OS 217: Systemic Diseases (Oncology)
2
Lec 02: Surgical Oncology
September 16, 2014
Mark R. Kho, MD, FPCS, FACS
o
Breasts were cruelly cut off and crushed. 
TOPIC OUTLINE
I.
II.
III.
IV.
V.
VI.
Introduction
A. Cancer
B. The Cancer Problem
C. Cancer Awareness Months
D. Nine Warning Signs of Cancer: CAUTION US
E. Safeguards vs. Cancer: Prevention and Early Detection
F. Surgeons in the Forefront of Cancer Care
Myths
Surgical Oncology
A. Definition of Surgical Oncology
B. Characteristics of Surgical Oncology
C. The Society of Surgical Oncology, Inc. (SSO)
The Future Direction
Multidisciplinary Effort
Final Notes on Surgical Oncology
C. CANCER AWARENESS MONTHS
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1.
2.
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5.
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8.
9.
This is the same as 2016.
I. INTRODUCTION
A. CANCER
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Uncontrolled growth of body cells
Spread/Metastasis
o Direct Extension
o Lymphatic Spread
o HematogenousSpread
Types
o Carcinoma
o Lymphoma
o Sarcoma
o Leukemia
B. THE CANCER PROBLEM
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7.6 Million (3/4 of Manila population) people worldwide killed by
Cancer in 2008;
55% of 12.7 M (22.2 M in 2030) cancer cases worldwide diagnosed
in 2008 were in less affluent, developing countries.
CANCER STATISTICS OF 2014
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The number of deaths due to heart disease has decreased over
time while the number of deaths due to cancer remained the
same.
o We now know more about heart disease. Unfortunately,
we don’t have that pleasure in cancer.
Cancer is the leading cause of death among men and women in
the US under the age of 85.
In the Philippines, malignant neoplasm ranks 3rd in terms of
mortality. (If you clump the top 2 together as heart disease,
neoplasm becomes top 2!)
Table 1. 10 Lead Cancer Sites
PHILIPPINES
WORLD
USA
(2010)
(2008)
(2014)
Breast
Breast
Prostate
Lung
Prostate
Breast
Liver
Lung
Lung
Colon & Rectum
Colon & Rectum
Colon & Rectum
Cervix uteri
Cervix uteri
Lymphoma
Leukemia
Stomach
Melanoma
Stomach
Liver
Urinary bladder
Prostate
Corpus uteri
Kidney
Brain
Esophagus
Thyroid
Ovary
Ovary
Uterine corpus
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Breast and lung cancer always at the top 
The prevalence of breast cancer in the Philippines is 5th in Asia, 50th
in the world. 
There are three times more breast cancer cases than cervical
cancer. 
The top leading cause of cancer deaths among males is prostate
cancer while among females is breast cancer. 
Top 3 causes of cancer in females are breast, cervical and lung
cancer. For males it’s lung, liver, and colorectal cancer. 
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CRUZ AM, CRUZ MG, CUA
D. NINE WARNING SIGNS OF CANCER: CAUTION US
C hange in bowel and bladder habits
A sore that does not heal
U nusual bleeding or discharge
T hickening or lump in breast or elsewhere
I ndigestion or difficulty in swallowing
O bvious change in wart or mole N agging cough or hoarseness
U nexplained anemia
S udden or unexplained weight loss
From 2014:
#1 like progressive constipation or alternating diarrhea and constipation
#2 pertains to oral cancer
#3 can be in gastrointestinal or gynecologic malignancies
#5 seen in malignancies of the oropharynx, esophagus, stomach
#7 seen in malignancies of pharynx, larynx or lungs
#8 seen in gastrointestinal malignancies
#9 seen in gastrointestinal malignancies; usually due to low food intake
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E. SAFEGUARDS VS. CANCER: PREVENTION AND EARLY DETECTION
Table 2.Prevention and Early Detection of Cancer
CANCER
PREVENTION
EARLY DETECTION
Lung
Do not smoke
None
Uterine Cervix
HPV
Vaccination; Regular Pap Smear
Having one sexual
partner lowers risk;
Clean safe sex
Liver
Hep B Vaccination; None
Minimal
alcohol
intake; Avoid fatty
foods
Colon & Rectum
High fiber, low-fat diet Regular
medical
check-up >40 years;;
yearly FOB DREI
Oral Cavity
Avoid
smoking Through
annual
tobacco/betel
nut dental and oral cavity
chewing,
alcohol; check-ups
Oral hygiene
Breast
No
conclusive Monthly Breast Selfevidence; Tamoxifen Exam (BSE); Clinical
or
Raloxifene
for Breast
Exam;
high-risk individuals
Mammography
for
high-risk or >40 years
Skin
Avoid excessive sun Skin self exam
exposure
Prostate
No
conclusive Digital Rectal Exam;
evidence
Prostate
Specific
Antigen (PSA)
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F. SURGEONS IN THE FOREFRONT OF CANCER CARE
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****St. Agatha of Catana (Virgin and Martyr)
o Patroness of Nurses 
o Invoked vs earhquakes and breast diseases 
o Born of illustrious family I Sicily 3rd Century (250 AD), early consecration 
o Poverty, charity and obedience Vow of a nun 
January – National Cancer Consciousness Month 
February – Cancer Screening and Early Detection Month 
March – Colorectal Cancer Awareness Month 
April – Cancer in Children Awareness Month 
May – Cervical Cancer Awareness Month 
June – Male and Prostate Cancer Awareness Month 
August – Lung Cancer Awareness Month 
September – Liver Cancer Awareness Month 
October – Breast Cancer Awareness Month 
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William Cance: “Let’s face it, we do not have very effective (cancer)
therapies…other than surgery. And surgery remains the most
effective therapy we have. And in a large part of the world, it is the
only therapy we have.”
Lex Eggermont: A rare hybrid (by Marc Beishon): “Clinical cancer
research is nowadays dominated by medical oncologists, so the
election last year of a surgeon to head up the EORTC might seem
an unusual choice. But then Alexander Eggermont is an unusual
man, whose pioneering work, with TNF in particular, has shown that
great things can be achieved by combining surgical and biological
know-how.”
American Society of Clinical Oncology (ASCO)
o Non-profit organization founded in 1964 by a group of physician
members of American Association of Cancer Research (AACR)
o Journal: Annals of Surgical Oncology
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Lec 02: Surgical Oncology
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National Cancer Institute
PGH: Division of Surgical Oncology, Head and Neck, Breast, and
Esophagastric Surgery, mastery in surgery, breast care center in
Cancer Institute
III. SURGICAL ONCOLOGY
A. DEFINITION OF SURGICAL ONCOLOGY
II. MYTHS AND FACTS
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“Biopsy triggers the spread of tumor”
o Biopsy is used to diagnose whether you have CA or not
o FNA vs Core vs Open – Consider sampling error, cell pattern
and ICH analysis
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Adequate tissue
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Viable area: Not the necrotic area
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Adequate depth
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Non-perturbing
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Treatment planning
“Surgery hastens death of cancer patients”
“Surgery can not cure cancer”
o FACT: Most cancers are cured by surgery
o Limitations:
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Follows zero-order kinetics
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Regional modality
 If the cancer has already spread, surgery (same as
radiation) cannot cure it because it is a locoregional
intervention, it does cure a systemic disease
o Part of multimodality approach concept
o Wide excision
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Margins of adequate distance
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Closest margin defines excision
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Tumor specific
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Surgical techniques
 Anatoic boundaries
 High risk areas
 Nerve sparing
 Functional outcome
o Challenges in Surgical Resection
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What is resectable?
 Challenge 1: Resection vs debulking
 Challenge 2: Functional outcome vs biologic behavior
 Challenge 3: Technical skills
 Challenge 4: Adequacy of adjuvant therapy
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Lymphadenectomy
 Diagnostic
 Therapetuci
 Prognostic
 Treatment
 Planning
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Cosmetic result: Needs careful pre-operative plan
“There is no way an organ can be preserved once surgery is
done for cancer”
“Patient is mutilated and is not the same whole person after
cancer surgery”
o Breast reconstruction
o Skin sparing mastectomy with immediate reconstruction
o Surgical reconstruction for cancer
“There is no role for surgery in a patient with widespread or
advanced cancer”
o Surgery for liver metastases and colorectal cancer
o Surgery is the only modality with long-tern curative potential
“Surgery is the only treatment for cancer and once a tumor is
resected, no more treatment is necessary”
o Adjuvant therapy is additional therapy given to improve the
survival of the patient
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Determine the adequacy of the cause of adjuvant therapy. If
not adequate, or no good adjuvant therapy, do radical surgery.
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Small spread is killed by medicine or radiotherapy
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Ex. Primary: Surgery, Adjuvant: Chemotherapy
(medicinces are given to kill the remaining cancer cells
left after the surgery)
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Remember: Tumor that invaded the base of the tongue, neck,
etc. wherein after patient was given taxanes, the tumor
shrunk and the patient was now able to close his mouth
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Surgery is usually the primary treatment, the adjuvant therapy
may include radiation, medication, etc; an exception is
leukemia where chemotherapy is the primary treatment
modality
o Intraoperative Radiation Therapy (IORT)
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Radiation therapy in conjunction with surgery
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Primary advantage: RT delivered during surgery to site with
highest risk of local failure in order to improve the local
control, thus less damage to surrounding normal cells
“There is no difference between a general surgeon and a
surgical oncologist”
CRUZ AM, CRUZ MG, CUA
OS 217
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“The application of a unique set of Surgical and Multidisciplinary
Principles to the cancer patient”
Definition of surgical oncology implies additional training beyond
the standard requirements of General surgery (5 yrs)
Ideally 2-4 years spent outside the usual General Surgery
environment including laboratory and clinical research.
B. CHARACTERISTICS OF SURGICAL ONCOLOGY
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Integrate the basic General Surgery skills into an oncologic practice
Components of Surgical Oncology:
o Diagnostic: Radiologic, surgical, pathologic, inferential
o Therapeutic
o Palliative
o Supportive
o Investigational: research
Teach advanced operative techniques
Introduce fellows to laboratory and clinical research
Develop skills in scientific writing and presently incorporate the
principles of inter- and multidisciplinary
C. THE SOCIETY OF SURGICAL ONCOLOGY, INC (SSO)
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Founded as the James Ewing Society, June 1940
Father of multidisciplinary approach to cancer
Change of name to SSO in 1975
Status as of 2014
o Over 2700 members
o USA and over 41 other countries
Multidiscipline to achieve better care for patient
Surgical oncology matching program
Breast Cancer: Do Specialist Make A Difference?
o 28,604 breast cancer cases stratified
o In the study, they employed SSO surgeons vs. non-SSO
member
o Endpoints:
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SSO showed better risk reduction (5 yr stage-adjusted
survival), are more likely to perform breast conservation
technique and has better outcome
o Results showed that treatment by Surgical Oncologist resulted in
a 36.3% risk reduction and likely to perform BCT
o Breast cancer patients treated by specialists tend to have better
outcome
o Before definitive treatment, “the survival of patients with breast
cancer is better if they are treated by a specialist who also
treats a large number of similar patients, and who has access to
the full range of treatment options in a multidisciplinary setting.”
IV. FUTURE DIRECTIONS
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20th century: cytotoxic therapy, radiotherapy, hormonal therapy,
surgery
21st century: oncogene oncogene based therapy, targeted therapy,
patient-specific therapy
o They found out that cells have complex molecular interactions,
so there are many targets, hence we can block target activity,
o New targets are currently being discovered in cancer therapy, to
impede the growth of cancer cells
o Tailored approach vs. One-shoe-fits-all
o Multidisciplinary Effort
New treatments of modality being explored
New researches focuses on the biology of cancer cells
Drugs are being formulated to target cancer cells’ metabolic
processes
V. MULTIDISCIPLINARY EFFORT
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Involves the following:
o Screening/Early Detection
o Modern Imaging
o Radiotherapy
o Rehabilitation
o Systemic medical treatment
o Psychosocial and Nursing support
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Lec 02: Surgical Oncology
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OS 217
o Surgery
o Medical students
o Pathologic and molecular diagnosis
To have an idea on the roles of various specialist
VI. FINAL NOTES ON SURGICAL ONCOLOGY
“Surgery is a mystical craft, which often defies explanation. To be
allowed with consent to cut into another human being’s body, to gaze
into the depth of the person’s suffering, and to excise the demon of the
disease – such doing assume and awesome responsibility.
“Man is an animal with primary instincts of survival. Consequently, his
ingenuity has developed first and his soul afterwards. Thus, the
progress of science is far ahead of man’s ethical behavior” –
Charles Chaplin
END OF TRANSCRIPTION
Cua: WELCOME TO CLASS 2017 Baby Adam!!! :D
Cruz: DR. GRACIEUX FERNANDO IS THE BEST!!! TedMed level!
Love is that condition in which the happiness of another person is
essential to your own. – Robert A. Heinlein
CRUZ AM, CRUZ MG, CUA
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