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Dr. Teguh Aryandono Division of Surgical Oncology Faculty of Medicine , GMU

To answer the questions
- Is there any malignancy - Prognosis - Decision of treatment

Patients and families

Suffered from cancer? Can I be cured? How long can I live? What symptoms ?


Answer that questions Plan treatment Guiding the patient and family


Anamnesis Physical examination Diagnostic imaging Laboratory examination Diagnostic pathology

Characteristic of information

Organ of origin Histological grade Local extension (T) Lymph node extension (N) Distant metastasis (M)


Tumor with same histologic type, from the same origin, grow and spread with the same pattern AJCC, WHO, FIGO

Clinical Staging

Anamnesis, physical examination, simple laboratory methods, radiodiagnostic and endoscopy Find everywhere

Radiologic staging

With modern radiology equipment CT Scan Lymphography MRI

Surgical Staging

Intraoperative findings Infiltration of tumor to surrounding tissues

Pathological Staging

Include histologic evaluation : tumor invasion, lymph node metastasis etc In breast cancer : node 1- 3 (N1) differ from 4 or more (N2)

Clinical stage T1, radiological stage T2, surgical stage T3


Tumor Patients - age - nutrition - immunological status Also : DOCTOR

Anamnesis and Clinical examination

No symptom and sign under 1 gram ( 1 cm3) Anamnesis and physical examination not sensitive Still important : tumor at this stage can be cured with locoregional treatment


Symptoms - Local : pain, function,bleeding, swelling etc - Metastasis : lung, liver, bone, brain - Product of metastasis: anorexia, febrile, leucocytosis


Localization of tumor Risk factors - smoking - Alcohol - Environment : asbes,benzen - Radiation : sunlight - Synthetic estrogen - Virus - Family history of cancer

Bone metastasis

Breast ca : 73% Lung ca : 33% Kidney ca : 24% Colorectal ca : 22% pain, pathologic fracture

Lung metastasis

30% of cancer patients Usually peripheral location ,no symptom Dyspnea and chest pain : malignant pleural effusion

Liver metastasis

More than 50% alimentary tract cancer metastasis to the liver Asymptomatic Pain, in the shoulder Malaise, anorexia, fever

Brain metastasis

30% from cancer patients Lung, breast cancer, melanoma Cephalgia - direct extension to nerve or meninges - increase intracranial pressure

Physical Examination

Depends on localization of tumor Intrathoracal or intrabdominal : difficult Superficial : skin, soft tissue, breast, relatively easy Lymph node : very important more than 1 cm : abnormal supraclavicular : abnormal

Causes of lymph node enlargement

Malignant 43% - Malignant lymphoma 37% - Metastasis 63% . Lung cancer 53% . Head and neck cancer 14% . Other tumors 33%

Non malignant 57% - No diagnosis 75% - Infection 15% - Granulomatous inflamation 5% - others 5%

Anamnesis and physical examination

No specific sign and symptom Depends on primary tumor and metastasis Clinical presentation : asymptomatic to multiple organ failure and disturbance of regulation mechanism Complicated by diagnostic methods, sometimes give more morbidity

Anamnesis and physical examination

Very important Diagnosis in the early stage Guidance for further examinations Prevent complication, manage in the early stage or give palliation

Diagnostic Imaging

Conventional radiology Digital radiography CT scan Echography MRI (Magnetic Resonance Imaging) Scintigraphy

Diagnostic Imaging

Primary tumor Metastasis Lymph node Bone Lung Liver CNS / Brain Peritoneal

Interventional radiology

Biopsy guided with Echography CT Scan (MRI) (Fluoroscopy)

Laboratory Diagnosis

No specific examination Tumor markers

Tumor markers
Can be measured quantitatively by biochemical or immunochemical in tissue or body fluid

Tumor markers

To detect a cancer and organ where possibly resides To establish the extent of tumor burden before treatment To monitor the response to treatment

Essential to understand

Sensitivity Spesificity Positive predictive value Negative predictive value

Screening and follow-up asymptomatic patients



Techniques for obtaining tissue

Aspiration Biopsy

Cytology analysis Major surgical resection should not be undertaken solely on the basis of evidence of aspiration biopsy

Needle Biopsy

obtaining a core of tissue sufficient for diagnosis of most tumor types soft tissue and bone sarcoma : difficult

Incisional biopsy

Small wedge of tissue from a larger tumor mass Preferred method for soft tissue and bone sarcoma

Excisional biopsy

Excision of entire suspected tumor tissue with little or no margin of surrounding normal tissue

Principles guide of all surgical biopsies

Needle tracts or scars should be placed carefully , so they can be conveniently remove as part of the subsequent definite surgical procedure Extremity : longitudinal

Not to contaminate new tissue planes during biopsy Large hematome >> tumor spread

Choice of biopsy technique : adequate tissue sample for the needs of the pathologist Handling of the biopsy tissue by the pathologist is also important - certain orientation >> mark - Certain fixatives