2. Surgical principle of Management of Tumors M.A.Kubtan, MD – FRCS 1 st Lecture 1M.A.K

3.  للإستماع إلى المحاضرة ينصح بوضع سماعة الأذن ليكون الصوت واضحاً.  يجب الضغط على الزر الأيسر للماوس فوق صورة مكبر الصوت لسماع الشرح الخاص بالسلايد المعروض على الشاشة في الجزء الأول من المحاضرة.  يتم الاستماع للمحاضرة ( الجزء الثاني ) اتوماتيكياً بمجرد ظهور السلايد. M.A.Kubtan2

4. A new growth or neoplasm has been defined as a :  Mass of cells.  Tissues.  Organ. Grows at the expense of the organism without at the same time subserving any useful purpose. 3M.A.K

5.  They have no respect for the rights of other cells.  They violate the democratic principles of normal cellular organization.  Their proliferation is uncontrolled;  Their ability to spread is unbounded.  Their inexorable ( عنيد ), relentless ( لا هوادة فيه ) progress destroys first the tissue and then the host.  Loss of function in a tumors suppressor gene will contribute to malignant transformation. M.A.Kubtan4

6.  Cancer cells will be able to evade apoptosis ( ( موت الخلايا المبرمج, which means that the wrong cells can be in the wrong places at the wrong times.  The ability of a tumors to form blood vessels is termed angiogenic competence and is key feature of malignant transformation.  Cancer cells acquire the ability to breach the basement membrane and thus gain direct access to blood and lymph vessels. M.A.Kubtan5

7.  A neoplasm is composed of living cells derived from normal cells of the body.  Proliferated cells is the disease.  Neoplasia cells continue proliferating without limit, Liver proliferation on demand ( Hyperplasia ).  Neoplasm grows at the expense of the organism and without reference to the needs of the body, Lipoma.  In highly malignant tumors the cells revert to primitive form and subserve no purpose except multiplication. M.A.K6

8.  Less malignant tumors retain a certain amount of differentiation but their secretory activity serves no useful purpose.  Alimentary canal will secret mucin.  Chondrosarcoma will produce cartilage.  Osteosarcoma will produce bone.  Endocrine tumors produce hormones with a chemical structure identical with the normal. In neither case is there any evidence of benefit to the organism. M.A.K7

9.  Continued growth is seen in grate majority of neoplasm.  Usually it may not exceed the rate of growth of the normal cells.  The most malignant of neoplasm enlarges less rapidly than most innocent of tumors, ( the normal fetus ) or normal tissues ( bone marrow or the Intestinal epithelium ). Role of cytotoxic drugs M.A.K8

10.  Governed by the rate of cell division.  In normal tissues there is a continuous wastage of cells.  In neoplasm unless the surface is ulcerated the derivative cells remain in place an contribute to the bulk of the tumor. M.A.K9

11.  Assuming a tumor will originate from a single cell and it divide at regular intervals, it will take approximately 30 doubling to produce a tumor of 1cm diameter.  The doubling time is believed to be of : 10 – 25 days for fast growing tumor such as some types of Sarcoma.  In slow-growing tumors the doubling time in the order of 100 days.  In between cancers of the Breast and Alimentary tract. M.A.K10

12. M.A.K11 If these assumptions are accurate it is clear that many tumors must have been in existence for a long time even several years before reaching a size to be detected

13. M.A.Kubtan12

14.  Simple Tumors.  Malignant Tumors. M.A.K13

15. M.A.K14 Continue Simple Tumors  Tend to reproduce.  The appearance an functional attributes of the cells from which originated.  Tend to grow slowly and some times rate of growth slows down. Malignant Tumors  Tend to deviate towards more primitive forms.  Shows no limitation of growth.

16. M.A.K15 Continue Simple Tumors  Tend to grow by expanding.  They may cause pressure atrophy of the surrounding paranchymatous tissues.  Thus become encapsulated within a capsule derived from the surrounding Stroma. Malignant Tumors  Extend by Invasion destroying adjacent normal cells and permeating tissue spaces.  Ignores contact inhibition.

17. Surgical principle of Management of Tumors M.A.Kubtan, MD – FRCS 2nd Lecture 16M.A.K

18.  Site-specialist surgeon  Surgical oncologist  Plastic and reconstructive surgeon  Clinical oncologist/radiotherapist  Medical oncologist  Diagnostic radiologist  Pathologist  Speech therapist  Physiotherapist  Prosthetist  Clinical nurse specialist (rehabilitation, supportive care)  Palliative care nurse (symptom control, palliation)  Social worker/counsellor  Medical secretary/administrator  Audit and information coordinator M.A.K17

19.  Staging is the process whereby the extent of disease is mapped out.  A change in staging system, or in the techniques used to provide baseline information concerning staging, can produce benefit’s to patients at all stages of the disease. M.A.K18

20. M.A.K19

21.  Diagnosis and staging : Aspirated fluids. FNA. Needle Biopsy. Surgical Biopsy. Excisional Biopsy. Lymph node biopsy. Sentinel node biopsy (Here, a radiolabelled colloid is injected into or around the primary tumour). Diagnostic Laparoscopy with ultrasound & Biopsy Diagnostic Thoracoscopy & Biopsy. Diagnostic Cystoscopy & Biopsy. Others. M.A.K20

22.  Radical surgery for cancer involves removal of the primary tumor.  Although the principle of local control is still extremely important, it is now recognized that ultra radical surgery probably has little effect on the development of metastatic disease.  Meticulous surgery taking care not to disrupt the primary tumor at the time of excision is of the utmost importance in obtaining a cure in localized disease. M.A.K21

23.  In certain circumstances, surgery for metastatic disease may be appropriate.  This is particularly true for liver metastases arising from colorectal cancer.  With multiple liver metastases, it may still be possible to take a surgical approach by using in situ ablation with cryotherapy or radiofrequency energy.  Another situation where surgery may be of value is pulmonary resection for isolated lung metastases, particularly from renal cell carcinoma. M.A.K22

24.  May increase the patient’s quality of life.  have little effect on the ultimate outcome.  Other examples include bypass procedures such as an ileotransverse colon anastmosis.  Gastrojujenostomy ( Gastric outlet obstruction, Ca head of Pancrease or ampulla  Cholecysto jujenostomy ( Ca Head of Pancrease or ampulla ).  Chledocojujenostomy ( Ca Head of Pancrease or ampulla ). M.A.K23

25.  Role of Surgery.  Role of Chemotherapy.  Role of Hormonal Therapy.  Role of radiotherapy. M.A.K24