Principles of Cancer Management20022013b.
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Transcript of 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
Establish a diagnosisEstablish a diagnosis
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Site of origin Breast common women, thyriod commoner inmales
Upper git & respiratory tract much more commonerin males
Establish a diagnosisEstablish a diagnosis
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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
Establish a diagnosisEstablish a diagnosis
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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
Establish a diagnosisEstablish a diagnosis
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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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Extent of dxExtent of dx
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Skin carcinomaSkin carcinoma
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Prostatic cancerProstatic cancer
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Extent of dxExtent of dx
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Extent of dxExtent of dx
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Breast cancerBreast cancer
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Extent of dxExtent of dx
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Extent of dxExtent of dx
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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.
Surgery as primary therapySurgery as primary therapy
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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.
Surgery as primary therapySurgery as primary therapy
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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.
Surgery as primary therapySurgery as primary therapy
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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.
Surgery as primary therapySurgery as primary therapy
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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
Surgery as primary therapySurgery as primary therapy
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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).
Surgery as primary therapySurgery as primary therapy
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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.
Surgery as primary therapySurgery as primary therapy
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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
Surgery as primary therapySurgery as primary therapy
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Surgery as primary therapySurgery as primary therapy
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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
The futureThe future
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3. Multidisciplinary therapy and primary care Better integration of sub specialties Better cooperation
Good outcome Less costs
The futureThe future
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Multidisciplinary, multimodal, highly speciailizedcare
Rapidly advancing Someday the fight may be won
conclusionconclusion