Surgical Oncology
Surgical oncology tests the principles that separate cancer operations from other surgery: staging before resection, achieving margins, harvesting nodes, and sequencing multidisciplinary treatment correctly.
Core principles
- Tissue diagnosis before definitive resection, except where the operation is both diagnostic and therapeutic, such as an obstructing colonic cancer.
- Stage before you resect: TNM, cross-sectional imaging, sentinel node where relevant, and staging laparoscopy for gastric or pancreatic cancer to exclude occult peritoneal disease.
- Margins: R0 no tumour at the margin, R1 microscopic, R2 macroscopic. Report the distance and status; a close margin may be acceptable after radiotherapy in some sites.
- En bloc resection of the tumour with its draining nodes; avoid tumour rupture, spillage and needle-track seeding.
- The multidisciplinary tumour board decides neoadjuvant versus adjuvant treatment, not the individual surgeon.
Site-specific points
- Gastric cancer: D2 lymphadenectomy; perioperative chemotherapy for stage ≥T2 or node-positive disease.
- Colorectal liver metastases: resect when technically feasible with an adequate future liver remnant; cytoreductive surgery with HIPEC for selected peritoneal disease.
- Soft tissue sarcoma: place the biopsy tract where it can be excised with the specimen; obtain wide margins; radiotherapy for high-grade lesions.
- Breast: sentinel node biopsy and endocrine therapy directed by receptor status.
- Palliative surgery for obstruction, bleeding or perforation in incurable disease is decided by performance status, not by imaging alone.
Worked example
A 60-year-old has a 5 cm gastric tumour on endoscopy and CT showing no distant disease. Reasoning: complete staging with chest and abdominal CT plus staging laparoscopy; if there is no peritoneal disease, give perioperative chemotherapy and then perform subtotal or total gastrectomy with D2 dissection. Operating immediately would risk a non-curative laparotomy in the roughly one fifth of patients with occult peritoneal deposits.
Traps
- Shelling out a sarcoma without imaging - it seeds the field and may make limb salvage impossible.
- Judging liver metastasis resectability by size alone rather than by anatomy and future remnant volume.
- Omitting or under-reporting the lymph node harvest.
- Using CEA or CA 19-9 to diagnose cancer; they monitor disease, they do not screen for it.