WCS26 Role Of Surgery For Malignancies Flashcards
Cancer cells
Genetic mutations —> Proliferation —> Angiogenesis —> Vascular invasion —> Metastasis
Surgeon’s role in HCC
- Prevention (Identify at risk group)
- Hepatitis B (trigger of genetic mutation)
—> Prevention: Hep B vaccine
—> **Tumour doubling time = 4-6 months
—> **Surveillance: USG, Serum AFP every 6 months
- Colorectal cancer
—> Colonoscopy / Stool occult blood from 40 (once every 5 years) - Diagnosis
- History + Physical examination
- Lab tests
—> blood tests (including tumour markers)
—> urine / stool / sputum examination
- Radiology / Endoscopy / Laparoscopy / Surgery
- Pathology study
—> cytology
—> biopsy
- Asymptomatic disease: Colorectal, Breast, Liver, Cervical
- Bleeding: GI bleeding, haematuria, haemoptysis
- Obstruction: intestinal obstruction, obstructive jaundice
- Mass effect: palpable mass, pain
- Systemic symptoms: anorexia, weight loss, lethargy, fever - Staging
- TNM staging
- Choice of treatment: Neoadjuvant, Extent of surgery, Adjuvant
- Prognosis (5-year survival)
- Monitoring treatment
- Comparison of results of treatment - Treatment
- Cure (Multidisciplinary)
—> Surgery
—> Endoscopic therapy
—> Radiologic procedures
—> Chemotherapy
—> Radiotherapy
—> Immunotherapy
- Cyto-reductive
- Palliation - Management of associated problems
- Treatment related
- Non-treatment related
Surgical resection
Primary mode of curative treatment
- best chance of cure
- low resection rate
Secondary mode of curative treatment
- after failure of non-operative therapy
Part of multi-modality treatment
- combined with chemotherapy, radiotherapy, immunotherapy
2-stage hepatectomy
ALPPS: Associating Liver Partition and Portal vein Ligation for Staged hepatectomy
Indication
Major liver resection but ***insufficient future liver remnant (future liver remnant FLR <30%) (i.e. resection >= 3 Couinaud segments)
- Ligate right portal vein —> allow blood shunted to left liver —> left liver hypertrophy (in 7 days)
- Remove right liver
Other surgical procedures in cancer
- Open biopsy for histologic diagnosis and staging
- Surgical bypass for obstruction
- Neurolytic therapy for pain relief
- Palliation of other complications e.g. bleeding
- Facilitate other treatment modalities
- insertion of central line for chemotherapy
- insertion of devices for local radiotherapy
- treatment for complications of non-surgical treatments
Non-operative treatment in cancer
- Endoscopic therapy
- Radiologic procedures
- Chemotherapy
- systemic
- regional - Molecular target therapy
- Radiotherapy
- external
- internal (brachytherapy) - Immunotherapy
Radiofrequency ablation (RFA) in HCC
- High frequency alternating current (480 kHz) across uninsulated needle electrode
- Excites electrons to vibrate at high frequency and generate heat to temperature exceeding 60oC
- Ultrasonographic guidance
—> Percutaneous
—> Laparoscopic / Thoracoscopic
—> Open surgery
Transcatheter arterial chemoembolization (TACE)
- Minimally invasive procedure performed in interventional radiology to restrict a tumor’s blood supply
- Small embolic particles coated with chemotherapeutic drugs are injected selectively through a catheter into an artery directly supplying the tumor
- These particles both block the blood supply and induce cytotoxicity, attacking the tumor in several ways
- For ***multi-focal tumour
Stereotactic body radiotherapy (SBRT)
High beam of radiation onto small focal point
- ***reduce collateral damage
- less SE
- Potent dose precision radiotherapy
- Image guidance technique
- Short treatment time
- ***No hospitalisation, no wound, no anaesthesia
Neoadjuvant vs Adjuvant vs Therapy for post-op recurrence
Neoadjuvant (before operation)
- ***Downstage disease (unresectable —> resectable)
- Increase resection rate
- Improve chance of cure
Adjuvant therapy (after operation) - ***Prevent / Delay recurrence
Therapy for post-op recurrence
- Prolong survival
- Palliation
Outcome measures
Cure:
- 5-year disease-free survival
Survival:
- 5-year survival
Palliation:
- QOL
