Surgical Mamnagent Of Cancer

Bharatiya Sanskriti Bharatiya Sanskriti Darshan Trust’sDarshan Trust’s

AYURVED MAHAVIDYALAYAAYURVED MAHAVIDYALAYAVISHWASHANTI DHAM, VISHWASHANTI DHAM,

WAGHOLI,WAGHOLI,TAL.-HAVELI, DIST.-PUNE-TAL.-HAVELI, DIST.-PUNE-

412207412207MAHARASHTRA, INDIAMAHARASHTRA, INDIA

NIMACON 2010.NIMACON 2010.

Divisional Conference 2010 Divisional Conference 2010

Organized by Organized by NIMA SOLAPUR BRANCH.NIMA SOLAPUR BRANCH.

Maharashtra Council of Maharashtra Council of Indian Medicines.Indian Medicines.

Surgical Management Surgical Management OF CancerOF Cancer

Dr.Shirish Kumthekar.Dr.Shirish Kumthekar.Surgeon Oncologist Surgeon Oncologist

Kumthekar General Hospital & Kumthekar General Hospital & Cancer Research Center Solapur.Cancer Research Center Solapur.

CancerCancer Cancer is one of the most formidable Health Cancer is one of the most formidable Health

Problems facing mankind today.Problems facing mankind today. Cancer is not a modern day disease!Cancer is not a modern day disease! Ramayana (C.2000B.C.)presents the earliest record Ramayana (C.2000B.C.)presents the earliest record

to identify malignant tumor as a disease entity.to identify malignant tumor as a disease entity. Egyptians (C.1500B.C.) were the first to identify Egyptians (C.1500B.C.) were the first to identify

that different tumors have different behavior.that different tumors have different behavior. Sushruta samhita(c.700 B.C.) mentions tumor Sushruta samhita(c.700 B.C.) mentions tumor

disease by various categoriesdisease by various categories Hippocrates (C.460-375 B.C.) was the first to name Hippocrates (C.460-375 B.C.) was the first to name

this disease as Cancer.this disease as Cancer. Galen (A.D.131-201) called it a “Neoplasm”.Galen (A.D.131-201) called it a “Neoplasm”.

CancerCancer

This being a complex disease, No This being a complex disease, No single approach is sufficient to treat it single approach is sufficient to treat it adequately.adequately.

A classical multimodality approach, A classical multimodality approach, employing 1.Surgery. 2. employing 1.Surgery. 2. Chemotherapy.Chemotherapy.

3.Radiation therapy &3.Radiation therapy & wherever required Hormonal Therapy/ wherever required Hormonal Therapy/

Immuno- therapy/ Genetic therapy are Immuno- therapy/ Genetic therapy are employed.employed.

Surgical Management OF Surgical Management OF CancerCancer

Surgery happens to be the oldest Surgery happens to be the oldest known methods to treat cancer. But known methods to treat cancer. But certainly not the only one!)certainly not the only one!)

Surgery ..as we are all aware deals Surgery ..as we are all aware deals with knife!with knife!

The surgical treatment of cancer has The surgical treatment of cancer has changed dramatically over the last changed dramatically over the last several decades.several decades.

Surgical Management OF Surgical Management OF CancerCancer

Historical Perspective.Historical Perspective. The earliest discussions of the The earliest discussions of the

surgical treatment of Tumors are surgical treatment of Tumors are found in the Edwin Smith Egyptian found in the Edwin Smith Egyptian Papyrus from the middle kingdom Papyrus from the middle kingdom (Circa 1600B.C.)(Circa 1600B.C.)

E.Mcdowell U.S.A. removed 22 lbs E.Mcdowell U.S.A. removed 22 lbs Ovarian Tumor in 1809.Ovarian Tumor in 1809.

Historical Perspective.Historical Perspective.

Two subsequent developments in Two subsequent developments in SurgerySurgery

1. Introduction General Anesthesia in 1. Introduction General Anesthesia in 1846 & Introduction of the Principles 1846 & Introduction of the Principles of Antisepsis in 1867, freed surgery of Antisepsis in 1867, freed surgery from Pain & sepsis, & greatly from Pain & sepsis, & greatly increased its use in tumor Surgery.increased its use in tumor Surgery.


1860-90 1860-90

+ Alber Billroth = First Gastrectomy, + Alber Billroth = First Gastrectomy, Laryngectomy & OesophagectomyLaryngectomy & Oesophagectomy..

1878.1878.

+ Richard Volkman = First Excision of + Richard Volkman = First Excision of Ca. Rectum.Ca. Rectum.

1880.1880.

+Theodore Kocher= First +Theodore Kocher= First thyroidectomy.thyroidectomy.


1890.1890.

William Halstedt= Radical Mastectomy.William Halstedt= Radical Mastectomy.

1896.1896.

G.Beatson.= First Oophorectomy G.Beatson.= First Oophorectomy Ca.breast.Ca.breast.

1904.1904.

H.Young = First Radical Prostatectomy.H.Young = First Radical Prostatectomy.


1906.1906.

E.Wertheim= Radical Hysterectomy.E.Wertheim= Radical Hysterectomy.

1908.1908.

W.Miles = Abdomino Perenial W.Miles = Abdomino Perenial Resection for Ca.rectum.Resection for Ca.rectum.

1913.1913.

Torek= Resection of Thoracic Torek= Resection of Thoracic OesophagusOesophagus..


1935.1935.

A.Whipple = Pancreatico Duodenectomy .A.Whipple = Pancreatico Duodenectomy .

1945 onwards…….1945 onwards…….

In the Post Second World war era of In the Post Second World war era of

Science & technology Revolution the Science & technology Revolution the surgeons knife has not left any part of surgeons knife has not left any part of Human Anatomy untouched!Human Anatomy untouched!

The Modern Era……..The Modern Era……..

As of Today Management Of Cancer As of Today Management Of Cancer with Surgery i.e. Surgical Oncology with Surgery i.e. Surgical Oncology has evolved from being the only has evolved from being the only treatment modality to being one treatment modality to being one essential component in the essential component in the multimodality approach in treating multimodality approach in treating cancer.cancer.

What is the Meaning of the What is the Meaning of the word “Management” in Clinical word “Management” in Clinical

Practice?Practice?

The term “Management “in the The term “Management “in the context of clinical practice, includes context of clinical practice, includes not only treatment ,but prevention, not only treatment ,but prevention, diagnosis, & as & when required diagnosis, & as & when required palliation!palliation!

The Role of Surgery in the The Role of Surgery in the management of cancermanagement of cancer

Surgery now encompasses all areas of Surgery now encompasses all areas of cancer care…cancer care…

1.Prevention.1.Prevention.

2.Diagnosis.2.Diagnosis.

3.Staging.3.Staging.

4.Treatment.4.Treatment.

5.Palliation.5.Palliation.

Role Of Surgery Role Of Surgery in Prevention of in Prevention of

Cancer.Cancer. The Role of Surgery is not limited to The Role of Surgery is not limited to

the Diagnosis & treatment of Cancer the Diagnosis & treatment of Cancer but extends to intervening earlier in but extends to intervening earlier in the natural history of Malignant the natural history of Malignant transformation.transformation.

Prophylactic SurgeryProphylactic SurgeryUndescended Testis (Cryptorchidism)Undescended Testis (Cryptorchidism)

Can cause Testicular CancerCan cause Testicular Cancer

Treatment is = Orchiopexy/ Treatment is = Orchiopexy/ OrchidectomyOrchidectomy

Prophylactic SurgeryProphylactic Surgery

2.Multiple Polyposis coli :2.Multiple Polyposis coli :

Can cause Colonic cancer..Can cause Colonic cancer..

Treated with Prophylactic Treated with Prophylactic ProctocolectomyProctocolectomy


3. Familial Colonic cancer :3. Familial Colonic cancer :

Treated with Prophylactic ColectomyTreated with Prophylactic Colectomy


4.Ulcerative Colitis = Colonic Cancer4.Ulcerative Colitis = Colonic Cancer

Treated with prophylactic Colectomy.Treated with prophylactic Colectomy.


5.Multiple Endocrine Neoplasia Type 5.Multiple Endocrine Neoplasia Type 2/3 2/3

Usually Causes Medullary Usually Causes Medullary

Cancer Of Thyroid.Cancer Of Thyroid.

Treated with Thyroidectomy.Treated with Thyroidectomy.


Strong history of Familial Breast Strong history of Familial Breast cancer & Familial History of Ovarian cancer & Familial History of Ovarian Cancer.Cancer.

? Prophylactic Mastectomy.? Prophylactic Mastectomy.

? Prophylactic Oophorectomy.? Prophylactic Oophorectomy.


Leucoplakia / Erythroplakia in Oral Leucoplakia / Erythroplakia in Oral Cavity.Cavity.

Treated with SurgeryTreated with Surgery

Prophylactic Surgery.Prophylactic Surgery.

Probably the Religious Practice of Probably the Religious Practice of Circumcision in males in very early Circumcision in males in very early age avoids the occurrence of Cancer age avoids the occurrence of Cancer of the Penis. of the Penis.

Role Of Surgery in Diagnosis Of Role Of Surgery in Diagnosis Of Cancer.Cancer.

Apart from the Process of history Apart from the Process of history taking & thorough clinical taking & thorough clinical Examination the Role of Surgery in Examination the Role of Surgery in the Diagnosis of Cancer basically the Diagnosis of Cancer basically deals with obtaining a Sample of deals with obtaining a Sample of tissue (Biopsy) so as to arrive at tissue (Biopsy) so as to arrive at correct Histo-pathological diagnosis.correct Histo-pathological diagnosis.

Biopsies are carried by surgeons in Biopsies are carried by surgeons in various ways……..various ways……..

Various Methods of Various Methods of biopsy….biopsy….

1.1. Aspiration Biopsy (FNAC)Aspiration Biopsy (FNAC)

2.2. Needle Biopsy ( Tissue Core biopsy)Needle Biopsy ( Tissue Core biopsy)

3.3. Incisional Biopsy.Incisional Biopsy.

4.4. Excisional Biopsy.Excisional Biopsy.

Guiding Principals for all Guiding Principals for all Surgical Biopsies…….Surgical Biopsies…….

1.Needle tracks Or Biopsy Incisions 1.Needle tracks Or Biopsy Incisions should be placed carefully.should be placed carefully.

2.Care should be taken so as not to 2.Care should be taken so as not to contaminate new tissue planes.contaminate new tissue planes.

3.Adequate tissue sample should be 3.Adequate tissue sample should be obtained.obtained.

4.The biopsy sample should be properly 4.The biopsy sample should be properly labeled, preserved & sent to the labeled, preserved & sent to the pathologist. Sufficient data is a must!pathologist. Sufficient data is a must!

Role of surgery in staging Role of surgery in staging Cancer.Cancer.

Staging of a Cancer means knowing Staging of a Cancer means knowing the extent & spread of the disease.the extent & spread of the disease.

Correct staging has the potential of Correct staging has the potential of altering treatment strategies.altering treatment strategies.

Surgical staging procedures are Surgical staging procedures are more sensitive than currently more sensitive than currently available imaging modalities in many available imaging modalities in many Cancers.Cancers.

Staging Of CancerStaging Of Cancer

Since 1959 all solid tumors are Since 1959 all solid tumors are staged under the Universally staged under the Universally accepted TNM System.accepted TNM System.

T = Tumor Size(TIS T0, T1,T2,T3,T4, T = Tumor Size(TIS T0, T1,T2,T3,T4, TX.)TX.)

N = Lymph Node Status (Nx N0, N = Lymph Node Status (Nx N0, N1,N2,) N1,N2,)

M = Metastatic Spread status.M = Metastatic Spread status.

Various procedures used for Various procedures used for surgical staging of cancer.surgical staging of cancer.

1.1. Laparotomy.Laparotomy.

2.2. Laparoscopy.Laparoscopy.

3.3. Mediastinoscopy.Mediastinoscopy.

4.4. Lymphadenectomy.Lymphadenectomy.

5.5. Sentinel node biopsy.Sentinel node biopsy.

Cancers in whom staging is Cancers in whom staging is useful are…useful are…

1.1. Hodgkin's Lymphoma.Hodgkin's Lymphoma.

2.2. Melanoma.Melanoma.

3.3. Breast Cancer.Breast Cancer.

4.4. Ovarian Cancer.Ovarian Cancer.

5.5. Testicular tumors.Testicular tumors.

6.6. Brochogenic Carcinoma.Brochogenic Carcinoma.

Role Of Surgery in Definitive Role Of Surgery in Definitive Treatment of CancerTreatment of Cancer

Surgery has been & remains the mainstay Surgery has been & remains the mainstay of treatment for most solid tumors.of treatment for most solid tumors.

In the early & middle part of the 20In the early & middle part of the 20thth century, surgeons were performing more century, surgeons were performing more radical operations in attempt to cure radical operations in attempt to cure patients & prevent recurrence.patients & prevent recurrence.

With the advent of modern multimodality With the advent of modern multimodality therapy ,surgical oncology has therapy ,surgical oncology has transformed from anatomic basis to transformed from anatomic basis to biologic basisbiologic basis

Role Of Surgery in Cancer Role Of Surgery in Cancer treatment.treatment.

Definitive surgical treatment for Primary Definitive surgical treatment for Primary cancer.cancer.

Surgery to reduce the bulk of primary or Surgery to reduce the bulk of primary or residual disease.residual disease.

Surgical resection of Metastatic disease with Surgical resection of Metastatic disease with curative intent.curative intent.

Surgery for the treatment of Oncologic Surgery for the treatment of Oncologic emergencies.emergencies.

Surgery for palliation.Surgery for palliation. Surgery for Reconstruction & Rehabilitation.Surgery for Reconstruction & Rehabilitation.

Definitive surgical treatment of Definitive surgical treatment of Primary Cancer…..Primary Cancer…..

Surgery in primary resections is dictated Surgery in primary resections is dictated by…by…

1.Stage of the Cancer.1.Stage of the Cancer.

2.Mechanism & knowledge of local spread.2.Mechanism & knowledge of local spread.

3. Morbidity & mortality of the procedure.3. Morbidity & mortality of the procedure.

4.General condition of the patient.4.General condition of the patient.

5. Risk of Anesthesia.5. Risk of Anesthesia.

Role of Definitive surgery….Role of Definitive surgery….

Primary goal of surgery is complete Primary goal of surgery is complete removal of Local & regional disease.removal of Local & regional disease.

This provides local control & reduces This provides local control & reduces the risk of local recurrence.the risk of local recurrence.

The extent of resection depends on The extent of resection depends on the organ involved & method of local the organ involved & method of local spread.spread.

Adequate margins of excision range Adequate margins of excision range from 1mm to 5cm for cutaneous & from 1mm to 5cm for cutaneous & hollow/solid organs.hollow/solid organs.

Role of definitive surgery…Role of definitive surgery… Resection of solid organ tumors is guided Resection of solid organ tumors is guided

by the blood supply.by the blood supply. It is mandatory to include any biopsy It is mandatory to include any biopsy

incision or needle track of a previously incision or needle track of a previously performed procedure.performed procedure.

If required & as a rule always the If required & as a rule always the contagious organs & regional Lymph contagious organs & regional Lymph nodes are required to be removed.nodes are required to be removed.

If after resection the margins are positive , If after resection the margins are positive , a redo surgery or addition of Radiotherapy a redo surgery or addition of Radiotherapy and /or chemotherapy are mandatory.and /or chemotherapy are mandatory.

Cytoreductive / Debulking Cytoreductive / Debulking SurgerySurgery

In some instances the extensive local In some instances the extensive local spread of cancer precludes the spread of cancer precludes the removal of all gross disease by removal of all gross disease by surgery.surgery.

This type of Surgery is of benefit only This type of Surgery is of benefit only when other effective therapies are when other effective therapies are available to control the disease.available to control the disease.

Classical examples are Burkitts Classical examples are Burkitts lymphoma & Ovarian cancer.lymphoma & Ovarian cancer.

Surgical Management of Surgical Management of Metastatic Disease/ Recurrent Metastatic Disease/ Recurrent

disease.disease. Cancer is characterized by its ability to Cancer is characterized by its ability to

spread to distant organs (Metastasis).spread to distant organs (Metastasis). Cancer is also known to recur at the Cancer is also known to recur at the

same site (Where primary excision has same site (Where primary excision has been done.been done.

In such instances ,surgical excision of In such instances ,surgical excision of metastatic/ Recurrent disease can metastatic/ Recurrent disease can greatly increase the possibility of cure.greatly increase the possibility of cure.

Surgery for Metastatic Surgery for Metastatic diseasedisease

Liver Metastasis from colorectal Liver Metastasis from colorectal cancer.cancer.

Lung metastasis from , Testicular Lung metastasis from , Testicular Cancer, Soft tissue sarcoma, Cancer, Soft tissue sarcoma, Osteosarcoma, Renal cell carcinoma.Osteosarcoma, Renal cell carcinoma.

Excision of solitary brain metastasis.Excision of solitary brain metastasis.

Surgical Management of Surgical Management of Oncologic Emergencies.Oncologic Emergencies.

Emergency /life threatening situations do arise Emergency /life threatening situations do arise in cancer patients.in cancer patients.

These situations usually include…These situations usually include…1.1. Exsanguinating Blood loss.Exsanguinating Blood loss.2.2. Hollow organ perforations.Hollow organ perforations.3.3. Acute abscesses.Acute abscesses.4.4. Surgical decompression of central nervous Surgical decompression of central nervous

system.system.5.5. Bowel / urinary obstruction.Bowel / urinary obstruction.6.6. Biliary obstruction with jaundice.Biliary obstruction with jaundice.7.7. Asphyxiation due to tracheal obstruction.Asphyxiation due to tracheal obstruction.

Palliative surgery.Palliative surgery. In many cases of advanced, inoperable, In many cases of advanced, inoperable,

unresectable cancers, significant improvement in unresectable cancers, significant improvement in the quality of life & alleviations of symptoms can the quality of life & alleviations of symptoms can be achieved by palliative surgical intervention..be achieved by palliative surgical intervention..

E.g. pleural/ pericardial tappingE.g. pleural/ pericardial tapping Ascitic tapping.Ascitic tapping. Local excision of Fungating Tumors.Local excision of Fungating Tumors. Hollow viscus bypasses.Hollow viscus bypasses. Ileostomies, colostomies, Feeding Gastrostomies, Ileostomies, colostomies, Feeding Gastrostomies,

feedind Jejunostomies,Oesophageal stenting, feedind Jejunostomies,Oesophageal stenting, Teacheostomies etc.Teacheostomies etc.

Reconstructive & Rehabilitative Reconstructive & Rehabilitative Surgery.Surgery.

Many Radical Cancer surgeries cause Many Radical Cancer surgeries cause massive tissue losses, resulting in massive tissue losses, resulting in dysfunction & bad cosmesis.dysfunction & bad cosmesis.

This applies particularly to Head & This applies particularly to Head & Neck cancers, Breast Cancer, Cancer Neck cancers, Breast Cancer, Cancer of Testis, Bone cancers.of Testis, Bone cancers.

Latest advances in Plastic surgery, Latest advances in Plastic surgery, Bio Prosthesis has radically improved Bio Prosthesis has radically improved this scene.this scene.

What lies in Future ?What lies in Future ?

Increasing application of Laparoscopic Increasing application of Laparoscopic Surgery , Video assisted surgery.Surgery , Video assisted surgery.

Increasing use of Lasers, Harmonic Increasing use of Lasers, Harmonic scalpels, Automatic stapling devices.scalpels, Automatic stapling devices.

Use of Robotic Surgery.Use of Robotic Surgery. Use of Nano Surgical techniques.Use of Nano Surgical techniques. Use of Super high voltage Gamma Use of Super high voltage Gamma

Knives (Cyber knife)Knives (Cyber knife)

Fergusson: A 19Fergusson: A 19thth century century Surgeon Stated that ……….Surgeon Stated that ……….

A Surgeon is supposed to have,A Surgeon is supposed to have,1.The Eye of an eagle.1.The Eye of an eagle.2.The heart of a Lion.2.The heart of a Lion.3.The Hands of A Lady.3.The Hands of A Lady.4. & the flair of an accomplished actor .4. & the flair of an accomplished actor .The personality of a surgeon has The personality of a surgeon has

always reflected his desire to perform always reflected his desire to perform the art of surgery in front of an the art of surgery in front of an appreciative audience!appreciative audience!

A surgeon with his knowledge A surgeon with his knowledge & skills happens to be the main & skills happens to be the main hero in this real life situational hero in this real life situational

drama that goes on while drama that goes on while treating Cancertreating Cancer

He happens to be the captain He happens to be the captain of a Ship……of a Ship……

A ship that has to sail safely A ship that has to sail safely with minimum turbulence.!with minimum turbulence.!

Role Of General Practioners in Role Of General Practioners in Cancer ManagementCancer Management

To keep a high level of Suspicion about To keep a high level of Suspicion about Cancer.Cancer.

To seek actively for early diagnosis of To seek actively for early diagnosis of Cancer.Cancer.

To encourage the patient for further To encourage the patient for further investigations & treatment.investigations & treatment.

To provide moral support to the patient & To provide moral support to the patient & his family.his family.

To keep in communication with the To keep in communication with the Oncologist treating the said patient.Oncologist treating the said patient.

To Summarize……..To Summarize……..

Advances in the Surgical techniques , Advances in the Surgical techniques , Anesthesia, & a better understanding Anesthesia, & a better understanding of Tumor Biology has allowed of Tumor Biology has allowed surgeons to perform successful surgeons to perform successful resections for an increased number resections for an increased number of patients.of patients.

The development of alternate The development of alternate treatment strategies has prompted treatment strategies has prompted surgeons to reassess the magnitude surgeons to reassess the magnitude of surgery necessary.of surgery necessary.

Surgical Mamnagent Of Cancer

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Transcript of Surgical Mamnagent Of Cancer