Introduction to

SURGICAL ONCOLOGY

Artanto WahyonoSMF Bedah RSUP Dr Sardjito

ONCOLOGY

• MULTIDISCIPLINARY FIELD OF MEDICINE

• Oncology ORCHESTRA

Oncology Orchestra• General Physician• Radiology Specialist• Pathology Specialist• General Surgeon• Surgical Oncologist• Medical Oncologist• Radiotherapy Oncologist• Oncologic Nursing Specialist• Palliative Medicine• Medical Rehabilitation• Nutrition specialist• Psychologist etc..

3 Factors

• Tumour Factors

• Patients Factors

• Doctor & Hospital Factors

Tumour Factors

• Clinical diagnosis

• Microscopic diagnosis

• Lymphatic metastase

• Hematogenic metastase

Patient Factors

• Physical General Status

• Psychological Status

• Socioeconomic Factors

Doctor & Hospital factors

• Competence of Doctors

• Supporting Facilities

Tumors

• Clinical dx

• Microscopic dx

• Treatment Planning

• Curative treatment or non curative Palliative treatment

• Temporary or definitive

Microscopic

• Tumor type

• Carcinoma, Sarcoma, Blastoma (embryonal), Lymphoreticular

• Histopathological grading

• Extent of the disease to surounding tissue

Microscopic Factors

• Differentiation degree

• Well, moderate, poorly differentiated

• Undifferentiated

• With/without surrounding tumor invasion

• Lymph node mets, is there any invasive lymphnode capsule

• Distant metastase

Grade of malignancy

• Pleomorphic changes of the cell

• Grade of differentiation

• The number of mitosis

• Cells necrosis

Natural History of Cancer

• Dysplasia• Carcinoma (malignancy in situ)• Invasive type/ Infiltrating type• Local extension• Spreading lymphatic or haematogenic

Special: Basal cell carcinomaLocally destruction

TNM staging

• Tumor• Node (Lymph node)• Metastase

To indicate treatment planningTo indicate prognosisTo facilitate evaluation and exchange of

treatment result

SPREAD

• Lymphatic spreading

• Extranodal growth

• Hematogenic spreading

TumorThe extent of primary tumor

• T 0 : no evidence of primary tumour

• Tis : insitu

• T 1-3, 4 (a, b, c) : increasing size, fixed

• T1 microscopic

Lymph nodeThe absence or presence and extent of regional lymph node

metastase

• N 0 : no evidence of regional lymph node involvement

• N 1-3 : increasing involvement numbermobility/ fixationconnection to one another

MetastaseThe absence or presence of distant

metastase

• Distant Metastase

• Hematogenic metastase

• Lymph node metastses beyond the regional lymph node area

Clinical and Pathological

• TxNxMx (Clinical TNM)

• pTxNxMx (Pathological)

• Postoperative microscopic examination of resected tissue

• Example:

preop cT2N0M0 become pT2N2M0

• Implications for treatment planning

The Basic

• No Cancer treatment may start before there is microscopic evidence of a malignant disesase

• Plays a significant role in oncology

Cytology: FNAB/FNAC Exfoliative cytology

Histolgy: Thick needle biopsy/ core needle biopsy, incisional biopsy, excisional biopsy

• Depends on the site and size of tumour

• The pathological information that is needed for treatment planning

• Bite punch biopsy

FNAB FNAC

• Easy, simple, quick

• Hardly any complications

• Disadvantages

• Histologic characteristics like invasive growth are misssing

• A possible false-negative result

• Bone?

• A NEGATIVE RESULT MEANS:

• NO TUMOUR CELLS ARE FOUND IN THE SAMPLE

• THIS DOES NOT MEAN THAT THIS EXCLUDES A MALIGNANT TUMOUR

• THE SAMPLE TOO SMALL

• TAKEN FROM ADJACENT TISSUE

WHEM THERE IS CLINICAL SUSPICION OF MALIGNANT

TUMOUR

• SHOULD BE REPEATED OR ANOTHER BIOPSY METHOD

TUMOUR SPILL IN BIOPSY

• CONTAMINATION OF THE SURROUNDING TISSUES WITH TUMOUR CELLS

• WHICH IN TURN CAN CAUSE RECURRENT TUMOURS

• IN THE IMMEDIATE SURROUNDING OF THE INVASIVE PROCEDURES

• IN CAVITIES

• SPONTANEOUSLY

• IATROGENIC

• FNAC, very rare

• Excisional biopsy extended microscopically wider than was expected clinically

• Incisional biopsy always occur

• Contaminated instrument

• Must be replaced

• From several lesions

• Use clean instrument for each new biopsy

• May be One of the tumour malignant the others are not

Local anesthesia

• Field block• Field wise at a distance around the lesion• NOT TO INFILTRATE UNDER OR IN THE

LESION

• LOCAL NERVE BLOCK OR GENERAL ANESTHESIA

• FNAC no need• Thick or Core biopsy only the skin area

Treatment

• Treatment Planning

• WATCHFUL WAITING

• Curative treatment or non curative Palliative treatment

• Temporary or definitive

• Locoregional treatment

• Systemic treatment

• Tumour type

• Biological behavioour

• Localization and the extent

• The Age and the general conditions

Locoregional Treatment

• Surgery• Radiation Therapy• Whether or not combined with cancer drug

treatment (adjuvant treatment)

Curation can be obtained whom the the tumour is restricted to the primary locoregional area and in the whom locoregional lymph nodes do not show extranodal growth

SYSTEMIC DISEASE

• Neoadjuvant treatment

• Cancer drug treatment

• Combination with Radiation Therapy

• Hormonal therapy

• Immunotherapy

• Spesific Receptors therapy

SURGERYThe most dramatic but not the only……

• Most tumours cancer surgery is usually more extensive than non-oncological surgery

• Tumor characteristics

• Biological behaviour

• Possibilities of radiation therapy, chemotherapy, hormonal therapy, immunotherapy

EVERY ONCOLOGICAL SURGICAL TREATMENT

WITH CURATIVE INTENT IS AIMED TO COMPLETE REMOVAL OF THE TUMOUR AND POSSIBLY PRESENT LYMPH NODE METASTASES

• Excision with small margins

• Excisions with large marins

• Excision en-bloc of the primary tumour and the regional lymph node area

• Lymph node dissection

EXAMINATION OF RESECTION MARGINS

• Enucleation (only in selected cases)

• Tissue destructive methods

• Isolated regional perfusion

• Excision of hematogenic metastases

Follow up

• IN ONCOLOGY FOLLOW UP IS AN IMPORTANT PART OF PATIENT MANAGEMENT

• FOR SEVERAL TUMOURS FOLLOW UP IS ALSO IMPORTANT IN THE EARLY DETECTION OF A SECOND PRIMARY TUMOUR

• IN THE CASE OF LOCAL OR DISTANT RECURRENCES, TREATMENT WITH CURATIVE INTENT CAN STILL BE OFFERED TO SEVERAL PATIENTS

THANK YOU

• TO SERVE AND TO PROTECT

• PROTECT YOURSELF BY PROTECT YOUR PATIENTs

• PRIMUM NON NOCERE

• Learn to communicate with patients and their family

• Learn to teach patients and their family

• Balanced informations