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Srgery - Coggle Diagram

- - - - Primary tumour: Radical surgery aims at excision of the primary tumour with as much normal tissue as possible. Usually, it is a bloc resection.
      - Lymph nodes: The treatment of lymph nodes varies from one tumour to another. In general and in most of the tumours, in the loco-regional and systemic, in both cases they are either resected or irradiated, while in head and neck and in skin cancers, the nodes are treated only, if they are (i.e., palpable) enlarged. Whenever possible lymph nodes are removed in continuity with the primary tumour, i.e., in a bloc resection.
      - Advantages: Surgical excision is both quick and effective. It accounts for the largest number of cured patients. It also has the definite advantage of giving the opportunity to confirm that a tumour has been fully excised, because a pathologist can examine the resected tissues for positive or negative margins.
      - Disadvantages and limitations: Surgery may produce functional and cosmetic defects. It is ineffective, if all the spread of the tumour is lead to a vital structure or if it has produced distant spread.
    - - Radiotherapy may replace surgery or may be given in addition.
      - Common indications include cancer of the larynx so as to preserve the voice, treatment of medulloblastoma, and for the treatment of early breast cancer, or for early breast cancer (after lumpectomy).
      - The X-rays or gamma rays, which are high-energy or heavy particles are directed to the tumour by one of two main methods. The radiation may be aimed at a tumour from outside the body (teletherapy), or it may be delivered by placing radioactive material (brachytherapy) into or near the tumour.
      - Advantages:
        
        Because healthy tissues can recover from radiation exposure more readily than most cancers. For specific lymphomas, radiation therapy may completely cure or surround a cancer growth, thus curing the cancer without sacrificing the patient's cosmetic integrity.
        
        Radiation can destroy microscopic extensions of cancerous tissue around a tumor and prevent local relapse.
        
        Radiation is a local option for frail patients who might have difficulty recovering from surgery.
        
        Treatment with radiation therapy do not require hospitalization.
      - Disadvantages:
        
        Some rare tumours as squamous cell carcinoma are sensitive to irradiation, adenocarcinoma, in general, is much less sensitive.
        
        Damage to surrounding normal tissues such as the skin or enteritis, which are very sensitive.
        
        Compared to surgery, radiotherapy is slower as it usually takes five to eight weeks.
    - - Common indications: Chemotherapy is the main line of treatment of leukemias. For solid tumours these drugs are used either as the main modality in case of distant metastases or in conjunction to other modalities as adjuvant therapy or by a combination of both.
      - Better results are obtained from combination chemotherapy rather than using one single drug, because cancer cells are less likely to become drug resistant, and lose their ability to replicate DNA.
      - These drugs are disseminated through the circulation and can reach malignant cells wherever located. Very high cure rates have been obtained for lymphomas and testicular cancer are now successfully treated by combinations of chemotherapeutic agents.
      - Disadvantages: The available chemotherapeutic drugs often kill many healthy cells besides malignant cells, particularly the bone marrow cells which are rapidly dividing. This can lead to anaemia, leucopenia, and thrombocytopenia. Other side effects of chemotherapy include diarrhoea, nausea, and hair loss. Sometimes, these drugs are injected locally into the tumour or can be targeted into the tumour using transarterial catheters e.g. transarterial chemoembolization (TACE) for hepatic carcinoma.
      - Chemotherapy is also used to shrink a large tumour, i.e., downstage it. Radical surgery, would then be possible.
    - - Hormone-blocking and hormone-supplementing therapies affect the rate at which cancer cells grow and spread in the body.
      - Anti-oestrogens for women with breast cancer that is positive for oestrogen receptors.
      - Androgen blockade for men with prostate cancer.
      - Thyroxine to suppress TSH for patients with papillary carcinoma of thyroid.
      - Advantages: These drugs are not very toxic for the patients, because its actions are limited largely to tissues with receptors for specific hormones.
    - - Tremendous advances in oncology and molecular biology allowed the recent development of specific therapies that target molecular biological pathways expressed by certain tumours. Table 10.4 provides some examples.
    - - o Non-specific. The tuberculosis vaccine BCG stimulates the immune system in general, and was found to induce remission in cases of transitional cell carcinoma of the urinary bladder.
      - o Specific. Administration of monoclonal antibodies from a single clone of lymphocytes that have been stimulated by a specific protein of the cancer cells. This method is still of limited use. It is currently in the stage of refinement and holds a great promise for the future.
  - - - Early (equivalent terms = loco-regional, potentially curable, operable) cancer.
        
        Treatment is essentially, by loco-regional modalities, i.e., surgery, radiotherapy, or by a combination of both.
        
        Chemotherapy (adjuvant therapy) treatment of systemic modalities such as chemotherapy is indicated if there is a high possibility of systemic microscopic spread in distant organs, or in the lymphatic channels (Micrometastasis). The higher the number of involved nodes, the higher is the possibility of microscopic distant spread.
        
        Cure is possible if this local disease is eradicated.
        
        Treatment is radical, i.e., aims at cure.
      - Late (equivalent terms = systemic, incurable, inoperable) cancer.
        
        There are usually distant metastases.
        
        Cure is not possible.
        
        Treatment aims at palliation of the patient's symptoms so as to provide him with a reasonable quality of life.
        
        In this stage, palliative treatment is also essentially by systemic modalities as chemotherapy and hormones.
        
        Occasionally, radiotherapy is indicated for palliation of local symptoms. In the gastrointestinal tract, the best palliation is achieved by surgical excision.
        
        Pain relief is commonly accomplished by the administration of non-steroidal anti-inflammatory agents or narcotic analgesics. In severe cases, neurosurgical procedures to interrupt pain pathway may be needed.
- - - - Some people may have a higher risk of developing certain malignant tumours. In this case it is sensible to follow certain screening programs to detect the neoplasm as early as possible. Common examples are:
        
        Annual soft tissue mammography for females who have a higher chance of developing breast cancer. These include patients who already had carcinoma of the breast on one side, the incidentally relatives of patients with breast carcinoma, or patients who had excision of benign dysplastic lesions.
        
        Annual colonoscopy for patients with ulcerative colitis who have a high risk of developing colorectal cancer. These are patients with pancolitis of more than ten-year duration.
        
        Annual prostate specific antigen (PSA) for men above fifty.
    - - The aim is to diagnose the disease and to determine its extent (stage). In addition to thorough clinical assessment, the following diagnostic aids are commonly used:
        
        Radiological: Various radiological techniques including contrast studies, ultrasound, CT (Fig. 10.7) and MRI are utilized for diagnosis.
        
        Endoscopy: This is very useful for diagnosis of most lesions of the respiratory, gastrointestinal and urinary systems. Bronchoscope, gastroscope (EGS) incorporates an U/S probe into the endoscope. Excellent cut display of the depth of tumour invasion can be achieved of the cancers of the esophagus, stomach, pancreas and rectum.
        
        Tumour sampling
        
        Tissue biopsy, tru-cut needle, endoscopic or operative biopsies obtain a piece of tissue from which sections are made for histological examination. Diagnosis of malignancy depends on cellular morphology as well as architectural disruption. The latter is the specific feature of malignancy. Histopathological findings are the most dependable.
        
        Cytology: The loss of cellular adhesion that is characteristic of malignancy allows easy retrieval of cells either by a fine needle aspiration or by a brush from surface lesions. Fine needle aspiration cytology is commonly used for diagnosis of the thyroid, breast, liver or prostate. Ultrasound or CT guidance of the needle allows accurate sampling of the suspicious area. Diagnosis depends on cellular morphology only, as the only cells and not tissues under the microscope. The test, therefore, requires an expert cytologist.
        
        Tumours markers:
        
        Tumour markers are substances that are produced by cancer or by other cells of the body in response to cancer. Most tumour markers are made by normal cells as well as by cancer cells. However, they are produced in much higher levels in cancerous conditions. These substances can be found in the blood, urine, stool, tumour tissue, or other tissues or body fluids of some patients with cancer. Most tumour markers are proteins. However, with recent advances of gene expression and changes to DNA have also begun to be used as tumour markers.
        
        Tumour markers may to diagnose some types of cancer, monitor the effect of treatment, and detect a recurrence. Although an elevated level of a tumour marker may suggest the presence of cancer, this alone is not enough to diagnose it. Therefore, tumour markers are usually used in with other tests, such as imaging and biopsy, to diagnose cancer. Fig. 10.8 illustrates some of the common tumour markers.
        
        Isotopic scanning as positron emission tomography (PET): Utilizes a fluorine tagged tracer as flouro-desoxy-glucose for a functional scan detecting tumours with high glucose metabolism. It is sensitive for the detection of small metastases. Anatomical sites of such metastases can be more accurately determined if combined with a CT scan (PET-CT). Together with laparoscopy, both are the only two means available, so far, for the detection of peritoneal nodules or small liver metastases.