Surgical Oncology.docx
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Surgical Oncology.docx
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SurgicalOncology
SurgicalOncology
DepartmentofSurgery
ShanghaiInstituteofDigestiveSurgery
RuiJinHospital
ShanghaiSecondMedicalUniversity
肿瘤
TUMOR
DefinitionofNeoplasia
adisorderofcellgrowthinwhichthereisapermanentandinheritedchangeincellsresultinginapathologicalproliferationoftissue.
TheEtiologyofCancer
●Viruses(papilloma,Epstein-Barr,
HepatitisB,retroviruses,HIV)
●Radiationexposure
●Environmentalindustrialcarcinogens
●Tobaccoandalcoholconsumption
●Geneticsusceptibilitysyndromes
HistoricalObservationof
ChemicalCarcinogens
DateObservationCarcinogen
1761ExcessiveuseofNitrosamines
snuffleadtonasal
polyps
1775Scrotalcancerinsoot
chimneysweeps
1860sbladdercancerAromaticamines
1915RabbitearspaintedBenzpyrene
withtardeveloped
papillomas
CancerMortality&Behavior/environmentalFactors
FactorPercentageofcancerdeaths
Smoking30
Diet30
Infectiousagents5
Alcohol3
Sedentarylifestyle3
Ultraviolet2
Airpollution2
Smoking-relatedcancers
●Lungcancer
●Oropharyngealcancer
●Stomachcancer
●Cervicalcancer
●Pancreaticcancer
●Renalcancer
●Bladdercancer
●Livercancer
●Leukemia
VirusesAssociatedwithCancer
VirusCancer
HepatitisB,CHepatocellularCancer
HIVKaposi’ssarcoma
Epstein-BarrvirusNasopharyngealcancer
Burkitt’slymphoma
HumanPapillomavirusCervicalcancer
Internalcauses
Hereditarysusceptibility
Endocrinefactors
Immunefactors
Prevention
Firststep
etiology
Secondstep
earlydetectionandtreatment
Thirdstep
improvequalityoflife
MajorGenesinDevelopmentofCancer
●Oncogenes
●Tumorsuppressorgenes
●DNArepairgenes
Oncogenes
●Growthfactors
EGF,TGF-α
●Growthfactorreceptors
EGFR,PTK
●Intracellulartransducers
cAMP
●Transcriptionfactors
c-myc
Multi-stepnature
ofColonCancer
Normalepithelium
ModernViewpointofCancerasaLong-termProcess
Theclassificationandnominationoftumors
NomenclatureofMalignantTumor
NamesoftumorTissueoforiginExamples
CarcinomaEpitheliumAdenocarcinomas
SarcomaMesenchymalLiposarcoma
Malig.lymphomaLymphocytesLymphoma
Malig.melanomaMelanocytesMalignantmelanoma
Malig.MesotheliomaMesotheliumPleuralmalig.Mesothelioma
TeratomaGermCellsTesticularteratoma
ChoriocarcinomaTrophoblastUterinechoriocarcinoma
BenignTumors
●Alimitedgrowthpotential
●theneoplasticcellscloselyresemblethoseoftheparenttissue(welldiff.)
●growingslowlybyexpansion
●awell-encapsulatedlesion
●donotusuallyproduceseriouseffect
MalignantTumors
●proliferaterapidly
●morepoorlydifferentiatedcells
●progressivegrowthandinvasionofthesurroundingtissues
●metastasesbylymphatic&bloodvessels
●ifnottreatedearly,eventuallycausedeath
TheDegreeofDifferentiation
●Welldifferentiated
●Moderatelydifferentiated
●Poorlydifferentiated
TheObjectivesofCancerStaging&HistologicalClassification
●toaidtheclinicianinplanningoftreatment
●togivesomeindicationofprognosis
●toevaluatetheefficiencyoftreatment
●tofacilitateexchangeofinformation
●toassistincontinuingclinicalstudiesofcancer
HistopathologicalStaging
&Classification
●Adenocarcinomas
●Squamouscarcinomas
●Smallcellcarcinomas
●Largecellcarcinomas
●Sarcomas●Lymphomas
●Leukemias●Gliomas
●Seminomas●Teratomas
TheHallmarkofMalignancy
●LocalDestructiveInvasion
●DistantMetastasis
------thecardinalbehaviortodistinguishbenign&malignanttumor
PathologicalFeatures
ofMalignancy
●aninfiltrativeuncapsulatedmargin
●invasionofbaselinemembraneorsurroundingstructure
●evidenceofinvasionofbloodvesselsorlymphaticsormetastases
●tumornecrosis
PathologicalFeatures
ofMalignancy
●architectureabnormalities
e.g.increasedgland/stromaratio
●cytologicalabnormalities
e.g.increasednuclear/cytoplasmratio
●numerousmitoticfigures&abnormalmitoses
TwoTerms
●Metaplasia
----thereplacementofonefullydifferentiatedtissuebyanother
●Carcinomainsitu
----thehistologicalabnormalitiesaresufficientlyseveretosuggestcarcinoma,butintheabsenceofbasementmembraneinvasion
EffectsofMalignancy
●Tumorarisingwithinahollowviscus
obstruction
●tumorarisingfromsurfaceoforgan
ulcerationandbleeding
SpreadofMalignantTumors
●Directinvasion---Rectalcancer
●Lymphaticsystemtolocallymphnodes
--Breastcarcinoma,Gastriccancer
●Bloodstreamtodistantorgans
--Liver,lung&brain
●Acrossbodycavities
--Ovariancarcinoma
Diagnosis
●History
●PhysicalExamination
●LaboratoryTests
●SpecificProcedures
SymptomsorSigns
ofCancer
●Alterationineatinghabit
●Lossofappetite
●Problemsinswallowing
●Changeinbowelhabit
●Thepresenceofalumpatanysite
SymptomsorSigns
ofCancer
●Theappearanceofbleeding
●Unexplainedrecurrentpain
●Recurrentfevers
●Unexplainedweightloss
●Repeatedinfectionswhichdonotclearwithtreatment
Para-neoplasticSyndrome
●SmallcellcarcinomassecretACTH
Cushing’ssyndrome
●Renalcarcinomassecreterythropoitin
polycythaemia
●Mucin-secretingadenomasincreasing
thecoagulability
thromboembolism
TheDiagnosticProcedures
ofCancer
History
●FamilyHistory●IndividualHabits
●SocialHistory●Occupation
●Marital&SexHistory●PastHistory
TheDiagnosticProcedures
ofCancer
PhysicalExamination
●Systemic
●Local
Tumor
Metastaticfoci
TheDiagnosticProcedures
ofCancer
SpecialProcedures
●DiagnosticRadiology
ChestX-rays
Bariumenemaradiography
Gastro-intestinalseriesradiography
Arteriography
Computerizedtomography(CT)
Radioisotopescanningtechniques
Mammography
Positronemissiontomography(PET)
TheDiagnosticProcedures
ofCancer
SpecialProcedures
●Ultrasonicexamination
●Endoscopy
●Cytology
●Biopsybone-marrowbiopsy
needlebiopsy
endoscopicbiopsy
●Magneticresonanceimagine(MRI)
TheDiagnosticProcedures
ofCancer
LabTest
●Routinetest:
blood,urine,stool
●Serumtest:
enzyme,hormone
glycoprotein,tumormarkers
●Immunologytest:
AFP,CEA,
tumor-relatedantigens
●Flow-cytometry(FCM):
DNAploidy
DNAindex
●GeneTest:
Oncogenes,DNArepairgens
Tumorsuppressorgenes
ToolsForEarlyClinicalDetection
●Completephysicalexamination
●Regularmammographyandbreastselfexam
●Haemoccultforoccultbloodinfeces
●Urineanalysisandbloodcount
●Acompleteclinicalhistory
●Anin-depthfamilymedicalhistory
TumorMarkers
TumormarkerExamples
TumorantigensAFP,CEA
EnzymesPSA
Hormonesβ-HCG
OncogenesRas,c-myc,P53
Tumorassociatedantigens
CA19-9,CA-242
MSCTMetastaticLN
TNMstaging
T---primarytumor
N---regionallymphnode
M---metastases
ThePrinciplesofCancerSurgery
Loeb’sRulesofTherapeutics
●Ifwhatyouaredoingisdoinggood,keepdoingit.
●Ifwhatyouaredoingisnotdoinggood,stopdoingit.
●Ifyoudonotknowwhattodo,doingnothing.
●Nevermakethetreatmentworsethanthedisease.
OncologyMultidisciplinaryTeam
●Surgicaloncologists
●Radiationoncologists
●Medicaloncologists
●Palliativecarespecialists
●Psychologists
●Socialworkers
●Nurses
●Chaplains
LandmarkadvancesinSurgicalOncology
YearEventSurgeon
1809ElectiveoophorectomyP.Pott
1846EtherasanesthesiaJ.C.Warren
1867CarbolicacidasantisepsisJoseph.Lister
1873LaryngectomyA.T.Billroth
1878ResectionofrectaltumorR.vonVolkman
1881GastrectomyA.T.Billroth
1890RadicalmastectomyW.S.Halstead
1908AbdominoperinealresectionW.E.Miles
1909ThyroidSurgeryT.M.Kocher
1935PancreaticoduodenectomyA.O.Whipple
SurgicalOncology
●Preventivesurgery
●Diagnosticsurgery
Resectionbiopsy
Samplebiopsy
Laparotomy
SurgicalOncology
●Radicaloperation
Lumpectomy
Extendedresection
RadicalorExtended
radicaloperation
SurgicalOncology
●PalliativeSurgery
Palliativeresection
BypassorOstomy
Endocrineglandsresection
Cytoreductivesurgery
SurgicalOncology
●Surgeryforrecurrence
ormetastasis
●Reconstructionandrecovery
●Surgicaloncologytechnique
non-cutting
en-bloc
non-touching
ThePrinciplesofCancerSurgery
●Staging
●Clinicalstaging
●Imaging--preoperative
●Fineneedleaspiration--preoperative
●Intra-operativeimaging
●Intra-operativepathology
●Resectionspecimen
KeyPointsofCancerSurgery
●Combinedtreatmentmodalities
●Preoperativechemotherapy--breast
●Postoperativechemotherapy--breast,colon
●Preoperativeradiotherapy--rectum
●Postoperativeradiotherapy
--lung,breast,rectum
CancerTreatmentareBasedUpon
●thebiologicalbehaviorofthecancer
●themortalityandmorbidityoftherapeuticprocedures
●theefficacyofthetherapeuticprocedure
●theperformancestatusofthepatient
Cancer
TreatmentareBasedUpon
●withlocalizedcancersarecurable
●presentingwithpositiveLymphNodestendtobadoutcome
●withdistantmetastasesarerarelycurable
●themostcommonlyparameterstomeasuresurvivalandbenefitoftreatment
--5-yrsurvivalrates
Chemotherapy
Indication:
●Tumorswithpriority
tochemotherapy
●Tumorscontrolledforlongtime
●Adjuvantchemotherapy
ClassificationofChemotherapeuticDrugs
ClassesExamples
AlkalatingagentsCisplatin
Antimetabolites5-FU,MTX
MitoticinhibitorsVP-16,Taxoids
NaturalproductsMMC,Bleomycin
OthersHydroxyurea
TheGreatertheTumorBurden
●the
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