An Introduction to The World

OfONCOLOGY

ByEmad Shash

Medical Oncology DepartmentNational Cancer Institute

Cairo University

Origin of the Word Cancer

• Believe it or not, cancer has affected people for several centuries. It is not a new disease.

• The word cancer came from the father of medicine, Hippocrates, a Greek physician.

• Hippocrates used the Greek words, carcinos and carcinoma to describe tumors, thus calling cancer "karkinos.“

• The Greek terms actually were words to describe a crab, which Hippocrates thought a tumor resembled. Although Hippocrates may have named "Cancer"; he was certainly not the first to discover the disease.

• The history of cancer actually begins much earlier.

The History of Cancer, Lisa Fayed, About.com July,2008

The First Documented Case of Cancer

• The world's oldest documented case of cancer hails from ancient Egypt, in 1500 b.c.

• The details were recorded on a papyrus, documenting 8 cases of tumors occurring on the breast.

• It was treated by cauterization. It was also recorded that there was no treatment for the disease, only palliative treatment.

• There is evidence that the ancient Egyptians were able to tell the difference between malignant and benign tumors.

The History of Cancer, Lisa Fayed, About.com July,2008

Ebers Papyrus treatment for cancer: recounting a "tumor against the god Xenus", it recommends "do nothing there against"

Ancient Egyptian medical instruments depicted in a Ptolemaic period inscription on the Temple of Kom Ombo.

http://en.wikipedia.org/wiki/Ancient_Egyptian_medicine

What Early Physicians Thought Caused Cancer

• Today, we know so much about the human body; however early Greek physicians weren't so fortunate. Hippocrates believed that the body was composed of four fluids: blood, phlegm, yellow bile and black bile.

• He believed that an excess of black bile in any given site in the body caused cancer. This was the general thought of the cause of cancer for the next 1400 years.

• In ancient Egypt, it was believed cancer was caused by the Gods.

The History of Cancer, Lisa Fayed, About.com July,2008

The Birth of the Pathological Autopsy

• Autopsies done by Harvey in 1628 paved the way to learning more about human anatomy and physiology.

• Blood circulation was discovered, opening the doors for more research on diseases.

• It wasn't until 1761 that autopsies were performed to research cause of death in ill patients.

• Giovanni Morgagni of Padua was the first to do such autopsies.

The History of Cancer, Lisa Fayed, About.com July,2008

Cancer Staging

What is staging?

Staging describes the extent or severity of an individual’s cancer based on the extent of the original (primary) tumor and the extent of spread in the body.

Why Staging is important?

1- Staging helps the doctor plan a person’s treatment.

2- The stage can be used to estimate the person’s prognosis (likely outcome or course of the disease).

3-Staging helps researchers and health care providers exchange information about patients. It also gives them a common language for evaluating the results of clinical trials and comparing the results of different trials.

What is the basis for staging? • Staging is based on knowledge of the way cancer

develops. • Cancer cells divide and grow without control or order

to form a mass of tissue, called a growth or tumor. • As the tumor grows, it can invade nearby organs and

tissues. • Cancer cells can also break away from the tumor and

enter the blood stream or lymphatic system.• By moving through the bloodstream or lymphatic

system, cancer can spread from the primary site to form new tumors in other organs. The spread of cancer is called metastasis.

Cancer develops in stages

Colon Cancer Progression

What are the common elements of staging systems?

– Location of the primary tumor.– Tumor size and number of tumors. – Lymph node involvement (spread of cancer into

lymph nodes). – Cell type and tumor grade* (how closely the

cancer cells resemble normal tissue). – Presence or absence of metastasis.

*Information about tumor grade is available in the NCI fact sheet Tumor Grade: Questions and Answers, which can be found at http://www.cancer.gov/cancertopics/factsheet/Detection/tumor-grade on the Internet.

What is the TNM system? • The TNM system is one of the most commonly

used staging systems. This system has been accepted by the International Union Against Cancer (UICC) and the American Joint Committee on Cancer (AJCC).

• Most medical facilities use the TNM system as their main method for cancer reporting.

• The TNM system is based on the extent of the tumor (T), the extent of spread to the lymph nodes (N), and the presence of metastasis (M).

• A number is added to each letter to indicate the size or extent of the tumor and the extent of spread.

TNM system

Primary Tumor (T)• T X: Primary tumor cannot be evaluated• T 0: No evidence of primary tumor• T is: Carcinoma insitu(early cancer that has

not spread to neighboring tissue)• T1, T2, T3, T4: Size and/or extent of the

primary tumor

TNM system

Regional Lymph Nodes(N)• N X: Regional lymph nodes cannot be

evaluated• N 0: No regional lymph node involvement (no

cancer found in the lymph nodes)• N1, N2, N3: Involvement of regional lymph

nodes (number and/or extent of spread)

TNM system

Distant Metastasis (M)• M X: Distant metastasis cannot be evaluated• M 0: No distant metastasis (cancer has not

spread to other parts of the body)• M 1: Distant metastasis (cancer has spread to

distant parts of the body)

TNM combinations correspond to one of five stages

Stage Definition

Stage 0 Carcinoma in situ (early cancer that is present only in the layer of cells in which it began).

Stage I, Stage II, and Stage III Higher numbers indicate more extensive disease: greater tumor size, and/or spread of the cancer to nearby lymph nodes and/or organs adjacent to the primary tumor.

Stage IVThe cancer has spread to another organ.

Impact of staging on survival

Data from Centre François Baclesse (Breast cancer patients survival)

www.oncoprof.net

Impact of staging on survival

Data from Centre François Baclesse (Breast cancer patients survival)

www.oncoprof.net

Are all cancers staged with TNM classifications?

• Most types of cancer have TNM designations, but some do not. • Different staging systems are also used for many cancers of the

blood or bone marrow, such as lymphoma. The Ann Arbor staging classification is commonly used to stage lymphomas and has been adopted by both the AJCC and the UICC.

• However, other cancers of the blood or bone marrow, including most types of leukemia, do not have a clear-cut staging system.

• Another staging system, developed by the International Federation of Gynecology and Obstetrics, is used to stage cancers of the cervix, uterus, ovary, vagina, and vulva.

NCI’s Surveillance, Epidemiology, and End Results Program (SEER)

– In situ is early cancer that is present only in the layer of cells in which it began.

– Localized is cancer that is limited to the organ in which it began, without evidence of spread.

– Regional is cancer that has spread beyond the original (primary) site to nearby lymph nodes or organs and tissues.

– Distant is cancer that has spread from the primary site to distant organs or distant lymph nodes.

– Unknown is used to describe cases for which there is not enough information to indicate a stage.

What types of tests are used to determine stage?

• Physical exams: The doctor examines the body by looking, feeling, and listening for

anything unusual. The physical exam may show the location and size of the tumor(s)

and the spread of the cancer to the lymph nodes and/or to other organs.

• Imaging studies These studies are important tools in determining stage. Procedures

such as x-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and positron emission tomography (PET) scans can show the location of the cancer, the size of the tumor, and whether the cancer has spread.

What types of tests are used to determine stage?

• Laboratory tests are studies of blood, urine, other fluids, and tissues taken from the body. For example, tests for liver function and tumor markers can provide information about the cancer.

• Pathology reports may include information about the size of the tumor, the growth of the tumor into other tissues and organs, the type of cancer cells, and the grade of the tumor (how closely the cancer cells resemble normal tissue).

Biopsy (the removal of cells or tissues for examination under a microscope) may be performed to provide information for the pathology report.

Cytology reports also describe findings from the examination of cells in body fluids.

• Surgical reports tell what is found during surgery. These reports describe the size and appearance of the tumor and often

include observations about lymph nodes and nearby organs.

Cancer treatment

Modalities of treatment1- Local therapy:

– Surgery.– Radiation therapy.

2- Systemic treatment:– Chemotherapy.– Hormonal therapy.– Monoclonal antibodies.– Radioactive material.

3- Supportive care.4- Non-conventional therapy.

SURGERY

Surgery

• Surgery was the first modality used successfully in the treatment of cancer.

• It is the only curative therapy for many common solid tumors.

• The most important determinant of a successful surgical therapy are the absence of distant metastases and no local infiltration.

Selected Historical Milestones in Surgical Oncology

Year Surgeon Event

1809 Ephraim McDowell

Elective abdominal surgery (excised ovarian tumor)

1846 John Collins Warren

Use of ether anesthesia (excised submaxillary gland)

1867 Joseph Lister

Introduction of antisepsis

1860-1890Albert Theodore Billroth

First gastrectomy, laryngectomy, and esophagectomy

1878 Richard von Volkmann

Excision of cancerous rectum

Year Surgeon Event

1880s Theodore Kocher

Development of thyroid surgery

1890William Stewart Halsted

Radical mastectomy

1906 Ernest Wertheim

Radical hysterectomy

1910-1930 Harvey Cushing

Development of surgery for brain tumors

1935 A. O. Whipple Pancreaticoduodenectomy

Surgery

• Microscopic invasion of surrounding normal tissue will necessitate multiple frozen section.

• Resection or sampling of regional lymph node is usually indicated.

• Surgery may be used for palliation in patients for whom cure is not possible.

• Has significant role in cancer prevention.– E.g familial polyposis coli.

Surgery for prevention

• Patients with conditions that predispose them to certain cancers or with genetic traitsAssociated with cancer can have normal life span with prophylactic surgery.

- Colectomy .- Oophorectomy.- Thyroidectomy.- Removal of premalignant skin lesion .

Determinants of Operative Risk

• General health status. • Severity of underlying illness. • Degree to which surgery disrupts normal

physiologic functions. • Technical complexity of the procedure

(related to incidence of complications). • Type of anesthesia required. • Experience of personnel.

Radiation therapy

Radiation therapy

• It is a local modality used in the treatment of cancer .• Success depends on the difference in the

radiosensitivity between the tumor and normal tissue.

• It involves the administration of ionizing radiation in the form of x-ray or gamma rays to the tumor site.

• Method of delivery: External beam(teletherapy).Internal beam therapy(Brachytherapy).

Radiation therapy

• Radiation therapy is planned and performed by a team of nurses, physician and radiation oncologist.

• A course of radiation therapy is preceded by a simulation session in which low-energy beam are used to produce radiograghic images that indicate the exact beam location.

Radiation therapy

• Radiation therapy is usually delivered in fractionated doses such as 180 to 300 cGy per day,five times a week for a total course of 5-8 weeks.

• Radiation therapy with curative intent is the main treatment in limited stage Hodgkin’s disease, some NHL, limited stage cancer prostate, gynecologic tumors & CNS tumors.

• Also can be used in palliative &emergency setting.

Complication of radiation

• There is two types of toxicity: acute and long term toxicity.

• Systemic symptoms such as Fatigue, local skin reaction, GI toxicity, oro-pharyngeal mucositis & xerostomia. myelosuppression.

• Long-term sequelae: may occur many months or years after radiation therapy.

• Radiation therapy is known to be mutagenic, carcinogenic and teratogenic and having increased risk of developing both secondary leukemia and solid tumor.

NUCLEAR MEDICINE

Radionuclides

• For decades have been used systemically to treat malignant disorders.

• They are administer by specialists in nuclear medicine or radiation oncologist.

• Radioactive iodine: In the from of 131I is effective therapy for well differentiated thyroid ca

• Strontium-89: Is used for the treatment of body metastasis.

CHEMOTHERAPY

Chemotherapy

• Systemic chemotherapy is the main treatment available for disseminated malignant diseases.

• Progress in chemotherapy resulted in cure for several tumors.

• Chemotherapy usually require multiple cycles.

Classification of cytotoxic drug

Cytotoxic agent can be roughly categorized based on their activity in relation to the cell cycle.

phase nonspecific. phase specific

cyto toxic drug

Cont.

• What is the difference between phase specific & phase non specific?…..

• Phase non-specific: – The drugs generally have a linear dose-response

curve( the drug administration ,the the fraction of cell killed).

• Phase specific:– Above a certain dosage level, further increase in

drug doesn’t result in more cell killing, but you can play with duration of infusion.

Chemotherapeutic agents

• Alkylating agents• Anti-metabolites• Anti-tumor antibiotic• Plant alkaloids• Other agents• Hormonal agent• Immunotherapy

Complication of Chemotherapy

Every chemotherapeutic will have some deleterious side effect on normal tissue .

• Myelo-suppression• Nausea & vomiting• Stomatitis • Alopecia

Criteria used to describe response are• Complete response (complete remission) is the

disappearance of all detectable malignant disease.• Partial response: is decrease by more than 50% in

the sum of the products of the perpendicular diameters of all measurable lesions.

• Stable disease: no increase in size of any lesion nor the appearance of any new lesions.

• Progressive disease: means an increase by at least 25% in the sum of the products of the perpendicular diameters of measurable lesion or the appearance of new lesions.

Please check the following web sites

• www.cancer.org• www.esmo.org• www.eso.org

If you need help don’t hesitate to contact me:emadshash@gmail.com

THANK YOU