Cancer Treatment Modalities: Surgical Oncology

What is Cancer? Cancer is a term used for diseases in which abnormal cells divide without control and are able to invade other tissues. Cancer cells can spread to other parts of the body through the blood and lymph systems. Surgical Oncology: A glimpse of the past Ancient History of Surgery for Cancer Treatment 1600 BC 400 BC First recorded description of the surgical treatment of cancer (in Egypt) Hippocratesdescribes the stages of cancer and advises against surgery for terminal disease; he coins the terms carcinoma(crab-leg tumor) and sarcoma (fleshy tumor) Galenidentifies cancer as a systemic disease (primary and metastasis)

200 AD

Historical Eras of Surgery to Treat Cancer Before 1850 1850-1950 1950-1960 960-1980 1980-2000 2000-present Early heroic attempts to resect cancer Development of standard surgical resection techniques Development of extended radical surgical procedures Exploration of combined-modality treatment Multimodality therapy improves organ preservation and survival Surgical practice incorporates improved understanding of the molecular basis of tumor biology

Roles for Surgery Diagnosis of Cancer Treatment of Cancer Resection of primary tumor Cytoreductive surgery Metastatic disease Palliation Reconstruction
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Cancer Treatment Modalities: Surgical Oncology

Oncologic emergencies Prevention of Cancer

SURGERY IN CANCER MANAGEMENT DIAGNOSIS OF CANCER Biopsy An examination of tissue removed from a living body in order to determine the presence or extent of a disease. Origin: 19th century French from Greek bios (life) and opsis (sight) Types of Biopsy Needle Biopsy - Fine Needle - Core Needle Open Surgical Biopsy - Incision Biopsy - Excision Biopsy NEEDLE BIOPSY 1. Fine Needle Aspiration Biopsy A cytologic technique in which cells are aspirated from a tumor using a needle and syringe with the application of negative pressure. Aspirated tissue consists of disaggregated cells rather than intact tissues Other related terms: o Fine needle cytology o Fine needle biopsy o Needle aspiration biopsy o Aspiration biopsy o Aspiration cytology
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Cancer Treatment Modalities: Surgical Oncology

o Needle biopsy Where is it done? o Office or clinic Advantages: o Office procedure o Cheap o Fast o High sensitivity Disadvantages: o Needs experienced cytopathologist o Low specificity o Can not distinguish invasive from in-situ malignancies 2. Core Needle Biopsy Performed with a large cutting needle, usually 14 gauge, deployed into the area of concern by a rapid-fire, spring-loaded, automated instrument. Retrieves a small piece of intact tumor tissue, which allows the pathologist to study the invasive relationship between cancer cells and the microenvironment. Advantages: o Sampled material familiar to most pathologists o Can differentiate invasive from in-situ cancer o No scar Disadvantages: o More expensive than FNAB o Less specificity than excision biopsy OPEN SURGICAL BIOPSY 1. Incision Biopsy
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Cancer Treatment Modalities: Surgical Oncology

Removal of a portion of tumor through an actual incision through the skin. Used for tumors that are too big to be removed in its entirety without doing major surgery Examples: o Portions of tumor taken during endoscopic examinations of the bronchus, esophagus, stomach, duodenum, colon and rectum o Endometrial curettage 2. Excision Biopsy An excision of the entire suspected tumor tissue with little or no margin of surrounding normal tissue is performed 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. Can be both diagnostic and therapeutic When is it done? o Needle biopsy not feasible o Prior biopsy results are non-diagnostic o Prior biopsy results are discordant with clinical findings Where is it done? o Usually in the operating room Other examples: o Polypectomy (during colonoscopy) o Removal of skin lesions o Hemithyroidectomy Advantages: o Allows pathologist to examine the entire lesion o Near 100% diagnostic accuracy

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Cancer Treatment Modalities: Surgical Oncology

o Can distinguish invasive from in-situ cancer o Diagnostic and therapeutic (sometimes) Disadvantages: o Invasive procedure o Scar formation o Most expensive o Needs heavy sedation, even general anesthesia o Done in the operating room Comparisons of different Biopsy Techniques FNA Yes + + + Core biopsy Yes ++ ++ ++ Yes ++ ++ Excision No ++ +++ +++ Yes +++ +

Office procedure Hemorrhage Wide sampling Ease of interpretation Ability to invasion Cost Rapid diagnosis

detect No + +++

HOW WILL YOU BIOPSY NON-PALPABLE LESIONS? Image-guided biopsy for non-palpable lesions of the breast Stereotactic guidance Ultrasound guidance Magnetic resonance imaging guidance Needle localization biopsy A. Stereotactic Guidance Uses the principle of parallax to determine the lesion position in 3-D space
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Cancer Treatment Modalities: Surgical Oncology

Two angled xray views (stereotactic pair) acquired with the beam 15 degrees on either side of the center are used to localize the mammographic lesion A computer algorithm /software is used to calculate the position of the lesion 1. Automated core biopsy guns necessary to ensure accurate sampling -10 samplings

2. Vacuum-assisted biopsy device (Mammotome Stereotactic or ultrasound guidance) once and rotated while in the breast to obtain samples from different areas of the lesion. sample notch and transported tothe collection chamber -assisted breast biopsy system, the probe is positioned at the lesion. It vacuums, cuts, and removes tissue samples, which are passed through the probes hollow chamber into a collection tray. This allows for multiple samples to be collected whole only one incision into the breast is made. Mammographic Needle Localization Biopsy Specimen Mammography

Not all tumors need to be biopsied prior to surgical removal Parotid neoplasms Tumors of the head of the pancreas or periampullary area causing obstructive jaundice Liver tumors Retroperitoneal tumors **Biopsy may be omitted in situations whereby the histopath result will not change the decision to operate and surgically remove a tumor Biopsy is mandatory to establish the presence of malignancy in
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Cancer Treatment Modalities: Surgical Oncology

-cancer treatment (chemotherapy, targeted therapy, etc) or radiation therapy. CANCER STAGING Why is cancer staging needed? To be able to prognosticate To be able to choose the appropriate management Staging Systems Which staging system to use depends on the type of malignancy AJCC/UICC uses TNM and is the most commonly used for almost all solid tumors Other systems for hematologic malignancies Clinical Tumor Signaling TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: Carcinoma in situ Tis Ductal carcinoma in situ Tis Lobular carcinoma in situ Tis Pagets disease of the nipple with no tumor. T1: Tumor < 2.0 cm or less T1mic: Microinvasion < 0.1 cm T1a: Tumor 0.1 cm 0.5 cm T1b: Tumor 0.5 cm 1.0 cm T1c: Tumor 1.0 cm 2.0 cm T2: Tumor 2.0 cm 5.0 cm T3: Tumor > 5.0 cm T4: Tumor of any size with direct extension to chest wall or skin

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Cancer Treatment Modalities: Surgical Oncology

T4a: Extension to chest wall, not including pectoralis muscle T4b: Edema (including peau dorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast T4c: Both T4a and T4b T4d: Inflammatory carcinoma. Clinical Nodal Staging NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis to movable ipsilateral axillary lymph node(s) N2: Metastasis in ipsilateral axillary lymph node(s) fixed or matted, or in clinically apparent ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastasis N3: Metastasis in ipsilateral infraclavicular lymph node(s) with or without axillary lymph node involvement, or in clinically apparent ipsilateral internal mammary lymph node(s) and in the presence of clinically evident axillary lymph node metastasis; or metastasis in ipsilateral supraclavicular lymph node(s) with or without internal axillary or mammary lymph node involvement Pathologic Nodal Staging pNX: Regional lymph nodes cannot be assessed pN0: No regional lymph node metastasis pN1: Metastasis in 1 to 3 axillary lymph nodes pN2: Metastasis in 4 to 9 axillary lymph nodes pN3: Metastasis in 10 or more axillary lymph node Distant metastasis MX: Presence of distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis present Cancer Staging
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Cancer Treatment Modalities: Surgical Oncology

Metastatic work-ups, usually in the form of imaging studies, are done to determine the presence of distant spread. Distant spread is defined by the staging system Usually refers to any area beyond the regional lymph node groups AJCC Stage Groupings for Breast Cancer

Diagnostic Studies for Breast Cancer Patients

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Cancer Treatment Modalities: Surgical Oncology

Breast Cancer 5 Year Survival Rates Stage I 94% Stage IIa 85% Stage IIb 70%

Stage IIIa 52% Stage IIIb 48% Stage IV 18%

TREATMENT OF CANCER 1. process. Removal of primary tumor provideslocal and regional control of the malignant

Local tumor itself with margin of normal tissue Regional draining lymph nodes BREAST CANCER Modified Radical Mastectomy vs. Lumpectomy

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Cancer Treatment Modalities: Surgical Oncology

SENTINEL LYMPH NODE BIOPSY o Used to determine the status of axillary lymph nodes without encountering the morbidities of doing full Axillary Lymph Node Dissection (ALND) o Usually performed before removal of the primary breast tumor o ALND has complication like lymph edema (LE). o To prevent LE, sentimental lymph node is taken out. o Nuclear Dye is used to localized the sentinel lymph node. Wide resection surrounding the normal tissue, regional control is disregarded. Stage III Locally Advanced Breast Cancer

there will be less recurrence and improved survival. surgery there is a chance for an early recurrence. TREATMENT OF CANCER 2. Cytoreductive Surgery In some instances, the extensive local spread of cancer precludes the removal of all gross disease by surgery. The partial surgical resection of bulk disease in the treatment of selected cancers improves the ability of other treatment modalities to control residual gross disease that has not been resected.

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Cancer Treatment Modalities: Surgical Oncology

Burkitt's lymphoma and ovarian cancer 3. Metastatic disease

of metastatic disease that can be resected without major morbidityshould undergo resection of that metastatic cancer 4. Oncologic Emergencies

5. Palliation resection often is required for the relief of pain or functional abnormalities. an improve the quality of life for cancer patients. ocedures to relieve mechanical problems, such as intestinal obstruction, or the removal of masses that are causing severe pain or disfigurement 6. Reconstruction and Rehabilitation ects can substantially improve function and cosmetic appearance en can be restored by surgical approaches. uscle transposition to restore muscular function that has been damaged by previous surgery or radiation therapy

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Cancer Treatment Modalities: Surgical Oncology

Sources: Poston, G., Beauchamp, D., & Ruers, T. (2007). Textbook of Surgical Oncology. India: Replica Press Pvt Ltd. Cancer Staging - National Cancer Institute. (n.d.). Retrieved April 17, 2013, from National Cancer Institute: http://www.cancer.gov/cancertopics/factsheet/detection/staging Langhorne, M., Fulton, J., & Otto, S. (2011). Oncology NUrsing. Elsevier Inc. What Is Cancer? - National Cancer Institute. (n.d.). Retrieved April 18, 2013, from National Cancer Institute: National Cancer Institute What You Need To Know About&#153; Cancer - National Cancer Institute. (n.d.). Retrieved April 16, 2013, from National Cancer Institute: http://www.cancer.gov/cancertopics/wyntk/cancer/page8

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