PRINCIPLES OF THE SURGICAL MANAGEMENT OF CANCER

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PRINCIPLES OF THE SURGICAL MANAGEMENT OF CANCER
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BIOLOGY OF CANCER IS DEPENDENT ON

• Increased Cell proliferation
• Decreased programmed cell death
• Combination of the two
• Adenoma-carcinoma progression
• Invasion and metastases.

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SCREENING

• A test for use in screening must
• be sensitive
• be specific
• be acceptable
• detect cancer at a stage when cure is possible
• be a reasonable cost

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EXAMPLES OF CANCER TYPES THAT ARE OF COULD BE THE
SUBJECT OF SCREENING PROGRAMMES

• CANCER SCREENING TEST
• Breast Mammography
• Cervix Smear Cytology
• Colon Faecal Occult blood test
• colonoscopy
  
  
  
• Prostate Prostate-specific Antigen

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PATIENTSS CANCER JOURNEY

• Asymptomatic phase
• Symptoms
• Consultation with GP
• Histological/cytological confirmation
• Investigation
• Referral to cancer specialist/centre
• Staging
• Surgery
• Adjuvant theraphy
• Palliative care
• Follow up
• Cure

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SYMPTOMS THAT SHOULD INITIATE INVESTIGATION

• Weight loss
• Rectal Bleeding/melena
• Haemoptysis/persistent Cough
• Haematuria
• Breast lump
• Dysphagia/Dyspepsia
• Persistent Headache

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INVESTIGATION FOR THE DIAGNOSIS OF CANCER

• Blood test Haematology FBC
• Biochemistry
  LFT
• 
  Tumour markers
• Cytology Sputum
• Urine
• Endoscopic brushings
• Radiology Plain Xrays
  CXR
• Contrast enhanced
  Barium Enema
• Ultrasound
• CT
• MRI
• Endoscopy Upper GI Endoscopy
• Colonoscopy
• ERCP
• Histology Fine needle aspiration, e.g.
  breast and thyroid cancer
• Radiologically guided
  FNA
• Endoscopic Biopsy
• Excision biopsy
• Excision biopsy e.g.
  lymph node

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PURPOSE OF STAGING

• Define the extent of disease
• Assess likely prognosis
• Allow the development of a treatment plan

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TNM STAGING

• T- extent of primary Tumour
• N- presence of distant metastases in regional
  lymph Nodes
• M- presence of distant Metastases

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PRINCIPLES OF SURGERY FOR CANCER

• Multidisciplinary team approach
• Accurate pre/post operative adjuvant theraphy
• Enbloc Radical Surgery
• Appropriate pre/postoperative adjuvant theraphy
• Good communication with patients and relatives
• Audit of results.

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PRINCIPLES OF SURGICAL MANAGEMENT OF CANCER

• Clinical Scenarios

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• 1) A 69 year old male ,who suffered from Rectal
  Bleeding for 3 months, was found to have a fixed
  irregular mass ,on the anterior rectal wall on
  rectal examination .The liver was enlarged but
  not palpably irregular.
• How would you confirm your provisional diagnosis?
• Which investigations should be done to determine
  the stage of the disease?
• What would you discuss with the patient at first
  consultation?

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• 2) A 33 year old female, who has one son
  ,presents with a painless lump in the right
  breast, which she noticed when washing. On
  examining her you confirm the presence of a
  lump,3cm in diameter but no nodes are palpable
  either in the axilla nor the Supraclavicular
  region.
• She asks you whether she will have to have her
  breast removed. How will you deal with this
  question?
• How will you determine if the tumour has
  metastasised to bone?
• Assuming that the lump proves to be
  malignant,which types of theraphy in addition to
  surgery,are available to treat her?
• What effect will surgery and adjuvant tharaphies
  have upon her fertility and her marital life?
• Does her disease have any implications for her
  two sisters?

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• 3) A 50 year old headmaster ,with a history of
  weight loss, tiredness and a poor appetite is
  found on gastroscopy to have an irregular ulcer
  in the antral region of the stomach. It proves
  to be a malignant ulcer.
• If surgery is advised, how should the patient be
  treated pre-operatively to optimise his medical
  condition?
• Where do the regional lymph nodes of the stomach
  lie ?
• What is meant by enbloc resection of the lymph
  nodes field?
• What findings in investigation would make surgery
  inadvisable or futile?