Management of tumour
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This document provides an overview of tumor management. It begins with objectives and an introduction defining tumors. It then covers tumor classification, risk factors, characteristics of benign vs malignant tumors, routes of metastasis, clinical assessment approaches, staging, grading, investigations, and various treatment modalities including surgery, radiotherapy, chemotherapy, hormonal and targeted therapy, palliative care, and the importance of a multidisciplinary team approach. The conclusion emphasizes understanding cancer burden is key to improving outcomes in Bangladesh.
Management of tumour
- 1. Welcome to CME program topic Management of tumor Dr. Md. Shahadad hossain Department of Surgery
- 2. Objectives • Introduction of tumor & classification of tumor • Etiology ,characteristics, comparison of different type of tumor • Approach of assessment of a tumor • Treatment modalities of tumor
- 3. Introduction • Tumor: Willis definition: “An abnormal mass of tissue, the growth of which exceeds and is uncoordinated with that of the normal tissues and persists in same excessive manner after cessation of stimuli which evoked the change” Bangladesh is the 9th most populous country in the world. There are 13 to 15 lakh cancer patients in Bangladesh, And about 2 lakh patients newly diagnosed with cancer each year.
- 4. Classification A . Behavioral classification 1.Benign tumor ( eg. squamous cell papilloma) 2.Malignant tumor A . Primary Carcinoma: malignant tumor of epithelial cell. eg. Adenocarcinoma, transitional cell carcinoma Sarcoma: malignant tumor of connective tissue of mesenchymal cells B. Secondary: Metastasize or local infiltration
- 5. Cont… B. Histogenetic classification 1.Epithelial tumor(eg. squamous cell carcinoma) 2.Mesenchymal tumor eg. fibroma, lipoma) 3.Mixed tumor(pleomorphic adenoma of salivary gland) 4.Tumor of totipotential cells (teratoma) 5.Tumors of blood cells( leukemia, lymphoma) 6.Tumors of embryogenic tissue (retinoblastoma 7.tumour of embryonic vestiges ( Chordoma)
- 6. Risk factor of tumor 1. Genetic : retinoblastoma, familiar adenomatous polyp 2. Environmental: gastric cancer 3. Chemical: lung cancer by asbestos `Nitrogen mustard : leukemia Smoking : Ca bronchus 4. Oncogenic virus :Burkitt’s lymphoma & nasopharyngeal Ca by Epstein- Barr virus, Cervical ca by HPV. 5. Radiation: ultra violet ray (malignant melanoma),X-ray, gamma ray: leukemia 6. Chronic irritation: urothelial carcinoma( calculi) 7. Other : bladder ca by schistosoma haematobiom infection
- 8. Characteristic of benign tumor • Well differentiated • Slowly growing • Non invasive • Capsulated • Vascularity may incresed
- 9. Characteristics of malignant Naked eye • Altered differentiation, anaplasia • Rapid rate of growth • Architecture abnormalities • Local inversion • Metastasis • Not capsulated • Highly vascularized Microscope • Necrosis • Numerus atypical mitotic activity • Nuclear change pleomorphism, enlargement, hyperchromatism, clumping of chromatic, enlargement & multiplication of nuclei)
- 10. Cont…. Warning signs of cancer: unexplained weight loss Anemia(unexplained) Change in the bowel or bladder habits Unusual bleeding or discharge Indigestion or difficulty in swallowing Thickening or lump in the breast or elsewhere Obvious change in wart or mole Cough or hoarseness ,No healing of sore
- 11. Route of metastasis of malignant tumor 1.Local extension/direct spread 2.Distant spread: A . Lymphatics: common pathway of carcinoma B . Blood stream: common pathway of sarcoma ,but renal, thyroid ,breast & bronchial cancers commonly disseminate via this route C. Implantation: carcinoma of stomach spreads to ovary ( Kruk Enberg's tumor)via trans colonic route are examples of this route D . Nerve sheaths : Adenocarcinoma, especially pancreas may disseminate along nerve sheaths
- 12. Approach of management Brief history from patient Physical examination Appropriate Investigation Biopsy & staging
- 13. History • Age • Sex • Occupation • History about lump • Duration of lump • Slowly/rapidly growing • Painless/ painfull • H/o weight loss • H/o bone pain & cough
- 14. Clinical examination General examination • Appearance • Body built • Anaemia • Jaundice • Cyanosis • Temperature • Respiatory rate • Thyroid gland • Lymph nodes • Breast examination
- 15. Cont… Local examination of a tumor 1.Inspection:- • Site • Color of overlying skin • Shape • Size • Surface • Edge • Number • Pulsation • Peristalsis • Movement with respiration • Movement on deglutition • Impulse on coughing • Skin over the swelling • Any pressure effect
- 16. Cont… • 2.Palpation: • Temperature • Tenderness • Size , shape • Surface • Margin • Consistency 4.Percussion 5.Auscultation 3.State of regional lymph nodes • Pressure effect • Compressibility • Pulsatility • Fixity to the overlying skin • Relation to surrounding structures
- 17. Malignant Tumor staging The staging of cancers is based on the size of the primary lesion, it's extent of spread to regional lymph nodes, and the presence of absence of blood-borne metastases. Staging procedure: (TNM system) ‘T’ for size of the primary tumor T0-carcinoma in situ(pre-invasive) T1 T2 -increasing size T3 T4 ‘N’ for regional lymph node involvement N0-no nodal involvement N1 N2 -Increasing number and range of lymph nodes N3 ‘M’ for metastasis M0-no metastasis M1-metastasis present
- 18. Cont… AJC system:. Stage-0 Stage-l Stage-II Considering the size of tumors, nodal involvement and distant metastasis Stage-III Stage-IV Manchester staging: it is method of staging clinical spread of carcinoma Dukes staging : method of classifying the spread of ca rectum
- 19. Malignant tumor grading Definition : Grading of a cancer is based on the degree of differentiation of the tumor cells and the number of mitoses within the tumor as presumed correlates of the neoplasm's aggressiveness. Grading procedure: • Grade -I-more than 75% cells are differentiated (normal cells) • Grade-II-75-50% cells are differentiated • Grade-III-50-25% cells are differentiated • Grade-IV-less than 25% cells are differentiated
- 20. Investigation Lab investigation: Complete blood count LFT(SGPT,SGOT,ALP,S. albumin) RFT(urine R/E,S. creatinine) TFT(TSH,FT3,FT4) Tumor marker(CA-19.9,CA-125) Imaging USG X-ray of affected part CT scan of affected part MRI of affected part PET-CT Histopathology Biopsy
- 21. Management of tumor As the management of cancer becomes more complex, it becomes impossible for any individual clinician to have the intellectual and technical competence that is necessary to manage all patients presenting with a particular type of tumour. The formation of multidisciplinary teams represents an attempt to make certain that each and every patient with a particular type of cancer is managed appropriately. Teams should not only be multidisciplinary, they should be multi professional.
- 22. Treatment modalities Surgery Radiotherapy Chemotherapy Immunotherapy Hormonal therapy Gene therapy Biological modifiers Palliative therapy
- 23. Role of surgery For most solid tumors, surgery remains the definitive treatment and the only realistic hope of cure. However, surgery has several roles in cancer treatment including diagnosis, removal of primary disease, removal of metastatic disease, palliation, prevention and reconstruction.
- 24. Different types of surgery • Curative surgery Surgeons use curative surgery when the cancerous tumor is localized to a specific area of the body. This type of treatment is often considered the primary treatment. • Preventive surgery Preventive surgery is used to remove tissue that does not contain cancerous cells, but may develop into a malignant tumor. For example, polyps in the colon may be considered precancerous tissue and preventative surgery may be performed to remove them. • Diagnostic surgery Diagnostic surgery helps to determine whether cells are cancerous. Diagnostic surgery is used to remove a tissue sample for testing and evaluation (in a laboratory by a pathologist).. • Staging surgery Staging surgery works to uncover the extent of cancer, or the extent of the disease in the body..
- 25. Cont….. DE bulking surgery DE bulking surgery removes a portion, though not all, of a cancerous tumor. It is used in certain situations when removing an entire tumor may cause damage to an organ or the body. Palliative surgery Palliative surgery It is used to treat cancer at advanced stages. It does not work to cure cancer, but to relieve discomfort or to correct other problems cancer or cancer treatment may have created. Supportive surgery Supportive surgery is similar to palliative surgery because it does not work to cure cancer. An example of supportive surgery is the insertion of a catheter to help with chemotherapy Restorative surgery Restorative surgery is sometimes used as a follow-up to curative or other surgeries to change or restore a person’s appearance or the function of a body part.
- 26. Cont… Cryosurgery This surgery technique uses extremely cold temperatures to kill cancer cells. Cryosurgery is used most often with skin cancer and cervical cancer. Laser surgery This technique uses beams of light energy instead of instruments to remove very small cancers (without damaging surrounding tissue), to shrink or destroy tumors, or to activate drugs to kill cancer cells Electro surgery Skin cancer and oral cancer are sometimes treated with electrosurgery. This technique uses electrical current to kill cancer cells. Microscopically controlled surgery This surgery is useful when cancer affects delicate parts of the body, such as the eye. Layers of skin are removed and examined microscopically until cancerous cells cannot be detected.
- 27. Radiotherapy • Different types of radiotherapy 1.Deep external beam X-ray therapy 2.Local radiotherapy
- 28. Complications of Radiotherapy • Nausea, vomiting & diarrhea • Pulmonary fibrosis • Myelosuppression • Stunt growth in children • Amenorrhoea , oligospermia
- 29. Chemotherapy • Chemotherapy means use of chemotherapeutic drugs to treat microbial infection or cancer without producing toxic effects on the host cell. • Types of chemotherapy • Neoadjuvant therapy ( before operation) • Adjuvant therapy(after surgery) • Some chemotherapeutic agents:- • Methotrexate • 5-fluorouracil • Vincristine • Cisplatin • Bleomycin etc
- 30. Complications of chemotherapy • Nausea, vomiting, diarrhea • Anemia, Granulocytopenia, Thrombocytopenia • Suppression of cellular and humoral immunity • Alopecia • Delayed healing • Infertility, Amenorrhea • Dermatitis, pigmentation • Teratogenic effect
- 31. Hormonal therapy • Commonly used in treatment of breast , endometrial cancer & prostate cancer. • Anti-estrogen (Tamoxifen) therapy given in breast cancer, • Luteinizing hormone releasing hormone analogues like goserelin and/or anti-androgens like bicalutamide given prostate cancer, • Progestogen use in endometrial cancer.
- 32. Cont… • Biological therapy • Herceptin used in breast cancer, • Imatinib used in CML • Immunotherapy • rituximab, an antibody against the common B-cell antigen CD20.
- 33. Combined therapy • Cytotoxic drugs are rarely used as single agents; radiotherapy and chemotherapy are often given together. • Basic principle of combined therapy: use drugs active against the diseases in question; use drugs with distinct modes of action; use drugs with non-overlapping toxicities.
- 34. Palliative treatment • The distinction between palliative and curative treatment is not always clear cut and will become increasingly blurred as professional and public attitudes to towards the management of cancer change. • its goal is the relief of symptoms. • Sometimes this will involve treating the underlying problem as with palliative radiotherapy for bone metastases, sometimes it will not • Sometimes it may be inappropriate to treat the cancer itself, but that does not imply that there is nothing more to be done, • it simply means that there may be better ways to assuage the distress and discomfort caused by the tumor.
- 36. Conclusion • Improvement of cancer scenario overnight is not very easy for a country like Bangladesh. It is very important to know the cancer burden of Bangladesh. • So, it is needed to find out disability-adjusted life year (DALY), Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) and overall health impact assessment (HIA) for cancer. • Policy makers may become interested in these issues when they understand that cancer causes a huge health impact and economic loss for Bangladesh.