Surgical Oncology and Multidisciplinary Management
What this domain tests
This domain covers oncological resection principles, the sequence of surgery versus systemic therapy, and how an MDT reaches and documents a decision. Questions often ask what the correct next step is, not what the operation is called.
Core rules
- R0 resection means microscopically negative margins; R1 is microscopic and R2 macroscopic residual disease. Margin adequacy is site-specific (e.g., 2 mm for rectal cancer, no tumour on ink for many others).
- Sentinel lymph node biopsy is standard for clinically node-negative breast cancer and melanoma; it spares axillary dissection and its lymphoedema risk. Completion dissection is now often omitted in selected patients with limited positive nodes receiving radiotherapy.
- Neoadjuvant therapy is chosen when it downstages, tests biology, or improves organ preservation (rectal, oesophageal, gastric, breast). Adjuvant therapy treats micrometastases after complete resection.
- Perioperative regimens are evidence-specific: FLOT for resectable gastric and gastro-oesophageal junction adenocarcinoma; neoadjuvant chemoradiotherapy or short-course radiotherapy followed by total mesorectal excision for locally advanced rectal cancer.
- Metastasectomy and cytoreductive surgery require demonstrated disease control, a realistic chance of complete resection, and adequate physiological reserve; HIPEC is reserved for selected peritoneal disease in expert centres.
- The MDT record should name the tumour type, stage, performance status, comorbidity, patient preference, the recommendation and the rationale.
Worked example
A 58-year-old has a mid-rectal adenocarcinoma staged on MRI as T3 with one suspicious mesorectal node, no distant disease. Staging is T3 N1 M0. Reasoning: T3 breaches the muscularis propria and the involved mesorectal node makes this node-positive. Standard management is neoadjuvant long-course chemoradiotherapy (about 50.4 Gy in 28 fractions with a fluoropyrimidine) or short-course radiotherapy, followed by total mesorectal excision and adjuvant chemotherapy. Operating first would risk a positive circumferential margin, so the MDT sequence matters more than the technical choice.
Traps
Offering surgery without staging the chest, liver and, where relevant, the peritoneum; forgetting that a complete response to neoadjuvant therapy may allow watch-and-wait only within a strict protocol; assuming all R1 resections benefit from re-operation.