1. The seminar discussed the basics of surgical oncology including the features of malignant transformation and the roles of surgery in cancer treatment such as prevention, diagnosis and staging, removing cancer, and relieving symptoms. 2. Different types of surgeries were covered like curative surgery, palliative surgery, debulking surgery, and preventive surgery. Tumor ablation techniques using energy such as radiofrequency and laser ablation were also summarized. 3. Newer surgical techniques in cancer treatment including laparoscopic surgery, robotics, cryosurgery, electrocautery, and microscopically controlled surgery were presented.

1. Seminar on basics of
Surgical Oncology
Moderator: Dr D Singha
Asso. Prof
Presenter : Dr Biswajit Deka
2nd yr PGT

2. Features of malignant transformation
• Establish an autonomous lineage (oncogenes)
• Resist inhibitory signal
• Sustain proliferative singling
• Obtain replicative immortality (Hayflick hypothesis)
• Evade apoptosis (loss of tumour suppressor genes)
• Acquire angiogenic competence
• Acquire ability to invade
• Acquire ability to disseminate & implant
• Evade detection / elimination
• Subvert communication to & from the environment
• Develop ability to change energy metabolism

4. Role of surgery in Cancer
1. Prevention
2. Diagnosis & Staging
3. Remove Ca
4. Relieve symptoms & signs
5. Lowers chance of recurrence
6. Repair damaged tissue
7. Support other treatment
8. Support body functions

5. Prevention of cancer
• the genetic mutation: malignancy with high
penetrance & expressed regardless of
environmental factors
• highly reliable test to identify mutated gene;
• the organ must be removed with minimal
morbidity and virtually no mortality;
• suitable replacement for the function of the
removed organ;
• reliable method of determining over time that the
patient has been cured by "prophylactic surgery."

6. Diagnosis & staging
• Incidental
• Primary or secondary
• e.g. ascitis of unknown cause — peritonal or POD
mets
• Previously for staging of Hodgkins dis
• Upstage or down stage
• Lap staging - common

7. Remove cancer
• Onco-surgery
• Onco-plastic surgery

8. Relieve symptoms & signs
• Palliative
• Curative

9. Lowers chance of recurrence &
residual disease
• chemo—lock cell kill theory (decrease in a % of
cells )
• active or dormant

10. Repair damaged tissue
• Remove residual tissue after chemo and
radiotherapy

11. Support other treatment
• Chemotherapy
• Radiotherapy
• Immunotherapy

12. Support body functions
e.g. cholangio carcinoma —remove tumour —
normal physiology is restored

13. Types of surgery in cancer treatment
Based on outcome
1. Curative surgery
2. Palliative surgery
3. Debulking
4. Preventive
5. Diagnostic
6. Staging
7. Supportive surgery
8. Restoration surgery
9. Oncoplastic surgery
10. Radioablaton surgery

14. Curative surgery
Curative surgery removes the cancerous tumour or
growth from the body. Surgeons use curative
surgery when the cancerous tumour 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

15. 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

16. Debulking surgery
Debulking surgery removes a portion, though not all, of a
cancerous tumor.
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.

17. 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.
• B/L risk reducing mastectomy
• Total proctocolectomy

18. 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.
• True cut biopsy - Ca cervix

19. Staging surgery
Staging surgery works to uncover the extent of
cancer, or the extent of the disease in the body.
Laparoscopy
Laparotomy
Endoscopic mucosal resection (EMR) provides
essential staging information that guides treatment
in CA oesophagus .

20. 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 intravesical chemotherapy.

21. Restoration surgery
• 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.
• 1895 - 1st attempt at true breast recontruction by
Czerny, who transplanted a large lipoma from pt’s
flank to mastectomy site
• 1906 - Tansini used latissimus dorsi myocutaneous
flap
• 1963 - silicon breast implant introduced

22. Options for breast reconstruction
• Abdominal based flap
• TRAM
• Single & double pedicle
• Deep inferior epigastric perforator flap (DIEP)
• Lattisimus dorsi myocutaneous flap
• Gluteal flap
• Rubens flap (deep circumflex iliac artery)
• Lateral thigh flap
• Silicone gel implant & with saline fill
• Latissimus dorsi or TRAM flap with implant

23. TRAM & Deep Inferior epigastric perforator flap

24. Oncoplastic surgery
• Extensive & unnecessary surgery avoided
• Earlier , reconstruction was not primary aim
• Now, increase demand & awareness —
reconstruction done

25. Based on technique
1. Open
2. Lap
3. Tumour ablation
4. Microscopically controlled surgery
5. Robotics
6. Telesurgery

26. Open surgery

27. Laparoscopic / endoscopic / minimally
invasive surgery
Stereotactic surgery or stereotaxy is a minimally
invasive intervention which uses 3D imaging to locate a
small target inside body ( eg. A brain tumour) and
perform some actions at the site like
Radio ablation
Taking biopsy
Injections
Implantation radio surgery

28. Tumour ablation
• Direct application of a chemical or energy based
(thermal & non thermal) therapy to eradicate or
substantially destroy focal tumours
(Vs. indirect )
• Used for both benign (fibroadenoma,
angiomyolipoma), metastatic lesion, and increasingly
for primary tumour
• Goal - 100% eradication of all viable cancer cells
• Chemical ablation or non energy based
• Energy based - thermal & non thermal
• Dependant on mange guidance

29. Potential benefits
• Ability to eliminate malignant cells with minimal damage
to normal tissue
• So , preserve functions
• e.g. preserve functional hepatic reserve in cirrhotic pts,
nephron sparing approach in RCC
• Decreased morbidity
• Cost effective
• Potential to stimulate anti-tumour immune response
• ABSCOPAL effect (impact on distant untreated tumour)

30. But, when compared, surgery ….
• Gold standard
• Permits pathological confirmation of complete excision
• Evaluation of margin status
• Tumour ablation- dependant on imaging studies
• Some tech- dependant on tumour micro environment -
density, fibrosis , water content , vascularity
• Also,on normal organ characteristic - thermal &
electrical conductivity , tissue elasticity

31. Types of Tumour Ablation (energy based)
• Radio frequency ablation
• Laser ablation
• Microwave ablation
• Ultrasound ablation
• Histotripsy
• Irreversible electrocorporation
• Cryoablation

32. • Principles of Hyperthermic ablation
• RFA, microwave ablation, laser & HIFU
• Interaction of heat with tissue to induce cell death
• Ideal temp- 50 to 100 deg. Celsius throughout the
entire target volume
• Most use percutaneous probe
• If temp near the probe>100 deg, boiling &
vaporisation occurs ; resultant gas serves as insulator
that prevent heat spread

33. • Repeatedly remove & replace probe in different
positions
• Use multiple probe simultaneously (more time &
technically challenging )
• Alternate high & low energy deposition
• Tissue factor - oven effect (in HCC within cirrhotic
liver)
• Heat sink effect (perfusion mediated tissue cooling)-
leads to incomplete ablation by preventing high temp
near vessels

34. • Radio frequency ablation
• Radio frequency- alternating electric current
oscillating in a high frequency range b/w 2
electrodes; creates a closed loop circuit
• Current flow - agitation of ions within the tissue (joule
effect )-frictional heat -coagulative necrosis
• Tumour and adequate margin treated to temp over
50 deg for 4-5 min
• May promote tumorigenesis in non target tissue

35. • Laser ablation
• Mainly , skin & ocular disorder
• Newer- ILT (interstitial laser therapy)
• Very efficient & precise method of generating heat
• Able to use MR guidance
• But, used only for smaller tumour (1-2cm)
• Co2— gas laser, used as medium to produce infra-
red light
• Nd:YAG—solid state laser, uses Neodymium(Nd) in a
crystal composed of Yattrium aluminium garnet

36. • Co2— gas laser, used as medium to produce
infra-red light
• Nd:YAG—solid state laser, uses Neodymium(Nd)
in a crystal composed of Yattrium aluminium
garnet to produce a light beam

37. • Microwave ablation
• Microwave - EM energy from 300 MHz to 300 GHz
• Induces a rapid & continuous realignment of polar
molecules (primarily, water )- kinetic energy -hyperthermia
• As the heat originates primarily from water agitation,
tissues with a larger water content (cancer cells) are
particularly susceptible
• Greater tissue penetration
• Less heat sink effect
• Presently studied- lung cancer & mets and bone ca

38. • Ultrasound ablation
• Direct / interstitial
• Extracorporeal / transcutaneous (HIFU)
• HIFU : covert mechanical energy to heat
• : kills through acoustic cavitation
• :can raise temp to 80 deg

39. • Histotripsy
• Uses only acoustic cavitation to destroy tumour
in non hyperthermic environment

40. • Irreversible electrocorporation
• Non thermal
• Repeated application of short-duration high-voltage
electrical pulses
• Irreversible injury to cell membranes

41. Laser surgery
This technique uses beams of light energy instead of
instruments to remove very small cancers (without
damaging surrounding tissue), to shrink or destroy tumours,
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

42. 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 (high pressure closed loop gas expansion system)
Cryosurgery is being evaluated as a surgical treatment for
several types of cancers

43. Advantage of Cryoablation
• As freezing is inherently anaesthetic, it can be
performed without GA
• Ice ball that forms around the tumour, can be
visualised on USG ,CT to MRI
• So,real time monitoring is possible

47. Electro cautery
Effects
Coagulation
Fulguration
Cutting

48. Principle of diathermy
The heat produced depends on
• The intensity of the current
• The wave form of the current
• The electrical property of the tissues through which
the current passes
• The relative sizes of the two electrodes

52. Skin cancer and oral cancer are sometimes
treated with electrosurgery. This technique
uses electrical current to kill cancer cells.

53. Microscopically controlled surgery
This surgery is useful when cancer affects delicate
parts of the body, such as
the eye. &
cutaneous ca (melanoma)
Layers of skin are removed and examined
microscopically until cancerous cells cannot be
detected.

55. Robotics

56. Robotic surgery
Some points
• 1985- the PUMA 560 used to place a needle
for a brain biopsy using CT guidance.
• 1987-robotics was used in the 1st lap chole.
• 1988- PROBOT - used in prostatic surgery
• 1992-ROBODOC - to aid in hip replacement
• Others - AESOP & ZEUS

57. Da vinci robot
• works on ‘master-slave’ principle
• The surgeon inserts his hands into a “master” that
translates motions of his hands into the motion of
robotic arms & hand-like instrument. The surgeon
acts as the master and the robot as the ‘slave’ in
this telerobotic ‘master slave’ system.
• prostatectomies, cardiac valve repair &
gynaecological procedures

58. Da vinci robot

59. Tele-surgery

60. Residual tumour ® classification
• Strong predictor of prognosis
• Reflects the effects of treatment & influences further
treatment planning
• R0 - no residual tumour
• R1 - microscopic residual tumour
• R2 - macroscopic residual tumour

61. Lymph node dissection (gastric Ca)
D1— only perigastric LN
D2— D1+ LN along hepatic, celiac ,left
gastric ,splenic artery , hilum & nodes >3cm
away from the primary tumour
D3— D2+ nodes in porta hepatis, retro-
pancreatic & peri-aortic region