Principles of Cancer Management20022013b.

7/30/2019 Principles of Cancer Management20022013b.

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Principles of management ofPrinciples of management of

cancer patientcancer patientDr Bashiru Aminu

Moderator:Dr Mai


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IntroductionKey wordsMolecular basis of cancer

Principles-diagnosis

-extent of disease

-counsel patient

-informed consent

-selection of treatment

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Preparation for treatment Deliver treatment Management of complications

Rehabilitation Follow up Recent trends

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Surgical mgt. of cancer remains a challenge to thesurgeon

It is assoc. with high morbidity, & mortality

Illiteracy further compounds difficulty in mgt Most patients present late Mgt is expensive to patient & GOVT Consumes large man hours of the surgical team

introductionintroduction


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Key wordsNeoplasm-abnormal mass of cells growth of whichexceeds, & uncoordinated with normal tissues,

persists in same excessive manner with removal ofstimuliNomenclature-benign or malignant

-transformed cells

-carcinoma-epithelial-sarcoma-mesenchymal

introductionintroduction


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Hypertrophy- increased organ growth due to an increasein size of its constituent cells

Hyperplasia-increased organ growth due to an increasein cell number

Metaplasia-replacement by cell type not normally presentin an organ Adjuvant chemotherapy refers to chemotherapy

administered postoperatively to treat presumed micrometastases.

Neoadjuvant chemotherapy refers to chemotherapyadministered before surgical resection of the primarytumor.

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Differentiation extent to which tumour cellresembles normal comparable cells

Lack of differentiation is anaplasia Displasia refers to disorderly but non neoplastic

growth Metastasis -tumour implant discontinuous with

primary tumour

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How far to place the resection away from thevisible growth resection margin

Tumour progression step wise acquisition of

malignant attributes Cure- a normal duration of life without furtherevidence of disease

Cure rate assessed by survival rates at different

times after treatment

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Molecular basis of cancerMolecular basis of cancer


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Haematogenous tumour spreadHaematogenous tumour spread


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History-evaluate pt, properly direct mgt(afterresuscitation)

Complaint

Course of illness Cause of illness Complications Current treatment received

Establish a diagnosisEstablish a diagnosis


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Age Risk increases with age except childhoodmalignancy

Sex Common in males 60



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Site of origin Breast common women, thyriod commoner inmales

Upper git & respiratory tract much more commonerin males



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Complaint Lump, ulcer, haematuria, weight loss dysphagia,

change in voice, jaundice, change in bowel movt

Course of illness Cause/aetiology-family hx, alcohol consumption-

gastric cancer & PLCC, smoking- lung cancer



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Age at marriage, first child, breast feeding What rx has PT received-mastectomy with residual

tumour, prostatectomy for BPH with cancersubsequently, radiotherapy with resulting sarcoma

Other hx also relevant erectile dysfunctionprospective prostatic procedure, hope of havingmore children affecting RX options



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Classifies dx into early and late Directs line of mgt-cure and palliative Prognosis

Influences outcome

Extent of dxExtent of dx


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Responsibility of surgeonprovide them with

-complete clinical hx

-indication of request

-however special handling should be

understood by all parties

-no room for misinterpretation due to

poor communication


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Skin carcinomaSkin carcinoma


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Prostatic cancerProstatic cancer


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Breast cancerBreast cancer


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Tell pt the diagnosis Available treatment options generally Available options locally

What is best for the pt at that time

Counsel ptCounsel pt


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Allow pt to choose Informed consent Documented

Best for the patient

Informed consentInformed consent


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Baseline investigation Optimise pt Chest physiotherapy

Breathing exersises Nasogastric and other tubes Nil per os

Preparation for treatmentPreparation for treatment


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Adequate Appropriate Multimodal

Optimal Uncompromised-not what is available

Deliver TreatmentDeliver Treatment


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The aim of surgical management is either curativeor palliative.

Those with obvious widespread tumours shouldnot be treated by a surgical effort to achieve cure;

a lesser procedure may be performed (e.g. bypassof a gastrointestinal tumour) to relieve distressingsymptoms such as pain or gastrointestinalobstruction.

Referral for non-surgical treatment or for palliativecare is then appropriate

Aim of surgeryAim of surgery


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1. early diagnosis & prevention

2. diagnosis & staging

3. surgery as primary therapy

4. surgery combined with other therapies5. surgery as salvage therapy

6. surgical procedures for specialized care

7. surgery for reconstruction

8. surgery for metastatic disease

9. surgery for palliation

Management optionsManagement options


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Early diagnosis & treatment Role in virtually all cancer Development of effective screening methods

Recognition of premalignant, preinvasiveconditions important Optimal mgt requires undividualization of RX Sentinel lymph node biopsy in breast ca

Management optionsManagement options


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Usually rx of choice for preinvasive dx Local excision is both diagnostic & curative Surgical margin shld clear only gross &

microscopic DX Removal of large areas of normal tissue notrequired

Surgery as primary therapySurgery as primary therapy


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the surgical margin must be appropriately defined. important when evaluating surgical procedures

and outcomes

one of four termsintralesional, marginal, wide, orradical.



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intralesional margin is one in which the plane of surgicaldissection is within the tumor.

-This type of procedure is often described as"debulking"

-it leaves behind gross residual tumor.- may be appropriate for symptomatic benign lesions

when only alternative is to sacrifice important anatomicalstructures

-This also may be appropriate as a palliative procedurein the setting of metastatic disease.



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A marginal margin is when plane of dissectionpasses through pseudocapsule.

- adequate to treat most benign lesions andsome low-grade malignancies.

-In high-grade malignancy pseudo capsuleoften contains "satellite" lesions.

-may lead to local recurrence if the remainingtumor cells do not respond to adjuvant

chemotherapy or radiation therapy.Wide margins are achieved when the plane ofdissection is in normal tissue.



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Radical margins are achieved when all the compartments thatcontain tumor are removed en bloc. For deep soft tissue tumors this involves removing the entire

compartment (or multiple compartments) of any involvedmuscles.

For bone tumors, this involves removing the entire bone andthe compartments of any involved muscles.

Radical operations were once the procedures of choice formost high-grade neoplasms;

however, with improvements in imaging studies, radicalprocedures are now rarely performed because equivalent

oncological results usually can be obtained with wide margins.



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For microinvasive lesions wide local excision witha 1-2 cm normal tissue margin may be appropriate

For most neoplasms treated by surgery thetechnical aim is to remove the tumour, the organ inwhich it is contained and the regional lymph nodedrainage (lymphatics and nodes) all in one piece:

en-bloc



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Surgical attempt at cure involves-total excision of all tumour-bearing tissues

-together with the associated lymphatic andvenous drainage

-e.g. radical gastrectomyInvasion of adjacent vital structures

- e.g. invasion of the trachea by anoesophageal cancer

-may determine the feasibility of removing atumour (its operability).



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By contrast-involvement of non-essential structures

--does not prevent resection of a tumour with theinvaded structures

-e.g. a colonic tumour that has invaded the smallbowelresection marginis decided by the behaviour of the

tumour and its propensity to local invasion.



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The opeations are designed to be curative findings at surgery may indicate need foraddditional RXadjuvant hterapy

Indicated because of potential for occult spread ofdx based on a surgical finding

-eg positive lymph nodes

-high risk group for recurrence



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Surgery is cornerstone in some dx but not curative whenused alone Chemotherapy before surgery to handle micro

metastasis- neoadjuvant-risk of excessive bleeding

-eg locally advanced breast ca Debulking for optimal activity of chemotherapy Radiotherapy for infraclavicular nodes following

modified mastectomy Histopathologic findings

Surgery combined with other RXSurgery combined with other RX


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Occassionally curative when other therapy fails Almost always extensive Produce limitation of function

Involve radical surgery

Surgery as salvage therapySurgery as salvage therapy


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Resection may produce prolonged disease free interval Resection of intra abdominal tumour may offer palliationby removal of tumour bulk

May allow chemotherapy or irradiation a better chance Resection of tumours with poor blood supply

-smaller tumour-with better supply for chemo & radioRX-also an increase amount of cell in activecell cycle

Surgery for metastatic dxSurgery for metastatic dx


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Placement of indwelling IV acess-for chemotherapy

-nutrition

Intracavity therapy with placement of temporary orsemipermanent chest tube or intraperitonealaccess device

Surgery for specialized careSurgery for specialized care


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May be done at resection of tumourOr as delayed procedure

-STSG ff local tumour excision

-rotational flaps-breast reconstruction following radiation ofsmall breast and residual distortion

Surgery for reconstructionSurgery for reconstruction


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To relieve symptoms May involve diversion of tract or bypass Relieve pain by interruption of nerve transmission

To relieve specific dysfunction-relief of urinary obstruction by ureteroneocystostomy or urinary conduit depending onlocation of obstruction

Surgery for palliationSurgery for palliation


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Use of ureteral stent , by cystoscopy or antegradevia percutaneous nephrostomy

Diverting colostomy or intestinal bypass Successful palliation improves median survival

Surgery for palliationSurgery for palliation


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Early Haemorrhage Respiratory distress

Complications of blood transfusion-DIC wound infections Wound break down

Late

Recurrence Scar, keloid

Management of complicationsManagement of complications


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Job adjustment-amputee Home adjustment-home care Legislation for special pts

rehabilitationrehabilitation


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Pre op-effective screening methods-assess pt well-choose appropriate mgt, neoadjuvant rx-education of pt

Intra op-good surgical technique-multidisciplinary

Post op-adjuvant therapy-multimodal-pt education, follow up

preventionprevention


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1. Changes in surgical therapy New materials, surgical instruments, devices for

better surgical mgt Advances in laparoscopic surgery Innovative methods of supportive care eg

computerized anaesthesia, newer generation ofantibiotics, mgt of cancer in elderly

Safer radiation, chemotherapeutics

The futureThe future


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2. Changes in indications for surgery & type ofprocedure with early diagnosis of tumours

Less disfigurement, greater preservation offunction

Larger proportion of pts will present with early dxfor curative surgery

Less costs



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3. Multidisciplinary therapy and primary care Better integration of sub specialties Better cooperation

Good outcome Less costs



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Multidisciplinary, multimodal, highly speciailizedcare

Rapidly advancing Someday the fight may be won

conclusionconclusion

Principles of Cancer Management20022013b.

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Transcript of Principles of Cancer Management20022013b.