SURGICAL

ONCOLOGY
Dr. John Adel Sedkey
MBBCh, MSc, MD
AGENDA
Introduction
How cancer develop
Classification of tumors
Etiology of cancer
Spread
Grading and Staging
Diagnosis
Treatment
INTRODUCTION
• Tumor: Is an autonomous, excessive, purposeless, and
pathological proliferation of cells.

• Neoplasm means new growth that can be benign or

malignant

• Cancer stands for malignant growth only

• Malignant epithelial growth are called carcinoma

• Malignant connective tissue growth are called sarcomas
Hypertrophy: Increase in size without increase in number of cells.

Hyperplasia: increase in size due to increase in number of cells

Metaplasia: change from one type of epithelium into another.

Dysplasia: alteration in cellular size, shape of nucleus they are

classified mild, moderate & severe.

Hamartoma: Abnormal arrangement of normal cells.

HOW CANCER DEVELOP
1. Gene mutation (cancer is a disease of genes)
Two gene classes ensures normal controlled cell growth and division
• Proto-oncogenes: genes responsible to encourage the growth
when mutated leads to uncontrolled cell growth (ex: erb-B)
• Tumor Suppressor gene: responsible to inhibit abnormal cell
growth and division
when mutated leads to loss of functional suppressor of
abnormal cell growth (ex: P53 gene)

2. Escaping the body defensive mechanism

• Apoptosis: programed cell death (cell that escape apoptosis
becomes immortal and divide indefinitely)
• Immune System: mutated cell produce abnormal proteins that can
be detected by immune system as foreign and activate humoral and
cell mediated immune response
CLASSIFICATION OF TUMORS

1- Behavior
2- Histogenecity
3- Histologically
4- Naked eye appearance
5- Functional
BEHAVIOR 1.
•
Benign tumors:
Differentiated.
• Grows slowly By expansion.
• Encapsulated.
• Remain localized.
2. Malignant tumors
• Variable degree of differentiation.
• Grows rapidly By infiltration.
• Not capsulated.
• Invade & metastasize.
3. Locally malignant tumors:
• They are locally invasive but never send metastasis.
• Example is(Adamantinoma, basal cell carcinoma,
craniopharyngioma, carcinoid tumor, astrocytoma,
osteoclastoma, pleomorphic adenoma of the salivary glands.
4. Carcinoma in situ:
• This is a proliferation of the epithelium that has the
cytological feature of malignancy with no invasion or
metastases.
 Cell Type Benign Malignant
HISTOGENETIC Epithelium
• Squamous • Papilloma • Squamous cell carcinoma
• Columnar • Adenoma • Adenocarcinoma
• Transitional • Papilloma • Transitional cell carcinoma
Connective Tissue
• Adipose • Lipoma • Liposarcoma
• Fibrous • Fibroma • Fibrosarcoma
• Cartilage • Chondroma • Chondrosarcoma
• Bone • Osteoma • Osteosarcoma
• Smooth MS • Leiomyoma • Leiomyosarcoma
• Striated MS • Rhabdomyoma • Rhabdomyosarcoma
Neuroectodermal
• Melanocytes • Nevus • Melanoma
Hemopoietic and • Leukemia
lymphoreticular • lymphoma
Blood vessels Hemangioma(Hamartoma) Hemangiosarcoma
Lymphatics Lymphangioma Lymphangiosarcoma
Embryonic cells Benign teratoma Malignant teratoma
Placenta Mole, hadatifom Choriocarcinoma
HISTOLOGICAL Malignant cells have the following criteria:
• Hyperchromatism.
• Cells are variable in size & shape.
• Increased mitotic index.
• Loss of polarity.
Histological grading of a tumor is based upon the
degree of differentiation, so they can be:
• Well differentiated.
• Moderately differentiated.
• Poorly differentiated.
• Undifferentiated.
NAKED EYE The naked eye picture of a tumor could be
• A lump.
APPEARANCE • An ulcer.
• Fungating.
• Annular especially in luminal organs.

FUNCTIONAL
• Some tumors secret hormones in sufficient.
amount to produce characteristic clinical changes.
• Examples are gastrinoma of the pancreas and
pheochromocytoma.
​ETIOLOGY OF CANCER
1. Agents that damage the genes
• Chemical carcinogens ( Smoking, Asbestos, benzidine, aromatic amines, )
• Physical carcinogens (Mechanical irritation, Ionizing radiation, UV rays)
• Viruses (HPV, Hepatitis B,C , Epstein Barr virus)
• Diet (Saturated fatty acid , Red meat , Alcohol)
• Idiopathic ( inherited cancer (FAP, HNPCC, MEN)

2. Selective enhancement of tumor cells

• Hormones as TSH and papillary thyroid cancer
Estrogen and progesterone and breast cancer
Androgens and prostate cancer
SPREAD
Properties that allow metastasis:

1. Defective cell adhesions.

2. Angiogenesis allows proximity of tumor cell to blood vessels.
3. Digestion of basement membrane by proteolytic enzymes.
4. Escape apoptosis when reaching different site.

Methods of spread:

1. Direct local spread 4. Nerve sheath spread

2. Lymphatic spread 5. Implantation

3. Blood born spread

Direct spread:
• Usually along CT planes.
• No structure is resistant.
• Fascia may limit extension (Denonvillier Fascia).
Lymphatic spread:
• Invasion (permeation)
• By growing along the wall of lymph vessels from the
primary growth.
• This may occur in a retrograde manner.
• Embolism:
• Cancer cells may shed & carried away to regional LN.
• So distant nodes may be first involved.
Blood spread:
• Invasion of veins & tumor cells are shed in the lumen &
carried out with circulation.
• So secondary deposits in the lung, liver, brain and bone
marrow.
Implantation:
• Kissing ulcer ( Carcinoma of lip may affect the other).
• Recurrence after operations due to implantation
• Trans coelomic  Krukenberg tumor.
• Intracavitary  cerebrospinal space.
Nerve sheath:
• Especially pancreas travels through nerve sheath.
GRADING AND STAGING
Both are used to assess the degree of malignancy.
So, determine Prognosis & need for Adjuvant therapy.

Grading (microscopic assessment):

• According to degree of differentiation.
• Nuclear & cellular appearance.
• Proportion of active mitosis.
• So they are:
• Grade1: Well differentiated.
• Grade 2: Moderately differentiated.
• Grade 3: Poorly differentiated.
GRADING AND STAGING
Staging (clinical assessment)
As regards:
Extent of primary Tumor (T)
Lymph Nodes affection (N)
Metastases (M)
Classifications:
• TNM classification
• Manchester classification: For Cancer breast
• Duke’s classification: For cancer Colon
GRADING AND STAGING
The staging of cancers is an evaluation of the extent of tumor
spread which is a major consideration in prognosis and therapy:

Stage 0: carcinoma in situ.

Stage 1: early local invasion but no metastases.
Stage 2: limited local invasion and/or minimal regional lymph node
involvement.
Stage 3: extensive local invasion and/or extensive regional lymph
node involvement.
Stage 4: usually inoperable extension of tumor and/or distant
lymph node metastases, or distant metastases regardless of the
local extent of the tumor.
DIAGNOSIS
 Early detection of asymptomatic cases:
(Screening)
Definition:
– Early detection of cancer for early treatment and better prognosis.

Criteria:
– In cases where early detection will improve the outcome.

Examples:
– Annual Soft tissue mammography for cancer breast.
– Annual colonoscopy for patient with ulcerative colitis.
– Annual estimation of Prostatic Specific Antigen (PSA) for men above fifty.
 DIAGNOSIS

LABS RADIOLOGICAL INTERVENTIONAL BIOPSY DIAGNOSIS OF

METASTASIS
UGI Endoscopy CXR
CBC Xray FNAC
LGI Endoscopy Bone Scan
LFT, KFT US True cut
Bronchoscopy Isotope Scan
Tumor Marker CT Brush
Cystoscopy PET CT
Hormonal profile MRI Excisional biopsy
ERCP
TUMOR MARKERS
1. Alpha Feto protein AFP: Liver tumors.
2. Prostatic specific Antigen PSA : prostate lesions.
3. Human chorionic gonadotrophins HCG: Germ cell tumors.
4. CA 125 in ovarian carcinoma.
5. CA 15-3 in breast cancer.
6. Carcinoembryonic Antigen CEA in GIT cancer, pancreas
and breast
7. CA 19.9 in GIT cancers and pancreas.
8. Thyroglobulin in thyroid cancer.
TREATMENT
Prophylactic treatment
Treatment of established case:
- Early - Late
Individual treatment modalities:
• Surgery
• Radiotherapy
• Chemotherapy
• Immunotherapy
• Hormonal therapy
• Biological therapy
 Prophylactic Treatment
Excision of well-known precancerous lesions.
Examples:
o Familial polyposis (FAP), which requires total
proctocolectomy .
o Families with Cancer breast who are BRCA-1 or
BRCA-2 positive, prophylactic bilateral
mastectomy and prosthesis.
 Treatment of established cases

Depends on stage and grade

Require multidisciplinary team

Early Late
• No distant metastasis • Metastatic
• Curable • Incurable
• Radical treatment • Palliative treatment
• Treatment could be surgery alone or • Treatment could be (Resection ,
surgery with neoadjuvant therapy Radio-chemotherapy, Relief of pain)
Individual Treatment Modalities

Surgery
Radiotherapy
Chemotherapy
Hormonal therapy
Immunotherapy
Biological therapy
 Surgery
Primary tumor:
Radical treatment = excision of tumor + safety margin.
Lymph nodes:
- Varies from tumor to other.
- GIT requires removal of draining LNs.
- Breast either removed or irradiated.
- Head & neck removed when contain deposits.
Precautions:
Avoid spillage of tumor cells.

Advantages Disadvantages
1-Quick and effective 1-Functional & cosmetic disabilities
2-Accounts for many cures 2-Cannot be applied in tumors with
3-Only way that confirms tumor removal distant metastasis & attachment to vital
structures
 Radiotherapy
May replace surgery or given in addition.
Indicated as primary treatment in:
• Early-stage cancer larynx (T1) , prostate and anal cancer.
• As a part of conservative breast surgery
• Hodgkin’s lymphoma.
Methods (deep x-ray): gamma rays, electrons or heavy particles.
• Tele-therapy: radiate the tumor from outside the body
• Brachy-therapy: placing radioactive pellets or needles at cancerous site.

Advantages Disadvantages
1-Radiation can preserve normal 1-Not all tumors are sensitive to
structures, so cure the cancer without irradiation.
disabling the patient. 2-Associated with burns of the skin and
2-Can destroy microscopic extensions enteritis to the bowel.
that escape surgical scalpel. 3-Like surgery cannot treat systemic
3-Safe in elderly and frail patient. metastasis
4-Does not require hospitalization.
 Chemotherapy
Used alone or in combination with surgery.

Prevents rapidly multiplying cells from replication by interfering with DNA

replication.

Is the main treatment for leukemias.

Best results are obtained by using combinations of chemotherapeutics.

Advantages Disadvantages
1-Given in systemic diseases such as 1-They also kill normal cells so induce
lymphomas and leukemia. systemic side effects, bone marrow
2-In management of systemic metastasis. depression.
2-Complications as Diarrhea, vomiting
hair loss.
 Hormonal Therapy

• Used in hormone dependent tumors such as

(Ca breast, Ca prostate and endometrial carcinoma)
• Either hormone blocking or hormone supplement.
• Examples:
1. Anti-estrogen in ER +ve breast cancer cases.
2. Androgen blockage for Ca prostate.
3. Thyroxin to suppress TSH for patient with papillary
carcinoma of the thyroid.
 Immunotherapy

BCG vaccine injected locally in the urinary bladder

help in regression of transitional cell cancer.
 Biological therapy

Monoclonal antibodies against a specific protein

antigen in tumor cells.

1. Imatinib in GIST
2. Mitotane in adrenal cancer
3. Herceptin in breast cancer
4. Infliximab for Crohn's disease
 ‫اﻟﻌﻼج اﻟﻤﺴﺎﻋﺪ‬
Adjuvant Therapy
Extra-remedy added to the primary treatment to increase the
effectiveness.
• Example is radiotherapy to breast after conservative
breast surgery.
• 5 FU chemotherapy after colonic cancer surgery.

N.B. When applied prior to surgery it is called Neo-adjuvant:

• Example : esophageal radiotherapy before surgery.
 Prognosis
Represented in terms of survival as (5yrs or 10 yrs.)
Depends on:
Tumor
Stage (size, depth, LN state)
Grade (well, moderate, poor differentiated)
Type (Tumor behavior) benign or malignant
Management
• Early detection
• Treatment in specialized center
Patient
• Age
• Debilitating illness ‫اﻟﻤﺮض اﻟﻤﻨﮭﻚ‬
• Immune state