Principles of Oncology PDF

1crn1 inal c11re -- Pain . orph1ne, . Opiates e.g. n_1_ I __1 bl~ks mar_be helpful. 0~ ·done and ondansetron. _ Nausea .de domper1 . Antiemetics, e.g. metodopram1 ' and vomiting Constipation • d . Regular laxatives and enemas may be reqwre • Dysphagia . . A stent can be inserted Tasty liqui...

1crn1 inal c11re -- Pain . orph1ne, . Opiates e.g. n_1_ I __1 bl~ks mar_be helpful. 0~ ·done and ondansetron. _ Nausea .de domper1 . Antiemetics, e.g. metodopram1 ' and vomiting Constipation • d . Regular laxatives and enemas may be reqwre • Dysphagia . . A stent can be inserted Tasty liquidized _food is helpful. -Mouth care . . Oral hy~ene, ny~atin to prevent caIJdidiasis. If ulcers dev_elop, they treated with Ioc~ anaesthetic gel and metronidazole gel. \,.,. Cough • This may be treated with !_llOrphine and codeine. - may be l'ls- ., I Sloping cd<'C ., uktr. _r:r,4 . --.--... • -~- --r.-e ~ (...J..C Punc11~ -qu . ki surface to make t he ulcer look . - - 0 }es: to the s n . -Th .. .edge drop:. do"-n a!!1~hl·!l g _; ch It indicates a localized, usuan" , ii. , kin with a pun • . , 3!\ if it has been cut out of the s d d by healthy tissue Fig. 9 .2,. ki I ss surroun e f full-thickness,F ea o s l'.½o... I have this type of edge. - m . • hi d am~bC u cers , IscbemJC. tro~ c an ~, c. 3 0) ) -....:, ./ ~ ( , t~~\ ;\f\<l:I I I I Fig. 9.2. Punched-out edge ulcer. s. ~ ~c.,<' r,,.n ~i<lu • •ned ed e: W..1~ (of'Pl..-oV'\ \ , The disease causing this type of ulcer spreads in and d.estrczys the subcutaneous tissues faster than it destroys the overlying skin. The overhanging skin is usually reddish-blue, friable and unhealth (Fig. 9.3). =tts~ti I) II l I- I/>"' "I• ,i > Tuberculous ulcers and ed res e usually undermined. -- Ulcers, Sinuses and_Fistulae ( " 4,,...ch . ( • LIi,.,, (P •~~;,- ......_ . L l:,\10 \Jlcers I r. (\~ ':\1661\ • •) ~ .. \ _.,!-...1 r- 1 1 ~t'r c.,,u J """"'~ ulccl' is a brcok of the continuity of ..~ n cps·ti1c1·su1 5urfacc. Ul cers fo 11ow tra11n1atic · . .rc111oval, or death and dcsquan1ntion by d"sscasc, o f th e w h ote or part o f J.11 cp1tlu?hun1, and n1ost occur in the lo\ver t·l lll b . · Unle!ili it is painless and in an inaccessible part of the body, patients notice ulcers fron, the 111on1 ent they begin, and will know a great deal about their chnscal . 1\n features. 7--History · Onset, presenting symptoms (pain or discharge), associated symptoms {interfering \~th activities like \valking or eating), course and previous ulcerations if present• ....... Examination .,j - - H'll:t.~c. •I _Li."l'o " f."-=,:,o \) ~ CT) ,,_ 0•- ,)A,..-.J. b.:vi , · TI1e features of an ulcer that must be examined and recorded are as the edge, base anJai~arge. .-a; b~ 1. d ·'nw ..J 1,, c.. ,. Jo. ~ ti~ • After recording the characters of the ulcer, you must examine the surrounding tissues, the state of the local lymph glands, and complete the general examination. C) S\oo~,. :d ,<. G ('<Ai-.1-Cd - c,..) ,. .. Theed ge r-,, .- - , .. rv _.r S I , a..- .,_ Sv.{~ - ~1 . The edge oCfan ~c:r·i ~ ~ because it is the junction benveen healthy and diseased tissue and takes a characteristic form according to the~erlying dis_:ase. Ther~e five common types of ulcer edge. , i;.~ ~ s ( i) ,,.- Gr""wc.H..,,tss.c..c: - ~ '1o.o u '- ~ 7 l( ~ e.d .--,.,--.---.--mo~ ( rn1.:+1<>1.) • C • ome > The edge slopes gently from the normal skin to the base of the ulcer. It is~ 1 @ \l and consists of new, healthy epithelium growing in over the base of the ulcer , 'tg•• 91 . ). > The (__ ;;;.. ..:C ~ - - - best examples are(healing.\.traumatiOand enous ulcers. 0 l K,t ,n..-• ,It •. i A' t,} \..,,..,,., f ra . ~ I)i.s1.barg~ I I • •• .. ' he dischnrgc frtlll\ ,,n ul1.cr 111ay h c(qcrou "' l 0 1,.; • ,.. r . .1 . . •~O ..,.,, :,«UKUlllQ ll"• p.)ol.Ul'cnt, p ,.. n e n 'liVO, copious, or so shght I hat 1t d1 lcs Into a s1.ab -..,-the . • It s I1ou IcI b c cu IturccI to ascertain .,turc of ,tn) infc1. ling organi!'.lns. 11 ev,:,.._ (I',. L ) _ ~ ~- ~ @c . ·rr.21,2,h i<:._ ~crs, u \(,~ \V'( r, (!S£ eCtal. tyecs of ulcers - ·-_,;;;;.;; ,\-, ~.. I •I, I II Q) f',/eny/d/~ 01,,,. . / \1,,J.cJ (.CIA t <... ~~\UP W'••- 'r ) > A[Jro pfilc ulcer is an ulcer which has developed as the result of the patient's in• • • sens1tJV1ty to repeated trauma. These ulcers are commonly associated with those forms of neurological disease ,vhich cause loss of the appreciation of pain and light touch in \V'eight- bearing areas. 0 ;.,. Relations > Describe the relations of the ulcer to its surrounding tissues, particularly those deep to it. It is important to know if the ulcer is adherent or invading deep structures such as tendons, periosteum and bone - which may indicate the presence of osteomyelitis. > The local glands must be carefully examined. They may be enlarged because of secondary infection or secondary tumor deposits. General examination . This is very important because many systemic diseases as well as many skin diseases present with skin lesions and ulcer. . Examine the whole patient with care, looking especially at their hands and faces, which can supply important clues to the diagnosis. & (" Sin u~ l'UI '11\.\: (-A't:>'~Ce ·,<,.\ . A sinus is a tract lined by granulation tissue which connects a cavity (usually an old ab:ess) with an epithelial surface• . Sinuses commonly follow surgicalrw--o_u_n_a...,... rn.-;;fe:-cti -.. OilSJ andCnecros~ of ~ors'. [JJ,~ ~I ~ ,yJ ~ s-:'l\u S (ci.,Jl~ "3,~ '"' °"J f:stJ~ L, ~o\o5~c,J.. (u '° swa.,~ be11.Xet1 , ~o c~oJ l ~--' (\i.ce. ... • • s 7 ! -------;-:;:---.-::-r,-,.-...---11:.ii,.i' mo 1--- C.:,,.,111, ~ ;,. ':, ,n ~ ~ · •U!!...dcrn1lned ed~ ulcer. ~ R~k~~g_e; "1:.l,,n:..~0/'Qi . - ~ (b ~I .~~) > A rolled ulcer edge (begded) develo • • _ ..,.,__ Giecrotic}at its center b t . ps \vhen an invasive@liilar d1sease: becomes • h the surface of the skin u(F'grows quite quickly at 1·ts penp cry, so t h at it rises above 1g. 9.4). > A rolled- edge ulcer is typical of a basal cell carcinomal -'f ~-t~u~~J~5~-~u;c. 1-;::;-.--,I ,,,_ - - w - @>.£vertededw /Jf$.f•llc. fig 9.•1. Rolled (beaded) edge ulcer. ~(oof > When an ulcer is caused by a fast-growing infiltrating cellular disease, the grow- ing portion at the edge of the ulcer heaps up and, in its malignant exuberance, spills over the normal skin to produce an everted edge (Fig. 9.5). ~ I ·~- ""f "' 9 6. An illustration 5howing a sinu~ (left unage) and a fistula (right image). • (si ® Or{fistuIJi may fail to close. In '.:J order to. identify the cau ses of failllt sin "-.-""' ,, ( ._,..,,,.e, -r ,, 0 A remember the mnemonic C:'f~_y:N~" • c~..,, , • ij .....-:_ -'vG,d-w'II tlo-4 c.lo5c2 © • _foreign body (e.g.,&t1tch mater1aJ. ,...• GiJ. Qia3iation1(causes ischemia which interfere with closure). (] . @emiaJ(@Dvascularity interferes with closure /Infections ( especially chron infw;ons, e.g.,@#nomyoovl, {iuberciil(!§l'sJ~ijD. lS:J • Epithelialization (epithelialized cavities fail to close). @) •(Neoplasia)(~!!,ty has undergone ~aliSl!ant):hanges do not close). f{J · Distal obstruction (obst:rY.ction to drainage _hinders healing). ID · Shortage of drainage (cavities in dependent positions heal better). ~ • edge ulcer. d fig. 9.5. F,vcrte 0 Gr""i.1.J;~" .\- ,.s,.. (. [ fV lhe bas~< -1;-r~:.,... ~ be examined carefulJy. It may be necessary l() . The : scl},(the ulcer should - /""'"" The base is Likely to consist of thre this can b ~ e remo,·e the slou_gh before - "'t:ypes of tissue. G) Cef°ranaj~tion]Iisue) . l d fibroblasts covered by a Th. is a red sheet of delicate capillary oops an l~yer •; f fibrin or pJasma. It is the first stage of the healing process. @ thin El-I:>eaa tiss.@ , This is called a slough. When a slough separates, it may expose healthy t issues, which then become covered with granulation issue or tissue becoming involved in the ischemic process. ;i ~ fu~ > The base of a squamous cell carcinoma is the malignant tissue itself. It may be slightly vascular or necrotic but does not develop healthy granulation tissue. Skin reconstruction 1 hi: n:con,tructi,·c ladder . Plastic surgerr is often concerned ,vith n1nking a surgical wound for example '"hen ren10,ing a ~kin cancer. Havmg n1ade the wound, the surgeon must then decide ho,\· be~l to a'-hievc closure of the ,vound . . In some cases, secondary intention healing or simple suturing to facilitate primary haling is al!!J1at ,is refill!_r!d . . In a larger or more complex wound, the surgeon bas to employ reconstructive techniques to close the wound in a way that is secure1 anatomical, functional and, if possible, co~metically_ acceptable. For this reason, many options may exist to dose a defect, but most reconstructive surgeons mentally ascend the so-called - •reconstructive )adder' 'Fig. l O 1, Free 11ssue transfer - ---- = - ~ Local tissue translec I TISSUe expansion .,. ~j~ Skingratts Primary ,ntentt00 -- - secondary ~e~ Reconstructive ladder. F,g. lo.1. I 10 I t"'"''' Site ,,nd complt.-xlty of d efect 1'.1tl<"t1I'~ 1,1c1or ,, 1,.,10 1nY ,1,,11,111h•n 115,uc lost <,..11,rnl h,:ilrh ,\ vuilnbillty of local tissue •rin,cfram e for wound A graft b .1 cl osure Gr,1fl one part of the body and transferr , ,d con1 plete Iy from td tissue n:ntO\ c . . bl00d supply and therefore depends • arated front ats to another ~,te, being sep d fi its revascularization. being placed on a healthy vascular be or on It i, classifietf into: . Split-skin graft (Partial thickness or 1biersch)• . FulJ thickness graft (Wolfe). Split-skin graft (partial thickness or 'Ihiersch) . This consists of the epidermis and upper papillary dernµ s. The graft is cut ,vith a special knife that controls the skin thickness (dermatome) (Fig. 10.2) • . The usuaJ donor sites include arms_and thigh. _The site can be reused as a donor .::: ... site in 7-10 days., • The main use for split-skin grafts is in the treatment of burns, and to close detects after removal of skin tumor. ~feshing of the graft: · Skin grafts may be meshed by being passed through a 'mesher', which creates multiple holes so that the graft looks like a string vest. • This has two advantages: > Greater coverage may be obtained. > Ser~ma or haematoma may escape through the interstices . • A d1sadvantage is that the final result also resembles a _r_1n;.;.cg;;i...;.ve.:.:s::.:t:.... st • - "' r 1,1·a•~ •ng cp 1•1h c llnl s tr u c tures, •1.1: L 1 C-"'- .,1 th•· ,i,,no . (ron, th e rc1nu n 1 .. • •1,11, ·1h••H1,1l1,,t ,on I . ,nc r the graft, the more . 1111~ h.:.,1~ h) •·P' I s,vcol g londs 'I h e t ,11 r"l>ll\ l~lllid••s, ~ J,u1ds. ,, n• s~·h,1et.•0U - 1Z • plication of ~ 11 ,., •. P th.: healing. 1· ' donor cite involves a . .- ~ t •nt o t,ie "' the ti ~ •f J . Tr,1dit1nn:1I n1:1n:1gen1c . 0 d •:fS and loc a ~ C--g@l l'eEt\lireq e bandage fo1 1 a • • cotton " ·ool and a crep ·- Fig. J0.3. Full-thickness skin graft, (a) The nose after basal cell carcinoma excision, (b) Tue graft held ,vi.th 'tie-over' dressing, (c) The mature graft Survival of skin grafts · Survival deRends on the graft being placed _o n a__hea\tby1rasc11lar bed to allow in ,... growth of a new vascular supply into the graft. • • • Fig. 10.2. A dermalome used in harvesting a spill-skin graft. Full thickness graft (Wolfe graft) • This consists of the «:Pidermis and dermis. and therefore includes all skin elements, • e.g., hair follicles, sweat glands. It can be harvested using a knife. . Only areas of thin skin can be used as donor sites (e.g., supraclavicular, postauricular areas, etc... . Toe donor area requir~ closure and if this cannot be closed primarily a splitskin graft may be re;_;;gi.::u:;ir:;.:e;,;:d::,___ _ _ __ . Main uses are for(facial areas and hands) Table. 10.2. Comparison between split- and full-thickness grafts. '('<' ' a Split-skin grafts ~f)~+,J' / Donor site factors r Large area ava1able ,:..------ full-thickness grafts Smaller area . Donor site heals spontaneously Donor site must be closed Donor site reusable V"' Donor site scars . Recipient factors Poor color match Good color match I Abrasion resistant Easily abra~d Inferior cosmetic result More reliable <talce> Shiny texture~ inelastic Good cosmetic result • Less reµabl~ Ind.ication6 for skin grafting . Traumatic skin loss, e.g., bums• • Extensive ulcers. . Follow~ wide excision of skin tumors• . Skin flap donor defects • . Covering large granulating areas. , -- - Normal texture, elastic . - lnhlc,. 111 , C,11,.c, ol grnll fntlurt l ~.,u~,,~ ol ,·.r.,lt r ,llurt ~---------. • Loss of .:ontn.:t of grllfi: I ( CllSiOll OJ' gJ"I) fl . ... , fluid ben eath the .graft, e.g .• scrun,, blood __, , pus. , 1novcn1cnt bctv,ccn graft and bed. ;....__ - • Tnfected ,v911nds. Grafts will ,\ot t·,kc • fccte d b ed . • on an 1n lhe n1ost com1non infective agent is Gro up An. • I-' I1ac1noIy1·1c streptococci. • G ra fting on to an unsuitable a~-s £U l nr b ase.J.. e.g. bone, cartilage, tendon at these sites a flap procedure is required. , • • 0 -Tissue expansion · An expanding mass is placed in the subcutaneous tissues will result in an incr eased amount of skin over the lesion, a phenomenon most frequently observed during - pregnancy. • A surgical tissue exp~der is basically an expandable balloon, usually constructed of silicone rubber, with a means of introducing fluid at intervals, usually via a selfsealing port (Fig. 10.4). • The expander is placed beneath the skin adjacent to the defect. At weekly intervals, the patient visits the outpatients' clinic for expansion of the balloon by injecting sterile saline through the skin via the ,port• . When the desired expansion is achieved, the expanded ~kin may then be. fashioned . into a local,.distant or free flap at)d used to .close the defect. Advantages: . Near perfect matching of color and texture • . Skin retains its capacity for hair growth (good for covering scalp defects) • . Retains its own .!,.ascular and nerve s~ply. Dic;advantages: . .slow (takes about 2-4 months). . V1Sible bulge of the expander. . Requires repeated visits for saline injection. . Risks of infection around the expander. . A 'flap' i~ a Fl~l~ . . h blood supply which can be used to . . t,le tissue wit a • · • • of V13 • p1t.>ct r~.:oni-tn1cl a tissu~ defect. . rtance to the survival of the flap and thus ount unpo · - f O . The blood supply is param • the healing of the ,vound. . t ms of their relation to the defect, their . It is most useful to think ,of flaps -~ er their constituent tissue types. d blood supp J)' an .,. hi , ..1 e. JO" C)as5ification of flaps according to location. . • A. flaps by location . Local: provides local cover, e.g., rhomboid, rotational, advancement, etc... . . Pedided: aJJo"·s flap to be brought from a distant site being attacked by a pedicle• . Free flap: needs microsurgery but allows flaps to be detached and brought from anywhere. Local flaps . A JocaJ flap is one that is raised adjacent to a tissue defect in order to reconstruct it. • Local flaps are created by freeing a layer of tissue and then stretching the freed layer to fill a defect. · They are often used to replace skin on the face following resection for skin cancer. · This includes rhomboid flap, advancemrnt flaps, rotation flaps, and traqsposition flaps (fig. l 0.5 and J·ig: 10.6). ' ;,·· ( i: ', 7 ~ ) • ""- \ ,.. > 1: . . .. ,., ( .' '~ I • \:__ l ~ ' 'tI \ Fl11. I0.5. Rhomboid Oop, lls ➔ Advancement nap -- ---.,. -- - _,,. Lt~-c;-~ Rotation nap Transposition nap l'ig. 10.6. Local flaps. Pedicled flaps · When the tissue adjacent to a defect is of an unsuitable type, insufficient in size or damaged, tissue can be mobilized from a donor area and brought to the defect while still attached by a pedicle that contains the blood supply of the flap. Free flaps • In some circumstan ces, local tissues or tissues that could be obtained ,,'i.th a pedicle do not achieve all the required properties for the reconstruction. • In such cases a better reconstruction is achieved when a flap is raised ,~ith its blood supply then disconnected from the donor area antl tra11sfcrred to a recipient artery and vein by ~icroyasca.tlar slJ.,!g_ery. A flap used in tl,is ,,,ay is c,,lled a free flap or a free tissue transfer. Rondon, llap, bl d supply i.e. no specific artery or ve·1 • • d a r-1ndon1 oo ' n '! . A !'kin flap ra,s(! on : • d , d on subdermal vessels for its !zlood sup~I included in the tlap, ,,·Juch epcn s • y.l\ . I d ,·n1ple advancement flaps, rotation flaps, an d transpos ~ . Exan1pIcs 111c u e s flaps. ,.Axial . Theseflaps have a kno,"'11 vascular supply based on a nam~d artery and veil1. Flaps of greater length may be obtained, the flap being up to four times the length of the base of attachment. • Examples include forehead flaps based on the sup_erficial temporal ~rtery, and the radial forearm flap based on branches of the radial artery. Table. 10.6. Classification of flaps according to tissue type. C. Flaps by tissue type · Skin flaps - may be axial or random. · Composite flaps - very useful for cover in major trauma eg. myocutaneous, fasciocutaneous and osteomyocutaneous. ~Jun flap • Cutaneous ~aps contain the ful~ thickness of the skin a • are used to fill small <leki:ts e g rh b .d fl • nd superficial fas9a and , • . om 01 ap. • Composite flap • Aflapco ntrun1ng • • ~r more tissue eleme bone, 5?r cartila~. ......;.;;;;;:,::,:.:;~ nts, usually skin, ~n addition to musclei . Ex::tn1plcs: >.fascioc~~aneous , fl1tps ~dd sub!-=utancqus tissue nnd deep fascia, resulting tn a n1 ore robust blood ,s,ura1ly mid ability to fill a larger defect, e.g., temporoparietal fasciocutaneous flap for coverag~ of the ear, orbit, anterior cranial base, and upper . . two thirds of the face . . ~ - Myocutaneous flaps fu~ther ad9 a layer of muscle to provide bulk that can fill a > • d~eper defect, e.g., pectoraUs 111ajor f\ap for head· and neck reconstruction. > Osteocutan~ous flaps in reconstruction of bones, e.g., osteocutaneous fibular flap • for mai1dibular reconstruction. • • Donor sites • The raising_and transfex: of an}'.' fl~p ~ill, of course, res~lts in ~ ~efect where the flap originates. This is known as the s.econdary defect,:, • ~e resulted de_fect is either c;losed directlr_ or by graft. Indications of flaps / •• Wound clos~e in areas of Eoor vascµij\rity, e.g., b_we hon~ or pu-tilag~ • Areas of bon~ where p_adding is ~eeded, e.g., ov~r sacrum or ~schial tuberosity. 0 • Facial reconstructive sur.gery: , 1,u\."nl lc111111l'N 0 ' 1 llcopl11"1n!i \ I" . ~f,1) be a prin1ary 1un1or or sccon<ln 1 • fu . ' r y Y•nphndcn opathy . ~f.t) be pnu, I or, n1orc co1n111only • • • pain1css. r • · due to . Local compression. . Clp:.ular stretch. • Infiltration of regional nerves by the twnor . Obstruction of a hollo\v lumen. • . Metastasis (e.g. bone pain). - • e.g. liver metastasis presenting with jaundice. • r.1, ,.Y1nb: due to • Local tumor ulceration. • Erosion into a large vessel. General featurcs of neoplasm 111, 11 • L,: due to I -• Occult or overt bleeding. • Poor nutritional state. • • Bone marrow infiltration. ' • Canrer ~chc.<l. • A wasting syndrome with progressive loss of.bod¥ fat and severe weakness. ' • Mostly caused due to excessive catabolism mediated by cr,tokines secreted by the tumor and poor nutritional state. -- Bone fl;,in -- ~,1<l pithc.,logical fractl1rcs ~ • Due to bony metastasis. · Cancers having marked tendency to bone metastasis include: kidney, th)'I'Oid, breast, prostate and lung. Principles of Oncology JI 1s the br,\I\Ch of 1\\Cdit.in c \Vh it. h d e-' ws ('I, •,;ili, .11ion ol W• l l 1l lu1nor11. l111no1 • Behavioral clllssification·• b enign or 111a 11gnant. · • Histogenctic classification: according l o cc II o f o rigin • • . • nchaviornl cl.,ssilication lhhlc. 11 I Differe nces bciwcc n a b en Ign and 11 mallgna.nl neoplasm. Benign M,11ign:u1l s10,v rate of growth Ilapid rate of growth GrO\\IS by expansion Grows by invasion Usually encapsulated Not encapsulated No recurrence after removal Tends to recur after removal Seldom causes death Causes death No metastasis Metastasis often occurs • • ! i,s,'<> gc . t. :i, classifica•:on > All have the suffix ' -oma'. > Benign epithelial twnors are either papillomas or adenomas. > Benign connective tissue tumors have prefix denoting the cell of origin, e.g. a _!!Eoma (fat), osteoma (bone). > A carcinoma is ~a.malignant.epitheli~l neoplasm • • > A sarcoma is a malign.ant connective tissue neoplasm. -- - ~ Eti, ,T, ,::>, f c~ncer Chemicals: ~-~e;;,osure to aromatic hydrocarbons in ~arettes and azodyes in rubber industries. Radiation: . Ultraviolet light is a major cause of skin cancer. rnolc \. h)pi• rumo" hor1t1Clll{ , '\. refill II •£Some tbot '"" no b,sis in endoc6M tiss ue can secrete peptide uIes th,t are vc.-y simH" in srructure to active hormones and these molcc cu1~, ,o,logucs. · Peptides tl,al ,,. commonly ,eC'eted are those stunulating ster oids resulting in O,shing syndrome. - ' "' ,, cele,.,, -e- l General features of::=:~ - - ~ - hu neoplasm (from to merus, acanthosls n.ignca . ns & ecto p, pie left to right)·leadin . steroids • Cancer cachex.ia, pathological , , g to Cush in acture of g syndrome• fr fj 111,11 " • loni.;in~ •11, k to ti ll• lll'<- • Jlsposc Lo c;arcino rn,1 ()f •n ,n.iy pre< t~,- In lhildrt kilt's lymP h omll and nosophnryri &c~, • tin nlld. • \ 'iru~l·~: . ·~ to uur :s\') prl•,hspoSc. . • •• Bur\"i111s(I • Jip:-h:1n • d' poses l o }(.,pos1'ssorcoma . ~n.inon1a. . . ·y \"irus (I-ii \') 1,rc 1s '1dl'h<.'.ll'l1l • f:lun1an Jnnnuuc iJies'). . N (·cancer fom Genetic: in fiimilics f .. KuJtiple Endocrrne eoplasia -,ear to run rt o iv• • Son1c tt1n1l1rs ap . (the thyroid as a pa ' ,..,_., carc1non1a o . e.g. nl edul1•(MEN) ~rndrome 2. - • l\lt·ta,taSJS their site of origin (primary) . ant ftlmors spread from The process \\•hereby mahgn ) distant sites. to form other tumors (secondary at -- • • ant tun1ors J\1cthods of spread O f nJ.t I•~n . ding tissues. . • Direct spread: into the surroun d . ·t1· ally via lymphatics. • omas sprea 1Jll • Lymphatic spread: Most caron • th Od is favored by sarcoma. • Blood spread: This me . ed along patural passage3 . • Natural passages: Tumor cells are cam . 1 t d m· • remova I' may get unp an e the surgical • Inoculation; During its surgical }}"QIID.d. , ' • Perineural: Along the nerves. ~/•i:,iaJ forn1s of neopla~ia: • Occult carcinoma: It is a term given to carcinoma which manifests itself primarily as metastasis because the original tumor is not sufficiently large to produce symptoms, e.g. carcinoma of the nasopharynx, antrum and thyroid gland. • Loe.ally malignant tumors: They are malignant tumors which are locally invasive 1 but they rarely give rise to distant metastasis, e.g. basal cell carcinoma, giant cell tumor of the bone, and adamantinoma of the jaw. • Teratoma: A germ ceJJ tumor representing all three germ cell layers · tod , 1.e. ec erm, mesoderm,and !ndoderm. • Hamartoma: A malformative lesion in which the tissues of th t d in a disorgani1..ed manner. e par are arrange 'l\1n101· gr1ull11g u ud .,,nging ,,,.,., 1 11r.ulin~ 11 • l nethod of ,\ssessn1cnt of the d egree of •' u 'i Ocr en t'1at'10n o f a tumor an d cc,rrcr.pon d s A l<l the ,tggn!ssivc behnvior of the tun,or. . n,mors ore graded as: , \ \'ell differentiated. Moderately differentiated. 1 1 poorly/Undifferet1tiatcd/ Anaplastic. 1\t ,·1 I •l I • ' \ . . It refers to the .sizt and ~prea!i of the neoplasm as assessed by surgeon, pathologist or radiologist. Used for decisions on management and prognosis. . Staging often requires extensive investigations of the sites most likely to be involved in disease and is aimed at assessing degree of tumor spread to regional nodes and distant sites. This includes: p}Q.9d ~sts (e.g. liver functions, tumor markers). 1 > _91.ology > X-ray > Bone or biQpsy for histology. or CT or MRI. scan . . The most commonly used one is TNM system. T:c Primary tu1nt1 r TO Tis Tx Tl-4 No primary tumor In situ primary tumor • Primary tumor can't be assessed Size of primary tumor N==Nodal mct~st~sjs NO Nx Nl-3 No nodes Nodal metastasis can't be assessed . ty or distant lymph node group involvement Relates to nuJE ber, fixi ' . :\I • I 1 -t .i•I' ~1nsls I N Ji,•ti111I n1ct11-. 't be nsscsscl (I c11tt 11,s,s ct11s • • 1 pist11n1 11 , . ,rcscnt (ll<t,1111 "MO ,.. ~1 X Ml ,n,· • Oish'" I 11,c111sl ;1:; IS 1 11 rJ-cr' b useful in monitoring o f s presence inaY e Pec,~t ·r11 n10• na . , the blood \vhose . substsnccs 11. omccrs. . in diagnosis, stagu1g, treatmen t and detectio n of recurrenc e. Ui ular carcinomas o f the th_yroid · The}' arc useful Examples: d ·n apUlary and fo c , .d • • 11l\'1l>,..h,[,11lin: elevate t _p • arcinoma of the thyro1 ·_ " d • medulla!Y c . Cttll·1tonin; Elevate in cancer treaune11t • Options: • Surgery. • Radiotherapy• . Chemotherapy. #. Hormonal therapy. • Others. Neo-adjuvant therapy is a therapy which is used pre-operatively to downstage or debulks a tumor. Adjuvant therapy is a therapy which is used post-operatively to reduce risks of recwrence or treat micrometastasis. Palliation is a therapy which relieves symptoms whilst being unable to remove the tumor burden and so it is not curative. I . (,. . . Surg'-'• y ,tole ot s u 1·gcry 111 l·,,nccr I 1·cnt '"l'nl: _ ,.,i ui n osi, a n d ,t.,~in ~ ,nost c.,ses, the diagnosis of cunc,. h _ •d out but occ ,sio,iall . er as been n,ad'- be fort definitive surgery is \.,u-nc • ' Ya surgical pro . d . . , tvinph node hio1,sy r , d" . '-C ure is rec1u1rl'd to make the d iagnosi,;. > e.g. , , cn1ove ,or h1stolog·1ca I d 1agno1;1 ' .s. , 111 i::- , ·1, . • ~ ,' . ,1 11 , ,r, di •li.\Sl curative surgery for cancer involves rcmo I f h . . . va o t e prunary tumor and as much of the surrour1d mg tissue and ly,11ph dr • ainage as possible in order not only to ensure local co11trol but also to prevent the sn d f • ,: rea o tumor through the lymphatics. 1 er •"il, , •c •iscase > Jn son1e circumstances surgery " • disease . . ,or metastatic may be appropriate. This .is particularly n:ue for Jiver n1etastasis and isolated lung metastasis. > Not ,,aJid for multifocal metastasis as. well as brain metastasis . . P.1 Tliation > In many cases, surgery is not appropriate for cure but may be extremely valuable for palliation. >A good example is the patient with symptomatic primary tumor who also bas distant metastasis. In this case, removal of the primary tumor may increase the patient's quality of life although it will have little effect on the ultimate outcome. > Other example is i.r1sertion of a tube for feeding in cases of inoperable _cancers of the head and neck iqvading the esophagus. • PreYcntion > There are some cf ear indications for surgery in the prevention of cancer. > For example, thyroidectomy for patients with , family ttlstory of medullary carcinoma of the thyroid or MEN, I) syndrome. • Recon~fr11Lri on > After surgical excision ~fa solid cancer, reconstruction is often an integral p_art . h b .d flap used to replace skin on the face follo,,'lng of an operation, e.g. r. om 01 resection of skin cancer. • ' . General: 0 > 1,eth,,rgy. 1r0 > toss of :,pp1.•titc. t ''J "'C. , ()Jigo!-pl!rn1i,,. C f\.)e,; ~?&,,...., , prc111,,turl.' n1l!11opausc. > H\lJ\I! n1arro,,· su1l prcssion. C hc111othcra , .i ,ninio;trnti,">n of chcn,othc rnpy •IY . Oral. . Topi cal. . Intravenous. . Intramuscular. . J11tracavitary. Uses of chcn, ot t era1~y . Curative (e.g., lymphoma) . . Neo-adjuvant. . Adjuvant. . palliative. Acf,•er~ effects nf ("hr.rr11ot 1e•·ary • . Nausea, vo~ting, meta1lic taste, general malaise. . . • Oral ulceration. • Infertility. • Bone marrow suppression. . Immunosuppression, Opportunistic infections. • AJopecia. Hor111onal ther,lpy L-Thyroxine for thyroid cancers. J{ucfiot hcr11 P>' • ,\d111inl,1r,1tHll 1 •• , 11hct I., ' 'I l 'I'' be treated. I ucs 10 . J · 1110 the I ss . 11,1t,nll" t ·J -ancer) • 111 . 131 tor I hy rot c; . toa1llr: (":111 [1l' • •. II,·• (t• a. tOl • hilt'· . sy~tc."nll'-a • • ·C' • L-an1 ntdJataon, . E'.'tcma I 1 ~ f(g J 1 ' ft. ) and external beam radiation Radiotherapy. Local radiotherapy (le image (right image). Uses of radiotherapy • Curative: for radiosensitive tumors (e.g. lymphoma, myeloma). • Neo-adjuvant. • AdjuvanL • Palliative: for symptomatic relief, from either primary or metastatic disease (e.g. relief of bone pain). Ad,·ersc effects of radiotherapy • Local: > Itching 1 and dry skin. Ulceration. Radiation eneterits. :r;f~,..,~41, o? SrwJl 'La~~h'~ dlLt. ~ 'rcd./J-1 ..., 1 Delayed wound healing. 1 Alopecia. 1 ' Osteoradionecrosis.