Principles of surgical

management of cancer patient

DR BASHIRU AMINU
MODERATOR:
DR E S GARBA
 outline

Introduction
Establish a diagnosis
-evaluate
-direct mgt properly
Extent of the disease
Management
-adequate
-appropriate
-optimal care
-uncompromised
 Management options

1. early diagnosis & prevention

2. diagnosis & staging
3. surgery as primary therapy
4. surgery combined with other therapies
5. surgery as salvage therapy
6. surgical procedures for specialized care
7. surgery for reconstruction
8. surgery for metastatic disease
9. surgery for palliation
Prevention
future trends
conclusion
 introduction

Surgical mgt of cancer remains a challenge to the

surgeon
It is assoc with high morbidity, & mortality
Illiteracy further compounds difficulty in mgt
Most patients present late
Mgt is expensive to patient & GOVT
Consumes large man hours of the surgical team
 introduction

Key words
Neoplasm-abnormal mass of cells growth of which
exceeds, & uncoordinated with normal tissues,
persists in same excessive manner with removal of
stimuli
Nomenclature-benign or malignant
-transformed neoplastic cells,
stromal tissues
-carcinoma-epithelial
-sarcoma-mesenchymal
Hypertrophy- increased organ growth due to an increase in
size of its constituent cells
Hyperplasia-increased organ growth due to an increase in
cell number
Metaplasia-replacement by cell type not normally present in
an organ
Adjuvant chemotherapy refers to chemotherapy
administered postoperatively to treat presumed micro
metastases.
Neoadjuvant chemotherapy refers to chemotherapy
administered before surgical resection of the primary tumor.
 -mixed tumours,teratoma
-choristoma, harmatoma
Differentiation extent to which tumour cell
resembles normal comparable cells
Lack of differentiation is anaplasia
Displasia refers to disorderly but non neoplastic
growth
Metastasis -tumour implant discontinuous with
primary tumour
How far to place the resection away from the visible
growth –resection margin
Tumour progression step wise acquisition of
malignant attributes
Cure- a normal duration of life without further
evidence of disease
Cure rate assessed by survival rates at different times
after treatment
Molecular basis of cancer
Haematogenous tumour spread
 resuscitation

Depends on presentation of patient

Generally ABC resuscitation
Maintain a patent airway
Pass nasogastric stube
Ensure breathing, give oxygen
Circulation-IV line,cvp
Pass urethral catether
 Establish a diagnosis

History-evaluate pt, properly direct mgt

Complaint
Course of illness
Cause of illness
Complications
Current treatsment received
Age
Risk increases with age except childhood malignancy
Sex
Common in males <10 yrs
Common in females 20-60yrs due to breast, cervix
Males again>60
Site of origin
Breast common women, thyriod commoner in males
Upper git & respiratory tract much more commoner
in males
Complaint
Lump, ulcer, haematuria, weight loss dysphagia,
change in voice, jaundice, change in bowel movt
Course of illness
Cause/aetiology-family hx, alcohol consumption-
gastric cancer & PLCC, smoking- lung cancer
Age at marriage, first child, breast feeding
What rx has PT received-mastectomy with residual
tumour, prostatectomy for BPH with cancer
subsequently, radiotherapy with resulting sarcoma
Other hx also relevant –erectile dysfunction
prospective prostatic procedure, hope of having
more children affecting RX options
Investigations
Confirm your diagnosis
Extent of disease
Optimise the patient
Extent of the disease
Directs line of mgt
Prognosis
outcome
Skin carcinoma
Prostatic cancer
Breast cancer
 management

Adequate
Appropriate
Multimodal
Optimal
Uncompromised-not what is available
 Aim of surgery

The aim of surgical management is either curative or

palliative.
 Those with obvious widespread tumours should not
be treated by a surgical effort to achieve cure;
a lesser procedure may be performed (e.g. bypass of
a gastrointestinal tumour) to relieve distressing
symptoms such as pain or gastrointestinal
obstruction.
Referral for non-surgical treatment or for palliative
care is then appropriate
 Management options

1. early diagnosis & prevention

2. diagnosis & staging
3. surgery as primary therapy
4. surgery combined with other therapies
5. surgery as salvage therapy
6. surgical procedures for specialized care
7. surgery for reconstruction
8. surgery for metastatic disease
9. surgery for palliation
 Management options

Early diagnosis & treatment

Role in virtually all cancer
Development of effective screening methods
Recognition of premalignant, preinvasive conditions
important
Optimal mgt requires undividualization of RX
Sentinel lymph node biopsy in breast ca
Eg breast
-Mammography
-Fnac
-Excisional biopsy
 Diagnosis & staging

Diagnosis of any surgical cancer requires biopsy

Accuracy depends on profficiency of surgeon
Plan or rx influenced by (1)histologic cell type and
histologic grade or differentiation
And (2)anatomic site and stage of DX
Good cooperation btw surgeon, pathologist,
cytologist
Responsibility of surgeon
provide them with
-complete clinical hx
-indication of request
-however special handling should be
understood by all parties
-no room for misinterpretation due to
poor communication
Closed image guided
-Stereotactic
-CT guided
-MRI
Open direct biopsy
-Incisional biopsy
-Excisional
Closed indirect biopsy.
-FNABC
-Tru-cut needle biopsy
-Punch biopsy
-Loop biopsy
-Endoscopic biopsy
 Surgery as primary therapy

Usually rx of choice for preinvasive dx

Local excision is both diagnostic & curative
Surgical margin shld clear only gross & microscopic
DX
Removal of large areas of normal tissue not required
 the surgical margin must be appropriately defined.
 important when evaluating surgical procedures and
outcomes
one of four terms—intralesional, marginal, wide, or
radical.
 intralesional margin is one in which the plane of
surgical dissection is within the tumor.
-This type of procedure is often described as
"debulking"
-it leaves behind gross residual tumor.
- may be appropriate for symptomatic benign
lesions when only alternative is to sacrifice
important anatomical structures
-This also may be appropriate as a palliative
procedure in the setting of metastatic disease.
A marginal margin is when plane of dissection passes
through pseudocapsule.
- adequate to treat most benign lesions and some
low-grade malignancies.
-In high-grade malignancy pseudo capsule often
contains "satellite" lesions.
-may lead to local recurrence if the remaining tumor
cells do not respond to adjuvant chemotherapy or
radiation therapy.
Wide margins are achieved when the plane of dissection
is in normal tissue.
Radical margins are achieved when all the compartments that
contain tumor are removed en bloc.
 For deep soft tissue tumors this involves removing the entire
compartment (or multiple compartments) of any involved
muscles.
For bone tumors, this involves removing the entire bone and
the compartments of any involved muscles.
 Radical operations were once the procedures of choice for
most high-grade neoplasms;
however, with improvements in imaging studies, radical
procedures are now rarely performed because equivalent
oncological results usually can be obtained with wide margins.
For microinvasive lesions wide local excision with a
1-2 cm normal tissue margin may be appropriate
For most neoplasms treated by surgery the technical
aim is to remove the tumour, the organ in which it is
contained and the regional lymph node drainage
(lymphatics and nodes) all in one piece: en-bloc
Surgical attempt at cure involves
-total excision of all tumour-bearing tissues
-together with the associated lymphatic and
venous drainage
-e.g. radical gastrectomy
Invasion of adjacent vital structures
- e.g. invasion of the trachea by an oesophageal
cancer
-may determine the feasibility of removing a
tumour (its operability).
By contrast
-involvement of non-essential structures --does
not prevent resection of a tumour with the invaded
structures
-e.g. a colonic tumour that has invaded the small
bowel
resection margin is decided by the behaviour of the
tumour and its propensity to local invasion.
The opeations are designed to be curative
findings at surgery may indicate need for
addditional RX—adjuvant hterapy
Indicated because of potential for occult spread of dx
based on a surgical finding
-eg positive lymph nodes
-high risk group for recurrence
 Surgery combined with other RX

Surgery is cornerstone in some dx but not curative when used

alone
Chemotherapy before surgery to handle micro metastasis-
neoadjuvant
-risk of excessive bleeding
-eg locally advanced breast ca
Debulking for optimal activity of chemotherapy
Radiotherapy for infraclavicular nodes following
modified mastectomy
Histopathologic findings
 Surgery as salvage therapy

Occassionally curative when other therapy fails

Almost always extensive
Produce limitation of function
Involve radical surgery
 Surgery for metastatic dx

Resection may produce prolonged disease free interval

Resection of intra abdominal tumour may offer
palliation by removal of tumour bulk
May allow chemotherapy or irradiation a better chance
Resection of tumours with poor blood supply
-smaller tumour
-with better supply for chemo & radioRX
-also an increase amount of cell in active
cell cycle
 Surgery for specialized care

Placement of indwelling IV acess

-for chemotherapy
-nutrition
Intracavity therapy with placement of temporary or
semipermanent chest tube or intraperitoneal access
device
 Surgery for reconstruction

May be done at resection of tumour

Or as delayed procedure
-STSG ff local tumour excision
-rotational flaps
-breast reconstruction following radiation of
small breast and residual distortion
 Surgery for palliation

To relieve symptoms

May involve diversion of tract or bypass
Relieve pain by interruption of nerve transmission
To relieve specific dysfunction
-relief of urinary obstruction by uretero
neocystostomy or urinary conduit depending on
location of obstruction
Use of ureteral stent , by cystoscopy or antegrade via
percutaneous nephrostomy
Diverting colostomy or intestinal bypass
Successful palliation improves median survival
 prevention

Pre op
-effective screening methods
-assess pt well
-choose appropriate mgt, neoadjuvant rx
-education of pt
Intra op
-good surgical technique
-multidisciplinary
Post op
-adjuvant therapy
-multimodal
-pt education, follow up
 The future

1. Changes in surgical therapy

 New materials, surgical instruments, devices for
better surgical mgt
 Advances in laparoscopic surgery
 Innovative methods of supportive care eg
computerized anaesthesia, newer generation of
antibiotics, mgt of cancer in elderly
 Safer radiation, chemotherapeutics
2. Changes in indications for surgery & type of
procedure with early diagnosis of tumours
 Less disfigurement, greater preservation of
function
 Larger proportion of pts will present with early dx
for curative surgery
 Less costs
3. Multidisciplinary therapy and primary care
Better integration of sub specialties
Better cooperation
Good outcome
Less costs
conclusion