Surgical oncology -د.جمال مسعد

Surgical oncology – Principles of cancer management

للدكتور جمال مسعد

كتبها لنا الاخ محمد أمين رمزون-جزاه الله خيرا

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Surgical oncology – Principles of cancer management
Lecturer: Dr. Jamal Mas3ad
Written by: “Mohd Amin” Ramzoon

The objectives of surgical management of cancer are cure and palliation.
Tumors in our country are discovered a bit late. That’s why palliative care is established to CONVERT a lethal disease (like breast cancer) to a chronic disease. The disease is living in the patient but the patient is coping.

WHAT is the role of the surgeon in cancer management?
• Diagnosis
• Prevention
• Treatment of primary tumor
• Resection of metastasis  improve quality of life and prolong survival
• Management of oncological emergencies
• Surgery for palliation
• Surgery for residual disease Surgery for reconstruction
• Cytoreduction
• Regional chemotherapy

FNAB (fine needle aspiration biopsy). They used to be afraid from FNA in the past, because they thought the cells from the tumor will go along the tract (made by the needle) and this will worsen the behavior of the tumor and the condition of the patient. NOW the studies proved that there is no harmful impact from using the FNA. RECENTLY the use of the FNA is becoming more common and feasible because of the emerge of GUIDED FNA, using the ultrasound or CT scan. We must give the site from where the biopsy was taken to the pathologist to in order to get the right picture.

SO the FNAB can be applied to any area in the body EXCEPT at 2 sites:
1- PAROTID: if we suspect a mass and in FNA it was found to be a benign tumor called Pleomorphic tumor, this tumor can propagate along the tract made by the needle.
2- TESTIS: to approach the testis, the surgeon should come from the scrotum. The lymphatic drainage of the testis (para-aortic LNs) is different from that of the scrotum (inguinal LNs). So probably while taking the FNA, some tumor cells will implant in the scrotum.
The Disadvantages of FNA:
1- It doesn’t give us histological diagnosis, it gives only cytological one. So we can’t find the stage or the grade of the tumor. I can’t find if the tumor is in-situ or invasive. So we can’t depend on it when there is a need to implement a major management.
2- It has a false positive and a false negative results. So if I did FNA in a suspected mass and I found it negative against my expectations, I consider myself as if I hadn’t done it at all. IT’S a good positive test but it’s a bad negative test. (false positive test can result from lab errors like fixation of cells is not good, the number of cells are not enough or the cells are dying or shrinked …etc, but this result is not critical as the false negative. The doctor are from the surgeons who don’t depend on the FNA results to do mastectomy, he prefers to do tru-cut biopsy first. But he can do wide local excision.

Tru-cut biopsy gives histological diagnosis. It must be done under mammogram, CT scan or computer guidance.
In OSCE:
• What are the malignant features (clinical signs)?
1- Retraction of the nipple
2- Peau’d orange
• What is the investigation done?
Tru- cut biopsy

Incisional biopsy means that we make incision through a suspicious mass, we don't remove the whole mass but part of it. Rarely used except in special circumstances where we must avoid big surgery, and when tru-cut biopsy is not suggested eg. If there is a mass in the floor of the mouth. and you are suspicious if it's benign or malignant then you remove it with safety margin, you will remove 50% of the tongue with it and finally you discovered that it's benign (this is a bad thing!!) so you better make incisional biopsy (small peace of tissue for histopathology) {{NOTE: in case of ulcers, you don't take from the floor because it's necrosed, you better take from the edge}}. Incisional biopsy give us bigger amount of tissue that we can use not only for histological diagnosis, but also for responsiveness for chemotherapy and radiotherapy.

(NICE POINT): Our dear dr. said that taking incisional biopsy and leaving the tumor in its place is better than removing the tumor without safety margin then after reaching the diagnosis return back to remove the remnants of tumor with confusion that where the safety margin should be now.

Excesional biopsy (THE MOST COMMON PROCEDURE DONE) must be done with safety margin (The best oncological procedure is done when you don't see the tumor (it remains inside the safety margin and you don't see it). We don't go directly to the site of the tumor, but we go around it). The distance we take as safety margin depends on behavior (TYPE) of tumor (more invasive, longer safety margin) as well as the SITE of tumor (under the eye not like the lower limb).

Surgery for Prevention:
It means that we don't allow the tumor to come to the site.
Eg. Female patient has high incidence to develop breast cancer (family history, BRCA1 BRCA2, age …etc) we may offer her to do surgery to remove the target tissue and thus prevent cancer to occur (this approach is not agreed upon between different surgeons).
Another eg. Patient with Undescended testis has higher incidence of malignancy, if we neglect it or miss it they have higher incidence to develop cancer (this approach is also not agreed upon because some physicians say that these patients have undescended testis have this problem because of the already formed genetic abnormalit, so even if we do orchoidectomy they will have the same percentage of malignancy. Also if it's bilateral we can't do orchoidectomy)
Another eg. Is familaial adenomatous polyposis in which there are multiple familial (inherited) polyps (adenomas) that will be malignant in age of 40, so we don't wait until they become malignant to remove them, we intervene early and resect the colon. (Some say we remove the whole colon (total colectomy) and make ileostomy. Others say we do subtotal colectomy and sparing the rectum which is not involved in this disease, also because the rectum is v. imp. in keeping the continuity of the GI tract)
Another eg. Is patients with ulcerative colitis. These patients are known to have much higher incidence to develop colon cancer more than others. We must treat these patients and follow-up them strictly (usually by colonoscopy and taking biopsies) and if they are proved to have severe dysplasia we offer them to have surgery to prevent colon cancer development.
When female patient, who is screened and found to have high incidence to develop breast cancer, is coming to you and you suggest her to do prophylactic mastectomy. Now there are many problems that both of you must deal with:
1- Cosmetic problems (Removing the whole breast is non-human you can deal with it by doing incision removing the contents of the breast and sparing the skin, and later replace the contents by flaps, synthetic materials…whatever)
2- Psychological problems (esp. if the patient is still young)
3- The most imp. point is that YOU DON”T GARAUNTEE THE RESULTS (there is no 100% removal of the breast tissue (you can’t do it)), but you decrease the risk dramatically.
YOU AS ONCOLOGICAL SURGEON MUST KNOW YOUR DIMENSIONS, LIMITATIONS, ADVANTAGES AND DISADVANTAGES. YOU MUST EXPECT COMPLICATIONS AND KNOW HOW TO DEAL WITH THEM.

Terms that you must know
The modern oncological surgery now go towards the term ADEQUATE SURGERY. In the past they used to remove the whole breast with the underlying muscles, lymph nodes and maybe the ribs in a procedure called Radical mastectomy. There were another terms like simple, total, subtotal, modified radical, but know they perform adequate surgery which can be any level between these terms according to the grade and stage of the tumor. Safety margin also depends on your expectations.

Remember destruction is easy but construction is important. In case of recurrent laryngeal cancer, they must do central neck dissection to remove the central neck compartment, where they remove larynx, pharynx, upper trachea…etc. In the past there was no reconstruction, thus the carotids will remain visible (exposed to environment) and with time they will dry and stiffen and then they will blow out. Now they have the ability to do RECONSTRUCTIVE SURGERY that go hand with hand with destruction.

WIDE LOCAL RESECTION: removing the tumor with a safety margin. Differ from tumor to another.
Eg. MELANOMA IS MAINLY TREATED BY SURGERY
Non invasive superficaial melanoma  1cm safety margin
Invasive nodular melanoma  3-5cm safety margin

In Mid rectum cancer treatment, they used to do abdomino perineal (AP) resection in which they remove the whole colon and anal canal and leaving the patient living with colostomy. Then they found that the most distal point doesn’t descend down more than 1-2cm, so if the tumor is far from the anal canal by 5cm and the anal canal it self is 4cm, so rather than AP they can do RESTORATIVE SURGERY where they can resect the involved part with safety margin and at the same time restoring the continuity of the GI tract.


LOCAL RESECTION:
Eg. Basal cell carcinoma (BCC) in the face. Surgeons prefer to avoid deformities here. So they remove with safety margin 2-3mm, and if it happens that one of the safety margins recur later, surgeons return and do another local resection. This happens firstly due to the site of the cancer, secondly due to the less invasive behavior of BCC where I can have time to keep tissue.

RADICAL LOCAL RESECTION:
Eg. Patients with soft tissue sarcoma in their extremities just above the knee and the knee is spared. Chance of recurrence local without safety margin > local with safety margin > amputation.

Now what do you think is better as adequate surgery, amputation or compartment excision (where we remove the compartment of the extremity containing the tumor)?
The answer is compartment excision, because in amputation we can have tumor cells spreading through the compartment planes and still there is chance of recurrence. But if you remove the whole compartment we can have better results.

EN-BLOCK EXCISION:
When we remove the tumor and the whole lymph nodes drainage
Eg. Inguinal block dissection (inguinal LNs with scrotal melanoma)
Eg. Axillary block dissection (axillary LNs with breast cancer)

LUMPECTOMY as a term it means to remove the lump only. It’s not enough for malignant tumor because it’s done without safety margin. But for a benign tumor like fibroadenoma it will be enough.













Surgery for residual disease:
After Neoadjuvent chemotherapy
After radiotherapy
After inadequate surgery

Done after the response found not to be 100% or there was no response.
Complete response  100% disappeared
Partial response  50%-99% reduce in the size
No response
But note: If the patient receives chemotherapy and the tumor remains stable in size (appear as no response, but actually it’s not), this is an indication to remain on chemotherapy.
NOTE: soft tissue sarcoma is one of the tumors that is highly vascular, we do radiotherapy first to shrink the tumor then we do surgery.
NOTE: in burkitt’s lymphoma where the main line of treatment is chemotherapy, if there was a large mass, in the neck for example, we can remove it by surgery but we must start the chemotherapy as fast as possible because there will be large volume of the tumor cells that are going to be destroyed and the end product of dead cells will make many problems to the patient on the top of them is tumor rising syndrome.
NOTE: In ovarian cancer where the main line of treatment also is chemotherapy. If it’s localized it’s enough to treat with chemotherapy. But if the mass is large extending to the peritoneum and pelvis making multiple metastasis to the liver pancreas…etc, in the past they were think that this is incurable, but now they remove the large masses and leaving the masses less than 2cm to be dealt with by the chemotherapy. SO CYTOREDUCTIVE SURGERY TRANSFORM THE INCURABLE CANCER TO CONTROLLABLE CANCERS.

Surgery for Metastatic Disease
metastases to: lung, brain, liver.
Pulmonary metastases The resection of in patients with soft tissue and bony sarcomas can cure as many as 30% of patients.
Solitary hepatic. In patients with metastases from colorectal cancer, resection can lead to long-term cure in about 25% of patients
The resection for cure of solitary brain metastases should also be considered when the brain is the only site of known metastatic disease. The exact location and functional sequelae of resection making should be considered when this treatment decision.

SURGERY FOR ONCOLOGIC EMERGENCIES
Hemorrhage
Abscesses
Perforation eg. gastrointestinal Perforation of the tract after effective treatment for lymphoma
Eg. Neurological symptoms due to compression of bone metastasis on the spinal cord after breast cancer. Central nervous cancer invading the system represents another surgical emergency that can lead to preservation of function.

GREAT PEOPLE TALK ABOUT… IDEAS
ORDINARY PEOPLE TALK ABOUT… THINGS
SMALL PEOPLE TALK ABOUT… PEOPLE !!

DONE