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ACCANIMENTO TERAPEUTICO IN ONCOLOGIA: VERO O FALSO PROBLEMA?

ACCANIMENTO TERAPEUTICO IN ONCOLOGIA: VERO O FALSO PROBLEMA?. Appropriatezze ed evidenze di beneficio clinico in chirurgia. CONGRESSO REGIONALE DELLA SICP EMILIA ROMAGNA Reggio Emilia 18/04/2008. Giampaolo Ugolini Dip. di Chirurgia Az. Osp. Policlinico S.Orsola Malpighi.

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ACCANIMENTO TERAPEUTICO IN ONCOLOGIA: VERO O FALSO PROBLEMA?

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  1. ACCANIMENTO TERAPEUTICO IN ONCOLOGIA:VERO O FALSO PROBLEMA? Appropriatezze ed evidenze di beneficio clinico in chirurgia CONGRESSO REGIONALE DELLA SICP EMILIA ROMAGNA Reggio Emilia 18/04/2008 Giampaolo Ugolini Dip. di Chirurgia Az. Osp. Policlinico S.Orsola Malpighi

  2. Filippo Brunelleschi 1377 - 1446

  3. Franz Torek (1861–1938). First esophagectomy for cancer in 1913

  4. Torek F. The operative treatment of carcinoma of the esophagus. Ann Surg 1915;61:385

  5. CASO CLINICO • 66 yo F diagnosed with breast cancer in 1999: surg + CHT/XRT • 2000 bone mets D3-D5: XRT/CHT/spinal stabilization • 2002 multiple bone mets: CHT • 2/2003 lung mets: CHT

  6. CASO CLINICO • 4/2003: anal abscess LOW RECTAL CANCER What to do? Colostomy vs. APR Is it worthwile? Is it right? Cost-effectiveness?

  7. CASO CLINICO 4/2003: Abdominoperineal excision 9/2004: bilat. ureteral stenting 12/2004: Small bowel obstruction due to peritoneal carcinomatosis: ex. lap. + ileostomy 3/2005: exitus

  8. Guidelines Have Done More Harm than Good, Amerling R et al.Blood Purif 26:73-76, 2008 • Proliferation of practice guidelines • Uncertain impact on actual practice and outcomes • They are unlikely to stimulate original research • Many guidelines are obsolete by the time they are published • ? Conflict of interest

  9. Guidelines Have Done More Harm than Good, Amerling R et al.Blood Purif 26:73-76, 2008 • A 'one-size-fits-all' approach is likely to benefit some, but not all • Guidelines do not encourage clinicians to consider and treat each patient as an individual • Certain patients may be harmed by adherence to specific guidelines

  10. “Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under abnormal conditions wich we know as disease” “Gentlemen, if you want a profession in which everything is certain you had better give up medicine!” William Osler, 1926

  11. Palliative cancer surgery Main goal is not cure but symptomatic treatment

  12. Palliative cancer surgery • Palliative surgery is one of several therapeutic modalities that are not intended to cure the patient’s cancer, but are carried out with an intention to: • prolong life, • relieve symptoms • - prevent symptoms

  13. Magnitude of the problem • 1/3 of the population will develop cancer in their lifetime • About 50% will develop metastases or local recurrence and soon or later will need palliative treatment

  14. Timing

  15. Fields of interest • Primary tumors and metastases may involve every organ • Multidisciplinary surgical teams might be involved in the clinical course of cancer patients

  16. Gastroenterologicsurgery • surgery related to the alimentary tract from the oesophagus to the rectum that improves functions, reduces pain or stops bleedings

  17. Neurologic surgery • surgery related to primary tumour or metastasis to the brain or the spine/spinal medulla in order to preserve neurologic functions

  18. Orthopaedic surgery • surgery related to pain and/or fractures or required reinforcements of arm, leg or spine due to bone metastases

  19. Thoracicsurgery • surgery on metastases in the lungs, reduction of compression of the superior vena cava and procedures to keep the airways open

  20. Urologicsurgery • surgery related to the urinary tracts in order to provide passage from the kidneys to the urinary bladder, facilitate voiding of the bladder and stop bleedings

  21. Feb 2003 SINTEF Group is the largest independent research organisation in Scandinavia -Norwegian Cancer Plan, -The Norwegian Center for Health Technology Assessment

  22. Palliative cancer surgery • The effect of several palliative surgical procedures is not documented through randomised controlled trials • It is difficult to give a comprehensive assessment of whether or not the criterion of effectiveness is filled • Few studies are available on the cost-benefit relationship

  23. Palliative cancer surgery • Effect of procedures that reduce symptoms from various organ systems, irrespective of the origin of the primary tumour. • Effect of procedures that aim at preventing well-known future symptoms from an incurable primary tumour.

  24. GI Surgery • 1. Dysphagia • 2. Jaundice (obstructive) • 3. Gastric retention/bleeding • 4. Intestinal obstruction/ileus • 5. Intestinal bleeding

  25. Dysphagia Oesophageal CaNormal intake of fluids and nutrition • Laser treatment • Self expanding metal better than rigid tubes • Endoscopic stenting = laser therapy (combination) • Gastrostomy/Jejunostomy vs TPN Vakil N et al.A prospective, randomized, controlled trial of covered expandable metal stents in the palliation of malignant esophageal obstruction at the gastroesophageal junction. Am J Gastroenterol. 2001 Jun;96(6):1791-6 Alderson D etal. Laser recanalization versus endoscopic intubation in the palliation of malignant dysphagia. Br J Surg. 1990 Oct;77(10):1151-3.

  26. Dysphagia

  27. Jaundice • Association with Pruritus - Diarrhoea - encephalopathy • Efficacy: Surg BP = stent (BP higher complication rate) • Endoscopic better than Percutaneus (lower mortality, higher success rate) Bornman PC et al.Prospective controlled trial of transhepatic biliary endoprosthesis versus bypass surgery for incurable carcinoma of head of pancreas. Lancet. 1986 Jan 11;1(8472):69-71. Taylor MC et al.Biliary stenting versus bypass surgery for the palliation of malignant distal bile duct obstruction: a meta-analysis. Liver Transpl. 2000 May;6(3):302-8.

  28. Jaundice

  29. Gastric obstruction/bleeding

  30. Gastric obstruction/bleeding • If gastric cancer cannot be treated with a curative intention • Gastrectomy (total or partial) under certain conditions is a valuable palliation (VS BP/explorative laparotomy) - longer survival - prevention of serious bleeding - removal of a relative obstacle in a passage Hartgrink HH et al. Value of palliative resection in gastric cancer. Br J Surg. 2002 Nov;89(11):1438-43. Haugstvedt et al.The survival benefit of resection in patients with advanced stomach cancer: the Norwegian multicenter experience. Norwegian Stomach Cancer Trial. World J Surg. 1989 Sep-Oct;13(5):617-21; discussion 621-2.

  31. Intestinal obstruction

  32. Intestinal obstruction • Relatively frequent • Non-surgical therapy laser, cryotherapy, stenting • Requires palliative gastroenterologic surgery (bypass, resection and/or stoma) • About 50% of patients develop a new obstruction within 2 to 3 months

  33. Intestinal Bleeding • Laser therapy, cryotherapy, embolization might be an alternative to surgery • Surgery is often more comprehensive in cancer of the rectum or the distal colon • CHT/XRT is a good option for high risk patient

  34. Palliative cancer surgery Prolonged recovery limited life expectancy Elevated morbidity and mortality Cost-effectiveness Problems Comorbidites (elderly) Multiple symptoms (prioritize ) Limited compliance Treatment vs prevention

  35. Conclusions

  36. Conclusions • Extensive knowledge of the “natural” course of the disease and defined endpoints of the effectiveness of the procedure • Statistical estimates vs individual patient • Prophylactic procedures should be simple, have a reliable effect and low risk of complications

  37. Surgeons are therefore often left with their colleagues’ and their own experience as a supplement

  38. Una gran parte di quello che i medici sanno e’ insegnato loro dai malati (Marcel Proust)

  39. Other surgeries • Neurological surgery - Cytoreductive surgery is useful in improving quality of life and survival in intracranial cancer. - Surgery of metastases to the brain is useful in patients with single metastasis and otherwise stable cancer disease. • Orthopedic surgery - Metastases to the long bones and hip bone may require surgery to relieve severe pain and maintain function. - Surgical treatment of metastases to the back is required to make support at a site of fracture and when pain relief has not been achieved with radiation treatment.

  40. Other surgeries • Thoracic surgery - Increased length of survival can be achieved in surgical removal of metastases from primary cancers of other organs (testis and soft tissue). - Pain, obstructed breathing and infection can be prevented by treating (laser or stenting) the obstruction caused by cancer of the central airways. - Cerebral symptoms and symptoms of localized pressure caused by tumor growth obstructing the superior vena cava can be prevented and treated by thrombolysis, blocking or stenting of the vein.

  41. Other surgeries • Urological surgery - The most common treatment of local symptoms such as haemorrhage and obstruction due to cancer of the prostate and bladder is transurethral resection (TUR) of the prostate and the bladder. - The use of stent is a good alternative in waiting for the effect of hormonal treatment on the obstruction to take place. - The embolizing of the kidney artery in persisting haemorrhage and radiating pain due to cancer of the kidney has virtually replaced the conventional operation of nephrectomy. - The chosen treatment of malignant obstruction of the ureter is now the minimally invasive technique of pecutaneous nephrostomy or internal ureter stent.

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