L-26 Surgical Oncology: Goals and Approaches

Learning Objectives

• Surgical oncology should be defined
• The goals of surgical oncology, concerning cancer diagnostics, cancer resection, cancer staging, supportive care, reconstruction, and cancer surveillance should be described
• Different surgeries should be described with regards to intent to cure, debulking, and palliation
• Surgical approaches in oncology, including open, laparoscopic, and robotic approaches should be defined and described
• Pertinent surgical oncology details with regards to specific cancers should be listed

Surgical Oncology

• Surgical oncology focuses on surgery to diagnose, stage, and treat cancer
• It surgically manages cancer related symptoms
• Surgical oncology works with a multidisciplinary team as part of a patient's comprehensive plan including medical, radiation, nutritional, and rehabilitation
• Palliative surgeries are used to control pain, increase comfort, and improve quality of life
• The role of surgery depends on the type of cancer, location, size, grade, and stage
• The role of surgery depends on general health factors of the patient, including age, physical fitness, and comorbidities

Goal of Surgical Oncology

• Cancer can be diagnosed
• Tumors can be resected or debulked
• Staging is used to determine location and metastasis
• Tissue can be removed as preventative surgery in precancerous states
• Supportive surgery can involve venous access ports, stents, and feeding tubes
• Body appearance or function can be restored through reconstructive surgery
• Side effects can be relieved through palliative surgery
• Follow-up care to detect recurrences is part of surveillance

Diagnostic

• Small Bowel (SB) obstruction vs. carcinomatosis
• Diverticulitis vs. colon cancer
• Cholecystitis vs. Gall Bladder (GB) cancer
• Appendicitis vs. appendiceal malignancy

Complete Resection

• The goal is complete resection for breast cancer, GI cancers (gastric, SB, colon), pancreatic cancer, sarcoma, and skin cancer

Debulking

• A surgically incurable malignant neoplasm can be partially removed without curative intent to make adjunctive measures more effective
• It is rarely indicated, and a palliation exemption
• It is used for sarcomas, some lymphoma subtypes, and is advocated for ovarian, Renal Cell Carcinoma (RCC), testicular, and Central Nervous System (CNS) cancers.

TNM Staging

• T = Original primary tumor size
• N = Lymph node status
• M = whether the cancer has spread to other areas

Tumor

• Tx = no information available.
• T0 = no primary tumor found.
• Tis = In-situ or precancerous (only growing in layer where started).
• T1, T2, T3, T4 = progressively larger or deeper spread into tissue layers

Nodes

• Nx = no information
• N0 = no cancer in lymph nodes
• N1, N2, N3 = Cancer has spread to lymph nodes (higher number corresponds with more nodes)

Metastasis

• Mx = unable to determine metastasis
• M0 = no distant spread
• M1 = metastatic disease identified

Additional Factors for Staging

• Grade/Differentiation = microscopic appearance
• TNM is used to assign STAGING
• STAGING is used to assign survival rates at time of diagnosis

Preventative surgery

• Colonoscopy with polypectomy
• Excision of DCIS, LCIS, sclerosing adenosis, ductal papillomas
• Mucinous appendiceal neoplasms
• Actinic keratosis and Bowen's disease
• Cervical dysplasia and anal dysplasia
• Bladder carcinoma in-situ
• Barrett's esophagitis

Supportive Procedures

• Venous Access Port
• Stents
• Feeding tubes

Oncoplasty

• Oncoplasty is an interdisciplinary branch of oncologic surgery
• It integrates the theories and technologies of oncology, general surgery, plastic and reconstructive surgery

Palliative

• Intestinal bypass (gastrojejunostomy, Small bowel bypass, colostomy)
• Biliary bypass
• Toilet mastectomy
• Biliary stents
• Gastrostomy tubes for decompression
• Peritoneal Dialysis (PD) catheters for paracentesis

Surveillance

• It is done in conjunction with a medical oncologist, PCP, GI, dermatologist, and gynecologist
• Examples: anal cancer, breast cancer, colon cancer, gyn cancers

Surgical Approaches

• Open surgery
• Laparoscopic surgery
• Robotic surgery

Open Surgery

• This is a traditional method and is very effective
• This approach allows systemic visualization and palpation of surfaces
• It involves a large incision and increased pain and healing complications compared to minimally invasive approaches

Laparoscopic Surgery

• There is less pain and fewer wound healing issues with this approach
• This may be all that is needed (diagnostic, biopsy)
• This approach might not allow adequate evaluation and may not be feasible if bowel distention or adhesions

Robotic Surgery

• It is a minimally invasive tool with greater dexterity
• It allows 3D optics/magnification/ergonomics
• There is no tactile feedback and it is an expensive technology

Specific Cancers

• Brain
• Breast
• Colorectal
• Endocrine
• Gastric
• Gynecologic
• Head and Neck
• Intestinal
• Lung
• Lymphoma
• Pancreatic
• Prostate
• Renal/Bladder
• Sarcoma
• Skin

Brain Cancer

• The most common brain tumor type among adults is metastatic, and classified as secondary brain tumors
• Meningiomas are the second most prevalent type, but they arise from the meninges surrounding the skull and vertebral canal
• Glioblastoma is the most common primary brain tumor
• May require a neurosurgeon

Breast Cancer

• Globally the most frequently diagnosed cancer
• Treatment depends on the stage at presentation and includes surgery, radiation, and chemotherapy
• Invasive ductal carcinoma is the most common type (70-80%)
• Breast-conserving therapy is an option, compared to mastectomy
• May require a general/breast/oncologic surgeon

Colorectal Cancer

• It is the second most common cause of death in men and third most common in women in the US
• Occult bleeding is the most common in right-sided cancers
• Obstructive symptoms are more common with left-sided cancers
• Colonoscopy is the most accurate diagnostic tool for Colorectal Cancer (CRC)
• Treated with surgical resection
• Radiation can be limited to the use of rectal cancers
• Chemotherapy is stage dependent
• May require a general/colorectal surgeon

Endocrine Cancer

• Adrenocortical carcinomas
• Most adrenal tumors are benign cortical adenomas and detected incidentally on CT or MRI
• Pheochromocytoma should be ruled out
• The larger the size leads to an elevated likelihood of cancer (>4cm)
• Also: neuroendocrine, thyroid, parathyroid, and pituitary tumors can be present
• May require a general/oncologic/endocrine surgeon

Gastric Cancer

• Most patients in the US have advanced, incurable disease at time of symptoms/presentation
• Screening is done in Japan, Korea, Venezuela, and Chile
• Common presenting symptoms are abdominal pain, weight loss, early satiety, and anemia
• Sister Mary Joseph's nodule can be present
• May require a general/oncologic surgeon

Gynecologic Cancer

• Most patients with ovarian cancer have spread throughout the peritoneal cavity and/or lymph nodes
• Cytoreduction followed by adjuvant chemotherapy is the management approach for most patients
• Most patients will relapse
• Younger patients usually have a better prognosis
• May require a gynecologic oncologist/gynecologist/general surgeon

Head and Neck Cancer

• Surgery is the primary mode of therapy for thyroid cancer
  • Papillary (85%)
  • Follicular (12%)
  • Anaplastic (undifferentiated) (3%)
• May require an ENT/general surgeon

Intestinal Cancer

• Adenocarcinomas can be present
• Neuroendocrine (carcinoid) tumors
• Sarcomas and lymphomas can be present
• Surgical excision is the primary treatment modality
• May require a general surgeon

Lung Cancer

• Common symptoms are cough, hemoptysis, and dyspnea
• Small Cell Lung Cancer (LC) accounts for 15% of LC, and almost all are smokers
• Surgery is rarely used for Small Cell LC (SCLC)
• Non-Small Cell Lung Cancer (NSCLC) includes adenoCA, squamousCA, adenosquamousCA, and large cell CA
• May require a cardiothoracic surgeon

Lymphoma

• Surgery can be done for diagnosis
  • This includes Follicular, Non-Hodgkin, Mantle cell, and Hodgkin lymphomas
• Chemotherapy by medical oncologist

Pancreatic Cancer

• It is the 4th leading cause of cancer death in the US
• Surgical resection is the only potential curative treatment
• Only 15 to 20% of patients are candidates for pancreatectomy
• Whipple Procedure
• Prognosis is poor, even after resection
• May require a general/oncologic surgeon/hepatobiliary surgeon

Prostate Cancer

• It is the second most common cancer in males
• Treatment is based on TNM stage, Gleason score, and Prostate-Specific Antigen (PSA) levels
• Surveillance can be used
• Radical prostatectomy is a treatment option
• Radiation therapy can be used
• Brachytherapy
• May require a urologist

Renal Cancer

• 90% of solid renal masses are malignant Renal Cell Carcinoma (RCC)
• Symptoms are rare and 50% are found incidentally on imaging
• Needle bx of renal masses have a high false negative rate
• Solid masses are often surgically resected without need for bx due to high rate of malignancy
• May require a urologist

Bladder Cancer

• Up to 33% of bladder cancer is related to occupational carcinogenic dye exposure (textile, rubber, cable printing, and plastics)
• Cigarette smoking is also a major cause
• Gross hematuria is the most common symptom of bladder cancer, but only present in 30% of cases
• May require a urologist

Sarcoma

• Arise from skeletal and connective tissues
• Surgical resection is a prerequisite for cure
• Most patients are treated with adjuvant radiation to minimize the risk of local recurrence
• May require a general surgeon/oncologic surgeon

Skin Cancer

• Includes Basal Cell Carcinoma, Squamous Cell Carcinoma, and Malignant Melanoma
• May require a Dermatologist/general surgeon/plastic surgeon/oncologic surgeon