3 in 1

Three cancers in one patient

Last year, a woman came to me with progressive jaundice (deepening yellowish discoloration of the skin). Initial investigations showed that it was an obstructive jaundice; meaning, the bile flow was obstructed resulting in bile seeping into the skin and sclera. In this lady, the obstruction was caused by a cancer in the head of pancreas, as shown in the CT-scan picture below.

However, she was also noted to have a fungating
tumour in her left breast. (picture below)

Biopsy (core-needle biopsy) showed that it was an infiltrating ductal carcinoma; meaning this was a confirmed breast cancer.


The CT-scan film showing the primary cancer of the left breast









Further examination also revealed a tumour in her right thyroid lobe.

Biopsy (Fine needle aspiration cytology - FNAC) showed that it was a follicular lesion.

A follicular thyroid swelling can be either benign or cancerous, but looking at the tumour clinically and on CT-scan, I was almost certain that it was a follicular cancer.



She underwent a surgery for the breast cancer (left mastectomy with axillary clearance ), a palliative by-pass of the pancreatic head cancer (gastro-jejunostomy, hepatico-jejunostomy - biopsy confirmed adenocarcinoma of the pancreas)

So, what am I trying to say ?

I am saying that this lady had three (3) primary cancers. This is extremely rare (I am waiting for my report to be published in a peer journal). But this is not my point to you. What I want to highlight here is how 'fantastic' our patient can be. Should she presented much earlier, she could have been saved. She succumbed to her diseases not long after the surgery.

By the way, it was reported in most news today, that the country is in need of more oncologists (cancer specialists) - "We need more than 200 oncologists but the country has only 39" - say the Health Minister. But with this attitude of not seeking treatment until it is too late, I dont see the urgency. The ministry of health has to come out with a policy / campaign / or what so ever to get cancer patients to the hospital, and to do so early !

CANCER TREATMENT; ADJUVANT THERAPY

Most solid cancers are treated surgically. Cancers such as breast and colon cancers require surgery as the mainstay of their treatment. However, for advanced diseases, other modes of treatment are required to eradicate 'left-over' cancer tissues or cancer cells that have spread to distant organs (metastasis). These treatments are called adjuvant therapies; examples are chemotherapy, radiotherapy, hormonal and etc. So if a patient presents with advanced disease, beside surgery, he or she would requires other form of adjuvant therapies to treat the cancer.

For example, patients with cancer of the rectum (the lower end of the colon) would need surgery to remove the segment that contains the cancer (see pictures below). The removed specimen would then subjected to a thorough examination by a pathologist to determine the aggresiveness (grading) and how advance (staging) the cancer is. The managing surgeon or the oncologist would then decides on whether the patient requires some form of adjuvant therapies or not.

Low rectal cancer removed in a surgery called abdomino-perineal excision

The specimen opened to show the cancer within it

What I want to highlight today is that many patients do not understant the importance of adjuvant therapy after having had their surgery. Today a patient whom I operated two weeks ago for 'stage 3' rectal cancer (Duke C - staging) refused chemotherapy. She is a nurse and she said "I have seen enough patients who suffers the side effects of chemotherapy.." What could I do? When I was a medical student, there was a patient with a lymphoma (cancer of the lymphatic system); the only curable cancer at that time (1984), when told that he requires chemotherapy, said 'cukuplah ..! Now almost 25 years down the line, the attitude is still the same. The problem is; when they are very sick and the cancers are very advance involving all over their body, they come back asking for all sort of things. Last month, a man requested me to insert a chemo-port (a special catheter for administeration of chemo-drugs). He had advanced renal cancer, had refused treatment earlier, and now in acute renal failure. In that condition nobody is going to give him the chemo ! He died a week later.

Bak kata pepatah....Bila sudah terantuk, baru terngadah.

KAMU BOLEH TUNGGU, TUNGGU DIA MATI.

Semalam, dalam HARIAN METRO terdapat satu berita yang memapar kekecewaan sebuah keluarga yang kehilangan seorang anggota keluarga mereka. Yang mereka kesalkan adalah sikap doktor yang merawat anak mereka, bersikap sombong dan biadap, sehingga sanggup mengeluarkan kata-kata 'Kamu boleh tunggu, tunggu dia mati" Mulanya saya rasakan ini biasalah bagi seorang yang baru ditimpa musibah (grief reaction). Apatah lagi dalam kesibukannya doktor itu gagal memberi penerangan yang memuaskan. Di petang hari yang sama seorang lelaki datang ke pejabat saya, bertanyakan sanggupkan saya merawat anaknya yang mengalami perdarahan di otak selepas satu kemalangan jalan raya. Anaknya masa itu sedang dirawat di unit Neurosurgeri hospital yang sama; beliau takut anaknya itu 'diapa-apakan' oleh seorang doktor di situ yang dikatanya sangat sombong dan tidak bertimbang-rasa. Saya jelaskan kepadanya bahawa pembedahan otak bukanlah kepakaran saya, dan saya nasihatkan beliau untuk selesaikan perkara itu dengan pehak bertanggungjawab di hospital tersebut.

Wow, mungkinkah ini satu sebabnya pesakit datang lewat mendapatkan rawatan seperti yang saya 'highlight'kan sebelum ini. Sikap doktor-doktor yang dikatakan sombong dan kurang bertimbangrasa. Sedangkan rata-rata tok bomoh dan singseh bermulut manis memukau. Bomoh patah mengurut tulang penuh sopan dan mesra sedangkan doktor otopedik menarik tulang sambil menyumpah seranah (pesakit mungkin sedar walau pun diberi sedation).

Petang tadi seorang pesakit datang kepada saya memohon penjelasan tentang penyakitnya. Beliau ada satu ketumbuhan kecil dipayudaranya, telah dibiopsi di hospital (yang sama di atas) dan tak faham penjelasan doktor yang merawat beliau. Lapurannya (biopsy report) tiada dibawanya. Saya terangkan kepada beliau, yang saya tidak dapat membantu, lainlah kalau ada lapuran itu ataupun beliau dapat sebutkan nama doktor berkenaan. Bolehlah saya 'hello'kan kepadanya dan tanyakan perkara tersebut. Inilah masaalahnya, sukar sangatkah untuk memberi penjelasan. Kalau pesakit tak faham istilah perubatan, buatlah analogi dengan barang, tumbuhan sekeliling agar mereka mudah faham. Kalau bahasa yang menghalang carilah seorang penterjemah. Hendak seribu daya, tak mahu seribu dalih!

Fikir-fikirkanlah .....................

Senyumlah wahai doktor-doktor ! It makes a lot of difference.

Malam Pertama - Rupanya Sudah Ditebuk Tupai !

When I was working in the university few years ago, I was once invited by a gynecologist colleague to assist him in a surgery to removed a huge fibroid (a non-cancerous uterine tumor). The patient was a 30 something year old lady who seek treatment only to proof that she was a 'virgin'. The story went on like this. This particular girl had a progressively enlarging tummy for several years. She used to avoid marriage proposals due to that, until the day she could not give anymore excuses to her parents. It was an arranged marriage - much a common practice in Kelantan. Came 'malam pertama' - the first night after concilliation of the marriage vow - in her husband's advance he noticed the big tummy, almost the size of a full-term pregnancy. Wow... he became furious...... accusing the poor girl and his in-laws of cheating him. "Apa ni, sudah ditebuk tupai !" Only to proof her innocence, did the girl came to the gynecologist. And we took out a 6.5 kg fibroid.

These pictures were given to me by another gynecologiost working in my present hospital. The presentation was more or less the same except this time it was a huge ovarian cyst, not a fibroid.

At the begining of surgery, I thought she was going to do a ceaserian section

A long midline incision; the usual ceaserian section is through a pfnenstiel or bikini incision

There was it; a huge cyst, the fluid was being sucked out !

So you see my point, our peoples wait till the last minute. If you are a girl, and something starts growing in your tummy, you should become worry, very worry. Unless you know for sure that it is your much-awaited baby.

I really hope that the authorities do something about this. I wish my ex-classmate (MU 80/85) who is the Deputy Minister of Health gives some emphasis on this. Forget about certain 'license to . . . . !

CUTI SEKOLAH - MUSIM BERSUNAT

(School Holiday - Circumcision time)

Di Malaysia, bila bermula cuti sekolah, tibalah musim bersunat. Kalau dulu inilah masanya tok-tok mudim buat bisness, tapi sekarang tak lagi. Ramai ibubapa membawa anak-anak mereka ke hospital atau ke klinik bertauliah untuk menyunatkan anak lelaki mereka. Namun masih ada yang selesa dengan yang tak bertauliah. Dalam banyak kes, yang haram tu lah yang seronoknya. Sesetengah tok-tok mudim itu pula adalah kakitangan paramedik yang cari duit tambahan. Musim cuti ni ambil cuti tahunan. Jadi kenalah buat cepat-cepat, maklumlah ramai yang beratur diluar menunggu untuk disunatkan. Setiap musim bersunat ini, ada saja kes yang dirujuk ke pakarbedah untuk tolong repairkan yang dah terlebih potong. Biasanya kes macam ini tidak dihantar ke hospital kerajaan, sebab besoknya akan terpampanglah cerita di Harian Metro yang tunggu saja berita-berita sensional.

Ini adalah satu darinya, habis seluruh kulit burung budak tu dilapahnya. Nak repair bukannya senang, terpaksa ambil kulit dari bahagian lain ditampalkan ke situ.

Akhir tahun lepas, seorang kena potong 'kepala'nya, terkulai. Ini baru yang datang kepada saya, tapi masih ramai lagi pakarbedah yang dapat kes semacam ini. Moga-moga cerita ini menyedarkan ibubapa. Janganlah kerana seringgit dua, naya anak tu. Tapi orang kita memang macam ini, duit beli rokok habis beratus ringgit sebulan, tapi untuk kesihatan atau pelajaran berkira macam nak mati.

Kepada ayah ibu tu, bawalah anak anda ke tok mudim atau doktor yang bertauliah. Bagi kebanyakan kanak-kanak yang berumur 9 tahun ke atas, bersunat dengan bius setempat adalah selamat. Bagi yang kurang dari 9 tahun, pilihlah bersunat dengan bius penuh (general anaesthesia). Sekarang telah jadi trend, bawak anak-anak berumur 5 - 6 tahun untuk bersunat, puas lah pujuk; dan setelah kena sejarum, selak budak tu. Kesian budak tu - sampai ke tua takutkan doktor. Selari dengan garis panduan Kementerian Kesihatan; bagi yang berumur kurang dari 9 tahun, bersunat disyorkan dengan bius penuh. Kalau tidak, tunggulah sehingga anak itu cukup umurnya.

Dan kepada anak-anak tu, selamat bersunat !

HEMORRHOIDECTOMY; Surgery for Hemorrhoids

Today I received an e-mail from someone who enquired about prolapsed hemorrhoids, and what to do to it. Hemorrhoids or piles is an interesting disease. It is an 'old' disease that surgeons thought the treatment is already established long time ago. However with the 'new' understanding on the pathogenesis (how it comes about) of the hemorrhoids, came new treatment modality. We believe that hemorrhoidal tissue is a part of a normal structure (endocushions) in the anal canal that helps in maintaining continence of the anal sphincter. You just imaging without this, if you fart or jump, you might get fecal soiling of your underpant. I prefer to use the word 'hemorrhoidal disease' to 'hemorrhoids' per se.

Some Malaysians go to Singseh or Tabib Buasir for their hemorrhoids. I am not against 'alternative medicines'. Unfortunately not all prolapsed anal lesions are hemorrhoids. I have seen many anal or rectal cancers 'treated' as hemorrhoids. Furthermore they are something called secondary hemorrhoids; these are hemorrhoids that formed as a result of (secondary to) other rectal disease, usually cancers. My advice is that if you notice some mucus on your feces or the blood from your 'hemorrhoids' mixed (not stain on the surface) of your feces; you should go to a surgeon instead of a singseh. You might be having life-threatening cancer.

This is a hemorrhoids, the more reddish inner part is the internal component,

while the darker outer part is the external component.

Prolapsed hemorrhoids is best treated surgically. The old surgical techniques are usually painful. Now, there is a new technique recently introduced by Prof. Antonio Longo from Italy called the Stapling Hemorrhoidectomy or the PPH (Procedure for Prolapse and Hemorrhoids). I personally believe that this method has revolutionised surgical treatment of hemorrhoids. The main advantage is painlessness of this surgery. This is how some of the staplers look like.

Basically it cuts out a segment of rectal mucosa and staples the two ends together with small titanium staples. As a result, the prolapsed tissues are pulled back into the anus and rectum back to their original position. Since the cutting and stapling are done well inside the rectum, you won't feel the pain. Some patients might complain of some degree of pain, this is from the stretching of the anal canal , and this is usually minimum. The only 'setback' of this instrument is its cost. You may need to pay about RM 1700 for this single-use gadget.

These pictures show the hemorrhoids after and before stapling (PPH)

Before procedure
Immediately after completion of surgery

A nurse told me this morning that one of her relatives has a 'huge' prolapsed piles that made him unable to wear a trouser for many months. The same old story, repeatedly....LATE PRESENTATION !

Apa nak jadi ni?

********************************

Mat Saleh pun sama laa ....

l

l

l

V

From the web !

WHY WAITING ?

Late presentation of cases occurs in all types of cancer. I believe the common cause for this is absence of pain. Unfortunately for many cancers, pain is not an important feature; unlike inflammatory disease such as infection. Look at these pictures; the elderly lady had a fungating cancer in the groin. An infective ulcer would usually be very painful, but this is a lymphoma; a potentially curable cancer of the lymphatic system. The lymphoma is usually treated with chemotherapy. Surgery is usually limited to biopsy in order to get to the diagnosis. The lady had to be operated, leaving a huge defect that required a vascularised myocutaneous flap from her thigh to cover the defect. She was then referred to the oncologist for chemotherapy, ...... and she defaulted !

The fungating tumour

Covering the defect with a flap

End of surgery

There are cases of neglected inflammatory or infective ulcers. As the general rule, this is usually painful, but some patients do come with advanced lesion; more appropriately neglected lesions. These are usually elderly peoples, diabetics or in the next pictures a schizophrenic.

You can see maggots squirming in it

During surgery; the infection was noted extending into the pelvis, perineum and even the bones. And at the end of the operation I did not charge for the procedure I did, but for the smell that I had to bear !

After all these, I am still wondering why patients need to wait till it is very late !