Principles of management of cancer patient

Dr Bashiru Aminu Moderator: Dr Mai

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Introduction Key

words Molecular 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

introduction

Surgical mgt. of cancer remains a challenge to the surgeon 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

introduction
Key words Neoplasm-abnormal mass of cells growth of which exceeds, & uncoordinated with normal tissues, persists in same excessive manner with removal of stimuli Nomenclature-benign or malignant -transformed cells -carcinoma-epithelial -sarcoma-mesenchymal

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Hypertrophy

increased organ growth due to an increase in size of its constituent cells Hyperplasia-increased organ growth due to an increase in cell number Metaplasia-replacement by cell type not normally present in an organ Adjuvant chemotherapy refers to chemotherapy administered postoperatively to treat presumed micro metastases. Neoadjuvant chemotherapy refers to chemotherapy administered before surgical resection of the primary tumor.

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Differentiation extent to which tumour cell resembles 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 the visible growth resection margin Tumour progression step wise acquisition of malignant attributes Cure- a normal duration of life without further evidence of disease Cure rate assessed by survival rates at different times after treatment

Molecular basis of cancer

Haematogenous tumour spread

Establish a diagnosis
History-evaluate pt, properly direct mgt(after resuscitation) Complaint Course of illness Cause of illness Complications Current treatment received

Establish a diagnosis
Age Risk increases with age except childhood malignancy Sex Common in males <10 yrs Common in females 20-60yrs due to breast, cervix Males again>60

Establish a diagnosis
Site of origin Breast common women, thyriod commoner in males Upper git & respiratory tract much more commoner in males

Establish a diagnosis
Complaint Lump, ulcer, haematuria, weight loss dysphagia, change in voice, jaundice, change in bowel movt Course of illness Cause/aetiology-family hx, alcohol consumptiongastric cancer & PLCC, smoking- lung cancer

Establish a diagnosis

Age at marriage, first child, breast feeding What rx has PT received-mastectomy with residual tumour, prostatectomy for BPH with cancer subsequently, radiotherapy with resulting sarcoma Other hx also relevant erectile dysfunction prospective prostatic procedure, hope of having more children affecting RX options

Extent of dx

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

Diagnosis & staging

Diagnosis of any surgical cancer requires biopsy Accuracy depends on profficiency of surgeon Plan or rx influenced by (1)histologic cell type and histologic grade or differentiation And (2)anatomic site and stage of DX Good cooperation btw surgeon, pathologist, cytologist

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 to poor communication

Extent of dx

Skin carcinoma

Prostatic cancer

Extent of dx

Extent of dx

Breast cancer

Extent of dx

Extent of dx

Counsel pt

Tell pt the diagnosis Available treatment options generally Available options locally What is best for the pt at that time

Informed consent

Allow pt to choose Informed consent Documented Best for the patient

Preparation for treatment

Baseline investigation Optimise pt Chest physiotherapy Breathing exersises Nasogastric and other tubes Nil per os

Deliver Treatment

Adequate Appropriate Multimodal Optimal Uncompromised-not what is available

Aim of surgery

The aim of surgical management is either curative or palliative. Those with obvious widespread tumours should not be treated by a surgical effort to achieve cure; a lesser procedure may be performed (e.g. bypass of a gastrointestinal tumour) to relieve distressing symptoms such as pain or gastrointestinal obstruction. Referral for non-surgical treatment or for palliative care is then appropriate

Management options
1. 2. 3. 4. 5. 6. 7. 8. 9.

early diagnosis & prevention diagnosis & staging surgery as primary therapy surgery combined with other therapies surgery as salvage therapy surgical procedures for specialized care surgery for reconstruction surgery for metastatic disease surgery for palliation

Management options
Early diagnosis & treatment Role in virtually all cancer Development of effective screening methods Recognition of premalignant, preinvasive conditions important Optimal mgt requires undividualization of RX Sentinel lymph node biopsy in breast ca

Surgery as primary therapy

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 not required

Surgery as primary therapy

the surgical margin must be appropriately defined. important when evaluating surgical procedures and outcomes one of four termsintralesional, marginal, wide, or radical.

Surgery as primary therapy

intralesional margin is one in which the plane of surgical 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 benign lesions when only alternative is to sacrifice important anatomical structures -This also may be appropriate as a palliative procedure in the setting of metastatic disease.

Surgery as primary therapy

A

marginal margin is when plane of dissection passes through pseudocapsule. - adequate to treat most benign lesions and some low-grade malignancies. -In high-grade malignancy pseudo capsule often contains "satellite" lesions. -may lead to local recurrence if the remaining tumor cells do not respond to adjuvant chemotherapy or radiation therapy. Wide margins are achieved when the plane of dissection is in normal tissue.

Surgery as primary therapy

Radical margins are achieved when all the compartments that contain tumor are removed en bloc. For deep soft tissue tumors this involves removing the entire compartment (or multiple compartments) of any involved muscles. For bone tumors, this involves removing the entire bone and the compartments of any involved muscles. Radical operations were once the procedures of choice for most high-grade neoplasms; however, with improvements in imaging studies, radical procedures are now rarely performed because equivalent oncological results usually can be obtained with wide margins.

Surgery as primary therapy

For microinvasive lesions wide local excision with a 1-2 cm normal tissue margin may be appropriate For most neoplasms treated by surgery the technical aim is to remove the tumour, the organ in which it is contained and the regional lymph node drainage (lymphatics and nodes) all in one piece: en-bloc

Surgery as primary therapy

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).

Surgery as primary therapy

By contrast -involvement of non-essential structures --does not prevent resection of a tumour with the invaded structures -e.g. a colonic tumour that has invaded the small bowel resection margin is decided by the behaviour of the tumour and its propensity to local invasion.

Surgery as primary therapy

The

opeations are designed to be curative findings at surgery may indicate need for addditional RXadjuvant hterapy Indicated because of potential for occult spread of dx based on a surgical finding -eg positive lymph nodes -high risk group for recurrence

Surgery as primary therapy

Surgery combined with other RX

Surgery is cornerstone in some dx but not curative when used 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 as salvage therapy

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

Surgery for metastatic dx

Resection

may produce prolonged disease free interval Resection of intra abdominal tumour may offer palliation by 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 active cell cycle

Surgery for specialized care

Placement

of indwelling IV acess -for chemotherapy -nutrition Intracavity therapy with placement of temporary or semipermanent chest tube or intraperitoneal access device

Surgery for reconstruction

May

be done at resection of tumour Or as delayed procedure -STSG ff local tumour excision -rotational flaps -breast reconstruction following radiation of small breast and residual distortion

Surgery for palliation

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 uretero neocystostomy or urinary conduit depending on location of obstruction

Surgery for palliation

Use of ureteral stent , by cystoscopy or antegrade via percutaneous nephrostomy Diverting colostomy or intestinal bypass Successful palliation improves median survival

Management of complications
Early Haemorrhage Respiratory distress Complications of blood transfusion-DIC wound infections Wound break down Late Recurrence Scar, keloid

rehabilitation

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

prevention
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

The future
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 of antibiotics, mgt of cancer in elderly Safer radiation, chemotherapeutics

The future
2. Changes in indications for surgery & type of procedure with early diagnosis of tumours Less disfigurement, greater preservation of function Larger proportion of pts will present with early dx for curative surgery Less costs

The future
3. Multidisciplinary therapy and primary care Better integration of sub specialties Better cooperation Good outcome Less costs

conclusion

Multidisciplinary, multimodal, highly speciailized care Rapidly advancing Someday the fight may be won