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SURG LE3 > Principles of Surgical Oncology > Flashcards

Principles of Surgical Oncology Flashcards

1
Q

What are the 5 principles of surgical oncology?

A
  1. Tumor biology
  2. Goals & principles in cancer surgery
  3. Principles of systemic therapy & radiation therapy
  4. Cancer treatment strategies under multisciplinary approach
  5. Advances in oncology
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2
Q

What should u take note of in tumor growth 7 occurence of metasis?

A
  • knowing abt the behavior of the tumor: how fast it grows, how quick it metastasizes
  • pattern & distribution of metastiasis
  • tumor factors affecting outcomes/prognosis
  • margins of resection
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3
Q

What are the phase of cell cycle?

A

Interphase: G1 -> S -> G2 -> M

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4
Q

What is the deciding factor for a ell to enter G0 phase?

A

Presence or absence of growth factors or nutrients

If present -> G1
If absent -> G0 -> can be reversible/irreversible

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5
Q

What are the 2 mechanisms of Cell Cycle control?

A
  1. Checkpoint control
  2. Cyclins
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6
Q

What are critical events in Checkpoint control?

A

DNA replication
Chromosome segregation

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7
Q

WHat are the differnt checkpoints in checkpoint control?

A

G1/S (R pont) CHeckpoint = primary determining factor for cell division to take place

G2 Checkpoint = represents commmitment for starting mitosis, DNA replicated correctly

M/Spindle checkpoint = ensures all chromosomes are attached to the spindle in preparation of mitosis

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8
Q

What happens if there are problems in the # of growht factors in G1, damge in replicated DNA in G2 or problem with spindl eformation in M phase?

A

Cell cycle proceeds —> uncontrolled cellular replication —> cancer

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9
Q

What are proteins tha tcontrol the progression of cells through the cell cycle?

A

Cyclins

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10
Q

What enzyme activates Cyclins?

A

Cycline-dependent kinase

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11
Q

What is a central part of all phases of the maintenance of cell cycle?

A

Regulation of Cyclin/CDK activity?

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12
Q

What can happen if Cyclin/CDK activity iscompromised?

A

Malignant transformation of cells

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13
Q

What are the diff factors assoc with Carcinogenesis?

A

Genes
Carcinogens
Cancer cells

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14
Q

What are the 2 classes of cancer genes?

A

Oncogenes = stimualtes growth of cells; positive growth regulators

Tumor suppressor genes = blocks G1/S phase; promotes apoptosis; negative growth regulators; loss of function mutation of proteins

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15
Q

What are ocongenes high in lung, pancreas, colon, thryoid, & breast?

A

Breast cancer = HER2 NEU

Lungs, pancreas, colon, & thyroid cancers = Ras

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16
Q

What hereditary cancer is associated with APC gene?

A

Familial adenomatous polyposis

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17
Q

What hereditary cancer is associated with BMPRIA gene?

A

Juvenile polyposis coli

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18
Q

What hereditary cancer is associated with BRCA1/BRCA2 gene?

A

Breast/Ovarian syndorme

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19
Q

What hereditary cancer is associated with hMLHI, hMSH2, hMSH6, hPMSI, hPMS2 gene?

A

Hereditary nonpolyposis colorectal cancer

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20
Q

What are the different oncogenic viruses?

A

EBV = Gastric cancer, lymphoma
HPV = Cervical cancer, vulvar cancer
Hepa B, C = liver cancer
HIV = Kaposi sarcoma

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21
Q

What are diff oncogenic causes of chemicals?

A

Aflatoxin = Liver cancer
Arsenic = Skin cancer
Estrogen replacement therapy & Tamoxifen = Endometrial cancer

Tobacco = Oral cavity cancer, lung cancer, pancreatic cancer, esophageal cancer

Benzidine = urinary bladder cancer

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22
Q

What are different carcinogenc caused by chronic irritation?

A

Ulcerative colitis = Colon cancer

GERD = Esophageal cancer

Marjolin’s ulcer = Squamou CC, Basal cell carcinoma of the skin

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23
Q

What are hallmarks of cancer cells?

A

Sustained proliferative signaling
Insensitive to growth suppressors
Resist cell death (apoptosis)
Replicative immortality
Induces angiogenesis
Evades immune response
Creates tumor microenvironment
Invasion & Metastasis

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24
Q

What are the 5 most common cancers in PH?

A

Breast cancer
Lung cancer
Colorectal cancer
Liver cancer
Prostate cancer

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25
Q

What are the most prevalent cancers in Males?

A

Lung
Colorectum
Prostate
Liver
Leukemia

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26
Q

What er the most prevalent cancers in Females?

A

Breast
Uterus/Cervix
Colorectum
Lungs
Ovary

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27
Q

What type of cancer has the highest incidence & mortality rate? Followed by?

A

Breast

  1. Prostate
  2. Lungs
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28
Q

What type of cancer is easily screened & should be screened early because of its aggressive behavior & high mortality rate?

A

Breast & prostate cancers

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29
Q

What is the scheduled screening test for breast cancer?

A

45 y/o & above
Annually

Mammography

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30
Q

What is the scheduled screening test for lung cancer?

A

50-80yo

Smoker with 20 pack yrs or have quit smoking for the last 15 yrs

Low dose chest
CT scan

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31
Q

What is the scheduled screening test for Cervical cancer?

A

25yo
Every 5 yrs until 65 yo

Pap smear
HPV test

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32
Q

What is the scheduled screening test for colorectal cancer?

A

45 yo
Annually until 75 yo for ave risk

Highly sensitive fecal immunochemical test
GFOBT

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33
Q

What are other scheduled screening for colorectal cancer?

A

Every 10 yrs = Colonoscopy
Every 5 yrs = Flexible sigmoidoscopy

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34
Q

At what age should one be screened for prostate cancer?

A

50 yo = ave risk; expected to live 10 yrs

45 yo = high risk

40 yo = even higher risk

screening every 1-2 yrs = Prostate Specific Antigen

50yo & > = DRE

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35
Q

Tumor growth is best described & tracked by what chart?

A

Gompterzian curve
- if tumor is small in size -> growth rate is close to 100% -> sensitive to tx/treatable

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36
Q

What happens to tumors that decrease in growth rate bcos of lack of nutrients and blood supply?

A

Bcomes more aggressive => cancer cells are in cell cycle phase -> easily metastasize/invade other surrounding structures -> very lethal

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37
Q

What is the expression of tumor growth?

A

Volume doubling time

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38
Q

Whta is the range of doubling time in breast, lugns, melanoma, & metastatic melanoma?

A

MM - 64 days
Breast = 130 days
Melanoma - 140 days
Lungs = 160 days

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39
Q

In clinical impression of breat CA, what do u do if a px comes to u w/ sonograpihc findings of a 1cm nodule, not highly suspicious ofmalignancy?

A
  1. Repeat ultrasound after 3-4 mons
  2. If size increases to 1.5 - 2cm, it is malignant and should undergo tissue biopsy
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40
Q

In clinical impression of lung CA, what should u do if a px comes to u w/ CXR of 1cm ndule on apex, no history of pulmonary TB?

A
  1. Request for another imaging after 3-4 mons
  2. If there’s increase in size -> suspicious for malignancy
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41
Q

What are the main diff betw slow growing & fast growing tumors?

A

Slow growing tumors
- curable with surgery alone
- Appendiceal Carcinoma with low malignant potential: Pseudomyxoma peritoei
- Well-differentiated thyroid carcinoma: Papillary thyroid carcinoma, Follicular thyroid carcinoma

Fast growing tumors
- likely metastatic
- curable with multimodal tx
- surgery + chemotherapy (+/- radiation)

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42
Q

What are examples of fast growting tumors?

A

Pancreatic adenocarcinoma
Gastric adenocarcinoma
Esophageal adenocarcinoma
Esophageal carcinoma

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43
Q

What is TUmoriogenesis?

A

Oncogene mutation -> cells likely to divide more -> Dysplasia stage -> overgrowing cells change orig form & behavior -> In situ cancer -> cells grow rapidly, lost their tissue identity, & grow w/o regulation -> malignant tumor -> invade neigboring areas & blood circulation system -> autophagy

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44
Q

What are the 2 roles of tumorigenesis?

A

Tumor-suppressing role during the early stage
Cancer promiting role during late stage

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45
Q

What occurs in early metastasis?

A

Primary organ: GIT, oral cavity
Histo: Adenocarcinoma
Diff: Poorly-differnetiated
Depth of penetration: Submucosal, higher rate of metastasis
Genetic profile: Her2+, Er-
Size: >2cm
Lymph node metastasis: Present

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46
Q

What are the occurence of late metastasis?

A

Primary organ: thyroid, breast
Hist: Neuroendocrine
Differentiation: well-differentiated
Depth of penetration: Mucosal
Genetic profile: Her 2-, Er +
Size: <2cm
Lymph node metastasis: Absent

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47
Q

What are the differnt patterns & distribution orgagns of metastasis?

A

Lymph nodes
Blood
Coelomic

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48
Q

What are the route & pattern of Metastasis?

A

Lungs = Mediastinal LN, + blood, - Coelemic

Breat = Axillary LN, + blood, - Coelemic

Thyroid = Cervical LN, + blood, - Coelemic

Colon/Rectal stomach = Mesenteric/Pelvic perigastric LN, + Blood, + Coelomic

Sarcoma = Rarely, + Blood, - Coelomic

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49
Q

What is the path of metastasis?

A

Carcinoma first metastasizes to the lymphatics
Sarcoma invades bloodstream

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50
Q

Does sarcoma produce transcoelomic metastasis?

A

Rarely EXCEPT for Intraperitoneal sarcomas

51
Q

What happens if abdominal cavity is ruptured in Uterine leiomyosarcoma?

A

Present with peritoneal carcinomatosis

52
Q

What are the different patterns of solid organ mestasis?

A

Site of metastasis: brain
Primary tumors: 1. Lung, 2. Breast, 3. Melanoma, 4. Renal cell, 5. Colorectal

53
Q

What is the pattern of solid organ metastasis of the lungs?

A
  1. Renal cell
  2. Colorectal
  3. Melanoma
  4. Breast
  5. Sarcoma
54
Q

What pattern of solid organ metastasis of the liver?

A
  1. Colorectal
  2. Pancreatic
  3. Breast
  4. Lung
  5. Stomach
55
Q

What is the pattern of organ metastasis of the Bone?

A
  1. Breast
  2. Lung
  3. Prostate
  4. Renal cell
  5. Colorectal
56
Q

Where does colroectal carcinoma metastasize?

A
  1. Lungs
  2. Lungs
57
Q

Where does Periphera/Extermities Sarcoma metastasize?

A

Lung

58
Q

Where does Retro/Intraperioneal Sarcoma metastasize?

A

Liver

59
Q

What are the significance of lymph node metastasis & pattern of spread?

A

Indicator systemic therapy +/- radiation therapy

60
Q

Into what regional lymph node does Stomah cancer drain to?

A

Perigastric LN

61
Q

What regional lymph node does rectal cancer drain to?

A

Mesorectal lymph nodes

62
Q

What regional lymph node does colon cancer drain to?

A

Mesenteric lymph nodes along vascular pedicle

63
Q

What are clinical implications of metastatic tumor?

A

Tumor of breast = remove breast + axillary LN

Gastric CA = remove stomach + perigastric lympph node

64
Q

What are factors that INC incidence of lNC metastasis?

A
  1. Size of primary tumor
  2. Depth of invasion of the primary tumor
  3. Histo features
65
Q

What are the sizes of breast cancer & Papillary thyroid cancer when incidence of LN metastasis?

A

Breast cancer = >2cm, >15% in the axilla
Papillary thyroid cancer = >5mm, 15-65% in the cervical LN

66
Q

What is the depth of invasion of the primary tumor that INC incidence of LN metastases?

A
  • 20% submucosal invasion in the GIT
  • > 15% tongue SCC >5mm
67
Q

What are histo features seen in INC of LN metastasis?

A
  1. Epithelial-adenocarcinoma of GIT = high chance of LN metastasis
  2. Mesenchymal tissue-sarcoma of the soft tissue = low chance, not expected LN metastasis
68
Q

What lymph node metasis influences prognosis of cancer?

A

Survival
Local recurrence
Least impact on the tumors of the thyroid

69
Q

What are the influence on survival & recurrence of LN metasis?

A

Decreased Survival rates
YES = breast, colon, gynecologic, sarcoma, oral cavity squamous CC

NO = thyroid

Increae loco-regional recurrence
YES = breast, colon, gynecologic, sarcoma, thyroid, oral cavity squamous cell carcinoma

70
Q

What is the route & pattern of LN Metastasis?

A
  1. Invasive ductal carcinoma of the breast
    A. Level 1, 2, 3 axillary LN -> intercostal -> mediastinal & supra-clavicular LN
  2. Squamous CC of the anterior tongue
    A. Level 1, 2, 3 cervical LN initially -> level 4-6 of cervical LN of the neck
71
Q

What are clinical implications of LN metastasis?

A

Prophylactic neck dissection or Supraomohyoid neck dissection

72
Q

What is TNM?

A

Staging of metastasis

Size of the primary Tumor
Number of Lymph node metastasis
Site of distant Metastasis

73
Q

What is stage 0 of cancer?

A

Carcinoma in situ (CIS)

Abnormal cells are present but have not spread to neaby tissue

74
Q

What is the tumor marker for colorectal & breast cancer?

A

CEA

75
Q

What tumor marker is fpr Hepatocellular carcinoma?

A

AFP

76
Q

What tumor marker is for pancreatic cancer?

A

CA 19-9

77
Q

What are the differnet ways to do a tissue biopsy?

A

Fine needle aspiration biopsy
Core needle biopsy
Incision biopsy
Excision biopsy

78
Q

What type of tissue biopsy uses a thin, hollow needle & used foor palpable superficial tumors like enlarge lymph nodes, breast lumps, and thyroid tumors?

A

Fine needle aspiration biopsy/Cytology

79
Q

What are advantages & disadvantages of fine need biopsy?

A

Advantages:
- diagnose benign vs malignant tumor
- safe, conventient & simple
- excellent for thyroid mass/nodule

Disadvantages
- inadequate to diff in-situ vs invasive (breast tumor), sarcoma vs carcinoma or lymphoma vs TB
- spx not enough for immunostaining

80
Q

What type of core needle biopsy makes use of a large-bore needle that is best used if histologic characteristics are consistent with the clinical scenario?

A

Core needle biopsy

81
Q

What are advantages of Core needle biopsy?

A
  • Provides a degree of architectural iinformation = increased diagnostic yield
  • used for genetic tests (breast cancer)
  • immunohistochemical staning can be performed
82
Q

What are disadvantages of core needle biopsy?

A
  • cannot be used in tissues near a major BV
  • longer fixation & processing time
  • more expensive
83
Q

What type of biopsy is used for indeterminate soft tissue masses as a more reliable, accurate, and confirmatory means of determining malignnacy, establishing the exact diagnosis?

A

Open biopsy

84
Q

What are the 2 types of open biopsy?

A

Incision biopsy
Excision biopsy

85
Q

In what case do u use incision biopsy?

A

For difficult to remove lesions due to size or location

86
Q

What type of open biopsy is used for complete removal of the mass with a margin of normal tissue?

A

Excision biopsy

87
Q

From open biopsy, core needle biopsy, and fine needle aspiration biopsy, which one is the most accurate among all the biopsy procedures?

A

Open biopsy

88
Q

In what cases do we give palliative surgery?

A

Px with unresectable tumors, incurable disease/metastatic but longevity and quality of life can still be improved

Address the pain, bleeding, or GIT obstruction

89
Q

What is a prophylactic surgery?

A

Risk reducing surgery = to prevent future cancer from developing

90
Q

What is a supportive surgery? Examples?

A

Performed for nutritional access or medical treatment

Port-A-Cath = implanted below the skin

Feeding tube (Jejunostomy/Gastrostomy) = px who can no longer eat through their mouth

91
Q

How do u assess the completeness of the primary tumor and draining of lymph nodes at risk of metastasis?

A

Margins of resection
Pattern of lymph node invovlement

92
Q

In what cases do u perform oncologic resection?

A

Non-metastatic tumors (stage 1-3)

93
Q

What are the goals of oncologic resection?

A
  1. Remove tumor w/ adequate margins of normal tissue & ensure no gross and microscopic cancer cells will be left behind

R0 = no microscopic tumor at the margins of resection

R1 = positive microscopic tumor at the margins of resection

R2 = positive gross residual tumors

  1. Primary tumor should be removed in continuity with regional lymph node
94
Q

what is lymph nodes are not at risk for metastasis, what is the goal of the surgery then?

A

Complete resection of the primary tumor with negative margins of resection only

95
Q

What happens if the primary tumor invades or seemed contiguous with another organ or tissue?

A

Do en bloc resection for the primary tumor (not piecemeal) to avoid spilage of cancer cells

96
Q

What is done in en block resection?

A

Remove part of the organ contiguous/involved by the tumor to achieve clear margins of resection of atleast 1cm -> negative surgical margin = no cancer cells at the resected margins (surgical gold std)

97
Q

What is the distance of Squamous/Adenocarcinoma Esophagus, Gastric adenoma, Colon adenocarcinoma, Rectal adenocarcinoma from the edge of tumor?

A

Squamous/Adenocarcinoma Esopagus:
- Proximal = >10cm
- Distal = >5cm
- Circumferential radial margin = >1mm

Gastric adenocarcinoma
- Proximal = >5cm
- Distal = >5cm

Colon adenocarcinoma
- corresponds to the vascular pedicle supplying of the colon
- 8-10cm

98
Q

What is the distance of rectal adenocarcinoma, invasive ductal carcinoma of the breast, non-melanoma skin tumor <2cm, oral cavity, sarcoma from the edge of tumor?

A

Rectal adenocarcinoma:
- Proximal = >5cm
- Distal = at least 1cm
- Circumferential radial margin should be NEGATIVE for tumor

Invasive ductal carcinoma of the breast
- if breast conserving surgery = atleast 2mm or NEGATIVE tumor in ink margin

Non-Melanoma Skin tumor <2cm: <5mm

Oral cavity: >1cm

Sarcoma: >5cm

99
Q

What are the characteristics of basal cell carcinoma of the skin?

A
  • marked the edge of tumor w/ at least >4mm margin
  • wide excision with atleast 4mm margin in a px with basal cell carcinoma
  • wide excision wtih atleast 4mm margin in a px with basal cell carcinoma
100
Q

What are descriptions of breat cancer curative surgery?

A
  • curative radical mastectomy with axillary LN dissection in a px with breast cancer with chest wall invasion non-responsive to neoadjuvant therapy
  • the margins of resection were negative
  • radical mastectomy with axillary LN dissection
101
Q

What are descriptions of of Liposarcoma of the thigh in curative surgery?

A
  • stage 2 liposarcoma of anterolateral thigh
  • performed a wide excision or muscle group resection with surgical margins of atleast 5cm
  • wide excision of tumor in a px with liposarcoma
102
Q

What is cytoreductive surgery?

A

Surgical removal of gross tumors in the metastatic setting

Cancers of the appendix w/ low malignant potential, ovarian cancers, & limited colorectal liver metastasis

103
Q

What is done in cytoreductive surgeryin px with Solitary colorectal liver metastasis?

A

Performed a ressection of the primary tumor together with the metastatic tumor to the liver

104
Q

What are the goals of chemotherapy?

A
  1. To kill cancer cells by interfering with its cell cycle with serious damage to normal cells
  2. Improve chances of cure/longer survival
  3. Lessen dose of each drug
  4. Allow normal cells to recover every 14-21 days
105
Q

what are the 3 types of systemic chemotherapy?

A

Chemotherapy
Targeted therapy
Immunotherapy

106
Q

What are type of cancer is chemotherapy effetive or ineffective?

A

Effective: Lymphoma, Colore adeniCA, Breast CA

Ineffective: Sarcoma, thyroid cancer, GI stroma tumor

107
Q

What drug classes target G1?

A

Hormonal drugs = Tamoxifen
Antineoplastic enzymes = Asparaginase, Pegaspargase

108
Q

What drug classes target S phase?

A

Topoisomerase-1 inhibitors = Tropotecan, Irinotectan

Antimetabolites:
- Folate Analogs; Methortraxate
- Purine analogs: Mercaptopurine, Thioguanine, Pentostatin
- Pyrmidine analogs: Fluorouracil, Cytarabine

Hydroxyurea

109
Q

What drug classes target G2 phase?

A

Epidophyllotoxin derivatives: Etoposide, Teniposide

Taxanes: Docetaxel, Paclitaxel

Bleomycin

110
Q

What drug class targets M phase?

A

Vinca alkaloids: Vinblastine, Vincristine, Vinorelbine

Taxane: Docetaxel, Paclitaxel

111
Q

What is the newest form of cytotoxic therapy where it blocks the growth of cancer cells by interfering with specific targeted molecules needed for carcinogenesis & tumor growth?

A

Targeted therapy

112
Q

What should be done in targeted therapy?

A

Must test first for the specific gene of that particular tumor wherein the drug will be effective

113
Q

What is the purpose of immunotherapy?

A

Blocks the protein molecule released by the tumor

Lung cancer: positive for programmed death lignad 1 blocked by Pemproluzimab

114
Q

What is radiation therapy?

A

Local therapeutic effects

Used if there is a risk for local reccurrence despite oncologic resection

115
Q

What are factors that affect radiosensitivity?

A

Oxygen tension = prolong 1/2 lfie of free radicals
Drugs that improve sensntivity to radiation = 5-Fluorouracil & Doxorubicin

116
Q

What are tx strategies in cancer?

A

Neoadjuvant therapy = prior to curative resection
Adjuvant therapy = after curative resection

117
Q

What is Genomics?

A

Determines the exact gene sequence of a particular tumor

118
Q

What are the targets specific molecules in cancers?

A
  1. Epidermal growth factor receptor & Lung Cancer
  2. Breast cancer
  3. Colon cancer
119
Q

What are predictive malignancy-risk gene signature?

A

Developed to stratify px with possible malignancies who would benefit from systemic chemotherapy

120
Q

What is Proteomics?

A

Proteins that are produced or encoded by the mutated genetic dequence in a prticular tumor

121
Q

What are local tx modalities for tumor control in stage 4 or unresectable tumor?

A

Radio frequency ablation
Microwave ablation
Selective intra-arterial radiation therapy

122
Q

What tx for stage 4 tumor is heat-dependent & uses a needle with a tip generating excessive heat to ablate the tumros?

A

Microwave ablation

123
Q

What tx for stage 4 tumor introduces radioactive mat to specific cannulated blood supply of tumros to control tumor growth & change of rupture/bleeding in the liver?

A

Selective intra-arterial radiation therapyh

SURG LE3 (4 decks)

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