Surgical management of cancer distant metastasis

Surgical management of cancer distant metastasis

as mentioned before surgical management of cancer included three groups 
 surgical management of primary tumour
surgical management of Regional lymph nodes basin
  Surgical management of Distant metastasis which will be discussed here

The treatment of a patient with distant metastases depends on the number and sites of metastases, the cancer type, the rate of tumor growth, the previous treatments delivered and the responses to these treatments, and the patient's age, physical condition. under desires.

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Surgical management or treatment of cancer

as mentioned before it divided into three groups

1- surgical management of the primary tumor

2- surgical management of the regional lymph nodes basin

3- surgical management of distant metastasis

2- Surgical management of the Regional lymph nodes basin which will be discuss

Most neoplasms metastasize via the lymphatics

 Therefore, most onocologic operations have been designed to remove the primary tumor and drainage  lymphatic en bloc

 This type of operative ap­proach is usually undertaken when the lymph nodes draining the primary tumor lie adjacent to the tumor bed, as is the case for colorectal cancer and gastric cancers

For tumors where the regional lymph node basin is not immediately adjacent to the tumor eg,melanomas  lymph node surgery can be performed through 
 separate incision

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Can be divided into
surgical  treatment of primary tumour

surgical treatment of the regional lymph node basin

  surgical treatment of distant metastasis

Although surgery is the most effective therapy for most solid tumors most patients die of metastatic diseases

Therefore to improve patient survival rates a multimodality approach with systemic therapy­
and radiation therapy is key for most tumors. It is important

that surgeons involved in cancer care know not only how to perform a cancer operation but also the alternatives to surgery and he well versed in reconstructive options
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 .cancer risk assessment is an important part of the initial evaluation of
a patient .A patient's cancer risk is not only an important determinant­
of cancer screening recommendations but also may alter how
.aggressively an in determinant finding will be pursued for diagnosis.
;a probably benign mammographic lesion. for example. defined as with less than a 2% probability of malignancy ­•  is usually managed with a 6-month
 follow up mammogram in a patient at baseline cancer risk.but
obtaining a tissue diagnosis may be preferable in a patient at high
risk for breast cancer

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Tumour markers

Tumour markers

Definition:Tumour markers are substances that can be detected in higher than normal amounts in the blood or serum urine nipple aspirate fluid or stool tissues of patients with certain types of cancer

How it is produced

Tumors markers are produced either by the cancer cells themselves or by the body as a response to the cancer
What are the aim of tumour markers
tumour markers are useful in diagnosis staging treatment and detection of recurrence of cancers

Over the past decade, there has been an especially large

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Tumour Typing Grading and Staging

Tumour typing grading and staging

 What these are mean and what the benefits from its

Typing, grading and staging are important for

Planning of treatment

Type and degree of surgical excision

Consideration of pre-operative radiotherapy or chemotherapy to downsize

To provide accurate prognostic information

For the patient

For the physician

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Cancer diagnosis as mentioned before cancer diagnosis can be done by laboratory and clinical features or pictures of the cancers now
what are the clinical features of malignancy
It can be divided into three groups as

 Local features of the tumours
 Distant clinical features
 Systemic or general clinical features

Local features of the neoplasm or tumours

Including either mass, pain ,changes in organ function obstruction in a hollow viscus ,bleeding or infarction


• May be palpable

• May be a primary tumour or secondary lymphadenopathy

• May be painful or more commonly, painless (eg breast lump, testicular lump

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Cancer Diagnosis

Cancer diagnosis

Can be divided into laboratory diagnosis and clinical features of the neoplasm or by it is clinically important effects into

Local clinical features
Distant clinical features
Systemic features of the tumour

 Laboratory diagnosis

The definitive diagnosis of solid tumors is usually obtained with a biopsy of the lesion

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Causes of cancer viral carcinogens

Viral Carcinogens

One of the first observations that cancer may be caused by transmissiblcell-free extracts from sarcomas in chickens could transmit sarco­mas to other animals injected with these extracts
e agents was by Peyton Rous in 1911 when he­
  demonstrated that
 This was subse­quently discovered to represent viral transmission of cancer by the Rous sarcoma virus RSV

At present, several human viruses are known to have oncogenic properties, and several have been causally linked to human cancers it is estimated that 15% of all human tumors worldwide are caused by viruses&
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     Physical carcinogens or physical causes of cancer

Physical carcinogenesis can occur through induction of inflamma­tion and cell proliferation over a period of time or through exposure to physical agents that induce DNA damage. Foreign bodies can cause chronic irritation that can expose cells to carcinogenesis by alter environmental agents

In humans it is associated with chronic irritation and inflammation such as
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Aetiology or causes of cancer
The aetiology of cancers can be classified into four main categories

Genetic causes or carcinogens

Chemical causes or carcinogens

Physical causes or carcinogens

Viral causes or carcinogens

 Genetic causes or cancer

One widely held opinion is that cancer is a genetic disease that arises from an accumulation of mutations that leads to the selection of cells with increasingly aggressive behavior. These mutations may lead ei­ther to a gain of function by oncogenes or to a loss of function by tumor suppressor genes. Most mutations in cancer are somatic and are found only in the cancer cells. Most of our information on human cancer genes has been gained from hereditary cancers. In the case of hereditary cancers, the individual carries a particular germline mutation in every cell. In the past decade, more than 30 genes for autosomal dominant hereditary cancers have been identified A few of these hereditary cancer genes are oncogenes, but most are tumor suppressor genes, Though hereditary cancer

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Cancer biology or molecular basis of cancer include

 Cancer metastasis

To explain how cancer tumour becomes spreading to surrounding structures or nearby organ (local spread) or

 Direct extension eg direct invasion of bladder from adenocarcinoma of the sigmoid colon

Blood or haematogenous spread eg bone metastasis from follicular cell carcinoma of the thyroid
Lymphatic spread eg axillary nodes from carcinoma of the breast  or by
 Transcoelomic spread eg ovary or implantation spread
 Spillage of tumour cells during surgery
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cancer biology or molecular basis of cancer include the following item Cancer Invasion

first what are the tumour or neoplasm progression means

Neoplastic progression is a term that refers to the generation of sub-clone­ the tumour. These sub-clones occur by accumulation of further genetic mutations and have an increasingly aggressive phenotype, allowing invasion and metastasis to distant sites
Neoplastic or cancer invasion
The ability to invade and spread determines the difference between a benign and a
malignant phenotype
Invasion is due to
Changes in adhesion molecules by the following methods
1- Cell-to-cell interactions
2- Cell-to-matrix interactions
Proteolysis , Migration and chemotaxis
Changes in adhesion by 
Loss of cell-to-cell adhesion
E-cadherin is the major cell adhesion molecule in epithelia; these cell adhesion­
are down-regulated in several carcinomas

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molecular basis or cancer biology abnormalities in neoplastic cell behaviour tumour angiogenesis

 What angiogenesis means

Angiogenesis is the establishment of new blood vessels from a pre­-existing vascular bed. This neovasculariztion  is essential for tumor growth and metastasis. Tumors develop an angiogenic phenotype a. as a result of accumulated genetic alterations and in response to local selection pressures such as hypoxia. Many of the common oncogenes and tumor suppressor genes have been shown to play a role in inducing angiogenesis. including ras, myc. HER2/neu. and mutations in p53
In response to the angiogenic switch. pericytes retract and the endothelium secretes several growth factors such as basic fibroblast growth factor (FGF), platelet-derived growth factor (pDGF). and insulin-like growth factor (FGF). The basement membrane and stroma around the capillary are proteolytically degraded, which is mediated in most part by uPA. The endothelium then migrates through the degraded matrix, initially as a solid cord, then forming lumina. Finally. sprouting tips anastomose to form a vascular network surrounded by a basement membrane

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Disucssion of Tumours abnormalities

Discussion of Tumours abnormalities

molecular basis or biology of cancers include the abnormalities in neoplastic cell behaviour which means the neoplastic cells exhibit different behaviour to normal cells in terms of





Karotype and progression

Stimulate angiogenesis

First tumour cell proliferation

the rate of cell proliferation within any population of cells depends on three things
the rate of tumour cell division: tumour cells can be pushed into the cell cycle more

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Genes involved in carcinogenesis there are four classes of genes can be affected to produce a neoplasm





  Oncogenes which means normal cellular genes that contribute to cancer when abnormal are called oncogenes .the normal counterpart of such a gene is called Proto-oncogenes which they are normal genes involved in cell division ,oncogenes are usually designated by three - letter abbreviations such as MYC or RAS .oncogenes are further designated by the prefix of (v-)for virus or (c-)for cell or chromosome
some. corresponding to the origin of the oncogene when it was first detected. Proto-oncogenes can be activated (have increased activity) or over expressed (expressed at increased protein levels) by translo­cation (e.g., abl). promoter insertion (e.g.c-myc), mutations (e.g . ras), or amplification (e.g .HER2/neu). More than 100 oncogenes have been identified

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What we means by carcinogenesis a tumour or neoplasm is an overgrowth of tissue formed by a clone of cells bearing cumulative genetic injuries confers an additional growth advantage to the clone that possesses it these mutations can be 1- congenital :already present in the genome heritable cancers 2- acquired mutations brought about by exposure to a carcinogen (sporadic cancers)what are the stage process of carcinogenesis
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Cell growth first what tumour mean the tumour literally means swelling is either physiological or pathological ,physiological swelling eg. pregnant uterus pathological swelling eg. neoplastic or non neoplastic eg abscess inflammatory and bony callus what neoplasia means is an abnormal mass of the tissue , the growth of which is uncoordinated exceeds that of the normal tissue and persists in the same manner after cessation of the stimuli that evoked the change
 Normal cell growth

Cells fall into several different categories according to their propensity to divide and
their degree of differentiations into three types of cells as

labile cells: which are constantly renewed cells (eg stratified squamous epithelium of the skin

Stable cells: usually quiescent cells but can be stimulated to divide eg hepatocytes

Permanent cells: do not undergo mitosis in post-natal life (eg neurones, skeletal muscle tissue , glomeruli . Cells divide as they progress through the cell cycle

There are many regulatory points inherent in the cycle, and disruption of these genes
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Incidence of common cancers
Cancer is a common disease affecting a third of the population
 in their life time There are 250 000 new cases diagnosed per year65% of cancer affects the> 65 age group Common cancers are different for different age groups (adults, teenagers children) Smoking and diet are the main environmental etiological factors (thought to be responsible for a third of cancer cases each

Cancer incidence by age and gender

Common cancers in adult 50% of adult cancer involves the big four: breast, prostate, lung, large bowel.Remember that the incidence of a cancer is not the same as the death rate cancer

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first of all there are criteria for screening programmes and for the screening test which they are used Screening programmes  -1what are the Criteria for screening programmes
A screening programme needs to fulfil certain criteria (defined by the WHO in 1966 these criteria are
• The condition is an important health problem
• Its natural history is well understood
• It's recognisable at an early stage
• Treatment is better at an early stage
• A suitable test exists
• An acceptable test exists
• Adequate facilities exist to cope with the abnormalities detected    Screening is done at repeated intervals when the onset is insidious • The chance of harm is less than the chance of benefit• The cost is balanced against benefit
2-criteria for screening tests 
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oncology malignancies cancers tumours

oncology malignancies cancers tumours

first of all what is definition of oncology this word can be  divided into two part first onco which mean mass or tumour or swelling or bulk and second logy which means study so oncology means it is the branch or the science which deal with everything about the tumours or cancers
In this section i will talk about  these contents
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Causes and types of Thalassaemias

Causes and types of Thalassaemias 
  • thalassaemias are inherited disorders of defective synthesis of globin chains in haemoglobin they cause haemolysis anaemia and ineffective erythropoiesis they are found mainly in Africa the Orient Mediterranean ,Asia and the middle East
  • There are three types of thalassaemias 1- beta -thalassaemia major(homozygous)2- beta- thalassaemia minor (heterozygous) 3- alpha- thalassaemia 
  • beta thalassaemia the most common of the thalassaemias beta thalassaemia minor is the heterozygous state it produces a symptmless microcytosis which may be accompanied by a mild anaemia
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Sickle cell disease or anaemia

Sickle cell disease or anaemia 

sickle cell disease is a genetic mutation commonly inherited causing changes in haemoglobin structure and altered oxygen binding it may be homozygous or heterozygous (sickle cell trait) the disease has predominance in Africa and is found in India and Middle east clinical problem include 1- haemolytic anaemia 2- vaso-occlusive crises
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Thrombocytopenia from surgical view

Thrombocytopenia from surgical view

thrombocytopenia means a platelet number less than 150,000
  • Causes of thrombocytopenia
  • platelet production failure as in aplastic anaemia drugs like cytotoxics alcohol viral infections as EBV, CMV  bone marrow infiltration as in leukaemia , myelofibrosis myeloma metastatic infiltration hereditary thrombocytopeniah
  • decreased platelet survival as in idiopathic thrombocytopenic purpura(ITP)  drugs like heparin penicillamine gold .infections as in subacute bacterial endocarditis meningococcus , thromboletic
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definition of anaemia
is the reduction in the concentration of circulating haemoglobin below the expected range for age and sex ,eg  adult male:<13 g\dl adult female<11.5 g\dl it may be acute or chronic anaemia 
mechanism of anaemia causes 1- decreases production as impaired erythrocyte formation or impaired erythrocyte function 2- increased loss as blood loss either acute or chronic and decreased erythrocyte lifespan eg. haemolysis nb. physiological anaemia occurs in pregnancy due to a relative increase in plasma volume . anaemia may be classified by cause or by the effects on cells when viewed as a blood film
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