INTRODUCTION

Diagnostics and treatment of malignant tumours is a significant part of the current problems and challenges of the modern medicine, not just in Czech Republic but worldwide. This is largely given by its widespread in amongst population where oncological diseases represent approximately, from one third to one half, of causes of death nowadays.

Surgical oncology – “oncosurgery” is a surgical subspecialisation dealing with the diagnostics and treatment of solid tumours and at the same time one of the main modalities of complex oncological therapy. Surgical methods in the treatment of malignant tumours have a long-standing traditions and have been mentioned in Egyptian writings early as 1700BC. Surgical oncology is a dynamic specialty with constant advancement depending on the development of new operative techniques and expanding knowledge about malignant diseases.

According to radicality of the performed surgical procedure we divide the surgeries into curative and palliative. In the case of curative procedure, the patient is fully cured. In contrast with palliative procedures in which the aim is to provide the best possible quality of life to patients with advanced stages of cancer.

Surgical removal of the tumour remains in the majority of cases the only hope for cure or ensures longer survival of the patient, especially in chemo- and radio-resistant tumours (e.g. some types of sarcomas). At the same time, it is a relatively inexpensive treatment compared to other fields dealing with the diagnosis and treatment of cancer. The more frequent detection of the earliest stages of cancer due to well-developed screening programmes makes the curative role of surgery in cancer therapy all the more important. 

Similar to other medical disciplines and oncology in particular, surgical care, on one hand, operates within certain national or international standards. On the other hand, an individual approach and adaptation of treatment methods to the characteristics and extent of the cancer and the overall health of the patient is required. We are talking about tailor-made medicine or personalised medicine. It is the matching of all treatment procedures to the optimal intensity and extent of care for a given patient.

The multidisciplinary approach is crucial in diagnostics and therapy of oncological diseases (in form of specialised so called multidisciplinary “indication committees”). These committees are composed of medical professionals from different medical fields (oncology, surgery, gastroenterology, radiology, etc.) that all cooperate in determining the correct diagnosis and setting the right treatment algorithm. Such committees classify the disease, evaluate the staging of the disease and based on the findings they recommend diagnostic and therapeutic modalities including their exact algorithm.

The current trend of modern surgery is miniinvasive surgical approach, the delicate handling of the tissues, shorter wounds, significantly decreases preoperatively stress and post-operative recovery period. The emphasis still remains on maintaining the rules of oncosurgery especially sufficient radicality (removal of all the cancerous tissue, even the microscopic particles of tumorous lesion including sufficient number of lymphatic nodes is technically possible). The aim is minimal possible manipulation with the tumour itself as well as with the tissue or organ affected, without damaging the tumour capsule this is to minimise the risk of formation of implantation metastases and assure the resection line is into the healthy tissue. Oftentimes the resection line is being sent perioperatively for histological cryocut examination, that will tell the surgeon whether the resection is radical enough (the result takes approximately 20-30 minutes).

The radicality of the surgical procedure is annotated in histopathological terminology with the letter “R” and further specified by numbers 0 to 2. An “R0” resection stands for a resection line without any residual tumorous cells. We talk about an “R1” resection f there is microscopic residuum of tumorous tissue and and “R2 resection” if a macroscopic tumorous residuum is apparent.

Without the “R parameter” we are not reliably able to decide the next treatment plan. It determines whether the follow up treatment regime to be chosen will be adjuvant or palliative. In terms of prognosis this signifies whether a local recurrence or dissemination is likely and with that the closely connected timing of follow up examinations.

During the surgical procedure it is crucial that the lead surgeon has excellent special awareness of the surgical field. An integral part of the procedure is labelling the critical portions of the resected tissue/organ as well as the critical areas directly in situ. The most frequently used material to mark these areas are radio-opaque clips that can also be used for orientation in the event of re-operation as well as for adjuvant radiotherapy.

Therefore for reliable radicality of surgical procedure a cooperation of both the surgeon and the pathologist is necessary.

Tumour (tumour, neoplasm, carcinoma, blastoma, neoplasm)

A dinase arising from the body's  own tissue. It is derived from a single cell after a series of genetic ganges caused by mutations that lead to genetic instability. The newly formed abnormal tissue has no physiological functions and its grow this independent of the organism's environment. The cell loses its precise shape and boundaries, does not respond to growth-inhibitory signals, and acquires the ability to divide uncontrollably. The resulting mass not only compresses and damages healthy tissue in its neighbourhood, but can further cross organ barriers and metastasize, which means that it colonizes distant tissues unlike a healthy cell, which has a definedshape and structure, and thrives among the ordered surrounding cells.

Almost all tissues in the body can succumb to this disease. About 30 trillion cells in a normal healthy organism coexist in a komplex inter connectedbundle and regulace each other's behaviour, including proliferation (division). This cooperation of cells ensures that each tissue of the body maintains its appropriate size and architecture. In the process of DNA replication and division, there is a constant threat of mutations and random ganges that can disrupt this regulatory cycle. Tumors have been shown to arise from a common cell, which has usually been in place for decades prior to the formation of a visible tumor. Malignant transformation (conversion) of the cell occurs throught heac cumulation of mutations in specific classes of genes. There are two classes of genes that together make up only a small part of the total genetic make-up, but play a major role in initiating the tumour formation process. In thein normal configuration, Theky control the life cycle of the cell, i.e. the semence of events in which the cell enlarges and divides.

Proto-oncogenes promote this growth, where as tumour suppressor genes inhibitit. If mutated or activated, proto-oncogenes become carcinogenic on cogenes that lead to excessive proliferation. The mutation usually causes the proto-oncogene to provide too much growth-stimulating protein or an over active form of it. Conversely, tumor suppressor genes contribute to can cerif they are inactivated by mutation. For cancer to develop, mutations must occur in multiple growth-controlling genes.

In a normal cell, the balance of stimulatory and inhibitory sinals is carefully regulated because it is related to cell cycle regulation, which is critical for cell proliferation and differentiation. In the tumor cell, the organization of the cell cycle is disrupted due to changes in signaling pathways.

The cell is also equipped with feedback mechanisms that can counteract abnormal changes in the cell division process. These include, for example, apoptosis, the ability of a cell to commit "suicide" undercertain conditions if it sessential components are disrupted or if its control system is deregulated. For example, chromosomal DNA damage acts in thisway. Specific genes such as p53 or bcl-2 are also involved in this process. Mutations in these genes then cause apoptosis disorders. It has been found that the inability to apoptosis contributes to the development of tumours and thein resistance to therapy. The second defence mechanism against continuous proliferation is a built-in cellular mechanism that counts and limits the total number of cell divisions, the cell ages and perishes. The molecular tools of this counting are segments of DNA at the ens of chromosomes called telomeres. These shorten with each division, and hen they reach a critical length, senescence and cell death occur. If this addition system is working properly in a tumour cell, its excessive proliferation is interrupted efore the tumour is too large. However, by activating the gene that encodesthe enzyme telomerase, whichis not active in most normal cells but functions in tumour cells, telomeric segments are restored and this allows the cell to proliferace indefinitely, i.e. become immortalised.

It usually takes decades for a pre carcinogenic population to accumulate enough mutations for malignantgrowth. In some individuals, however, this time is greatly reduced. This is explained by the inheritance of certain cancer-causinggenes. If the parental germ cell contains a mutation, the mutation is present in all cells of the body in the offspring and the probability of developing a tumour is high.

Metastases are secondary foci of a tumour made up of cells that have separand from the primary tumour and have spread to other tissues where they continue to grow.

A condition without metastases or only regional nodes are metastatically affected, as opposed to generalized disease, is assessed as localized disease.

The tumor can sprej through the body via the lymphatic system, establishing lymphatic metastases first in locoregional and then in distant locations, through the blood stream, or forming implantation metastases, spreading through natural cavities (e.g. pleura, puncture biopsy duct...). According to the localization, metastases can be dividend into visceral metastases, where the deposits are in parenchymal organs (liver, lung, brain,etc.), deposits in other localizations are collectively referred to as non-visceral, bone metastases, are more common in some tumors (breast cancer, prostate cancer). Bone foci can be osteolytic (bone dissolves) or osteoplastic (bone thickens) and soft tissue metastases e.g. in lymphnodes, skin, rallye i. g. in muscle etc.

According to the time of manifestation, they are dividend in to synchronous (they are detected at thesametime as the diagnosis of the primary tumour) and metachronous (they are detected in a porter or longer period of time (evens ever al years) after the diagnosis of the primary tumour). A solitary metastases is defined as a single metastatic lesion in the whole body (not a single lesion in one organ when metastases occur in other locations, which is sometimes in correctly used). Micrometast ases are small foci that can not be detected clinically (e.g. by CT scan).

Types of oncosurgical interventions

Oncological operability (resectibility) of a tumour is given by the possibility of removal of the entire tumour without severely endangering the functions of the surrounding organs.

1.    PROPHYLACTIC – or preventive surgery is indicated only very rarely after careful consideration. An example would be an orchidopexy in cryptorchism or a bilateral mastectomy in patients with a BRCA mutation. Usually it is a resection of a whole organ predisposed for cancer development based on an existing genetic mutation in such a patient.

2.      DIAGNOSTIC – the aim of this procedure is to obtain a tissue sample for histopathological examination and subsequent diagnosis determination. Also, it could be used to explore the area affected by tumorous disease.

3.    CURATIVE – or therapeutic is such a surgery where there is a complete resection of the malignant infiltration, including the removal of a sufficient number of draining lymph nodes and all known metastases. It is only possible for localized anterior or "in situ" tumours. We can talk about an R0 resection optimally with sparing the healthy tissue

 4.    PALLIATIVE- aims to ensure the best possible quality of life for the patient. During surgery, the tumour is not completely removed, i.e. it is not possible to radically resect it. We can either opt for decreasing the tumour mass and thus increase the effectiveness of other treatment modalities (debulking), or we can aim to resolve problems or complications arising from the tumour compressing neighbouring structures, such as restoration of passage through the gastrointestinal tract “Surgery, stoma - intestinal outlet), or surgical treatment of pain.

 5.    SENTINEL LYMPH NODE RESECTION - these are the node(s) that are most likely to be the first to be affected by metastatic spread. They are marked using an indicator (dye, radiopharmaceutical, magnetic particle…), which is applied to the tumour and then detected in the lymph nodes around the tumour. In case of negativity, it is not necessary to perform a radical lymphadenectomy (i.e.the removal of all descending nodes)

 6.    METASTASECTOMY – is the surgery of distant foci of primary cancerous lesion. The indication for surgery is strictly individual and depends on the type of primary lesion, number of metastases, their location, time of diagnosis of the primary tumor, the overall condition of the patient… indication for surgery must always be assessed by a multidisciplinary team

7.    - an inoperable condition is such in which the patient cannot be operated on for some reason either oncological (extent of the cancer, its location, oncological generalization) or internal (comorbidities)

According to the scope, operations can be dividend into:

- Excision, polypectomy and low performance in CA in situ and pre cancerous lesions

- Partial and total resectionoforgans

- Exenteration - remov al of multiple organs

- Peritonectomy (remov al of the peritoneum)

- HIPEC (Hyperthermic Intraperitoneal chemotherapy)

Peritonectomy and hyper thermic intra peritoneal chemotherapy (HIPEC)

In the first part of the operation, the surgeon first removes all visible and remov able primary tumours or metastases. In case of the parietal and visceral peritoneum with omentectomy. In case thet heorgansoftheabdominalcavity are affected, the procedure is extended by thein resection (colectomy, splenectomy, gastrectomy, hysteradnexectomy...). The second part of the procedure follows there section phase, in the form of lavage of the abdominal cavity with a cytostatic solution heated to a temperature of 42-43 °C. The heated cytostatic has a higher tumouricidal effect. Lavage can be performed with the peritoneal cavity open or after closure of the abdominal cavity by means of inflow and outflow drains.

Indications for HIPEC include metastatic mucinous tumors of the appendix, peritoneal mesothelioma, and selected patiens with locoregionally advanced colorectal cancer, gastric tumor, or tumors with malignant ascites.

Surgical approach options:

Minimallyinvasive (surgery using minimaxy invasive instrumentation and camera) - endoscopy, laparoscopy, thoracoscopy, robotic surgery).

Classical surgery (open approach, using conventional instruments, direct view of the surgeon) - thoracotomy, laparotomy, amputation.

CLASSIFICATION AND STAGING of TUMOURS

The basis for establishing a correct diagnosis is histological or cytological examination. Without pathological verification, a diagnosis can be made exceptionally. Tumours are classified according to a number of criteria, e.g. biological behaviour (benign/malignant), degrese of differentiation (grade), extent of tumour (stage).

The International Classification of Tumours (ICT) adopted by the World Health Organisation (WHO) has been established using an alpha numeric systém comprising one letter and two digits.

The codes C00-C97 are for malignit tumours, D00-D36 for neoplasms in situ, D37-D48 for tumours of uncertain origin and behaviour

Typing is the microscopic determinativ of the type of tumour. In terms of biological behaviour, they are dividend into two forms, namely benign tumours - benign, thein behaviour is biologically favourable, and malignit tumours - malignant, thein behaviour is biologically unfavourable. However, there are also semi-malignant tumours, border-line tumours, which are tumours of uncertain biological behaviour, such as pre-malignancy. Precanceris a condition that is not a tumour but has a higher risk of turning into a malignit tumour. Topically malignant tumours are tumours that are benign in behaviour, but grow in locations where thein expansit threatens the life of the patient; these are typically intra cranial tumours.

Some benign tumours can develop in to malignant tumours over time, e.g. intestinal polyps are site sat risk of developing intestinal cancer, while other benign tumours have the same risk of becoming malignant as healthy tissue, e.g. uterine leiomyomas. Finally, many malignant tumours can arise in healthy tissue. Therefore, itis certainly not possible to say that a benign tumour is a precursor of a malignant tumour, although this is sometimes the case.

Classification according to the extent of the tumour (Staging)

Staging is the determinativ of the extent of the tumour. A number of systems are used for staging. The most common is the TNM classification system, which assesses three components of disease extent (T, N, M) and is published by the International Union Against Cancer (UICC).

According to the time of diagnosis, TNM is dividend into

·         cTNM - pre-treatment, itisbased on clinical examination, imaging methods, findings are obtained before treatment

·         pTNM - post-treatment, pathological classification, for its determination it is necessary to remove the primary tumor and locoregional nodes or biopsy.

·         yTNM – post therapeutic classification

·         rTNM – recurrence classification

T (tumour; indicatestumoursize)

·         Tx – size can not be determined

·         T0 - no evidence of primary tumour

·         T1-4 – increasing size of primary tumor

·         Tis - carcinoma in situ

N (nodus; indicates if regional lymphnodes are affected)

·         Nx – can not be determined

·         N0 – regional lymphnodes are not affected

·         N1 - 3 extent ofregional lymph node involvement

M (metastasis; tellsif distant metastases have been established)

·         Mx – can not bedetermined

·         M0 – no metastases present

·         M1 - metastases are present, may be accompanied by the abbreviation of the organ in which they are present

In the final stage, 5 stages with different prognosis are created:

·         St.0 - carcinoma in situ; no metastases

·         St.1, 2 – localised disease, no metastases

·         St.3 – locally advanced disease

·         St.4 – distant metastases at any extent of the primary tumor; generalized disease

Classification of residual tumors after treatment:

·         R0 – no tumour

·         R1 – microscopic residue

·         R2 – macroscopic residual

Other staging systems to mention are:

·         Dukes system (I-III): used for staging colorectal cancer.

·         FIGO system (International Federation of Gynecology and Obstetrics) (I-IV): used for cervical cancer staging.

·         Clark and Breslow classification: used for staging malignant melanoma and other...

Rating: Rating is a collective term for determining the expression of important proteins and receptors in cancer cells. For example, the following markers are determined by

·         immunohistochemistry:Ki-67, p53.

·         hormone receptors: estrogen and progesterone receptors (breast cancer), androgen receptors (prostate cancer)

·         receptors relevant for therapy: HER-2/neu (breast cancer)

Other important classifications include the Patient Performance Classification

Performace status (PS) is an assessment of the patient's overall condition/physical performance status. It is an aid in deciding the most appropriate treatment. For example, there i bursement of certain drugs by health instance companies is conditional on the corresponding PS.

In practice, three scales are used

·         Karnofsky Performance Status (KPS) indicates the percentage of performance from 0 to 100 = fully active

·         ECOG* performance status (ECOG PS) gives a score on a scale of 0 = fully active to 5

·         WHO** performance status (WHO PS) gives a score on a scale of 0 = fully active to 5, similar to ECOG PS

Karnofsky PS

·         100 Capable of normal activities, no special care required. Normal, no difficulties, no signs of illness

·         90 Capable of normal activities, mild signs or symptoms of illness

·         80 Normal activity with increased effort, signs or symptoms of illness.

·         70 Unable to work, able to live normally at home and take care of most personal items, assistance of varying degrees needed. Caring for self, unable to engage in normal activities or work

·         60 Can take care of most of own needs, needs occasional assistance

·         50 Significant assistance required, frequent medical care

·         40 Unable to care for self Requires institutional care or hospitalization, illness may arsen rapidly.

·         Incapacitated, specialized care and assistance required

·         30 Severely incapacitated, hospitalization indicated, death not imminent

·         20 Very ill, hospitalisation required, active supportive care necessary

·         10 Dying

·         0 Dead

ECOG PS (top rows in table) WHO PS (bottomrows in table)

·         0 Fully active, capaje of all normal activities without limitations

·         Fully active, more or less to the same extent as before illness

·         1 Restrictions on physically demanding activities, ambulatory, able to do lighter work e.g. house work, office work

·         Unable to do heavy physical work but able to do any thing else

·         2 Ambulatory, able to care for self but unable to do any work, out of bed more than 50 % of the day.

·         Out of bed more than half of the day, able to care for self, unable to work

·         3 Capable of limited self-care, bed ridden more than 50 % of the day

·         In bed or chair more than half of the day, assistance required to care for self

·         4 Totally incapacitated, unable to care for self, confined to bed or chair

·         Bed ridden or chair-bound all the time, signifiant need for assistance

·         5 Dead

Epidemiology of tumours

Epidemiology is the branch of science that studies the incidence and causes of disease in a population. Cancer epidemiology assesse show common canceris in a population and how many people die from it. It is also concerned with fading causal links between suspected risk factors and cancer.

In the Czech Republic, the national source of information on cancer epidemiology is the National Cancer Registry (NCR) and the Letter of Examination of the Deceased (LODD) database.

The incidence rate indicates the number of newly diagnosed cancers in the population of interest during the period under study

·         Cancer mortality –the number of patiens who died of cancer during the reference period in the population of interest, the number who died of cancer out of the total.

·         Cancer mortality – number of patiens who died; indicates the number of patiens who died during the reference period in the population of cancer patients (number of deaths from cancer out of the number of cancer patients).

·         Cancer prevalence –number of patiens alive; indicates the number of patiens living with cancer.

·         Lifetime risk (lifetime risk of cancer) - the probability that a person will develop a particular cancer in his/her lifetime; depends on risk factors (smoking, hereditary cancer mutations, environment...)

·         Population survival - used to assess the outcome and quality of medical care, or may reflect improving diagnosis and detection of less advanced disease. Itis most often interpreted as 5-year survival.

National Cancer Registry (NCR)

Registers oncological diseases, but also periodically evaluates their evolution in the population. Its data are the basis for designing and evaluating preventive health programmes, including screening, and for estimating the neceséry financial cosi of providing cancer care. Data from the NOR are publicly available on the website www.svod.cz. A summary and commentary on the NOR data is provided by the publication „Tumours“. 

Cancer Epidemiology in the Czech Republic

In 2013-2017, 86 thousand malignant neoplasms were diagnosed annually in the Czech Republic. The most common malignancy diagnosed was non-melanoma skin cancer. The mortality rate of cancer was 257 persons per 100,000 population. Malignancies are the second most common cause of death in both sexes. In the Czech Republic, the incidence of cancer has been risik for a long time, the mortality rate is stationary, but after correction for population ageing it is slightly decreasing.

The most common cancers in men in the Czech Republic are:

·         Prostate cancer (139.6 per 100,000 men)

·         Colorectal cancer (90 per 100,000 men)

·         Cancers of the trachea, bronchus and lungs (84.5 per 100,000 men)

Compared to the global incidence of these cancers, Czech men rank 40th in prostate cancer incidence (1st place USA), 1st in colorectal cancer incidence and 9th in bronchial, bronchial and lung cancer incidence (1st place Hungary).

The most common cancers in women in the Czech Republic are:

·         Breast cancer (134.8 per 100,000 women)

·         Colorectal cancer (59.1 per 100,000 women)

·         Cancer of the trachea, bronchus and lung (41 per 100,000 women)

Compared to the global incidence of these cancers, Czech women rank 30th in the incidence of breast cancer (1st place USA), 9th in the incidence of colorectal cancer (1st place New Zealand), and 25th in the incidence of trachea, bronchus and lung cancer (1st place USA).

For these most common diagnoses, there has been a stabilisation in mortality but an increase in prevalence in recent years. The exception is cancer of the trachea, bronchus and lung, whose high mortality rate reduces the prevalence value even at high incidence. Interestingly, the incidence of bronchial, bronchial and lung cancer in men in the Czech Republic has been declining in recent years, while in womenit has been rising. In addition to the above-mentioned cancers, the incidence of pancreatic cancer, stomach cancer and ovarian cancer in women is increasing in the Czech Republic.

Tumour markers and liquid biopsy

Tumour markers (synonym oncomarkers) are chemical substances present in a tumour or produced by a tumouror host in response to the presence of a tumour. These substances are present in much lower concentrations or not at all in a healthy individual. The concentration of an oncomarker in plasma or body fluids depends on the size of the tumour, the intensity of secretion of the tumour marker by the cells and the metabolit degradation of the marker molecules.

For the diagnosis of cancer, the determination of most markers has low specificity and sensitivity, and they are not indicated for screening of the general population. An exception is the determination of PSA (prostate specific antigen). Monitoring the level of oncomarkers is an auxiliary method of monitoring the development of the disease during and after treatment.

The main pitfalls in the determination and evaluation of cancer markers are that their elevated levels maybe due to a benign cause, they are not elevated in every individual with a given type of cancer, they are rarely detectable at an early stage of the disease, and they are often tumor nonspecific.

A new method of personalised oncology is the continuous monitoring of genetic changes in tumour cells by liquid biopsy (circulating tumour cells and free DNA). 

Circulating tumor cells, or CTCs, are cancer cells released from a primary tumor or metastasis in to the blood stream. This makes them part of the hematogenous dissemination process. The tumour cells can then settle in various organs and initiate metastasis.  CTCs are routinely isolated from peripheral blood (non-clotting) using various separation methods. The advantage of cell size-based separation is that the cells are isolated alive and can be cultured in vitro for further cellular and molecular analysis. Based on standardized fluorescent staining, cytomorphological analysis can then be performed and then umber of CTCs present in the blood volume examined can be determined. If multiplesamples can be compared, it is possible to define whether the disease is progressive or regressive. The first sample is taken before the start of therapy, the next one during or after the end of therapy. Viability of isolated CTCs is also a pre requisite for molecular analysis - e.g. gene expression analysis (RNA isolation from living cells). Gene expression provides information on both tumour-associated genes and chemoresistance-associated genes. The informatik can then be used to optimise the treatment of individual patients. Similarly, it is then possible to test DNA and create a personalized mutation profile for patients based on sequencing analysis.

The clinical implementation of CTC testingis not yet officially supported by the international societies (ASCO, ESMO), but methods for CTC analysis are continuously improving and can the refore be expected to beused clinically in the kontext of personalising cancer treatment. An undeniable advantage of CTC testing is that compared to tumour biopsy, blood sampling is a relatively non-invasive method.

Cancer screening

Their aimis to detect cancers early and to diagnose pre-cancerous conditions if necessary. The screening technice should be relatively inexpensive, revealing early stage disease followed by effective treatment.

Currently, there are screening programs for colorectal cancer in the Czech Republic (tesk for occult bleeding in stool once a year at the age of 50. - 54 years of age, if positive, colonoscopy, if negative, another test in 10 years is sufficient), otherwise at the age of 55 screening colonoscopy), breast cancer (mammography of the breast from the age of 45 years without upper limit, once every two years) and cervical cancer (as part of regular gynecological examinations at the age of 15 years once a year.

Others may include prostate cancer screening (PSA), Low dose CT of the lungs in heavy smokers, AFP determination in patiens with liver cirrhosis or HBV and HCV. 

Pre-operative and peri-operative preparation is an inseparable part, not only of a successful surgery, but also of the post-operative phase and the reconvalescence.  Patients with an oncological diagnosis have an overall higher risk of post-operative morbidity and mortality than the non-oncological patients. Patient with tumours have also a higher risk of thromboembolism, cytopenia and complicated healing. The reason behind these complications being malnutrition, immune system disorders and mineral disbalances.

Special techniques and indications in oncosurgery

Peritonectomy and hyperthermic intraperitoneal chemotherapy (HIPEC)

In the first part of the operation, the surgeon first removes all visible and removable primary tumors or metastases in the parietal and visceral peritoneum with omentectomy; if the organs of the abdominal cavity are affected, the procedure is extended to their resection (colectomy, splenectomy, gastrectomy, hyster-adnexectomy...). The second part of the procedure follows for the resection phase, in the form of lavage of the abdominal cavitywith a cytostatic solution heated to a temperature of 42-43 °C. The heated cytostatic has a higher tumouricidal effect. Lavage can be performed with the peritoneal cavity open or after closure of the abdominal cavity by means of inflow and outflow drains.

Indications for HIPEC include metastatic mucinous tumors of the appendix, peritoneal mesothelioma, and selected patients with loco-regionally advanced colorectal cancer, gastric tumor, or tumors with malignant ascites.

In Conclusion:

The goal of surgical treatment of solid tumors is not only the removal of the primary tumor and its accessible and resectable metastases, but also the overall successful recovery of the patient after surgery. The fulfilment of this goal depends on the extent of the tumour, its anatomical context and, in particular, the surgical technique and skill of the surgeon.

Experienced specialists from various medical specialties participate in the diagnosis and treatment within multidisciplinary committees with an individual approach to each patient within the framework of personalised medicine.

A trend in modern surgery is the so-called minimally invasive, or robotic, surgical procedure.

Sources:

Cancer, Introduction and Basic Concepts | Genotoxicity and Carcinogenesis | Facultyof Science, Masaryk University (muni.cz) https://is.muni.cz/do/rect/el/estud/prif/ps13/genotox/web/pages/01_nador.html

Z. Krška, D. Hoskovec, L. Petruželka. Chirurgická onkologie. Grada 2014, ISBN:

9788024742847 8024742845

Y.Shane Morita, Text book of general Surgical Oncology. Mcgraw Hill Medical, 2017

ESMO (European society for Medical Oncology), Guidelines Methodology. https://www.esmo.org/

ASCO (American society of clinical oncology), https://www.asco.org/