Rajeev AgarwalSenior Consultant- Surgical Oncology

Cancer : IInd biggest killer among non

communicable diseases.

Overall incidence has not changed in last

fifty years, however, few cancers have

gone up or down.

In US chances of cure for a cancer patient

is creeping up by 1% every year for last

two decades.

Who is a surgical oncologist ? In what way, onco-surgery is

different ? Role of surgery in cancer

cure/care ? Amalgamation of surgery with other

branches of oncology Changing patterns in onco-surgery

Surgical oncologists are clinical scientists with knowledge of and experience in

cancer surgery that come from additional training, limitation of the

scope of general surgical practice, familiarity with the biology and

natural history of cancers, and the role of the other oncologic specialties

in their diagnosis and management.

-Frozen section facility

-Concept of margins-Coordination with radiation & medical oncologist, pathologist, radiologist, reconstructive surgeon & rehabilitation team-Deciding the sequencing of treatment-Radical surgery v/s organ conservation in selected cases

Preventive surgery Diagnostic & staging surgery Curative surgery Metastasectomy & Cytoreductive

surgery Palliative surgery Supportive surgery Reconstructive surgery

1809 Mxdowell Elective abdominal surgery 1867 Lister Introduction of antisepsis 1860-1890 Billroth Gastrectomy,

laryngectomy & oesophagectomy

1880s Kocher Thyroid surgery 1890 Halsted radical mastectomy 1904 young radical prostatectomy 1906 Wertheim radical hysterectomy 1908 Miles Abdominoperineal resection 1933 Graham Pneumonectomy 1935 Whipple Pancreaticoduodenectomy 1958 Fisher NSABP trials

Curative surgery:-all early stage solid tumors, surgery alone

gives a very high cure rate

- Even in early stage, in selected malignancies, in collaboration with C T & R T, one can think of less radical surgery i.e. breast conservation surgery, sphincter preservation in low ca rectum, limb preservation surgery in bony tumors

-In locally advanced disease, preop. C T & R T can facilitate surgery with significant improvement in survival i.e. LABC

Cure remains ellusive for most pts afflicted with metastatic liver or pulmonary disease

There is a paradigm shift for the treatment of liver metastasis

Surgery is evolving rapidly as a part of treatment for metastatic disease

Improved pt selection, better staging, safe hepatic resections & significant advances in systemic therapies

Metastatic disease- ?? Cure Does surgery has a role ?– cure or prolongation Colon cancer :

-Liver met. Metastasectomy may give survival of around 40%- 74%(3yrs), 25%-58%(5 yrs), & 22%- 38%( 10 yrs )

-Synchronous or Metachronous pulmonary met.

-five yr survival 24% - 62%

Neuroendocrine tumor: Carcinoid, insulinoma, gastrinoma,

glucagonoma, somatostatinoma, VIPoma

Role of surgery is well established in selective & symptomatic metastatic disease

5 yr survival in various series 41%- 92%

Evolving but unproven role:- Kidney tumors( some role)-Melanoma ( if R0

Resection)-GIST-G I cancers-Pancreatico- biliary cancers-Uterine & ovarian ca

Peritoneal involvment:-30% pt. of colon ca on presentation

-70% of ovarian ca on presentation-Primary peritoneal ca-Endometrial ca – papillary serous adeno ca

Melanoma: -more for symptomatic relief

Cytoreduction, palliation, debulking & curative metastsectomy – pt selection

Minimize complication & maximize surgical benefit

Coordination of multimodal treatment Acceptable mortality & morbidity

Effective systemic treatment

Most appropriate definition of optimal cyto reduction Maximizing rates of optimal cyto reduction Which pt benefit from cyto reduction Role of intraperitoneal chemotherapy Neoadjuvant chemotherapy Role of secondary cyto reduction Cytoreductive surgery- removal of as much disease as

possible,. Optimal cyto reduction:

-No macroscopic res.disease- 60% five yr survival-macroscopic small volume disease-35% five yr

survival10% increase in cytoreduction, median survival

increased 5.5

To decrease morbidity & to improve quality of life without compromising cure

-Organ preservation:

-Breast conservation surgery-Sphinter saving op. in ca rectum avoiding

colostomy-Voice preserving operations in laryngeal ca-Functional neck dissection

-Reconstruction:-Free flaps & pedicle flaps transfer in head & neck

ca-Custom made prosthesis Leading to limb

preservation in Soft Tissue Sarcoma

Post MRM Post Skin Grafting

Not acceptable as of today

BCT

Lumpectomy & Axillary dissectionSpecimen

BCT - Follow Up

Fibula Free Flap

Laparoscopic surgery for GI malignancies is more acceptable than before: it will probably be accepted as standard of care in colorectal cancer

More & more integration with other modalities & sequencing of treatment

Extended radical surgery may not improve cure rates

but no cure is possible

without adequate locoregional control of

disease

In the world of surgical oncology: Biology is the

king, Selection is the queen, Technical maneuvers

is the prince(Black Cady)

Thank You