resulting to abnormal growth and
  differentiation of the cell.
• Multi-factorial
• Lung / breast CA

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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 w/o definite pattern
• High index of mitoses
• Invasion of adjacent sturctures

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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)
• Also produced biologically active subs. Normally
  produced by the cells. (hyperparathyroidism)
  also that are not normally produced by the cells
  of origin (bronchogenic CAACTH)

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CANCER BIOLOGY

• Growth rates of neoplasm
• Doubling time is doubled
• Takes 30 doubling time to produce 1cm nodule

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CANCER BIOLOGY

• Effector mechanism in tumor immunity
• Host provides a number of effector mechs. That
  destroys the tumor
• Tumor-antigen-specific antibodies
• Mononuclear phagocytes
• Natural killer cells
• Cytotoxic T lymphocytes
• Neutrophils
• K cells

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CANCER BIOLOGY

• Effector mechanism in tumor immunity
• Tumor Necrosis Factor (TNF)
• Cytokines produced by monocytes, machrophage,
  endothelial cells, large granular lymphocytes and
  neutrophils
• Properties
• Direct cytotoxicity for certain cells
• Stimulation of procoagulant activity by vascular
  endothelial cells
• Induction of fever by direct effect on the
  hypothalamic thermoregulatory center

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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).

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CANCER PATHOLOGY

• Grading of malignancy
• Broders classified carcinoma into 4 grades
  according to
• Degree of differentiation
• Appearance of cells, their nuclei and the number
  of mitotic figures
• Grade I least malignant
• Grade IV most malignant
• Carcinoma in Situ
• Has cytologic characteristic of malignant tumors
  but w/ no detectable invasion into the
  surrounding tissue or infiltration into deeper
  cell layers

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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
  (except for basal cell CA)
• Vascular spread
• Either thru 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)

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CLINICAL MANIFESTATION

• The onset of neoplastic state is difficult to
  date (asymptomatic).
• Seven Danger Signals of Cancer (Direct
  manifestation)
• 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 or mole
• Nagging cough or hoarseness

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CLINICAL MANIFESTATION

• Indirect or Systemic Manifestation
• Secondary to metastasis
• Cachexia
• Secondary to none metastatic
• Ectopic production of known hormones
• Secretion of unidentified, hormone like
  substances
• Toxic substances secreted from the tumor
• Autoimmune host is sensitized to an antigen
  from the tumor

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CLINICAL MANIFESTATION

• Signs of Expansile growth
• Obstruction
• Destruction
• Signs of Infiltrative Growth
• Tumor infiltrates the nerves
• Pain
• Numbness
• paralysis

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CLINICAL MANIFESTATION

• Signs of Tumor necrosis (Bleeding Infection)
• Tumor may become necrotic, ulcerate and bleed
• Fatigue and weakness in right colon cancer due to
  anemia
• Inflammation caused by cecal CA can mimic the
  clinical symptoms of acute AP or cholecystitis.
• Unknown primary tumors prsenting as metastases

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DIAGNOSIS OF CANCER

• Clinical History
• Warning signs for Cancer
• Weight loss
• Loss of Appetite
• Bleeding or a discharge from any body orifice or
  nipple
• Sore that is slow to heal
• Persistent cough or wheeze
• Change in voice
• Difficulty of swallowing
• Change in bowel habit
• Growing lump in the skin, breast, abdomen or
  muscle

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DIAGNOSIS OF CANCER

• Physical Examination
• Palpable masses (movable, non-movable)
• LN enlargement
• Laboratory Examination
• Blood examination
• Radiological procedure
• X-ray, esophagoram, Barium enema, mammography,
  thyroid scan, CT scan, MRI

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DIAGNOSIS OF CANCER

• Laboratory Examination
• 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)

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STAGING OF CANCER

• Clinical Staging of Cancer
• TNM
• Stage I cancer confined to its primary site
• Stage II more locally advanced disease
• Stage III metastasis to regional LN
• Stage IV metastasis to distant sites
• Use all information available prior to 1st
  definitive treatment

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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 1st diagnosed at
  autopsy.

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CANCER TREATMENT

• Interdisciplinary Approach
• Surgical resection 55 (40 alone)
• Radiation therapy 34 (16 alone)
• Chemotherapy 22 (alone or combination)
• Surgery radiation tx represents treatment of
  cancers that remains localized to its primary
  site or regional LN.
• Chemotherapy and Immunotherapy tx effective
  against tumor cells already metastatic to distant
  organ sites.

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CANCER TREATMENT

• GOALS of Therapy
• Vary w/ extent of the cancer
• Localized w/o evidence of spread
• Eradicate the cancer and cure THE PATIENT
• Spread beyond the local site
• Control patients symptoms and to maintain
  maximum activity for the longest possible period
  of time.

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CANCER TREATMENT

• CRITERIA of Incurability
• Distant metastasis (most common)
• Evidence of extensive local infiltration of
  adjacent organs or structures
• Pts general condition and the presence of any
  coecisteing disease must be considered in
  planning therapy.
• The PSYCHOLOGICAL makeup of the patient and the
  patients life situation must be considered.

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CANCER TREATMENT

• SURGICAL RESECTION
• Surgical Curative Resection
• Wide local resection
• Low grade malignancy
• Basal cell CA of the skin
• Radical Local Resection
• High grade malignancy
• En Bloc LN dissection for breast, esophagus,
  gastric, colorectal CA
• Surgical Palliative Resection
• To relieve symptoms
• To prolong a useful comfortable life
• Gastrojejunostomy, colostomy

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CANCER TREATMENT

• RADIOTHERAPY
• Destroy tumor with preservation of anatomic
  structures
• Direct toxic effect to cells due to ionization of
  water

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CANCER TREATMENT

• CHEMOTHERAPY
• Antimetabolites
• Inhibit enzymes of nucleic acid synthesis
• Methotrexate 5-FU
• Alkylating agents
• Substitute alkyl grp for the hydrogen atom
• Alkylation of DNA molecule interferes with
  replication in transcription

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CANCER TREATMENT

• CHEMOTHERAPY
• 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

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CANCER TREATMENT

• IMMUNOTHERAPY
• Inhibit proliferation of cancer cells w/o
  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 immunotherapyBCG vaccine

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PROGNOSIS

• DETERMINANTS
• Site of origin of primary tumor
• Stage of the disease
• Histologic features of the cancer
• Host immune factors
• Age of the patients