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Surgical oncology ; introduction • Surgery is the treatment of choice for most localized, solid neoplasms. • Surgery has recognized limits in its application. • Surgery is increasingly combined with other treatment modalities. Role of the Surgical Oncologist • Consultant Special training or skills Tumor board • Educator Cancer conferences Teaching programs • Organizer and Leader Cancer programs Cancer committee Tumor registry Oncology section • Researcher Clinical protocols Roles of Surgeon in Management of Cancer Patients • Prevention • Diagnosis • Definitive treatment • Palliation • Rehabilitation Prevention • Educating patients about carcinogenic hazards • Surgical intervention for the preventable cancer Sugery That can Prevent Cancer • Underlying condition cryptochidism polyposis coli familial colon cancer ulcerative colitis MEN type II, III familial breast cancer familial ovarian cancer • Prophylactic surgery Orchiopexy Colectomy Colectomy Colectomy Thyroidectomy Mastectomy Oophorectomy Role of Surgeon in Management of Cancer Patients • Prevention • Diagnosis • Definitive treatment • Palliation • Rehabilitation Diagnosis of Cancer • Acquisition of tissue for histologic diagnosis • Staging of patients Techniques for Obtaining Tissue • Needle biopsy • Incisional biopsy • Excisional biopsy Needle biopsy ; advantages • Simplest method • Inexpensive • Causes minimal disturbance of the surrounding tissue Needle biopsy ; disadvantages • Danger of implanting tumor cells in a needle tract • Not representative of the total tumor • The needle misses the lesion Needle biopsy ; types • Fine needle aspiration biopsy • Large bore needle biopsy ; Vim Silverman needle Tru cut needle Principles of the performance of all surgical biopsies • Needle tract or scar should be removed as part of subsquent definitive surgical procedure Principles of the performance of all surgical biopsies • Do not contaminate new tissue plane during the biopsy Principles of the performance of all surgical biopsies • Choice of biopsy technique should be selected carefully in order to obtain an adequate tissue sample for the needs of the pathologist Diagnosis of Cancer • Acquisition of tissue for histologic diagnosis • Staging of patients TNM Classification System Describes the anatomic extent of disease based on assessment of three components T Primary tumor size and extent N Regional lymph node involvement M Distant metastasis absent or present TNM Classification System • Primary tumor (T) TX T0 Tis T1,T2 T3,T4 Primary tumor cannot be assessed No evidence of primary tumor Carcinoma in situ Increasing size or local extension Increasing extent of primary tumor TNM Classification System • Regional lymph nodes (N) NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1,N2,N3 Increasing involvement of regional lymph nodes TNM Classification System • Distant metastasis (M) MX Presence of distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis (may be further specified according to size of occurrence) Role of Surgeon in Management of Cancer Patients • • • • • Prevention Diagnosis Treatment Palliation Rehabilitation Considerations in choosing therapy • Disease and results obtained from each type of therapy • Patient’s general conditions and co-existing disease • Patient’s life situation and psychological makeup American Society of Anesthesiologists Physical Status Classification CLASS DESCRIPTION Ⅰ Healthy patient Ⅱ Mild systemic disease, no functional limitation Ⅲ Severe systemic disease, definite functional limitation Ⅳ Sever systemic disease that is a constant threat to life Ⅴ Moribund patient unlikely to survive 24 hours with or without operation From Miller RD: Principles and Practice of Anesthesia, 2nd ed. New York, Churchill Livingstone, 1986, with Permission. Eastern Cooperative Oncology Group Performance Scale and Corresponding ECOG-PS GRADE 0 DESCRIPTION 1 Restricted in physically strenuous activity, but ambulatory and able to carry out work of a light or sedentary nature 80-90 2 Ambulatory and capable of all self-care, but unable to carry out any work activities; up and about more than 50% of waking hours 60-70 3 Capable of only limited self- care; confined to bed of chair 50% or more of waking hours 40-50 4 Completely disabled; cannot carry on any self-totally confined to bed or chair ≤30 Fully active, able to carry on all predisease activities without restriction KARNOFSKY RATING 100 Major Challenges Confronting the Surgical Oncologist I • Accurate identification of patients who can be cured by local treatment alone Major Challenges Confronting the Surgical Oncologist II • Development and selection of local treatments that provide the best balance between local cure and the impact of treatment morbidity on the quality of life Major Challenges Confronting the Surgical Oncologist III • Development and application of adjuvant treatments that can improve the control of local and distant invasive and metastatic disease Cancer surgery ; principles • Enucleation or incomplete excision of tumor mass is never indicated as a therapeutic measure • Prevention of tumor cell implantation during surgery • Prevention of vascular dissemination at surgery Types of cancer operations • Local resection • Radical local resection • Radical resection with en bloc excision of lymphatics • Extensive surgical procedures Adequate margin of Resection • A complete margin of normal tissue around the primary lesion • Frozen sections used to evaluate tissue margins in instances of doubt • Complete removal of involved regional lymph nodes • Resection of involved adjacent organ • En bloc resection of biopsy tracts and tumor sinuses Roles of Surgery in the Treatment of Cancer • Definitive surgical treatment for primary cancer • Surgery for reduce the bulk of residual disease • Surgical resection of metastatic disease with curative intention • Surgery for treatment of oncologic emergencies Surgery for residual disease • In selected cancers, surgical resection of bulk disease may lead to improvement in the ability to control residual gross disease that has not been resected Surgery for metastatic disease • Resection of pulmonary metastasis in patients with soft tissue and bony sarcomas • Resection of pulmonary metastasis in patients with colon cancer • Resection of hepatic metastasis in patients with colorectal cancer Surgery for oncologic emergencies • • • • exsanguinating hemorrhage perforation drainage of abscess impending destruction of vital organs Role of Surgeon in Management of Cancer Patients • Prevention • Diagnosis • Definitive treatment • Palliation • Rehabilitation Surgery for Palliation • To improve the quality of life • Examples ; relief of intestinal obstruction, removal of mass causing pain Role of Surgeon in Management of Cancer Patients • Prevention • Diagnosis • Definitive treatment • Palliation • Rehabilitation THE CANCER SURGEON • AS A CARE PROVIDER Brings surgical skill and compassionate care to patients Leads screening, prevention, and risk assessment programs Facilitates molecular characterization of tumor and surrogate tissues Coordinates mu1tidisciplinary clinical care teams THE CANCER SURGEON • AS A RESEARCHER Facilitates laboratory research Coordinates epidemiologic studies Conducts clinical trials research Develops novel approaches to education THE CANCER SURGEON • AS A TEACHER Ensures excellence in surgical care Leads a multidisciplinary team to implement integrate oncology training Stomach and Duodenum • • • • Anatomy Physiology Operative procedures Gastric disorders peptic ulcer diseases tumors structural disorders inflammatory and infectious diseases traumas Tumors of the Stomach • • • • • • • Adenocarcinoma Lymphoma Stromal tumors Gastric carcinoid Metastasis to the stomach Gastric polyps Miscellaneous Gross Classification of Advanced Gastric Cancer • Borrmann 1형 : 융기형(fungating, polypoid type) • Borrmann 2형 : 궤양-융기형(ulcerofungating type) • Borrmann 3형 : 궤양-침윤형(ulceroinfiltrative type) • Borrmann 4형 : 미만형(diffuse infilrative, linitis plastica type) • Borrmann 5형 : 분류 불능(unclassified type) Gastric Cancer – As a Public Health Problem • Accounts for about 10% of cancers worldwide • Is the 2nd leading cause of cancer death worldwide(after lung cancer) • Has a low 5-year case survival(approx.20%) Gastric Cancer – Epidemiological Trends • Regional variations: - Low incidence in economically developed “western” pop. (+ India) - Risk reductions reported in migrants moving to low Regions Gastric Cancer – Epidemiological Trends • Incidence higher in: - Males (male-to-female ratio approx. 2 - Older age groups (eg, 70+ yrs) - Lower socio-economic groups - Some races (eg, in the USA: Black and Asian pop.) to 1) Gastric Cancer – Epidemiological Trends • Secular reductions in: - Incidence - Mortality (more so) - Case fatality(?) • Diminished secular reductions in incidence/mortality Gastric Cancer incidence in KOREA Seoul(1992-94) Male Female Crude rate 45.7 26.7 ASR 71.4 30.4 Kangwha(1986-92) Male Female 80.2 65.9 34.4 25.0 Cancer of the Gastric CardiaEpidemiological Trends • Higher male-to-female ratio - approx. 4 to 1 c/f 2 to 1 for other gastric cancers • Younger age distribution • Regional variations: - High incidence in economically developed “western” pop.(+ China) - Preponderance in males higher in economically developed “western” pop. (+ China) • Secular increases in incidence Risk Factors associated with gastric cancer • Nutritional factors • Environmental factors • Social factors • Medical factors Nutritional factors • Low intake of fruit & vegetables • High intake of salted food & smoked, cured & picked foods • (?) High intake of high-nitrate & high Starch foods • Low intake of allium products (eg,garlic and onions) and green tea Environmental factors -Lack of refrigeration -Ionizing radiation -(?)Alcohol and tobacco -Helicobacter pylori Medical factors • • • • • • • previous gastric surgery Helicobactor pylori infection gastric polyp achlorhydria and pernicious anemia atrophic gastritis intestinal metaplasia giant hypertrophic gastritis Patterns of Spread • Local extension • Lymphatic metastasis • Peritoneal metastasis • Hematogeneous dissemination Staging • Clinical staging - cTNM • Pathologic staging - pTNM 병기분류의 목적 • 환자의 예후 판정 • 치료계획의 수립 • 치료방법에 따른 결과의 비교 Definition of TNM Primary tumor (T) • • • • • • • TX T0 Tis T1 T2 T3 T4 primary tumor cannot be assessed no evidence of primary tumor carcinoma in situ tumor invades lamina propria or submucosa tumor invades muscularis propria tumor invades adventitia tumor invades adjacent structures T1 T2 T3 T4 Regional lymph nodes (N) • • • • • Nx N0 N1 N2 N3 regional lymph node scannot be assessed no regional lymph node metastasis metastasis in 1 - 6 regional lymph nodes metastasis in 6 - 15 regional lymph nodes metastasis in >15 regional lymph nodes M: Distant Metastasis • MX : 원격전이 유무를 알 수 없음 • M0 : 원격전이 없음 • M1 : 원격전이 있음 P: Peritoneal Metastasis • PX : 복막전이 유무를 알 수 없음 • P0 : 복막전이 없음 • P1 : 복막전이 있음 H: Hepatic Metastasis • HX : 간전이 유무를 알 수 없음 • H0 : 간전이 없음 • H1 : 간전이 있음 Stage IA T1 N0 M0 Stage IB T1 T2 N1M0 N0M0 Stage II T1 T2 T3 N2M0 N1M0 N0M0 Stage IIIA T2 T3 T4 N2M0 N1M0 N0M0 Stage IIIB T3 N2M0 Stage IV T4 N1, N2, N3 M0 T1, T2, T3 N3M0 Any T Any NM1 위암수술의 기본요건 • 근치성 (Complete resection with no residual tumor) • 안전성 • 기능보존성 • Quality of life의 유지 및 향상 Technique of Operation • intraoperative staging • determine the extent resection Basic Information Required for Surgical Decision Making • Epidemiology • Grading and tumor growth pattern • Rules of tumor progression • Location and Lymphatic drainage Location 1995 1999 Lower third 44% 45% Middle third 34% 32% Upper third 10% 12% 2% 3% Entire stomach Local extension • penetration into the gastric wall • through the intramural lymphatics Operative Procedures • Gastric Resection • Combined Resection • Lymph node Dissection Gastric Resections • Total gastrectomy • Distal gastrectomy • Proximal gastrectomy • Wedge resection • Segmental gastrectomy Function preserving procedures • • • • • • Endoscopic mucosal resection Laparoscopic wedge resection Segmental resection Pylorus preserving distal gastrectomy Vagus nerve preserving gastrectomy Proximal gastrectomy Single Jejunum(21) Pouch(13) A limited fundectomy includes limited resection of the upper stomach, limited dissection of lymph nodes along the resected stomach (right cardia, lesser curvature, left cardia, and upper part of greater curvature), and preservation of the vagal nerve. The reconstruction was performed using the single jejunum in 21 patients and the jejunal pouch in 13 patients. Segmental Resection SR. The middle portion of the stomach, including the cancerous lesion, is resected and the pylorus is preserved. Lymph node dissection is limited to nodes near the resected portion of the stomach (DO-1). The omentum is preserved. The hepatic and celiac branches of the vagal nerve are completely preserved. Reconstruction is performed as a gastro-gastrostomy. Combined resections • • • • • • • Spleen Liver Pancreas Transverse colon Gall bladder Adrenal gland Ovary Total gastrectomy with splenectomy and pancreaspreserving dissection of lymph nodes along splenic artery. The splenic artery is cut at the distal site of branching of the dorsal pancreatic artery. Extended operation-left upper abdominal exenteration plus Appleby’s method. The whole stomach, pancreas body and tail, spleen, transverse colon, gallbladder, and left adrenal are removed en bloc. The celiac artery is resected at the root. Lymph node dissection • D0 ; no dissection or incomplete dissection • D1 ; dissection of the N1 group ( MRD ) • D2 ; dissection of N1 and N2 group ( SRD ) • D3 ; dissection of N1, N2, and N3 group ( ERD ) • D4 ; dissection of N1, N2, N3, and N4 group ( SERD ) Controversies in lymph nodes dissection • • • • • • Local or systemic disease Difference of biological characteristics Stage migration phenomenon Patient’ factors Surgeon Randomized prospective study Surgery for Palliation • palliative resection • intestinal bypass • enterostomy Aims of palliative surgery • Relief of symptoms to improve quality of life • prolongation of comfortable survival without producing new symptoms or incurring excessive mortality or morbidity Palliative surgery ; preoperative consideration • Reasonable length of life • cost-benefit equation • balancing symptoms with operative morbidity and postoperative symptoms Survivals in Gastric Cancer 100 % 91.6 79.2 82.0 stage Ⅰ 66.9 stage Ⅱ 50 47.6 36.4 stage Ⅲ 21.9 14.7 0 5 years after operation stage Ⅳ 10 ys CADO,1985 Gastric Cancer Surgery Survival - US vs. Japanese vs. Korea US Stage I II III IV (%) (18.1) (16.2) (35.6) (30.1) Japan 5-yr sur 50 29 13 3 (%) 5-yr sur (45.7) 91 (11.9) 72 (21.8) 44 (20.6) 9 Korea (%) 5-yr sur (28.9) 89 (15.0) 69 (43.3) 38 (13.2) 9 Maruyama et al., World J Surg 11:418-25, 1987 Recent advances in gastric cancer Surgical Treatment for Gastric Cancer size Depth M elevated depressed 0.1-1.0 1.1-2.0 2.1- EMR* EMR* Limited Surg* EMR* EMR/Lim.Surg Limited Surg* SM MP subtotal/total Gx+D2 dissection SS SE-SI s/t Gx+D2/Extended* Adjuvant Chem.* Scirrhous ca. Extended(LUAE)* Adjuvant Chem.* P1H1CY1M1 Chemotherapy* Adjuvant Surg.* * Study Gx:Gastrectomy SCH Limited Surgery for Early Gastric Cancer Early gastric cancer is really cancer which has a potential to grow to advanced cancer. (1)Natural History (2)Treatment 1) EMR 2) Limited Surgery Fundectomy for cancer in the upper stomach Segmental Resection for ca. in the middle SCH Interval from early cancer to advanced cancer 100% 50 Median:37 months 0 0 10 20 30 40 50 60 70 Interval from the time of endoscopic diagnosis of early gastric cancer(months) 80 Survival Curve of Early Cancer 100% 5-year survival rate:64.5% 50 Median:77 months 0 0 10 20 30 40 50 60 70 80 90 100 months Proximal Resection Eligibility: Early Cancer(M) Upper stomach Less than 5 cm longitudinally Out of criteria of EMR Surgical Methods: Proximal Gastrectomy(-1/2) D0-1 lymph node dissection Reconstruction using pouch jejunum Single Jejunum(21) Pouch(13) A limited fundectomy includes limited resection of the upper stomach, limited dissection of lymph nodes along the resected stomach (right cardia, lesser curvature, left cardia, and upper part of greater curvature), and preservation of the vagal nerve. The reconstruction was performed using the single jejunum in 21 patients and the jejunal pouch in 13 patients. Results (Proximal Resection) Surgical Risk blood Loss(cc) Postoperative Complication anastmosis failure pancreas fistula stenosis infection gallstone Prox. Gx Total Gx p 300±193 555±316 < 0.05 1 (2.9) 0 0 0 0 2 (5.0) 6 (15.0) 3 (7.5) 4 (10.0) 3 (7.5) < 0.05 Segmental Resection Eligibility: Early Cancer(M) Middle stomach Less than 5 cm longitudinally Out of criteria of EMR Surgical Methods: Segmental Gastrectomy(-1/2) D0-1 lymph node dissection Gastro-gastro-anastomosis Segmental Resection SR. The middle portion of the stomach, including the cancerous lesion, is resected and the pylorus is preserved. Lymph node dissection is limited to nodes near the resected portion of the stomach (DO-1). The omentum is preserved. The hepatic and celiac branches of the vagal nerve are completely preserved. Reconstruction is performed as a gastro-gastrostomy. Results (Segmental Resection) Segm. Gx 50 Distal Gx 50 239 342 < 0.05 1 7 < 0.05 1 8 < 0.05 p Surgical Risk mean blood loss(cc) Postoperative Complication Gallstone Subtotal/total Gx+D2 dissection (1)Common surgery in Japan safer D2 dissection lower incidence of postoperative complication (2)Survival rate in common operation(D2) is better than that in Western countries (3)Guideline of JGCA has no plan to compare D2 surgery and D1. Pancreas Preserving D2 Dissection (Phase Ⅲ) Eligibility: MP-SE advanced cancer in the upper/middle of the stomach curative operation Surgical Methods: Total Gx+Pancreatosplenectomy(Group A) vs Total Gx+Splenectomy(Group B) Endpoint: 5 year survival rate, Surgical risk Total gastrectomy with splenectomy and pancreaspreserving dissection of lymph nodes along splenic artery. The splenic artery is cut at the distal site of branching of the dorsal pancreatic artery. Results (Total Gx + pancreas preserving dissection) Surgical Risk blood Loss(cc) amylase(drain) Group A Group B 994.0±473.7 904.2±428. 6 16/55(29%) (≧10,000u/L) Postoperative Complication pancreas fistula 8 (14.5) anastmosis failure 2 (3.6) liver dysfunction 2 (3.6) bleeding 1 (1.8) Dissected Nodes dissected nodes 4.6±2.9 nodes with metastasis 4/55(7.3%) 6/55(11%) 5 (9.1) 2 (3.6) 1 (1.8) 4.1±2.6 0 (0) 3/55(5.5%) p < 0.05 Thoracotomy vs Conventional mediastinal node dissection(JCOG) Eligibility: cardia cancer invading to esophagus(< 3cm) curative operation Surgical Methods: Thoracotomy vs Laparotomy Endpoint: 5 year survival rate Under registration of patients Extended Surgery (1)A phase Ⅲ study:Para-aortic nodes dissection (JCOG, ongoing) (2)A phase Ⅲ study: Extended surgery (Left Upper Abdominal Exenteration:LUAE) for scirrhous gastric cancer vs Common surgery for SGC(JCOG, plan) Para-aortic Lymph Node Dissection (JCOG)(phase Ⅲ) Eligibility: SS-SI curative operation Surgical Methods: D2 node dissection vs D2+para-aortic node dissection Endpoint: 5 year survival rate - Under follow-up after registration - Extended Operation for Scirrhous Gastric Cancer(LUAE)(phase Ⅱ) Eligibility: Scirrhous gastric cancer(Type 4 cancer) curative operation Surgical Methods: Total Gx+pancreatosplenectomy vs Left Upper Abdominal Exenteration:LUAE) Endpoint: feasibility, 5 year survival rate Extended operation-left upper abdominal exenteration plus Appleby’s method. The whole stomach, pancreas body and tail, spleen, transverse colon, gallbladder, and left adrenal are removed en bloc. The celiac artery is resected at the root. Mortality and Morbidity Complication LUAE(+Apl) Control (%)(Death) (%) Pancreatic fistula (16) 22(33) (1) 5 Liver dysfunction (16) 9(14) (1) 5 Anastomosis failure (19) 2 (3) 6 Infection 1 (2) - Others 2 (3) 1 (3) Survival Rates of Patients with Scirrhous Gastric Cancer(stageⅢ) 100 % Groups 1988-92 1983-87 1973-77 50 1978-82 0 1 2 3 4 5 6 7 8 9 10 SCH Gastric Cancer Surgery Survival - US vs. Japanese vs. Korea US Stage I II III IV (%) (18.1) (16.2) (35.6) (30.1) Japan 5-yr sur 50 29 13 3 (%) 5-yr sur (45.7) 91 (11.9) 72 (21.8) 44 (20.6) 9 Korea (%) 5-yr sur (28.9) 89 (15.0) 69 (43.3) 38 (13.2) 9 Maruyama et al., World J Surg 11:418-25, 1987 Gastric Cancer Surgical Techniques 4 Randomized D1 vs. D2 Studies Hong Kong N.S. South Africa N.S. U.K. N.S. Holland N.S. Gastric Cancer Adjuvant Chemotherapy Individual Studies and Meta-analyses No significant benefit Gastric Cancer Sites of Failure Local Regional (Total) 87% Distant (Only) 25% Local/Regional (Only) 53% Adapted from Gunderson et al. Subtotal/total Gx+D2 dissection Studies (1)A phase Ⅲ study:Total Gastrectomy + pancreato-splenectomy vs Total gastrectomy + splenectomy(Furukawa, published) (2)A phase Ⅲ study:Total gastrectomy + splenectomy vs spleen preserving total gastrectomy (JCOG plan) (3)A phase Ⅲ study:Thoracotomy vs conventional mediastinal dissection(JCOG ongoing)