Sx in Oncology

1. Surgical oncology
…past, present &
future
Dr Ravindra babu
Surgical oncologist

4. Surgical oncology ; introduction
 Surgery is the treatment of choice for most localized,
solid neoplasms.
 Surgery has recognized limits in its application.
 Surgery is increasingly combined with other
treatment modalities.

5. Timeline of landmark developments in
breast cancer surgery.
Nature Reviews Clinical Oncology 12, 115–124 (2015) doi:10.1038/nr
clinonc.2014.191

6. Timeline of landmark developments in
minimally invasive surgery
Nature Reviews Clinical Oncology 12, 115–124 (2015) doi:10.1038/nr
clinonc.2014.191

7. Role of the Surgical Oncologist
 Consultant
Special training or
skills
Tumor board
 Organizer and
Leader
Cancer programs
Cancer committee
Tumor registry
Oncology section
 Educator
Cancer conferences
Teaching programs
 Researcher
Clinical protocols

16. Operating Room

17. Robotic Sx

18. Image guided Sx
Transition from open surgery to laparosc
opic or video-assisted surgery and soon
after to robotic surgery

19. Intraoperative navigation

20. The Genomic Era: The Changing Roles of
the Surgeon
 More recently the new biomolecular targeted
treatments: Her 2 inhibitors for MBC, imatinib for
GIST, BRAF inhibitors for melanoma, EGFR TKIs for
NSCLC
 Neoadjuvant treatments are currently being used for
downstaging. (CT and RT, as well as HT) are shown
to decrease the extent of the solid tumors, rendering
operable, without excising the affected organ.

21. Early detection of cancer has
contributed significantly to the
advance of surgical oncology, as it was
shown to affect both the treatment
strategy toward minimal intervention
and organ saving techniques, and the
prognosis.

23. Roles of Surgeon in Management of
Cancer Patients
 Prevention
 Diagnosis
 Definitive treatment
 Palliation
 Rehabilitation

24. Prevention
 Educating patients about carcinogenic hazards
 Surgical intervention for the preventable cancer

25. Sugery That can Prevent Cancer
 Underlying
condition
cryptochidism
polyposis coli
familial colon cancer
ulcerative colitis
MEN type II, III
familial breast cancer
familial ovarian cancer
 Prophylactic
surgery
Orchiopexy
Colectomy
Colectomy
Colectomy
Thyroidectomy
Mastectomy
Oophorectomy

26. Role of Surgeon in Management of
Cancer Patients
 Prevention
 Diagnosis
 Definitive treatment
 Palliation
 Rehabilitation

27. Diagnosis of Cancer
 Acquisition of tissue for histologic
diagnosis
 Staging of patients

28. Techniques for Obtaining Tissue
 Needle biopsy
 Incisional biopsy
 Excisional biopsy

29. Needle biopsy ; advantages
 Simplest method
 Inexpensive
 Causes minimal disturbance of the
surrounding tissue

30. Needle biopsy ; disadvantages
 Danger of implanting tumor cells in a needle
tract
 Not representative of the total tumor
 The needle misses the lesion

31. Needle biopsy ; types
 Fine needle aspiration biopsy
 Large bore needle biopsy ;
Vim Silverman needle
Tru cut needle

32. Principles of the performance of all
surgical biopsies
 Needle tract or scar should be removed as part of
subsquent definitive surgical procedure

33. Principles of the performance of all
surgical biopsies
 Do not contaminate new tissue plane
during the biopsy

34. Principles of the performance of all
surgical biopsies
 Choice of biopsy technique should be
selected carefully in order to obtain
an adequate tissue sample for the
needs of the pathologist

35. Diagnosis of Cancer
 Acquisition of tissue for histologic
diagnosis
 Staging of patients

36. TNM Classification System
Describes the anatomic extent of disease
based on assessment of three components
T Primary tumor size and extent
N Regional lymph node involvement
M Distant metastasis absent or present

37. TNM Classification System
 Primary tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1,T2 Increasing size or local extension
T3,T4 Increasing extent of primary tumor

38. TNM Classification System
 Regional lymph nodes (N)
NX Regional lymph nodes cannot be
assessed
N0 No regional lymph node metastasis
N1,N2,N3 Increasing involvement of regional
lymph nodes

39. TNM Classification System
 Distant metastasis (M)
MX Presence of distant metastasis cannot be
assessed
M0 No distant metastasis
M1 Distant metastasis (may be further
specified
according to size of occurrence)

40. Role of Surgeon in Management of
Cancer Patients
 Prevention
 Diagnosis
 Treatment
 Palliation
 Rehabilitation

41. Considerations in choosing
therapy
 Disease and results obtained from each type of
therapy
 Patient’s general conditions and co-existing
disease
 Patient’s life situation and psychological makeup

42. American Society of Anesthesiologists
Physical Status Classification
CLASS DESCRIPTION
Ⅰ Healthy patient
Ⅱ Mild systemic disease, no functional limitation
Ⅲ Severe systemic disease, definite functional
limitation
Ⅳ Sever systemic disease that is a constant threat
to life
Ⅴ Moribund patient unlikely to survive 24 hours
with or without operation
From Miller RD: Principles and Practice of Anesthesia,
2nd ed. New York, Churchill Livingstone, 1986, with
Permission.

43. Eastern Cooperative Oncology Group
Performance Scale and Corresponding
ECOG-PS
GRADE
DESCRIPTION KARNOFSKY
RATING
0 Fully active, able to carry on all predisease
activities without restriction
100
1 Restricted in physically strenuous activity,
but ambulatory and able to carry out work
of a light or sedentary nature
80-90
2 Ambulatory and capable of all self-care, but
unable to carry out any work activities; up
and about more than 50% of waking hours
60-70
3 Capable of only limited self- care; confined
to bed of chair 50% or more of waking
hours
40-50
4 Completely disabled; cannot carry on any
self-totally confined to bed or chair
≤30

44. Major Challenges Confronting the
Surgical Oncologist I
 Accurate identification of patients who can be
cured by local treatment alone

45. Major Challenges Confronting the
Surgical Oncologist II
 Development and selection of local
treatments that provide the best balance between
local cure and the impact of treatment morbidity on the
quality of life

46. Major Challenges Confronting the
Surgical Oncologist III
 Development and application of
adjuvant treatments that can improve
the control of local and distant
invasive and metastatic disease

47. Cancer surgery ; principles
 Enucleation or incomplete excision of tumor mass is
never indicated as a therapeutic measure
 Prevention of tumor cell implantation during
surgery
 Prevention of vascular dissemination at
surgery

48. Types of cancer operations
 Local resection
 Radical local resection
 Radical resection with en bloc excision of
lymphatics
 Extensive surgical procedures

49. Adequate margin of Resection
• A complete margin of normal tissue around the
primary lesion
• Frozen sections used to evaluate tissue
margins in instances of doubt
• Complete removal of involved regional lymph
nodes
• Resection of involved adjacent organ
• En bloc resection of biopsy tracts and tumor
sinuses

50. Roles of Surgery in the Treatment of
Cancer
 Definitive surgical treatment for primary cancer
 Surgery for reduce the bulk of residual disease
 Surgical resection of metastatic disease with
curative intention
 Surgery for treatment of oncologic emergencies

51. Surgery for residual disease
 In selected cancers, surgical resection
of bulk disease may lead to
improvement in the ability to control
residual gross disease that has not been resected

52. Surgery for metastatic disease
 Resection of pulmonary metastasis in
patients with soft tissue and bony sarcomas
 Resection of pulmonary metastasis in
patients with colon cancer
 Resection of hepatic metastasis in patients with colorectal
cancer

53. Surgery for oncologic emergencies
 exsanguinating hemorrhage
 perforation
 drainage of abscess
 impending destruction of vital organs

54. Role of Surgeon in Management of
Cancer Patients
 Prevention
 Diagnosis
 Definitive treatment
 Palliation
 Rehabilitation

55. Surgery for Palliation
 To improve the quality of life
 Examples ; relief of intestinal obstruction,
removal of mass causing pain

56. Role of Surgeon in Management of
Cancer Patients
 Prevention
 Diagnosis
 Definitive treatment
 Palliation
 Rehabilitation

57. THE CANCER SURGEON
 AS A CARE PROVIDER
Brings surgical skill and compassionate care to
patients
Leads screening, prevention, and risk assessment
programs
Facilitates molecular characterization of tumor and
surrogate tissues
Coordinates mu1tidisciplinary clinical care teams

58. THE CANCER SURGEON
 AS A RESEARCHER
Facilitates laboratory research
Coordinates epidemiologic studies
Conducts clinical trials research
Develops novel approaches to education

59. THE CANCER SURGEON
 AS A TEACHER
Ensures excellence in surgical care
Leads a multidisciplinary team to implement
integrate oncology training