Surgery

Question 1

What are the principles of surgical resection of a tumour?

Answer 1

1. adequate margin of resection
2. prevention of tumour spillage
3. minimal manipulation
4. anatomical reconstruction

Question 2

What are the principles of treatment in relation to the TNM grading of tumours?

Answer 2

T1 and T2: Radical surgery
- aim is to cure the disease
T3: Radical surgery +/- combination treatment (radio/chemotherapy)
T4: Radical/palliative surgery + combination treatment
- aim = achieve long disease free survival

Node -ve (N0): usually don’t have any additional treatment
Node +ve (N1-2): combination treatment with curative intent
Node +ve (N3): combination treatment with palliative intent

M1: combination of surgery,. radiotherapy and chemotherapy

Question 3

What are the two different surgical approaches to removing tumours?

Answer 3

1. Minimally invasive surgery (MIS)
   - Hand assisred
   - Laparoscopic
   - Robotic assisted
   - Natural orifice
2. Image guided surgery

Question 4

What are the complications on surgery in cancer?

1. anaesthetic
2. general
3. specific

Answer 4

1. Anaesthetic
   - local trauma: teeth, throat from intubation
   - drug related: reaction/allergy
   - aspiration of oesophageal/gastric contents
   - anaesthetic line complication:
2. arterial ine: bleeding
3. central venous line complication
4. epidural catheter complication
   - lung injury from high pressure ventilation
5. General
   - bleeding
   - infection, UTI, wound infection
   - DVT/PE
   - Scar/adhesion
   - psychological
6. Specific
   a. abdomen:
   - damage liver/spleen/intestine
   - abdominal adhesions and obstruction
   - incisional hernia
   - nutritional deficiency
   b. chest:
   - anastomotic leak
   - broncho-oesophageal fistula
   - thoracic duct injury
   - recurrent laryngeal nerve injury
   bronchial injury
   - pericardial/heart injury
   - rib fractures
   - chest infection/effusion/collection

Question 5

What methods are there for controlling the recurrence of cancer? Give examples of types of cancer where this is important.

Answer 5

1. Adjuvant treatment (chemo/radio –> after surgery), for:
   - Dukes C colon cancer
   - Breast cancer (lymph node +ve)
   - Close resection margins
   - Lympho-vascular invasion
   - Poorly differentiated cancer
2. Neo-adjuvants (before curative surgery –> chemo/rad):
   - improve resectability
   - down staging the disease
   - treat occult metastasis
   - reduce tumour cell spillage intra-op
3. Pre-operative:
   - radiotherapy: rectal cancer
   - chemotherapy: oesophageal cancer

Question 6

Where do each of these cancer usually metastasise to?

1. Lung cancer
2. Colon cancer
3. Prostate cancer
4. Breast cancer

Answer 6

1. Brain or bones
2. Liver
3. Bones
4. Bones, lungs, liver, or brain

Question 7

Why might cancer recur?

Answer 7

• Micro-metastasis
• new primary
• local excision of tumour and lymph node was inadequate
• primary tumour disrupted during operation
• exfoliated cancer cells implanted into:
  1. the wound
  2. tumour bed
  3. anastomosis

Question 8

What is percutaneous radio frequency ablation?

Answer 8

• Insertion of a needly type electrode into tumour with an AC current
• cause ionic agitation, frictional heating

*ideally tumour is surrounded by hepatic parenchyma at least 1cm deep to liver capsule and 2cm away from major structures

Question 9

What is cryoablation?

Answer 9

• ablation of tumour by delivering subfreezing temperatures via penetrating or surface cryoprobes
• be cooled -20 degrees to -30 degrees
• cell death by denaturing cellular protein, rupturing the cell membrane, dehydrating the cell, and causing ischaemic hypoxia

Question 10

What can hepatic artery infusion pump be used for?

Answer 10

To pump into the blood supply the liver allowing chemotherapy medication to be delivered directly into the liver

Question 11

What is chemoembolisation?

Answer 11

Catheter enters through the skin into femoral artery
chemoembolisation mixture is administered to the carcinoma through the catheter
microspheres injected during chemoembolisation ‘lock in’ chemotherapy

Question 12

What is radioembolisation? What type of cancer is it mostly used in?

Answer 12

Enters through a Cather from the groin
placing radio-active beads into the artery that supplies the tumour to cause cell death
radioactive isotop Yttrium 90 is incorporated into the beads to deliver radiation directly to the tumour

*used in metastatic colorectal cancer

Question 13

What are the different types of surgery in oncology?

Answer 13

1. local resection
2. radical resection with en-block resection of lymph nodes
3. supra-radical resections = LN + Organs
4. surgery for metastasis
5. surgical management of complications
6. vascular access surgery