Introduction to Surgical Oncology
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Transcript of Introduction to Surgical Oncology
![Page 1: Introduction to Surgical Oncology](https://reader031.fdocuments.net/reader031/viewer/2022012311/544bf2bdaf7959ac438b5790/html5/thumbnails/1.jpg)
Introduction to
SURGICAL ONCOLOGY
Artanto WahyonoSMF Bedah RSUP Dr Sardjito
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ONCOLOGY
• MULTIDISCIPLINARY FIELD OF MEDICINE
• Oncology ORCHESTRA
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Oncology Orchestra• General Physician• Radiology Specialist• Pathology Specialist• General Surgeon• Surgical Oncologist• Medical Oncologist• Radiotherapy Oncologist• Oncologic Nursing Specialist• Palliative Medicine• Medical Rehabilitation• Nutrition specialist• Psychologist etc..
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3 Factors
• Tumour Factors
• Patients Factors
• Doctor & Hospital Factors
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Tumour Factors
• Clinical diagnosis
• Microscopic diagnosis
• Lymphatic metastase
• Hematogenic metastase
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Patient Factors
• Physical General Status
• Psychological Status
• Socioeconomic Factors
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Doctor & Hospital factors
• Competence of Doctors
• Supporting Facilities
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Tumors
• Clinical dx
• Microscopic dx
• Treatment Planning
• Curative treatment or non curative Palliative treatment
• Temporary or definitive
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Microscopic
• Tumor type
• Carcinoma, Sarcoma, Blastoma (embryonal), Lymphoreticular
• Histopathological grading
• Extent of the disease to surounding tissue
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Microscopic Factors
• Differentiation degree
• Well, moderate, poorly differentiated
• Undifferentiated
• With/without surrounding tumor invasion
• Lymph node mets, is there any invasive lymphnode capsule
• Distant metastase
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Grade of malignancy
• Pleomorphic changes of the cell
• Grade of differentiation
• The number of mitosis
• Cells necrosis
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Natural History of Cancer
• Dysplasia• Carcinoma (malignancy in situ)• Invasive type/ Infiltrating type• Local extension• Spreading lymphatic or haematogenic
Special: Basal cell carcinomaLocally destruction
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TNM staging
• Tumor• Node (Lymph node)• Metastase
To indicate treatment planningTo indicate prognosisTo facilitate evaluation and exchange of
treatment result
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SPREAD
• Lymphatic spreading
• Extranodal growth
• Hematogenic spreading
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TumorThe extent of primary tumor
• T 0 : no evidence of primary tumour
• Tis : insitu
• T 1-3, 4 (a, b, c) : increasing size, fixed
• T1 microscopic
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Lymph nodeThe absence or presence and extent of regional lymph node
metastase
• N 0 : no evidence of regional lymph node involvement
• N 1-3 : increasing involvement numbermobility/ fixationconnection to one another
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MetastaseThe absence or presence of distant
metastase
• Distant Metastase
• Hematogenic metastase
• Lymph node metastses beyond the regional lymph node area
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Clinical and Pathological
• TxNxMx (Clinical TNM)
• pTxNxMx (Pathological)
• Postoperative microscopic examination of resected tissue
• Example:
preop cT2N0M0 become pT2N2M0
• Implications for treatment planning
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The Basic
• No Cancer treatment may start before there is microscopic evidence of a malignant disesase
• Plays a significant role in oncology
Cytology: FNAB/FNAC Exfoliative cytology
Histolgy: Thick needle biopsy/ core needle biopsy, incisional biopsy, excisional biopsy
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• Depends on the site and size of tumour
• The pathological information that is needed for treatment planning
• Bite punch biopsy
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FNAB FNAC
• Easy, simple, quick
• Hardly any complications
• Disadvantages
• Histologic characteristics like invasive growth are misssing
• A possible false-negative result
• Bone?
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• A NEGATIVE RESULT MEANS:
• NO TUMOUR CELLS ARE FOUND IN THE SAMPLE
• THIS DOES NOT MEAN THAT THIS EXCLUDES A MALIGNANT TUMOUR
• THE SAMPLE TOO SMALL
• TAKEN FROM ADJACENT TISSUE
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WHEM THERE IS CLINICAL SUSPICION OF MALIGNANT
TUMOUR
• SHOULD BE REPEATED OR ANOTHER BIOPSY METHOD
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TUMOUR SPILL IN BIOPSY
• CONTAMINATION OF THE SURROUNDING TISSUES WITH TUMOUR CELLS
• WHICH IN TURN CAN CAUSE RECURRENT TUMOURS
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• IN THE IMMEDIATE SURROUNDING OF THE INVASIVE PROCEDURES
• IN CAVITIES
• SPONTANEOUSLY
• IATROGENIC
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• FNAC, very rare
• Excisional biopsy extended microscopically wider than was expected clinically
• Incisional biopsy always occur
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• Contaminated instrument
• Must be replaced
• From several lesions
• Use clean instrument for each new biopsy
• May be One of the tumour malignant the others are not
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Local anesthesia
• Field block• Field wise at a distance around the lesion• NOT TO INFILTRATE UNDER OR IN THE
LESION
• LOCAL NERVE BLOCK OR GENERAL ANESTHESIA
• FNAC no need• Thick or Core biopsy only the skin area
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Treatment
• Treatment Planning
• WATCHFUL WAITING
• Curative treatment or non curative Palliative treatment
• Temporary or definitive
• Locoregional treatment
• Systemic treatment
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• Tumour type
• Biological behavioour
• Localization and the extent
• The Age and the general conditions
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Locoregional Treatment
• Surgery• Radiation Therapy• Whether or not combined with cancer drug
treatment (adjuvant treatment)
Curation can be obtained whom the the tumour is restricted to the primary locoregional area and in the whom locoregional lymph nodes do not show extranodal growth
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SYSTEMIC DISEASE
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• Neoadjuvant treatment
• Cancer drug treatment
• Combination with Radiation Therapy
• Hormonal therapy
• Immunotherapy
• Spesific Receptors therapy
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SURGERYThe most dramatic but not the only……
• Most tumours cancer surgery is usually more extensive than non-oncological surgery
• Tumor characteristics
• Biological behaviour
• Possibilities of radiation therapy, chemotherapy, hormonal therapy, immunotherapy
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EVERY ONCOLOGICAL SURGICAL TREATMENT
WITH CURATIVE INTENT IS AIMED TO COMPLETE REMOVAL OF THE TUMOUR AND POSSIBLY PRESENT LYMPH NODE METASTASES
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• Excision with small margins
• Excisions with large marins
• Excision en-bloc of the primary tumour and the regional lymph node area
• Lymph node dissection
EXAMINATION OF RESECTION MARGINS
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• Enucleation (only in selected cases)
• Tissue destructive methods
• Isolated regional perfusion
• Excision of hematogenic metastases
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Follow up
• IN ONCOLOGY FOLLOW UP IS AN IMPORTANT PART OF PATIENT MANAGEMENT
• FOR SEVERAL TUMOURS FOLLOW UP IS ALSO IMPORTANT IN THE EARLY DETECTION OF A SECOND PRIMARY TUMOUR
• IN THE CASE OF LOCAL OR DISTANT RECURRENCES, TREATMENT WITH CURATIVE INTENT CAN STILL BE OFFERED TO SEVERAL PATIENTS
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THANK YOU
• TO SERVE AND TO PROTECT
• PROTECT YOURSELF BY PROTECT YOUR PATIENTs
• PRIMUM NON NOCERE
• Learn to communicate with patients and their family
• Learn to teach patients and their family
• Balanced informations