Principle of Surgical Oncology

Woramin Riansuwan, M.D.

Colorectal Surgery Unit
Division of General Surgery
Department of Surgery
Faculty of Medicine Siriraj Hospital
Multidisciplinary Team
y Surgeons
y Medical oncologists
y Radiation oncologists
y Reconstructive Surgeons
y Pathologists
y Radiologists
y Primary Care Physicians
Definitions
y Primary (or definitive) therapy
en bloc resection of tumor with adequate
margins of normal tissues and in some cases
regional lymph nodes
y Adjuvant therapy
refers to radiation therapy and systemic
therapies, including chemotherapy,
immunotherapy, hormonal therapy, and
increasingly, biologic therapy.
Goals of Treatment

y Primary goal of surgical and radiation therapy

: local and regional control

y Primary goal of systemic therapies

: systemic control by treating distant foci of
subclinical disease to prevent recurrence.
Cancer Epidemiology
Cancer Epidemiology
Ten most common cancer in Thai male

2007 Thailand NCI Cancer Registry

Ten most common cancer in Thai female

2007 Thailand NCI Cancer Registry

Trends in Cancer Incidence and Mortality
Acquired Capabilities of Cancer

Cell, Vol. 100, 57–70, January 7, 2000,

Metastatic Process
Three steps of Tumorigenesis
: initiation, promotion &
progression
Cell-Cycle Dysregulation in Cancer
 Cancer Etiology
Genes Carcinogens

Cancer
Genes
y Oncogenes

y Tumor Suppressor Genes

 Genes Associated with Hereditary Cancer
Genes Syndrome

APC Familial adenomatous polyposis

(FAP)
BMPRIA Juvenile polyposis coli

BRCA1 Breast/ovarian syndrome

BRCA2 Breast/ovarian syndrome
hMLH1; hMSH2; Hereditary nonpolyposis
hMSH6; hPMS1; colorectal cancer
hPMS2
Criteria suggest of Hereditary Cancer
y Tumor development at a much younger age
than usual
y Presence of bilateral disease
y Presence of multiple primary malignancies
y Presentation of a cancer in the less affected
sex (e.g., male breast cancer)
y Clustering of the same cancer type in relatives
y Cancer associated with other conditions such
as mental retardation or pathognomonic skin
lesions
Carcinogens

y Chemical Carcinogens
y Physical Carcinogens
y Viral Carcinogens
 IARC Group 1 Chemical Carcinogens
Chemical Predominant Tumor Type
Aflatoxins Liver cancer
Arsenic Skin cancer
Benzene Leukemia
Benzidine Bladder cancer
Ethylene oxide Leukemia, lymphoma
Estrogen replacement therapy Endometrial cancer, breast cancer
Tamoxifen Endometrial cancer
Tobacco smoke Lung cancer, oral cancer, pharyngeal
cancer, laryngeal cancer, esophageal
cancer (squamous cell, pancreatic
cancer, bladder cancer, liver cancer,
renal cell carcinoma, cervical cancer,
leukemia)
 Selected Viral Carcinogens
b
Virus Predominant Tumor Type
Epstein-Barr virus Burkitt's lymphoma
Hodgkin's disease
Immunosuppression-related lymphoma
Sinonasal angiocentric T-cell lymphoma
Nasopharyngeal carcinoma
Hepatitis B Hepatocellular carcinoma
Hepatitis C Hepatocellular carcinoma
Human immunodeficiency virus-1 Kaposi's sarcoma
Non-Hodgkin's lymphoma

Human papillomavirus types 16 and 18 Cervical cancer

Anal cancer
Human T-cell lymphotropic viruses Adult T-cell leukemia/lymphoma
 Cancer Screening
Cancer Site Population Test or Procedure Frequency

Breast Women, age 20+ Breast self-examination Monthly, starting at age 20

Clinical breast examination Every 3 years, ages 20–39

Annual, starting at age 40

Mammography Annual, starting at age 40

Colorectal Men and women, age 50+ Fecal occult blood test (FOBT) Annual, starting at age 20

Flexible sigmoidoscopy Every 5 years, starting at

age 50
Fecal occult blood test and flexible Annual FOBT and flexible
sigmoidoscopy sigmoidoscopy every 5,
years, starting at age 50
Double-contrast barium enema DCBE every 5 years,
(DCBE) starting at age 50
Colonoscopy Colonoscopy every 10
years, starting at age 50
Prostate Men, age 50+ Digital rectal examination (DRE) and Offer PSA and DRE
prostate-specific antigen test (PSA) annually, starting at age 50,
for men who have life
expectancy of at least 10
years
Cancer Staging
American Joint Committee on Cancer (AJCC)
Union Internationale Contre Cancer
(International Union Against Cancer, UICC)
three components:
y Primary tumor (T),
y Nodal metastases (N),
y Distant metastases (M)
Clinical staging (cTNM or TNM), Pathologic staging
(pTNM), re-treatment (rTNM) or autopsy staging
(aTNM)
 TNM Staging of Colorectal Carcinoma
Tumor Stage (T) Definition
Tx Cannot be assessed
T0 No evidence of cancer
Tis Carcinoma in situ
T1 Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades through muscularis propria into
subserosa or into nonperitonealized pericolic or
perirectal tissues

T4 Tumor directly invades other organs or tissues or

perforates the visceral peritoneum of specimen

Nodal Stage (N)

NX Regional lymph nodes cannot be assessed

N0 No lymph node metastasis

N1 Metastasis to one to three pericolic or perirectal
lymph nodes
N2 Metastasis to four or more pericolic or perirectal
lymph nodes
N3 Metastasis to any lymph node along a major
named vascular trunk
Distant Metastasis (M)
MX Presence of distant metastasis cannot be assessed

M0 No distant metastasis
M1 Distant metastasis present
TNM Staging of Colorectal Cancer and 5-Year Survival

Stage TNM 5-Year Survival

I T1-2, N0, M0 70–95%

II T3-4, N0, M0 54–65%

III Tany, N1-3, M0 39–60%

IV Tany, Nany, M1 0–16%

 Tumor Markers
Marker Cancer Sensitivity Specificity
PSA (4 g/L) Prostate 57–93% 55–68%

CEA Colorectal 40–47% 90%

Breast 45% 81%

Recurrent disease 84% 100%
AFP Hepatocellular 98% 65%
CA 19-9 Pancreatic 78–90% 95%
CA 27-29 Breast 62% 83%
CA 15-3 Breast 57% 87%
Roles of Surgery in Cancer

y Prevention of Cancer
y Diagnosis of Cancer
y Treatment of Cancer
Prevention of Cancer

y Some underlying conditions

y Congenital or Genetic traits

y high incidence of subsequent cancer

Familial Adenomatous Polyposis (FAP)
y 50% develop colon
cancer by age of 40.
y By age 70, virtually all
develop colon cancer
y prophylactic
proctocolectomy
before age 20 to
prevent CRC is
advised for who
carry APC gene
Ulcerative Colitis (UC)
y 40% of UC (Pancolitis)
die of colon cancer
y 3% of children with UC
develop colon cancer by
the age of 10, and 20%
develop cancer during
each ensuing decade
y Colectomy is indicated
for patients with
ulcerative colitis if the
chronicity of this disease
is well established.
Breast Cancer
y risk of cancer in some
women is increased
substantially over the
normal risk (but does not
approach 100%),
y counseling that explains the
benefits and risks of
prophylactic mastectomy?
y Genetic tests for BRCA1
and BRCA2 mutations
provide valuable information
Diagnosis of Cancer

Acquisition of tissue for

exact histologic diagnosis

Biopsy
Biopsy
y Aspiration Biopsy
y Needle Biopsy
y Incisional Biopsy
y Excisional Biopsy
Aspiration Biopsy
 Needle Biopsy

y A core of tissue is obtained through a specially designed

needle introduced into the suspect tissue.
y The core of tissue provided by needle biopsy is sufficient
for the diagnosis of most tumor types.
y Soft tissue and bony sarcomas often present major
difficulties in differentiating benign and reparative lesions
from malignancies and often cannot be diagnosed
accurately.
y Needle tract tumor seeding ???
Imaging Guide Biopsy

U/S guide biopsy CT guide biopsy

Incisional Biopsy

y removal of small wedge tissue from a larger tumor mass.

y Incisional biopsies often are necessary for diagnosis of
large masses that require major surgical procedures for
even local excision.
y Incisional biopsies are the preferred method of diagnosing
soft tissue and bony sarcomas
Excisional Biopsy

y excision of entire suspected tumor tissue with

little or no margin of surrounding normal tissue
y Excisional biopsy is the procedure of choice for
most tumors if it can be performed without
contaminating new tissue planes or further
compromising the ultimate surgical procedure
y e.g. Lymph node biopsy
Endoscopic Biopsy

Incisional Biopsy Excisional biopsy

(Polypectomy)
Principles of Surgical Biopsy (1)

y Needle tracks or scars should be placed carefully so

that they can be conveniently removed as part of the
subsequent definitive surgical procedure.
y Care should be taken to avoid contaminating new tissue
planes during the biopsy procedure.
y It is not uncommon to take biopsy samples from several
suspected lesions at one time.
y Care should be taken to avoid using instruments that
may have come in contact with tumor when obtaining
tissue from a potentially uncontaminated area.
Principles of Surgical Biopsy (2)
y Adequate tissue samples must be obtained to meet the
needs of the pathologist.
y mark distinctive areas of the tumor carefully to facilitate
subsequent orientation of the specimen by the
pathologist.
y Certain fixatives are best suited to specific types or
sizes of tissue..
y Placement of radiopaque clips during biopsy and staging
procedures is sometimes important to delineate areas
of known tumor and to guide the subsequent delivery
of radiation therapy to these areas.
Treatment of Cancer

y Curative Resection of Primary Cancer

y Cytoreductive Surgery
y Metastatic Disease
y Oncologic Emergencies
y Palliation
y Reconstruction and Rehabilitation
Surgical Challenges in Curative Treatment of Solid Tumors

y Identification of patients who cured by

local treatment alone;
y Best balance between local cure vs.
morbidity and the QoL of treatment
y Apply adjuvant treatments which improve
the local control and distant metastasis.
cancer type and the site of involvement

Vary in selection of the

appropriate local therapy in cancer
treatment
Definitive surgical therapy with sufficient
margins is sufficient local therapy

y wide excision of primary

melanomas of skin can be cured
locally by surgery alone in 90%
of cases.
y The resection of colon cancers
with a 5-cm margin from the
tumor results in anastomotic
recurrences in fewer than 5% of
cases.
Surgery obtain histology confirmation of diagnosis

Long bones Ewing's sarcoma Nasopharyngeal Cancer

primary local therapy is achieved through

nonsurgical modality
( e.g. Radiation Therapy)
Lymphatic mapping & sentinel lymph node biopsy
The magnitude of surgical resection is
modified when use of Neoadjuvant treatment

y Surgery alone
Rhabdomyosarcoma
: 5yr survival rates
is 10% - 20%
y Neoadjuvant
Radiation therapy
combined with
Chemotherapy.
:long-term cure rates
are now 80%.
 Cytoreductive Surgery
Ovarian Cancer
y extensive local spread of cancer
precludes the removal of all gross
disease by surgery
y partial surgical resection of bulk
disease in selected cancers improves
the ability of other treatment
modalities to control unresectable
residual gross disease.
y cytoreductive surgery is of benefit
only when other effective treatments
are available to control unresectable.
residual disease
Burkitt's lymphoma
Metastatic Disease
y Single site of metastatic disease that
can be resected without major
morbidity should undergo resection
y Limited lung, liver or brain
metastases can be cured by surgical
resection.
y Appropriate for cancers that not
respond well to systemic
chemotherapy.
y resection of colorectal hepatic
metastases, in whom the liver is the
only site metastasis can lead to long-
term cure in 25%.
Oncologic Emergencies
y Exsanguinating Hemorrhage
y Perforation
y Drainage of Abscesses
y Impending Destruction of Vital Organs
Oncologic Emergencies: Hemorrhage
Oncologic Emergencies : Advanced Cancer

Non-Surgical Intervention

y Endoscopic Therapy

y Intervention Radiology
 Exsanguinating Hemorrhage

Angiography and Embolization Endoscopic Therapy

Drainage of Abscesses : Percutaneous Drainage
Palliation

y Relief of Pain
y Relief of Functional Abnormalities
(Relieve mechanical problems e.g. intestinal
obstruction)
y Improve the Quality of Life

y Advances Stage : Non Surgical Intervention

Palliation: Pain

y Pain Medications
y Nerve Block
y Epidural Block
y Celiac Ganglion Block: EUS guide
y Pain Clinic
Palliation: Obstruction - Stent
Reconstruction and Rehabilitation
y Reconstruction and rehabilitation after definitive Tx
y Improve function and cosmetic appearance
y Free flaps using microvascular anastomotic techniques is
having a profound impact on the ability to bring fresh
tissue to resected or heavily irradiated areas.
y Lost function (especially of extremities) often can be
restored by surgical approaches.
y Lysis of contractures or muscle transposition to restore
muscular function damaged by previous surgery or
radiation therapy.
Reconstruction and Rehabilitation
Thank You