This deals with types, principles, goals and current trends in surgical oncology.

1. SURGERY
• Surgical oncology is a cancer care field that
focuses on using surgery to diagnose, stage
and treat cancer.
• Surgery is done to remove tumors that are
cancerous.
• Surgery can be used by itself to treat the
cancer or it can be done with other
treatments such as chemotherapy, radiation
therapy and/or hormone therapy.

2. • Nonsurgical treatments may be administered
before surgery (neoadjuvant therapy) or after
surgery (adjuvant therapy) to help prevent
cancer growth, metastasis or recurrence.

3. • Patient features determining the selection for
surgery depends on factors such as the type,
size, location, grade and stage of the tumor, as
well as issues related to the patient’s health,
including age, physical fitness and other
medical conditions

4. PRINCIPLES / GOAL

5. 1. Prevention and identification of
trends
• Evidence has demonstrated that surgical
resection of premalignant lesions can effectively
prevent some types of tumors from developing
further into invasive cancers.
• The removal of precancerous lesions of the
cervix, vulva, and oropharynx is a common
example of the role of surgery in cancer
prevention

6. • Surgical removal of noncancerous polyps
detected at the time of screening or
diagnostic colonoscopy effectively prevents
further development of such polyps into
malignancies

7. • The presence of the cancer susceptibility genes
BRCA1 and BRCA2 confers a high risk for breast
and/or ovarian cancer.
• In such cases, prophylactic mastectomy and/or
oophorectomy may be one option.
• Prophylactic surgery for individuals at high risk for
developing breast and ovarian cancers may be
one approach for risk reduction along with more
conservative management.

8. 2. Diagnosis and staging of disease
• Surgery represents the primary method of obtaining
tissue necessary for pathologic or cytologic diagnosis of
malignancy.
• A tissue diagnosis is a requirement for new malignancies
and generally for the first recurrence of a known primary
tumor.
• Surgery is also used to diagnose second primary tumors
and to differentiate the source of metastasis if a second
primary tumor is suspected.

9. • The location and extent of the tumor determines the
method to obtain adequate tissue for diagnosis.
• Advances in interventional and guided imaging
techniques have enabled clinicians to obtain necessary
tissue using less invasive and often more precise
procedures than open surgical approaches.
• CT-directed or stereotactic biopsies use computer
imaging to pinpoint tumor locations and facilitate biopsy
for diagnosis—for example, lung cancer and primary
brain tumors.

10. • Positron emission tomography (PET) scans with
[18F]flurodeoxyglucose (FDG) imaging may detect
primary, second primary, metastatic, and recurrent
tumors.
• Endoscopic evaluation provides a means to remove
tissue (eg, a polyp) for diagnosis while also resecting
a potentially premalignant lesion.

11. • Three methods are commonly used to biopsy
suspicious lesions: needle biopsy (fine needle
aspiration (FNA) or core), open incisional, or
excisional biopsy.
• Open biopsy may be reserved for lesions that
are inaccessible by less invasive techniques,
considered too risky (eg, because of the risk of
pneumothorax or other complications), or
best treated with debulking surgery

12. • Cytology, using fine-needle aspiration (FNA),
may be the optimal means for diagnosis in
palpable tumors.
• Cytologic examination often can confirm the
presence of malignancy in a brief period of
time.
• Intraoperative diagnosis of tissue may be
obtained using a pathologic technique termed
frozen section.

13. 3. STAGING OF DISEASE
• Preoperative care for patients with a known or
suspected diagnosis of cancer includes an
adequate staging workup.
• The size of the tumor, as determined by clinical
and radiologic evaluation, and the involvement of
lymph nodes or distant sites are used for staging.

14. • Preoperative staging is a critical element in
deciding whether the patient would benefit from
surgical approaches and what the goal of therapy
might be—cure, control, or palliation.
• The use of CT scans, FDG-PET scans, nuclear
medicine scans, mammography, and other
radiologic techniques may aid in determining the
extent of tumor involvement locally, regionally,
and in distant organs.

15. • Pathologic examination of the tumor, lymph
nodes, and any other tissue removed is crucial
for effective patient management
• The stage, histologic cell type and grade of
tumor, status of margins of resection (whether
involved with the tumor or not), and degree of
vascular invasion contribute to determination
of the risk of recurrence

16. and assessment of whether surgery is likely to
represent a long term control or cure of the
malignancy.
• Accurate staging of disease continues to
function as the principal prognostic factor for
most cancers because stage of disease is often
correlated directly with long-term survival

17. • Tumors are staged by site, typically using the
tumor nodes metastasis (TNM) classification
system from the American joint committee for
cancer staging and end results reports (AJCC
SEER).
• It describes the tumor based on size and local
extension (T), nodal involvement (N), and distant
metastasis (M)

18. • The American Joint Committee on Cancer (AJCC) has
recommended a staging system ranging from stage I
(small, localized malignancy) to stage IV (distant
metastatic spread)
• Both the AJCC and the Union Internationale Contre
Cancer (International Union Against Cancer, UICC) have
adopted a shared TNM system that defines a cancer in
terms of the primary tumor (T), the presence or
absence of nodal metastases (N), and the presence or
absence of distant metastases (M).

19. • Increasing numerals after the T, such as T1, T2,
T3, or T4, indicate lesions of increasing size or
depth of penetration that are usually associated
with a poorer prognosis.
• The absence of nodal metastasis is designated as
N0, the presence of nodal metastasis is N1, and
for more extensive nodal involvement, additional
numbers may be used.
• Finally, distant metastases are indicated by
adding the numeral 1 following M for metastases,
or the numeral 0 signifying their absence.

20. • The clinical classification (cTNM or TNM)
represents the extent of the disease before first
definitive treatment as determined from physical
examination, imaging studies, endoscopy, biopsy,
surgical exploration, and any other relevant
findings.
• The pathologic classification (pTNM) incorporates
the additional information available at the time
of surgery or derived from pathologic
examination of a completely resected specimen.

21. • A y prefix may be added to denote pathologic
staging after initial systemic or radiation therapy
has been performed (ypTNM).
• The retreatment classification (rTNM) is used to
stage a cancer that has recurred after a disease-
free interval; it includes clinical and/or pathologic
evidence of recurrence.
• Finally, the autopsy classification (aTNM) is based
on post mortem examination

22. 4. TREATMENT
• RESECTION FOR CURE
• RESECTION WITH MINIMAL RESIDUAL DISEASE
• RESECTION IN ADVANCED DISEASE

23. a) Resection For Cure
• When a malignancy is diagnosed at an early or
localized stage, surgical resection represents
the best option for long-term survival and
cure.
• Early-stage solid tumors, especially in situ or
encapsulated tumors where margins are
clearly defined and less radical surgery is
indicated, are most amenable to minimally
invasive surgical resection

24. • Knowledge of the biology of the tumor and
natural history of the disease is imperative
when planning surgical resection. This
principle is demonstrated by a comparison of
two types of skin cancer: malignant
melanoma, where wide resection with
adequate margins is required for long-term
control of disease, versus basal cell carcinoma,
where less aggressive resection is often
adequate for cure

25. • Surgical resection for cure can be problematic
when the tumor is large or invades vital organs or
tissues with critical functions.
• Analysis of risk : benefit ratio: The need for an
adequate surgical margin must be weighed
against potential loss of function, change in body
image, and age and general health of the patient.

26. B) Resection With Minimal Residual Disease
• If the primary tumor is not amenable to complete
resection with adequate margins, or if malignant
cells are found in regional lymph nodes, then some
form of adjuvant therapy may be considered either
before (neoadjuvant) or after (adjuvant) surgery.
• The presence of even minimal residual disease in
surgical margins or draining nodes generally indicates
a high risk of recurrence.

27. • The use of adjuvant chemotherapy or
radiation therapy or a combination of these
modalities is often recommended pre- or
postoperatively.
• Novel therapies such as biologic or targeted
therapies also may prove to be effective in the
setting of minimal residual disease.

28. C) Resection IN ADVANCED DISEASE
• Surgical resection of advanced disease
generally is performed to achieve one of two
goals:
(1) resection of solitary or limited metastatic
disease or
(2) palliation of symptoms.
• Resection of a solitary metastatic lung or liver
nodule is performed routinely in advanced
disease to improve survival.

29. • Resectability of metastatic disease will depend
on size, number, and anatomic location of the
tumors; patient performance status; and the
surgeon’s ability to ensure negative surgical
margins while leaving adequate viable tissue
with reasonable organ function

30. • Brain metastases occur in about 20% to 40% of all
cancer patients.
• For patients with a good performance status and
limited or controlled systemic disease,
radiosurgery alone or surgical removal of a
solitary brain metastasis often in combination
with whole-brain radiation can yield favorable
long-term results

31. 5. REHABILITATION AND
RECONSTRUCTION
• The growing population of persons that
achieve long term periods of remission,
survival, and cure directs us to the importance
of cancer rehabilitation.
• Rehabilitation to improve physical,
psychologic, social, and spiritual outcomes
should be considered at the time of diagnosis
and throughout the cancer trajectory.

32. • The need for and degree of rehabilitation
depends on
(1) the extent of surgery performed and organ
preservation achieved,
(2) The age and performance status of the
individual,
(3) Comorbid conditions,
(4) the patient’s physical activity/mobility level prior
to surgery,
(5) additional treatment (eg, chemotherapy and/or
radiation) given prior to or following surgery,
(6) the overall goals of therapy

33. • RECONSTRUCTION
• The goals of reconstruction in surgical oncology are
fourfold:
(1) restoration of function,
(2) skin closure or wound covering for surgical defects,
(3) restoration of cosmetic appearance (cosmesis) for
improvement of body-image changes, and
(4) maintenance or enhancement of quality of life.

34. • Recent advances in reconstructive surgery include the
use of minimally invasive techniques to preserve function
and improved ability to reconstruct surgical deficiencies.
• Depending on the extent of reconstruction and the
specialized expertise required, reconstructive surgery
may be undertaken by the primary surgeon alone or in
collaboration with various other specialists, such as
plastic and reconstructive surgeons, urologic surgeons,
and gynecologic surgeons. (refer cancer nursing)

35. 6. SURGERY AS ANCILLARY INTERVENTION
• Surgery plays an important role in comprehensive cancer care
outside the realm of diagnosis, tumor resection, staging, and
reconstruction.
• The surgical team, along with interventional radiology
specialists in some centers, is responsible for placement of
central vascular access devices (VADs). Placement of VADs
may be a routine part of patient workup and staging when a
diagnosis of cancer is known and the decision regarding
systemic chemotherapy has been made.

36. • Placement of VADs or implantable devices for other
purposes (eg, drug delivery) may occur at the time of
more definitive surgery to avoid the need for
additional anesthesia.
• Other ancillary surgical procedures, including
therapeutic bronchoscopy, thoracentesis for
malignant pleural effusion, or repair of other
complications (eg, extravasation or removal of
infected catheters), may be required throughout the
course of the patient’s care.

37. 7. Palliation
• The WHO defines palliative care as an “approach
that improves the quality of life of patients and
their families for problems associated with life
threatening illness, through the prevention and
relief of suffering, provides relief from pain and
other distressing symptoms, will enhance quality
of life, and may also positively influence the
course of illness.

38. Purposes of palliative surgery
• Relief of symptoms when the extent of tumor
is already known
• Resection of residual tumor after surgery
• Resection for recurrent or persistent disease
when primary treatment has failed
• Supportive care with technical intervention
required by the multidisciplinary team.

39. • Examples of indicated palliative surgical
procedures include:
(1) colostomy, enteroenterostomy, or
gastrojejunostomy to relieve intestinal
obstruction;
(2) cordotomy or celiac block to control pain;
(3) hepaticojejunostomy to relieve biliary
obstruction and pruritis;

40. (4) amputation for intractably painful tumors of the
extremities;
(5) Simple mastectomy for carcinoma of the breast,
when the tumor is infected, large, ulcerated, and
locally resectable (even in the presence of
distant metastases);
(6) Resection of obstructing colon cancer in the
presence of disseminated metastatic disease.

41. CURRENT SURGICAL STRATEGY ,
SPECIAL SURGICAL TECHNIQUES AND
FUTURE DIRECTIONS AND ADVANCES

42. Categories of therapies
• The role of surgery in cancer can be divided into
six categories:
• Definitive surgery for primary cancer, local
therapy, and integration with other adjuvant
modalities.
• Surgery for residual disease
• Surgery for metastatic disease with curative
intent
• Surgery for oncologic emergencies
• Surgery for reconstruction and rehabilitation
• Surgery for palliation

43. • Newer surgical techniques are less invasive, use
different types of surgical instruments, and lead
to less pain and shorter recovery times. The most
effective surgical oncology techniques are:
• laser surgery
• cryosurgery
• electrosurgery
• radiofrequency ablation
• mohs surgery
• laparoscopic surgery
• thoracoscopic surgery
• robotic surgery and other forms of surgery.

44. • Definitive surgery
• It aims to remove the cancer with a margin of
clear tissue around the cancer itself. This
include assessment and or removal of
adjacent or regional structures to verify the
stage of disease. The initial surgery alone may
be curative in nature.

45. • Curative surgery
Curative surgery removes the cancerous tumor or
growth from the body. Surgeons use curative
surgery when the cancerous tumor is localized to
a specific area of the body. This type of treatment
is often considered the primary treatment.
However, other types of cancer treatments, such
as radiation, may be used before or after the
surgery.

46. • Cytoreductive surgery or surgery for residual
disease:
• It may enhance the ability of other
interventions to improve the outcome for a
specific cancer. Eg: burkitts lymphoma and
ovarian cancer, where other cancer modalities
such as chemotherapy, may make an impact
on remaining disease that is unresectable.

47. • Surgery for metastatic disease may be curative in
nature, based on the type of cancer, location and
number of metastatic deposits, and other available
treatment options.
• Oncologic emergencies may necessitate surgery related
to impending destruction of vital organs, hemorrhage,
perforation, obstruction, compression or abscess
formation. Surgical intervention may promote comfort
and ease pain.

48. • Restorativesurgery
Restorative surgery is sometimes used as a follow-up to
curative or other surgeries to change or restore a person’s
appearance or the function of a body part.
• For example, women with breast cancer sometimes need
breast reconstruction surgery to restore the physical shape
of the affected breast(s).
• Curative surgery for oral cancer can cause a change in the
shape and appearance of a person’s mouth. Restorative
surgery may be performed to address these effects.

49. • Preventive surgery
Preventive surgery is used to remove tissue
that does not contain cancerous cells, but may
develop into a malignant tumor. For example,
polyps in the colon may be considered
precancerous tissue and preventative surgery
may be performed to remove them.

50. • Palliative surgery
Palliative surgery is used to treat cancer at
advanced stages. It does not work to cure
cancer, but to relieve discomfort or to correct
other problems cancer or cancer treatment
may have created.

51. • Supportive surgery
Supportive surgery is similar to palliative
surgery because it does not work to cure
cancer. Instead, it helps other cancer
treatments work effectively. An example of
supportive surgery is the insertion of a
catheter to help with chemotherapy.

52. • Staging surgery
Staging surgery works to uncover the extent of
cancer, or the extent of the disease in the body.
Laparoscopy (a viewing tube with a lens or
camera is inserted through a small incision to
examine the inside of the body and to remove
tissue samples) is an example of a surgical staging
procedure.

53. Debulkingsurgery
Debulking surgery removes a portion, though not
all, of a cancerous tumor. It is used in certain
situations when removing an entire tumor may
cause damage to an organ or the body. Other
types of cancer treatment, such as chemotherapy
and radiation, may be used after debulking
surgery is performed.

54. • Diagnostic surgery
Diagnostic surgery helps to determine
whether cells are cancerous. Diagnostic
surgery is used to remove a tissue sample for
testing and evaluation (in a laboratory by a
pathologist). The tissue samples help to
confirm a diagnosis, identify the type of
cancer, or determine the stage of the cancer.

55. TRENDS

56. • Sentinel lymph node biopsy and mapping: it
is the procedure for breast cancer and
melanoma, it enables the surgeon to perform
intraoperative lymphatic mapping with vital
blue dye and or a radioactive tracer.
• The sentinel lymph node basin is noted
visually; the gamma ray counter and probe
verify in vivo radioactivity.

57. • The sentinel node is dissected, with pathologic
examination of this first draining lymph node of
tumor.
• At the time of surgery, if sentinel node is negative
for tumor, most often a lymph node dissection is
not necessary. If the sentinel node is positive, a
regional lymph node dissection may occur.

58. • The ability to assess lymph node involvement
while avoiding potential additional
comorbidities associated with axillarylymph
node dissection (ALND) is the major
advantage of SLN mapping.

59. • The primary indication for using SLN
techniques involves palpable and non
palpable T1 and T2 tumors, with limited data
supporting SLN application for other stages of
disease.

60. • Vascularized lymph node transfer surgery: This is
an intricate microsurgical procedure used to treat
patients with advanced lymph edema affecting
the skin tissue in the arms or legs.
• Our plastic surgeons transfer working lymph
nodes from another part of the body, typically
the upper groin or lower abdomen, to the
damaged site.

61. • We then divide the existing blood vessels that
supply the nodes and connect them at the site
where the lymph nodes are needed.
• We use reverse lymphatic mapping to reduce
the chance of lymphedema occurring in the
areas where lymph nodes were harvested.

62. • Lymphatico venular bypass surgery: This surgery
is an intricate super-microsurgical procedure used
to treat patients with mild to moderate
lymphedema.
• Our plastic surgeons perform the surgery by
shunting, or moving, fluid from several dilated
lymphatics in the affected limb to adjacent
venules (tiny veins) to reduce pressure.

63. • Radioguided parathyroidectomy RGP) and radio
immunoguided surgery – intraoperative radiotherapy
(RIGS – IORT)
• RGP patients are injected with a radioactive tracer; the
neoprobe is used to localize parathyroid tissue .
• Colorectal cancer utilized the neoprobe to define areas
of residual microscopic disease labeled with
radioactive monoclonal antibodies, with intended
maximal resection of tumor and possible IORT.

64. • video-assisted thoracoscopic surgery instead
of a thoracotomy. The minimally invasive
procedure allows us to diagnose and treat
some of the same diseases and disorders as
with a thoracotomy, but with potentially less
post-operative pain, fewer complications and
a shorter hospital stay.

65. • Visualisation of the chest is enhanced, offering
access for biopsies from the pleura, the
diaphragm and treatment of metastatic
pleural effusions, allowing pleurodesis with
the avoidance of frequent thoracentesis.

66. • During the VATS procedure, one or more small
incisions, or “ports,” are made in the chest. Then,
a thorascope (a type of endoscope with a small
video camera) and surgical tools are inserted
through the incision(s). The thorascope transmits
an image of the chest cavity onto a video monitor
to help guide the procedure.

67. • Lasersurgery
This technique uses beams of light energy instead of
instruments to remove very small cancers (without
damaging surrounding tissue), to shrink or destroy
tumors, or to activate drugs to kill cancer cells. Laser
surgery is a very precise procedure that can be used to
treat areas of the body that are difficult to reach
including the skin, cervix, rectum, and larynx.

68. • It is more commonly used on the surface of the
body or the lining of intraluminal organs. Laser
therapy is administered through endoscopic
instruments, resulting in less bleeding and
damage to normal tissue than traditional surgical
procedures.
• Laser induced interstitial thermotherapy (LITT)
or interstitial laser photocoagulation utilizes laser
light and heat to kill tumor cells.

69. • Photodynamic therapy (PDT) utilizes a
photosensitizing agent injected in the body,
followed by targeted laser therapy to destroy
cancer cells.

70. • Cryosurgery
This surgery technique uses extremely cold
temperatures to kill cancer cells. Cryosurgery
is used most often with skin cancer and
cervical cancer. Depending on whether the
tumor is inside or outside the body, liquid
nitrogen is placed on the skin or in an
instrument called a cryoprobe (which is
inserted into the body so that it touches the
tumor).

71. • Cryosurgery is being evaluated as a surgical
treatment for several types of cancers.
• It is a less invasive method of targeting and
destroying tissue, with decreased bleeding
and pain than traditional surgical methods.

72. • Electrosurgery
Skin cancer and oral cancer are sometimes
treated with electrosurgery. This technique uses
electrical current to kill cancer cells.
• Microscopically controlled surgery
This surgery is useful when cancer affects delicate
parts of the body, such as the eye. Layers of skin
are removed and examined microscopically until
cancerous cells cannot be detected.

73. • Radiofrequency ablation (RFA): it destroys the
tumors insitu by thermal coagulation and
protein denaturation. High frequency
alternating current flows from uninsulated
electrode tips into surrounding tissue,
resulting in friction heating as tissue ions
follow the change in direction of alternating
current. It is presumed that this heating
mechanism forces extracellular and
intracellular fluids out of tissue thus resulting
in coagulative necrosis.

74. • Laproscopy is evolving with multiple clinical trials
to identify its efficacy and safety in the care of
cancer patients, from diagnosis and staging
through treatment and palliation.
• It enables a surgeon to diagnose intraperitoneal
and retroperitoneal masses, lymph nodes, and
visceral lesions without a large abdominal
incision.

75. • ERBEJET® 2
• ERBEJET2 uses a high-pressure water jet to
selectively target and dissect water-soluble
tissue and provide precise margins along the
line of dissection.
• This technique is designed to help spare
critical structures, like blood vessels, nerves
and ducts and may help reduce the potential
for blood loss.
• ERBEJET2 may be used in both open and
laparoscopic surgical procedures, typically
with shorter operating times.

76. • Flexible robotic surgery (Flex® Robotic
System)
• The Flex® Robotic System is a surgical system
with a flexible robotic endoscope.
• The minimally invasive technology allows
surgeons to access hard-to-reach areas of the
mouth, throat, rectum and colon.

77. • In the throat, the system's flexible scope is
designed to allow surgeons to view and reach
areas of the throat that aren’t typically or
easily accessible with standard instruments. A
traditional endoscope moves in straight lines
and is limited to lines of sight. In the rectum
and colon, the scope allows surgeons to view
and reach areas that were previously only
accessible by surgery.

78. • Robotic surgery (da Vinci® Surgical System)
• The da Vinci® Surgical System offers a
minimally invasive alternative to both open
surgery and laparoscopy. Because it requires
only a few tiny incisions and offers greater
vision, precision and control for the surgeon,
patients can often recover sooner, move on to
additional treatments if needed, and get back
to daily life quicker. Potential benefits of the
da Vinci system for patients include less pain,
lower risk of infection, less blood loss and less
scarring.

79. • Hyperthermic intraperitoneal chemotherapy
(HIPEC)
• HIPEC is a highly concentrated, heated
chemotherapy treatment that is delivered directly to
the abdomen during surgery. Unlike systemic
chemotherapy delivery, which circulates throughout
the body, HIPEC delivers chemotherapy directly to
cancer cells in the abdomen.

80. • Before patients receive HIPEC treatment, doctors
perform cytoreductive surgery to remove visible
tumors in the abdomen. Cytoreductive surgery is
accomplished using various surgical techniques.
Once as many tumors as possible have been
removed, the heated, sterilized chemotherapy
solution is delivered to the abdomen to penetrate
and destroy remaining cancer cells.

81. • Tracheo esophageal puncture
• A tracheoesophageal puncture, or TEP, may be an
option for patients who undergo a laryngectomy
(removal of the larynx/voice box) either because
they have laryngeal cancer (cancer of the voice
box) or because they have a non-functioning
larynx, from radiation or trauma.

82. • To perform a tracheoesophageal puncture, a
head and neck surgeon places a small, one-
way valve between the trachea and the
esophagus, either during the laryngectomy or
during a secondary surgery that may be
performed any time after the laryngectomy.

83. • The valve allows for air to travel from the wind
pipe (trachea) into the esophagus, but it
blocks food, saliva and liquids from the airway.
As air enters the esophagus, it produces a
vibratory signal that the patient may use for
voicing

84. • Biologic therapies and other adjuvant therapies are very
useful. Human granulocyte colony stimulating factor (G-CSF)
used with neoadjuvant or concurrent radiation therapy or
chemotherapy can decrease neutropenia related infections
and complications.
• The use of preoperative recombinant human erythropoietin
or iron in anemic surgical patients may enhance the ability to
sustain red blood cell levels, provide autologous blood, and/or
reduce the need for allogenic blood transfusions.

85. Organ Preservation
• Organ preservation is important in most cancers,
but particularly in patients for whom retention of
most of the organ tissue is critical for either
function or cosmetic appearance.
• Such cases include cancers of the anus, rectum,
or bladder; sarcomas, especially of the
extremities; breast cancer; and head and neck
cancers.

86. • The principles of organ preservation rely on
multimodality therapy to achieve maximum
shrinkage of the tumor prior to surgery
(neoadjuvant) so as to render the tumor
resectable while retaining organ function and
possibly appearance.
• Patients may experience a complete
pathologic response to neoadjuvant therapy.
A less favorable response or complete lack of
response indicates a poorer prognosis and the
need for more radical surgery.

87. Neoadjuvant therapy
• Chemotherapy for solid tumors given
preoperatively (termed neoadjuvant) has been
reported to produce significant improvements
in clinical response rates as well as enhance
the ability to perform organ-preserving
therapy.

88. • Originally intended for large and/or locally
advanced tumors, neoadjuvant therapy is
increasingly being used to reduce the size of
the primary tumor as part of an effort to
achieve good cosmesis or improved function
in organ conservation.

89. • Adjuvant therapy in breast cancer
demonstrated improved outcomes, including
reduction in risk of recurrence and increased
survival

90. • The use of neoadjuvant therapy also has
shown the ability to increase clinical response
rates as well as to achieve breast
conservation.
• Other advantages of neoadjuvant therapy
include its use to demonstrate
chemosensitivity in the presence of clinical,
often measurable disease, as well as its role in
allowing the analysis of biomarkers as
potential predictors of response

91. FUTURE
• By 2020, the number of patients undergoing
oncological procedures is projected to increase by 24–
51%. If a shortage of surgeons performing these
procedures does occur, the result will inevitably be
decreased access to care.
• To prevent this from happening, the ability of surgeons
to cope with an increased burden of work needs to be
critically evaluated and improved.

92. • Given that there are no more than approximately
50 surgical oncologists produced yearly in the
United States, it is clear that the traditional
surgical oncology educational roles in academic
medical centers as well as in the larger health
care community will continue and perhaps come
under increasing pressure to expand

94. • An important effort to strengthen the position of
surgical oncology in medical community has been
establishing board certification in surgical
oncology, beginning in 2014.
• The past half-century has seen the
unprecedented evolution of surgical specialties
into their current status as discrete disciplines,
with specialized knowledge, techniques,
anatomic challenges, and diseases of focus.

95. • There is an emerging understanding that the
surgical oncologist has specialized knowledge
that is not acquired in general surgical training:
knowledge of the natural history of malignant
disease, knowledge of the multidisciplinary care
for the cancer patient, and, certainly, knowledge
of how to perform some very unusual and
technically demanding oncological operative
procedures.

96. • Problems during surgery may include:
• Damage to organs in the body
• Blood loss
• Adverse reactions to medication
• Problems after surgery may include:
• Pain or discomfort (a common problem following
surgery that can often be relieved with medication and
with the help of your cancer care team)
• Infections
• Other illnesses, such as pneumonia
• Blood loss or clots