Theme 5:
Neoplasms II
Summary
1
,Content
Week 16: On death.................................................................................................................................. 5
On life and death ................................................................................................................................. 5
Medical vs cultural and historical perspectives .............................................................................. 5
Philippe Aries: nature vs culture ..................................................................................................... 5
Death mentality in history ............................................................................................................... 5
Ethical issues with end of life decisions on the ICU ............................................................................ 7
Intensive care .................................................................................................................................. 7
Case ................................................................................................................................................. 7
Definitions ....................................................................................................................................... 8
Ethical issues: .................................................................................................................................. 8
Futility .............................................................................................................................................. 9
APACHE and SAPS score ................................................................................................................ 10
Forensic science................................................................................................................................. 11
Post-mortem ................................................................................................................................. 11
The process of dying ...................................................................................................................... 12
Suspicious signs ............................................................................................................................. 14
Finally............................................................................................................................................. 15
Medicalisation of death..................................................................................................................... 16
Historical and sociological perspective ......................................................................................... 16
Medicalisation of death: crisis in the early 1970s ......................................................................... 16
The Dutch response....................................................................................................................... 17
Euthanasia: dilemma’s and debate ............................................................................................... 17
Death (de-)medicalised ................................................................................................................. 18
Coping with stress in clinical practice................................................................................................ 19
Case ............................................................................................................................................... 19
Stages of a burnout: ...................................................................................................................... 19
What can you do for someone with symptoms: ........................................................................... 20
Week 17: Skin cancer ............................................................................................................................ 22
Histology: epithelial tissue ................................................................................................................ 22
Classification .................................................................................................................................. 22
Cell polarisation ............................................................................................................................. 24
Keratinised squamous epithelium ................................................................................................. 25
Melanocytes .................................................................................................................................. 26
Formation of glands ...................................................................................................................... 26
Histology: connective tissue .............................................................................................................. 29
2
, Classification .................................................................................................................................. 29
Cells of the connective tissue ........................................................................................................ 29
Extracellular matrix ....................................................................................................................... 29
Connective tissue proper .............................................................................................................. 30
Adipose tissue................................................................................................................................ 30
The skin.............................................................................................................................................. 31
Benign skin tumours .......................................................................................................................... 34
Seborrhic keratosis ........................................................................................................................ 34
Solar lentigo................................................................................................................................... 34
Sebaceous hyperplasia .................................................................................................................. 35
Dermatofibroma ............................................................................................................................ 36
Neurofibroma ................................................................................................................................ 36
Pyogenic granuloma ...................................................................................................................... 37
Haemangioma ............................................................................................................................... 38
Skin cancer......................................................................................................................................... 39
Basal cell carcinoma (least aggressive).......................................................................................... 41
Squamous cell carcinoma .............................................................................................................. 43
Melanocytic tumours .................................................................................................................... 46
Immunotherapy................................................................................................................................. 52
New developments ....................................................................................................................... 53
Week 18: Cancer of the male genital system ........................................................................................ 55
Anatomy of the pelvis ....................................................................................................................... 55
Muscles .......................................................................................................................................... 56
True and false pelvis ...................................................................................................................... 57
Pelvic peritoneum ......................................................................................................................... 59
Male pelvis..................................................................................................................................... 60
The prostate .................................................................................................................................. 62
Vascularisation of the true pelvis .................................................................................................. 64
Lymphatic drainage ....................................................................................................................... 66
Physiology.......................................................................................................................................... 67
Spermatogenesis ........................................................................................................................... 67
The male sexual act ....................................................................................................................... 68
Male sex hormones ....................................................................................................................... 68
Prostate cancer.................................................................................................................................. 70
Epidemiology ................................................................................................................................. 70
Screening ....................................................................................................................................... 70
3
, Evaluation ...................................................................................................................................... 70
Causes ............................................................................................................................................ 71
Staging and grading ....................................................................................................................... 71
Treatment ...................................................................................................................................... 73
Testicular cancer ............................................................................................................................... 76
Penile carcinoma ............................................................................................................................... 78
Week 19: Painful swelling in the leg – Osteosarcoma and bone metastasis ........................................ 79
Diagnostics..................................................................................................................................... 79
Staging for benign tumours ........................................................................................................... 82
Staging for malignant disease ....................................................................................................... 82
RECIST criteria ............................................................................................................................... 82
Bone metastasis ................................................................................................................................ 83
Benign tumours ................................................................................................................................. 86
Benign bone tumours .................................................................................................................... 86
Malignant tumours ............................................................................................................................ 90
Malignant bone tumours............................................................................................................... 90
Malignant soft tissue tumours ...................................................................................................... 91
Rehabilitation .................................................................................................................................... 92
International Classification of Functioning, Disability and Health (ICF) ........................................ 92
4
,Week 16: On death
On life and death
Medical vs cultural and historical perspectives
Medical Historical
Protocols and guidelines for: Research into human and cultural attitudes
- Palliative sedation and euthanasia towards death in the course of history
- Research into the organic process of
dying
- Determination of death
- Time and causes of death
- Regulation of organ donation
Instrumental rationality (utility) Substantive rationality (meaning)
Medical-juridical motive Existential motive
Philippe Aries: nature vs culture
➔ Working hypothesis: death is (as part of nature) wild and threatening, but it can be
tamed (by culture).
Nature: wild and threatening? → disease, decay, death (human condition) = nature
Culture: order in chaos, some control? → medicine/dealing with death = culture
➔ Cultural history: collective death mentality continuously changes
Death mentality in history
Phase 1: tamed death (500-1200)
- Death was not an individual fate, but a public collective event
- Collective/public experience mediated and tamed by rituals
- Waiting for Return of Christ + eternal bliss
Phase 2: one’s own death/death of the self (1200-1500)
- Shift from death as a collective, anonymous event to the death of an individual
identity
- Shift from return of Christ to Final Judgement
- New preoccupation with individual death the final judgment based on the deathbed
(e.g. transi tombe, dance macabre, ars moriendi)
2 pillars:
- Momento mori
o Spiritual purification of an individual
o Death as preacher, judge and confessor
o Growing importance of moment of dying
- Social didactics: inequality in earthly society → but in the end everyone is equal
Shift: remote and imminent death (1500-1780)
- End of phase 2
5
, - Impact of Renaissance (humanism
o Remote death: alienation with death
o Imminent death: remained momento mori
➔ First signs of modern fear of death
- Impact of reformation and counter-reformation
o Not just deathbed, but entire life is decisive for last judgment
o Restraint and modesty as life motto: Protestantism
Phase 3: thy death/death of the other (1780-1950)
- Romantic sensitivity: the beloved other
o Origin of privacy
o Evolution of family from financial unit to emotional entity
o Relatives do not grief for death as such, but for the physical spereation from
the disease
o Belief in heaven, hell faded to the background
o Increased focussed on earthly relations
- More elaborate mourning culture
- Beginning of privatization (no longer public event) and denial of death
Phase 4: forbidden/invisible death (1950-present)
- Death disappeared from intimacy and community or family, became private event in
hospital, supervised by hospital
o Rationalization and medicalisation of death: medical technology dismisses
one from his responsibility for intimacy
o Juridification of death: regulation of unnameable
- Deritualisation
- Threat
Criticism: death has become to scientific and technological
➔ We are not as good anymore in dealing with death, we lost the sense of meaning
Sherwin Nuland: “We have become good at the art of saving life, but this cost our ability of
dealing with death”.
Nuland’s plea: change of culture
- Acceptance of death
- Not stretching life
- More intimate setting of dying
Phase 5: spectacular death (Jacobsen) (1980-present)
- New mediated/mediatised visibility of death
- Commercialisation and re-ritualisation of death
- Palliative care revolution
Paradoxical death: accepting death vs prolonging life
6
,Ethical issues with end of life decisions on the ICU
Intensive care
Critically ill patient = someone who presents with severe physiological instability requiring
technical and/or artificial life support
➔ Also medications that are not allowed to be given on a regular ward
Elective admission:
- Arranged on forehand
- Minimize morbidity/mortality
- Lower long turn medical costs
Intensive care unit:
- Lifesaving
- High mortality rates
- Often prolonged length of stay
Pros Cons
Diagnostics and therapy: No added value:
- Everything is possible - Unnecessary suffering
- Valuable for the family - Loss of dignity
- Good feeling
- Time for the doctors
Family:
- Endure considerable emotional
pressure
- False expectations
Waste of money: resources are limited
Case
- 24 years old
- 26+1 weeks pregnant
- Healthy
- Just married
- Comatose: trapped brain → suspected cerebral bleeding
- Cause: cerebral lesion
Then: admitted to the ICU
- Emergency craniotomy
- Mechanically ventilated
- Hemodynamic support
- Wide pupils → not reacting to light
Hours after the operation:
- Serious brain injury
- Risk: vegetive state
7
, Definitions
Coma: unconsciousness/unresponsiveness due to severe brain injury or drug induced (XTC,
anaesthetics)
Minimally conscious state: patient is able to produce subtle and intermittent signs of
consciousness
Vegetative status: patient shows no sign of consciousness or adequate response to stimuli.
The patient has brain and brain stem activity
Brain death: cessation of brain and brain stem activity, the patient is unresponsive
Ethical issues:
- Neurologically severely damaged patient
- 26+1 weeks pregnant
- Who decides over mother and child
- Where do we draw the line in treating mother/child when mother deteriorates
Options:
- Extubate after 3 days
- We need more time to clarify
- This patients should go to a coma rehabilitation centre with mechanical ventilation
facilities
Why do intensivists sometimes admit patient without any chance of survival?
- Uncertainty or disagreement
- Pressure:
o Patient/family
o Colleagues
o Nursing shortage on general ward
Who decides for a comatose patient? Shared decision making:
- The patient:
o Living will
o Written advanced directive: CPR, coma, feeding, etc.
- Medical team:
o Expertise
o Paternalistic
- Others: surrogate decision maker
o Family
Problems with family as surrogate decision makers:
- Close to the patient
o No experience
o Emotional
- Feel responsible
8
Neoplasms II
Summary
1
,Content
Week 16: On death.................................................................................................................................. 5
On life and death ................................................................................................................................. 5
Medical vs cultural and historical perspectives .............................................................................. 5
Philippe Aries: nature vs culture ..................................................................................................... 5
Death mentality in history ............................................................................................................... 5
Ethical issues with end of life decisions on the ICU ............................................................................ 7
Intensive care .................................................................................................................................. 7
Case ................................................................................................................................................. 7
Definitions ....................................................................................................................................... 8
Ethical issues: .................................................................................................................................. 8
Futility .............................................................................................................................................. 9
APACHE and SAPS score ................................................................................................................ 10
Forensic science................................................................................................................................. 11
Post-mortem ................................................................................................................................. 11
The process of dying ...................................................................................................................... 12
Suspicious signs ............................................................................................................................. 14
Finally............................................................................................................................................. 15
Medicalisation of death..................................................................................................................... 16
Historical and sociological perspective ......................................................................................... 16
Medicalisation of death: crisis in the early 1970s ......................................................................... 16
The Dutch response....................................................................................................................... 17
Euthanasia: dilemma’s and debate ............................................................................................... 17
Death (de-)medicalised ................................................................................................................. 18
Coping with stress in clinical practice................................................................................................ 19
Case ............................................................................................................................................... 19
Stages of a burnout: ...................................................................................................................... 19
What can you do for someone with symptoms: ........................................................................... 20
Week 17: Skin cancer ............................................................................................................................ 22
Histology: epithelial tissue ................................................................................................................ 22
Classification .................................................................................................................................. 22
Cell polarisation ............................................................................................................................. 24
Keratinised squamous epithelium ................................................................................................. 25
Melanocytes .................................................................................................................................. 26
Formation of glands ...................................................................................................................... 26
Histology: connective tissue .............................................................................................................. 29
2
, Classification .................................................................................................................................. 29
Cells of the connective tissue ........................................................................................................ 29
Extracellular matrix ....................................................................................................................... 29
Connective tissue proper .............................................................................................................. 30
Adipose tissue................................................................................................................................ 30
The skin.............................................................................................................................................. 31
Benign skin tumours .......................................................................................................................... 34
Seborrhic keratosis ........................................................................................................................ 34
Solar lentigo................................................................................................................................... 34
Sebaceous hyperplasia .................................................................................................................. 35
Dermatofibroma ............................................................................................................................ 36
Neurofibroma ................................................................................................................................ 36
Pyogenic granuloma ...................................................................................................................... 37
Haemangioma ............................................................................................................................... 38
Skin cancer......................................................................................................................................... 39
Basal cell carcinoma (least aggressive).......................................................................................... 41
Squamous cell carcinoma .............................................................................................................. 43
Melanocytic tumours .................................................................................................................... 46
Immunotherapy................................................................................................................................. 52
New developments ....................................................................................................................... 53
Week 18: Cancer of the male genital system ........................................................................................ 55
Anatomy of the pelvis ....................................................................................................................... 55
Muscles .......................................................................................................................................... 56
True and false pelvis ...................................................................................................................... 57
Pelvic peritoneum ......................................................................................................................... 59
Male pelvis..................................................................................................................................... 60
The prostate .................................................................................................................................. 62
Vascularisation of the true pelvis .................................................................................................. 64
Lymphatic drainage ....................................................................................................................... 66
Physiology.......................................................................................................................................... 67
Spermatogenesis ........................................................................................................................... 67
The male sexual act ....................................................................................................................... 68
Male sex hormones ....................................................................................................................... 68
Prostate cancer.................................................................................................................................. 70
Epidemiology ................................................................................................................................. 70
Screening ....................................................................................................................................... 70
3
, Evaluation ...................................................................................................................................... 70
Causes ............................................................................................................................................ 71
Staging and grading ....................................................................................................................... 71
Treatment ...................................................................................................................................... 73
Testicular cancer ............................................................................................................................... 76
Penile carcinoma ............................................................................................................................... 78
Week 19: Painful swelling in the leg – Osteosarcoma and bone metastasis ........................................ 79
Diagnostics..................................................................................................................................... 79
Staging for benign tumours ........................................................................................................... 82
Staging for malignant disease ....................................................................................................... 82
RECIST criteria ............................................................................................................................... 82
Bone metastasis ................................................................................................................................ 83
Benign tumours ................................................................................................................................. 86
Benign bone tumours .................................................................................................................... 86
Malignant tumours ............................................................................................................................ 90
Malignant bone tumours............................................................................................................... 90
Malignant soft tissue tumours ...................................................................................................... 91
Rehabilitation .................................................................................................................................... 92
International Classification of Functioning, Disability and Health (ICF) ........................................ 92
4
,Week 16: On death
On life and death
Medical vs cultural and historical perspectives
Medical Historical
Protocols and guidelines for: Research into human and cultural attitudes
- Palliative sedation and euthanasia towards death in the course of history
- Research into the organic process of
dying
- Determination of death
- Time and causes of death
- Regulation of organ donation
Instrumental rationality (utility) Substantive rationality (meaning)
Medical-juridical motive Existential motive
Philippe Aries: nature vs culture
➔ Working hypothesis: death is (as part of nature) wild and threatening, but it can be
tamed (by culture).
Nature: wild and threatening? → disease, decay, death (human condition) = nature
Culture: order in chaos, some control? → medicine/dealing with death = culture
➔ Cultural history: collective death mentality continuously changes
Death mentality in history
Phase 1: tamed death (500-1200)
- Death was not an individual fate, but a public collective event
- Collective/public experience mediated and tamed by rituals
- Waiting for Return of Christ + eternal bliss
Phase 2: one’s own death/death of the self (1200-1500)
- Shift from death as a collective, anonymous event to the death of an individual
identity
- Shift from return of Christ to Final Judgement
- New preoccupation with individual death the final judgment based on the deathbed
(e.g. transi tombe, dance macabre, ars moriendi)
2 pillars:
- Momento mori
o Spiritual purification of an individual
o Death as preacher, judge and confessor
o Growing importance of moment of dying
- Social didactics: inequality in earthly society → but in the end everyone is equal
Shift: remote and imminent death (1500-1780)
- End of phase 2
5
, - Impact of Renaissance (humanism
o Remote death: alienation with death
o Imminent death: remained momento mori
➔ First signs of modern fear of death
- Impact of reformation and counter-reformation
o Not just deathbed, but entire life is decisive for last judgment
o Restraint and modesty as life motto: Protestantism
Phase 3: thy death/death of the other (1780-1950)
- Romantic sensitivity: the beloved other
o Origin of privacy
o Evolution of family from financial unit to emotional entity
o Relatives do not grief for death as such, but for the physical spereation from
the disease
o Belief in heaven, hell faded to the background
o Increased focussed on earthly relations
- More elaborate mourning culture
- Beginning of privatization (no longer public event) and denial of death
Phase 4: forbidden/invisible death (1950-present)
- Death disappeared from intimacy and community or family, became private event in
hospital, supervised by hospital
o Rationalization and medicalisation of death: medical technology dismisses
one from his responsibility for intimacy
o Juridification of death: regulation of unnameable
- Deritualisation
- Threat
Criticism: death has become to scientific and technological
➔ We are not as good anymore in dealing with death, we lost the sense of meaning
Sherwin Nuland: “We have become good at the art of saving life, but this cost our ability of
dealing with death”.
Nuland’s plea: change of culture
- Acceptance of death
- Not stretching life
- More intimate setting of dying
Phase 5: spectacular death (Jacobsen) (1980-present)
- New mediated/mediatised visibility of death
- Commercialisation and re-ritualisation of death
- Palliative care revolution
Paradoxical death: accepting death vs prolonging life
6
,Ethical issues with end of life decisions on the ICU
Intensive care
Critically ill patient = someone who presents with severe physiological instability requiring
technical and/or artificial life support
➔ Also medications that are not allowed to be given on a regular ward
Elective admission:
- Arranged on forehand
- Minimize morbidity/mortality
- Lower long turn medical costs
Intensive care unit:
- Lifesaving
- High mortality rates
- Often prolonged length of stay
Pros Cons
Diagnostics and therapy: No added value:
- Everything is possible - Unnecessary suffering
- Valuable for the family - Loss of dignity
- Good feeling
- Time for the doctors
Family:
- Endure considerable emotional
pressure
- False expectations
Waste of money: resources are limited
Case
- 24 years old
- 26+1 weeks pregnant
- Healthy
- Just married
- Comatose: trapped brain → suspected cerebral bleeding
- Cause: cerebral lesion
Then: admitted to the ICU
- Emergency craniotomy
- Mechanically ventilated
- Hemodynamic support
- Wide pupils → not reacting to light
Hours after the operation:
- Serious brain injury
- Risk: vegetive state
7
, Definitions
Coma: unconsciousness/unresponsiveness due to severe brain injury or drug induced (XTC,
anaesthetics)
Minimally conscious state: patient is able to produce subtle and intermittent signs of
consciousness
Vegetative status: patient shows no sign of consciousness or adequate response to stimuli.
The patient has brain and brain stem activity
Brain death: cessation of brain and brain stem activity, the patient is unresponsive
Ethical issues:
- Neurologically severely damaged patient
- 26+1 weeks pregnant
- Who decides over mother and child
- Where do we draw the line in treating mother/child when mother deteriorates
Options:
- Extubate after 3 days
- We need more time to clarify
- This patients should go to a coma rehabilitation centre with mechanical ventilation
facilities
Why do intensivists sometimes admit patient without any chance of survival?
- Uncertainty or disagreement
- Pressure:
o Patient/family
o Colleagues
o Nursing shortage on general ward
Who decides for a comatose patient? Shared decision making:
- The patient:
o Living will
o Written advanced directive: CPR, coma, feeding, etc.
- Medical team:
o Expertise
o Paternalistic
- Others: surrogate decision maker
o Family
Problems with family as surrogate decision makers:
- Close to the patient
o No experience
o Emotional
- Feel responsible
8
