TUMOUR AND THEIR MANAGEMENT

(PRINCIPLES)
Dr (Ms) Farrah-Hani Imran
Head of Plastic & Reconstructive Surgery
Head of Burns Unit
Head of Wound Care Team
Department of Surgery
UKM
UKM Dental Student Lecture Series 2016-2017
 Modalities of treatment:
◦ 1-local therapy:
◦ -surgery.
◦ -radiation therapy.
◦ 2-systemic treatment:
◦ chemotherapy.
◦ Hormonal therapy.
◦ Monoclonal antibodies.
◦ Radioactive material.
◦ 3-supportive care.
◦ 4-non-conventional therapy.
 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.
◦ Microscopic invasion of surrounding normal tissue will necessitate multiple
frozen sections.
◦ 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.
Radiation therapy:
 Radiation therapy:
◦ Radiation therapy: is a local modality used in the treatment of cancer .
◦ Success depends on the difference in the radio sensitivity between the tumor and normal
tissue.
◦ It involves the administration of ionising 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 is planned and performed by a team of nurses, dosimetrists, oncologists
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.
 Cont:

◦ 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 ca
prostate,gynecologic tumors&CNS tumor .
◦ Also can use 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,oropharyngeal mucositis&xerostomia.myelosuppression.
◦ Long-term sequelae:may occur many months or years after radiation
therapy.
◦ Radiation therapy is known to be mutagenic,carcinogenic,and
teratogen,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.it is an
alkaline earth element in the same family as calcium
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.

cytotoxic drug

phase nonspecific. phase specific

 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.
What are the chemotherapeutic
agent?…..
 Chemotherapeutic agents:

◦ Alkylating agents:
◦ Antimetabolites:
◦ Antitumor antibiotic:
◦ Plant alkaloids:
◦ Other agents
◦ Hormonal agent:
◦ Immunotherapy:
 Complication of Chemotherapy:

◦ Every chemotherapeutic will have some deleterious side effect on normal tissue .
◦ E.G; Myelosuppression,nausea&vomiting,
Stomatitis,and alopecia are the most frequently observed side effects.
 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.
Endocrine therapy:
 Endocrine therapy:

◦ Many hormonal antitumor agents are functional agonist or antagonist of the

steroid hormone family.
◦ Adrenocorticoids:
◦ Antiandrogen:
◦ Estrogen:
◦ Antiestrogen:
◦ Progestins
◦ Aromatase inhibitor:
◦ Gonadotropin-releasing hormone agonists:
◦ Somatostatin analogues:
 Adrenocorticosteroid:

◦ Are frequently used in combination regimen for the treatment of

lymphocytic leukemia and lymphoma.
◦ They function by binding to glucocorticoid-specific receptors present
in lymphoid cells and initiate programmed cell death
◦ They most commonly used agent are
prednisone,methylprednisone,dexamethosone.
 Antiandrogens:

◦ Flutamide :
Effectively blocks the binding of androgen to its receptor in the periphral tissue .
It is used in the treatment of disseminated prostate ca
Biological therapy:
 Biologic therapy:

◦ Immunotherapy:
◦ Cytokines
◦ Cellular therapy.
◦ Tumor vaccine:

◦ Hematopoietic growth factors.

 Overview

HEAD & NECK CA

Normal Oral Cavity
Tongue cancer
 What is Head and Neck Cancer

◦ Cancer of the nose, mouth, lips, gums, tongue, throat, voicebox and other sites
◦ Affects 50,000 people in the US each year
◦ Curable 50% of the time
 What causes head and neck cancer?

1) Smoking
2) Smoking
3) Tobacco and smoking
4) Alcohol
5) sexually transmitted virus (HPV 16), Environmental, hereditary
 How To Treat Head and Neck
Cancer

◦ Find it, usually late

-over 80% of tumors are late stage
◦ Surgery (cut it out)
◦ Radiation (burn it)
◦ Chemotherapy (selective poisoning)
◦ Combine the above
Surgical Approaches
◦ Transoral
◦ Visor
◦ Lip Split with or without mandibulotomy
◦ Lip Split with Mandibulectomy
◦ Approach determined before incision and mandibulectomy or mandibulotomy
◦ Accurate assessment of bone erosion, involvement of neural structures
 Surgical Resection Advances

◦ Reconstruction
◦ Free Tissue Transfer
◦ Mandibular reconstruction (fibula, scapula, etc.)
◦ Soft tissue/tongue (radial forearm, rectus abdominus, lateral thigh, etc.)

◦ Resection is rarely limited by size or extent of tumor

Contraindications to Resection
invasion of masticator space,
pterygoid plates, skull base, or
carotid encasement

Patient perception of
quality of life
 Development of Multimodal Therapy
for Head & Neck Cancer

Gene
Therapy

Targeted
Therapy

Chemotherapy

Radiotherapy

Surgery

1900 1950 1960 1970 1980 1990 2000 2005

Levels of Evidence
1. Randomized controlled trial or
Meta-analysis
2. Nonrandomized controlled clinical trial,
subset analysis of RCT
3. Case series, population based,
consecutive or not
4. Opinions of respected authorities based
upon clinical experience or reports of
expert committees
Surgery Remains Initial Definitive Treatment
for Most Sites in Head & Neck
1. SCC of Oral Cavity
2. SCC of Nasal Cavity and Paranasal Sinuses
3. Advanced Carcinomas (T4) of the
Larynx and Hypopharynx
4. Salivary Tumors
5. Thyroid Cancer
6. Sarcomas
7. Skin Cancer and Melanoma
 Surgery for
Complications and Sequelae of
Radiotherapy / Chemotherapy

1. Oro-nasopharyngeal stenosis
2. Laryngeal edema/obstruction
3. Radionecrosis of larynx

4. Pharyngoesophageal stricture
5. Osteoradionecrosis of mandible
Surgery Employed for Palliation

1. Pain
2. Bleeding
3. Airway Obstruction

4. Oesophageal Obstruction
5. Fungating Tumor
6. Distant Metastases
THANK YOU