Transcript Principles of Surgical Oncology

Principles of Surgical
Oncology
Dr. Khdair Al-Rawaq
Lec Highlight
• Definitions
• The history of surgical oncology
• The role of surgery in management of cancer,
including :
1.
Prevention
2.
3.
4.
5.
6.
Screening
Diagnosis
Treatment
Rehabilitation
Palliative care
• Future of Surgical Oncology
Definitions
• Surgical oncology, It is refered to the specific
application of surgical principles to the oncologic
setting. These principles have been derived by
adapting standard surgical approaches to the unique
situations that arise when treating cancer patients.
• The surgeon is often the first specialist to see the
patient with a solid malignancy, and, in the course of
therapy, he or she may be called upon to provide
diagnostic, therapeutic, palliative, and supportive
care. In each of these areas, guiding paradigms that
are unique to surgical oncology are employed.
Definitions
• A surgical oncologist is a well-qualified
surgeon who has obtained additional training
and experience in the multidisciplinary
approach to the prevention, diagnosis,
treatment, and rehabilitation of cancer
patients, and devotes a major portion of his
or her professional practice to these activities
and cancer research.”
Ancient History of Surgery for Cancer
Treatment
• 1600 BC First recorded description of the
surgical treatment of cancer (in Egypt)
• 400 BC Hippocratesdescribes the stages of
cancer and advises against surgery for
terminal disease; he coins the terms
“carcinoma”(crab-leg tumor) and
“sarcoma”(fleshy tumor)
• 200 AD Galenidentifies cancer as a systemic
disease (primary and metastasis)
Ancient History of Surgery for Cancer
Treatment
• Before 1850 Early heroic attempts to resect
cancer
• 1850-1950 Development of standard surgical
resection techniques
• 1950-1960 Development of extended radical
surgical procedures
Historical Eras of Surgery to
Treat Cancer
• 1960-1980 Exploration of combined-modality
treatment
• 1980-2000 Multimodality therapy improves
organ preservation and survival
• 2000-present Surgical practice incorporates
improved understanding of the molecular
basis of
Landmark Advances in Surgical
Oncology
• 1775 Etiologic basis of cancer Percival Pott
• 1809 Elective oophorectomy
Ephraim McDowell
• 1829 Metastatic process
Joseph Recamier
• 1846 Ether used as anesthesia
John Collins Warren
• 1867
Carbolic acid used as antisepsis
Joseph Lister
• 1873 Laryngectomy
Albert Theodore Billroth
Landmark Advances in Surgical
Oncology
• 1878 Resection of rectal tumor Richard von
Volkman
• 1880 Esophagectomy Albert Theodore
Billroth
• 1881 Gastrectomy Albert Theodore Billroth
• 1890 Radical mastectomy William Stewart
Halstead
• 1896 {Oophorectomy for breast cancer}
G. T. Beatson
Landmark Advances in Surgical
Oncology
• 1904 Radical prostatectomy
Hugh H. Young
• 1906 Radical hysterectomy Ernest Wertheim
• 1908 Abdominoperineal resection
W. Ernest Miles
• 1909 Nobel prize for thyroid surgery
Theodore Emil Kocher
• 1910 Craniotomy
Harvey Cushing
Landmark Advances in Surgical
Oncology
• 1912 Cordotomyfor the treatment of pain
E. Martin
• 1913 Thoracic esophagectomy
Franz Torek
• 1927 Resection of pulmonary metastases
George Divis
• 1933 Pneumonectomy
Evarts Graham
• 1935 Pancreaticoduodenectomy
Allen O. Whipple
Landmark Advances in Surgical
Oncology
• 1945 Adrenalectomy for prostate cancer
Charles B. Huggins
• 1957 Isolated limb perfusion
Oliver Creech
• 1958 First multicenter clinical trial
Bernard Fisher
• 1965 Hormone therapy for cancer
Charles Huggins
• 1971 Microvascular free-tissue transfer
Harry Buncke
Surgery for
Cancer Prevention
Role of Surgery in Cancer Prevention
• Pre-cancerous lesions
– Leukoplakia of the tongue
– Thyroid gland in MENS II
– Colon in FAP
• •Organs at high risk of malignancy even
where a pre-cancerous lesion has not been
identified
– Breast in cariers of deleterious BRCA mutations
– Colon in HNPCC
Surgery for
Cancer Screening
Role of Surgery in Cancer Screening
•Colonoscopy in colon cancer
•Digital rectal examination in prostate cancer
•Clinical breast examination
Surgery for
Diagnosis
Role of Surgery in Diagnosis
History
•
•
•
•
•
•
•
•
•
Ascertain presence of risk factors
Evidence of metastases
Presence of co-morbid factors
Family and social history
Psychological assessment of patient
Ascertain patient’s social and economic resources
Ascertain patient’s expectation from therapy
Patient’s treatment preferences
Educate patient on diagnosis, treatment and follow-up,
and correct mis-information
Role of Surgery in Diagnosis
Investigations
•Knowledge of all available modalities of
investigating particular case
•Microscopic diagnosis is compulsory
Biopsy
Surgeon’s responsibilities:
•Selection of appropriate biopsy method and
site
•Responsible that the tissue reach the
pathologist timely and properly .
•Communicate the results to the patient,
family, other physicians
•Provide initial prognosis and information on
follow-up care
Types of Biopsy Methods
•Transcutaneous
•Image-directed (with fine-needle aspiration or
cutting needle)
–Ultrasonography
–Computerized tomography
–Magnetic resonance imaging
•Open incisional (A portion of the tumor)
•Open excisional (All tumor mass removed)
Types of tissue Biopsy
1. Lymph node biopsy
• lymphoma
• metastatic carcinoma.
2. Biopsy of a tissue-based mass
• Lymphoma
• The goal of biopsy in the patient with an abnormal lymph
node and suspected lymphoma is to make the general
diagnosis and to establish the lymphoma type and subtype.
Additional analyses of the cells in the node, its internal
architecture, and the subpopulations of cells are critical for
subsequent treatment.
• Diagnosis of lymphoma should be made on a completely
excised node that has been minimally manipulated
• The use of needle aspiration does not consistently allow
for the complete analyses. Eg. RS cell
• can be performed as needed.
• Carcinoma
• The diagnosis of metastatic carcinoma often requires less
tissue than is needed for lymphoma. Fine-needle
aspiration (FNA), core biopsy, or subtotal removal of a
single node will be adequate in this situation.
• For metastatic disease, the surgeon will use a
combination of factors, such as location of the node,
physical examination, and symptoms, to predict the site of
primary disease. When this information is communicated
to the pathologist, the pathologic evaluation can be
focused on the most likely sites so as to obtain the highest
diagnostic yield. The use of immunocytochemical analyses
can be successful in defining the primary site, even on
small amounts of tissue.
Sentinel node biopsy
• Technique
• The node or nodes that preferentially drain a
particular primary tumor”basins” are identified by
mapping and then surgically excised.
• The mapping agents include radiolabeled materials
and vital dyes that are specifically taken up by, and
transported in, the lymphatic drainage systems. These
mapping and localizing agents, used alone or in
combination, are critical in defining the unique flow
patterns to specific lymph node(s) and ambiguous
drainage patterns (eg, a truncal melanoma that may
drain to the axilla, supraclavicular, or inguinal spaces).
Biopsy of a tissue-based mass
– Several principles must be considered
• Mass in the aerodigestive tract In the aerodigestive tract, biopsy of
a lesion should include a representative amount of tissue taken
preferably from the periphery of the lesion, where the maximum
amount of viable malignant cells will be present. Because the
treatment of in situ and invasive diseases varies greatly, the biopsy
must be of adequate depth to determine penetration of the
tumors. This is particularly true for carcinomas of the oral cavity,
pharynx, and larynx.
• Mass in the trunk or extremities For soft-tissue or bony masses of
the trunk or extremities, the biopsy technique should be selected
on the basis of the planned subsequent tumor resection. The
incision should be made along anatomic lines in the trunk or along
the long axis of the extremity. When a sarcoma is suspected, FNA
can establish the diagnosis of malignancy, but a core biopsy will
likely be required to determine the histologic type and plan
neoadjuvant therapy.
• Breast mass
Although previously a common procedure, an open surgical
biopsy of the breast is rarely indicated today
• A core biopsy/FNA, performed either under image guidance
(ultrasonography or mammography) or directly for palpable
lesions, is the method of choice.
• The core biopsy method establishes the histologic diagnosis,
provides adequate tissue for analyses of hormone-receptor
levels and other risk factors, causes little or no cosmetic
damage, does not perturb sentinel node analyses, and does
not require extended healing prior to the initiation of therapy.
In addition, a small radioopaque clip can be placed in the
tumor to guide the surgical extirpation.
•
Surgeon’s Tasks in Performing Biopsy
•Orient the specimen
•Ensure the integrity of the tissue plane
•Ensure the adequacy of the tissue sample
•Be sure tissue reach the pathologist !
Appropriate Open
Biopsy
•Scar is parallel to the
long axis of the
extremity
•Tissue planes and
compartments are
intact
•En bloc resection will
be easy to accomplish
•Biopsy is only the first
step
Surgery and Staging
•Classifies patients according to the degree of
spread of cancer in order
•Guide selection of primary and adjuvant
treatment
•Estimate prognosis
•Assist in evaluating result of treatment
•Facilitate exchange of information
•Contribute to continuing investigation of cancers
Types of staging
•
•
•
•
TNM
AJCC
FIGO
Duke
most common
head & neck
Gyenicological Malig.
GIT
Surgery for
Cancer Treatment
Role of Surgery in Cancer Care
•Surgery
Zero-order kinetics—100% of cells at risk are killed
with a single treatment
•Radiotherapy/Chemotherapy
First-order kinetics—only a portion of cells at risk
are killed during treatment, which is followed by
regrowth
Preoperative Assessment and
Preparation
•Surgeon’s responsibility to assess the risk-tobenefit ratio and identify and correct
underlying, relevanthealth problems .
–Nutritional status
–Co-morbid medical conditions
–Hypertension
–Diabetes
–Congestive heart failure
–Liver or renal insufficiency
–Immunosuppresion
Types of surgery
•Local resection
•Radical resection with en-bloc resection of
lymph nodes
•Supra-radical resections
•Surgery for metastasis
•Surgical management of complications
•Vascular access surgery
Treatment
Principles of surgical resection of tumor
•Adequate margin of resection
•Prevention of tumor spillage
•Minimal manipulation
•Reconstruction
Metastasectomy
This is done when:
•The primary tumor is controlled or can be
controlled
•Metastasis is single or where multiple is localized
•Evidence that metastasectomy is associated
clinical benefits
•Tumor doubling time is sufficiently long
•No significant co-morbid factor
Surgery
and Rehabilitation
Role of surgery in the rehabilitation of
cancer patients
•Restoration of form
•Restoration of function
•Care of ostomies
•Psychological treatment and support
•Maintenance and improvement of quality of
life.
Surgery
and Palliative care
Goals of Palliative Surgery
•Relieve symptoms for patients beyond cure when
non-surgical measures are not feasible, not
effective, or not expedient
•Palliation means patient should be better at the
completion of the procedure
“It is axiomatic that one cannot palliatively
improve an asymptomatic patient using a
scalpel.”
R. G. Martin, 1982
Palliative Improvement of Function
and quality of life
•Adequate control of pain
•Relief gastrointestinal and biliary obstruction
•Stop hemorrhage
•Supplement poor nutrition
•Airway obstruction
•Renal failure
•Rectal or urinary incontinence
Factors that influence outcome of
treatment
1. •Patient related factors
2. •Health care provider related factors
3. •Environment related factors
Surgical Oncology in the Future
•Preemptive surgery in populations at genetic risk
for the development of cancer
•Tissue and function
-preserving improvements
–Minimally invasive and robotic surgery
–Implantable monitors
–Treatment sensitizers
–Tissue-engineered, implantable “spare parts”
•Refinements in surgical practice will be driven by
the underlying molecular basis of tumor biology