principles of the surgical management of cancer

1. PRINCIPLES OF THE SURGICAL MANAGEMENT OF CANCER

2. BIOLOGY OF CANCER IS DEPENDENT ON Increased Cell proliferation Decreased programmed cell death Combination of the two Adenoma-carcinoma progression Invasion and metastases.

3. 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

4. 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

5. PATIENTS�S 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

6. SYMPTOMS THAT SHOULD INITIATE INVESTIGATION Weight loss Rectal Bleeding/melena Haemoptysis/persistent Cough Haematuria Breast lump Dysphagia/Dyspepsia Persistent Headache

7. 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 Operative Examination under anaesthetic and biopsy Diagnostic laparoscopy and biopsy

8. PURPOSE OF STAGING Define the extent of disease Assess likely prognosis Allow the development of a treatment plan

9. TNM STAGING T- extent of primary Tumour N- presence of distant metastases in regional lymph Nodes M- presence of distant Metastases

10. 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.

11. PRINCIPLES OF SURGICAL MANAGEMENT OF CANCER Clinical Scenarios

12. 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?

13. 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?

14. 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?