principles of surgical management of cancer patient

8/9/2019 Principles of Surgical Management of Cancer Patient

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D R B A S H I R U A M I N U

M O D E R A T O R :

D R E S G A R B A

Principles of surgicalmanagement of cancer patient


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outline

y Introduction

y Establish a diagnosis

-evaluate

-direct mgt properlyy Extent of the disease

y Management

-adequate

-appropriate-optimal care

-uncompromised


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Management options

1. early diagnosis & prevention

2. diagnosis & staging

3. surgery as primary therapy

4. surgery combined with other therapies

5. surgery as salvage therapy

6. surgical procedures for specialized care

7. surgery for reconstruction8. surgery for metastatic disease

9. surgery for palliation


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y Prevention

y future trends

y conclusion


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introduction

y Surgical mgt of cancer remains a challenge to thesurgeon

y It is assoc with high morbidity, & mortality

y Illiteracy further compounds difficulty in mgt

y Most patients present late

y Mgt is expensive to patient & GOVT

y

Consumes large man hours of the surgical team


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introduction

Key words

y Neoplasm-abnormal mass of cells growth of whichexceeds, & uncoordinated with normal tissues,

persists in same excessive manner with removal ofstimuli

y Nomenclature-benign or malignant

-transformed neoplastic cells,stromal tissues

-carcinoma-epithelial

-sarcoma-mesenchymal


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

y Hyperplasia-increased organ growth due to an increasein cell number

y Metaplasia-replacement by cell type not normallypresent in an organ

y Adjuvant chemotherapy refers to chemotherapyadministered postoperatively to treat presumed micro

metastases.y Neoadjuvant chemotherapy refers to chemotherapy

administered before surgical resection of the primarytumor.


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-mixed tumours,teratoma

-choristoma, harmatoma

y Differentiation extent to which tumour cell

resembles normal comparable cells

y Lack of differentiation is anaplasia

y Displasia refers to disorderly but non neoplasticgrowth

y Metastasis -tumour implant discontinuous withprimary tumour


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y How far to place the resection away from the visiblegrowth resection margin

y Tumour progression step wise acquisition of

malignant attributesy Cure- a normal duration of life without further

evidence of disease

y Cure rate assessed by survival rates at different times

after treatment


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Molecular basis of cancer


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Haematogenous tumour spread


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resuscitation

y Depends on presentation of patient

y Generally ABC resuscitation

y Maintain a patent airway

y Pass nasogastric stube

y Ensure breathing, give oxygen

y Circulation-IV line,cvp

y Pass urethral catether


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Establish a diagnosis

History-evaluate pt, properly direct mgt

y Complaint

y Course of illness

y Cause of illness

y Complications

y Current treatsment received


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Age

y Risk increases with age except childhood malignancy

Sex

y Common in males 60


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Site of origin

y Breast common women, thyriod commoner in males

y Upper git & respiratory tract much more commoner

in males


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Complaint

y Lump, ulcer, haematuria, weight loss dysphagia,change in voice, jaundice, change in bowel movt

y Course of illness

y Cause/aetiology-family hx, alcohol consumption-gastric cancer & PLCC, smoking- lung cancer


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y Age at marriage, first child, breast feeding

y What rx has PT received-mastectomy with residualtumour, prostatectomy for BPH with cancer

subsequently, radiotherapy with resulting sarcomay Other hx also relevant erectile dysfunction

prospective prostatic procedure, hope of havingmore children affecting RX options


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Investigations

y Confirm your diagnosis

y Extent of disease

y Optimise the patient

Extent of the disease

y Directs line of mgt

y Prognosisy outcome


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Skin carcinoma


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Prostatic cancer


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Breast cancer


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management

y Adequate

y Appropriate

y Multimodal

y Optimal

y Uncompromised-not what is available


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Aim of surgery

y The aim of surgical management is either curative orpalliative.

y Those with obvious widespread tumours should not

be treated by a surgical effort to achieve cure;y a lesser procedure may be performed (e.g. bypass of

a gastrointestinal tumour) to relieve distressingsymptoms such as pain or gastrointestinal

obstruction.y Referral for non-surgical treatment or for palliative

care is then appropriate


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Management options

1. early diagnosis & prevention

2. diagnosis & staging

3. surgery as primary therapy

4. surgery combined with other therapies

5. surgery as salvage therapy

6. surgical procedures for specialized care

7. surgery for reconstruction8. surgery for metastatic disease

9. surgery for palliation


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Management options

Early diagnosis & treatment

y Role in virtually all cancer

y Development of effective screening methods

y Recognition of premalignant, preinvasive conditionsimportant

y Optimal mgt requires undividualization of RX

y

Sentinel lymph node biopsy in breast ca


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y Eg breast

-Mammography

-Fnac

-Excisional biopsy


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Diagnosis & staging

y Diagnosis of any surgical cancer requires biopsy

y Accuracy depends on profficiency of surgeon

y Plan or rx influenced by (1)histologic cell type and

histologic grade or differentiationy And (2)anatomic site and stage of DX

y Good cooperation btw surgeon, pathologist,cytologist


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y Responsibility of surgeon

provide them with

-complete clinical hx

-indication of request

-however special handling should be

understood by all parties

-no room for misinterpretation due topoor communication


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Closed image guided

-Stereotactic

-CT guided

-MRI

Open direct biopsy

-Incisional biopsy

-Excisional


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Closed indirect biopsy.

-FNABC

-Tru-cut needle biopsy

-Punch biopsy

-Loop biopsy

-Endoscopic biopsy


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Surgery as primary therapy

y Usually rx of choice for preinvasive dx

y Local excision is both diagnostic & curative

y Surgical margin shld clear only gross & microscopic

DXy Removal of large areas of normal tissue not required


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y the surgical margin must be appropriately defined.

y important when evaluating surgical procedures andoutcomes

y one of four termsintralesional, marginal, wide, orradical.


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y intralesional margin is one in which the plane ofsurgical dissection is within the tumor.

-This type of procedure is often described as

"debulking"-it leaves behind gross residual tumor.

- may be appropriate for symptomatic benignlesions when only alternative is to sacrifice

important anatomical structures-This also may be appropriate as a palliative

procedure in the setting of metastatic disease.


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y A marginal margin is when plane of dissection passesthrough pseudocapsule.

- adequate to treat most benign lesions and somelow-grade malignancies.

-In high-grade malignancy pseudo capsule oftencontains "satellite" lesions.

-may lead to local recurrence if the remaining tumorcells do not respond to adjuvant chemotherapy or

radiation therapy.y Wide margins are achieved when the plane of dissection

is in normal tissue.


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y Radical margins are achieved when all the compartmentsthat contain tumor are removed en bloc.

y For deep soft tissue tumors this involves removing theentire compartment (or multiple compartments) of anyinvolved muscles.

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

y Radical operations were once the procedures of choicefor most high-grade neoplasms;

y

however, with improvements in imaging studies, radicalprocedures are now rarely performed because equivalentoncological results usually can be obtained with widemargins.


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y For microinvasive lesions wide local excision with a1-2 cm normal tissue margin may be appropriate

y For most neoplasms treated by surgery the technical

aim is to remove the tumour, the organ in which it iscontained and the regional lymph node drainage(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 and

venous drainage-e.g. radical gastrectomy

Invasion of adjacent vital structures

- e.g. invasion of the trachea by an oesophageal

cancer-may determine the feasibility of removing a

tumour (its operability).


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By contrast

-involvement of non-essential structures --doesnot prevent resection of a tumour with the invaded

structures-e.g. a colonic tumour that has invaded the small

bowel

y resection margin is decided by the behaviour of the

tumour and its propensity to local invasion.


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y The opeations are designed to be curative

y findings at surgery may indicate need foraddditional RXadjuvant hterapy

y Indicated because of potential for occult spread of dxbased on a surgical finding

-eg positive lymph nodes

-high risk group for recurrence


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Surgery combined with other RX

y Surgery is cornerstone in some dx but not curative whenused alone

y Chemotherapy before surgery to handle micrometastasis- neoadjuvant

-risk of excessive bleeding-eg locally advanced breast ca

y Debulking for optimal activity of chemotherapyy Radiotherapy for infraclavicular nodes following

modified mastectomy

y Histopathologic findings


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Surgery as salvage therapy

y Occassionally curative when other therapy fails

y Almost always extensive

y Produce limitation of function

y Involve radical surgery


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Surgery for metastatic dx

y Resection may produce prolonged disease free interval

y Resection of intra abdominal tumour may offer palliationby removal of tumour bulk

y

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

-smaller tumour

-with better supply for chemo & radioRX

-also an increase amount of cell in activecell cycle


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Surgery for specialized care

y Placement of indwelling IV acess

-for chemotherapy

-nutrition

y Intracavity therapy with placement of temporary orsemipermanent chest tube or intraperitoneal accessdevice


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Surgery for reconstruction

y May be done at resection of tumour

y Or as delayed procedure

-STSG ff local tumour excision

-rotational flaps

-breast reconstruction following radiation ofsmall breast and residual distortion


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Surgery for palliation

y To relieve symptoms

y May involve diversion of tract or bypass

y Relieve pain by interruption of nerve transmission

y To relieve specific dysfunction

-relief of urinary obstruction by ureteroneocystostomy or urinary conduit depending onlocation of obstruction


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y Use of ureteral stent , by cystoscopy or antegrade viapercutaneous nephrostomy

y Diverting colostomy or intestinal bypass

y Successful palliation improves median survival


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prevention

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

-education of pty Intra op

-good surgical technique-multidisciplinary

y Post op

-adjuvant therapy-multimodal-pt education, follow up


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The future

1. Changes in surgical therapy

y New materials, surgical instruments, devices forbetter surgical mgt

y Advances in laparoscopic surgeryy Innovative methods of supportive care eg

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

y Safer radiation, chemotherapeutics


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

y Less disfigurement, greater preservation of

functiony Larger proportion of pts will present with early dx

for curative surgery

y Less costs


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3. Multidisciplinary therapy and primary care

y Better integration of sub specialties

y Better cooperation

y Good outcomey Less costs


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conclusion

principles of surgical management of cancer patient

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