Oncosurgery MUDr. Zuzana Krivdová Trauma Hospital, Brno Trauma Departement, Medical Faculty, Masaryk Univerzity, Brno •Cancer – malignant growth Locally nonregulated tissue growth Autonomous Always a result of DNA mutation •Spot mutation •Gene amplification •Deletion (loss of DNA sequence) •Chromosome rebuilding Definition Epidemiology • Incidency – number of newly diagnosed cases per year (absolute x relative (per 100k)) • Prevalence - actual number of cases alive with a specific disease (in treatment + remission) • Mortality – frequency of occurrence of death in a defined population • Lethality - number of deaths / over number of sick with a specific disease (mortality:incidence; 5-year survival) Epidemiology • Most frequent in male patients • Prostate cancer (40th) • Colorectal cancer (1st) • Malignant tumors of trachea, bronchi, lungs (9th) • Most frequent in female patients • Breast cancer (30th) • Colorectal cancer (9th) • Cervical tumors (106th) • Malignant tumors of trachea, bronchi, lungs (25th) Cancer incidency development in age groups according to WHO • women • men Cancer mortality of people up to 64 years of age in ČR compared to EU Etiology - noninfluenceable factors • Genetics - hereditary transfer of mutations (Wilms tumor, von Hippel-Lindau syndrome) • (proto)oncogens – high level expression in tumor cells, supressing apoptosis Etiology – influenceable factors •Influenceable factors • Nutrition (high fibre diet, antioxidants) •Hormonal growth stimulation • Irritation (chronic inflammation) • Smoking (↑ lungs, mouth, stomach, pancreas, urinary bladder cancer) • Infection (HBV+HCV, HPV, Helicobacter, EBV, HIV...) • Sexual behavior, workplace (tar, cancerogenic chemicals) • Physical factors – radiation Virus induced oncogenesis • HPV – verruca vulgaris, ca of cervix • EBV – lymphomas, nasopharyngeal ca • Hepatitis B, C – hepatocelular ca • HHV8 – Kaposi sarcoma • HTLV - leukaemia Kaposi sarcoma Prevention • Primary: HBV, HPV vaccination • Secondary: screening, self examination -> early diagnosis • Tertiary: keeping QoL, control of progression www.loono.cz Screening • Early detection of disease (asymptomatic) • Quick, cheap testing with high specifity • 3 screening schemes in Czech rep. • Colorectal cancer > 55y (haemoccult/2y; colonoscopy/10y) • Breast cancer >45y (mammography/2y) • Cervical cancer (cervical smear/1y) Examination • Anamnesis • Familiary (cancer occurence, early onset) • Polymorbidity, other diseases with likely connection with suspected cancer or influencing the therapeutic plan) • Work/social (cancerogens in workplace) • Abuse (alcohol, smoking, drug use) • Epidemiological • Gynaecological Examination • Thorough physical examination •Local changes (tenderness, consistency/color change, naevi changes, blood in the stool/urine •General changes (loss of weight >10% in 6 months, lack of appetite, intolerance of specific foods, fatigue, night sweating, fevers of unknown etiology, cough, depression....) •Per rectum! Colorectal cancer Oncomarkers • Biomarkers found in bodily fluids or tissues • ↑ levels can indicate cancer • Screening (false positivity – Ca 125 endometriosis) • Monitoring Oncomarkers • AFP • Ca 15-3 • Ca 19-9 • Ca 125 • CEA • CYFRA • hCG • PSA • Hepatocelular carcinoma • Breast cancer • GIT cancer • Ovarian, endometrian cancer, GIT • GIT, cervix, lung, ovarian, breast cancer • Carcinomas, sarcomas • Choriocarcinoma • Prostate cancer Tumor characteristics • Metastasizing – forming new focuses in distant body parts (>3 generalisation) • Invasion – primary tumor cells -> submucosis -> vessels • Extravasation • Angiogenesis – vessel growth stimulation Tumor division • Pseudotumors • Hypertrophy • Hyperplasty • Cyst • Inflamatory pseudotumor (Schloffer) • Hamartoma – tissue not involved in the organ structure • Choristia – cell cumulation in abnomal places Tumor division – biological activity • Benign tumors – limited, slow growth, do not form mts, capsulated, well differentiated x meningeoma • Semimalignant tumors - basalioma • Malignant tumors – quick, destructive growth, low differentiation, no borders, form mts • Carcinoids – potentially malignant, rare, serotonine production -> flush Tumor division – biological activity Precanceroses • State preceding malignancy • Fastened cell proliferation -> higher risk of genetic mutation • Metaplasia (Barret‘s oesophagus, leukoplakia, intestinal metaplasia of stomach lining) • Inflammation (inflamatory hyperplastic polyps in ulcerative colitis, HPV infection) • Hyperplasty in hormone-dependant organs (endometrium, prostate) Precanceroses Precanceroses •stationary (lower risk of malignant changes, e.g. hyperplastic reaction around chronic fistulas) •progredient (Barret‘s oesophagus, familiary adenomatous polyposis) Carcinoma in situ • Signs of malignancy • Latency, resting state Metastases • Selective mts (prostate ca -> axial skeleton) • Generalised mts • Solitary mts (lung mts in renal carcinoma) • Lymphogenic mts (vessel -> node) • Hematogenic mts (direct growth into vessel) • Implantation mts (peritoneum) Peritoneal carcinomatosis Peritoneal carcinomatosis Tumor classification •Typing, staging, grading •MKN-O /ICD-O/ classification •3-degree coding XXXX/YZ •R classification after treatment Histopathology – Typing • Tissue of origin •Mesenchymal (connective tissue –sarcoma) •Epithelial (-carcinoma) •Neuroectodermal (malignant melanoma) •Germinal (germinal cells, gonads – seminoma, yolksac tumor, teratom) •Choriocarcinoma (trofoblastic cells) •Mesothelioma (pleura, pericard, peritoneum) Mesenchymal tumors • Connective tissue tumors • Fibrous tissues (fibroma, myxoma, myofibroma) • Fat cells (lipoma, liposarcoma, xanthoma) • Cartilage (osteochondroma) • Vessels • Muscle cells • Blood & lymphatic cells (leukaemia, lymphoma, myeloma) • Fibroma (benign) – fibrosarcoma (malignant) Epithelial tumors • Benign – papiloma, fibroepithelioma • Malignant – squamous carcinoma, basalioma, urothelioma, adenocarcinoma (mamma, colon) • Types •Covering epithelium •Glandular epithelium (adenomas) •Neuroendocrine epithelium (carcinoid) Neuroectodermal tumors • CNS, peripheral nerves, skin tumors /melanocytes/ • Types •CNS: Neuro-, retinoblastoma, meningeoma, astrocytoma, oligodendroglioma, feochromocytoma •Peripheral: Schwannoma, neurofibroma •Skin: naevus pigmentosus (benign), malignant melanoma • Two tissues of different origin (mixed tumors) Histopathology – Grading Microscopic determinated degree of tumor diferentiation Important prognostic + predictive information Higher = more sensitive to treatment • G1 – high differentiation, low malignity level • G2 – average diff., average malig. • G3 – low diff., high malignity • G4 – not differentiated tumor • GX – impossible to determine differentiation Histopathology – Staging • Determination of clinical phase • Precancerosis -> preclinical stage -> -> clinical symptoms • TNM classification, MKN-O classification • Dukes system – colorectal cancer staging • FIGO system – cervical cancer staging • Clark & Breslow class. – malignant melanoma TNM Classification • T = tumor (T0, TIS, T1-4, TX) •N = lymph node (N0, N1-4, NX) • M = metastasis (M0, M1, MX) pTNM y – adjuvant therapy r – relapse of malignancy C – certainity factor (surgery, histology, autopsy) Classification • MKN-O (ICD-O; International classification of diseases for oncology) • 3-degree coding XXXX/YZ •XXXX = morphological type of tumor •Y = biological activity •Z = histopathological grading Classification • C24 – infiltration of nonspecific parts of biliary tract • C24.1 – tumor of major duodenal papilla (Vater papilla) • C24.1 M-8160 – cholangiocarcinoma of Vater papilla • C24.1 M-8160/3 (malig.) cholangiocarcinoma of Vater papilla • C24.1 M-8160/32 averagely differentiated cholangiocarcinoma of Vater papilla R classification • R0 - without residual tumor • R1 - microscopic residual tumor • R2 - macroscopic residual tumor • R2a - macroscopic residual tumor, microscopically not verified • R2b - macroscopic residual tumor, microscopically verified National oncological registry • Collecting data since 1976 • Under IARC (International agency for research on cancer) • screening, manifestation, date of 1st visit vs. date of dg., smoking, laterality,... Fundamentals of surgical oncology • Solid tumor removal • Acute x planned therapy • Curative x palliative therapy • Qol improvement (cytoreductive surgery – debulking) Prophylactic surgery • Inherited abnormalities - Surgery as a primary prevention of illness BRCA 1, BRCA 2 – prophylactic mastectomy Familiary adenomatous polyposis – colectomy Cryptorchism - orchidopexis Familiary adenomatous polyposis Diagnostic surgery • Various ways of obtaining tissue sample • Needle biopsy (CT, USG controlled) • Explorative laparoscopy/laparotomy Diagnostic surgery • Biopsy •FNAB (thyroid gland) •Core biopsy (breast) •Incisional biopsy (forceps – endo) •Probatory excision Diagnostic surgery Endosurgery Curative surgery •Radical surgical intervention to prevent relapse •Multivisceral surgery – removes surrounding tissues & organs with primary tumor •Used in localised forms of illness Regional lymph nodes removal • Elective •Prophylactic lymph node disection (no signs of dissemination in surgery + histology) • Therapeutic •Removal in damaged lymph nodes (thyroid gland papilar Ca) Sentinel node biopsy Sentinel node biopsy • Sentinel = guard • First grade lymph node • Ca mammae • Melanoma Treatment of metastases • Paliative surgical intervention (lung + liver mts of CRCA) • 1/3 increase of long term survival in colorectal cancer patients • Ethanol instilation • Cryodestruction • Locoregional chemotherapy (intraarterial port-catheter) • Solitary mts – better prognosis Colon resection Colon resection Palliative surgery •↓ tumor tissue mass •↑ other treatments effectiveness •Method of choice in case of imminent local complications •Ileotransverstotomy to alleviate symptoms of obstruction (inoperable caecal cancer) •Choledochojejunostomy to prevent jaundice (uresecable pancreatic tumor) Nonsurgical methods •Chemotherapy •Radiotherapy •Hormonal / Immunotherapy •Laser •Cryosurgery •Radiosurgery (gamma knife) •Endoscopic mucosectomy Interdisciplinary care • Masarykův onkologický ústav • Indication committees •Mammary, Melanoma, Digestive oncology, Urology Interdisciplinary care Special oncosurgery Gastrointestinal surgery • Oesophagus • Stomach • Intestines + rectum • Liver • Pancreas, gall bladder, biliary tract Oesophagus • Risk factors: alcohol abuse, smoking, GERD, Barrett‘s precancerosis • Dg.: X ray – passage, endoscopy, CT • Symptoms: dysphagia, weight loss, cough, back pain • Therapy: rt, cht, surgery Stomach • Risk factors: smoking, poor food choices, infection (H. Pylori) • Dg.: US, endoscopy, CT • Symptoms: ditto + anemia • Therapy: rt, cht, surgery – partial/total resection, palliative - gastroenteroanastomosis Liver Primary tumor – hepatocelular Ca (hep C) Secondary – liver mts (CRCA), more frequent Dg.: US, oncomarkers – AFP Symptoms: from primary tumor, cirrhotic – like symptoms Therapy: surgical – metastatectomy, liver resection (segmentectomy, lobectomy) Pancreas, gall bladder, biliary tract • AdenoCa (most frequent) • Chemoresistant • Late diagnosis • Therapy: palliative bypass surgery, liver resection, RT Colorectal carcinoma •No. 1 cause of death in males, 2nd in females in CZ (7800 newly diagnosed/year) •Unvaforable prognosis •Short term troubles •Occurence under 30y •Nondifferentiated Ca •Infiltrating form •Angioinvasion •Lymphatic metastases Colorectal carcinoma • Unknown etiology • High fibre diet x diet rich in red meat • Familiar anamnesis !! • Preexisting adenomas -> precanceroses -> tu • Colonoscopic polypectomy decreases the risk of CRCA Colorectal carcinoma • Early diagnosis -> better prognosis • Adenomatous polyp -> Ca (10 years) • Prevention – screening (50 years >> – I.+II. St. TNM 90%) •Haemoccult test, colonoscopy • Follow up in risk groups •Adenom. polypi, FAP, UC, M. Crohn CRCA examination • Anamnesis • Examination (per rectum!) • Rectoscopy, biopsy • Colonoscopy / irrigography • Lung Xray • Ultrasound, CT, MR, PET • Gynaecological / urological examination CRCA examination • CT • Local tumor staging, extracolonic propagation • Regional lymph nodes • Distant mts detection • Virtual colonoscopy • PET • Preoperative tumor detection, staging • Local relapse detection • MR • Tumor relapse detection • Tu / scar tissue / postradiation changes differentiation CRCA surgery • Resection • Radical • Paliative • Planned x acute • Anastomoses – colostomy, ileostomy • Explorative laparotomy (ascites evacuation) • Pain management • Psychotherapy CRCA surgery • Radical – curative resection •Excision of ca incl. Lymph nodes en bloc •„no touch technique“ • Colon ligature over + under tumor, ligation of vessels •Block resection (spreading to surrounding tissues) •Mts resection (ONLY in solitary mts in one surgery) CRCA surgery • Total pancolectomy (PCE) + ileostomy (Brooke) • Total PCE + continent ileostomy (Kock) • Restorative PCE + IPAA (ileo-pouch anal anast.) • Subtotal colectomy + IRA (ileo-rectal anast.) Total pancolectomy (PCE) + ileostomy (Brooke) + Permanent stomy without special training Eliminated CRCA risk Peristomic irritation Psychological effect Urinary + sexual dysfunction Total PCE + continent ileostomy (Kock) + Same as PCE sec. Brooke Complicated surgery Risk of pouchitis Restorative PCE + IPAA (ileo-pouch anal anastomosis) + elimination of colorectal mucosa, continence, no permanent stomy, w/o sexual dysfunction - ongoing small CRCA risk Subtotal colectomy + IRA (ileo-rectal anastomosis) + No permanent stomy w/o sexual dysfunction Easy follow up Risk of CRCA Lifelong follow up Emergency room X rays Hartmann‘s surgery Rectal carcinoma • Lower 15cm • Special surgical approach • Upper 1/3 • Lower 2/3 Rectal carcinoma •Upper 1/3 of rectum (12-15cm) •Mobilisation and transection 5cm under tumor •Partial mesorectal excision •Lower anterior resection + anastomosis •Stapler / by hand Rectal carcinoma •Lower 2/3 of rectum (5-6cm to 11-12cm) •Lower anterior resection + anastomosis (colorectal/coloanal) •a.+v. mesenterica inferior ligation •Lienal flexure mobilisation •Total mesorectal excision (TME) •12> lymph nodes in resecate (-> TNM) •<12 lymph nodes -> incorrect clinical staging Rectal carcinoma • Tumor localisation under 5-6cm • Abdominoperitoneal extirpation of rectum sec. Miles Rectal carcinoma Mammary carcinoma • Most frequent Ca in women • Hormonally dependent • > 30% of all malignancies • ČR – 1 in 12 women • Europe – 1 in 10 women • USA, GB, Scandinavia – 1 in women -> endemic occurence Mammary carcinoma • Sporadic occurence (spontaneous mutation) • Familiar occurence (genetic abnormalities) • Hereditary occurence (BRCA1, BRCA 2) Invasive ductal Ca (72%) Invasive lobular Ca (13%) Ca in situ (6%) Erysipeloid. Ca, Paget‘s Ca Mammary carcinoma • Clinical findings •Squamae, encrustation •Usuration of nipple •Propagation to areola •Propagation deep to the mammary tissue •50% palpable mass -> invasive ductal Ca Mammary carcinoma Mammary carcinoma Mammary carcinoma in men • 1 male to 100 females per year • 36 newly diagnosed per year • Maximal incidency +- 70 years • 85% infiltrative ductal Ca Diagnostic methods •Ultrasound •Mammography •CT, PET CT •MR •Ductography, ductoscopy •Laseromammography •Transluminiscence •Digital thermography – dynamic optical breast imaging system Prognosis according to tumor size • Diameter of tumor in cm • <1cm • 1-3cm • >3cm • 5year survival • 99% • 91% • 85% Surgical treatment •Breast surgery •Breast sparing surgery •Radical mastectomy •Reconstructive surgery •Axillar region surgery •Radical exenteration •Sentinel node extirpation Segmentectomy technique Sanative surgery Fasciocutaneous flap Latissimus dorsi flap Postradiation risks •Edema, altered skin sensation •Fibrosis of mammary tissue •Rib fractures •Damage to lungs + heart Damage to the lymphatic vessels •Fixed chronic lymphoedema -> elephantiasis •Lymphostasis – limited arm movements, feeling of heaviness in the arm, increased circumference •Dg.: examination + lymphoscintigraphy