Goal of surgery
remove the malignant tumor
leave margin of adjacent normal tissue
minimal structural, functional, and cosmetic changes
Surgery depends on:
size
location
morbidity - effects on neighboring organs and structures
Onc Surgery uses:
prevention
diagnosis of primary site or metastatic disease
staging
cure with resection of disease (if local, DCIS)
reconstruction
vascular access (port, PIC, triple lumen cath)
control of disease (debulking)
onc emergencies (spinal cord compression)
paliation (reduce suffering, make comfortable)
Surgical diagnosis
tissue Required for new malig. diagnosis (except wilms in peds)
tissue for 1st recurrence for diagnosis
surgical biopsy required for tissue
Surgical diagnosis complications
inadequate tissue
FNA (fine needle aspiration)
Types of biopsies
Fine Needle Aspirate (FNA)
Core Needle Biopsy
FNA
small needle to aspirate cells from lesion
guided by palpation or imaging
used in head and heck cancers
preservation of future radiation field is needed
breast and lymph nodes
Core needle biopsy
larger needle to take cores of tissue
guided by palpation or imaging
yields adequate tissue for histology, little cosmetic problem
Clips may be inserted as landmarks
Treatment plans
may require chemo first if tumor mass is large
Sentinel lymph node biopsy (SLNB)
radioactive isotope 1st one from tumor is biopsied
“sentinel node” - first one next to
Node Mapping
radioactive dye injected into breast at tumor site
scan performed to visualize location of nodes
time of surgery - blue dye injected near tumor
scanner is used to find “hot nodes”
less invasive than tradiational dissection
Excisional Biopsy
completely removes suspicious lesion during surgical procedure (incision, laprosopic, thorascopic)
goal to remove lesion with a margin of normal around
Surgical Cytoreduction
- goal to reduce the overall tumor burden
- ultimate goal to remove all visible tumor and leave behind only nodules as small as 1-2mm
*debulking, removing some mass so chemo can work better
Cryosurgery
good results
brief period of subfreezing, cells dehydrate and metabolically deranged, resulting in apoptosis
does not ensure complete destruction, rarely used for cancer
Thermal surgery
minimizes operative blood loss
cells heated up to 140F, damages membrane and cell dies
Radiofrequency ablation
radiowaves
Laser surgery
aims beams of monochromatic light
focused energy on precise spot
Lung cancer
Wedge resection (part removed) Lobectomy Multiple lobectomies pneumonectomy minimally invasive
Mohs Micrographic surgery
removes in stages, chunks until margins clear
-a skin cancer excisional procedure
major ablative surgery
aggressive strategy
an amputation or a pelvic examination
interventional radiologic procedures
CT guided biopsy
Breast Cancer
multimodality therapy lumpectomy wider excision mastectomy modified Radical mastectomy sentinal lymph node detection and removal newer cell markers guide therapy: ---HER2 (Herceptin) --- ER + (aromatase inhibitor)
Surgical: Colorectal cancer
hemicolectomy low anterior resection abdominal peritoneal resection ant/post exenteration pelvic exenteration transanal excision ostomy - now reversible
Surgical: anorectal
squamous cell - wide local excision
benign anal diasease - hemorrhoids, fissures, anorectal abcess, fissure-in-ano, rectal prolapse
Colorectal cancers surgery
ostomy reversible
Prostate cancer
surgery robotic and nerve sparing
brachytheapy
Gleason’s scale (1-5) - higher score may require surgery
*try to avoid surgeries, affects sexual heath
Gleason Scale
1-5
higher requiring surgery
Urological cancer
Bladder
Kidney
Bladder cancer surgery
cystectomy with ileal conduit
continent reservoirs
segmental cystectomy
Kidney cancer
nephrectomy
partial nephrectomy
Stomach cancer surgery
Radical Gastronomy
-distal, proximal, palliation, gastrojejunostomy, duodenostomy
Bypass disease: Billroth I -II
Esophageal cancer surgery
esophagastrectomy –.> pilmonary complications, leaks, poor nutrition
esophageal obstructions –> balloon, photodynamic therapy, celestin tube
Pancreatic cancer surgery
Whipple (pancreoduodenectomy) –> poor nutrition, poor prognosis + node
distal pancreatectomy
total pancreatectomy –> sugical diabetic, rare
Liver cancer surgery
?
Surgical Approach Esophagectomy
Left transthoracic approach
Three holes Esophagectomy
Ivor-Lewis (belly and right chest)
Transhiatal (no chest incision)
Pancreatic surgical treatment
for: Adenocarcinoma
- –cystic malignancies
Whipple procedure
Total Pancreatectomy
Distal Pancreatectomy
Gynecologic onc surgey
Fertility sparing surgery: --trachelectomy --ovarian resections Radical Hysterectomy Exenteration (total vs anterior)
Soft tissue: Sarcoma
high and low grade site: -soft tissues -retroperitoneal -gastric/SB/LB/gyn Surgery: -adjuvant chemo/XRT -radical amputation -palliation
Soft tissue: melanoma
depends on: -depth of invasion -LN involvement -distant mets. Surgery initial treatment
Head and neck cancer
dissection modified - radical extended with or without free flap
- losing airway
- loss of flap
- necrosis of wound
- major vessel bleed
- infection (respiratory, wound vs URT, wound collection)
Brain tumors
200,000 new tumor cases annually 170,000 mets. brain tumors 30,000 primary 15,00o astrocytic/glial 9,000 GBM
Brain tumor surgical coals
- to achieve image complete resection (ICR) of enhancing tumor to impact prognosis
- reserve incomplete resections for diagnosis or buying time for other therapies to have effect
Neurosurgery
Benign tumors: Meningioma, acoustic neuroma, pituitary tumor
Malignant: Glioblastoma, Astrocytoma, Ependyoma
Mets
Orthopedic cancers
adamantinoma angiosarcoma chondrosarcoma chordoma clear cell classic osteosarcoma ewing's sarcoma fibrosarcoma giant cell tumor
Orthopedic cancer treatments
resection
joint replacement
bone grafts
amputations
Malignant muscle tumors
leomyosarcoma
rhabdomyosarcoma
APRN role with surgical oncology
education support therapy helping adjustment body image issues/scars fatigue eating/absorption - GI ostomy/catheter care