Syrian private UniversityMedical FacultyDepartment of Surgery

المبادئ الجراحية لتدبير األورام

Principles of cancer surgeryM.A.Kubtan , MD-FRCS

M.A.Kubtan 1

دراسـة األمـراض التنشـؤيـة Study of neoplastic diseases

Neoplasm: Altered cell population

characterized by an excessive, non-useful proliferation of cells that are unresponsive to normal control mechanisms and to organizing influences of adjacent tissue.

التنشؤ

تبدل في عدد الخاليا يتظاهر بزيادة العدد ، دون جدوى أو فائدة

لتكاثر هذه الخاليا ، و التي ال تتجاوب مع اآلليات

الطبيعية الناظمة لتكاثر الخاليا و التي تخضع لتأثير

األنسجة المجاورة

M.A.Kubtan 2

Neoplasm التنشـؤ

.1Malignant : Cancer cells that exhibit

uncontrolled proliferation and impair the function of

normal organs by local tissue invasion and

metastatic spread to distant anatomic sites.

.2Benign:Composed of normal

appearing cells that do not invade locally or

metastasize to other sites

األورام الخـبـيثــة 1.تتكون من الخاليا الورمية 1.

V ال V خلويا التي تبدي تكاثرايخضع لآلليات المنظمة لتولد الخاليا ، كما يعمل على تخريب أو تعطيل عمل األعضاء الطبيعية

بسبب االنتقاالت الموضعية و البعيدة .

األورام الحميدة 2.) السليمة (

تتشكل من خاليا طبيعية المظهر ، ال تغزوا األعضاء

V و المجاورة موضعياV التنتقل بعيدا

M.A.Kubtan 3

الوبائيات ) اإلمراض ( EPIDEMIOLOGY Overall cancer death

rates shows slow steady increase

Lower death rates during past 50yrs:

1. Stomach2. Uterus

Increase death rates:1. Lung2. pancreas

تظهر الدراسات تزايد بطيء وتدريجي في عدد الوفيات

الناجمة عن األورام . يقابلها انخفاض الوفيات خالل الـ

سنة الماضية في :50سرطانات المعدة .1.سرطانات الرحم .2.

: زيادة الوفيات في .سرطانات الرئة. سرطانات البانكرياس

M.A.Kubtan 4

الوبائيات اإلمراض EPIDEMIOLOGY

Cancer incidence) نسبة الحدوث (by sites and sex

Male Female

Lung 20% Breast 27%

Prostate 20% Colon & Rectum 16%

Colon & Rectum 14% Lung 11%

Urinary 10% Uterus 10%

Leukemia & Lymphoma

8%Leukemia & Lymphoma

7%

Skin, pancreas and oral

3-4%Skin, pancreas and oral

3-4%

M.A.Kubtan 5

الوبائيات اإلمراض EPIDEMIOLOGY

Cancer death ) نسبة الوفيات(by sites and sex:

Male FemaleLung 36% Lung 20%

Colon & Rectum

11% Breast 18%

Prostate 10% Colon & Rectum 14%

Leukemia & Lymphoma

9%Leukemia & Lymphoma

9%

Pancreas & Urinary

5% each

Pancreas & Ovary

5%

Urinary & Uterus

4% each

M.A.Kubtan 6

ETIOLOGYالمسـببـات المسرطنات الكيميائية 1.

المسرطنات الفيزيائية 2.

المخرشات و الرضوض المتكررة3.

االنتانات الطفيلية4.

االنتانات الفيروسية5.

العوامل الوراثية6.

العوامل الجغرافية7.

العادات و األجواء المحيطة8.

هجرة المجموعات اإلنسانية9.

الحاالت ما قبل السرطانية 10.

M.A.Kubtan 7

ETIOLOGY المسـببـات

Chemical carcinogens المسرطنات الكيميائية Hydrocarbons from coal ta r = skin, larynx & bronchial CAAromatic amines = urinary tract CABenzene = leukemiaAsbestos = mesothelioma

Physical carcinogens المسرطنات الفيزيائية

Ionizing radiations = bone cancer

Multiple x-rays = skin/thyroid CA Atomic bomb (Japan) = leukemia

M.A.Kubtan 8

ETIOLOGYالمسـببـات

Mechanical )chronic irritation(:Marjolin’s ulcer = burn scar cancer

Infection:Parasitic: Schistosomas – Liver & bladder CA

Viruses:Hepatitis B – hepatocellular CAEpstein-Barr virus – Burkitts lymphomaHerpes simplex virus 2 – cervical CAAids

M.A.Kubtan 9

ETIOLOGY المسـببـات Hereditary factors:

Familial polyposis – colonic CABreast CA – 2-3x in daughters and in younger age

Geographic factors:Inc. CA of stomach – Scandinavian, Iceland and JapanInc. CA of liver – South & West AfricaInc. CA of Nasopharynx – ChinaInc. CA of urinary bladder – EgyptDec. CA of colon – Black/AfricaDec. CA prostate / breast – JapanDec. CA of uterine/cervix – Israel/JewishDec. CA of skin – Blacks

Customs & environment plays an important role in the development of CA.

Migration of populations usually causes a shift towards the patterns of cancer incidence of the host country

M.A.Kubtan 10

ETIOLOGY المسـببـات

Precancerous conditions:Leucoplakia Actinic keratosisPolyps of colon & rectumNeurofibromasDysplasia of cervix, bronchial epithelium Chronic ulcerative colitis

M.A.Kubtan 11

Neurofibromas Neurofibromas Chronic ulcerative colitis

Actinic keratosis

ETIOLOGY المسـببـات

Oncogenes & Growth Factors:

RNA tumor viruses cause: Carcinomas SarcomaLeukemiaLymphomasRetrovirus have an enzyme that alters the viral genomic RNA resulting to abnormal growth and differentiation of the cell.

Multi-factorial: Lung / breast CA

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Hodgkins Lymphomas

CANCERالتشريح المرضي PATHOLOGY

Classification of Neoplasm:

Carcinoma – arising from epithelial cells

Sarcoma – arise from connective tissue and cells of mesenchymal origin (fibrous, muscular, fatty, vascular & skeletal).

M.A.Kubtan 13

Bladder Cancer

CANCER PATHOLOGY التشريحالمرضي

Grading of malignancy:Broders classified carcinoma into 4 grades according to:

Degree of differentiationAppearance of cells, their nuclei and the number of mitotic figures

Grade I – least malignantGrade IV – most malignant

Carcinoma in Situ:Has cytologic characteristic of malignant tumors

but with no detectable invasion into the surrounding tissue or infiltration into deeper cell layers

M.A.Kubtan 14

ROUTES OF SPREAD طرائق انتشار األورام الخبيثة

Metastasis may entirely dominate the clinical picture, while the primary tumor remains latent and asymptomatic

Direct extensionLymphatic spread

Common in epithelial neoplasms of all types (except for basal cell CA)

Vascular spreadEither through the thoracic duct or by the invasion of blood vesselsCapillaries are almost invaded, veins invaded frequently but arteries rarely.More common in sarcomas

Spread through serous cavitiesPeritoneal seedings (gastrointestinal CA)

M.A.Kubtan 15

CLINICAL MANIFESTATION المظاهرالسريرية

The onset of neoplastic state is difficult to date (asymptomatic).

Seven Danger Signals of Cancer (Direct manifestation):1.Change in bowel or bladder habits2.A sore that does not heal3.Unusual bleeding or discharge4.Thickening or lump in breast or elsewhere5.Indigestion or difficult in swallowing6.Obvious change in wart or mole7.Nagging cough or hoarseness

M.A.Kubtan 16

CLINICAL MANIFESTATION المظاهرالسريرية

Indirect or Systemic Manifestation:1. Secondary to metastasis

Cachexia

2. Secondary to none metastatic:a. Ectopic production of known hormonesb. Secretion of unidentified, hormone like

substancesc. Toxic substances secreted from the tumord. Autoimmune – host is sensitized to an antigen

from the tumor

M.A.Kubtan 17

CLINICAL MANIFESTATION المظاهر السريرية

Signs of Expansile growth:

1. Obstruction

2. Destruction

Signs of Infiltrative Growth:Tumor infiltrates the nerves

1. Pain

2. Numbness

3. paralysis

M.A.Kubtan 18

CLINICAL المظاهر السريرية MANIFESTATION

Signs of Tumor necrosis )Bleeding & Infection(:

1. Tumor may become necrotic, ulcerate and bleed

2. Fatigue and weakness in right colon cancer due to anemia

3. Inflammation caused by cecal CA can mimic the clinical symptoms of acute Appendicitis or cholecystitis.

Unknown primary tumors prsenting as metastases

M.A.Kubtan 19

DIAGNOSIS OF تشخيص األورام الخبيثة CANCER

A. Clinical History:Warning signs for Cancer:1.Weight loss2.Loss of Appetite3.Bleeding or a discharge from any body orifice or nipple4.Sore that is slow to heal5.Persistent cough or wheeze6.Change in voice7.Difficulty of swallowing8.Change in bowel habit9.Growing lump in the skin, breast, abdomen or muscle

M.A.Kubtan 20

DIAGNOSIS OF CANCER تشخيص األورام الخبيثة

B. Physical Examination:1. Palpable masses (movable, non-

movable)2. LN enlargement

C. Laboratory Examination:1. Blood examination2. Radiological procedure:

X-ray, esophagoram, Barium enema, mammography, thyroid scan, CT scan, MRI

M.A.Kubtan 21

DIAGNOSIS OFتشخيص األورام الخبيثة CANCER

C. Laboratory Examination:, cystoscopy

Biopsy:To document presence of malignancyTypes:

1. Needle biopsy (cytological)2. Incisional biopsy

D. Excisional biopsy

E. Endoscopy:Bronchoscopy, esophagoscopy, gastroscopy, proctosigmoidoscopy, colonoscopyRapid frozen biopsy / exfoliative cytology (Pap smear)

M.A.Kubtan 22

STAGING OF تصنيف درجات الورم الخبيث CANCER

A. Clinical Staging of Cancer:TNM:

Stage I = cancer confined to it’s primary siteStage II = more locally advanced diseaseStage III = metastasis to regional LNStage IV = metastasis to distant sites

Use all information available prior to 1st definitive treatment:

M.A.Kubtan 23

STAGING OF CANCERتصنيف درجات الورم

B. Post-surgical Resection Staging: Pathological Staging:

The extent of disease using all data available at the time of surgery and on examination of a completely resected specimen.

C. Re-treatment Staging: Restaging is necessary for additional or secondary

definitive treatment after a (disease-free) interval following 1st treatment.

D. Autopsy Staging; Used only when the cancer is 1st diagnosed at

autopsy.

M.A.Kubtan 24

CANCER TREATMENTمعالجة األور ام الخبيثة

Interdisciplinary Approach:1. Surgical resection 55% (40% alone)

2. Radiation therapy 34% (16% alone)

3. Chemotherapy 22% (alone or combination)

Surgery & radiation tx represents treatment of cancers that remains localized to it’s primary site or regional LN.

Chemotherapy and Immunotherapy effective against tumor cells already

metastatic to distant organ sites.

M.A.Kubtan 25

CANCERمعالجة األورام الخبيثة TREATMENT

GOALS of Therapy: Vary w/ extent of the cancer:

1. Localized without of evidence of spread: Eradicate the cancer and cure THE PATIENT

2. Spread beyond the local site: Control patient’s symptoms and to

maintain maximum activity for the longest possible period of time.

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CANCERمعالجة األورام الخبيثة TREATMENT

CRITERIA of Incurability:

1. Distant metastasis (most common)

2. Evidence of extensive local infiltration of adjacent organs or structures

Patient’s general condition and the presence of any coecisteing disease must be considered in planning therapy.

The PSYCHOLOGICAL makeup of the patient and the patient’s life situation must be considered.

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CANCERمعالجة األورام الخبيثة TREATMENT

SURGICAL RESECTION:

A. Surgical Curative Resection: Wide local resection:

Low grade malignancy Basal cell CA of the skin

Radical Local Resection: High grade malignancy En Bloc Lymph Nodes dissection for breast,

esophagus, gastric, colorectal CA

B. Surgical Palliative Resection:1. To relieve symptoms2. To prolong a useful comfortable life3. Gastrojejunostomy, colostomy

M.A.Kubtan 28

CANCERمعالجة األورام الخبيثة TREATMENT

RADIOTHERAPY: Destroy tumor with preservation of

anatomic structures Direct toxic effect to cells due to

ionization of water

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CANCERمعالجة األورام الخبيثة TREATMENT

CHEMOTHERAPY:Antimetabolites:

Inhibit enzymes of nucleic acid synthesis Methotrexate & 5-FU

Alkylating agents: Substitute alkyl group for the hydrogen

atom Alkylation of DNA molecule interferes

with replication in transcription

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CANCERمعالجة األورام الخبيثة TREATMENT

CHEMOTHERAPY:Antibiotics:

From soil fungi Forms stable complexes with DNA and

inhibit synthesis of DNA and RNA Actinomycin D, Doxorubicin, Bleomycin

Vinca Alkaloids: Bind to microtubular proteins

necessary for cell division causing cell death during mitosis

Vincristine & Vinblastine

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CANCERمعالجة األورام الخبيثة TREATMENT

IMMUNOTHERAPY: Inhibit proliferation of cancer cells w/o

affecting function of normal cells Stimulates the host to generate specific

immune response to its tumor-vaccine from tumor cells

TUMOR SPECIFIC ANTISERUM: Murine monoclonal antibodies Immunotoxins

None-specific immunotherapy=BCG vaccine

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اإلنذار PROGNOSIS

DETERMINANTS: Site of origin of primary tumor Stage of the disease Histologic features of the cancer Host immune factors Age of the patients

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