Principles of Cancer Surgery

1. Principles of
Cancer Surgery
Jibran Mohsin
Assistant Professor Surgery,
Akhtar Saeed Medical & Dental College,
Lahore
MBBS (SIMS), BSc, MRCPS (Glasgow), MRCSEd,
FCPS (Surgery), FCPS (Surgical Oncology),
European Board (Surgical Oncology),
FICS (General Surgery), FICS (Surgical Oncology),
associate FACS (USA)
Fellowship Surgical Oncology (Shaukat Khanum
Memorial Cancer Hospital & Research Centre,
Lahore)

2. Etymology
• Surgery
• Greek word 'Cheir' (Hand)
'Ergon' (to work)
• Latin word 'Chirurgia' "treatment
of disease, injury or deformity by
manual or instrumental operations,
as the removal of diseased parts of
tissue by cutting"

3. Etymology
• Oncology
• Greek word ὄγκος (óngkos), meaning
• "burden, volume, mass"
• Greek word λόγος (logos), meaning "study".

4. Etymology
• Cancer
• from Latin, ‘crab or creeping
ulcer’,
• translating Greek karkinos, said
to have been applied to such
tumours because the swollen
veins around them resembled the
limbs of a crab.
• canker was the usual form until
the 17th century

5. Terminology
Oncology
Oncologist
Radiation Oncologist
Medical Oncologist (Chemotherapy,
targeted therapy)
Surgical Oncologist

6. Introduction
Solid tumors
• Surgery remains the definitive
treatment
• Only realistic hope of cure
Role of surgery
• Diagnosis
• Removal of primary disease
• Removal of metastatic disease
• Palliation
• Prevention
• Reconstruction

7. Multi
disciplinary
approach
Although surgery is an effective therapy for
most solid tumors
• patients who die from cancer usually die of metastatic
disease.
Radiation therapy
Systemic therapy
Targeted including hormonal therapy
Improved survival

8. Multi
disciplinary
approach
• Surgical Oncologist:
• techniques for performing a cancer operation
• Alternatives to surgery and
• Reconstructive options
• indications for and complications of
preoperative and postoperative
chemotherapy and radiation therapy.

9. Surgical Oncology: NOT just surgery
• History and Physical examination
• Investigation for general health and cancer specific
• Hematological
• Radiological
• Pathological
• Preoperative assessment/fitness/optimization
Preoperative care (Diagnosis + Staging + Optimisation)
Intraoperative care
• HDU / ICU / SECU care
• Wound / Drains / Diet / DVT care
• Discharge
• Follow up in clinic / surveillance
• Referral for adjuvant as per histopathology report
Postoperative care

10. Diagnosis and
Staging
Occasionally a surgical procedure is
required to make the diagnosis
Malignant ascites
• Laparoscopy for obtaining tissue for
diagnosis
Staging laparoscopy
• Intra abdominal malignancy, particularly
esophageal and gastric cancer
• < 5mm liver and peritoneal lesions missed
on imaging.

11. Diagnosis and
Staging
• Useful adjunct for diagnosis of
intrahepatic metastases
Laparoscopic ultrasound
• Suspicion of testicular cancer
Orchidectomy
• Lymphoma
Lymph node biopsy

12. Diagnosis and
Staging
Sentinel node biopsy
• Melanoma and breast cancer
• Radiolabelled colloid
Staging laparotomy
• Lymphoma (in past; replaced
with more accurate cross-
sectional imaging and
chemotherapy)

13. Removal of
primary disease
Goal: Oncologic Cure
• Removal of primary tumor + as much of the
surrounding tissue + lymph node drainage as
possible
• Local control
• Prevent spread of tumor through lymphatics
Radical Surgery
• Little effect on development of metastatic disease
• Radical versus simple mastectomy for breast
cancer
• WLE versus compartmental resection for
extremity sarcoma
Ultra-radical Surgery

14. Removal of primary disease
• High quality, meticulous surgery
• Not to disrupt the primary tumor at time of excision
• Important to obtain cure in localized disease and preventing local recurrence

15. Surgical
Management of
Lymph basins
Halsted theory: LND for staging and survival
Fischer theory: LN involvement means
systemic disease (staging , but not survival)
LN involvement most important prognostic
factor
Will Roger / Stage migration phenomenon

16. Surgical
Management of
Lymph basins
Removed enbloc (colorectal)
Separate incision (Melanoma)
Sentinel lymph node dissection
(Identification Rate , False Negative Rate)
• Lymphatic mapping
• Blue dye +/- Radiolabeled colloid
Therapeutic lymph node dissection
Elective / Prophylactic lymph node
dissection

17. Surgical
Management of
Lymph basins
• Regional control / recurrence
• Total mesorectal excision (TME) in rectal cancer

18. Removal of
metastatic
disease
Patient selection is key to success
Tumor biology
• Type : colorectal versus pancreatic
• Growth rate: Disease free interval
Control of primary site
Limited / resectable metastatic disease
Patient fitness (operable)

19. Removal of
metastatic
disease
Metastasectomy / Oligometastases (≤ 5)
Liver metastases from colorectal cancer
• Resection of all detectable disease
• Long term survival in about one-third cases
• Surgical approach for in situ ablation with
cryotherapy or radiofrequency energy
Pulmonary resection for isolated lung
metastases (RCC)
Brain metastases (isolated superficial –
melanoma)

20. Palliation
• Symptomatic primary tumor with distant metastases
• Removal of primary tumor
• Increase QoL (Quality of life)
• Little effect on ultimate outcome
• Unresectable cecal cancer leading to
obstruction
• Bypass procedure
• Proximal diversion stoma
• Unresectable carcinoma of head of pancreas
leading to biliary and gastric outlet obstruction
• Cholecysto or choledocho-jejunostomy /
gastrojejunostomy

21. Palliation
• Toilet mastectomies for large ulcerated breast
tumors.

22. Unresectable
versus
inoperable
•Due to tumor spread
Unresectable
•Due to patients'
medical condition
Inoperable

23. Approaches
Open
Laparoscopic
Robotic
NOTES (natural Orifices Transluminal Endoscopic Surgery)
• Trans anal excision (early rectal cancer)
• Endoscopic mucosal resection (EMR for esophageal/Gastric Cancer)

24. Role of surgery
in emergency
Proximal Obstruction
Pale (Bleeding)
Perforation
(Pain)

25. RO versus R1
versus R2
resection
RO : No residual microscopic
or macroscopic disease
• Goal of cancer surgery (local
control/ recurrence and survival)
R1: Microscopic residual
disease
R2: Macroscopic residual
disease

26. Basic Steps
Reach (Access)
Release (Mobilize/dissect)
Resect
Retrieve/remove
Reconstruction
Reapproximating (closure)

27. Neoadjuvant /
Intraoperative/
Adjuvant/
Perioperative
therapy
Neoadjuvant -- Surgery (preoperative)
Surgery (intraoperative RT IORT; Heated
Intra peritoneal chemotherapy – HIPEC)
Surgery  Adjuvant (Post operative)
Neoadjuvant - surgery - Adjuvant
(Perioperative)

28. Synchronous /
Metachronous
Syn (together/same)
chronous (time) : 2
tumors at same time
Meta (in middle)
chronous (time): 2
tumors at different time

29. References
• Chapter 10 Principles of Oncology: Bailey & Love’s
Short Practice of Surgery (27th edition)
• Chapter 10 Oncology: Schwartz’s Principles of
Surgery (10th edition)

30. THANK YOU