Minor – Comprehensive care and anatomy
4/9
Surgical oncology – basic principles
Surgery only treatment option for cancer until 1900. Gamechangers in surgery:
- Aseptic protocols
- General anaesthesia
Cancer staging ----->
Doelen chirurgie;
• Diagnostisc
o Goal: prove / rule out presence of cancer
o Cancer yes/no
§ Diagnostic excision
§ Surgical biopsy
o Staging of the disease:
§ N-stage: lymph node excision (e.g. sentinel node procedure)
§ M-stage: e.g. diagnostic laparascopy for peritoneal metastases
• Curative
o Primary tumors (margins)
o Lymph node dissections
o Metastasectomies
• Palliative
o Goal: not to cure, but to relieve
o Indications:
§ Bleeding
§ Obstruction
§ Pain
§ Wounds
• To facilitate application of chemo-/radiotherapy
o Vascular access procedure
§ Central venous cathether
§ Port-a-cath (PAC) (= onderhuids implanteerbaar toedieningssysteem
dat bestaat uit een metalen reservoir en een flexibele katheter)
o Chemotherapy
§ Isolated limp perfusion
§ HIPEC (hypertherme intraperitoneale chemotherapie) (eerst zoveel
mogelijk tumorweefsel verwijderen, daarna buikholte spoelen met
verwarmde chemotherapie)
o Radiotherapy
§ Brachytherapy (inwendige bestraling)
§ Intra-operative radiotherapy (bestraling tijdens een operatie)
• Prophylactic
o Goal: prevent cancer in high-risk population
o Examples:
, § Prophylactic mastectomy in BRCA-mutation-carriers
§ Prophylactic colectomy in Lynch syndrome
• Reconstructive
o Goal: to improve functional / cosmetic outcome after cancer surgery
o Techniques:
§ Autologous
§ Prothesis
Reducing the extent of surgery thanks to improved (neo-)adjuvant treatment.
Surgical oncology – breast cancer
Oorzaken borstkanker:
• 20-25% familiaire borstkanker (geen genetische oorzaak bekend)
• 5-10% erfelijke borstkanker (BRCA-mutatie) (bekende genetische oorzaak)
• 65-75% sporadische borstkanker (onbekende oorzaak)
How are patients diagnosed?; referred to hospital breast clinics via:
- BC population program (50-75 yr)
- GP (swelling / symptoms)
- Screening in case of high risk family history
Breast clinic;
• Medical history
• Physical examnn
• Mammography, ultrasound
• FNAC (fijne naald aspiratie cytologie) or biopsy
Symptomen:
• Knobbel in borst
• Heldere / bloederige tepeluitvloed
• Ingetrokken tepel (als dit normal niet was)
• Sinaasappelhuid
• Verharding
• Deuk
• Asymmetrie
Pathologie;
• Ductal vs lobular:
o ‘Invasive ductal carcinoma’ --> milk duct tissue invading the surrounding
tissue
o ‘Invasive lobular carcinoma’ --> milk lobules invading the surrounding tissue
§ Moeilijk te zien op mammogram, vaak pas in later stadium ontdekt
(uitkomsten zijn wel gelijk)
o ‘DCIS: ductal carcinoma in situ’ --> abnormal, cancerous cells that are
confined to the milk ducts and have not spread to surrounding breast tissue
, • Grade:
o Grade 1: low grade
§ Well differentiated, resembles normal tissue (>75% tubules)
§ Generally less aggressive
o Grade 2: intermediate grade
§ Moderately differentiated cells (10-75% tubules)
§ Faster growth then normal cells (mitosis)
§ Cancer celsl stick together
o Grade 3: high grade
§ Cancer cells stop resembling healthy breast cells (<10% tubules)
§ High mitotic count
• Hormone receptor / HER2 status:
o Hormoongevoelige borstkanker (ER+ en/of PR+)
o HER2-positieve tumor
o Triple negatief borstkanker (typisch voor jonge vrouwen met BRCA-mutatie)
Wie mag MRI?
• Screening in BRCA-mutatie
• Chemotherapy response
• Lobular cancer
• High grade DCIS
• Multifocality / multicentricity
• Breast cancer in dense tissues (ACR C/D)
FDG-PET-CT indicatie:
• (Lymph node) metastasis
• Tumor > 3 cm
Treatment strategies:
• Chirurgie
o Breast conserving surgery (BCS)
o Wide local excision (WLE)
§ D.m.v. magnetic marker, iodine seed, wire, …
o Mastectomie (met/zonder reconstructie)
§ cT4 (skin involvement), multicentricity, previous radiotherapy, large
tumor size, BRCA1/2 mutation, cannot undergo radiotherapy, patient
preference
• Bestraling (teleangiëctasieën vaak bijwerking)
o Indicaties:
§ Breast – (almost) standard after breast conserving surgery
§ Breast & axilla – after breast conserving surgery or higher stage (stage
III)
§ Thoracic wall after mastectomy – positive margins after resection, cT4,
tumor > 5 cm
o Bijwerkingen: radiation dermatitis, skin irritation, skin discoloration, …
• Systeemtherapie
o Chemotherapie
, o Endocriene therapie (tamoxifen)
o Targeted therapie / immunotherapie (alleen triple negatief reageert op
immuuntherapie)
Lymph nodes;
• No clinical node metastasis --> sentinel node biopsy (SNB)
• Lymph node metastasis after systemic therapy --> taking out the marked lymph node
• Axillary lymph node dissection (ALND): bulky disease, or >3 lymph nodes containing
tumor after systemic therapy
Endocrine surgery: (para)thyroid and adrenal pathology
Hyperparathyreoidie --> calcium verhoogd, pth verhoogd (aantonen met choline PET)
MEN1-mutatie --> multigland disease, alle 4 aangedaan
4 bijschildklieren:
• 4-8 mm groot
• 2 dorsaal van de bovenpool
• 2 caudaal van de bovenpool
• Ontstaan in 3e en 4e kieuwbogen
• Kunnen tijdens ontwikkeling/indaling op verschillende plekken terecht komen
Ectopic glands;
• 5-10% multigland disease
• 15% ectopic localisation
o ~5% intrathoracaal
Revision surgery: 3 R’s;
• Revise – diagnosis
• Review – pathology
• Redo – imaging
Neuro-endocriene tumor;
• Gastroenteropancreatic 67%
• Bronchopulmonary 27%
• Other sites 6%
Enterochromaffine cellen (in dunnedarm wand) --> produceren 5-HT (= serotonine)
Hormonale productie;
• Long carcinoid
o PTHrp
o ACTH
• Dunnedarm
o Serotonine (carcinoïd)
4/9
Surgical oncology – basic principles
Surgery only treatment option for cancer until 1900. Gamechangers in surgery:
- Aseptic protocols
- General anaesthesia
Cancer staging ----->
Doelen chirurgie;
• Diagnostisc
o Goal: prove / rule out presence of cancer
o Cancer yes/no
§ Diagnostic excision
§ Surgical biopsy
o Staging of the disease:
§ N-stage: lymph node excision (e.g. sentinel node procedure)
§ M-stage: e.g. diagnostic laparascopy for peritoneal metastases
• Curative
o Primary tumors (margins)
o Lymph node dissections
o Metastasectomies
• Palliative
o Goal: not to cure, but to relieve
o Indications:
§ Bleeding
§ Obstruction
§ Pain
§ Wounds
• To facilitate application of chemo-/radiotherapy
o Vascular access procedure
§ Central venous cathether
§ Port-a-cath (PAC) (= onderhuids implanteerbaar toedieningssysteem
dat bestaat uit een metalen reservoir en een flexibele katheter)
o Chemotherapy
§ Isolated limp perfusion
§ HIPEC (hypertherme intraperitoneale chemotherapie) (eerst zoveel
mogelijk tumorweefsel verwijderen, daarna buikholte spoelen met
verwarmde chemotherapie)
o Radiotherapy
§ Brachytherapy (inwendige bestraling)
§ Intra-operative radiotherapy (bestraling tijdens een operatie)
• Prophylactic
o Goal: prevent cancer in high-risk population
o Examples:
, § Prophylactic mastectomy in BRCA-mutation-carriers
§ Prophylactic colectomy in Lynch syndrome
• Reconstructive
o Goal: to improve functional / cosmetic outcome after cancer surgery
o Techniques:
§ Autologous
§ Prothesis
Reducing the extent of surgery thanks to improved (neo-)adjuvant treatment.
Surgical oncology – breast cancer
Oorzaken borstkanker:
• 20-25% familiaire borstkanker (geen genetische oorzaak bekend)
• 5-10% erfelijke borstkanker (BRCA-mutatie) (bekende genetische oorzaak)
• 65-75% sporadische borstkanker (onbekende oorzaak)
How are patients diagnosed?; referred to hospital breast clinics via:
- BC population program (50-75 yr)
- GP (swelling / symptoms)
- Screening in case of high risk family history
Breast clinic;
• Medical history
• Physical examnn
• Mammography, ultrasound
• FNAC (fijne naald aspiratie cytologie) or biopsy
Symptomen:
• Knobbel in borst
• Heldere / bloederige tepeluitvloed
• Ingetrokken tepel (als dit normal niet was)
• Sinaasappelhuid
• Verharding
• Deuk
• Asymmetrie
Pathologie;
• Ductal vs lobular:
o ‘Invasive ductal carcinoma’ --> milk duct tissue invading the surrounding
tissue
o ‘Invasive lobular carcinoma’ --> milk lobules invading the surrounding tissue
§ Moeilijk te zien op mammogram, vaak pas in later stadium ontdekt
(uitkomsten zijn wel gelijk)
o ‘DCIS: ductal carcinoma in situ’ --> abnormal, cancerous cells that are
confined to the milk ducts and have not spread to surrounding breast tissue
, • Grade:
o Grade 1: low grade
§ Well differentiated, resembles normal tissue (>75% tubules)
§ Generally less aggressive
o Grade 2: intermediate grade
§ Moderately differentiated cells (10-75% tubules)
§ Faster growth then normal cells (mitosis)
§ Cancer celsl stick together
o Grade 3: high grade
§ Cancer cells stop resembling healthy breast cells (<10% tubules)
§ High mitotic count
• Hormone receptor / HER2 status:
o Hormoongevoelige borstkanker (ER+ en/of PR+)
o HER2-positieve tumor
o Triple negatief borstkanker (typisch voor jonge vrouwen met BRCA-mutatie)
Wie mag MRI?
• Screening in BRCA-mutatie
• Chemotherapy response
• Lobular cancer
• High grade DCIS
• Multifocality / multicentricity
• Breast cancer in dense tissues (ACR C/D)
FDG-PET-CT indicatie:
• (Lymph node) metastasis
• Tumor > 3 cm
Treatment strategies:
• Chirurgie
o Breast conserving surgery (BCS)
o Wide local excision (WLE)
§ D.m.v. magnetic marker, iodine seed, wire, …
o Mastectomie (met/zonder reconstructie)
§ cT4 (skin involvement), multicentricity, previous radiotherapy, large
tumor size, BRCA1/2 mutation, cannot undergo radiotherapy, patient
preference
• Bestraling (teleangiëctasieën vaak bijwerking)
o Indicaties:
§ Breast – (almost) standard after breast conserving surgery
§ Breast & axilla – after breast conserving surgery or higher stage (stage
III)
§ Thoracic wall after mastectomy – positive margins after resection, cT4,
tumor > 5 cm
o Bijwerkingen: radiation dermatitis, skin irritation, skin discoloration, …
• Systeemtherapie
o Chemotherapie
, o Endocriene therapie (tamoxifen)
o Targeted therapie / immunotherapie (alleen triple negatief reageert op
immuuntherapie)
Lymph nodes;
• No clinical node metastasis --> sentinel node biopsy (SNB)
• Lymph node metastasis after systemic therapy --> taking out the marked lymph node
• Axillary lymph node dissection (ALND): bulky disease, or >3 lymph nodes containing
tumor after systemic therapy
Endocrine surgery: (para)thyroid and adrenal pathology
Hyperparathyreoidie --> calcium verhoogd, pth verhoogd (aantonen met choline PET)
MEN1-mutatie --> multigland disease, alle 4 aangedaan
4 bijschildklieren:
• 4-8 mm groot
• 2 dorsaal van de bovenpool
• 2 caudaal van de bovenpool
• Ontstaan in 3e en 4e kieuwbogen
• Kunnen tijdens ontwikkeling/indaling op verschillende plekken terecht komen
Ectopic glands;
• 5-10% multigland disease
• 15% ectopic localisation
o ~5% intrathoracaal
Revision surgery: 3 R’s;
• Revise – diagnosis
• Review – pathology
• Redo – imaging
Neuro-endocriene tumor;
• Gastroenteropancreatic 67%
• Bronchopulmonary 27%
• Other sites 6%
Enterochromaffine cellen (in dunnedarm wand) --> produceren 5-HT (= serotonine)
Hormonale productie;
• Long carcinoid
o PTHrp
o ACTH
• Dunnedarm
o Serotonine (carcinoïd)
