Surgical Oncology J. Žaloudík V. Fait Department of Surgical Oncology Masaryk Memorial Cancer Institute Surgical Oncology •Understanding varies either in countries, but even individually •Surgical oncology cannot be simply divided from other surgical specialisations •Nearly in every surgical sub specialisation you can meet oncological problematic. On the other side the oncological cases can be solved only with very good knowledge of this specialisation. •So, there is no universal surgical oncology clinic and even no universal surgical oncologist. Always a surgical oncologist is a surgeon, who is mostly dealing with oncological cases and is appropriately educated 11.4.2020 21:43 MOÚ Brno 2 IMG_1322 IMG_1321 IMG_1324 IMG_1330 IMG_1497 Imaging diagnostics Surgical oncology Laboratory diagnostics Medical oncology Radiation oncology Indication boards clinical oncology Is mostly about Multidisciplinary cooperation IMG_0163 Before every oncological therapy should precede a complete diagnostic. Typing – proofing of the tumor by biopsy Staging – the TNM classification showing the extent of the disease The local amount of the tumor (T), regional nodal metastases (N), distant metastases (M) Grading – The degree of histological dediferentiation and other crucial characteristics applicable for the treatment Statistics in the Czech republic 97 diagnostic groups according to the International Classification of Diseases and Related Health Problems(ICD) Incidence ( new tumors per year) 90 000 including: 6000 „liquid“ (haematological) malignancies, 500 tumors in children Prevalence (total number of patien in therapy and after therapy) 560 000 Mortality (cancer caused deaths per year) 30 000 Letality (index mortality/incidence, MI index ) - deaths to diagnosed cases ratio per year Figures different in various diagnoses, dependent on the effectivity of therapy and aerliness of diagnostic (examples : lung cancer 0,90, pancreas 0,89, colorectal 0,49, ovary 0,76, kidney 0,38, breast 0,30, prostate 0,26, testes 0,14, melanoma 0,17 etc.) Timing of surgery in the combination therapy of solid tumors Usually depends on the clinical stage of the disease operation only (early stages) Operation + afteroperation (adjuvant) chemo – radio-therapy Before operation (neoadjuvant) chemo-radio-therapy + operation Before operation ch-r-therapy + operation + afteroperation ch-r-therapy Main therapy chemo-radio-therapy (late stages) + operation as a helping procedure Notice : chemotherapy mens here any systhemic medical treatment by use of cytostatics, hormones, biotherapy or immunotherapy or combination Three fases and goals of any oncological operation 3 in 1 Removal of the tumor Reconstruction of the operated region More specifying diagnostics All the points are of the same validity! Lymphatic nodes surgery- the most often first site of solid tumors metastasing Diagnostic biopsy of suspect node (punction, open biopsy) Targeted biopsy of the sentinel lymph node Complete dissection (exenteration) of axilla, ilioinguinal region, neck trigonum Retroperitoneal lymphfadenectomy (testicular and ovarial cancers ) Organ dependent regional lymphadenectomy (perigastric, pericolic, iliac, mediastinal) Extirpation of suspect juxtaregional nodes (supraclavicular, mesenterical, retroperitoneal) Axillary dissection 11 Sentinel node biopsy technique SNB-O.jpg exnodeSNB mikrometaN exnodeSNB IMG_0158 IMG_0127 IMG_0142 IMG_0138 microstaging Radionavigated node surgery Magnetic detection of the sentinel node Specific approaches and concepts in surgical ocolgy Narrow cooperation wíth histopathologist even in the operation theatre Pelvic surgery (cooperation of surgeon, gynecologist and urologist in the same time) Oncoplastic surgery (using techniques of plastic surgery) OpeDelayed operation after another therapy Intraoperation intersticialí brachytherapy Regional chemotherapy Cytoreductive operations and HIPEC in localy advanced tumors Miniinvasive and robotic operations Kryosurgery - local destruction of tumors by low temperature Direct cooperation in keeping the tissue bank Round-bloc_1 Round_postup_3 Grisotti_B1 IMG_0152 Grisotti Round-block resections Parenchymal flaps Oncoplastic surgery P9080371 P9080372 P9080374 Huge recostruction Covering of the chest wall defect by use of a mesh and rotation skin flap P7220282 P7220288 P7220292 P7220295 Mesh implantation Radical and reconstructive operation Intersticial intraoperation brachyradiotherapy higher dose in the tumor site, lower dose in the skin, lower number of local recurrencies P5240150 synovSTS angioSTS Regional intraarterial chemotherapy G3 Isolated hyperthermic limb perfusion perfuze.jpg 20 Isolated hyperthermic limb perfusion C:\Users\umbertocarletti\Desktop\Foto\ILP IOV\DSC_0258.JPG Mutidisciplinary cooperation – proper timing •Adjuvant systhemic treatment •„Classical“ – after radical surgical removement •Neodjuvant– before radical surgical removement •Radiotherapy •Preoperational •Postoperational •Perioperational Multidisciplinary indication boards A) TRUS before treatment: localy advanced rectal cancer with involved regional lymph node B) TRUS after neoadjuvantí chemoradiotherapy : lymph node regresion, node of a normalí echostructure operation after neoadjuvant chemo kompletní sestava Prostate with cancer, removed with use of robotic surgery C:\Users\sefr\Desktop\ROBOT\FOTO\1. prostata 23 05 18\robot foto sál.JPG Robotic surgery HI covers now: Robotic radical prostatectomy Robotic kidney resection Robotic rectal resection Robotic hysterectomy Robotic lymfadenectomy of iliac or retroperitoneal nodes Tissue bank and predictive oncology on-line cooperation with pathologist B-resekát C-přikrajování D-Dewarky F-box H-datacentrum odberMTT MTTplate Surgical treatments results evaluation 1)Subjective patient contentment - operation after.effects, functional result, cosmetic result 2)Objective parameters a) postperation complications b) number of local recurrencies c) PFS – progression-free survival d) OS – overal survival – dependig on clinical stage - comparing with the country or region average comparing with the world - comparing own results in time example : MMCI results for the most often diagnoses on www.mou.cz c) a d) allways in context with another modalities ! 3) Economical parameters cost versus benefit ratio ( hard to use in individual – not used, cost effectivity can be judged statistically in bigger cohorts Survival analysis ( MMCI ) : Rectal cancet st. III comparing 10-year survival (MMCI)MOÚ a Czech rep(ČR) MOÚ průměr ČR Rectal cancer st. III comparing results in time 2000-2004 2005-2009 2010-2014 Diagnostic criteria derived from surgeon and pathologist : No – Nodes T – Tumor : T cathegory/ histological Typing/ Re – Resection margins (as estimated by histopathologist) St - postoperative Stage, pT pN pM InG – Investigation on Grade (and also target molecules,receptors) Performance of surgical department Sur – Survival rates ( general, in particular hospital or team, if available ) GEO – Guaranteed Estimation by Oncologists ( multidisciplinary team) Ns – Numbers of treated cases by team (volume effect) No/T Re/St/InG Sur/GEO/Ns (J.Zaloudik, 2009) 8 parameters for surgical oncology, for patient information & decision making Mnemotechnical tool for use in the proffesional and private life WHAT SHOULD I KNOW, if I, may nearets or my patient got a cancer? ? Four levels of preventive dealing in the fight with cancers and as a base for effective surgical intervention primary prevention : „Not to allow the cancer to arise“ (precanceroses removal, vaccination – HBV, HPV) secondary prevention : „if the cancer occurs, to be found in time and curable by surgical removement with low risk of recurrence “ (screening programs, systematic preventive investigations) tertiary prevention : „if the cancer was not found and treated in time and comes back, to find the still curable recurrency„ (consistent folow up, operative treatment of metachronous metastases ) quartery prevention : „ if the cancer is not curable , to prevent complications and useless suffering, physical, psychical and social“ (palliative opertions, nutritional care, pain treatment, social care ) Useful webs www.svod.cz data from the Czech national oncological registry www.nccn.org international guidelines i oncology) www.onconet.cz the Czech oncological web www.linkos.cz Czech Oncological Society www.mou.cz Masaryk Memorial Cancer Institute www.prevencenadoru.cz preventive oncology www.mamo.cz Czech mammological screening www.kolorektum.cz Czech colorectal screening www.cervix.cz Czech cervical cancer screening Sarkom 014 Ve ?