الجامعة السورية الخاصة كلية الطب البشري قسم الجراحة

1. الجامعة السورية الخاصةكلية الطب البشريقسم الجراحة Surgical principle of Management of Tumors M.A.Kubtan , MD – FRCS 1st Lecture M.A.K

2. هذه المحاضرة صوتية • 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.Kubtan

3. Tumors 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 . M.A.K

4. Cancer cells are psychopaths • 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.Kubtan

5. continue • 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.Kubtan

6. A Mass of Cells • 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.K

7. Continue • 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.K

8. Rate of Growth • 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.K

9. The size of tumor • 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.K

10. The Doubling effect • 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.K

11. 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 M.A.K

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13. Classification of Tumors • Simple Tumors . • Malignant Tumors . M.A.K

14. Continue M.A.K 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 .

15. Continue M.A.K 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 .

16. الجامعة السورية الخاصةكلية الطب البشريقسم الجراحة Surgical principle of Management of Tumors M.A.Kubtan , MD – FRCS 2nd Lecture M.A.K

17. Members of the multiprofessional team • 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.K

18. Investigation and staging • 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.K

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20. Principles of cancer surgery • 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.K

21. Removal of primary disease • 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.K

22. Removal of metastatic disease • 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.K

23. Palliation • 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.K

24. Over all Management • Role of Surgery . • Role of Chemotherapy . • Role of Hormonal Therapy . • Role of radiotherapy . M.A.K