GC202 Surgery May Cure Your Cancer Surgical Oncology
Surgical oncology is the branch of surgery focused on the curative resection of malignant tumors, aiming to achieve complete removal of cancerous tissue with adequate margins to eliminate disease.
Surgery May Cure Your Cancer: Surgical Oncology
This GC 202 lecture by Prof. SC Chan is a foundational surgical oncology lecture that asks one deceptively simple question: Can surgery cure cancer? The answer is "yes, but with important caveats." The lecture systematically covers:
- The roles of surgery in cancer (prevent, diagnose, stage, treat, palliate)
- How cancer spreads (the biological basis for why surgery works — and why it sometimes fails)
- Principles of cancer surgery (what makes an operation "curative")
- Measurement of surgical outcomes (how we know if surgery worked)
- Factors contributing to success and failure
- Deficiencies of surgery and the role of adjuvant/neoadjuvant therapy
- HCC as the running clinical example throughout
This lecture integrates with virtually every organ-specific cancer lecture in the GC curriculum (breast, colorectal, lung, head & neck, liver, pancreas, gynaecological). The principles taught here are universal surgical oncology principles that examiners can test in any cancer scenario.
Learning Objectives (from slides):
- How cancer spreads
- Principles of cancer surgery
- Measurement of surgical outcomes
- Factors contributory to success / failure [1]
Surgery for cancer serves five purposes: [1]
- Prevent — e.g. excision of premalignant conditions
- Diagnose — e.g. biopsy of inaccessible locations
- Stage — e.g. lymph node dissection, staging laparoscopy
- Treat — e.g. cure, control
- Palliate — e.g. bypass for obstruction
Why each matters:
| Role | Explanation | Clinical Example |
|---|---|---|
| Prevent | Remove tissue before malignant transformation | Total colectomy for FAP; prophylactic mastectomy for BRCA |
| Diagnose | Tissue is required for histological diagnosis | Open biopsy of deep retroperitoneal mass; frozen section intraoperatively [7] |
| Stage | Surgical findings provide pathological staging (more accurate than clinical) | Sentinel LN biopsy in breast CA; staging laparoscopy for pancreatic CA |
| Treat | Complete excision = only chance of cure for most solid tumours | Hepatectomy for HCC; colectomy for colon CA |
| Palliate | Relieve symptoms when cure impossible | Bypass for duodenal obstruction in pancreatic CA; defunctioning colostomy |
II. How Cancer Spreads
Cancer is an aberration of cell growth. Cells survive and multiply indefinitely, grow without orderly histology, spread/invade/destroy tissue locally, spread to distant organs via blood stream, lymphatics, nerve fibers, and replace and destroy distant organs. [1]
Six mutations convert a normal cell into a cancer cell: [1]
| Hallmark | Simple Analogy | Why It Matters for Surgery |
|---|---|---|
| Self-sufficiency in growth signals | "Accelerator pedal stuck on" | Tumour grows autonomously — won't stop without removal |
| Insensitivity to anti-growth signals | "Brakes don't work" | Normal regulatory mechanisms fail |
| Evading apoptosis | Won't die when body would kill defective cell | Cancer cells resist programmed death |
| Limitless replicative potential | Infinite generations of descendants | Tumour can grow indefinitely |
| Sustained angiogenesis | Telling body to give it blood supply | Tumour develops its own vasculature (basis for anti-VEGF therapy) |
| Tissue invasion and metastasis | Migrating and spreading to other organs | The fundamental reason surgery must clear margins and nodes |
Why does understanding hallmarks matter for the exam?
The hallmarks explain why surgery works (physically removing the aberrant cells before they spread further) and why it sometimes fails (if cells have already metastasised via bloodstream/lymphatics before surgery, the horse has bolted). They also explain the rationale for targeted therapies and immunotherapy — each hallmark is a potential drug target.
Spread of cancer: [1]
- Local — primary site and adjacent tissues or organs
- Regional — lymph node, perineural
- Distant — lung, bone, transperitoneal (e.g. ovarian cancer)
The metastatic cascade (from lecture slides): [1]
- Primary malignant neoplasm forms
- Vascularization (angiogenesis)
- Tumour growth
- Invasion of surrounding tissues
- Vascular invasion → transport through bloodstream
- Arrest and extravasation at distant site
- Metastasis established
A similar process occurs with lymphatic spread.
Exam Discriminator: Perineural Spread
Perineural spread is particularly relevant in pancreatic cancer, head & neck cancer (especially adenoid cystic carcinoma), and some rectal cancers. It's a route often forgotten by students. The lecture explicitly lists it as a mode of regional spread.
Causes of mortality related to cancer: [1]
- Cancer invasion of organ of origin, adjacent organs, or distant sites leading to loss of organ function
- Cancer cachexia
- Esophageal cancer
- Pancreatic cancer
- Liver cancer
Cancer cachexia involves: [1]
- Anorexia
- Weight loss
- Muscle wasting, lethargy, malnutrition
- Infection, e.g. aspiration pneumonia
Why cachexia matters surgically: A cachectic patient is malnourished → poor wound healing, impaired immunity, higher operative mortality. This is why nutritional optimization is critical before major cancer surgery.
Clinical examples from slides:
- Multiple liver metastases leading to loss of liver function [1]
- Large HCC extending into inferior vena cava [1]
- Lung metastases after HCC (patient on 18th cycle Opdivo at 15 months) [1]
III. Principles of Cancer Surgery
This is the core exam-testable section of the lecture. These principles apply to ALL solid tumour surgery.
Principles of cancer surgery: [1]
- Complete extirpation of tumor with a rim of tumor-free tissues (margin > 1 cm)
- Clearance of lymphatic drainage which may harbor microscopic or macroscopic spread
- En-bloc resection of primary tumor with adjacent resectable organ or tissue
- Minimum manipulation of tumor and tumor-bearing organ
- Preservation of organ function, e.g. 30% liver
- Minimum blood loss and blood transfusion
Let me explain each in depth:
The surgeon must remove the tumour plus a cuff of normal-appearing tissue around it. The lecture states margin > 1 cm as a general principle [1].
Why? Cancer cells infiltrate microscopically beyond what you can see or feel. If you cut through tumour (positive margin / R1 resection), you leave cancer behind and the surgery is futile.
Margin standards vary by organ:
| Organ | Required Margin | Notes |
|---|---|---|
| Colon | ≥ 5 cm proximal and distal [2][3] | Actual margin depends on blood supply |
| Rectum (proximal) | ≥ 5 cm [2] | — |
| Rectum (distal) | ≥ 2 cm (1 cm if below distal mesorectal margin) [2] | Compromise for sphincter preservation |
| CRM (rectum) | ≥ 1 mm [2] | Concept of TME |
| Stomach | ≥ 5 cm gross negative [4] | — |
| Liver (HCC) | > 1 cm [1] | Per lecture general principle |
| Oesophagus | Depends on approach | — |
| Breast | Negative ("no tumour on ink") | Current standard |
Clearance of lymphatic drainage which may harbor microscopic or macroscopic spread [1]
Why? Cancer cells travel through lymphatics to regional nodes. Even if the primary tumour is removed completely, residual cancer in lymph nodes will lead to recurrence. Lymph node status is also the most important prognostic factor in most solid tumours and determines need for adjuvant therapy.
Key numbers to remember:
- Colon: minimum 12 lymph nodes for adequate N staging [2][3]
- Stomach: 15 lymph nodes for adequate staging with D2 dissection [4]
- Rectum: minimum 12 lymph nodes [2]
Clinical example from slides: Resection of sigmoid colon cancer with clearance along the inferior mesenteric artery [1]
En-bloc resection of primary tumor with adjacent resectable organ or tissue [1]
Why? If tumour is directly invading an adjacent structure, you cannot simply peel it off — that would leave cancer cells behind and potentially violate the tumour surface, seeding cancer. You must remove the primary tumour AND the invaded structure as one single block of tissue.
Clinical examples from slides:
- Carcinoma of sigmoid colon invading into small intestine — both sigmoid and involved small bowel removed en bloc [1]
- Cholangiocarcinoma of left hepatic duct — requires resection of common hepatic duct AND left liver [1]
- Whipple operation (pancreaticoduodenectomy) — for lower CBD cancer, removes head of pancreas + duodenum + distal stomach + CBD + gallbladder en bloc [1]
- Right radical nephrectomy en bloc with IVC tumor thrombus [1]
What the ERCP cholangiogram shows: contrast-filled biliary tree with a yellow arrow on a narrowed/irregular lower CBD (carcinoma of distal CBD) — the imaging reason a Whipple, not a simple bile-duct excision, may be required for en-bloc clearance. [1]
Minimum manipulation of tumor and tumor-bearing organ [1]
Manipulation or mobilization of vascular liver cancer may induce dissemination of cancer cells into systemic circulation [1]
Why? When you handle a tumour, you literally squeeze cancer cells into blood vessels and lymphatics. The "no-touch" technique was developed to prevent iatrogenic tumour dissemination.
No-touch colectomy technique (from slides): [1]
- Division of inflow and outflow vasculatures (ligate vessels first)
- Division of colon (proximal and distal to tumour)
- Mobilization of colon bearing the cancer (last step)
Conventional technique (contrast): [1]
- Cancer-bearing segment mobilized first
- Colon divided at resection sites
- Lymphovascular pedicles divided last
The Turnbull et al. (1968) study demonstrated markedly superior 5-year survival for the no-touch isolation technique vs conventional technique in C-stage colon cancers: 57.84% vs 28.06% [1].
No-touch hepatectomy: [1]
- Division of liver inflow & outflow vascular tract BEFORE mobilization of liver
- This is the "anterior approach" (Liu et al. Ann Surg 2006) [1]
Risk of conventional approach for right hepatectomy: [1]
- Tearing of right hepatic vein
- Twisting of inflow and outflow pedicles
- Dissemination of cancer cells into systemic circulation
- Iatrogenic rupture of soft tumour, e.g. HCC
No-Touch Technique: Key Exam Concept
The sequence matters: Vessels first → Divide bowel/organ → Mobilize last. This applies to both colectomy and hepatectomy. The rationale is the same: prevent squeezing cancer cells into the circulation during manipulation.
Preservation of organ function, e.g. 30% liver [1]
Why? If you remove too much functional tissue, the patient dies of organ failure rather than cancer. There's a balance between oncological completeness and functional preservation.
Organ function loss after surgery — Reasons: [1]
- Part of organ bearing the tumour has been removed
- Physiological disturbance induced by massive bleeding
Clinical examples:
- Removal of uninvolved liver results in loss of functional liver mass [1] — The liver can regenerate, but you need approximately 25-30% of functional liver remnant (more in cirrhotic livers: ~40%)
- Pancreas cancer — result of tissue loss: [1]
- Just adequate resection → No DM, No steatorrhoea
- Excessive resection → Diabetes mellitus + Steatorrhoea (loss of both endocrine and exocrine function)
Organ function loss leads to: [1]
- Poor quality of life
- Need for medication
- ↑ Hospital cost
- ↑ Mortality
Minimum blood loss and blood transfusion [1]
Effects of major bleeding: [1]
- Hypotension
- Hypoperfusion of major organs
- Postoperative organ failure
- Need for massive blood transfusion
Blood transfusion & cancer recurrence: [1]
- Rapid growth of microscopic spread or foci of cancer after surgery if blood transfusion has been given
- Loss of immune control of cancer cell growth induced by blood transfusion
- Transfused histocompatibility antigen induces specific immunologic non-reactivity
Blood Transfusion and Cancer Recurrence
This is a commonly tested concept. Blood transfusion causes immunosuppression (transfusion-related immunomodulation — TRIM). This allows residual microscopic cancer foci to escape immune surveillance and grow. This is why surgical oncologists strive to minimise blood loss — not just for haemodynamic stability, but to avoid needing transfusion which could worsen cancer outcomes.
Evidence from lecture (Chan et al. Arch Surg 2003): In a study comparing liver transplant surgeons (LTS) vs hepatobiliary surgeons (HBPS) performing major hepatectomy for HCC [1]:
- Intraoperative blood loss: 1.36 ± 1.37 L vs 2.21 ± 2.40 L (P < 0.001)
- Patients requiring transfusion: 16.7% vs 38.5% (P < 0.001)
Multivariable analysis confirmed blood transfusion as an independent risk factor for overall survival (RR 1.61, 95% CI 1.06–2.45, P = 0.03), along with cirrhosis (RR 1.96, P = 0.001) and venous invasion (RR 2.77, P < 0.001) [1].
Local Ablative Therapy: [1]
- Absolute alcohol injection
- Radiofrequency ablation (RFA)
- Microwave ablation
- High Intensity Focused Ultrasound (HIFU)
Why do these exist? For small, unresectable tumours (e.g. HCC in cirrhotic liver where resection would leave insufficient liver remnant), local ablation can destroy the tumour in situ without removing tissue.
RFA is the most commonly used: a needle electrode is inserted into the tumour under imaging guidance, and radiofrequency energy generates heat (~60-100°C) causing coagulative necrosis.
Limitations: Generally effective only for tumours ≤ 3 cm (some centres up to 5 cm). Cannot achieve the same margin clearance as resection. Higher local recurrence rate than surgery.
Transarterial and Locoregional Therapies
Beyond ablation, the lecture presents additional locoregional approaches for hepatic malignancies [1]:
| Modality | Mechanism | Key Contraindications |
|---|---|---|
| Bland embolization | Occlusive particles via arterial supply | Liver involvement > 70%, main PVT, bilirubin > 2–3 mg/dL |
| Transarterial chemoembolization (TACE) | Chemotherapy + lipiodol with embolization (or drug-eluting beads) | Liver involvement > 70%, main PVT, Child–Pugh C, arterio-portal fistula |
| Radioembolization (⁹⁰Y) | Intra-arterial yttrium-90 microspheres | Liver involvement > 70%, hepatopulmonary shunt, Child–Pugh ≥ B8 |
| Intra-arterial chemo-infusion | Direct chemotherapy infusion via tumour arterial supply | Liver involvement > 70%, bilirubin > 2–3 mg/dL |
Yttrium-90 radioembolization can achieve simultaneous tumour treatment and contralateral liver hypertrophy ("radiation lobectomy"), potentially converting initially unresectable patients to surgical candidates [1].
V. HCC-Specific Content (Running Example Throughout Lecture)
The lecture uses HCC extensively to illustrate surgical oncology principles.
Treatment failure from: 1. Recurrence 2. New primary [1]
This is a critical distinction: In HCC (which arises in a diseased liver — usually cirrhotic from HBV/HCV), even after successful resection:
- Recurrence = same cancer returning (from residual microscopic disease)
- New primary = a completely new cancer arising in the remaining diseased liver
This is why liver transplantation is attractive for HCC — it removes BOTH the cancer AND the diseased liver (the "field defect").
Stage II HCC — For liver transplantation: [1]
- Single tumour ≤ 5 cm
- OR ≤ 3 tumours, each ≤ 3 cm
- Overall recurrence-free survival 75%
These are the Milan criteria — the most important criteria determining eligibility for liver transplantation for HCC. Patients meeting Milan criteria have excellent outcomes post-transplant.
Primary Liver Transplantation vs. Primary Resection & Up-to-7 Criteria Score (tumor size + number of tumors) [1]
The "up-to-7" rule: sum of the size of the largest tumour (in cm) + the number of tumours should be ≤ 7. This is a slightly expanded criterion beyond Milan that still identifies patients with reasonable transplant outcomes.
The lecture presents the full AJCC 8th Edition staging system for HCC [1]:
Primary Tumour (T):
| T Stage | Definition |
|---|---|
| T1a | Solitary tumour ≤ 2 cm, with or without vascular invasion |
| T1b | Solitary tumour > 2 cm without vascular invasion |
| T2 | Solitary tumour > 2 cm with vascular invasion, or multifocal tumours none > 5 cm |
| T3 | Multifocal tumours, at least one > 5 cm |
| T4 | Tumour involving major branch of portal vein or hepatic vein, or direct invasion of adjacent organs (other than gallbladder), or perforation of visceral peritoneum |
Stage Groupings:
| Stage | T | N | M |
|---|---|---|---|
| IA | T1a | N0 | M0 |
| IB | T1b | N0 | M0 |
| II | T2 | N0 | M0 |
| IIIA | T3 | N0 | M0 |
| IIIB | T4 | N0 | M0 |
| IVA | Any T | N1 | M0 |
| IVB | Any T | Any N | M1 |
Vascular invasion (portal vein, hepatic vein) is a critical adverse prognostic factor — note that T4 specifically includes major branch portal/hepatic vein involvement [1].
Queen Mary Hospital data shows 5-year survival by stage after curative resection (P < 0.0001) [1]:
- Stage I: ~78–80%
- Stage II: ~60%
- Stage III: ~35%
- Stage IV: ~8–10%
A 20-year experience (Ann Surg 2011) demonstrated continuous improvement in both overall survival (P < 0.0001) and disease-free survival (P = 0.0024) comparing 1989–1998 vs 1999–2008 cohorts, with significant improvement seen in Stage II (P = 0.0032), Stage IIIA (P = 0.0106), and Stage IVA (P = 0.0069) [1].
What the Kaplan–Meier panels show: Group 2 (1999–2008) curves sit above Group 1 (1989–1998) for both overall and disease-free survival after hepatectomy — surgical oncology “works” when technique, selection, and peri-op care improve over decades, not only when the knife is sharper. [1]
From the Chan et al. Hep Int 2012 data shown in lecture [1]:
- Without vascular permeation: transplant and resection have similar outcomes for tumours meeting criteria
- With vascular permeation: outcomes are worse for both, but liver transplant may still offer benefit
- LDLT (living donor liver transplant) = 70 cases; DDLT (deceased donor) = 25 cases shown [1]
The Liu et al. Ann Surg 2006 prospective RCT compared anterior approach vs conventional approach for right hepatectomy (60 patients each) [1]:
| Comparison | Disease-Free Survival | Overall Survival |
|---|---|---|
| All major right hepatectomy | P = 0.8822 (NS) | P = 0.0061 (anterior superior) |
| Stage II disease (18 vs 25 pts) | P = 0.7179 (NS) | P = 0.0009 (anterior superior) |
| Lymphovascular permeation (37 vs 39 pts) | P = 0.8902 (NS) | P = 0.0343 (anterior superior) |
Key finding: The anterior (no-touch) approach significantly improved overall survival across all subgroups, though disease-free survival was similar — suggesting the benefit comes from preventing intraoperative tumour dissemination rather than reducing local recurrence [1].
VI. Measurement of Outcomes of Surgery
Measurement of outcome of surgery: [1]
- Hospital mortality rate — death within the same hospital admission for surgery
- 30-day operative mortality rate
- 5-year disease-free survival rate
- 5-year overall survival rate
- Quality of life
Current survival statistics of cancer treatment: [1]
- Hospital mortality rate: 1-5%
- 5-year survival rates:
- Breast cancer: 85%
- Colon cancer: 50%
- Lung cancer: 45%
- Liver cancer: 55%
- Pancreas cancer: 20%
5-Year Survival Rates — Know These!
These numbers are commonly tested. Note the hierarchy: Breast > Liver > Colon > Lung > Pancreas. Pancreatic cancer has the worst prognosis among common solid tumours largely because it presents late, is often unresectable, and has high recurrence rates.
The majority of patients could be considered cured if there is no extrahepatic recurrence beyond 5 years [1]
The lecture shows a graph demonstrating that most HCC recurrences (intrahepatic and extrahepatic) occur within the first 5 years. Beyond 5 years, the risk of recurrence drops dramatically. This is why 5-year survival is the standard benchmark for cancer cure.
Important nuance: Intrahepatic "recurrence" after 5 years in HCC may actually represent a new primary rather than true recurrence, because the underlying diseased liver continues to be at risk.
Factors contributing to success/failure of surgical treatment for cancer: [1]
- Surgical technique, blood loss volume
- Completeness of tumor clearance
- Function of organ remnant
- Close surveillance after surgery and prompt treatment of recurrence
- TNM stage of tumor at time of surgery
Each of these has already been discussed in the principles section, but the lecture re-emphasizes them as a checklist. The most important single factor is the TNM stage at the time of surgery — early-stage cancers have fundamentally better outcomes than advanced-stage cancers, regardless of surgical technique.
Deficiencies of surgery in treating cancer: [1]
- Morbidity and mortality related to operation could be significant
- Loss of organ/limb/tissue function may affect quality of life
- Disfigurement may induce psychological disturbance
- Microscopic spread is already present at time of surgery
- Recurrence is still possible even after curative operation
- Not all cancer can be treated by surgery when discovered
This is the honest assessment: surgery is powerful but imperfect. The last three points are the most important conceptually:
-
Microscopic spread already present — By the time a tumour is clinically detectable, cancer cells may have already disseminated. This is the fundamental rationale for adjuvant therapy.
-
Recurrence after curative operation — Even with R0 resection (negative margins), cancer can recur from dormant micrometastases that were below the detection threshold at the time of surgery.
-
Not all cancers are operable — Many cancers present at an advanced stage where surgery cannot achieve cure (e.g. locally advanced with major vessel encasement, or widespread metastatic disease).
IX. Adjuvant and Neoadjuvant Therapy
Treatment of microscopic foci after surgery: [1]
- Adjuvant chemotherapy / radiotherapy / immunotherapy
- Eradication or control of microscopic foci
- Indicated for patients with advanced disease or high risk for recurrence
Indicators of advanced disease for adjuvant therapy: [1]
- Regional lymph node metastases in resected specimen
- Vascular permeation by cancer cells on histological examination
- Advanced TNM stage
- Genetic marker
Why adjuvant therapy? After curative surgery, there may be residual microscopic cancer cells (micrometastases) that are too small to detect by any imaging or blood test. Adjuvant therapy aims to kill these cells before they can grow into clinically detectable recurrence.
Clinical examples from lecture:
- Neoptolemos et al. NEJM 2004: Patients receiving chemotherapy after pancreatic cancer resection had significantly better survival (P < 0.05) [1]
- PRODIGE-24/CCTG PA.6 trial (ASCO 2018): Adjuvant mFOLFIRINOX vs gemcitabine after R0/R1 resected pancreatic cancer [1]:
- Median OS: 54.4 months vs 35.0 months (HR 0.64, P = 0.003)
- Median DFS: 21.6 months vs 12.8 months (HR 0.58, P < 0.0001)
- 3-year OS: 63.4% vs 48.6%
- mFOLFIRINOX regimen: oxaliplatin 85 mg/m², leucovorin 400 mg/m², irinotecan 150–180 mg/m², 5-FU 2.4 g/m² over 46 h, q2w × 12 cycles
Eradication of microscopic foci by extirpation of organ: [1]
- Liver transplantation (removes diseased liver with field defect)
- Total colectomy (e.g. in FAP to remove all at-risk mucosa)
- Total pancreatectomy (removes entire pancreas when multifocal/diffuse disease)
Treatment of inoperable cancer — Downstaging: [1]
- Chemotherapy or radiotherapy → Surgery → Postop chemotherapy or radiotherapy
- Downstaging of tumor:
- Evidence of tumor response
- Facilitates surgery
Why neoadjuvant? Some tumours are initially too large or too invasive to resect safely. Pre-operative chemotherapy/radiotherapy can shrink the tumour (downstage), making surgery possible. Even if the tumour was initially operable, neoadjuvant therapy can:
- Test tumour chemosensitivity in vivo
- Treat micrometastases early
- Improve margin-negative resection rates
Examples by cancer type (from supporting notes):
Immunotherapy — the lecture shows the example of nivolumab (Opdivo) for inoperable HCC [1]:
- F/86 Inoperable HCC, 12th cycle Opdivo (nivolumab)
- AFP dropped from 245,000 ng/mL → 4 ng/mL
Checkpoint inhibitor mechanisms (from lecture): [1]
- CTLA-4 pathway: CTLA-4 checkpoint protein prevents dendritic cells from priming T cells to recognise tumours → CTLA-4 inhibitors (e.g. ipilimumab) block this checkpoint, allowing T-cell priming
- PD-1 pathway: PD-1 checkpoint protein prevents T cells from attacking cancer cells → PD-1 inhibitors (e.g. nivolumab, pembrolizumab) release this brake, allowing T-cell cytotoxicity
This demonstrates the dramatic potential of checkpoint inhibitors in converting what was once a death sentence (inoperable HCC) into a manageable disease.
X. Organ-Specific Surgical Oncology Examples
| Principle | Application in CRC |
|---|---|
| Margins | ≥ 5 cm proximal/distal for colon; 2 cm distal for rectum [2][3] |
| LN clearance | Minimum 12 nodes; high ligation of arterial pedicle [2][3] |
| En-bloc | Multivisceral resection if T4 invading adjacent organ [2] |
| No-touch | Ligate vessels first, then divide bowel, then mobilize [1] |
| TME | Total mesorectal excision for mid/low rectal cancer — sharp dissection in avascular plane to achieve negative CRM [2][3] |
| Adjuvant | Stage III colon: FOLFOX; Rectal: neoadjuvant chemoRT [2][5] |
| Cancer | Operation | Key Points |
|---|---|---|
| HCC | Hepatectomy / Liver transplant / Ablation | Anterior approach; Milan criteria for transplant [1] |
| Cholangiocarcinoma (hilar/Klatskin) | Major hepatectomy + caudate lobectomy + confluence resection [1][8] | Caudate has own biliary drainage into confluence |
| Cholangiocarcinoma (distal CBD) | Whipple operation [1] | En-bloc with head of pancreas, duodenum |
| CA Gallbladder | Radical cholecystectomy [4][8] | GB + liver segments 4b/5 + LN dissection |
-
Whipple operation (pancreaticoduodenectomy) for head of pancreas / distal CBD / ampullary cancers [1]
-
High operative risk due to cachexia, liver derangement, biliary sepsis [8]
-
Adjuvant chemotherapy improves survival (Neoptolemos NEJM 2004) [1]
-
5-year survival only ~20% even with surgery [1]
-
Adjuvant mFOLFIRINOX is now the standard of care after resection (PRODIGE-24: median OS 54.4 vs 35.0 months with gemcitabine) [1]
From AOS Pathology [7]:
- Indications: Guides intra-operative surgical decisions — confirm/exclude malignancy, assess margin status, evaluate sentinel LN
- Advantage: Short turnaround (minutes vs. day for paraffin sections)
- Clinical scenario: Lung nodule — if frozen section confirms malignancy, surgeon proceeds to lobectomy; if benign, wedge resection may suffice
Summary: [1]
- Surgery may cure cancer
- Most applicable for early and middle stage cancer
- Clean extirpation of cancer is mandatory otherwise purpose of surgery defeated
- Selective adjuvant therapy
Exam Intelligence
- Principles of cancer surgery — know all 6 principles and be able to explain the rationale for each
- No-touch technique — the specific sequence (vessels → divide bowel → mobilize)
- Blood transfusion and cancer recurrence — mechanism (TRIM → immunosuppression → loss of immune control)
- Milan criteria — single ≤ 5 cm OR ≤ 3 tumours each ≤ 3 cm
- 5-year survival rates by cancer type
- Indications for adjuvant therapy — LN metastases, vascular permeation, advanced TNM, genetic markers
- Neoadjuvant therapy concept — downstaging inoperable → operable
- Measurement of surgical outcomes — hospital mortality, 30-day mortality, 5-year DFS, 5-year OS, QoL
- Organ function preservation — minimum 30% liver remnant; excessive pancreatic resection → DM + steatorrhoea
| Trap | Correct Understanding |
|---|---|
| "All cancers are curable by surgery" | No — microscopic spread may already be present; not all cancers operable at diagnosis |
| "Positive margin = still cured" | No — positive margin (R1) means cancer left behind; purpose of surgery defeated |
| "Blood transfusion is safe in cancer surgery" | Transfusion causes immunosuppression → increased recurrence risk |
| "5-year survival = permanent cure" | Most patients are considered cured at 5 years, but late recurrence/new primaries can occur (especially HCC) |
| "Adjuvant therapy is for all patients" | Only for patients with high-risk features (LN+, vascular permeation, advanced stage) |
| "No-touch means don't touch at all" | It means control vessels and divide organ BEFORE mobilizing the tumour-bearing segment |
High Yield Summary
-
Surgery may cure cancer
- but ONLY if performed correctly with complete tumour extirpation, tumour-free margins (> 1 cm), lymph node clearance, en-bloc resection of invaded structures, no-touch/minimum manipulation technique, organ function preservation, and minimised blood loss/transfusion.
-
Cancer spreads
- locally, regionally (LN, perineural), and distantly (haematogenous, transperitoneal). The six hallmarks of cancer explain why cancer cells behave the way they do.
-
Outcomes are measured
- by hospital mortality (1-5%), 30-day mortality, 5-year DFS, 5-year OS, and quality of life. Five-year survival rates: Breast 85% > Liver 55% > Colon 50% > Lung 45% > Pancreas 20%.
-
Blood transfusion promotes cancer recurrence
- through transfusion-related immunomodulation (TRIM).
-
Adjuvant therapy
- (chemo/RT/immunotherapy) is indicated when histology shows LN metastases, vascular permeation, advanced TNM stage, or adverse genetic markers.
-
Neoadjuvant therapy
- can downstage initially inoperable tumours to make surgery possible.
-
Milan criteria for HCC transplant
- Single ≤ 5 cm OR ≤ 3 tumours each ≤ 3 cm.
-
No cancer is considered cured
- until at least 5 years without recurrence.
Active Recall - Surgical Oncology
[1] Lecture slides: GC 202. Surgery may cure your cancer Surgical oncology.pdf; GC 202. Surgery may cure your cancer Surgical oncology - Notes.pdf [2] Senior notes: Maksim Surgery Notes.pdf (pp. 104-106) [3] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (pp. 694-702) [4] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (pp. 383, 417, 509, 572) [5] Senior notes: Maksim Medicine Notes.pdf (p. 54) [6] Senior notes: Ryan Ho Urogenital.pdf (p. 208) [7] AOS material: AOS - Pathology.pdf (p. 23) [8] Senior notes: Ryan Ho Fundamentals.pdf (p. 303)
GC201 Skin Ulcers Skin And Subcutaneous Lesions; Skin Cancer
Skin ulcers are open wounds with loss of epidermis and dermis due to vascular, infectious, or inflammatory causes, while skin cancers (basal cell, squamous cell, melanoma) are malignant neoplasms arising from cutaneous cells, and subcutaneous lesions include benign or malignant growths within or beneath the skin.
GC202 Surgery May Cure Your Cancer Surgical Oncology - Notes
Surgical oncology is the branch of surgery dedicated to the diagnosis, staging, and curative or palliative resection of solid tumors, often integrated with multimodal cancer therapies.