Surgical oncology is the branch of surgery applied to oncology; it focuses on the surgical management of tumors, especially cancerous tumors.
Cancer management usually requires a multidisciplinary team and consists of medical oncology that deals with chemotherapy, radiation oncology that deals with radiotherapy and surgery. Many cancers require multimodality treatment. For example, stomach cancer will require surgery to remove the growth followed by adjuvant chemotherapy to decrease the chance of recurrence. Sometimes for example in oesophageal (food pipe) cancers one may be treated with chemotherapy and radiotherapy followed by surgery.
Nowadays, most cancers that require surgery can be treated with minimal access approach such as Laparoscopic and Robotic surgery. This has tremendous benefits in terms of early recovery, less pain and faster return to normal activity. It causes much less risk of infections which may further delay in your recovery. Laparoscopic or key hole surgery causes minimal tissue damage inside your body and therefore causes less adhesions inside the body and hence has less chance of adhesion related long term complications in the future. In the rare chance you need another surgery in the future, having a laparoscopic surgery done before makes it easier for the surgeon to perform he second surgery.
Common tumor surgeries performed at JR surgery:
Gastric cancer is a disease in which malignant (cancer) cells form in the lining of the stomach.
The stomach is a J-shaped organ in the upper abdomen. It is part of the digestive system, which processes nutrients (vitamins, minerals, carbohydrates, fats, proteins and water) in foods that are eaten and helps pass waste material out of the body. Food moves from the throat to the stomach through a hollow, muscular tube called the esophagus. After leaving the stomach, partly-digested food passes into the small intestine and then into the large intestine.
The wall of the stomach is made up of 5 layers of tissue. From the innermost layer to the outermost layer, the layers of the stomach wall are: mucosa, submucosa, muscle, subserosa (connective tissue) and serosa. Gastric cancer begins in the mucosa and spreads through the outer layers as it grows.
Stromal tumors of the stomach begin in supporting connective tissue and are treated differently from gastric cancer.
Risk factors for gastric cancer include the following:
These and other signs and symptoms may be caused by gastric cancer or by other conditions.
In the early stages of gastric cancer, there may be no symptoms at all!!
In other instances the following symptoms may occur:
In more advanced stages of gastric cancer, the following signs and symptoms may occur:
The following tests and procedures may be used:
The prognosis and treatment options depend on the following:
When gastric cancer is found very early, there is a better chance of recovery. Gastric cancer is often in an advanced stage when it is diagnosed.
After gastric cancer has been diagnosed, tests are done to find out if cancer cells have spread within the stomach or to other parts of the body.
The process used to find out if cancer has spread within the stomach or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.
The following tests and procedures may be used in the staging process:
Cancer can spread through tissue, the lymph system and the blood:
Cancer may spread from where it began to other parts of the body.
When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.
The metastatic tumor is the same type of cancer as the primary tumor. For example, if gastric cancer spreads to the liver, the cancer cells in the liver are actually gastric cancer cells. The disease is metastatic gastric cancer.
Stage 0 (Carcinoma in Situ)
In stage 0, abnormal cells are found in the mucosa (innermost layer) of the stomach wall. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.
Layers of the stomach wall. The wall of the stomach is made up of the mucosa (innermost layer), submucosa, muscle layer, subserosa and serosa (outermost layer). The stomach is an organ in the upper abdomen.
Stage I
Stage I is divided into stages IA and IB.
Stage II
Stage II gastric cancer is divided into stages IIA and IIB.
Stage III
Stage III gastric cancer is divided into stages IIIA, IIIB, and IIIC.
Stage IV
In stage IV, cancer has spread to other parts of the body, such as the lungs, liver, distant lymph nodes and the tissue that lines the abdomen wall.
Gastric cancer can recur (come back) after it has been treated.
The cancer may come back in the stomach or in other parts of the body, such as the liver or lymph nodes.
There are different types of treatment for patients with gastric cancer.
Different types of treatments are available for patients with gastric cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials.
Seven types of standard treatment are used:
Endoscopic submucosal Dissection
Endoscopic mucosal resection is a procedure that uses an endoscope to remove early-stage cancer and precancerous growths from the lining of the digestive tract without surgery. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also include tools to remove growths from the lining of the digestive tract.
Surgery
Surgery is a common treatment of all stages of gastric cancer. The following types of surgery may be used:
Nowadays, we prefer to perform laparoscopic (keyhole) or robotic surgery. This is better than the traditional open surgery as the scar is much smaller, therefore the patient is granted less pain with earlier recovery. The surgeon is also able to visualise structures better and perform more accurate surgery with less blood loss.
If the tumor is blocking the stomach but the cancer cannot be completely removed by standard surgery, the following procedures may be used:
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated. Chemotherapy can be given after surgery which is called adjuvant chemotherapy or it can be given before surgery which is called neoadjuvant chemotherapy.
A type of regional chemotherapy being studied to treat gastric cancer is intraperitoneal (IP) chemotherapy. In IP chemotherapy, the anticancer drugs are carried directly into the peritoneal cavity (the space that contains the abdominal organs) through a thin tube.
Hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment used during surgery that is being studied for gastric cancer. After the surgeon has removed as much tumor tissue as possible, warmed chemotherapy is sent directly into the peritoneal cavity.
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. External radiation therapy uses a machine outside the body to send radiation toward the area of the body with cancer.
Chemoradiation
Chemoradiation therapy combines chemotherapy and radiation therapy to increase the effects of both. Chemoradiation given after surgery, to lower the risk that the cancer will come back, is called adjuvant therapy. Chemoradiation given before surgery, to shrink the tumor (neoadjuvant therapy), is being studied.
Targeted therapy
Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells. Targeted therapies usually cause less harm to normal cells than chemotherapy or radiation therapy do. Monoclonal antibodies and multikinase inhibitors are types of targeted therapy used in the treatment of gastric cancer.
Immunotherapy
Immunotherapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or biologic therapy.
Immune checkpoint inhibitor therapy is a type of immunotherapy.
Immune checkpoint inhibitor therapy: PD-1 is a protein on the surface of T cells that helps keep the body’s immune responses in check. When PD-1 attaches to another protein called PDL-1 on a cancer cell, it stops the T cell from killing the cancer cell. PD-1 inhibitors attach to PDL-1 and allow the T cells to kill cancer cells.
Immune checkpoint inhibitor. Checkpoint proteins, such as PD-L1 on tumor cells and PD-1 on T cells, help keep immune responses in check. The binding of PD-L1 to PD-1 keeps T cells from killing tumor cells in the body (left panel). Blocking the binding of PD-L1 to PD-1 with an immune checkpoint inhibitor (anti-PD-L1 or anti-PD-1) allows the T cells to kill tumor cells (right panel).
Immunotherapy uses the body’s immune system to fight cancer. This animation explains one type of immunotherapy that uses immune checkpoint inhibitors to treat cancer.
Treatment of Stage 0 (Carcinoma in Situ)
Treatment of stage 0 may include the following:
Treatment of Stage I Gastric Cancer
Treatment of stage I gastric cancer may include the following:
Treatment of Stages II and III Gastric Cancer
Treatment of stage II gastric cancer and stage III gastric cancer may include the following:
Treatment of Stage IV Gastric Cancer, Gastric Cancer That Cannot Be Removed By Surgery, and Recurrent Gastric Cancer
Treatment of stage IV gastric cancer, gastric cancer that cannot be removed by surgery or recurrent gastric cancer may include the following:
Surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).
Mount Elizabeth Novena Hospital